Category Archives: UK Trainwrecks

The Wrong Arm of the (f)Law

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Courtesy of Steve Tuck and Privacy International comes this great story from the UK of how a simple error, if left uncorrected, can result in significantly unwelcome outcomes. It is also a cautionary tale for those of us who might think that flagging a record as being “incorrect” or inaccurate might solve the problem… such flags are only as good as the policing that surrounds them.
Matthew Jillard lives on Repton Road in a suburb of Birmingham. In the past 18 months he has been raided over 40 times by the police. During Christmas week he was raided no fewer than 5 times, with some “visits” taking place at 3am and 5am, disturbing him, his family, his family’s guests, his neighbours, his neighbour’s guests….
According to Mr Jillard,
9 times out of 10 they are really apologetic.
Which suggests that 1 time out of 10 the visiting police might annoyed at Mr Jillard for living at the wrong address(??)
The root cause: The police are confusing Mr Jillard’s address with a house around the corner on Repton Grove.
(scroll the map to the right to find Repton Grove)
Clancy Wiggum from the Simpsons
Not a spokesman for West Midlands Police

View larger map
Complaints to the police force in question have been met with apologies and assurances that the police have had training on how important it is to get the address right for a search. Some officers have blamed their Sat Nav for leading them astray.
Given the cost to the police of mounting raids, getting it wrong 40 times will be putting a dent in their budget. Also, the costs to the police of putting right any damages done to Mr Jillard’s home due to the incorrect raids (which have included kicking in his door at 3am on Christmas Day) will also be mounting up.
The police have said that “measures” have been taken to prevent Mr Jillard’s home being raided, including putting a marker against his address on the police computer systems. None of these measures appear to have stopped the raids, which come at an average frequency of more than one a fortnight (40 raids in 18 months).
This Trainwreck highlights the impact of apparently simple errors in data:
  1. Mr Jillard’s home is being disturbed without cause on a frequent basis
  2. His neighbours must be increasingly suspicious of him, what with the police calling around more often than the milkman
  3. The police force is incurring costs and wasting man power with a continuing cycle of fruitless raids.
  4. The real target of the raids are now probably aware of the fact that the police are looking for them and will have moved their activities away from Repton Grove.

8 year old orphaned by a fat finger key stroke error

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Daragh O Brien has written and presented in the past for the IAIDQ on the topic of how the legal system and information quality management often look at the same issues from a different perspective, ultimately to identify how to address the issues of the cost and risk of poor quality.

This was brought home very starkly this morning in a case from the UK High Court which has opened the possibility of six figure damages being awarded to an 8 year old boy who was orphaned by a data quality error.

A single key stroke error on a computer cost a mother her life from breast cancer and left her eight-year-old son an orphan, the High Court has heard.

Two urgent letters informing the single mother of hospital appointments were sent to the wrong address – because the number of her home was typed as ’16’, instead of ‘1b’.

Read more: http://www.dailymail.co.uk/news/article-1366056/Mistyped-address-leaves-mother-dead-cancer-son-8-orphan.html#ixzz1GfRPOOHJ

In a tragic series of events a young mother discovered a lump on her breast. She was treated in hospital and given the all clear, but continued to be concerned. Her GP arranged further tests for her but she never received the letters due to a simple mis-keying of her address which meant she never received her appointment letters. As her cancer went untreated for a further 12 months by the time she was diagnosed her only treatment option was palliative care. Had she been treated in time, the Court heard, she would have had a 92% chance of survival for another 10 years.

Her doctor admitted liability arising from the failure of the surgery to follow up with the the woman on her tests, which might have uncovered that she hadn’t received the letters.

The Court dismissed an argument by the defence that the woman should have followed up herself, on the grounds that, while they would never know what had been in her mind, she had already been given an “all clear” and that she was likely either trying to get on with her life or may have been scared to return to the doctor.

A key lesson to be learned here is that ensuring accurate information is captured at the beginning of a process is critical. Equally critical is the need for organisations where the data is potentially of life and death importance to ensure that there is follow up where the process appears to have stalled (for example if expected test results are not received back from a hospital).

A simple error in data input, and a failure of or lack of error detection processes, has been found by the UK High Court to be the root cause for the death of a young mother and the orphaning of an 8 year old boy.  This is a SIGNIFICANT legal precedent.

Also, the case raises Data Protection Act compliance issues for the GP practice as sensitive personal data about a (now deceased) patient was sent to the wrong address.

RELATED POST: Daragh O Brien has a related post on his personal blog from 2009 about how Information Quality is getting some interesting legal support in the English legal system.

So exactly HOW pregnant is he?

