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Decision Report 201508104

  • Case ref:
    201508104
  • Date:
    October 2016
  • Body:
    Grampian NHS Board
  • Sector:
    Health
  • Outcome:
    Some upheld, no recommendations
  • Subject:
    record-keeping

Summary

Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner.

Following investigation, we were of the view that the practice had taken reasonable action to try to establish the accuracy of the record which detailed a consultation alleged to have taken place between Mr C and a locum GP. As the locum no longer worked for the practice they were unable to speak to him. In order to establish if the record actually related to another patient the practice conducted a search of their records, including patients seen just before and after Mr C on the date in question. They also reviewed the records of patients with similar names and/or dates of birth. We considered that the practice had taken reasonable action to establish whether or not the record was inaccurate, but had been unable to do so. We did not uphold this complaint.

On the matter of Mr C's complaint to the board, we found that there had been delays in dealing with Mr C's complaint. However, Mr C had been kept informed during the process. Although we upheld this complaint, we did not make any recommendations on this matter.

Updated: March 13, 2018