The HSSIB's second interim report found the NHS electronic referral service (e-RS), which is used by GPs and other health workers to refer patients to hospital and clinic specialists, was automatically removing referrals from a provider's worklist when there had been no action after 180 days.

Nick Woodier, senior safety investigator at HSSIB, said: ‘We are asking all providers using e-RS to review the safety prompts in our report and assess whether their processes would identify referrals that drop off worklists, including during periods of pressure. Where there is any doubt, we encourage them to act now. This risk cannot currently be removed from the system, but it can be mitigated, and local checks will reduce the potential for patients to be lost.'

Referrals through e-RS rose by around 40% between 2019 and 2025, and referrals on appointment slot issue lists by around 60%. The HSSIB said that with outpatient services under pressure, patients may now stay on worklists for longer, making it more likely that their referrals reach the 180-day limit.

In response, NHS England has committed to a safety action (reference A/2026/003). As the supplier of e-RS, it is updating the system's clinical risk documentation to recognise the risk created by the 180-day limit, in line with DCB0129, the digital clinical safety standard for suppliers of health IT systems. It will then share the updated documentation with providers to help them assess and manage the risk locally.

The report sets out safety prompts that providers should consider when reviewing their own arrangements. These include:

• how does your organisation support collaboration between digital, patient safety, patient experience and complaint teams to identify incidents where patient referrals may have been lost?
• has your organisation formally assessed and documented the clinical risk of patients disappearing from e-RS worklists, including as a result of the 180-day function?
• does your organisation routinely review the EBSX12 weekly worklist drop-off extract and act on the findings?
• how does your organisation assess whether administrative processes for managing referrals, reviewing worklists and validating dropped-off referrals remain effective, including during periods of staffing change or service pressure?