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NHS POLICY FLAW_missing records_anyone else has simliar experience?


EIVAD5
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Good morning Frankieg

 

So very sorry to hear about your dad's appalling treatment.

 

I got my wife's notes reasonably quickly from one hospital (plus an invoice for £38.00:mad:) after the initial request was "lost"!

 

Almost entirely written by hand and containing some material omissions and untruths.

 

Have been marking time until I could get legal advice and picked up a contact from a thread on this site - avma.org - but won't comment further as it might be considered touting.

 

Suffice it to say I ran it past our son who practises at the Criminal Bar and who said "go for it", adding he was anti in principle to the type of solicitor required, but agreed that as avma was a registered charity they should be taken seriously.

 

His view was that the NHS has deep pockets and that they will pay out to

avoid bad publicity.

 

We are not looking for damages: just sufficient compensation to cover the cost of treatment we know exists in this country and which, so far, the NHS has refused to fund.

 

Our (my wife is home now but deteriorating due to lack of home care) problem is in completing the sequence of events in the manner suggested by Van minor i.e. without elaborating unnecessarily, making personal observations, or confusing any details regarding previous strokes.

 

My wife is giving me the facts as she recalls them; I am ensuring nothing stated is so related (fortunately we have an independent witness to many events) and - with luck - the form will be submitted by the week's end.

 

I did say above I would start another thread, as suggested by Eivads, but decided this would be non-productive in view of my December 2007 thread entitled Re: Legal action against the NHS (suggest you read it) which contained some serious advice together with what I considered to be vituperative and vicious comments by people of a certain ilk.

 

I'll now wind up that thread and, if Eivads has no objection, continue here.

 

Obviously all subject to the site moderators' approval.

 

I am always available if you feel a pm is required.

 

Good luck and best regards.

 

Van

Edited by vandermerwe
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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?quote]

 

 

Accepting responsibility and apologies are what most of us want, but you are more likely to get blood from a stone. You can escalate your complaint to the Ombudsman, although I have to say I found them to a bit like a chocolate teapot. You could get a lawyer, but expect a long battle that will exhaust you mentally, physically and possibly financially. Justice won't necessarily follow.

 

If your letters from the hospital admit to lack of resources I would be tempted to send it to the local paper. The hospital may deal with your complaint much more 'effectively' if you go public. Certainly if I were a potential patient, I would want to know if there were issues. There is such a lack of transparency within the NHS that we only find out just how bad things are when we or our loved ones suffer.

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Sali - I've got a copy his chart and lets say there a lot of things in it that show that there were so many mistakes made. And, best of all, I've got e district nurses notes that are usually removed from the home after treatment and distroyed. The district nurse's were horrified at the condition he was sent home in and wrote it all down. there's photos of his wound, memeos they sent demanding an investigation into his dismissal condition, and actually state he recieved a poor discharge. So much stuff. Thats what I've contacted legal department about.

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I wish you luck. Every case will be different. I too had proof that my relative was overdosed on a drug and mis-diagnosed causing death. The doctor only found out the cause of death because I insisted on a post-mortem. The Ombudsman did not investigate. Apart from the hospital, whose major aim is to avoid responsibility and blame, there is absolutely nowhere else to turn to but private ligitigation.

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You see the Ombudsman will only investigate fully if they consider that the response from the hospital has been unreasonable. This is not a criteria which appears on their website, but it will be part of their communication to you once you have escalated a complaint. Consequently your relative may be butchered and mistreated and all the Trusts have to do is to sound 'reasonable' in response to your formal complaint. They are good and practiced at this. The Ombudsman decision is final. You have no appeal unless you go to judicial review.

 

A member of the public cannot even report poor care to the CQC. Complaints to the hospital will merely result in a 'thank you for your feedback' and 'we have learned lessons.' It's complete flimflam. We have seen only too clearly recently that the GMC also only exists to protect its own.

 

Our healthcare system and the processes in place to protect us are a disaster zone.

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Hello

Just to give you all an update on my situation if anyone can help further!...

 

The Ombusdman have proved useless in assisting to locate the records - and legally there is nothing to protect us the public when records go missing.

 

Its been 2 years now and the trust have still not found over 4 weeks of medical records that have mysteriously gone missing - its crazy.

 

It looks like I am hand tied as cant seem to do anything now!.....or legally no solicitor is even willing to assist in helping find the records...

 

Help ?

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I think you need to forget about these records they wont be found. And to be honest even if you do have it its prrobably not going to help you much. I have my dads chart solidly backing up my complaint but its not helping as much as you'd think it would..I think all you need to show that her care didnt meet the accepted standard and make that the basis of your arguement -that's not going to be difficult because its obvious from what you've said.

