Incident: NHS Covid-19 App Unable to Link Test Results.

Published Date: 2020-09-26

Postmortem Analysis
Timeline 1. The software failure incident where people tested for Covid-19 in NHS hospitals and Public Health England labs were unable to share their results with the NHS’s contact-tracing app in England happened around September 2020 [Article 104812].
System 1. NHS Covid-19 contact-tracing app in England [104812]
Responsible Organization 1. Public Health England labs and NHS hospitals [104812]
Impacted Organization 1. People tested for Covid-19 in NHS hospitals and Public Health England labs [104812] 2. Users of the NHS Covid-19 contact-tracing app in England [104812]
Software Causes 1. Lack of integration between the NHS Covid-19 contact-tracing app and test results from Public Health England labs and NHS hospitals, leading to the inability to link test results with the app [104812]. 2. Design issue limiting the ability of users who test negative, including those using home-testing kits or private providers, to log their results in the app [104812].
Non-software Causes 1. Lack of provision of a code for test results from Public Health England labs or NHS hospitals to be linked with the app [104812]. 2. Design issue limiting the ability of users who test negative, including those using home-testing kits or private providers, to log their results in the app [104812].
Impacts 1. People tested for Covid-19 in NHS hospitals and Public Health England labs were unable to share their results with the NHS's contact-tracing app in England, causing inconvenience and potential delays in contact tracing efforts [Article 104812]. 2. Users who received negative test results from home-testing kits or private providers were also unable to log their results in the app, leading to a lack of comprehensive data on test results within the app [Article 104812]. 3. The software failure incident highlighted a design issue where users who reported symptoms via the app but booked their test outside of the app would only receive a code to input if their test result was positive, potentially creating confusion and inefficiencies in result reporting [Article 104812].
Preventions 1. Proper testing and validation procedures before the launch of the app could have potentially identified the issue with linking test results from NHS hospital labs and Public Health England labs to the app [104812]. 2. Involving a wider range of stakeholders, including healthcare professionals and technical experts, in the design and development process of the app could have helped in foreseeing and addressing potential integration issues [104812]. 3. Implementing a more robust and comprehensive feedback mechanism during the app development phase to capture user concerns and suggestions could have highlighted the need for features like logging negative test results, thus preventing user dissatisfaction and usability issues [104812].
Fixes 1. Ensuring that the app can link test results from public labs such as NHS hospital labs and PHE labs, not just tests carried out via the outsourced Lighthouse lab network, would help fix the software failure incident [104812]. 2. Addressing the design issue that limits the ability of users who test negative, including those using home-testing kits or private providers, to log their results in the app would also be crucial in resolving the software failure incident [104812].
References 1. The Department of Health and Social Care [104812] 2. NHS Covid-19 app Twitter account [104812] 3. Prof Stephen Reicher [104812] 4. Labour’s shadow health secretary, Jonathan Ashworth [104812] 5. Welsh health director for digital technology and transformation, Ifan Evans [104812]

