GP’s follow-up care and record-keeping found to pose a serious risk of harm

Poor medical record-keeping is not simply a failure to comply with professional standards. It may pose a serious risk of harm to patients if it means other clinicians or carers do not have all the information they need to provide appropriate continuity of care, as a case involving a procedure on a child demonstrates.  

Follow up care 

A child, E, continued to suffer post-operative bleeding after Dr N performed a circumcision. 

E’s parents claimed they telephoned Dr N the evening after the operation and again the following day when E was distressed and the bleeding continued. They had sent photos of the wound and said they were told on both occasions that there was nothing to worry about.  

By contrast, Dr N said that he had told the parents to call back with an update in two hours, or if they were still concerned, to bring the child in.  

Expert evidence considered the photos indicated the child’s condition was serious and Dr N should have advised the parents to come to the clinic or go to hospital. 

Two days after the procedure, the parents sought a second opinion from their local GP who advised them to take the child to the emergency department immediately.   

E ultimately was re-admitted to hospital and underwent a blood transfusion and further operation. 

Where E’s parents’ version of events conflicted with Dr N’s, the tribunal preferred the parents’ evidence. Dr N’s version was not supported by any contemporaneous notes. 

The tribunal concluded Dr N’s care fell below the required standard.  

Medical records 

The tribunal was highly critical of the doctor’s record-keeping as well as his clinical care.  

His notes about the procedure were minimal, consisting only of a note that “circumcision” was the “reason for contact”. There were no notes about any examination of the child, reason for the procedure, and whether the child’s health, physiology and appearance made the procedure appropriate. There was no documentation of how the procedure itself was conducted.  

The tribunal was also critical of the documentation regarding consent, including the failure to make notes about whether the procedure had been explained to the parents and any discussion of risks.  The consent form was also inadequate.  

Dr N gave evidence that he had set up a short cut in his practice software to document his usual practice regarding discussion of circumcision with parents. The tribunal commented that even this note would have been inadequate documentation given that it did not include any information about clinical assessment of the patient. In any event, Dr N did not use that short cut note on this occasion. 

Dr N had made no contemporaneous notes of the phone calls with the parents and only made a retrospective note after he was advised the child had been hospitalised.  

The tribunal considered Dr N’s documentation fell below the expected standard. 

Failure to obtain informed consent 

Dr N claimed his usual procedure was to explain the procedure and the possibility of risks and complications. He also showed pictures of the procedure and explained the risk of post-operative bleeding. 

E’s mother claimed she had a 5-minute consultation with Dr N to discuss E’s circumcision. He explained that E’s penis was partially buried but that he could perform the procedure that day to save her coming back. Her evidence was that Dr N did not mention any potential complications or risks of the procedure or the anaesthetic, nor was she advised that a partially buried penis carried higher risk of bleeding. E’s mother said a nurse showed her the plastibell but no photos or diagrams and then she was given the consent forms to sign.  

The consent form contained no mention of risks or complications, or whether these had been explained.  

The tribunal accepted E’s mother’s evidence. It concluded Dr N had failed to obtain effective informed consent. 

The tribunal found that Dr N’s consent process and clinical care posed a serious risk of harm such that immediate action to protect public health and safety was required. 

These deficiencies were compounded by a lack of documentation about the care provided. It found his failure to adequately document the consultation and procedure posed a serious risk of harm to patients. 

The tribunal considered that poor documentation itself might pose a serious risk to the patient if the notes: 

• did not give other clinicians involved in his care the information they needed, or  
• failed to record something about the child that was important for other clinicians to know.  

Dr N had been cautioned previously regarding his follow-up care, consent process and clinical records. 

The tribunal imposed conditions. Dr N was required to report monthly to the regulator on all surgical procedures undertaken, including circumcisions, during that month, detailing the clinical notes of each procedure, informed consent obtained and follow-up care provided. 

Your medical records must include enough information to allow another medical practitioner to continue management of the patient’s care.  

They are also important contemporaneous evidence if your care is ever questioned. 

Have a system in place to document any discussions with the patient or family, including follow-up phone calls after hours, as close to the time they occur as possible. 

Make sure that you document your discussion with the patient (or their substitute decision-maker) about the procedure including your discussions about specific risks, any alternatives explored, the information and any aids or diagrams you provided, any other issues or questions the patient raised and your responses. If written consent is required for the procedure, ensure that you keep a copy of the consent form in the patient’s records. 

Discharge information should include an indication of what complications may occur and the appropriate response and escalation. 

Avant factsheet – Medical records: the essentials 

Avant factsheet – Consent: the essentials 

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