NHS POLICY FLAW_missing records_anyone else has simliar experience?

[EIVAD5]

Did you know that if a Doctor, GP, Nurse, NHS Trust or any medical professional who feels that they have done something wrong during treatment to a member of the public, and doesn’t want to get caught out, all they have to do is destroy or ‘lose’ the medical records for the person in question and they will never get found out and consequently avoid any prosecution.

 

In fact, missing records is not seen as a negligent act in the eyes of the law, NHS or any UK body. No one is ever made accountable or takes responsibility for such maladministration because there is nothing enforced in the UK to question such matters.

 

These findings come about over a very real situation that has occurred to me and my family over the past 18months. My mother, was diagnosed with very early stages of Multiple Myeloma in May 2007. Following various consultations she was advised to undergo Stem Cell treatment at London, to help give remission to the cancer. Following an intense and successful course of treatment between 3rd and 19th December 2007, she was discharged early to recover from the treatment at home. This was a surprise to us because we were told at the outset that she will be in hospital between 4 to 6 weeks after the treatment.

However, she was instructed to come to the hospital on the 21st of December for a check-up and to undergo blood and platelet transfusions. The treatment on the 21st was undertaken in the Hospital Day Unit and whilst wearrived with my mother at 9am to start the treatment (as advised), it in fact did not begin till about 5pm that day. She was told that she needed 2 pints of blood and 2 bags of platelets, all of which were administered within 3.5 hours. The treatment ended just after 8.30pm (the Day Unit shuts at 8pm) and she was discharged immediately without any final doctor’s approval.

The following morning she died. The ambulance arrived immediately and tried to revive her, but after 20/30mins they pronounced her dead. The shock and unexpectedness of this was not only clear amongst my family and me, but equally so with the hospital team.

A post mortem was undertaken, and Bronchopneumonia was the coroner’s conclusion for my mother’s death. This was of some surprise to all. The post mortem also highlighted acute pulmonerary oedema, for which the coroner commented is often caused by transfusion volume overload. Whilst I am no medical expert, having done some research on this I immediately took some time to meet with the consultant at St Barts to discuss my mother’s treatment during the 24hours prior to her death, to help understand what could have gone wrong.

These meetings proved very unproductive as I was informed within the few weeks of meeting the consultant after my mother’s death that all her medical records have gone missing. The consultant could not help, and told us to formalise the complaint of her treatment and the missing records via the NHS complaints procedure. This was duly done on and after 3 months wait a response was received answering the questions, but without mentioning the missing records being found.

In my distress I turned to a number of organisations that I could find on the internet to advice on what I needed to do (AVMA, PALS, ICO). They all incidentally were unclear on the situation about missing records and clearly this was a unique case and one that they were convinced the hospital is negligent of and yet nothing they could do to help.

As a last resort I contacted my local MP, and the Healthcare Ombudsman. Even though the ombudsman philosophy is to help the public in cases of maladministration, they dismissed my case on the basis of the missing records and were unable to help. A formal complaint of their decision has led to no further support.

I have written again to the Hospital to ask for an update on the medical records - but clearly it shows that there is a fundamental flaw in the NHS system.

I have written to the Health Secretary about this - but to date no response.

Does anyone else have similar experiences that relate to this???.......How can we stop this occurring in the future - and help protect the public??

Edited December 11, 2009 by EIVAD5
Made font smaller!....easier to read

[Sali]

Evidad5 I can totally understand your distress, anger and frustration.

 

Are there no rules or guidelines (NICE/BMA/BMF) for transfusions stating how many units can be given in a period of time? Even if the paperwork was missing could the coroner not have requested that those responsible for administering the transfusion provide the details under oath? How much information would be kept on computer (a question for any nurses out there). Is the Trust saying that it followed its own procedures in this area? Are these procedures available for you to see?

 

It really is only when you face such failures that you realise how flakey the system in place is in putting things right and making sure it doesn't happen again.

