Watchdog and critics raise concerns over reliability of NHS medical records

ByAndrew Picken

BBC News Scotland

Concerns have been raised about the reliability of the NHS medical records systems used in Scotland.

Their accuracy has been questioned by the public services watchdog and critics warned there were doubts about their reliability in safety investigations and court cases.

Victims of disgraced brain surgeon Sam Eljamel have complained of "significant gaps" in their records and said they often do not reflect the reality of their care.

The Scottish government said it took the concerns raised seriously and was engaging with health boards over ways to improve the reliability of patient records.

There are millions of patient records in Scotland, which contain information about your health, care and treatment.

When things go wrong they are relied upon for investigations and legal challenges.

However, there is no central NHS system where these records are kept and a number of concerns about their accuracy have been raised in recent years.

The long-running Scottish Hospitals Inquiry's probe into patient safety issues at Glasgow's Queen Elizabeth University Hospital campus has heard concerns about missing medical records and about how information was recorded.

The issue of accurate medical records will also feature heavily in the recently started public inquiry into the actions of Eljamel at Dundee's Ninewells Hospital.

Alan Ogilvie, who was operated on by Eljamel in 1995, is spokesman for the Patients Action Group which campaigned for the inquiry.

Ogilvie said many of those affected had found their official medical records "often don't match their lived reality".

He added: "We see significant gaps where complications occurred, and narratives that seem massaged to suit the clinician's reputation rather than the patient's history.

"When the 'official' computer record says one thing, but our own letters and memories prove another, you have to ask: Is the system there to record the truth, or to protect the institution?

"If we cannot trust the records from the past, how can we trust the lessons they claim to be learning for the future?"

The Scottish Public Services Ombudsman (SPSO) has often raised the issue of accurate medical records.

Last month, NHS Lothian was criticised by the watchdog for not carrying out a Significant Adverse Event Review into the death of a patient who died from a blood infection at the Royal Infirmary of Edinburgh.

The SPSO found "concerning" gaps or incomplete nursing records for the patient, external.

These included four occasions where it said in the clinical notes that the doctor in charge had asked for a microbiology report - but there was no evidence of such a report in the patient's clinical records.

The sharing of information from patient records between NHS boards is the focus of an ongoing fatal accident inquiry (FAI) into the death of two-month-old Michael Wilson at the Royal Aberdeen Children's Hospital.

The inquiry has heard from a doctor who said he would have advised against operating on Michael if he had known, from the child's medical records, about an inherited heart condition.

It had been the suspected cause of death of Michael's older brother in Glasgow two years previously.

At an earlier hearing the Press and Journal reported that Sheriff Christine McCrossan said: "It's almost verging into a public inquiry situation - something as fundamental as the medical records situation in the country.

"These boards are inde­pend­ent and they set up com­puter sys­tems that don't seem to talk to each other."

Labour MSP Daniel Johnson said medical records were an invaluable resource for medics.

"But at the point they are being relied upon by other public agencies, including the Crown Office, we need absolute clarity about their reliability," he added.

"Important questions need to be answered about how the Crown Office, the Central Legal Office and other publicly funded bodies assess the reliability of patient medical records and the user protocols which support their use."

A Scottish government spokesperson said: "We recognise that accurate, complete and accessible patient records are essential to safe care, continuity of treatment and effective investigation of adverse events.

"NHS boards are responsible for the electronic patient record systems they operate and for ensuring that clinical information is accurate, secure, accessible and appropriately governed."

The added a range of assurance mechanisms to support the reliability of patient record systems were used including national standards and data quality controls.

The spokesperson said: "We take the concerns raised from recent inquiries seriously and continue to engage with boards to consider findings and any recommendations for improving the reliability of patient records to support safe and effective care."