An issue at Great Western Hospital that contributed towards the death of a beloved 'family man' has improved but is described as still “patchy”.
The insight came from local health chiefs at an inquest on November 8 into the death of Maurice Small, whose death on July 29, 2023, was partly caused by record-keeping problems at the Swindon hospital.
A coroner ruled Maurice Small died partly because GWH failed to arrange and communicate appointments, meaning he did not get the antibiotics that may have saved his life.
Although the coroner was reassured sufficient changes have been made to ensure there is no risk of a repeat incident, Jon Westbrook, managing director, said the rate of discharge letters being sent across the hospital is “patchy still”.
Maurice Small died from an infection in his lungs which likely could have been avoided had the hospital arranged a follow-up to check if antibiotics had worked.
A total of four administrative failures by the hospital contributed to Small’s death.
Coroner David Ridley called it 'a gross failure to provide basic medical attention' to not provide a further set of antibiotics.”
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Ridley expressed concern about the number of neglect cases.
"In the last two years, I have done, I think more neglect cases than the previous 14 years put together," he said.
"There's a problem at the moment. I know that you had your challenges, having got through COVID and the like, and we know the pressures on the NHS at the moment, but we are seeing the effects of those and the families are seeing the effects of those as well.
"It's not a good picture at the moment."
The inquest heard administrative errors which led to Small’s death were related to the methods used to keep patient records and send out discharge letters.
Until recent improvements, GWH doctors would have to use multiple programmes and read handwritten “squiggly” notes to put together a discharge letter, which Mr Westbrook called “a significant undertaking.”
This meant the job was sometimes missed, and letters were not sent.
Things have improved since then, especially in the respiratory ward, and a new electronic patient record system (EPR) is being introduced in 2026 for the three hospitals which will simplify how discharge letters, such as the one Small did not receive, are sent.
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This comes as part of a government drive for digitalization in the NHS, with a move away from paper-based records to more sophisticated and reliable electronic systems.
It remains the case that a Manchester hospital, for example, would not be able to access your medical record from GWH due to them not using the same record-keeping system.
Dr Robert Allcock, clinical lead for respiratory medicine, said that in 2021, GWH was at a “base level of digital maturity”, but has made “pretty good headway” since then.
This includes £4.5 million being spent on new hardware since 2021.
Until the new system is introduced in 2026, GWH is “on a journey” of improvement, said Allcock.
He added: “Jon, like me, would like to have more resources to be able to invest in having the IT developers and informatics colleagues.”
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Westbrook said: “Tech organisations would typically have five per cent of their budget on their informatics IT digital services.
“Healthcare doesn't come close to that. It's a tiny fraction and that makes it hard to achieve stuff.”
He said GWH spends £1.4 million every day, adding: “The current financial constraints within which all healthcare providers are operating and will be for the next three or four years are very tight.
“And so difficult decisions about where we spend that £1.4 million a day are having to be made.”
£21 million of central funding has been secured to fund the new EPR, with a commitment of an extra £40 over the next decade. The government also announced £2 billion to fund digitalisation projects.
GWH states that while money is tight, funding has been secured for the new EPR system.
A spokesperson speaking on behalf of the three hospital trusts said: “While always learning and improving we have confidence in our current systems but are pleased to have secured investment for a new shared electronic patient record across Bath and North East Somerset, Swindon and Wiltshire.
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“Funding from NHS England was approved in April 2024 and the new system will be rolled out across our three Trusts in 2026.
"Since Mr Small’s death, we have made a number of improvements to prevent anything similar from occurring and we will also soon be moving from our previous electronic discharge system to a new digital tool which will ensure a better process for handover of care from one organisation to another."
In the autumn budget, an extra £25.7 billion was allocated to the NHS over this year and next. In spring 2025 a 10-year plan will be published for the NHS.
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