 

Personally I think the Ombudsman SHOULD take this on. Loss of records to me is maladministration. I also think the ICO SHOULD take the Trust to task. The inertia in both these organisations reflects the casual attitude the Trusts have to lost and mislaid records. It truly is a disgrace.

 

I'm guessing you do not even have the option for judicial review with the Ombudsman.

[shocked14]

The only way to check if the records really have gone missing is to write and ask for the clinical coding relating the treatment.

 

Clinical coding is the billing process in the NHS, every treatment has a code and the coding states who performed it eg Consultant, Assoc.Specialist, Nurse etc. As she had treatment, then the coding trail is either;

 

Incomplete, which will allow you to work out which department last had her records,

 

If complete then they have to prove where they got the information from, was it verbatum or based on notes?

 

This sort of request is unusual but often it can highlight where the system went wrong.

 

It is a sherlock homes approach but it works. I worked in clinical risk for 2 years and i grequently 'found' lost records based on tis approach and it is in the domain of freedom of information.

 

expect them to be annoyed at the request, as if the treatment has been coded and then billed for and not properly logged based medical records then this is fraud by the NHS Trust in question

[EIVAD5]

Hello

 

Thank for this I will investigate and ask the question

Frustratingly I wrote to the secretary of health, who forwarded my note to the Department of Health - they did nothing to help, apart form refer me back to the TRUST.

 

Do you know legally where I stand with this issue at all?

regards

[shocked14]

Well, to be fair the initial legal requirement lies with the Hospital, which is an NHS Foundation Trust, these trusts are designed to devolve decisions from central government. This is where you will find the legal culpability to this matter.

 

Also FYI

medical records from the Hospital are 'tracked' on a system called PAS, and every time the notes are moved to a new location there are 'tracked' based on the unit number. So the records are reliant on people being efficient. I would dare to suggest if the Trust checked the Medical Records Library for Discharges for 2007, these notes would have found their way back there.

 

If i was being dishonest in my role and I wanted to hide some notes i would simply walk into the Library and put them back in their correct numeric slot. As they are not tracked it requires some one to use logic to find them. You could write to the Medical records Manger responsible for the location of records and ask him/her to do a search. You never know they may turn up also, ask for the computer record of where the notes were tracked prior to being lost. This will freak them out!!!!! trust me you may find that they were 'there all along'

 

Shocked

[EIVAD5]

Thank you again for this.

however have a feeling they have been maliciously lost to hide the truth.

My solicitor some 10 months ago did get from the hospital something called a statement of truth saying they are lost?...in hindsight I should have asked them to get a court order to find them, but was advised by the solicitor this would not really help as the hospital would just simply say they have done everything they can and confirm they are lost.

I will write to them asking what you suggested – I just really need to know what happened to them...

 

Thank you

[shocked14]

Well ask them for evidence of how they searched and the audit trail and all IR1 responses re the lost records. I have just re-read the original post and I noted that a Consultant told you the records are lost and this is most odd.

 

Also leave this until the new year, let Christmas pass (as it is an emotional time) and from the 18th of December a lot of the admin staff will be on wind down so the first week in January is better time as people are more focused on this practical consideration. Remember to get your solicitor to express the fact that you seek answers and that there may be no wrong doing on the part of the hospital. I found that similar claims i dealt with were always dealt with in a more sympathetic manner by clinical staff if the complainant expresses this possibility, because when you work in a clinical environment, death in those over the age of 50 is a permanent possibility and complaints for 'unexpected deaths' often relate to the families in ability to cope with this fact than the hospitals actions, I know HOWEVER as they have lost the notes you are not in this position and are entitled to have a clear record of what happened.

 

if you need to know the correct terminology when asking for records just let me know, that is another trick i learned was that the information given to the public may not have been correct as they did not know what to ask for.

 

Good Luck

[zippygbr]

in terms of rates for transfusions

 

platelets it's 30 -60 mins per bag

 

red cells less than 4 hours per unit , if someone is not volume sensitive you generally aim for around 2 hours / unit

 

reference for that

 

Blood-transfusion - How does it work?

