| Recurring |
one_organization, multiple_organization |
(a) The software failure incident related to the NHS 111 call center system failing to properly triage and assess the severity of medical conditions in children has happened again within the same organization. In 2019, concerns were raised about the call center triage software after three children died due to missed diagnoses and improper assessments [127738].
(b) The software failure incident related to the issues with the NHS 111 call center system has also occurred at multiple organizations. The incidents involving missed diagnoses and improper assessments in children have led to warnings issued by coroners to prevent future deaths. Similar concerns were raised about the ability of children to understand call handlers' questions or articulate their symptoms in different cases, indicating a broader issue beyond just one organization [127738]. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident related to the design phase is evident in the case of the NHS 111 call centre triage software, known as NHS Pathways. The algorithm used in this software relies on answers given over the phone to a set series of questions, guiding call handlers who are not medically qualified to direct patients to further assessment and treatment. However, concerns were raised that the system failed to consider specific factors such as disabilities and the inability to verbalize symptoms, particularly in cases involving children like Hannah Royle, Myla Deviren, Sebastian Hibberd, and Alexander Davidson [127738].
(b) The software failure incident related to the operation phase is highlighted by the missed opportunities and shortcomings in the operation of the NHS 111 call centre triage software. Call handlers, who are not medically qualified, were found to have missed serious conditions in children due to the system's limitations in assessing pain, understanding symptoms, and communicating effectively with young or vulnerable patients. These operational issues contributed to the failures in correctly triaging and providing appropriate care to patients like Hannah Royle, Myla Deviren, Sebastian Hibberd, and Alexander Davidson [127738]. |
| Boundary (Internal/External) |
within_system |
(a) within_system: The software failure incident related to the NHS 111 call center triage software, known as NHS Pathways, was primarily due to factors originating from within the system. The algorithm of the software relies on answers given over the phone to a set series of questions, guiding call handlers who are not medically qualified to direct patients for further assessment and treatment [127738].
The coroners' reports highlighted that the call handlers failed to consider the disabilities and inability to verbalize symptoms of patients, particularly children, when using the triage software. There were missed opportunities to save lives due to the software not allowing a meaningful assessment of pain in children, the inability of children to communicate symptoms effectively, and struggles with comprehending medical terminology used by call handlers [127738]. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident in the NHS 111 system was primarily due to non-human actions, specifically related to the shortcomings in the call centre triage software (NHS Pathways algorithm) used by NHS 111. The algorithm relies on answers given over the phone to a set series of questions, guiding call handlers who are not medically qualified to direct patients to further assessment and treatment [127738].
(b) However, human actions also played a role in the failure as call handlers failed to consider the disabilities and inability to verbalize of patients, particularly in the case of Hannah Royle who had autism and suffered a twisted stomach. The coroner mentioned that NHS 111 staff failed to consider her disabilities and inability to verbalize when using the triage software [127738]. |
| Dimension (Hardware/Software) |
software |
(a) The software failure incident occurring due to hardware:
- The article does not mention any specific hardware-related contributing factors that led to the software failure incident reported in the NHS 111 cases [127738].
(b) The software failure incident occurring due to software:
- The software failure incident in the NHS 111 cases was primarily attributed to the shortcomings in the call centre triage software known as NHS Pathways. The algorithm relied on answers given over the phone to a set series of questions, guiding call handlers who were not medically qualified to direct patients for further assessment and treatment. The software failed to consider the disabilities and inability to verbalize symptoms in patients, particularly in children like Hannah Royle, Myla Deviren, Sebastian Hibberd, and Alexander Davidson, leading to missed opportunities to provide appropriate care [127738]. |
| Objective (Malicious/Non-malicious) |
non-malicious |
(a) The software failure incident related to the NHS 111 call center system can be categorized as non-malicious. The incident involved failures in the NHS Pathways algorithm used by call handlers to triage patients over the phone. The algorithm relied on a set series of questions to guide call handlers, who were not medically qualified, to direct patients to further assessment and treatment. The coroners' reports highlighted concerns about the system's inability to effectively assess and understand symptoms in children, leading to missed diagnoses and subsequent deaths [127738]. The failures were attributed to shortcomings in the software design and the lack of consideration for patients' specific conditions and communication abilities, rather than any malicious intent to harm the system. |
| Intent (Poor/Accidental Decisions) |
poor_decisions |
(a) The intent of the software failure incident related to poor decisions:
- The software failure incident in the NHS 111 call center, specifically related to the NHS Pathways algorithm, was due to poor decisions made by call handlers who failed to consider the disabilities and inability to verbalize of patients, particularly children like Hannah Royle who had autism [127738].
