Ram Psychology

 

 

 

 

 

 

 

 

 

Case Information

 

Following on from the case study work that I have been engaged in, since 1997, it continues to be clear that there is a real need for psychological assessment services that combine careful clinical considerations with occupational practicalities. Patients and families also need to be totally confident that any statements made to professional practitioners will be carefully noted, and accurately recorded, if notes or letters are written, when disclosures are reported to GPs or psychiatrists, or any other mental health professionals, including nurses; and, if errors are made, in any records, then practitioners and the NHS authorities should readily accept, as correct, all subsequent, honestly disclosed statements, and they should, at the very least, formally acknowledge that what was previously recorded, during the earlier assessment, was not, in fact, correct. Failure to correct a recorded diagnosis, or any false, misleading or inaccurate information, recorded during an assessment or clinical interview, and omitting or ignoring key relevant facts, would indicate real disrespect towards the client, and would also undermine future care or treatment decision-making.

 

      Unfortunately, it would appear that the NHS has failed to recognise this quite fundamental principle. Furthermore, it would appear that once a medical opinion has been printed, or formed, the NHS is not then organisationally capable of examining recorded evidence and statements to assess whether a documented opinion may have been wrong or negligently made. The NHS authorities’ responses, over many years, after receiving relevant details, have revealed huge problems. Following an Independent Convenor’s decision that my case could not be further investigated by the NHS, a local strategic health authority later ruled, in 2003, that it was now the responsibility of the primary care trust to look at the information governance and occupational issues I raised in a document, dated 2nd September 2003. This followed the decision, made in 1997, that the local health authority could investigate a complaint about a GP’s medical report containing false information. That first NHS mediation led to the outcome, reinforced by the local healthy authority, that the GP need not rescind his report, or modify it in light of further information or evidence, while concurrently stating that the GP would have been “failing in his duty” had he not revealed any relevant parts of my recorded medical history.

 

Having received confidential personal and family statements from me, plus relevant confidential NHS documents related to the case, for the purpose of a formal NHS investigation, which the strategic health authority stated was now the responsibility of the primary care trust, the primary care trust decreed that the Information Commissioner’s Office should deal with the case, refusing to properly investigate the diagnosis that had been recorded on a computerised journal at the GP’s surgery, despite the NHS’ corporate intention to implement an online Care Records Service, in which it was envisaged that historical patient information would be available to be shared between NHS bodies. The GP had refused to support a claim for Incapacity Benefit, in 1996, after it was determined that I was medically unfit for teaching, and after I was instructed to make a claim for this benefit, by the Benefits Agency, in 1996, while I was concurrently attempting to obtain a clean bill of health for employment reasons. The refusal to modify or rescind his inaccurate and highly misleading report, coupled with the lack of understanding of the occupational issues that his decision had raised, in terms of a valid assessment for future employment, and a claim for Jobseeker’s Allowance that I would have to make, following my loss of employment working in a training consultancy role, still remains a vexed issue today. The Information Commissioner’s Office has made it clear that they cannot deal with cases involving medical opinions. There is and there was thus a clear need for organisational development consultancy that addresses both the assessment and the information governance issues raised by the case.

 

      The report which the GP refused to rescind, or modify, after receiving a psychiatrist’s report confirming that she could find “no evidence of psychiatric illness” during interviews with me, from June 1995, contained information about an arrest, in February 1995, after I had tried to check in at the Oxford Youth Hostel, but arrived too late to be booked in. Due to pouring rain, I sheltered at a bus stop close to the hostel. I later attempted to get assistance at two houses close to the bus shelter. I had hoped to make a phone call home. Although I did not speak to anyone, the police were called, and I was arrested and taken to Oxford police station. I was collected, later that night, by my father and stepmother. Due to their concern about the arrest, they called a GP at their local practice where I had started to register, after recently moving in with them. I was concerned about a diarrhoeal condition that I had contracted, in India, and had booked a new patient appointment, prior to returning by train from my mother’s home, in Dorset, to my father’s home in Berkshire, following a visit. Due to falling asleep, I missed my stop, at Reading Station, ending up in Oxford. I decided to return earlier than I intended, due to a row with my mother, which I explained to a GP, during a home visit arranged by my father. Instead of being admitted, by ambulance, to a general hospital, which I agreed to, to investigate the diarrhoeal condition, I was admitted to a psychiatric hospital due to the arrest. No evidence of mental illness was found, but it was falsely recorded, on no evidence, that I went into a state in which I did not know who I was prior to the hospital admission.