This blog post contains wording about suicide that some people may find triggering. If you are in the UK, and your need is urgent, please call 999. If you need support, please call 111, (option 2) or The Samaritans, freephone helpline; 116123.
Introduction
‘The act of falsifying medical records refers to the deliberate act of altering, changing or omitting a patients’ health-related documentation with the intent to deceive or mislead.’[1] ‘Falsification and tampering come in many forms; removing a diagnostic report, inserting information without standard documentation, destroying the record, and omitting significant facts. Often it is an attempt at damage control for a known error or an adverse medical outcome.’[2]
This post recounts the falsifying of my medical records by my GP practice. This has happened on four separate occasions. My discoveries regarding the falsifying my medical records are recent, and I am still in a state of acute shock. I have never experienced anything as alarming as this before. I am writing this post in the hope that by recounting these incidents, self-regulating healthcare practitioners will one day, not be allowed to do what my GP practice has recently done. Not without watchful scrutiny.
Incident 1; Altering
The first incident relates to my GP practice altering an entry on my records. I recounted this in This is A Cover Up. In July, 2022, I had an MRI neck scan, which showed abnormality. I saw that my GP had written; Scan abnormal, to be expected, No Further Action, in my records. On 8th December, 2023, 18 months later, I told a clinician from the Mental Health team, that I had seen my GP’s comment in my medical records, and that I was saddened by it.
That same day, my GP practice locked me out of my System One portal. They changed my password without telling me. On 11 December, 2023, when I requested a new password, I saw that the GP practice had amended that record. They had inserted; No Review Applicable to the entry, as highlighted below.
They did not indicate anywhere when they amended this entry, who did it and why. When retrospectively adding notes to the patient’s record, the record should include (in a way that is immediately apparent to an objective reader):
- The name of the person adding the information.
- The time and date of the addition.
- An explanation of which information has been added.
- An explanation of why these were not recorded at the time of the original entry and why they are being entered now.
‘Retrospectively amending patient records without an appropriate explanation in a non-transparent way, especially when it has been done so in a self-serving way, has serious implications that could result in criminal action, withdrawal of indemnity, or a GMC sanction.’ [3]
Context to Next Incidents
The strain of enduring facial pain for this long, as well as the blockade that the healthcare system has erected to me accessing treatment for my pain, has pushed me into a suicidal crisis. I have been dealing with this crisis since October, 2019. I had no previous episodes of suicidal ideation before this date. It is a direct result of dealing with unrelenting pain, and the way I have been treated by the healthcare system. I have had to present at Accident & Emergency (A&E) on a number of occasions, re my suicidal thoughts. When a patient has attended an A&E department, the hospital sends an electronic discharge summary to the GP, who then updates the patient record.
Incident 2; Deleting
On May 17th, 2024, I attended an A&E department for help with my suicidal feelings. I saw two liaison officers, who sent a letter to my GP and MH team, (who have discharged me.) The GP practice logged my visit to A&E onto my records. The record said;
17th May, 2024; Suicidal Thoughts (1BD1) (Ongoing Episode.)
17th May 2024; Seen in Accident and Emergency Department (9N19)
On June 7th, 2024, when I logged into my System One portal to request some cream, I saw that the practice had deleted the entry from May 17th, 2024. It was no longer there. I was dumbstruck. I didn’t take a photo of the original entry, but A&E provided me with the electronic discharge summary that they sent to my GP after my visit on May 17th. There is no log of this visit on my medical record. They have deleted it. As I do not have my paper records, I don’t know if the practice has also destroyed the letter that the liaison team sent to the practice. If they omitted record of me attending A&E, it is possible that they have destroyed this correspondence too.
This is the Electronic Discharge summary that A&E sent to my GP practice, after I attended on 17th May, 2024.
My casualty card from A&E on 17th May, 2024.
The red arrow shows where the record was that I attended A&E on 17th May for suicidal thoughts, that the GP practice has deleted.
Incident 3; Falsifying
On March 29th, 2023, I attended A&E for low mood and suicidal thoughts. The GP practice logged this onto my records;
29th March, 2023; Depressed Mood (XEO re) (Ongoing episode.)
29th March, 2023; Seen at Accident and Emergency (9N19.)
29th March, 2023: Suicidal Thoughts. (1BD1) (Ongoing Episode.)
