Decision Report 201401247

Summary

Mrs C wrote to the practice to complain about her medical records. She thought there were a number of inconsistencies between the two copies of the records she had, which she said showed that her notes appeared to have been rewritten or that information had been re-entered by the practice at some point. Mrs C also referred to the coded acronym 'DNR' which she believed related to not resuscitating her and meant that she had at some point been identified for palliative care (care provided solely to prevent or relieve suffering). The practice responded explaining that Mrs C's medical notes had not been altered and a resuscitation-related code had never been entered into her records.

Mrs C complained to us that the practice unreasonably failed to respond to her complaint about information held in her medical notes, particularly the use of the abbreviation DNR. After taking independent advice from one of our medical advisers on the clinical aspects of Mrs C's complaint, we found that the practice's explanations were reasonable. We also found no evidence that Mrs C's medical notes were purposely altered, and we did not uphold Mrs C's complaint.