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From the #dataquality correspondents on Twitter comes this great story of a classic IQ Trainwreck.

Hilton Plettell is pregnant and is expected to deliver in 7 months, according to the NHS. They’ve invited him to a scan to see his bundle of joy.

Yes. We did say HIM and HIS, because Hilton is a 50 year old department store merchandising manager. But that is not the end of the IQ Trainwreck here.

  1. The hospital he was directed to is 162 miles from his home (a long way to travel with the full bladder needed for an ultrasound scan).
  2. A sticker attached to the letter correctly identified Mr Plettell as being Male.

So, 3 errors or inconsistencies in the letter which indicate a Data Quality kerfuffle in the NHS (at least in Norwich).

A spokesperson for the hospital thanked Mr Plettell for raising the issue with them and indicated they were undertaking a Root Cause Analysis to see where their processes and procedures could be improved to prevent this type of obvious error.

We can’t help but wonder if the root cause might be similar to the problem encountered by DataQualityPro.com’s Dylan Jones last year, which we reported here in June 2009.

The story is covered in the Daily Male  Mail, which reproduces a picture of Mr Plettell’s hospital letter (but that image is copyright so we can’t republish it here).

Organ Donor Records Mix-up

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The Sunday Times reported in April 2010 that NHS Blood and Transplant, who run the UK organ donor register, last year wrote to new donors with their consent details. After respondents complained the information was incorrect it was discovered 800,000 individuals’ details had been recorded incorrectly. 45 of those affected have since died and their incorrect wishes carried out!

“The mistake occurred in 1999 when a coding error on driving licences wrongly specifying donors’ wishes was transferred to the organ registry.”

400,000 of the affected records have been changed, and the remaining 400,000 people will be contacted soon and asked to update their consent.

The perils of perpetuating errors

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Courtesy of Dataqualitypro.com on twitter comes this story about how Virgin Media in the UK have sent a letter to a customer prospect addressing them as “Mr Illegal Immigrant”.

Virgin Media have investigated the issue and state that it was an isolated incident arising from data purchased from a 3rd party. This suggests that Virgin Media might have issues with the quality control processes they apply to vetting data purchased from 3rd parties.

From an IQ Trainwrecks perspective, this ticks a lot of boxes as it has resulted in embarrassment for Virgin Media and hassle and trouble for the actual householder, a Mr Needham who told the Daily Telegraph that:

… he was offended by the letter: ”I was a bit shocked. I was taken aback. I have tried to ring up and complain and they have not really done anything about it.

”They kept passing me from pillar to post. They tried to say it was not their fault, it was somebody else. It is not good.” Continue reading →

Know your customer, know yourself

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From today’s SUN tabloid newspaper in the UK comes this great story about how automated processes without adequate business rules and checks on information can cause embarrassment.

It seems that local government authorities in the UK have been fining themselves for parking offences and then suing themselves when the fines aren’t paid. Things have even gone as far as councils seeking awards of legal costs against themselves when they haven’t complied with their requests to themselves to pay themselves the fines that they imposed on themselves for parking their vehicles in places where they had decided people shouldn’t park.

It seems that none of them have yet tried to argue the defence that was put forward in Ferguson vs British Gas.

The lesson here is that when defining an objective in a process one should take the time to consider the various scenarios that might occur in that process and then ensure you have adequate checks and balances and controls to prevent embarrassing and costly errors from occurring.

Oh… and knowing that your customer is yourself is also a good idea.

You can’t make an omlette with out breaking a few Eggs

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A correspondent in the field, Nic Jefferis has sent in this story about how a “database glitch” has affected customers of the Egg on-line bank who have been trying to pay their bills using their NatWest debit cards.

The BBC describes the problem very succintly:

“The problem is that the Egg website does not recognise Natwest Visa Debit cards as being legitimate cards.”

The root cause seems to stem from the fact that key base data used by Egg’s on-line bank, the valid set of Bank Identification Numbers, appears to to not include NatWest Visa debit cards as they are only being rolled out at the moment to replace the existing Maestro Debit card facility currently in use at NatWest.

And at this point the second common component of IQTrainwrecks raises its head – who is responsible for the data.

Egg get their data from Experian. As soon as the problem arose, Egg contacted Experian to get a solution.  Natwest state that they were “aware of this problem and raised it with Egg at the outset” and were waiting for Egg to sort out the problem in their systems.

Somewhere in the process for maintaining BIN master data something has gone awry which has affected the ability of NatWest customers to pay bills using their new Visa debit cards. As the problem appears to be in the underlying base data, it is possible that there are impacts wider afield than just Egg’s payment systems.

