Liz McAnulty, of the Patients Association, said: “The failure of the NHS to manage essential medical correspondence effectively is scandalous, and the lack of transparency about these errors is at least as bad. Patients have become totally lost in all this: it has become a matter of contracts and administration – neither of them remotely well managed. The system clearly lost sight of the people it was supposed to serve.”

Even after the publication of the National Audit Office’s report, the impact on patients remains alarmingly unclear. We know that at least 1,700 patients could have been harmed, but how many have in fact suffered harm as a result is still being investigated.

The Patients Association is calling on NHS England to set out a new approach to sharing patient information between clinicians, that has a clear focus on the needs of patients. This must involve much clearer accountability – although it’s obvious things went badly wrong this time, it’s not at all clear who should have been responsible for the effective operation of the system. Another arrangement that involves a complex web of contracts will be vulnerable to the same problems happening again.

This episode is also likely to dent patients’ confidence in the safety of their data with the NHS. This is a major problem for the future – patient data will be ever-more vital to planning services, empowering patients through controlling their own data, and to medical research. But if patients lack confidence in the system, they will be reluctant to allow their data to be used.