A consultant gastroenterologist, Dr P, is contacted by the complaints and feedback officer at the hospital where he works. A 34-year-old patient Mr L has written a letter of complaint disagreeing with the content of a clinic letter which was sent to his GP summarising a consultation he had with Dr P to assess his chronic abdominal symptoms.
In the complaint, Mr L is demanding that portions of the letter be redacted, including reference to possible psychological factors (including depression) and a differential diagnosis of functional gastrointestinal disorder. Mr L believes that these observations are “unwarranted” and an attempt “write off” his distressing symptoms as being psychosomatic. He does not want this “damaging speculation” to be included in his permanent medical record.
Dr P asks MDDUS for guidance in his reply to the complaint, which will be incorporated into the formal hospital response.
An MDDUS adviser writes to Dr P offering advice on composing a reply.
She reminds him that, under UK GDPR, patients have the right to ensure personal data held by the NHS is correct and to request that factual inaccuracies are amended. A patient may disagree with a clinical opinion or differential diagnosis, however it may still be necessary to retain this information within the clinical records. The Information Commissioner’s Office states that a clinical opinion is not necessarily inaccurate simply because the individual disagrees with it.
A patient can request for a comment or entry to be made in the record to show that they disagree with the content and what it should say. Any changes must be clearly marked, showing the name of the person making the change and the date the change was made.
Dr P sends his draft response to MDDUS for review. In the draft text he first expresses regret at Mr L’s dissatisfaction with the content of the clinic letter and summarises the concerns as he understands them. He then confirms that in reassessing the content of the letter he believes it to be an accurate reflection of his clinical judgement at the time and he explains the reasons for this conclusion.
Dr P further explains that considering differential diagnoses guides the investigative process. Further investigations may exclude possible diagnoses or confirm their likelihood and is a standard process in medical practice.
The letter further states that Mr L can request that a note explaining his views is included in or appended to the record but it would not be appropriate to redact details from the letter.
The MDDUS adviser suggests some changes to the draft text and it is forwarded to the complaints officer to be incorporated into the formal response.
- Patients have a legal right to have inaccurate personal data held about them rectified and reasonable steps should therefore be taken to investigate any requests for rectification.
- Patients also have a right to ask for a note to be added to their records if they dispute an entry.
- Complainants are entitled to raise their concerns with the ombudsman if unsatisfied with a complaint response, or to the ICO if their concerns relate to the processing of their data.
This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.