The management of medical records is being examined for the Infected Blood Inquiry. Once upon a time, medical consultations were written out by hand, in spidery handwriting, difficult to interpret and subject to deterioration over time leaving the next clinician/reader a difficult task. With the digital age, the records have over the years made their way onto electronic databases in an attempt to bring this up to date. The Inquiry itself is exposing the gaping flaws that have been occurring before, during and after the transfer of these records, often resulting in many of them being simply missing.
The criticism does not end there. When you begin to analyse the medical records that do exist, they can contain false and/or inaccurate information. Sometimes, they even contain an alarming level of personal bias. Sadly, such inaccuracies only ever come to light several years later. For the purposes of this blog, we are dealing with the first matter; those records that have vanished.
The retention policy
Record holders are under a legal and ethical obligation to maintain records safely and securely. Under the Public Records (Scotland) Act 2011, NHS Boards are required to comply with information Governance standards applicable to administrative and patient records.
For Scotland, the minimum length of times apply:
|Type of Patient||Minimum period for retention|
|Adult (over 18 years old)||6 years after the last entry or 3 years after a patient’s death|
|Children/young people||Until the patient’s 25th/26th birthday if entry was made when young person was 17; or 3 years after the death of the patient if sooner|
|Mentally disordered people defined by the Mental Health Act||20 years after the date of last contact|
|GP records||Records should be retained for a patient’s lifetime and 3 years after their death.|
When identifying records that should be kept on a permanent basis, consideration is given to the long-term historical or research value of the records.
After the minimum period has passed, the following actions occur: the records are reviewed and may be kept for an ongoing clinical/research need; they may be transferred onto an NHS archivist if they have historical or research value; or they may be destroyed.
Records that are identified for destruction after this period are records that have no clinical, historical or research value. Whenever the content of a record has been examined and a clinical decision has been made to destroy them, the Master Patient Index entry will be updated with ‘Destroyed’ along with the destruction date so that this is immediately known should an enquiry be made to the status of the health records at a later date.
The missing records
For the infected blood patients, sometimes it is not the whole record that has gone astray, just certain years and, interestingly, they are commonly the years that a patient has been infected. Tracing back what has happened to these records is not always clearly recorded within the Master Patient Index; often what has happened remains a mystery. This raises questions from poor administration, to conspiracy accusations. Examples of records turning up in drawers within hospitals or filing cabinets and places they simply should not be, does occur to this day. GDPR breaches happen when patient A receives their own records and halfway through on page 53 suddenly there is a record slotted inside for patient B, with no explanation other than it is a mistake. However these mistakes seem to be repeated and are a horrible breach of a patient’s rights. Indeed, now, if a patient’s medical records are requested, it has also been known for the records to have been held elsewhere within a hospital, not on the system and unless the patient requesting the records has prior information of this, then the requester is out of luck.
The only accurate way that a person can currently keep a guaranteed updated record of their treatment, is if they hold a copy of each treatment record themselves. Critics would say that the information is on the NHS systems and available, but it will still be destroyed after a period if the patient moves away.
Why has this happened for the infected blood patients? Those affected have been left with a destroyed faith in the NHS which requires an explanation. Whether this be incompetence, poorly implemented policies or conspiracy, this will be for the Inquiry to determine.
We all have our own medical histories and this history should follow us throughout our lives. The doctor- patient relationship is a partnership. When a doctor creates a record, a patient should be given the opportunity to view that. They should also be given the opportunity to either agree or challenge it, without the need of legal intervention. This would raise significant challenges in itself, but considering how to strengthen the doctor-patient partnership and protect our patient rights should be essential.
Bloy by Stephanie Spencer