 

a unit of red cells prepared for transfusion is somewhat less than a pint in volume , although the original donation is not far off a pint in volume ...

 

if they are volume sensitive you go a little slower and /or give a diuretic along with the transfusion is encourage the kidneys to excrete the additional fluid

[EIVAD5]

Hello

 

Shocked14 thank you for your message.

So i dont lost sight of this...can I articualte what I need to ask for now and can you advise if its correctly written, i will send this as you mention early next year.

 

- Confirm if the hospital tracked the records using the PAS system.

- If yes please provide full audit trail and all IR1 responses.

- Confirm what the records coding would have been and if all Discharge records for 2007 have been checked against these codes?

 

Is this correct? Please let me know.

 

Zippygbr - thank you for the link. I have seen this before. Whilst we are probably ok with the time it took to do the tranfusion the main isuse seems to lie surrounding the 'care' pre, and post the transfusion...as there was very little or non existence 'checks' being done. Thanks anyway.

 

THANKS!

[shocked14]

You need to ask for the following.

 

The PAS screen tracker for your mothers notes using the Code T3, including History and Audit (tell them that you want the screen print version) very important. To accompany this you would like a written explanation of the tracking codes; this will be 4 parts in all

eg

Location ward 7

Sub Location nurses station

Tracking noted for doctor to finish summary

Person tracking should be a name like j smith

 

This should tell you when they disappeared, also you need the print screen version of the patients 'Hospital attendances' and appointments, the tracker should show mirror this. Do not accept a typed version as there is room for human error, the print screen version stops this.

 

Then ask for copies of all the IR1's relating to your complaint about the medical records and the audit trail relating to the complaint. This should prove that they have looked and what lengths they went to etc.

 

Once you have looked at the tracker information and if you are not happy, then ask for the medical library for discharges (all though your mum is deceased the notes will be in there) for the year in which she died, and for the years either side to be checked too. I say this as hospital notes are the size of a phone book, you could not sneak it in your bag or destroy them easily, they are likely to be in the hospital, but not tracked etc. Also you do not need to destroy them as a 'dodgy employee' you simply mis-file them , the NHS is filled with admin staff who will not correct some one elses error, as an act of kindness.

 

Then you need to ask the Trust the following questions;

 

Was the treatment that my mother received subject to clincal coding?

if so when was this done?

What form did the clinical coding take? eg was it from notes, another IT system etc? Then ask what treatments did she have based on clinical coding record, eg full blood count is H358. This then gives you a coding reference point to ask for the test results, as they will be held on computer and as they have been 'coded' then the record will exist, it would be illeagal for them not to keep these records for 25 years.

 

For now that should do it, but treat it like a long campaign, do each step one at a time. This way it show that you know enough not to be lied to but are reasonable. Also very few members of staff who deal with your complaint have any idea about the day to day admin side of a hospital or how the pieces join up. The reason is that the complaints side of an NHS trust usually recruit from a marketing background and they have never worked in a clinical setting (there is a big difference between admin staff that have to deal with patients and those who never see them, they have different rules re behaviour etc)

 

I will post a dummy patient tracker from the pas training schedule on monday in a pdf for you this should all make sense then and you will know what to expect.

 

Shocked 14

 

 

You

[Night Owl]

Eivad5 I hope this is some help for you.

 

A doctor will prescribe a blood and platelet transfusion.

 

In my area this will be on one sheet of paper where you will find all of the patient details and hospital number, the blood or platelets request, amount to be transfused and over how many hours, any diuretic required, nursing observations at transfusion start, 15 mins into transfusion and at the end of transfusion. All of this information will be on one sheet of paper which will then be filled in the notes as the transfusion history and record.

 

Have you ggot any paperwork that relates to the transfusion? it must be documented.

Have you got the nursing documentation that this transfusion was given?

The Haematology Lab should have records that it was requested by a doctor and the record that it was taken and used for transfusion. If it was taken from the lab but not used the bag should be returned as unsafe and unused for the lab to destroy. This will all be recorded by Haematology.

