This blog post contains wording about suicide that some people may find triggering. If you are in the UK and need urgent help, please call 999. If you need support, please call 111 (option 2) or Samaritans freephone: 116123.

---

Introduction

In On the Falsifying of My Medical Records #1 that I published on 29 June, 2024, I recounted five serious incidents where my GP Practice has falsified my medical records. The incidents involve the GP practice amending a record 18 months after it was made, deleting a record, falsifying two records, omitting a record, and deleting and then re-entering a record. I explain in On the Falsifying of My Medical Records #2 that these incidents breach GMC guidance and The Data Protection Act, 2018.

I am writing this post with a further two incidents that have occurred since 29 June 2024. In this post, I recount these incidents with supporting evidence, where my GP practice has falsified my medical records and breached GMC guidance once again. While one of these incidents is not directly linked to my facial and periocular pain story, it is linked to the narratives of my medical story. These narratives are NHS bodies neglecting their duty of care, appearing to cover for one another, and lacking transparency.

Incident 6: Context

On 26 June 2024, I developed a rash on my right arm and hand. I sent an email to my GP practice, in which I asked them to prescribe something for the rash and I included 15 clear photographs of the rash.

I didn’t hear anything back from them, so I emailed them on 3 July (one week later) asking them for an update. The GP practice emailed to say that they aimed to ‘get the issue resolved as soon as possible.’ They told me that they had sent the photos to a “clinical pharmacist.” They said that they were waiting for his opinion.

On 18 July, I still had not heard back from them with an update or a prescription. My rash was worsening. I contacted the GP practice again and told them that the rash was itchy. I requested some cream or medication, and I received an email from one of the doctors at the practice.

The Email Said:

Dear Felicia,

Thanks so much for your message.

I’ve just seen the photos of your skin rash that you sent in 3 weeks ago. I think the clinical pharmacist was going to get back to you, but I’ve just had a look at the pictures after I was sent a task by our secretaries today.

The rash does look sore. I wonder if the rash higher up your forearm might possibly be urticaria, which can sometimes be triggered by an allergy. The rash on your hand looks slightly different.

I’ve prescribed you some more Fexofenadine tablets for the itch, and I would advise trying Eurax 10% cream on the rashes, which can be soothing/settling for such rashes. I’ve sent the prescription for this to the pharmacy now.

I’ll also ask Dr. for her opinion, as she has a special interest in skin conditions.

 Best wishes,

Dr

Falsifying A Record

The Eurax cream had no effect, and my rash continued to worsen. I did not hear anything from the clinical pharmacist, and the GP did not get back to me, regarding consulting with his colleague, ‘who has a special interest in skin conditions.’ I booked an appointment to see a dermatologist at a private hospital.

On 9^th August, I saw the dermatologist privately. She diagnosed my rash as dry eczema, and she gave me a ‘Treatment Request Form’ to give to my GP to prescribe a 100-mg tube of Elocon ointment (Mometasone Furoate). The appointment with the dermatologist cost £200.00.

On 12 August, I sent an email to the GP practice with the ‘Treatment Request Form’ that the dermatologist told me to give to them. The GP practice sent me an email saying that they would prescribe the cream that my dermatologist requested. They did dispense the cream that day.

When I logged into my System One online portal, I saw, again to my horror, that the clinical pharmacist, who I never heard from, had entered onto my record that he had prescribed the cream and that he had seen me. The record said:

12 August 2024; seen by clinical pharmacist, (Y20a6)

The clinical pharmacist hadn’t seen me. I have never seen or spoken to him. I do not know who he is. This is a false record.

Falsification is often an attempt at damage control for a known error or an adverse outcome. [1]

Incident 7:

Omitting Significant Facts

I have been suffering with suicidal ideation since 2019 because of the intensity of my undiagnosed facial pain and because of the constant obstacles that I have faced from the healthcare system in accessing treatment for my facial pain. My suicidal ideation has intensified in the last few months, but my mental health team has discharged me, so I have no support. I have been to A&E on a number of occasions to get help for my suicidal thoughts. I recounted in my first post on the falsifying of my medical records how my GP practice deleted a record that documented that I went to A&E on 17 May 2024 because of my ongoing suicidal thoughts.

On August 27, 2024, I went to A&E about my suicidal thoughts again. I saw a mental health liaison officer who assessed me and said that she was going to write to the Community Mental Health Team (CMHT) and ask them to see me again and that she was going to write to my GP and ask them to review my sleep medication because I am sleeping, on average, 1 hour a night. This is because of severe head pain, which is keeping me awake.

The Omitted Fact

On my medical record, my GP practice has omitted a significant fact regarding my attendance at A&E on 27 August. The GP practice has recorded that I went to A&E for an ‘ongoing episode.’ However, they have not stated what I went to A&E for or what that ‘ongoing episode is.’ They haven’t said that I went to A&E for suicidal thoughts.

The records state:

27 August: Seen in accident and emergency department (9N19) (Ongoing Episode.)

The summary from my attendance at A&E on 27 August, which shows that I attended for ongoing suicidal feelings. Not stated by GP on record above.

