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Case ref:201204261
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Date:August 2013
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Body:A Medical Practice in the Dumfries and Galloway NHS Board area
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:record keeping
Summary
Mr C complained that when he made a request to the practice for a copy of his late mother's GP clinical records he was not provided with a full copy of her records for the previous ten years. He also had concerns that since 2005 his mother had visited the practice with recurrent ear infections, but it was not until late 2010 that she was referred to an ear nose and throat consultant, who diagnosed a tumour in her ear.
We did not uphold Mr C's complaints. Our investigation found that the practice had provided a full copy of his late mother's records and had explained that they initially kept paper records before moving to electronic records. We also found that although Mr C's mother had reported ear infections intermittently since 2005, these had cleared with treatment. By 2010 the ear problem with which she presented to the practice was different.