 

Hope this is of some help.

Good luck.

[EIVAD5]

Thank you Shocked 14 for the information. Do let me know if you kindly managed to get hold of a dummy patient tracker.

 

Dear NightOwl thank you for the information. The trust is saying they have lost all the notes in relation to the tranfusion. I have some information from the computer about blood counts etc that were taken on admission....but nothing else.

The transfusion defintely took place - I was there to witness it - the notes to tell us about the time it started, supposedly the checks that were taken etc are not available.

 

Kind regards

[VikkiBP]

Do you know which hospital this is? Shocked 14 it sounds as though you are referring to Mckesson's PAS in your response?

[EIVAD5]

Hello

 

The hospital is a london one...please let me know what this means?...is PAS not used in all hospitals?

 

Thanks

[VikkiBP]

Hi there. PAS is an acronymn for Patient Administration System, all hospitals in some form or other have them but they are not all the same and there is a drive to migrate to 2nd generation PAS's especially in the South East (National Programme for IT - NPfIT). Different companies provide different systems although the purpose of them is essentially the same, the functionality may be different, especially the 2nd generation ones at this moment in time. I recognised a menu option previously mentioned, which led me to believe McKesson TotalCare PAS was being referred to, and to my knowledge only one teaching hospital uses this at the moment (unsure about any other London hospitals). I was concerned that menu options etc were going to be quoted for the wrong system as part of any legal action. Casenote Tracking will always be a somewhat hit and miss affair even where there are procedures and training in place. Any system that is encumbent on human intervention, with the best will in the world be subject to human error, whether accidental or intentional. It's a pity the hospital in question does not have an EPR (electronic patient record system) as any amendments to records incl purposeful deletions would be auditable. Have you had any contact/support from your Health Authority or the Ombudsman?

[EIVAD5]

Thank you VikkiBP for the information.

 

I have contacted the HA, Ombudsman and other similar organisations. They have proved so far to be very unhelpful as they themselves are not sure what happens when records go missing - its been 18months now since I have bene asking the TRUST for the records.

 

Recently, I have sent a note to the TRUST to ask for update on the records, and have copied this to the HO who hopefully are chasing them too......

 

Its very frustrating as it does seem the Trust is getting way with severe maladminstration....

 

Regards

[VikkiBP]

Just a thought, have you contacted the GP practice, there may have been a discharge summary sent to them from the hospital. There are targets to be met in terms of turnaround time. Some d/c summaries are typed documents, some produced from bed management software and some from pharmacy systems. It may be a shot in the dark in your case, but it may be worth persuing? Best wishes, Vikki

[EIVAD5]

Hello VikkiBP,

Yes I have contacted the GP - they were sent nothing unfortunately.

Regards

[vandermerwe]

My wife has spent over a year in 4 hospitals and one rehabilitation unit following a stroke in 2008.

 

All were located in the county in which we live except for one which was just over the border in an adjacent county.

 

My wife is currently at home, but badly paralysed on the left side (she is left handed)

 

Without going into detail we wish to take action with a view to obtaining compensation to cover the cost of private treatment which both we and our GP know could help immeasurably, but which will not be funded by the NHS

 

As a first step she has asked for and received her medical records from the hospital in the other county, and which we both view with suspicion. All pages have been completed by hand (with many spelling mistakes and much illegible writing) and have been presented as about 150 A4 pages, many of which have been completed on both sides of the page. There is no numbering, no order to the pages and my wife is strongly of the opinion they are incomplete, particularly as far as physiotherapy is concerned.

 

In scanning through the bundle I noticed some blank pages, one of which is endorsed 'this page has been left blank intentionally'

 

Can anyone advise whther my wife can ask for an affidavit or statement of truth that the documentation is complete and accurate in all respects?

 

We shall ask for records from the other three hospitals and try and get a specialist lawyer on a 'no win no fee' basis or on Legal Aid, but obviously must give a concise but comprehensive brief.

