A PRIVATE LETTER
Q We have had a request from a patient for access to part of his medical record, specifically a recent letter from his psychiatrist. However, the psychiatrist expressly asked that the letter should not be shared with the patient as she was afraid it may upset him. Should we withhold it?
A The Data Protection Act entitles the patient to see a copy of his medical records, including any correspondence from other healthcare professionals such as psychiatrists. The main exception to this rule would be if disclosure would cause serious physical or mental harm to the patient (or another person). It may be useful to discuss the matter further with the psychiatrist, or with a colleague, to help you decide whether this exception applies here. You should also double check that none of the information requested relates to a third party who has not consented to disclosure and that there are no legal restrictions regarding disclosure (i.e. a court-ordered restriction or legal professional privilege applies).
WHO WRITES UP THE NOTES?
Q The principal dentist in our surgery has been pushing to make it practice policy for associates to have dental nurses write up clinical notes. One of our dentists is resistant to the idea and wants to record his own notes. What are the guidelines on this issue?
A GDC guidance clearly states that all dentists must “make and keep accurate and complete patient records, including a medical history, at the time you treat them”. The ultimate responsibility for what is recorded in the records lies with the dentist providing care for that patient. In the situation of your associate, he would be responsible for what is recorded and should check all notes and sign or initial them. In many practices, especially those using computerised databases, the nurse would record the findings of the consultation or treatment visits and the dentist would check and then initial them at the end. In essence there is no right or wrong answer as to who should make the recording. It is entirely a personal choice and if your associate prefers to do this then it would be reasonable to judge it is his decision and your principal should respect that decision.
Q A patient recently attended our practice for a blood test and the result revealed a low haemoglobin level. The patient is now currently in prison and our GP wants to request a follow-up test. Are we allowed to contact the prison to facilitate a follow-up or must we first have consent from the patient?
A It would probably be best first to contact the patient in prison to inform him that the prison doctor will be contacted in regard to the abnormal blood test – unless there are any objections. Failing this it would then be acceptable for the GP to contact the prison doctor directly. Healthcare staff at the prison will have a formal duty of care to the patient in which confidentiality will be maintained. The GMC states that: “Most patients understand and accept that information must be shared within the healthcare team in order to provide their care. You should make sure information is readily available to patients explaining that, unless they object, personal information about them will be shared within the healthcare team, including administrative and other staff who support the provision of their care.”
ON THE REGISTER
Q We have a number of dental care professionals (DCPs) in the practice and it is assumed that they will take care of their own registration with the General Dental Council. I discovered recently that there has been a problem in the past with one or two of the DCPs failing to pay their annual retention fee on time. I am a new manager and do not want to have to deal with this kind of disruption but I also do not want to cause offence.
A Practice managers are advised to ensure that all DCPs are registered with the GDC in order to avoid compromising patient care. Anyone who is not registered, or whose registration lapses for whatever reason, cannot carry out duties associated with their role. As you acknowledge, this could cause major disruption for the practice as appointments may have to be cancelled and temporary cover found. MDDUS often deal with cases where DCPs believe they have paid their ARF, only to discover the payment has failed. This can often be caused by a change in personal information, such as home address or direct debit details. It would be wise to ensure that your DCPs have their registration in order (check on the GDC website) and that their payment details are correct and up-to-date. Reregistering is time consuming and not simply a matter of filling in a form.
Q Our practice is based in London and a 12-year-old patient attended this morning with her older sister complaining of stomach pains. She has recently returned from a trip to Kenya to visit family and she made reference to an “operation” she had over there. She seemed very withdrawn and unhappy but wouldn’t give any more details when asked about the procedure. We are concerned she has undergone FGM. Is this something we should report to social services or the police?
A Doctors in England and Wales now have a legal obligation to report to police cases of female genital mutilation (FGM) in girls under the age of 18. If a girl under the age of 18 discloses that she has undergone FGM, or has physical signs of having had FGM in the past, then this must be reported to the police. This should be done as soon as possible and certainly within a month of the initial disclosure or finding. Failure to do so is a breach of a doctor’s statutory duty. According to the Serious Crime Act 2015, doctors who report FGM will not be held to have breached any duty of confidentiality or any other restriction on the disclosure of information. Any concerns should be carefully noted in the patient record, including any decision to report or not. Where a doctor suspects a girl under 18 is at risk of FGM, then follow local safeguarding procedures and comply with GMC guidance on child protection. It may be useful to discuss the case in more detail with the local safeguarding lead and an MDDUS adviser.
