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.

Smart Grid, Dumb Data

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In September 2010 a massive gas explosion ripped through the San Francisco suburb of San Bruno, not too far from San Francisco International Airport. The explosion was so powerful it was registered as a magnitude 1.1 earthquake.

Subsequent investigations have identified that poor quality data was a contributory factor in the disaster. According to Fresnobee.com

The cause of the deadly rupture has not yet been determined, but the PUC said it is moving ahead with the penalty phase after the National Transportation Safety Board recently determined that PG&E incorrectly described the pipe as seamless when in fact it was seamed and welded, making it weaker than a seamless pipe.

Read more: http://www.fresnobee.com/2011/02/25/2285689/pge-faces-big-fine-over-gas-pipeline.html#

According to the San Francisco Chronicle the problems with PG&E’s data were nothing new, with problems stretching back almost 20 years.

Omissions or data-entry errors made when the system was developed – and left uncorrected – may explain why PG&E was unaware that the 1956-vintage pipeline that exploded in San Bruno on Sept. 9, killing eight people, had been built with a seam, according to records and interviews. Federal investigators have found that the explosion started at a poorly installed weld on the seam.

Continue reading →

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).

The importance of context

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Data is often defined as “Facts about things” and Information is often defined as “Facts about things in a context”.

From Lwanga Yonke (IAIDQ Advisor and one of the visionaries behind the CIQP certification) comes this great example of where, without consistent application of context, it is possible for the Data to give rise to poor quality and misleading information.

Sign showing population, feet above sealevel and year founded with the data totalled

Image linked from "thepocket.com"

What we see in the sign opposite are three distinct contexts:

  1. A count of the population (562)
  2. The height of the town above sealevel (2150)
  3. The year the town was founded (1951)

And of course, when we see a column of figures our instinct (since our earliest school days) is to add them all up… to give us 4663.

Of course, that figure is meaningless as information, and is also poor quality data.

I have personally experienced similar “challenges of context” in tracking back root cause analyses in Regulatory Compliance projects.. the stakeholder pulling the incident reports together didn’t consider context and as such was comparing apples with ostrich eggs (if he’d been comparing apples to oranges at least they’d both have been fruit).

I’d love to hear your stories of Contextual conundrums that have lead to poor quality data and erroneous Information.

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.

Zero Entertainment in Norway

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This story comes from our Norwegian Correspondent, Mr. Arnt-Erik Hansen (former IAIDQ Director of Member Services). We let him tell his tale in his own words, with only minor editing….

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Norway is the only country in the world, as far as I know, with full transparency with regards to personal income, wealth and state tax. One of the big Autumnal Entertainments in Norway is the annual publication of the list of taxpayers, their incomes, and the amount of tax they have paid. . Here you can search for your neighbor, your friends, enemies, public companies or government officials to find what their income was, how much they contributed to the state and how wealthy they are. On October 20, 2010 the list was published on the internet

Newspapers, TV, and blogs (including this one) find this a great event to generate stories.  Every year there are stories about the person earning the least and the most. Not only that, they compare a person’s income to the average income in the country, according to your age. They will even go as far as determining the street in Norway with the lowest average income. This is business intelligence on real live data.

However the Norwegian tax authorities are not immune to data quality problems. Here are some of the stories I read in the newspapers today (all online of course [editor: Links to the stories will be posted here soon])

A polish citizen, address in Polen and with a modest Norwegian income is reported to have paid more than 119’000’000 Norwegian Kroner (approx US$20.4 million, or €14.6million ) in taxes for 2009. As a consequence he can claim to be the biggest contributor to the state coffers. Thanks Polen, I am sure that someone will be there to collect the money soon.

This is of course wrong and the reason is, most likely, that someone punched in the wrong number – a number with too many zeros. We’ll call this “The Fat Finger Zero Error“.

Apart from errors in the data itself, there appear to be errors in the actual interpretation of the data. For example, a lady working as a cleaner got a tax claim of no less than 84’005’501 Norwegian Kroner (€10.3million or US$14.4million). Her income for 2009 was reported by one newspaper to be 324’000 (US$55,600, or €39,818) so this is an obvious error. Another newspaper reported her income to be 240’000.

A key question is: What has happened here?