Problem number one she was discharged when you were told she was going to be in another few weeks. Have you tried establishing the actual standars of care for her treatment-First you need to check on how long she should have stayed and,if it was early, did she met discharge standards? . NHS information site- not NHS direct - NICE and Uk patient care are very informative.Then if the standard of care that should have been followed wasnt thats the basis for your complaint of negligence.

problem 2 the blood transfussion. Again find the standard of care Check and see how blood transfussion should have been done- the rules on vital sign checks, rate of administion( basicly fast loss fast replacement, chronic loss slow replacement ususally no less then 4 hours and wow 2 half hours is just to fast!!) . And to be honest, ishe suffered fluid overload and it wasnt treated , so it was pure negligence. if she was elderly or had chronic heart, lung or kidney problems that should have been a warning that she was at risk and given diruretics between units. Get hold of the GP notes if you suspect she had underlying problems.

I supose what I am saying is you know something went wrong and someone needs to acept they were resposiable. Oh and in any meeting they will say they dont know what happened - because there isnt a chart- agree thats a problem because they cant prove they met the 'standards of care ' without it and let them do most of the talking its suprising what they say. Matron at my meeting not only 'dug a hole' but dropped the whole hospital, doctor and nursing staff right in it. .

Edited by frankieg
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sorry to be posting so quickly but I've just re- read your post- and had a thought , the coroner commented that acute pulmonary oedemia its often caused by transfussion overload- but what was the actual verdict as to the cause of death? If it was rulled natural causes then no wonder you cant get the records!! I dont know much about coroners but can you go from that end- is it possiable to have a new inquiry??

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problem 2 the blood transfussion. Again find the standard of care Check and see how blood transfussion should have been done- the rules on vital sign checks, rate of administion( basicly fast loss fast replacement, chronic loss slow replacement ususally no less then 4 hours and wow 2 half hours is just to fast!!) . And to be honest, ishe suffered fluid overload and it wasnt treated , so it was pure negligence. if she was elderly or had chronic heart, lung or kidney problems that should have been a warning that she was at risk and given diruretics between units. .

 

 

blood MUST be transfused within 4 hours of removal from the cold chain i. e. removal from the transfusion lab fridge ... which realistically means there is 3 and half or so hours to give the transfusion

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Where i worked it only took a few minutes for the blood to come from the fridge to us which is why I said 4 hourly but certainly ,its aceptable to transfuse a unit in 3 1/2. In this case 2 units were infused between 5pm and 8.30pm

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hello both

 

thank you for your comments.....the problem I am having is from a legal standapoint in that my solicitors are struggling to prove negligence without the records- as it the hospital's word against ours!....

 

We clearly know what happened...and yet the Trust has responded in their offical complaints procedure things that apparently took place...for which some a blatant lies. Thats what makes the case of the missing records highly supsicious.

 

The coroner concluded the reason for death was brochonupnoia, which at the time we did not question...and even though we did question this afterwards, he confirmed that the pneomina was 'fully established' which in turn, again questions why the relevant checks pre and post transufions were not properly conducted.

 

Anyway legally missing records is not seen as an issue in the eyes of the law, and without these records I am stuck....its crazy - thats 4 weeks of medical records vanished!

 

any other thoughts / help please...

thanks

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What a mess. But you know its this diagnosis that the cause of death was broncial - pnemonia that bothers me. As rapidly as it hit, it sounds like a chemicial pnemonia- literally the fluid seeping into her lungs inflamed them- not a viral or bacterial pnemonia. Its hard to tell the difference without a sputum culture. What about the the time period for the transfusions? do they deny she had all that fluid in a couple hours? . when I worked in a british hospital years ago there was a book in the blood bank that whoever collected the blood had to sign.If this hospital has one that might show what time the blood units were released-unless they lose that of course.

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Good morning Eivad5.

 

Just a thought -- is your solicitor on AvMA's approved list? You can find out from their website and I believe it might be worth getting a second opinion:confused:.

 

My wife is in a similar situation having obtained her notes only to find some missing. The ones, in fact, that show negligence and poor care! I have a feeling this is all too common.

 

She has just submitted details to AVMA to commence litigation. Too early to get a response, but the hospital wants to be paid for the notes now so we'll agree once they are complete.

 

Regards.

 

Van

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Hello Frankieg

Thank you for your message.

