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Case ref:201100473
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Date:December 2011
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Body:A Medical Practice, Lothian NHS Board
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:policy/administration
Summary
Mr C complained on behalf of his daughter (Miss A) who attended her medical practice about a rash on her head. He said that she did not complain during her appointment of migraine or any kind of headache. At that time, Miss A was in the process of applying to join the Army and has since been told that she has been rejected on medical grounds due to her history of migraine.
Miss A said that the GP erroneously noted on her records that migraine was discussed at the consultation, and this caused the Army to reject her. The GP maintained that the note she made at the time was correct and that she completed a medical form she was sent by the Army properly, as she was required to do.
Our investigation showed that there was no evidence to suggest that the note recorded by the GP was incorrect. Further, the GP complied with the guidance she had been sent by filling out the form and making reference to a history of migraine. Our medical adviser confirmed that Miss C's medical records show that she did have a history of migraine, which the GP was bound to disclose.