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Case ref:201806950
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Date:May 2019
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Body:A Medical Practice in the Tayside NHS Board area
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Sector:Health
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Outcome:Upheld, recommendations
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Subject:policy / administration
Summary
Mr C complained about the information which a GP entered on a form for Employment Support Allowance (ESA). The GP had included historical information in Mr C's medical records, which Mr C felt was not relevant.
We took independent medical advice from a GP. We found that although the information was contained in Mr C's medical records, it was not relevant to the reasons why Mr C was unable to work at that time. The form does not ask for a summary of a patient's past medical history but rather about the patient's current medical conditions which may be a barrier to them being fit for employment. We upheld the complaint.
Recommendations
What we asked the organisation to do in this case:
- Apologise to Mr C for including information which was not relevant to his current medical condition. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/leaflets-and-guidance.
What we said should change to put things right in future:
- The GP concerned should ensure that in future only relevant information regarding the patient's current medical condition is entered in the ESA form.