Inaccurate medical reports.

[jennydog]

I am thinking that I am going to have to record interviews by nurses re my AF following a second review letter which is seriously inaccurate.

In the first interview I said that I had had malignant melanoma on my left arm and I also said that I had never sunbathed in my life. It was recorded that I had had myeloma which is a blood cancer.

Following the 3 month post-ablatio interview, I have now received 2 copies of the same report, on consecutive days.

I keep a daily diary if bp, rate, incidents, change of medication etc. I gave her a photo stated copy. It read :-

Heart not felt once for 8 weeks post-ablation.

30/9/14 woke at 06.00 Pulse erratic. Hot and sweaty.

At 10.00 104/64. 74.

Her report states " She has had a difficult period following her ablation. ---- Her first episode lasted 3-4 hours with severe symptoms of light-headedness and palpitation."

I nearly had a fit! I have told everyone who has listened that I have never had palpitations and I've stated that on this forum too. More seriously I had to have a new driving licence last month ( 70th birthday ) and I certified that I had NEVER suffered from dizziness/light-heaviness. And honestly, I never have!

The implications of this are serious! What if I have an accident and they access my records?

I have had to write to the EP, with copies to my Cardiologist and GP, asking for all references to light- headedness to be removed from my records.

[Finvola]

That is worrying, jennydog and a few things occur to me:

The most serious is, what if you hadn't got copies of the inaccurate reports? How many such reports exist on all of us - something we know nothing about until the crunch comes? For example - as you say, being certified in writing as subject to light-headedness.

The person writing the report mixing up two completely different medical terms is either medically incompetent and should be dealt with, lazy and should be dealt with or totally overworked to the point of mixing up patients' records and should be dealt with. The second scenario sounds to me like it was written from memory - ie shoddy work.

Have you had any response from your physicians? Perhaps a personal visit to the one you trust most and have the best relationship with would be a good idea to discuss your concerns and follow up on your letter? I know how unwilling I would be to make a formal complaint but what you have described needs addressing.

Good luck with it.

[wpw62]

Sorry to hear you are having problems. It really is up to us to get things under control. We know our bodies better than anyone hope you get this sorted out

[Rellim296]

It sounds as if you have had someone else's report put on your records second time round, and I think you are absolutely right to draw it to the attention of your EP, GP and cardiologist. And to alert us. As Finvola says who knows what errors we have on our records. Very worrying.

[jennydog]

Thank you for your kind replies. My letters were only posted yesterday so I have no replies. It did occur to me that posting on this forum would be proof that I was contradicting the report if I were to need it.

[jennydog]

Hi Ectopic1, thank you for going to so much trouble to give such a comprehensive reply. I also thought that it was just me! I hesitated to spell it all out and then decided that I should do so as it would serve as a warning to everyone.it's all very alarming!

And on the subject of "is it just me?". Why do they always assume that I'm brainless? Do they think that I'm woolly-headed and light-headed?

Very best wishes.

[Whatamug1]

I sent my CQC back - although I kept a copy - You're so right - Have noticed errors of an extremely serious nature in my hospital records. Very few Medics will admit to mistakes - I have only received apologies after I've intervened (ie Registrar going to inject my months old baby 'to bring his BP down' & I refused to allow it as although never listened too - I knew it would peak & then drop away drastically) ...was told in no uncertain terms that I was no one, threatened with the legals etc ..... by the time they pulled me off him his BP had dropped. I have been pretty unlucky with my experiences really but I managed to keep my son alive despite of them. Ann

[Hidden]

Silly question, but if you have no right to access your notes, how do you get to know whether they are right or wrong? In these days of openness being enshrined in the law I find this amazing, if not illegal.

[jennydog in reply to Hidden]

I understand that you can pay to see your records but they can blank out huge chunks. There is increasing use of Data Protection to hide things.

One day last week someone with a hedge cutter severed the main electric supply line into this village. We had no power for 5 hours and my flat screen TV died a death as a result. Scottish Power won't tell me who was responsible because of Data Protection. If I want to claim damages I will have to claim from my own insurance. When I told them that the supply line should not have been in such a vulnerable position I was told that I was being very unfair to Scottish Power.

