Advice centre

A baby was born by caesarean section at 27 weeks gestation with a birth weight of 980grams. The baby was intubated, ventilated and endotracheal surfactant was administered.

Mr S was a 35-year-old taxi driver who was visiting his extended family abroad. While he was there he decided to have a routine health check in a private clinic. He told the doctor in the health clinic that he had noticed some rectal bleeding over the previous four months.

Certain circumstances can mean you are obliged to disclose information about a patient, even if you do not have their consent; under other circumstances, disclosure may be justifiable. This factsheet gives you further information about these circumstances.

An important starting point is your written report on the circumstances of the incident. This factsheet gives more information about writing this report.

One incident can be investigated in a number of different ways – as a complaint, a clinical negligence claim, a criminal case, a disciplinary matter by your employer, a Coroner’s inquest or a complaint to the GMC.

Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.