The Trust have not commented on the procedure of hte transfusion, instead have supplied me the policy producedure document. This simply says that the time to give the transfuion is as per recommendation of the Doctor on duty and written in the notes....without the notes I am stuck!

I tried to see if there is any UK guidelines in giving transfusions and timings but its all abit wooley - nothing concrete.

 

Hello Vandermwe - thanks for your post. Yes the solicitor I am using is on AVMa's list. To be honest AVMA have been very unhelpful in advicing on the missing records - its seems they dont have a clue what to do about this...and from a legal point of view our solictor is in a similar mess...

 

regards

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  • 3 weeks later...

I am saddened to hear stories like these, I feel your pain as this happened to my father in 2008.

 

It was a similar scenario to F's, irriductable hernia/obstruction and perforation. He was only given 5mg of iv morphine for his pain. His medical notes states PRN morphine 2 hourly, however he was not given this because of staffing difficulties. He died an excruciating death a few hours later.

 

My fathers medical notes are also incomplete, care notes and an x-ray are missing. I have made an official complaint to the NHS regarding his care and have received a response letter, which they deny any wrongdoing.

 

I am not interested in compensation, I just want the truth, is that to much to expect?

If anyone would like to contact me with regards to forming a support group, personal messages are welcome.

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hector 205, so sorry to here about your dad. But it shocks me that there can actually be another patient who had almost the same thing happen to them as what happened to dad- except somehow my dad survived his initial hospital admission! Just out of interest, how old was your father? Mine is 87 which I think had a lot to do with the long delay for surgery. like you I don't want compensation - i want to know what steps they have taken to address 'the trust's ongoing problems with only having' access to one emergency theater which requires we prioritize patients' which is what they wrote to me. It was that delay that set off the sequence of events that followed and now as per his new doctor he is terminal care!. Suppose to seeing some departmental manager on Friday. But I have had some outside advice which is to contact my MP because of this policy

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Hi Frankieg,

 

Regards the meeting you - if possible, secretly record the meeting; give them a list of questions you want answered regards the theatre (put it in every day real terms Eg "How would you like it if..." or "What if your dad..."); ask how the Trust is going to prevent a repeat and hold managers to account; ask how the information from your meeting will be fed back into the Clinical Governance system (and ask for a copy of evidence).

 

The meeting is to try and "appease" you and stop things going further. This is an "acute emergency situation", they will try to play this down. Research the medical condition on the internet, find the associated protocols - what should have been done. Go with your gut instincts, as they are probably right.

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Hi Evade5

 

Check out: npsa.nhs.uk

 

Patient safety resources/patient safety topic/patient admission/right patient, right blood 9.10.2006

 

This patient safety organisation issues alerts/instructions to hospitals, which should be complied with.

 

Print out the above document and attach it to your complaint.

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Hello Hector 205

 

Thank you for your link. I have already submitted the complaint, and as per my log you will read that the trust are simply telling me what they should have done..implying the did it - and without the medical records I am lost!.

 

the missing records - thats over 6 weeks of treatment has vanished - that is the biggest hurdle I am trying to overcome and understand.

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My meeting was canceled because dad came home that day-terminal care. Its been decided-by them- that there wont be any meeting, I'm getting a final letter based on this managers 'investigation' and have been told I'm free to take my complaint further if I so wish!

OK EIVAD5, back to these records- its obvious your not going to get them- because they'd obviously back up your claim. So I still think your best bet is the coroners report that she had pulmonary edema.have you got her GP notes? If so is there any disease mentioned in them that might show it was 'natural' as apposed to transfusion. - congestive heart failure, kidney problems- that kind of thing.If not then something triggered it and logic says the transfusion. You may have to reslant your complaint - Who saw the transfusions given so quickly -was it just you or several family and friends? would they be willing to say what they saw to the trust? If they will ,could your complaint be changed to 'your concerns , from what was observed that hospital policy wasn't followed' and that it could happen to someone else. If they argue they did follow policy ask them to provide a copy of this guide line and to prove it was followed. And as I've been advised can you go public? like you I've contacted a lot of so called 'assistance' organizations and have found all they will do is 'advise 'some not even that. I'm afraid I'm not much help because in the USA things are so different, the chart is a legal document and if the hospital 'loses' it, it's regarded as an admission of guilt.

Edited by frankieg
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  • 2 weeks later...

Hello Frankieg

 

Thank you for you message.

 

Its very clear that the policy document they have shared with me has not been followed...clearly reason why they have lost the ENTIRE records.

 

I am completely stuck...clearly this fundamental flaw is something that can effect anyone...and its very worrying.

 

Regards

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