Full disclosure - medical case study

...The practice receives a request for release of medical records relating to the mental health of a patient over the past six years...

BACKGROUND: A practice manager receives what appears to be a court order for the release of medical records relating to the mental health of a patient, Mr G, over the previous six years. The order is on behalf of the patient’s estranged wife, Ms D. The manager arranges for the records to be copied and sent off to Ms D’s solicitors.

Two weeks later, the practice receives an angry letter of complaint from Mr G demanding to know why his entire medical record – including details of a previous sexually transmitted infection – was sent to Ms D’s solicitors without his consent. The practice manager re-checks the court document and is shocked to discover it is merely a notification of intent to apply for a court order, rather than an actual order. The practice realise that not only did they not have the authority to release Mr G’s record, the court order would only have required sections of the record relating to his mental health from the previous six years.

In his complaint letter, Mr G says the accidental disclosure has caused him considerable distress and he has also incurred solicitors’ fees.

The practice partner Dr H contacts MDDUS for advice on how to proceed.

ANALYSIS/OUTCOME: An MDDUS adviser assists Dr H in drafting an appropriate reply to Mr G in which he explains how the error came about and profusely apologises. He accepts the practice should have read the court correspondence more carefully and says measures have been put in place to ensure the error is not repeated. MDDUS agrees to a modest settlement with Mr G to cover his legal costs.

KEY POINTS

• Always carefully read documents relating to requests for disclosure of patient records.

• Be sure to provide only the minimum necessary information to meet the terms of any request/court order.