Missing Medical Records _ Help !

[EIVAD5]

Hello

 

hoping someone can help.

 

I have been trying to get justice in understanding what protection the public have over missing medical records. My mother (a GP herself) died unexpectedly after treatment about 18months ago. Soon after her death her medical records were asked for and I was informed by the hospital and consultant that they had gone missing.

In fact the hospital has lost the entire medical notes - thats over 4 weeks treatment she had just completed. Having written a formal NHS complaint, I received a pathetic note apologising and saying that they will continue to search. In my distress I contacted the Healthcare Ombudsman who after a 6 month wait, said they cannot help as the records are missing – which is clearly what I know already and hence need their help!

 

Please let me know what else I can do – its clear there has been a severe case of Maladminstration by the hispital in question, and yet there is NOTHING that can be done in order for this matter to be investigated further.

 

Any feedback / thoughts welcome!

[Sali]

Contact the ICO (Information Commissioners Office) by phone - they take an age to respond to post or email - and ask them the question.

 

Do you suspect that they have been genuinely or purposely mislaid?

 

There will almost certainly be some data on computer for your mum. Have the hospital supplied this?

 

I have a relative who works in Occupational Health in the NHS and they have been experimenting with the clipboards that produce a written copy of the notes whilst storing the text in memory, which can easily be uploaded to a PC. Yes, there is the handwriting recognition samples to go through, but ultimately time is saved and it could also mean notes can be searched by keyword or phrase. So often, in my experience, great wads of paper notes are not read by consultants, to the detriment of the patient. Or they are lost forever.

Edited September 28, 2009 by Sali

[EIVAD5]

Hello Sali

 

I have already contacted the ICO and they do not assist in matters where the person in question is deceased.

 

We have recieved the computer records, which are purely blood results etc. Its the written clinical notes that have gone missing.....and yes I do believe they have been done to hide the truth; which is the worrying part, as there is nothing to protect the public in such circumstances.

In fact it seems to be that if any medical professional has done something 'wrong' that they do not want known, they simply have to 'lose' any records....

[Sali]

Well, I would challenge them and have found the following article where the ICO were involved.

 

Powered by Google Docs

 

Yes, we are at ther mercy of Trusts who deliberately lose or even alter notes.

[EIVAD5]

The ICO have confirmed to me they cannot help - the fact that the records are missing is something they will not assist with.

 

I contacted the Healthcare Ombudsman, who equally were dissmissive of questioning what the Ttust have done with the records.

 

There is a real lack of protection in such cases.....

[Sali]

Which goes against the article I posted, where they obviously were involved.

 

I can quite understand how frustrated and angry you must feel. Have you spoken with your MP?

 

I don't want to depress you more but there is a good blog site with various articles written by like-minded people.

 

http://nhsexposedblog.blogspot.com/

Edited September 28, 2009 by Sali

[EIVAD5]

Thanks Sali.

 

I contact my local MP - utterly useless....

 

Thanks for the information / links.....

[MRSWESTHAM]

Have you checked with the GP whether a copy was sent to them?

Where we are this is standard practice now and if you mum had had treatment in the Hospital it would be very iffy if the Drs didnt have anything on record. I am sorry to hear of your loss

[EIVAD5]

Hello

 

Yes have checked with GP and he was never sent the records of her treatment.

it seems the 'losing' of records is the best way to hide any wrong doings.

[MRSWESTHAM]

Contact your local PCT i guess, this is pants

[EIVAD5]

Thanks - apparently the Local PCT will just contact the NHS trust in question which will end up giving the same response.

 

Does anyone else has any simliar stories........my next route is probably the GMC and the Secretary of Health....as clearly there is no public protection in such cases?

 

regards

[Sali]

I think you'll find the GMC and the Secretary of State just as useless. I still think that the ICO is responsible and your MP should have followed this up. Whether an individual is deceased or not, medical records - in fact any personal data - should, by law, be kept safe and secure for a defined period of time.

 

It is only when we suffer the consequences of maladministration that we find just how hopeless the system is in supporting individuals and preventing a recurrence.

Edited September 30, 2009 by Sali

[MsWeatherwax]

EIVAD5, firstly I'm very sorry to hear of your loss.

 

Can I just clarify something? You say:

 

" In fact the hospital has lost the entire medical notes - thats over 4 weeks treatment she had just completed."

 

When you say that, do you mean she'd had no treatment AT ALL at that hospital in the past and that 4 weeks constituted her entire set of case notes?

 

The only reason I ask, I'm just wondering if somebody created a temporary set of notes for her for this course of treatment...this sometimes happens if for example someone has had no treatment/visits for a very long time so their original notes are sent for storage. The idea is that the patient has current available notes while they are in hospital, but then the two sets are "married-up" to give the complete record.

 

It's a long shot, but truly "LOST" notes are a thing of rarity in the NHS - they've usually been misfiled. I'm wondering if this has happened and the 2 sets have been misfiled somewhere. Just trying to give you another avenue to pursue really.

[EIVAD5]

Hello Ms Weatherwax

 

My mother did have over 4 weeks of treatment and the hospital has lost all her medical notes for the entire period she was there.....!

