Trusts urged to act as e-RS function removes patient referrals from worklists without warning

We identified incidents where referrals had disappeared from e-RS worklists without warning. This included e-RS automatically removing referrals from a provider's worklist when there had been no action after 180 days. It does not alert staff when this happens. This means referrals can disappear before patients are booked in.

The interim report highlights that the 180-day function has been in place for many years and protects e-RS from performance problems caused by large worklists, but we found gaps in awareness of the function across providers. NHS England told us the system was not designed for current referral volumes, so the 180-day limit cannot be extended. This means providers need robust local checks to catch referrals before patients are lost.

What the investigation found

Referrals through e-RS rose by around 40% between 2019 and 2025, and referrals on appointment slot issue lists by around 60%. 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.

We also found gaps in safety assurance, starting at a national level. The risk was not recorded in the national e-RS hazard log. None of the providers we spoke to could evidence compliance with DCB0160, the clinical safety standard for deploying digital health systems, and some clinical safety officers were not aware of the risk.

We identified a number of incidents since 2018 where referrals had dropped off worklists after 180-days before patients were booked in. In some incidents, reduced administrative capacity and unclear roles had contributed to patients being lost and some organisations had seen the same type of incident happen more than once.

No harm was reported in the incidents identified but we could not establish how often this happens across England, partly because some organisations were not aware of the risk.

Calling on providers to take action

We are calling on trusts and other providers to formally assess the risks associated with losing referrals. We are also asking providers to support their digital, patient safety, patient experience and complaints teams to work together to identify cases where patient referrals may have been lost, including through the use of e-RS weekly drop-off data.

In response to our report, 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.