The patient sitting before me in the neurosurgery department was a 50-year-old professional who had been brought in with a small brain haemorrhage.
I first sent him for a CT scan to assess what had caused the bleeding, but this was inconclusive. I then ordered a more detailed and invasive test, known as a digital subtraction angiogram.
This involves injecting a dye into the tiny blood vessels in the brain and monitoring its flow to detect the damage. The radiologist wrote up his assessment based on a video of the procedure.
A couple of days later, the consultant asked me, then a junior, for the results. But when I opened the patient’s folder, the radiologist’s report was missing.
I spent two hours desperately trying to find the missing notes or the original video. In the end, the consultant ruled we had no choice but to repeat the procedure.
However, the procedure has a 1 per cent chance of causing a stroke and although the first one had passed off smoothly, minutes after the repeat procedure was performed, the patient — who had been admitted with only a minor headache — suffered a stroke and was left unable to speak or move.
My attempts to highlight the problems of missing paper records with hospital management were simply rebuffed.
The scary thing is, this is not an isolated incident. Colleagues often tell me they have had to ask patients to undergo repeated tests — sometimes invasive ones with a risk of serious side-effects — all because their original test results were missing.
While the rest of society has embraced a paperless culture, some NHS records are still written on easily lost bits of paper.
For although virtually every GP has a computer on their desk for instant access to medical records and the ability to take notes electronically, in hospitals, contemporaneous medical notes (recorded during assessment and treatment) are almost always handwritten on paper or card.
This means every time a doctor assesses or treats a patient, the details are written by hand and stored — along with any X-rays and scans — in a folder that goes back into a filing cabinet for safe-keeping, before being scanned into a computer file at a later date.
Yet the evidence suggests those records are anything but safe. A 2011 study by Imperial College London, published in the journal BMC Health Services Research, found 15 per cent of people attending outpatient appointments at hospital arrived to find key medical information about them was missing from their file.
A friend recently waited three months for an outpatient appointment only to find staff couldn’t locate part of his medical records, so they sent him home until they could. For him, it was an inconvenience, but for others, such mishaps can be devastating.
A friend recently waited three months for an outpatient appointment only to find staff couldn’t locate part of his medical records, so they sent him home until they could. For him, it was an inconvenience, but for others, such mishaps can be devastating.
Meanwhile, many NHS trusts still rely on fax machines to send vital clinical information. I had to do this myself recently after a patient had a heart attack and I needed to send the test results to a cardiologist several miles away.
I had to photocopy the thin test paper so it would feed through the fax machine, dial the number and hope the machine at the other end had enough toner and paper to print it out. Then I paged the cardiologist and hoped they got to see the scan before it got lost or chucked to one side.
Meanwhile, every minute a heart attack patient is kept waiting, more of their heart muscle is dying, increasing the risk of serious long-term problems or death.
My frustration propelled me to set up a company that provides software to the NHS which allows any doctor to have access to any inpatient’s medical records on an iPad they carry around with them. It also means nothing needs to be written on paper: scan results and notes can be typed and stored on the iPad there and then.
Two NHS trusts currently use the system, but it’s taken nearly six years to get this far. And it’s just as difficult for other software firms trying to break into the health service.
So while most of us now rely on smartphones, tablets and laptops to communicate and record information, the health service, for which accurate, readily available medical records are vital, is lagging far behind — and, I fear, putting lives at risk in the process.
Dr Mike Brooks is a part-time A&E doctor and chief medical officer for PatientSource, an electronic patient record system.