Software Taxonomy of Faults

Category Option Rationale
Recurring one_organization (a) The software failure incident having happened again at one_organization: The NHS Covid-19 app in England experienced a software failure where people tested for Covid-19 in NHS hospitals and Public Health England labs were unable to share their results with the app. This issue was revealed on the app's official Twitter account, and it was mentioned that a similar incident had happened before with the app not being able to link test results from public labs [104812]. (b) The software failure incident having happened again at multiple_organization: The article does not provide specific information about similar incidents happening at other organizations or with their products and services.
Phase (Design/Operation) design, operation (a) The software failure incident related to the design phase can be seen in the article where it mentions a design issue that limited the ability of users who tested negative to log their results in the app. This issue affected users who used home-testing kits or private providers such as the Lighthouse lab network [104812]. (b) The software failure incident related to the operation phase is evident in the article where it states that people who reported symptoms via the app but then booked their test outside of the app would only receive a code to input if their test result was positive. This operational limitation impacted the user experience and the functionality of the app [104812].
Boundary (Internal/External) within_system, outside_system (a) within_system: - The software failure incident within the system was related to the inability of the NHS Covid-19 contact-tracing app in England to link test results from Public Health England labs and NHS hospitals. This issue prevented users from sharing their results with the app [104812]. - The app required a code to link test results, which was not provided in some cases, leading to users being unable to log their results [104812]. - The failure within the system also involved a design issue that limited the ability of users who tested negative, including those using home-testing kits or private providers, to log their results in the app [104812]. (b) outside_system: - The software failure incident was exacerbated by the separation between the new privatised testing system and NHS/Public Health structures, as highlighted by Prof Stephen Reicher. This separation contributed to the failure of the app to include test results from public labs [104812]. - The issue of not being able to link test results from NHS hospital labs and PHE labs was a result of the divorce between the new privatised testing system and NHS/Public Health structures, indicating external factors influencing the failure [104812].
Nature (Human/Non-human) non-human_actions (a) The software failure incident occurring due to non-human actions: - The article mentions that people tested for Covid-19 in NHS hospitals and Public Health England labs were unable to share their results with the NHS’s contact-tracing app in England due to an issue where test results from these facilities could not be linked with the app, whether they were positive or negative. This issue was not due to human actions but rather a technical limitation in the app's functionality [104812]. (b) The software failure incident occurring due to human actions: - The article does not provide specific information about the software failure incident being directly caused by human actions.
Dimension (Hardware/Software) software (a) The software failure incident related to hardware: - The article mentions that people tested for Covid-19 in NHS hospitals and Public Health England labs were unable to share their results with the NHS’s contact-tracing app in England. This issue was due to the fact that test results from Public Health England labs or NHS hospitals could not be linked with the app, whether they were positive or negative [104812]. (b) The software failure incident related to software: - The software failure incident in this case was primarily due to a software issue within the NHS Covid-19 contact-tracing app. Users reported that they were unable to log their test results on the app, specifically if their tests were conducted in Public Health England labs or NHS hospitals. This issue was related to the app's functionality and the lack of provision for entering test results from certain testing facilities [104812].
Objective (Malicious/Non-malicious) non-malicious (a) The software failure incident described in the article does not indicate any malicious intent. The issue with the NHS Covid-19 contact-tracing app in England was primarily due to technical challenges and design flaws rather than any deliberate actions to harm the system. Users were unable to share their test results with the app, and there were issues with linking test results from public labs to the app, leading to functionality limitations and user frustration [104812]. (b) The software failure incident can be categorized as non-malicious, as it stemmed from technical issues, design limitations, and challenges in integrating test results from different sources rather than any intentional harm or sabotage to the system. The problems with the app's functionality, including the inability to link test results from certain labs and difficulties in logging negative results, were highlighted as areas that needed improvement to enhance the app's effectiveness in contact tracing [104812].
Intent (Poor/Accidental Decisions) poor_decisions, accidental_decisions (a) The software failure incident related to the NHS Covid-19 contact-tracing app in England can be attributed to poor decisions. The incident was caused by a design issue where test results from Public Health England labs and NHS hospitals could not be linked with the app, whether they were positive or negative. This limitation was highlighted by various individuals, including Prof Stephen Reicher and Labour's shadow health secretary, Jonathan Ashworth, who criticized the app for not including test results from these public labs. The failure to incorporate results from these sources was seen as a flaw in the app's design, indicating a poor decision-making process during the app's development and launch [104812]. (b) The software failure incident can also be linked to accidental decisions or unintended consequences. For example, the inability of users to log negative test results in the app was mentioned as an issue that was still being looked at, indicating a potential oversight or unintended consequence of the app's design. Additionally, the article highlighted a separate design issue that limited the ability of users who tested negative using home-testing kits or private providers to log their results in the app, further suggesting accidental decisions or unintended consequences in the app's functionality [104812].
Capability (Incompetence/Accidental) development_incompetence, accidental (a) The software failure incident related to development incompetence is evident in the article as it mentions various issues with the NHS Covid-19 contact-tracing app. The app faced problems where people tested for Covid-19 in NHS hospitals and Public Health England labs were unable to share their results with the app due to a code not being provided in the text and email received with the result [104812]. Additionally, there were complaints that the app did not work on older phones and was hard to find and download, indicating potential development shortcomings. (b) The accidental aspect of the software failure incident is also highlighted in the article. For instance, the inability of users to log negative test results in the app, the design issue limiting the ability of users to log negative results, and the delay in the launch of the app by four months all point towards accidental factors contributing to the failure [104812].
Duration temporary (a) The software failure incident in the article appears to be temporary. The issue with the NHS Covid-19 app not being able to link test results from Public Health England labs and NHS hospitals was acknowledged and fixed by the Department of Health and Social Care [104812]. The problem was specifically related to the inability of some users to share their test results with the app due to missing codes, and steps were taken to address this issue.
Behaviour omission, other (a) crash: The software failure incident mentioned in the article is not specifically described as a crash where the system loses state and does not perform any of its intended functions. The issue reported is related to the inability of the NHS Covid-19 app to link test results from Public Health England labs and NHS hospitals with the app, both positive and negative results. This issue led to users being unable to log their results on the app [104812]. (b) omission: The software failure incident can be categorized as an omission failure. Users who had their tests conducted in Public Health England labs or NHS hospitals were unable to link their test results with the NHS Covid-19 app, resulting in the omission of the intended function of allowing users to log their results on the app [104812]. (c) timing: The software failure incident is not related to a timing failure where the system performs its intended functions correctly but at the wrong time. The issue reported in the article is more about the inability to link test results with the app rather than a timing-related problem [104812]. (d) value: The software failure incident does not align with a value failure where the system performs its intended functions incorrectly. The issue described in the article is more about the inability to link test results with the app rather than the system providing incorrect results [104812]. (e) byzantine: The software failure incident is not characterized as a byzantine failure where the system behaves erroneously with inconsistent responses and interactions. The issue reported in the article is more about the inability to link test results with the app rather than erratic or inconsistent behavior of the system [104812]. (f) other: The behavior of the software failure incident can be categorized as a data integration failure. The issue stemmed from the lack of integration between the NHS Covid-19 app and test results from Public Health England labs and NHS hospitals, leading to users being unable to log their results on the app [104812].

IoT System Layer

Layer Option Rationale
Perception None None
Communication None None
Application None None

Other Details

Category Option Rationale
Consequence harm, delay, theoretical_consequence The consequence of the software failure incident described in the articles is primarily related to delays and potential harm: - Delay: The software failure incident caused delays in people being able to share their Covid-19 test results with the NHS contact-tracing app in England [104812]. - Harm: There is a potential for harm as the delay in sharing test results could impact the effectiveness of contact tracing and isolation measures, which are crucial in controlling the spread of Covid-19 [104812].
Domain health (a) The failed system was related to the health industry, specifically the NHS Covid-19 contact tracing app in England [104812].

Sources

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