Alleged falsification of notes

BACKGROUND

A GP Dr T makes a home visit to an elderly patient with a suspected respiratory infection and history of COPD (chronic obstructive pulmonary disease). Mr M is breathless and finding it difficult to walk even a few steps to the bathroom. Just before the doctor’s arrival Mr M’s sister, Mrs V, had checked both his pulse and oxygen levels using a pulse oximeter and claims both readings were low.

Dr T examines Mr M and records his vital signs: temperature normal, respiratory rate 16, pulse rate 66, oxygen saturation 88% in one finger and 98% in the other. She observes that with a history of COPD some fluctuation in oxygen saturation is to be expected. Dr T has difficulty checking the patient’s blood pressure but eventually notes a reading of 100/60.

Dr T documents a history of worsening shortness of breath against a background of known COPD, and that Mr M is able to speak in sentences and denies any chest pain or haemoptysis. Dr T considers a diagnosis of possible infective exacerbation of COPD.

Mrs V is worried and insists on phoning 999. Dr T agrees that Mr M requires further assessment, however she arranges for Mr M to be transported by ambulance to a local clinical assessment unit (CAU) with a referral letter documenting her assessment.

On arrival at the CAU it becomes clear that Mr M has suffered a heart attack. He is transferred by ambulance to hospital and dies later than evening.

Six months later Dr T receives a letter from the General Medical Council (GMC) informing her that it has received a formal complaint in regard to her care of Mr M. In the letter Mrs V states that Dr T failed to correctly check her brother’s vital signs and falsified readings in her letter to the assessment unit. She also alleges that Dr T refused to phone an ambulance for urgent transfer to hospital even though Mr M’s condition was clearly an emergency.

Dr T is informed by the GMC that a provisional inquiry will determine whether the concerns raised merit a full investigation into her fitness to practise. An expert opinion from a GP will be obtained based on the medical records.

ANALYSIS/OUTCOME

An MDDUS adviser assists Dr T in dealing with the complaint. He explains the GMC process in investigating fitness to practise matters and reassures Dr T of the full support of MDDUS.

Dr T is advised to fill in a Work Details Form provided by the GMC. She is also advised against sending any comments to the GMC at this point, in the absence of clear allegations. It is considered prudent to await the outcome of the GMC’s initial review.

Two months later the GMC writes to Dr T with the outcome of the provisional enquiry: it is now assured that the concerns raised do not require further investigation.

A copy of the decision reasoning is attached to the letter summarising the expert opinion. In regard to the allegation of falsifying records the expert observes that the vital signs recorded by Dr T are consistent with those taken at the CAU and later in the ambulance en route to hospital, and reflect a rapid deterioration in Mr M’s condition.

The expert concludes that Dr T’s provisional diagnosis of respiratory infection exacerbating existing COPD was appropriate given Mr M’s presentation and clinical history. Commenting on Dr T’s decision to send Mr M to the CAU rather than A&E, the expert advises that this may in fact have resulted in a shorter wait for assessment. The expert concludes that it is not possible to determine whether the myocardial infarction occurred before or after Dr T’s examination, particularly with an elderly patient where presentation may be atypical.