Public ‘frustrated and distressed’ by lost medical records – report
PATIENTS and their families are being left feeling frustrated and suspicious by health and social care providers losing their medical records, a special Ombudsman report has revealed.
The Public Services Ombudsman for Wales highlighted a sample of cases in his latest thematic report, Justice Mislaid: Lost Records and Lost Opportunities, where health and social care records have been mislaid or lost.
He warned that in some cases complainants were left with additional distress at a time when a loved one has died.
Examples included:
■ Consultants mistakenly discussing another patient’s medical records in a meeting with a grieving daughter following her father’s death;
■ a health board not having any record of a woman giving birth to her newborn child at a hospital, apart from a copy of a prescription held at its pharmacy; and
■ a patient who was already concerned about the security of his treatment records being repeatedly sent records relating to a different patient.
The report, which anonymises all complainants and the bodies complained about, states: “In many of the examples, the patient records lost or misplaced have related to the period of care immediately before that patient’s death.
“It is therefore understandable that the relatives of those patients who were pursuing a concern relating to the care or treatment provision have, when learning of the loss or misplacement, expressed great concern that their opportunity to obtain answers might have been lost.
“Mrs S said that she felt unable to grieve as answers could not be provided to her concerns. It is unacceptable that many of these complainants have encountered this additional distress at what would already have been a difficult and emotional time.
“The discovery that records have been lost has led to many complainants voicing feelings of distrust of the service provider or a loss of faith in the complaints process. Mr H, Mrs L, Mr Q, Mrs S and Mr CD’s experiences were such that they suspected that the health boards were deliberately concealing information about the quality of care provided to their loved ones.
“Mr Q and Mrs S felt that the loss of records might have been used by the service providers as a deliberate tactic to frustrate their pursuit of these matters.
“Although the Ombudsman has not found evidence of deliberate action in any of the cases considered, it is understandable that the complainants reacted in this way. It is deeply unfair to complainants that their concerns can never be addressed.
“In Ms A and Mrs D’s cases, the health board’s responses to their complaints suggested that events complained about had not occurred or that their recollections were disputed in some way. Both complainants said they felt insulted by this and felt that they were being called ‘liars.’
“Mrs E’s and Mr Q’s experiences with the health boards left them questioning the quality of the investigation of their complaints, again undermining trust in the service provider and the complaints process. Additionally, Ms A and Mr B were put to the inconvenience of having to supply evidence to enable further investigation by the Ombudsman.
“Further, in Mrs E’s case, she was not told that some of her records were missing.
“In Mr W‘s case, the inclusion of another person’s confidential medical records within his own records caused him to question the nature and quality of his treatment. These cases highlight the importance of open and transparent communication when issues of this kind arise.”
In all the cases referred to, the complainants were so dissatisfied with the responses they received that they decided to go to the Ombudsman.
The report says: “It is therefore understandable that the Ombudsman’s inability to independently consider matters further because of a loss of records, as in Mr F, Mr H and Mrs K’s cases, was met with deep feelings of disappointment and concern.”
Ombudsman Nick Bennett called for effective records management policies and processes, robust training and clear and detailed search and reporting procedures for use when records are misplaced or lost.
He said: “I urge all public services to consider Justice Mislaid: Lost Records And Lost Opportunities and ensure best practice is a good traveller across Wales. The detrimental effect of the lost records on complainants is evident as they are left feeling frustrated and suspicious as their concerns are left unanswered. Tragically, in some cases, relatives have been left feeling that they cannot grieve properly because of a health board’s lack of a full investigation.
“At the same time, organisations are missing out on an invaluable learning opportunity if complaints cannot reach their conclusion.”