The answer from the tax authorities when asked to comment on this was simply – errors happen, unfortunately, and will be corrected immediately. However, the reason was, most likely, that someone punched in the wrong number – a number with too many zeros. Well, seems that someone has a problem with zeros.

There is another story to come about the “Fat Finger Zero” error.  But first we need to share some insight into the tax reporting and collection process in Norway works.

It’s not too different to any other country. Except in Norway the State sends you your forms filled in with the information the tax authorities have about you and you simply have to sign them and send them back.  And, like most tax authorities, they most likely know more about you than yourself.

For instance, banks in Norway send megabytes of data about all customers and their accounts to the tax authorities. Which leads us to our third IQTrainwreck example in this story…

This year two banks managed to put zeros behind the customer account balances instead of in front for 500 customers.  So €00000500 became €500,0000.

A possible root cause: the definition of the attributes in the file has gone astray.

But from two banks?

Or was the requirement wrong?

It  seems that Norway has a problem with zeros.

Oh, almost forgot to mention – today the Norwegian State Fund was valued above the 3’000 Billion mark for the first time. That’s 3’000’000’000’000 Norwegian Kroner (US$514,610,220,303).

I think I understand the problems with zeros. (But how much of that is due to tax collection errors? – the sting in the tail for Norwegian tax payers is that if there is an error in their tax calculations they have to pay the decided amount and then are refunded the amount of any error).

PS! If you look up my name you will find income 0, wealth 0 and taxes 0. The reason: I lived in Switzerland in 2009 and in that country you are invited to pay taxes and it is not a criminal offence if you don’t tell the state everything.

Bank overcharging in Ireland (again)

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In a taste of the change of emphasis that is seeping through the global financial services industry, the Irish Financial Services Regulatory Authority is pursuing 24 cases of overcharging by banks and insurance companies, according to this morning’s Irish Independent

Of course, stories of financial services overcharging and other information quality disasters in that industry are not new to the IQTrainwrecks reader. Over the years we’ve covered them here, here, here, here, here , here, here, and here (to select just a few).

We’ve also covered the growing “hard touch” trend in Financial Services that is bringing a clear “cost of non-quality” to bear on banking/financial services processes (see this post from August of last year).

Why is this now an IQTrainwreck again?

  • Regulators are adopting a tougher line with banks about overcharging/undercharging (a bit like the regulators did in my former industry – telecommunications).

The new chief of the Irish Financial Services regulator is concerned about the number of overcharging cases and recently said that:

It is clear from recent cases that change is needed in how firms handle charging and pricing issues.

  • Financial services companies, facing into severe cutbacks in budgets and man power are potentially increasingly exposed to the risks of manual work arounds in processes simply stopping, end-user computing controls not being run,  and ultimately inaccuracies and errors creeping into the information they hold about the money they hold for or have loaned to customers.

As the regulatory focus shifts from ‘light touch’ to ‘velvet fist’, those financial services companies who invest in appropriate strategies for managing the quality of information in a culture of quality will be best placed to avoid regulatory penalties.

Police Untelligence

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From The Register comes this wonderful example of the problems that can arise where data is used for unintended purposes, resulting in poor quality outcomes for all involved.

The NYPD have been regularly raiding the home of an elderly Brooklyn couple. They’ve been hit 50 times over the past 4 years, which might mark them out as leading crime kingpins but for the fact that their address has wound up included in police data used to test notification systems. The Reg tags this as “a glitch in one of the department’s computers”, but Information Quality trainwreck observers will immediately recognise that the problem isn’t with the technology but with the Information.

The trainwreck is compounded by two facts which emerge in the article:

  1. NYPD believed that they had removed the couple’s address from the system back in 2007, but it appears to have not been the case (or perhaps it was restored from a backup)
  2. The solution the NYPD have now implemented is to put a flag on the couple’s address advising officers NOT to respond to calls to that address.

The latter “solution” echoes many of the pitfalls information quality professionals encounter on a daily basis where a “quick fix” is put in to address a specific symptom which then triggers (as el Reg puts it) “the law of unintended consequences”.  To cut through implication and suggestion, let’s pose the question – what happens if there is an actual incident at this couple’s home which requires a police response?

What might the alternative approaches or solutions be to this?

(And are the NYPD in discussions with the Slovak Border police about the perils of using live data or live subjects for testing?)

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.