Too much information - medical case study

BACKGROUND: A 42-year-old patient, Mr F, recently suffered a cut to his forehead during a trip to a DIY store when part of a display toppled over and hit him. He visits his GP, Dr S, who agrees to refer him to a plastic surgeon. Mr F explains that he has also consented to the disclosure of his medical records to the DIY store who have accepted responsibility for his injury.

Following the consultation, Dr S writes a referral letter for Mr F using the practice’s standard letter template. The template includes a feature that automatically includes any active or significant past health problems at the bottom of the letter. Mr F had recently sought treatment at the practice for a sexually transmitted infection and details of this are included at the bottom of his referral. Dr S sends the referral without noticing it includes the extra patient information. The referral letter is also included amongst the medical records sent to the insurance company acting for the DIY store.

One week later, the practice receives a letter of complaint from Mr F regarding the disclosure of sensitive medical information which was not relevant to his referral.

ANALYSIS/OUTCOME: Dr S contacts an MDDUS adviser for help in responding to the complaint. He admits it was a mistake to include details of Mr F’s STI in the referral and explains the practice has since apologised verbally to the patient. The MDDUS adviser recommends that the complaint response letter reiterates the apology and explains the steps the practice has taken to ensure the error is not repeated.

In the letter, Dr S explains the practice held a significant event meeting and decided to change the referral letter template so that recent patient health problems are no longer automatically included. He also highlights an issue concerning the consent form provided by the DIY store that Mr F signed. Under the very general terms of the consent form, Dr S explains that the practice would have had the authority to release Mr F’s entire record to the store, but acted to limit the disclosure to relevant information. Patients, however, are often unaware of the extent of the disclosure they are authorising when signing such consent forms. Dr S goes on to highlight the practice’s plans to raise awareness of this issue with a number of larger insurance companies.

Mr F is also provided with information on the next stage of the complaints procedure but the matter is not taken any further.

KEY POINTS

• Only include relevant medical information when making patient referrals.
• Ensure the practice referrals system does not automatically include supplementary patient information which may not be relevant to the referral.
• Only disclose the minimum information necessary when responding to requests for patient records.