Coronavirus: NHS trust apologises to family of elderly patient whose medical records were altered

22 May 2020, 15:31 | Updated: 22 May 2020, 23:53

An NHS trust has apologised to the family of an elderly patient after her medical records were altered leading to confusion over whether she had COVID-19 or not. 

Barbara Stead was admitted to hospital in Dewsbury, West Yorkshire, after fracturing her ankle in a fall at home on 5 April.

After two days in hospital, local care homes in the area were asked if they would take the 80-year-old accompanied with a discharge form containing her medical notes.

But one care manager became suspicious after noticing that the results of a COVID-19 test had been scribbled on and changed from positive to negative.

Then the words "not tested but temp of 38.8" - one of the symptoms of COVID-19, was also scribbled out, but not signed or dated.

This document was being given to care homes at a time when the sector was deeply worried about taking patients with coronavirus for fear of it spreading to other residents.

Guidance issued by Public Health England in early March said that care homes would get clear information on patients they were being asked to admit.

Care home owner Pearl Jackson was asked to take the patient, but refused.

She said: "The impression I gleaned from that document was that something didn't quite stack up.

"So I advised my manager not to take this lady as I felt something wasn't right and it wasn't clear whether she was COVID positive or negative. It's absolutely essential that these documents are crystal clear.

"We couldn't run the risk for the safety of the other residents."

Ten days later, Mrs Stead was back in hospital after suffering another fall, this time she had a cough and a high temperature and was later tested positive for COVID-19.

It is not clear where she caught the virus.

John Stead, Mrs Stead's son, said he had no idea his mother's medical notes had been changed in this way.

"It certainly looks confusing to anyone looking at this document. It's just not clear from reading it if she had the virus or not."

The Mid Yorkshire NHS Hospitals Trust said the form was altered to make it accurate because Mrs Stead had not been tested when she was first discharged to a care home.

It is not known whether she had the virus or not at that point.

A trust spokesperson said they had not been able to track down the person who made the alteration.

Martin Barkley, chief executive at the Mid Yorkshire Hospitals NHS Trust, said: "We fully accept the way the form was amended did not comply with national best practice on documentation as the amendment was not signed or dated and could have caused confusion at what was a very challenging time for everyone in the NHS.

"We intend to reiterate to our staff the importance of accurate and clear communication with care homes and families, and we are very sorry if this has caused any distress."

Care managers have told Sky News that they have faced growing pressure from hospitals to accept patients into care homes.

Care homes played a big part in freeing up hospital beds at the height of the pandemic.

In some cases, managers have refused to accept patients because information relating to their COVID-19 status was not complete.

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Marina Glaves is the registered manager at Beechy Knoll care home in Sheffield, a dementia nursing home that is one of the 60% of homes to remain free of coronavirus.

She said: "I see my role as the gatekeeper, which ensures that residents and staff are safe. I'm not bringing anybody back that has got COVID-19 to spread to everybody else in the building.

"It's so important that we have clear information about whether they have the virus or not and the slightest doubt causes so much anxiety.

"We are fighting all the time just to get the very basic, often negative text.

"I'm not asking for somebody to come fighting fit or miraculously cured. I'm asking for negative tests to COVID-19.

"We are asking for clarity and I'm afraid sometimes we're getting anything but."