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Case ref:201402052
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Date:May 2015
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Body:A Medical Practice in the Dumfries and Galloway NHS Board area
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Sector:Health
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Outcome:Not upheld, no recommendations
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Subject:record keeping
Summary
Mr C complained to us that his medical practice had failed to diagnose his heart condition. We took independent advice on this complaint from one of our medical advisers and found that there was no evidence in the medical notes that indicated that the practice had failed to follow up on the symptoms Mr C had reported. There were no recorded symptoms of possible heart problems and so we did not uphold the complaint.
Mr C then wrote to us to complain that some of his consultations with the practice had not been recorded accurately. In view of this, we decided to reopen the case to investigate his complaint that his medical records were inaccurate. We obtained a full historical print out of Mr C's computer record from the practice and considered this along with the information he provided to us. However, there was no evidence that the practice had altered or deleted any of the records of the consultations that he had referred to. Our adviser also considered that the GPs had acted reasonably in summarising the consultations in the computer records. In view of all of this, we did not uphold this complaint.