GP practice leaders have been advised of the importance of keeping minutes of practice meetings, appointment books and results follow-up books for as long as possible, in the event of claims that arise a long time after an incident.
The Medical Defence Union (MDU) issued the warning in response to a case in which six GPs were sued when a woman developed cervical cancer after failing to attend for smear tests over a nine-year period, despite several reminders.
The case was successfully defended at trial and the GPs were able to use meeting minutes to prove that the practice's policy on when postnatal smear tests were carried out had changed.
The woman was diagnosed with cervical cancer when aged 28 and later developed secondary lung metastasis. The patient alleged this was because she had not been told in strong enough terms that she needed a repeat smear at age 19. The judge found that the woman would not have attended even if warned of the risks.
Dr Glynis Parker, senior medical claims handler at the MDU, said: "The case was brought 16 years after the patient alleged she had not been properly informed about the importance of attending for a repeat smear.
"Fortunately, the practice had kept meeting minutes and one of the GPs involved was able to use these to show that a smear had not been done at a six-week postnatal check because the practice had changed its policy to perform smears at six months post delivery.
"Documents such as meeting minutes and appointment books are important in providing a complete picture of practice policies and procedures in the event of a claim, which can arise many years after an incident."
"The MDU has long advised about the importance of documenting all patient advice fully in the medical records, to ensure a clear and accurate picture of patient care and to help resolve any patient dissatisfaction.
"In this case, although the records were of a reasonable standard, the GPs did not record in the first few years every time the patient had been advised to attend for a smear. Later consultations did record this, however.
"While GPs have a responsibility for the overall care of their patients, patients themselves also retain some responsibility for their care, such as attending for routine screening. Despite the practice repeatedly reminding the patient in this case, both verbally and in writing, to attend for smear tests, she did not attend for many years, with severe consequences."
Your comments (terms and conditions apply):
"Yes, religiously – when a temporary member of staff tried to claim disability discrimination minutes were used in dealing with her 'questionaire ' procedure – we later found out that she had pulled exactly the same routine with at least two other small employers. Employed and finished before I took over though I got to deal with the questionaire procedure – a warning to get recruitment right too and document everything!" – Name and address withheld