I'm still confused!

[CDreamer in reply to jennydog]

The ORIGINAL purpose of the Data Protection Act was to prevent large companies passing on address lists which could be electronically replicated without getting your express permission that you agreed to that. It provides a register which every company or individual has to enrol if they hold any personal information, which includes names and addresses so technically, anyone who holds their christmas card address list on a computer should register. LOL Usage to hide and protect from liability is not what it was designed for but it is the outcome. Technically they are correct, unless the person who used the hedge cutter agreed to have their contact details released to you they would be breaking the law.

You would have to make a legal case for negligence, unfair, maybe but that is the price of having YOUR data protected.

[CDreamer in reply to Hidden]

Data protection allow you to access anything that is written about you, but that is it. Challenging it is another matter. I had quite a few cases I was involved in and it is a very delicate matter. Best practice says that opinions should not be recorded, only evidence but all you need to do is put the word 'seemed' to be and you will be OK because the you are making clear it is an opinion.

How you go about complaining about this type of error is the key and basically charm usually works much better than anger. As soon as anger is sensed people become very protective. Charm and logic can often work a treat!

Doesn't make it any less frustrating and yes, it does have huge implications for insurance, I had clients who were refused life insurance because they had a diagnosis of depression, the insurers have access to medical notes as do social services and in some cases the police.

Don't anyone ever let you believe ther is anything called confidentiality in any profession!

[CDreamer in reply to Hidden]

Koll just copied this from RD&E website:-

How to access your clinical records

You are also entitled to access your clinical records or any other personal information held about you. This is not under the Freedom of Information Act, this type of information can only be accessed under the Data Protection Act. Should you need access to personal information please contact:

Goes on to give name of person to contact and details which for obvious reasons I am not going to post. You have the right of access, but not to obtain copies although most medical centres these days do send you copies of letters and you can ask for that but I believe that is a matter of policy not a right.

I am not sure that you have the right to have them amended, especially in the case of opinion. You would have to prove negligence or incompetence in some way and that would be a legal process, I think Ectopic is correct, trying to get anything amended would entail an admission of error and for legal reasons of proving negligence no medic would be allowed to admit their mistakes.

[CDreamer in reply to Hidden]

Koll just copied this from RD&E website:-

How to access your clinical records

You are also entitled to access your clinical records or any other personal information held about you. This is not under the Freedom of Information Act, this type of information can only be accessed under the Data Protection Act. Should you need access to personal information please contact:

Goes on to give name of person to contact and details which for obvious reasons I am not going to post. You have the right of access, but not to obtain copies although most medical centres these days do send you copies of letters and you can ask for that but I believe that is a matter of policy not a right.

I am not sure that you have the right to have them amended, especially in the case of opinion. You would have to prove negligence or incompetence in some way and that would be a legal process, I think Ectopic is correct, trying to get anything amended would entail an admission of error and for legal reasons of proving negligence no medic would be allowed to admit their mistakes.

[CDreamer in reply to CDreamer]

sorry guys I only pressed submit once, I promise! Well I might of got a wee bit impatient and thought the thing wasn't working.

I apologize!

[Hidden in reply to CDreamer]

Thanks for that CD very interesting.

[Offcut]

My lung consultant mentioned my Pacemaker having an effect on my breathing? But I do not have one as they cancelled the Pace and Ablate? Plus the xray they asked me to have would surely have shown it? He also mentioned my Oblations (not a spelling mistake by me)

[Hidden]

I was in hospital for a fairly serious facial operation many years ago. The surgeon came in to see me, show me the XRays of my face, and tell me what he was going to do in quite some detail. Towards the end I said I didn't think the person in the XRay was me because my dental work appeared to be on the wrong side, but not sure as you're looking at a mirror image. He was adamant it was me and continued. I said, I'm sorry, I really think that is not me. Guess what, it wasn't. We're all human. Someone's else's XRay was in my file, same problem as me, even the same dental work, just the other side.

