CONFIDENTIALITY: FULL DISCOSURE
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
CAPACITY: A PERSONAL DECISION
BACKGROUND: A practice sends out a letter to a 42-year-old patient, Miss B, inviting her to attend for a cervical smear test. Miss B has learning difficulties so her mother responds on her behalf a few days later to say she will not be undergoing the test. GP, Dr N, notes that Miss B has never had a smear before and believes it would be in her best interests to have one now. However, he is unsure about whether or not he should accept the mother’s response or pursue the matter further. There is no indication in Miss B’s record that her mother (or anyone else) has previously made healthcare decisions for Miss B, nor is there any note of a formal authority to make decisions on her behalf.
He contacts an MDDUS SUMMER 2013
Should any disagreement arise with the patient’s mother then every attempt should be made to reach a consensus. This might include such measures as seeking a second opinion or involving an independent patient advocate but much will depend on the patient’s capacity. All discussions should be clearly documented in Miss B’s notes.
medical adviser for assistance.
ANALYSIS/OUTCOME: An MDDUS adviser tells Dr N that he must first establish whether Miss B is capable of consenting to or refusing this treatment. It would be advisable to invite Miss B to attend the practice, accompanied by her mother if she wishes. Dr N should discuss the issue with Miss B
(and her mother, if she attends) and determine whether Miss B understands the treatment being offered, the reasons for the treatment and any potential side-effects or consequences. Miss B must be able to retain the information long enough to make a decision and be able to clearly communicate her decision, with support where necessary.
KEY POINTS • Where a relative/carer seeks to make healthcare decisions for a patient, first check whether the patient has capacity to decide for themselves.
• Make every attempt to reach a consensus with relatives/ carers regarding the healthcare of patients with potential capacity issues.
• Keep a clear record of all discussions.
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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.
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