Facing a complaint or claim: getting your records in order
For doctors, nurses and other clinicians, the first few weeks after a complaint, claim or serious incident shape everything that follows. An early, honest review of the records is the strongest starting point.
1. Tell the right people early
Contact your medical defence organisation or indemnity provider as soon as you learn of a complaint, claim, inquest or regulator enquiry, and before you reply to it. If you work for an NHS body, also tell your employer, since clinical negligence claims against NHS organisations are handled through their indemnity schemes. Early contact protects your position and is usually a condition of your cover.
2. Never alter the original records
Records must not be changed, backdated or removed after the event. If something needs to be added or corrected, make a separate entry that is clearly dated and signed at the time it is written, and explains why it is being added. Altering records is treated very seriously by regulators and courts, and is far more damaging than the gap it was meant to fill.
3. Read the whole record, in order
Before writing anything, read the full record for the period, not only your own entries. Nursing notes, observation charts, drug charts, results and the entries of colleagues often show the context of a decision: what information was available, when results came back and how busy the shift was. Build a short chronology with dates and times taken directly from the records.
4. Separate what you remember from what is recorded
When you write a statement or a response, make it clear which facts come from the records and which come from your own memory. If you cannot remember an event, say so, and describe your usual practice instead, stating that it is your usual practice. Keep to the facts, write in the first person, and avoid speculation about the actions of others.
5. Be open with the patient
Every healthcare professional has a professional duty of candour: to be open and honest with patients when something has gone wrong, to apologise, and to explain what will happen next. An apology is not an admission of legal liability. Health and care organisations in England also have a statutory duty of candour for notable safety incidents.
6. Get an independent clinical view
An independent review by an experienced clinician can identify the evidence in the records that supports the care given, the points that are genuinely open to criticism, and the questions an investigator, coroner or expert is likely to ask. Knowing the weaknesses early allows you, your defence organisation and your solicitor to respond accurately and in proportion.
What we offer clinicians and providers: independent records reviews, help with chronologies and statements, preparation for regulator investigations and inquests, incident reviews, and audits of documentation and consent practice. We work alongside your defence organisation or solicitor, not instead of them.
7. Look after yourself
Complaints and claims are stressful, and most are resolved without any finding against the clinician. Talk to a trusted colleague, use your organisation's support services, and seek help from your GP or a practitioner health service if it is affecting your wellbeing.
Advice for healthcare professionals
This article gives general information only. It is not legal advice and does not replace the advice of your medical defence organisation, indemnity provider or solicitor. Please refer to your regulator's current guidance, such as the GMC's Good medical practice or the NMC Code.