An Inpatient Service in the Darlington area

3. Mr I complains in September 2020, the Inpatient Service disclosed his personal and mental health records to a local NHS Trust (also his employer) without his consent and in direct contradiction of his wishes. He also complains his medical notes incorrectly record his behaviour and treatment from his inpatient stay.

4. Mr I says that the impact of this disclosure, and incorrect recording of his mental health, has resulted in significant psychological injury and anxiety and made his employment and ongoing career untenable. This has led to significant financial loss and hardship.

5. Mr I has advised that apologies and service improvements are not appropriate and believes he is due a significant financial remedy commensurate with loss of earnings, loss of career, and psychological distress.

6. Mr I is a nurse who was diagnosed with significant mental health problems that required inpatient hospital treatment, as voluntary patient.

7. Mr I requested he be admitted to, and treated by, an outside organisation to avoid the embarrassment of contact with colleagues and patients with whom he has had professional contact. This was agreed and he was admitted out of area.

Disclosure of medical records without consent

9. Mr I says that the Inpatient Service’s decision to refer his mental health case to his employer led to significant psychological trauma, distress, anxiety, embarrassment, and loss of income and career. He says that his wishes to have his care provided by an outside provider were disregarded. He is looking to achieve a financial outcome that matches the impact claimed.

10. The Health Service Commissioners Act 1993 (s4) says we cannot investigate a complaint where a person has (or had) the option to take legal action, unless we consider this is (or was) unreasonable in the circumstances. We have discussed this with Mr I to understand his circumstances and the outcomes he wants. We do not consider whether legal action would succeed but whether it would be a reasonable option to explore.

11. We discussed with Mr I, why he had not explored legal action and whether this was a reasonable path. We fully appreciate the difficulties mental health trauma brings and accept that Mr I may not have considered this avenue until now. In discussing the options with Mr I, we discussed the possibility of legal action and discussed whether he could obtain independent legal advice to get a better understanding of that option. Mr I noted he had not considered this but there was no reason why he could not pursue this matter through the courts. He has implied he is willing to pursue this avenue in the first instance. He confirmed he was looking for a significant financial remedy, which is something that could be achieved in that way.

12. We also considered whether legal action would achieve everything he was hoping to achieve. Mr I explained that he does not accept the Inpatient Service’s apology or promise of service improvements. He is seeking only a financial remedy equal to both past and future loss of earnings, because of his need to resign from his chosen career. We are therefore persuaded and Mr I has implied that the financial remedy desired is significant.

13. We are persuaded there is a legal remedy available, which is more likely to meet his desired outcomes. We have seen no barriers in him pursuing and bringing legal action through the courts to achieve his desired outcomes and therefore do not consider it unreasonable for him to do so.

Failure to keep accurate medical records

14. Mr I says that the Inpatient Service failed to keep accurate records and recorded events and activities that did not happen. Mr I would like his records amended to remove incorrect information. This is a focus for him. This is not something that is within the powers of the Ombudsman to achieve for him. Amendments to, and removal of, clinical records may only be achieved by a court order. Accordingly, such an outcome would have to be pursued through the courts. We have also seen he is keen to achieve a financial remedy and consider this is something that can be explored as part of legal action.

15. We previously discussed with Mr I, why he had generally not explored legal action and whether this was a reasonable path. In doing this we discussed whether advice from an independent legal adviser may give him a better understanding of his options. Particularly as changes to records can only be actioned by a court. He confirmed he was looking for a financial remedy separate from his desire to change his records. Mr I understood we cannot achieve medical record changes for him, and he has agreed that it is appropriate for him to explore this separately through the courts. He also agreed that he could get advice regarding the additional financial remedy sought for this part of his complaint. It therefore seems likely he could achieve all his desired outcomes in that way, while he would only be able to consider a financial remedy through ourselves.

16. Mr I noted he had not considered legal advice but there was no reason why he could not pursue this matter through the courts and has suggested that he is willing to pursue this avenue.

1. We have carefully considered Mr I’s complaint about an Inpatient Service in the Darlington area (the Inpatient Service). Following our consideration and discussion with Mr I, we have come to the view that he could take legal action on the whole of the matter brought to us.

2. We appreciate Mr I has explained that this has had, and is continuing to have, a detrimental effect on his ongoing mental health and recovery, as well as causing him financial hardship.