Q I was chatting to a patient this morning and she mentioned in passing that she recorded her last consultation with the dentist as she wanted to keep track of what was discussed. Surely she should ask permission before doing this?
A The increasing use of smartphones and tablets makes audio/video recording much easier and increasing numbers of patients (both medical and dental) are taking advantage of this in consultations. Despite what you may think, patients do not need to ask permission before taping a consultation, as section 36 of the Data Protection Act 1998 considers that the information in the recording belongs to them. Conversely, the dentist would not be allowed to record without the patient’s permission. MDDUS experience suggests most patients make these recordings for positive reasons (i.e. to help their understanding of health advice) rather than to challenge their clinician. Dentists acting professionally should have nothing to fear. As ever, by keeping clear, comprehensive and accurate records of consultations, dentists can justify their actions in court if necessary.
ACCESS AFTER DEATH
Q The daughter of one of our elderly patients who died last month has been asking questions about the nature of the care provided before her mother’s death and has now requested access to her mother’s medical records. Am I allowed to provide this to her?
A Requests for access to a deceased person’s records are covered by the Access to Health Records Act 1990. The GMC’s Confidentiality guidance is also a useful reference (paragraphs 70 to 72). After death, access may be granted to the deceased’s personal representative (i.e. the administrator or executor of their will) or to anyone who may have a claim arising from the death. Before disclosing, first check whether the patient had specifically requested her records remain confidential after her death and be sure to comply with her wishes (unless there is an overriding public interest in disclosing). Then confirm with the daughter the nature of her request as she should only be supplied with relevant information. Make sure you do not disclose any information in the record that may cause mental/physical harm to anyone, and remember to redact any third party information.
TRANSFER OF RECORDS ABROAD
Q A family in our practice has moved abroad and is requesting that full medical records be sent to their new practice. Should the records be sent via an “International Signed [for]” service to ensure secure delivery and can we charge for the extra postage?
A Subject access requests from patients abroad would not differ from those made within the UK under The Data Protection Act. The maximum amount that can be charged for copies is £10 for computer copies and up to £50 for paper copies or a mixture of the two. This figure would include postage. It would be reasonable to be able to show that you have made every effort to ensure safe delivery should a complaint arise later – thus an International Signed [for] service may be advisable. But you may also wish to advise the patients that the practice is no longer responsible for the records once they have been posted. Remember that all requests for medical records should be made in writing and signed – and you should take all reasonable steps to ensure you have checked the identity of the patients (or parental guardians) requesting the records. In this case, a signed request and copy of passports showing the signature would be reasonable.
REQUEST TO RE-REGISTER
Q A former patient has contacted our practice wanting to re-register her, her husband and her children. The family had previously been registered but moved to another practice after the husband was removed from our list for verbally threatening reception staff. The partners have met and decided that the practice would be willing to take on the patient and her children but do not want to allow the husband to re-register. We would also want assurance that the husband would not accompany her or the children to the practice, nor be present if a home visit was required. Is this reasonable?
A It would be reasonable to re-register the former patient and her children but to stand by your original decision and refuse to take the husband back on the list. However, it may be difficult to enforce the condition that the husband not be allowed to accompany the children or be present during necessary home visits as there may be circumstances when this is not possible, particularly in medical emergencies when the practice would be in no position to refuse treatment. Thus, this would be best framed as a request rather than a condition of re-registering the family.
COPYRIGHT ON PATIENT DATA
Q A partner in our practice has been requested to complete an army medical form and he wants to include a copy of a CAMHS (Child and Adolescent Mental Health Services) assessment letter – but the letter includes a note stating: “Not to be copied without permission of the author”. Can we copy and send the letter without permission of the author?
A Once a document is placed in a patient’s records it becomes available for the patient (or a representative acting with the patient’s consent) to see or allow disclosure upon request. If it contains third-party information or anything the clinician believes could cause serious harm to the patient then this should be redacted. Letters from specialists or other health professionals do not count as third party and therefore anything they have written that is held in the patient records can be disclosed. Thus, it would be reasonable for the GP partner to send a copy of the letter. GMC guidance states that doctors should be honest when writing reports or signing forms and “must not leave out relevant information”.
Q Our practice is considering setting up a private clinic to administer travel vaccinations. The plan is to have our practice nurse carry out the injections – would one of the GPs have to be present while she does this?
A The key issue to consider when delegating is whether the person who will be carrying out the task is competent to do so. The practice must be confident that the staff member administering the vaccines has the qualifications, experience, knowledge and skills to provide the treatment. For example, would she be competent to deal with a potential anaphylactic reaction to a vaccination? The GMC states clearly that: “Although you will not be accountable for the decisions and actions of those to whom you delegate, you will still be responsible for the overall management of the patient, and accountable for your decision to delegate.” When delegating, doctors must always pass on enough information about the patient and the treatment they need. Ultimately, if the GPs are satisfied these requirements can be met, then they can go ahead with their plans for the nurse to work in the clinic without direct supervision.
Q A police officer has contacted the practice following a report from one of our patients who claims she was secretly photographed by another patient while they were both sitting in the waiting room. The officer wants access to the consultation list to see who was booked in for an appointment at the time of the alleged incident. When I asked, he said he had not yet secured a court order for the disclosure. Should I give him this information?
A Whenever police ask for access to confidential patient information there are a number of key issues to confirm. One of these is a court order – if this is in place, then you are required by law to disclose the necessary relevant information. Without such an order, you must exercise your professional judgement. Ideally, no disclosure would be made without first securing consent from the patient(s) concerned, but you should check first with police whether doing so would undermine their investigation. You should also be satisfied that seeking consent would not put you or others at risk of serious harm. Without either a court order or patient consent, you must consider whether disclosing could still be justified. The GMC recognises that there can be a public interest in disclosing information without consent where it is in the public interest “to protect individuals or society from risks of serious harm, such as… serious crime”. Having considered all these factors, if you feel disclosure would not be justified in this case (without consent) then the police would have to seek a court order.
Q A patient who was recently diagnosed with dementia was seen arriving in the practice car park this morning in his car. He has been told on two occasions he is not fit to drive and that he must inform the DVLA of his diagnosis. His GP has discussed the matter with the patient and his daughter, but to no avail. What should we do next?
A All drivers have a legal obligation to alert the DVLA if they suffer from one of a list of conditions, including dementia, cognitive problems and other related conditions. It would appear the practice has followed all the necessary steps so far in discussing the issue with the patient and highlighting his legal obligations. As the patient is still driving, it would be advisable for his GP to meet with him again – ideally involving his daughter/another family member – and inform him that if he continues to drive then the doctor will report it to the DVLA in the public interest. Details of the discussion should be noted in the patient’s record and a letter sent to him outlining any action taken. See GMC guidance - Confidentiality: reporting concerns about patients to the DVLA or the DVA.
Q Our receptionist has informed me that one of our patients has posted a number of negative and derogatory comments about the practice on Facebook. She is not happy about the treatment she has received and she claims our dentists and staff are incompetent. This is very unfair and makes the practice look bad. How should we respond?
A Firstly, however unfair this seems and however much the practice wishes to defend itself, you should resist the urge to reply directly (and publicly) to the comments via Facebook. This will not help and will likely make matters worse, as well as potentially breaching patient confidentiality. Instead, consider contacting the patient to let her know you are aware she is unhappy about certain aspects of her dental care and invite her to come into the practice to discuss it. Advise her about the practice complaints procedure which could give her a constructive means to air her concerns and allow you to respond accordingly. It is important to make sure that any written communication is carefully composed and should not contain any warnings or threats to deregister her. (It has been known for such letters to also find their way onto Facebook.)