Datix for failing to document

Case Study

Subsequent to the death of a patient in a nursing home, a Datix report was raised against a GP, who sought advice from MDS regarding the appropriate course of action.

Following an out-of-hours clinic, our member assessed a terminally unwell patient at a nursing home with suspected aspiration pneumonia. In consultation with the patient’s family and nursing home staff, the decision was made to manage the patient with oral antibiotics in the nursing home, as hospital admission was deemed not to be in their best interests. 

Although the GP had a laptop, they were unable to immediately document the review on the electronic GP system due to connectivity issues. Consequently, our member recorded the consultation in the nursing home’s paper records and made a note to transcribe this into the electronic system at their practice the following day. Unfortunately, the member failed to complete the transcription as planned.

When the patient died a few days later, the Datix was raised as no GP consultation was recorded. Our member was asked to write a statement for the Datix investigation.

MDS Advice

Our Medico-legal advisor recommended preparing a detailed factual statement. This statement should explain the consultation’s circumstances and the actions taken, specifically addressing the connectivity issues and confirming that the visit was documented in the nursing home records. This approach is intended to clearly demonstrate that the consultation took place, that it was clinically appropriate, and to allay any concerns regarding patient safety.

The MDS team recommended that the member should acknowledge and admit the documentation shortcomings and the omission. Furthermore, the member was advised to demonstrate insight and outline steps to prevent future documentation omissions.

The assistance provided in drafting the statement and offering guidance led to the Datix being closed with no further action, a positive result for our member.

Learning Points

• This case underscores the critical need for accurate and contemporaneous documentation of observations. Doing so is essential for ensuring continuous, high-quality patient care and for safeguarding the clinician’s practice.
• The absence of documentation makes it challenging to prove that a consultation occurred, irrespective of the quality of care delivered. This underscores the crucial principle: “if it’s not written down, it didn’t happen.”
• There are several strategies to support documentation during out-of-hours home visits, particularly when electronic access is limited. If using paper notes, ensure they are stored securely and clearly labelled for later transcription. Consider using technology such as a secure dictaphone or approved mobile apps to record key points. Some clinical systems offer offline-capable software that can be synced once internet access is restored. Additionally, setting a task or sending yourself a reminder email prior to the visit can help ensure timely completion of documentation
• Should you frequently experience documentation difficulties due to poor internet connectivity, it is vital to communicate these issues to your organisation. Implementing a formal process for handling and protecting consultation notes during such connectivity outages is crucial. This proactive measure will help mitigate medico-legal risks, safeguard clinicians, and guarantee the maintenance of accurate records, which is essential for defensible practice.

MDS can help with your contract review

Find yourself in a similar situation? Contact MDS as soon as possible to discuss your situation, our team will support you in making the best decision for you and your patients. Call our office on 0300 30 32 442 or email or case managers at [email protected] mentioning your membership number.

Not an MDS member? Get in touch and join today!