Encompass, which had only been operational for just over four months – since May 8 – went down for one working day on September 17, leading to around 1,600 patients’ appointments in the Southern Health and Social Care Trust to be rescheduled.
Addressing the board of the Southern Health and Social Care (HSC) Trust last Thursday, Elaine Wilson, Director of Planning, Performance and Informatics, explained that she was now in a position to outline what had gone wrong on the day.
She said an Incident Review Group that was set up to review the major incident has now presented its findings and recommendations.
Southern Health Trust director Elaine Wilson
Independent group chair Professor Graham Evans, who was attending the meeting remotely, told board members: “Digital transformation is not just about technology, it’s about people, process and technology.
“The main technical root cause was reported as a human process error. An individual was working on some critical infrastructure, undertaking a process that had happened several times previously, but on this particular occasion was working on the active data centre, rather than the inactive data centre.
“As a result of that, when the software change was applied, we had the resulting system outage.
“Human error does take place, but what we can do is put some checks and balances, some safety nets within our process, to minimise the chance of these things occurring again.
“I’m very careful using my words to ‘minimise’ rather than ‘prevent’, because it’s very difficult to completely eliminate human error, but the process and the recommendations that we’ve come up with is to implement a second-stage review, a second pair of eyes where another person within that process can double-check that the actions that are about to be taken are the correct actions.
“And we believe, in this particular instance, working on critical infrastructure, that this step will minimise the risk of a reoccurrence.
“In addition, what we’ve done working with vendors within the supply chain, is to implement better and strengthened chain controls.
“So, rather than reaching out to the supply partners during this process after the event, we want to be more proactive and involve them in the planning and preparation of critical infrastructure change.
“The second pair of eyes, [as well as] being more proactive, are really the key recommendations that have now been implemented, and will strengthen the learning as we go forward.
“We’ve also considered strengthening the Trust’s governance.”
The launch of Encompass at Daisy Hill Hospital
Prof Graham went on to praise all involved for being so focused on restoring the new IT system so quickly.
“From my experience of these types of situations, to get critical infrastructure back up and running within a business day was no mean feat,” he said.
“It was a real, Herculean effort from all of the Trust, its partners, and during that time, there was a laser-light focus on patient safety and patient care.”
Ms Wilson explained that lessons would be learned from the incident, and recommended measures fully implemented.
The IT outage affected some 1,600 appointments this week
News catch up – Monday 2 February
She told board members: “While we have started with the implementation of the recommendations, they’re not all complete, so we will be bringing an action plan to our senior leadership team to set out all the recommendations that were made, where we are in terms of the progress in implementing those, and what else we still need to do.
“Some of them will take a little bit more time, but all the recommendations we will be taking forward.
“One of the things to mention in relation to the technical side of things, the technical recommendations, we have now implemented all of those.”