• Case ref:
    201806950
  • Date:
    May 2019
  • Body:
    A Medical Practice in the Tayside NHS Board area
  • Sector(s):
    Health
  • Subject:
    policy / administration
  • Outcome:
    Upheld, recommendations

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.