Q Our practice has received an anonymous call claiming that a patient has been selling their prescription medications, including temazepam and co-codamol. One of the GPs had already suspected the patient of this activity. Should we inform the police of our suspicions?
A Prescription-only medicines (POMs) can only be sold or supplied at a registered pharmacy and under the supervision of a pharmacist in accordance with an appropriate practitioner’s prescription. Sedatives and hypnotics are also subject to the Misuse of Drugs Act 1971 and classified as Class C drugs. It is not necessarily an offence to possess and use such medications without a prescription but it is illegal for a patient to sell or supply any Class C drug to another person. Given the allegations against the patient are “hearsay” it may be worthwhile investigating matters further by inviting the patient in to discuss the fact these concerns have been brought to the practice’s attention – but only if you feel safe doing so. There is no legal obligation on the practice to disclose crime of this kind, but a decision should be taken on whether or not it is in the public interest to disclose such information to a relevant authority. GMC guidance on this matter advises that personal information may be disclosed in the public interest to protect individuals or society from risks of serious harm or serious crime. Where a decision to disclose has been taken, the patient should normally be informed unless this in itself would pose a risk to you or others or would undermine the purposes of the disclosure, e.g. by prejudicing the prevention or detection of serious crime. In this instance further discussion with an MDDUS adviser on the exact particulars of the case is required.
Q The hygienist in our dental practice does not offer direct access to patients and therefore can only work under prescription from one of the dentists. Can you confirm from a legal perspective how long a prescription to a hygienist is valid for?
A Prescriptions in these circumstances will be made after a dental examination and as part of a full treatment plan. It can include single or multiple visits to the hygienist and should include specific items of treatment. The prescription should indicate a reasonable time frame for the care to be provided: for example, the dentist may wish for the patient to receive some hygiene phase therapy, including sub-gingival scaling and polishing and oral hygiene instruction with a three-month review. Generally, the prescription lasts until the patient has completed the course of treatment. They cannot be left open-ended and it is unwise, for example, to prescribe three-monthly scalings without a plan for the next dental examination. As such, there is no formal limit on a prescription to a hygienist but it is unlikely that a treatment plan made more than six months ago would still be valid if the patient had not attended over this period.
SEEING MEDICAL RECORDS AFTER DEATH
Q The daughter of a deceased patient has requested to see a copy of her mother’s medical records. What are her rights in this matter?
A The practice should have consent from the deceased patient’s executor or personal representative prior to releasing any records. Should the daughter herself be the executor then this is straightforward but the practice should first obtain written confirmation of the identity of the executor (or a copy of the will or extract confirmation). There is also the possibility of disclosure if the daughter has a claim arising out of the death and the request is relevant. You might also consider asking the daughter to attend the surgery so that a GP or other member of practice staff can summarise/explain the medical records as they may be very clinical and possibly distressing to read.
Q The employer of one of our patients has faxed over a copy of a fit note that was completed by one of our GPs. They suspect the patient has made changes to it, adding extra conditions to the diagnosis and extending the required time off work. They want us to confirm if the note has in fact been altered (which it has been), but we are concerned about confidentiality.
A A fit note is a formal, standardised statement issued by the Department for Work and Pensions that is completed electronically by GPs. As such, any unauthorised alteration is viewed as an act of fraud. It would be appropriate therefore for the practice to confirm the note is not now as it was completed, but to give no more detail than that. You may consider it appropriate to first contact the patient directly to explain you are aware of the alteration and that you intend to confirm this to their employer. It may also be worthwhile exploring the reasons behind the patient’s decision to amend the note, in case any mental health or other issues are present. This further detail may impact on any decision you make regarding disclosing information to the employer, e.g. disclosure may cause significant harm to the patient’s mental health.