Justice mislaid is justice denied – why record-keeping matters
Today the Public Services Ombudsman for Wales publishes a new special report examining the problem of lost records in health and social care. Here, Nick Bennett explains why good record-keeping matters, and the devastating consequences for patients and fa
ANEW report – Justice Mislaid: Lost Records and Lost Opportunities – is released by my office today, looking at the serious issue of lost records in health and social care.
The report looks at a sample of cases that have come to my attention where health and social care records have been misplaced, misfiled or lost.
It also includes recommendations for the entire public sector to improve the way records are kept and managed.
Why does good record-keeping matter?
As well as being a legal requirement in health and social care settings, records are collected and retained to ensure that service providers can take a person-centred approach when dealing with individuals, and to ensure that there is adequate continuity of care.
Good record-keeping also helps providers and patients when things go wrong.
Complaints are essential for any service provider looking to improve service and build on good practice.
And to fully consider a complaint, the service provider should have access to all relevant information, including contemporaneous records, which are vital.
This not only allows the body to make a reasonable and informed decision, and provide a full explanation to the complainant, but also instils confidence in the complainant, who will feel that the complainthandling process has been open, transparent and objective.
What are the consequences of bad record-keeping?
Lost or inadequate records detrimentally affect the ability of an organisation to investigate a complaint thoroughly.
If a body is unable to reassure the complainant that matters have been dealt with appropriately, the complainant may be left with a degree of suspicion and dissatisfaction.
The consequences include a prolonged complaints process, a delay in justice and a breakdown in the relationship between the service user and provider.
Additionally, the organisation is unable to satisfy itself that the matter was dealt with correctly and may not identify any lessons that should be learned.
Importantly, the failings may be repeated, with potentially significant outcomes for patients.
These outcomes, and the additional injustice they cause to citizens and service users, are unnecessary and avoidable.
Robust information governance and records management on the part of providers of public services in Wales would prevent this additional injustice.
In compiling our special report, I have identified four significant barriers to satisfactory complaint-handling caused by misfiled, misplaced or lost records, as follows:
■ Incorrect information is shared with the complainant;
■ the service provider is unable to investigate the complaint;
■ the service provider undertakes an inadequate investigation of the complaint; and
■ I, as Ombudsman, am unable to investigate the complaint.
It is evident from the cases contained in our report that, despite having guidance, policies and processes available, there are occasions when service providers fail in their statutory duty to safeguard the information in their control.
The case studies in my report also illustrate the impact of misplaced or lost records on the complainant’s experience of the process. 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 health board not upholding a complaint about the care and treatment of a woman who underwent surgery to remove skin cancer despite the absence of records.
Another example is the case of Mr W, who had concerns about the accuracy and security of his care and treatment records held by a health board.
His fear was compounded by the health board sending him, on more than one occasion, documents relating to a different patient.
This is worrying, given the health board’s statutory duties to manage records.
The detrimental effect of the lost records on complainants in these cases 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 full investigation.
At the same time, organisations are missing out on an invaluable learning opportunity if complaints cannot reach their conclusion.
Service providers must make every effort to ensure they have effective records management policies and processes in place.
Robust training for all staff is also essential, as are clear and detailed search and reporting procedures for when records are misplaced or lost.
I urge all public sector bodies to consider Justice Mislaid: Lost Records and Lost Opportunities and ensure best practice is a good traveller across Wales.