One of the GP partners at the practice, who I have never met or spoken to, has falsely entered onto my records, that on March 23rd and March 31st, 2023, (either side of my A&E visit) she did ‘interim depression reviews.’ She did not conduct these depression reviews. I don’t know who she is. I do not take any psychiatric medication, so she could not have done a review by paper either. On March 31st, when she falsely entered that she did a ‘depression review,’ it looks like she retrospectively entered the ‘depression review’, that she falsely claims to have done on 23rd March.
Red arrow shows the falsified record made by the GP partner, who I have never met or spoken to, who entered that she did a depression review, 2 days after I attended A&E for suicidal thoughts.
Red arrows show the second falsified record made by the same doctor, who entered she also did a depression review 6 days before I attended A&E.
New Incidents
Incident 4; Deleting Data.
I am updating this post with 2 further incidents re; my GP practice falsifying my medical records, that have both happened since I published this blog post on 29th June, 2024. These new incidents refer to deleting, re-entering and omitting records. On 10th June, 2024, I attended Accident and Emergency (A&E) for suicidal thoughts. My intensified suicidal ideation was triggered after incident 2, (recorded above.) I was in a very bad way after this. The secretary at the GP practice, recorded my visit to A&E on 10th June, with 2 entries.
Entry 1 said;
10 June, 2024; Suicidal Thoughts (1BD1) (Ongoing Episode.)
10 June, 2024; Seen in Accident and Emergency, (9N19)
Entry 2 said;
10 June, 2024; Suicidal Thoughts, (1BD1) (Ongoing Episode.)
10 June, 2024; Mental Health Assessment, (Xa1YN) (Ongoing Episode.)
This is how the records looked on 15th June, 2024.
On Monday July 22nd, 2024, I logged into my System One portal to see if the GP practice had prescribed medication for a rash on my right hand. I saw that they had deleted the first entry from 10th June, 2024, which recorded that I was seen at Accident and Emergency. This is how the entry looked on 22nd July, 2024.
This is how the record looked on 22nd July.
Today, 26th July, 2024, when I logged into my System One portal, I saw that the GP practice has reinserted the first entry from 10th June, which they must have re-entered between the dates of 22/07/24 – 26/07/24. There are no notes to explain why one entry was deleted and then put back. This is how the record looks today. This photo was taken on 26th July, 2024.
Incident 5; Omitting Data
I had to call 111 on July 22nd, 2024 at 2.46am for suicidal thoughts. The First Response handler triaged me as needing to speak to crisis support urgently. She put me through to a mental health practitioner, who I spoke with for one hour in the early hours of the morning. The GP practice have not recorded my call to 111 on 22nd July, on my medical records.
Red arrow shows that GP practice have made no record of me calling 111 on 22nd July, 2024.
This is very sinister. I think it is the female GP partner, (who owns the practice) who is deleting these records. It is she, who falsely entered that she did two depression reviews with me in 2023, (incident 3.) It seems that the admin team are desperately trying to correct the falsifying of my records with the best intentions, and may explain why they re-identified the deleted first entry from 10th June, 2024. I am certain that if someone did an audit trail of my records, they would find that it is the GP partner who has deleted and falsified my records.
On July 3rd, 2024, I spoke out on X, (formerly Twitter) about the GP deleting the record on 17th May, 2024. That same day, the practice added an admin note to my record, which I think corresponds to that issue.
Administration note that GP practice added to my record on 3rd July, when I spoke out on social media about incident 2.
Falsification of medical records can compromise patient safety and break trust. It may also lead to inappropriate treatment, delayed or incorrect diagnoses, and potentially fatal medical errors. Not to mention that it’s illegal.[4]
Good Medical Practice
The GMC states that a registered medical practitioner is required to;
Record your work accurately
69 You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous and legible. (Contemporaneous means making records at the same time as the events you are recording, or as soon as possible afterwards.)
Act with honesty and integrity
81 You must make sure that your conduct justifies patients’ trust in you and the public’s trust in your profession.
Communicating as a Medical Professional
88 You must be honest and trustworthy, in all your professional written, verbal and digital communications.
89 You must make sure any information you communicate as a medical professional is accurate, not false or misleading. This means:
a. you must take reasonable steps to check the information is accurate
b. you must not deliberately leave out relevant information
c. you must not minimise or trivialise risks of harm[5]
Reflection
These incidents of falsifying my medical records are a disgraceful breach of Good Medical Practice. Amending a record 18 months after the original entry was made, is not contemporaneous, (69.) Nor is it contemporaneous to delete and then re-enter a record six weeks after the record was entered. Claiming to have done two depression reviews with a patient who you have never met or spoken to, is not honest, (88). It is false and misleading, (89.) Deleting and omitting entries that record a patient attending A&E and phoning 111 for suicidal thoughts is trivialising risk of harm and putting a patient at grave risk of harm. The GP practice’ conduct neither justifies patients’ trust in them or the public’s trust in the profession, (81.) How can a patient trust a GP practice, who has a history of altering medical records?