 

Falsification and tampering come in many forms—removing a diagnostic report, inserting information without standard documentation, rewriting or destroying the record, and omitting significant facts. [2]

Serious Concern

I am disturbed that my GP has omitted something as serious as my suicide risk. The GP practice has falsified my medical records in varying degrees seven times now. To experience this abuse of power first-hand as a patient is alarming and distressing. I am concerned that my records are missing vital information.

My immediate concern is how much other data the GP practice has potentially destroyed. Each time that I have attended A&E for suicidal feelings, a mental health liaison officer has written to the GP.  I am concerned that my GP practice has either destroyed or not uploaded some of these letters to my medical records. I am most concerned about the letter that the liaison officer sent to my GP on 17th May 2024. It was this visit to A&E on 17th May that the GP deleted from my medical record. (They have since added an administration note to my record after I spoke out about this incident on social media on 3rd July.)

Good Medical Practice

Good medical practice states that a doctor ‘must’:

51 You must put patient safety first at all times.

Record Keeping

69 You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous and legible.

70 You should take a proportionate approach to the level of detail, but patients’ records should usually include:

a relevant clinical findings

b drugs, investigations, or treatments proposed, provided, or prescribed

c the information shared with patients

d concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed

f decisions made, actions agreed (including decisions to take no action), and when/whether decisions should be reviewed

71 You must keep records that contain personal information about patients, colleagues, or others securely and in line with any data protection law requirements.

Patient Safety

73 To help keep patients safe you must:

b contribute to adverse event recognition

c report adverse incidents involving medical devices (including software, diagnostic tests, and digital tools) that put the safety of a patient or another person at risk or have the potential to do so.

d contribute to incident reviews and/or investigations. [3]

Breaching Guidelines

These recent incidents are a breach of Good medical practice. GMC guidance states that doctors must ensure records are accurate. It is not accurate that the clinical pharmacist ‘saw me’ on 12 August. I’ve never met the man, and omitting the reason I went to A&E is neither accurate. The GP practice should have clearly stated the reason that I went to A&E and stated what the ‘ongoing episode’ is on my records. A new medical professional looking at my record would have no idea from that entry why I went to A&E or that I am suffering with suicidal ideation.

GMC guidance states that you must put patient safety first at all times and report adverse incidents that have the potential to put the patient at risk. Omitting such a serious fact from my records is not putting my safety first. It does the opposite. It puts me, the patient, at higher risk. Attending A&E for suicidal thoughts is an adverse incident. The GP should have accurately reported this on my medical records.

Conclusion

It is difficult to find the words to express how it feels to be at the receiving end of conduct like this. It is saddening that the GP practice has omitted such serious information from my medical records. I am hurt that they are acting as if I do not exist. I do exist. However, they are ignoring and downplaying my reality. I feel invisible, which is contributing to and worsening my suicidal feelings.

Change and reform must come. I would like to see a system that prohibits conduct like this and in which a GP would not dare consider doing what my GP practice has done. The change must bridge the gap between words on paper and reality on the ground. Real change would mean that the term “patient safety” would not just be a platitude, a politically correct term that is spouted by politicians; it would be a reality that is enforced by far greater surveillance and stricter regulation.

Doctored data can throw into doubt the basis of a diagnosis, the treatment plan, and communications with patients, which can have serious implications for the quality of patient care. [4]

Blog Post Update.

Today is 14 November 2024. I published this blog post on September 9, 2024, just over two months ago. Since publishing this post, my GP practice has tampered with my records again. They have amended one of the entries to my medical records without being transparent about why they did it.

I explain in incident 7 that after I attended A&E for help with suicidal thoughts on 27 August, my GP practice omitted vital data when they recorded my visit to A&E. The GP practice recorded that I went to A&E for an ‘ongoing episode’, but they did not state what that ‘ongoing episode was.’ They did not state that suicidal ideation was the ongoing episode. On August 27, the record that they made said: Seen in Accident and Emergency (9N19) (ongoing episode). That was it.

I published this post (September 9). When I logged into my System One account last week, I saw that the practice had amended the record. The GP practice added to my record that suicidal ideation was the ‘ongoing episode.’ First, this indicates that my GP practice is definitely reading my blog. Secondly, they have been dishonest. They have dated the new record to 27 August. However, they did not make this amendment on 27 August. They made it between September 9 and today. The GP practice did not indicate who made this amendment and why they did it. This is expected of all medical professionals. The record looks like this today, 14 November 2024.

This is the eighth time that my GP has falsified my medical records.

Foot Notes

[1] Falsifying Medical Records | Med Law Advisory Partners Med Law Advisory Partners

[2] Medlaw Advisory Partners: Falsifying Medical Records, February 2021, About Us | Med Law Advisory Partners Med Law Advisory Partners

[3] General Medical Council: Good Medical Practice, January, 2024. All of the citations in this paragraph are taken from this source.

[4] Thompson Jayne, LL.M: What Are the Consequences of Falsifying Medical Records? December, 2018, www.legalbeagle.com

Photo Credits: StockSnap, Fathromi Ramdlon, Gerd Altman and Alexandra Hal on Pixabay. CottonBro studio, Tima Miroschnichenko, Mikhail Nilov, Anete Lusina and Chuck on Pexels.