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

[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

[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

[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!

[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

[EIVAD5]

Hello

 

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

 

Thanks

[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

[EIVAD5]

Hello VikkiBP,

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

Regards

[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

[EIVAD5]

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 ?

[EIVAD5]

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

[EIVAD5]

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

[EIVAD5]

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.

[EIVAD5]

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

[EIVAD5]

Hello there.

 

I have contacted the BMA, GMC and my MP.

 

I have now written again to the MP to investigate this as its clearly is a risk to other patients....let alone whats happened here.

 

Its very sad that there is no protection at all for patients if they unexpectedly die, and records go missing.....bizarre.

 

Regards

[EIVAD5]

Hello

 

yes I have tried the Health Commission and frustratingly they cannot do anything - whilst they pride themselves in solving issues of maladminstration - they just cannot help - in fact they where utterly useless in even suggessting what can be done.

 

I have tried so many organisations such as:

 

AVMA

PAL

PoWHER

Healthcare Commission

Local NHS trust

NHS Records Office

Information Commissioner

The GMC

Data Protection Support

Local MP

Department of Health

 

Unfortuantely I am getting no where.

 

The issue is no one seems to know what to do when records go mysteriously missing. the sad part is - that whilst its very personal to me to find out what went wrong - this does highlight a huge public risk, and a fundamental NHS flaw. The fact remains that if a NHS patient unexpectedly dies after treatment - all the trust has to do is 'lose' the records and nothing further can be done. Even on a legal standpoint - its a struggle as the medical records ais the key evidence needed - and when they are not around, a legal case is very tough to pursue.

 

Any suggesstions anyone else has please do let me know.

 

Thank you!

[EIVAD5]

Hello - yes I contacted ICAS - and even they are unclear on what to do next. They really cannot help in taking or investigating this matter.

 

Very worrying!

[EIVAD5]

Hello

 

IF anyone has any similiar experiences of this - please do get in touch!...it seems that this Flaw in the NHS system is more common than we think......clearly the NHS knows that if they have done potentially something wrong - all they need to do is loose records - there is nothing that can be done!