An independent investigation into the care and treatment of mental health service user MB: Published 19 March 2018

The Tees, Esk and Wear Valleys NHS Foundation Trust (‘TEWV’) reviews its procedures concerning the provision of medical records to investigative and regulatory bodies including the Police, General Medical Council and Nursing and Midwifery Council, with a view to being able to ensure the return of any original records provided to such bodies at the end of those proceedings.

Given the considerable impact which the absence of a legible and complete set of records relating to MB’s care has had upon the Independent Investigation into his care and treatment, the Independent Investigation Team is of the view that MB’s case raises a significant issue for all NHS Trusts. There are a number of organisations with statutory responsibility to investigate specific types of incidents which may involve the delivery of healthcare and therefore can coincide with serious incident investigations led by the health service. It is essential that the interfaces between these organisations do not create a barrier to the investigation of serious incidents due to the loss of records or key information contained within those records. Accordingly, it is recommended that NHS England issue guidance to Trusts to highlight that Trusts comply with their legal duties and internal policies relating to records management to ensure that the whereabouts of original NHS records are known and that upon completion of investigations carried out by other statutory bodies, that the notes are tracked and returned to the NHS.

Accordingly, it is recommended that NHS England issue guidance to Trusts to highlight that Trusts comply with their legal duties and internal policies relating to records management to ensure that the whereabouts of original NHS records are known and that upon completion of investigations carried out by other statutory bodies, that the notes are tracked and returned to the NHS.