Mix-up of patient records

The scene

A GP partner called the MDU advice line following the death of a patient. The GP knew the patient well, the death was expected and she was content to issue a medical certificate as to the cause of death.

However when she had phoned to offer her condolences to the family that morning, the patient's son complained that when they had called the practice to request a home visit for the patient, nobody had been out to see him. He said they had therefore had to call for an out-of-hours doctor later in the evening who had visited the patient and provided treatment for symptom control in his last hours. The GP apologised and said she would look into this for the family.

Our member had reviewed the patient's records for the previous day, when the practice's GPST3 had been triaging the home visit requests. On reading the note made by the trainee it was apparent that this was about an entirely different patient. The GP member asked us what she should do.

MDU advice

The adviser agreed that it had been right for the practice to agree to investigate the son's complaint. A letter should be sent out to him acknowledging this verbal complaint, setting out the practice's understanding of his concern, explaining how this would be investigated and when a full response could be expected.

The practice would need to tell the trainee about the complaint and try to understand what had happened about the triaging of the home visit request. It would be sensible to review the records for all the patient's triaged that day to see how this mix-up had occurred, and to make sure that no home visits were outstanding. Where notes had been entered into the wrong patient's records these should be corrected. Our member was advised to write in so that we could assist her in responding to the complaint.

It transpired that the GP trainee had made all the triage calls and then wrote the notes up in a batch later. In doing so he had mixed up two patients' records. On his way home he had called at the other patient's address to make the visit and had been surprised to find nobody at home. The trainee had not realised the mix-up until our member spoke to him about the complaint.

In discussion they agreed that in future the GP trainee would confirm the address with the patient/carer when agreeing a home visit, which should help avoid such mistakes in future. The practice amended the medical records of the two patients to ensure the correct information was recorded for each of them, explaining that there had been an error.

Our member apologised sincerely to the family for the mistake and explained that processes had been reviewed at the practice, and the trainee reflected on the case in his e-portfolio. The family were satisfied that the practice had taken steps to learn from the incident and did not take matters further.

This guidance was correct at publication 16/07/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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