Mr F and the nurse had different recollections of what happened during the appointments, and Mr F was concerned that some of the records had been altered. We decided that the only way to resolve the complaint would be to check the audit trail for the electronic records.
The audit revealed that, following Mr F’s complaint to the Practice, the nurse had retrospectively altered Mr F’s computer records. This was more than two years after the events occurred. Some of the existing entries had been deleted and replaced with a different version, which said that Mr F had been offered and then refused treatment and a referral to a specialist – something that Mr F vehemently denied. The nurse had also created some new entries for appointments that were not recorded at the time. We interviewed the nurse. She was unable to provide a plausible explanation for the alteration of the records.
We found service failure and that an injustice arose to Mr F in consequence of it. We therefore made recommendations to the Practice, which included an apology, £500 compensation, an addendum to Mr F’s records to show what had been altered, and an action plan describing what had been learnt.
Given the seriousness of what we found the nurse had done, we also shared our concerns about the nurse’s behaviour with the Nursing and Midwifery Council, in line with our powers to share information in the interests of the health and safety of patients.