 

regards

[MsWeatherwax]

OK...had she had any treatment at that hospital in the years prior to the 4 week + period of treatment?

 

If so, was it in the recent past, or distant past?

[EIVAD5]

hello

 

Yes she had a few tests / check ups etc at the same hospital few months prior to this main treatment taking place. All those records are available - its the 4 weeks of treatment, and 24hours prior to her death, for which the records are missing.

 

regards

[MsWeatherwax]

Good, good. I promise that there is method to my madness here, but I need to ask a couple more questions if that's OK? I'm not being wantonly nosey, I just think I may have a vague idea what has happened here - it may not get you the records back, but it might help you give them a shove in the right direction.

 

Was the 4 week period of treatment as an in-patient, or an out-patient? Also, was the treatment planned, or resulting from an emergency admission?

[EIVAD5]

Hello there,

Feel free to be nosey - any help is valuable to me.

 

Anyway answer to your question: The 4 week period was as an in-patient for a planned piece of treatment.

But they have also lost a outpatient reports for a check up / transfusion she had 24hours prior to her death. (this outpatient appointment was couple days after she was discharged from her 4 week inpatient treatment).

 

Regards

[MsWeatherwax]

Right, I'm hazarding a pretty big guess here, but it's something I've seen in the past and it wouldn't surprise me if this is the case here.

 

The bouts of treatment/exams your Mum had PRIOR to her admission would have had would have been raised as her main set of notes.

 

If for any reason that set of notes were not available when she was admitted for some reason (for example, if they were with a radiologist who needed them to report a scan she had as an outpatient), the ward MIGHT have raised a temporary set of notes to avoid delaying her admission until they could get hold of the main set. In an ideal world, the two sets would be married up pretty quickly and preferably while the patient is still on the ward, but sadly in some cases this doesn't happen.

 

I'm betting what has happened here is that the temporary set of notes have been sent to the hospital's medial record centre for filing rather than being sent to whomever had the main set of notes.

 

Has anyone broached the possibility with you that what is actually missing is a temporary set of notes, rather than just pages from the main set?

[EIVAD5]

Hello

 

The hospital has confirmed that the FULL medical notes for the 4 weeks treatment period and the last 24hrs is missing.

Prior to this there was very little clinical notes taken - and we have got copies of those.

 

Regards

[MsWeatherwax]

What I'm driving at is, the initial notes would have been placed in one folder, (usually) with a barcoded sticker with her name and DOB on it. This would be the main case notes.

 

IF (and I have to stress, it's an IF) this folder was unavailable when she was admitted, they MAY have made up another folder in the same manner, but labelled it as a "Temp" set of notes. This would have been done with the intention of incorporating the two sets.

 

As I said, this information in itself won't get you the notes back, but it might be worth asking them if this could have happened and if they could instigate another search of the medical records department/locations that the main set of notes had been, based on the possibility that this is what happened. If this is the case. the temp set are likely languishing in the med recs department waiting to be filed.

 

If you're looking into this due to a claim of negligence or similar, have you got a solicitor? If you have, I would recommend getting them onto this rather than you exhausting yourself with it.

[EIVAD5]

Hello

 

Thank you for this.

We do have a solicitor on board, but the records is the key piece of evidence needed.....

The hospital have done all they can apparently...but I am approaching the GMC / Health Secretary to see what can be done.

 

There clearly is no support out there for such cases...

[MsWeatherwax]

Tough one this, Eiv.

 

Personally speaking, I'd be inclined to let the solicitor do the leg work now.

 

The fact that a month of records has gone missing is not going to go down well in any court case you have pending, and that fact alone will provide a lot of incentive to the Trust involved to sort themselves out and find them.

 

I'm not sure you're going to have a huge amount of luck finding them any other way...suffice to say that in my experience there's no such thing as "lost forever", just "misfiled". I do think as you get closer to a court date, they may well reappear from somewhere.

 

If there's anything else I can help you with, please just give me a shout.

[EIVAD5]

thanks!

 

The problem is 'missing records' in the eyes of anyone is not negilgence....and without the records we are by no means near to getting anything concrete from a legal perspective.......as the notes are the evidence of any wrong doing.

 

It seems that by 'losing' the records the Trust knows nothing can be done...and out solictor is someone lost by not having them.

 

Hence why I think its in the TRUST favour not to find them, as if they do the consequences for them will be huge.......and we are left with a injustice system that does not protect the public....

 

Its crazy.....

[MsWeatherwax]

Not knowing the exact details of what happened makes it hard to say much more, but the consequences of the Trust NOT finding the notes will be pretty huge also.

 

I would still go down the route of getting in touch with the Chief Executive of the Hospital in question, and also the PCT - I know that you mentioned that they will just go back to the hospital and you'll get the same response, but from what you've said the only thing I can think of is to put mass pressure on them to do something. Copy the letters you send to your MP as well - I know you've been to see him/her already, but it's not going to hurt to let people know that you're not just going to slink off quietly without a fight.

 

After that - local press. Trusts don't like negative local or national publicity.

 

I know all of this seems very repetitive, but sometimes you just have to keep kicking the wall 'til it falls down.

 

Keep your chin up, and keep us posted.