As a source quoted in the BBC report says, this should be a straightforward process and an error like this would be highly unusual. But as we know here at IQTrainwrecks, it is often the simple errors that can have the biggest knock on impacts in downstream systems and processes resulting in loss, damage, injury, or frustration.

Information Quality – Every Little Helps

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[Thanks to Tony O’Brien for sending this one in to us recently. For those of you not familiar with Tesco and their marketing slogans, this is their corporate website.]

ManagementToday.com has a great story (from 25th November) of how six bicycles purchased by Tesco from a supplier came with an apparent£1million (US$1.62 million) price tag.

Some red faces at Tesco HQ this morning, after news emerged that Britain’s biggest supermarket accidentally paid one of its suppliers almost £1m for six bikes.

The unit cost for each bicycle turns out to be a whopping £164000 instead of the usual £164.

While the majority of the money was repaid, the trouble for Tesco is that they are engaged in a dispute with the supplier in relation to other matters so the supplier has held on to 12% of the money. So Tesco have called in their lawyers. Which means that the total cost of failure will inevitably be much higher by the time the whole mess is sorted out.

Of course, simple consistency checks on data entry could have trapped that error and saved Tesco money and embarrassment.

It seems that with Information Quality, as with Retail Grocery, every little helps.

Poor Quality Information costs money – and you can take that to the Bank

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via Keith Underdown comes this story hot off the press release engine in the UK’s Financial Services Authority.

Barclay’s Bank have been fined stg£2.45 million for “failing to provide accurate transaction reports to the FSA and for serious weaknesses in systems and controls in relation to transaction reporting”. The fine would have been higher (stg£3.5 million but for the fact that Barclay’s co-operated with the investigation and agreed to settle the matter quickly). According the the FSA press release

“Complete and accurate transaction reports are an essential component of the FSA’s market monitoring work. Barclays’ reporting failures could have a damaging impact on our ability to detect and investigate suspected market abuse.

“The penalty imposed on Barclays is significantly higher than previous penalties imposed for transaction reporting errors. This reflects the serious nature of Barclays’ breaches and is a warning to other firms that the FSA will not tolerate inadequate systems and controls.”

This is an interesting warning that serves as an indicator of how Regulatory systems and enforcement will be changing in a post-Recession world.

Of course, the true cost to Barclays is much greater than the cost of the fine. For one, there is the reputational damage that comes from being fined to this extent by the FSA. And then there is the cost of correcting errors and fixing the defective processes, which Barclays has done “including commissioning a review of its transaction reporting process and committing extensive resources to improve its processes and resolve the errors.”

Reviews and resources don’t grow on trees you know.

This is a clear example of an IQ Trainwreck.

I am not a number – I’m a human being!

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Information Quality professionals (and indeed quality management professionals in general) often recite a mantra that good quality begins at the beginning of a process, that it must be designed in, and that defects need to be fixed as close to the start of the information chain as possible.

A post today on DataQualityPro.com from Dylan Jones highlights the significant truth that lies behind all these statements.

Dylan’s son was born in April. The first thing the State did for him was to slap an identifier on him. The second thing they did (to summarise Dylan’s excellent and forensic post) was to make a mess of linking the local hospital ID to a National patient record.

That error propogated and resulted in the parents of another child over 90 miles away getting an appointment for a medical checkup relating to Dylan’s son. It seems that the efforts made to correct the error Dylan spotted when his son was born haven’t propogated half as fast as the original error.

And that’s the problem. How many other processes and silo’d systems has this error propogated into? How many more times in Dylan’s son’s life will be be confused with another child 90 miles away? What other ‘life-events’ will this error impact? In future, how will he find himself trapped by his number?

Ultimately, Dylan’s son is not a number, he’s a human being.

We recently posted a long Trainwreck on the problems with Google Health due to poor quality information. It is possible that an error like the one affecting Dylan’s son could result in incorrect patient data about Dylan’s son being transferred to this type of electronic patient record. Who would be responsible for the impacts if that information was acted on in haste without Dylan (or Mrs Jones) being there to point out that the information was wrong?

Given that in an Irish hospital in 2003 the medical staff failed to act on an error in an expectant mother’s chart and delivered a baby 39 days prematurely, despite the parent’s insistence that there were errors in the chart, highlights that simple errors in medical records can have significant impacts. That the baby in question died further highlights that these impacts can be catastrophic, which means that the standard of care for quality in medical records needs to be high.

Dylan’s investigations also uncovered some other weaknesses/flaws in patient data quality which are unsettling. We’d suggest you take a look at Dylan’s post for more details on those.

For actual inconvenience and annoyance to Dylan’s family, and for the potential for catastrophic loss or injury, this counts as a definite IQTrainwreck.