The NHS trust in charge of Watford General Hospital has published a review into its failed management of cancer referrals, which may have resulted in the deaths of two patients.
West Hertfordshire Hospitals NHS Trust breached national guidelines by not always giving patients another appointment when they did not attend their first appointment in the two-week wait cancer pathway.
The Trust identified three patients potentially harmed by the failings in the administrative system for cancer appointments - two of those patients had died.
The failings came to light when staff were given training in managing cancer referrals after a GP made a formal complaint to the chief executives office in November 2012.
Stephen Ramsden, chair of the panel which conducted the independent external review, found there were no failsafe systems in place for patient tracking, notes were not kept consitently and referrals were faxed to the Trust which was not always acknowleged to have arrived.
Some cancer referral patients who missed their first appointment were rescheduled into routine clinic appointment slots, in some cases because of demand and capacity issues.
Mr Ramsden also made reference to "misrepresentation or lack of knowledge of complex national/local cancer waits guidence regarding ‘did not attends’".
And noted attempts by the Trust to reduce the number of general outpatient ‘did not attends’ "contributed to misrepresentation and, in some cases, the practice of discharging cancer referral patients who did not attend their first or second appointment".
Mr Ramsden said: "We have carefully recommended actions and mechanisms to ensure the standards are met and that patients receive the best care experience possible.
"It is important that clinical and non-clinical staff at all levels understand their responsibilities and take ownership for putting things right. I hope these recommendations will help the Trust build on the work already underway and I have offered to provide continuing support to help improve cancer services for patients."
The report recommended West Herts create a new cancer plan, improve IT and communications infrastructure, strethen relationships between key clinical staff and outpatients department and improve the two-week wait system to encourage better attendence.
Trust chief executive Samantha Jones said a significant number of measures in place to prevent the issues occuring again.
These include a new IT system to track patients’ appointments, missed appointments and cancellations and daily reviews of all patients who miss a booked cancer appointment.
She said: "We welcome the findings from the external review report and will carefully reflect and implement actions. We have recently approved and published a comprehensive cancer improvement plan to build on improvements already underway following our internal review. We will continue this work to deliver against these recommendations to ensure patients see real benefits from improved management of cancer referral pathways.
"I apologise unreservedly to the patients and families affected and wish to assure them that we have already put failsafe mechanisms in place to stop these issues arising again. We have published the report to share the findings with our patients and local community and will continue to work in partnership with local and national health partners to ensure all aspects of the cancer referral pathway can be improved to enhance the patient care experience."