- Coroner reports highlighted that the call handlers using the NHS Pathways algorithm did not adequately assess the severity of the children's conditions, leading to missed opportunities to save lives. This failure to consider the unique needs and communication challenges of young and vulnerable patients reflects poor decision-making in the implementation and use of the software [127738]. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident in the NHS 111 system, specifically related to the call centre triage software known as NHS Pathways, can be attributed to development incompetence. The incident involved failures by NHS 111 staff to consider the disabilities and inability to verbalize of patients, particularly children like Hannah Royle, who tragically died after the system failed to realize she was seriously ill [127738]. The coroners' reports highlighted that the system did not adequately account for the challenges faced by vulnerable patients, such as children, in articulating their symptoms, leading to missed diagnoses and preventable deaths [127738].
(b) Additionally, the incident can also be categorized as accidental, as the failures in the software system were not intentional but rather resulted from shortcomings in the design and implementation of the NHS Pathways algorithm. The call handlers, who were not medically qualified, relied on the system to guide them in directing patients to further assessment and treatment within the NHS, indicating an unintentional introduction of contributing factors that led to tragic outcomes [127738]. |
| Duration |
temporary |
The software failure incident related to the NHS 111 call center's triage software can be categorized as a temporary failure. The incident involved failures in the software's ability to appropriately triage patients, particularly children, leading to missed diagnoses and subsequent deaths. The coroners highlighted issues with the software not considering the disabilities and inability of patients to articulate their symptoms effectively, which contributed to the failures in patient assessment and treatment [127738]. The incidents involving the deaths of Hannah Royle, Myla Deviren, Sebastian Hibberd, and Alexander Davidson were all linked to shortcomings in the software's design and the call handlers' reliance on a set series of questions without considering the unique circumstances of each patient [127738]. The software failure was not permanent but rather a result of contributing factors introduced by certain circumstances, such as the limitations in the software's ability to adapt to the needs of vulnerable patients. |
| Behaviour |
omission, value, other |
(a) crash: The software failure incident in this case did not involve a crash where the system lost state and did not perform any of its intended functions. The failure was more related to the system's inability to correctly assess and triage patients, leading to missed diagnoses and subsequent deaths [127738].
(b) omission: The software failure incident can be categorized under omission, as the system failed to perform its intended functions of accurately assessing and triaging patients, particularly children, leading to missed diagnoses and preventable deaths [127738].
(c) timing: The software failure incident was not primarily related to timing issues where the system performed its intended functions correctly but either too late or too early. Instead, the issue was more about the system's failure to accurately assess patients' conditions in a timely manner [127738].
(d) value: The software failure incident can be associated with a value failure, as the system was performing its intended functions incorrectly by not adequately considering the specific needs and conditions of patients, especially children, leading to fatal misdiagnoses [127738].
(e) byzantine: The software failure incident did not exhibit characteristics of a byzantine failure where the system behaves erroneously with inconsistent responses and interactions. The primary issue was the system's failure to appropriately assess and triage patients, particularly vulnerable individuals like children, rather than displaying inconsistent behavior [127738].
(f) other: The software failure incident can be described as a failure related to inadequate consideration of patients' specific conditions and needs, leading to missed diagnoses and preventable deaths. This failure could be categorized as a systemic failure in the design and implementation of the triage software used by NHS 111, rather than a specific type of technical malfunction [127738]. |