UK anaesthetist admits to misconduct over altering clinical records

After an adverse event, it can be tempting to amend the clinical records to attempt to portray the incident in a better light or suggest a different course of events. Even if the amendment is not clinically significant, such alterations will be treated very seriously and may have significant professional consequences, as a UK case highlights.

Dr A was a specialist anaesthetist. He assisted with surgery for a patient for an aortic valve replacement and triple coronary artery bypass graft. The patient experienced multiple complications after surgery, including ischaemia in one hand. This was initially treated with heparin infusion and a brachial embolectomy. Further tests led to a diagnosis of Heparin Induced Thrombocytopenia Thrombosis (HITT). The heparin was stopped, but his arm had to be amputated. His condition continued to deteriorate, and he died two weeks after the original surgery.

The case came before the coroner, and then was considered by the tribunal.

Medical records

Dr A admitted that after the HITT diagnosis but before the patient’s death, he had altered the notes regarding the procedure. Instead of recording that the heparin infusion was continued, the amended record suggested that the heparin infusion was stopped pending a haematology review to rule out HITT.

Professional communication - false and misleading statements

At the time of the coronial investigation, Dr A wrote in an email to his supervisor that he had considered HITT after seeing the patient’s platelet count and that he clearly remembered discussing this possibility with a colleague at handover. He subsequently agreed that none of these claims were true.

Responding to adverse events

Dr A admitted that these incidents were dishonest and amounted to misconduct.

He said he feared he would be blamed for missing the diagnosis of HITT and contributing to the patient’s death.

On the evidence of Dr A’s colleagues, the tribunal accepted that as a junior clinical fellow, Dr A had not been responsible for the patient’s care. At worst he had failed to suggest the heparin be stopped, but he had not contributed to the patient’s death. Altering the record was not an attempt to conceal his clinical error.

However Dr A accepted his actions had led to the adjournment of the inquest, caused distress to the patient’s family, and required a prolonged hospital investigation. He agreed his actions had called his professional integrity into question, reduced his colleagues’ trust in him and may have reduced public trust in the profession. He came to understand the importance of his professional obligation to respond fully and honestly to complaints and co-operate with any inquiries or investigations.

The tribunal accepted Dr A had undertaken extensive training and mentoring and had genuine insight into his behaviour. On the evidence of Dr A’s supervisors and senior colleagues they accepted that he was unlikely to act the same way in future. Extensive audits of his clinical records showed no other concerns.

Ultimately the tribunal concluded Dr A’s actions were unprofessional and that a warning was an appropriate penalty in the circumstances.

Never attempt to delete or rewrite records at a later date.

Never attempt to portray an error or incident in a better light. This will raise concerns about your professional integrity and may be seen as risking patient safety and public confidence.

If you need to correct an error in a record, strike through the error and note the changes in a way so as not to obliterate the error or delete any information originally entered.

Dealing with an adverse event can be a confronting and stressful experience, not only for you but for those close to you.  It is essential to prioritise your well-being during this time.  Avant’s Key Support Services include a variety of resources to assist you through this challenging time.

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