An investigation by the Health Services Safety Investigations Body (HSSIB) has found that thousands of NHS patients are getting removed from electronic referral service (e-RS) waiting lists without any warning or notice.
Referring patients from general practice to specialist care is a common process, with around 400,000 referrals made each week in England.
The e-RS system generates digital worklists, which are used by provider organisations to manage patient referral processes.
Referrals are automatically removed from a provider’s worklist within e-RS when a user performs an action, like accepting a referral or booking a patient appointment, or when 180 days pass with no action.
The 180-day function was meant to reduce the risk of large worklists affecting productivity, but the investigation found that this function was creating a hazard to patients.
The HSSIB interim report said: "There is an ongoing risk that patients may experience missed or delayed care as a result of the 180-day function.
"The level of risk is difficult to determine but has potentially increased in light of demands on outpatient services and longer waits for appointments."
This is HSSIB's second interim report into electronic patient record systems – electronic referrals for ongoing care, as there is an immediate risk to patient safety.
HSSIB said that e-RS was not designed to manage the current volume of referrals seen across the NHS, particularly since the COVID-19 pandemic.
The 180-day function was heard to be necessary and the associated risk cannot currently be eliminated, it added.
Referral processes have the potential to cause harm when patients miss out or experience delays in specialist care.
Research by Healthwatch (2025), for example, found that one in seven people ended up in a ‘referral black hole’ – where a referral was delayed, lost, rejected or not sent – with three in four reporting a negative impact on their health and wellbeing.
The HSSIB report noted that incidents were recognised only after general practice raised concerns that patients had not heard from the provider about their referrals, or where the patient had made a complaint.
The watchdog called upon provider organisations to identify the risk caused by the 180-day function, and ensure that controls are in place.
However, its investigation found "limited evidence" that all provider organisations were aware of the existence of the hazard, had assessed the risk, and/or had controls in place.