 

After six weeks in the rehabilitation centre she was walking and mounting and descending stairs at the unit; since she has returned home she has seen two physiotherapists in a six week period and is now confined to a wheelchair on an upstairs floor.

 

I have some medical knowledge, a son who is a consultant orthopaedic surgeon, another who practises at the criminal bar, and a daughter who is a midwife, but clearly we can only give general advice but understand how appallingly bad the NHS is in our area.

 

Hope I haven't butted in too much on this site - maybe someone could suggest a title for a new thread.

 

Please, any help would be appreciated.

 

Vandermerwe

Edited December 24, 2009 by vandermerwe
typos - what else knowing Van

[zippygbr]

 

In scanning through the bundle I noticed some blank pages, one of which is endorsed 'this page has been left blank intentionally'

 

 

because it;s page where there is no printed content - as much beloved of booklet format exam papers , one of the care pathways in use in the trust i work for has 3 or 4 such pages , a couple are at the end of sections and one is where a observation chart was removed from the re-print because the trust has moved to a single A3 obs chart for all patients

 

most hospital notes are handwritten as handwriting is still considered more 'secure' than computerised records.

[vandermerwe]

Thanks zippygbr - I appreciate your explanations.

 

Van

[EIVAD5]

Hello Vandermewe

 

you may want to start a new blog as you will probably get some more advice... / help....that way people cna respond to my one as well as yours...

 

thanks

[frankieg]

Say I cant believe the help here- you guys are very up on all this. I've turned in a complaint about my dads care and since I've been nursing overseas so long I dont know how the NHS works anymore and all this stuff is invaluable. I've applied for dads medical records and have a feeling theres going to be a problem so I'm going to really follow this thread.

[vandermerwe]

Good morning frankleg.

 

Thanks for responding to my post even though I've clearly butted in on eivad5's.

 

Like you, my wife and I spent much of our time abroad and our experience with the NHS under Harold Wilson's reign and Mrs. van's first pregnancy and firstborn resulted in the next two being under the care of a private gynaecologist throughout.

 

You say you don't know how the NHS works any more; the short answer it basically doesn't:mad:.

 

Good luck with the records you're after.

 

I'm going to repost again with a different heading because we are going to sue the NHS once we can get all our ducks in a row.

 

Hope 2010 is better for you.

 

Regards.

 

Van

Edited December 31, 2009 by vandermerwe

[frankieg]

I was lucky, I got dads records within 4 weeks of requesting them. On the other hand 7 weeks ago my complaint went to some unit manager and thats the last I've heard of it. But I'm so angry that I have to tell you the terriable things that happened to my dad 14 weeks ago in the wonderful NHs. Our hospital only has one emergency theater and all the ER and emergency patients are channeled through it.After waiting 4 hours in ER to see a doc, Dads irriduciable hernia was declaired an emergency. But his operation kept being put back and he didnt have it for 17 hours by which time his bowel was dead and he needed a resection. That led to an obstruction. He was on a very light diet but got given chicken and broccie(sp) and sandwiches and of course he started vomiting. the vomit went into his lungs and he developed pnemonia. The vomiting and coughing tore his wound open wide open and it took 14 weeks to finally heal and he's had constant chest infections. 5 days after the wound healed he developed another bowel obstruction caused by the original resection.Had to have another major surgery to cut more bowel out and suffered a heart attack in surgery. Two days later he had another heart attack, pnemonia and one of his lungs isnt inflating properly. he's been resusitated twice. So still in hospital, cant breath without oxygen, cant walk and incontinent. If he'd had the original surgery when he should have it would have been a fairly simple operation to push the bowel back and fix the hernia and he wouldn't be in this pitiful condition. All i want is someone to take resposability and say sorry- all i get is excuses and letters about 'the ongoing problem the trust has with only one emergency theater 'and the 'lack of resorces' . So what do I do now? I'd like to contact a lawyer but its hard suing the nhs isnt it? well sorry to rant on so long but it was nice to get it all out.