| Recurring |
one_organization, multiple_organization |
(a) The software failure incident at Guy's and St Thomas' Hospital in London is not the first time such issues have occurred within the organization. An internal report earlier this year highlighted that the hospital's IT infrastructure "had reached the end of its life" [130057]. This suggests that there were existing problems with the IT systems prior to the recent incident.
(b) The incident at Guy's and St Thomas' Hospital is not isolated, as the whistleblower mentioned that other, less well-resourced district hospitals are functioning fine despite the challenges faced by Guy's and St Thomas' [130057]. This implies that similar IT issues may have occurred at other healthcare organizations as well. |
| Phase (Design/Operation) |
design, operation |
(a) The software failure incident at Guy's and St Thomas' Hospitals was attributed to poor planning and chronic underfunding, indicating issues related to the design phase of the IT system [130057]. The whistleblower mentioned that the hospital's IT infrastructure had reached the end of its life earlier in the year, suggesting a lack of proper design and maintenance of the system.
(b) The operation phase also played a significant role in the software failure incident. The breakdown of IT servers during the heatwave led to operations being canceled, and staff had to resort to using paper notes due to the malfunctioning IT system [130057]. Patients reported delays in receiving critical test results and information, impacting their mental health and well-being. The inability to access necessary data and communicate effectively with patients highlighted operational challenges caused by the software failure. |
| Boundary (Internal/External) |
within_system |
(a) The software failure incident at Guy's and St Thomas' Hospitals was primarily within the system. The failure was attributed to issues such as poor planning, chronic underfunding, and the hospital's outdated IT infrastructure [130057]. The internal report mentioned that the IT infrastructure had reached the end of its life, indicating that the root cause of the failure was within the hospital's own systems and management. The impact of the failure, such as the breakdown of IT servers during a heatwave, the reliance on paper notes, misspelling of names, and delays in accessing critical patient data, all point to internal system issues contributing to the failure. |
| Nature (Human/Non-human) |
non-human_actions, human_actions |
(a) The software failure incident at Guy's and St Thomas' Hospitals was primarily attributed to non-human actions. The IT servers stopped working during a heatwave, reaching temperatures of 40C (104F) on 19 July, leading to the breakdown of the IT system [130057]. The incident was exacerbated by poor planning and chronic underfunding, indicating that the failure was primarily due to environmental conditions and technical issues rather than human actions.
(b) However, human actions also played a role in the software failure incident. The whistleblower mentioned that the hospital had not been upfront about the IT problems, indicating a lack of transparency and potentially poor communication from the management [130057]. Additionally, the article highlighted issues such as misspelling names, misplacing patient results, and the inability to access critical patient data, which could be attributed to human errors in data entry or system management. |
| Dimension (Hardware/Software) |
hardware, software |
(a) The software failure incident at Guy's and St Thomas' Hospitals was primarily attributed to hardware issues. The IT servers stopped working during a heatwave, with temperatures reaching 40C (104F) on 19 July. An internal report earlier in the year had highlighted that the hospital's IT infrastructure "had reached the end of its life" [130057].
(b) The software failure incident also had software-related contributing factors. The breakdown of the IT servers led to a situation where staff had to resort to paper notes as the IT system was not functioning. This caused issues such as misspelling of names, scans not showing up, difficulty in tracking patients, and delays in accessing critical test results. The broken IT system affected various aspects of patient care and hospital operations, indicating software-related challenges in data management and system functionality [130057]. |
| Objective (Malicious/Non-malicious) |
non-malicious |
(a) The software failure incident at Guy's and St Thomas' Hospitals in London was non-malicious. The failure was primarily attributed to poor planning, chronic underfunding, and an outdated IT infrastructure that had reached the end of its life [130057]. The incident occurred during a heatwave, causing IT servers to stop working, leading to the cancellation of operations and impacting various aspects of patient care and hospital operations. The whistleblower highlighted issues such as staff reverting to paper notes, misspelling of names, difficulty in tracking patients, delays in accessing test results, and potential loss of research data. Patients also reported delays in receiving critical medical information, affecting their mental health. The hospital's spokesperson acknowledged the ongoing impact of the IT problems on services, including the postponement of operations and appointments. |
| Intent (Poor/Accidental Decisions) |
poor_decisions |
(a) The software failure incident at Guy's and St Thomas' Hospitals in London seems to have been influenced by poor decisions. A whistleblower mentioned that "poor planning" and "chronic underfunding" were contributing factors to the IT issues that arose during the heatwave [130057]. Additionally, an internal report earlier in the year highlighted that the hospital's IT infrastructure "had reached the end of its life," indicating a lack of proactive decision-making regarding IT system upgrades or replacements. These instances suggest that poor decisions played a role in the software failure incident. |
| Capability (Incompetence/Accidental) |
development_incompetence, accidental |
(a) The software failure incident at Guy's and St Thomas' Hospitals was attributed to "poor planning" and "chronic underfunding" according to a whistleblower who works as a doctor at the hospital [130057]. The incident was exacerbated by the fact that the hospital's IT infrastructure was reported to have "reached the end of its life" earlier in the year, indicating a lack of proper maintenance and upgrades [130057].
(b) The software failure incident at the hospital was worsened by the extreme heatwave conditions, with IT servers breaking down in temperatures of 40C (104F) [130057]. This accidental factor of the heatwave impacting the IT system's functionality contributed to the overall failure experienced by the hospital. |
| Duration |
temporary |
The software failure incident at Guy's and St Thomas' Hospital was temporary rather than permanent. The incident occurred due to specific circumstances, particularly the extreme heatwave that caused the IT servers to break down. The whistleblower mentioned that the IT issues were ongoing and having an impact on services, indicating that efforts were being made to address and resolve the problem [130057]. |
| Behaviour |
omission, other |
(a) crash: The software failure incident at Guy's and St Thomas' Hospital resulted in operations being canceled after IT servers broke down in high temperatures, leading to the hospital reverting to paper notes and facing issues with tracking patients, misspelling names, and receiving incorrect test results [130057].
(b) omission: The broken IT system at the hospital caused delays in providing test results to patients, with some patients not being called for appointments and individuals like Claire experiencing anxiety and mental health issues due to the lack of communication and information about their health status [130057].
(c) timing: The software failure incident led to delays in accessing critical information such as urgent blood results, causing a backlog and making time-sensitive results impossible to interpret, impacting patient care and treatment timelines [130057].
(d) value: The malfunctioning IT system resulted in the hospital struggling to see patients, affecting the ability to request routine blood tests or urine cultures, which are essential for diagnosing and monitoring patients' health conditions [130057].
(e) byzantine: The labs at the hospital faced challenges due to the software failure, with staff spending hours trying to communicate with the lab for urgent blood results, encountering backlogs, and experiencing difficulties in interpreting time-sensitive results, leading to inconsistencies and delays in patient care [130057].
(f) other: The software failure incident also resulted in the hospital risking the loss of months or even years of research data if shared drives were not recovered, highlighting the potential long-term consequences and impact on data integrity and research activities [130057]. |