Case study: RTA disclosure

BACKGROUND

Ms G is driving her car through an intersection and is struck by another motorist running a red light. She makes numerous visits to her GP, Dr T, in regard to back and neck injuries, which cause her considerable pain and distress, including depression.

Ms G lodges a compensation claim with the other motorist’s insurance company. The practice receives a request from the insurance company for disclosure of her medical records, which detail the nature and extent of her injuries and treatment following the road traffic accident (RTA). Ms G consents to the disclosure.

Dr T responds by sending the insurance company Ms G’s entire medical record. A few months later Ms G writes to the practice complaining that Dr T has breached doctor-patient confidentiality by disclosing her full medical record instead of only the section relating to the RTA injuries.

Ms G states that some information contained in her full medical file was used against her by the insurance company, who went on to raise a counter-claim. This meant she was forced to accept a poorer settlement. She demands an explanation and assurance that this will not happen again.

ANALYSIS/OUTCOME

An MDDUS adviser assists the practice in wording a letter of response to the complaint. This includes an apology and expression of regret at the distress suffered by Ms G. It points out that the wording of the disclosure request was ambiguous and that Dr T was acting in what he thought was the best interests of Ms G in disclosing the full record.

Ms G is reassured that the case has been discussed in a practice meeting in regard to data protection and that all staff have been reminded that legal disclosures should be limited only to what is necessary in relation to the purposes for which they are required.

The practice manager offers to meet with Ms G to discuss the matter and she is reminded that it is her right to take the matter to the ombudsman if dissatisfied with the practice response.

KEY POINTS

• Read carefully any official request for disclosure of personal patient information. Contact an MDDUS adviser if in doubt.
• Provide only the minimum information necessary when complying with a court order or other request for disclosure of records.
• Ensure you have checked with the patient that consent to disclose is valid.
• Fully document your reasons for making a disclosure.