The NHS Constitution for England
The NHS Constitution states that the NHS is ‘there to improve our health and well-being. It touches our lives at times of basic human need, when care and compassion are what matter most.’ It’s a beautiful document, but each time that I read it, I feel sad. This is because of how far removed the conduct of these clinicians is, from the values listed below, that the NHS Constitution upholds;
- Working together for patients
- Respect and dignity
- Commitment to quality of care
- Compassion
- Improving lives
- Everyone counts.[6]
Respect and Dignity
The NHS Constitution says;
Every individual who comes into contact with the NHS should always be treated with respect and dignity. This value seeks to ensure that organisations treat people as individuals, valuing and respecting different needs, aspirations and priorities. The NHS aims to foster a spirit of candour and a culture of humility, openness and honesty, where staff communicate clearly and openly with patients.[7]
Compassion
The NHS Constitution says;
Compassionate care ties closely with respect and dignity in that individual patients must be treated with sensitivity and kindness. The business of the NHS extends beyond providing clinical care and includes alleviating pain and distress and ensuring people feel valued and that their concerns are important.[8]
Reflection
When I saw that the GP practice had falsified and omitted these entries from my medical records, I felt sick with shock. I did not feel like they had treated me with respect and dignity. Quite the opposite. I felt dehumanised. This was not compassionate care. Their conduct felt violent, like they were eradicating any trace of my feelings or of my reality. How can an NHS body destroy medical data about the health of a patient, who they know is this worn down, just to protect another NHS service?
Final Reflection
The falsifying of my medical records is a breach of GMC guidance and a betrayal of the values of the NHS Constitution of England. The impact of my GP’s actions on me has been profound. I am shaken and demoralised, and I am extremely concerned about the data that the practice has deleted from my record. It needs reminding that there is a human life at the heart of this story. A human being who is simply seeking answers about her facial pain, and seeking support for the crisis that has ensued from the lack of treatment for that pain.
In; On Good Medical Practice #3, I ask if self-regulation of doctors works. No, it doesn’t. Not if doctors can falsify medical records like this, without regulation or accountability. I struggle to understand how it is possible for a GP to delete an entry from a patient’s record, amend an entry, and add false information without it being noticed. Conduct like this should not be able to go unregulated in healthcare. Reform is urgently needed so that perilous behaviour like this, which puts patients at grave risk of harm, is prohibited.
Patients must be able to trust medical professionals with their lives and health, and medical professionals must be able to trust each other.[9]
In the summer of 2023, there was a serious incident at my GP practice, that hit the UK headlines. In light of this, and my recent experiences that I have recounted here, I am concerned about the potential welfare of other vulnerable patients. I worry about how many other patients they are doing this to. Something is wrong, and it needs flagging.
Foot Notes
[1] The Dangers of Falsifying Medical Records; A Deep Dive, www.ifaxapp.com
[2] Falsifying Medical Records and Identifying Missing or Misleading Information, Medlaw Advisory Partners, Feb 27, 2021, www.medlawadvisory.com
[3] Amending Medical Records-Appropriate Circumstances and How It Should Be Done, February, 2022, www.lmc.org.uk
[4] Information quoted from same source as footnote 1.
[5] The General Medical Council; Good Medical Practice, 2023. This guidance came into effect o 30 January, 2024. www.gmc-uk.org/guidance
[6] Department of Health & Social Care; Guidance; Handbook to The NHS Constitution for England, October, 2023, www.gov.uk
[7] Information quoted from same source as footnote 6. www.gov.uk
[8] Information taken from same source as footnote 6 & 7
[9] The General Medical Council; Good Medical Practice, 2023. This guidance came into effect on 30th January, 2024.
Photo Credits; Carlos De Toro, Usman Yousaf, Onur Binay and Artem Kovalev on unsplash. Pixabay and Marlon Retratos on Pexels. Who_Made_This, Gerd Altmann and unknown on Pixabay.