It would have been so easy just to accept what he said and let him carry on. Hopefully they would have noticed at some point, maybe during the op !!!

K

[Dadog]

Blimey!..........scary....just scary!

[CDreamer]

Just for clarification, what you CAN do if you find an error on your records is to ask for a note to be added to your file that you believe such and such is inaccurate or incorrect.

[jennydog in reply to CDreamer]

Thank you for going to so much trouble and supplying all this information. I've certainly learned a great deal. I will report back if I have a response about the light- headedness. I have another appointment booked for mid-Feb and will definitely seek assurance that everything has been corrected then.

Very best wishes.

[Mrs-Gilly]

Front page Saturday's Daily Telegraph:

"The Department of Health admitted that the NHS has "potential liabilities" of £26.1 billion, of which £25.7 billion relates to clinical negligence. This is an increase of £3.1 billion in a year."

So much for George Osbourne's pledge of an extra £2 billion intended for the NHS front-line services.... and no wonder they want to cover their backs. I feel very sad as going back, I had a great career in the NHS.

Mrs Gilly

[loobylou777]

I had a recent appointment with cardiologist where I gave him my history. I told him my first AF episode took me to hospital A and that I had a failed cardio version with Flecanide. I received a copy of the letter he had sent to my Gp which stated I had visited hospital B and my AF had reverted to NSR!

I wrote to both the consultant and my Gp and requested that my records be amended. Two weeks later I received a copy of the ammended letter

Cardiologist took 3 calls on his mobile discussing other patients whilst I was having my appointment with him and he told one caller he should have been at another hospital half an hour ago!

No wonder then that I wasn't given his full attention!

[jennydog]

Thank you for taking the trouble to reply. That is most helpful as I am hoping for a similar letter of response. Light- headedness was never mentioned during the interview and I would have strenuously denied it. I spoke to a police woman yesterday and she said that it would cause me great difficulty if I were to have a car accident even if I was totally blameless.

Best wishes.

[Finvola in reply to jennydog]

That was my worry for you when I posted originally, jennydog. Sincerely hope you get it removed.

[jennydog in reply to Finvola]

Thanks Finvola. The more I think about it the more angry I become. I could well refuse to see another nurse when I go back in Feb. Fortunately I have always been adamant that I didn't get palpitations so they may think that it's odd. Also her spelling and general literacy are very poor - so there's hope yet. I will report back.

Very best wishes.

[Hidden in reply to jennydog]

Jennydog: I worked in the NHS for many years and your experience is not the exception, it happens all the time. I agree it is appalling and I have always thought so. I have had experiences such as you would not believe. Once the xray dept personally brought down to me an xray result which showed that the patient had developed secondaries in the lungs following surgery for endometrial cancer. I personally made sure the doctor was handed the xray packet with the report. Later that day, this doctor (a gynaecologist) dictated a letter to the GP saying that she had seen Mrs X and "all was well. Follow up in 6 months". I heard her dictate this and immediately queried it. She hadn't even looked at the results! She was too embarrassed to ring Mrs X and asked me to ring her instead. The lady had to return urgently the next day.

Regarding what gets written up in your medical records, it stated in my mother's notes that she was walking up hills following heart surgery. She had never been able to do this for years, particularly following the surgery from which she never really recovered. Her lips were blue, but the consultant (a professor at Hammersmith Hospital) wrote that she looked well. She died the next day. Poor poor Mummy. It never goes from my mind.

No-one need tell me about medical "professionals". Good ones are in the minority. These days, many of them are semi-literate as well. Any trust people have in medics is due to their naivity, Sorry to be so cynical. There are a few good people. But you will need a lot of luck trying to find them.

[jennydog]

Apparently this reference to lightheadedness cannot be removed from my records but a denial has been recorded. I corrected all the factual errors, the grammatical mistakes and the spelling mistakes in her letter and gave copies to my GP, Cardiologist and EP. I am now so disenchanted with Arrhythmia Nurses that I never want to see one again.

Best wishes