can my mum see her hospital notes whilst on the ward?

[hospitalstay]

My mum is in hospital and wanted to see her ward notes for example to see what pain killers she is on and how her leg injuries (which occurred since arrival on the ward) had been logged. She has been told she is not allowed to look until after she is discharged via a 40 day turnaround request. Does anyone know if this is correct? Surely there should be paperwork she can sign to enable her to look whilst on the ward if she is certified as of sound mind (which she certainly is). Thanks

Pain killers being prescribed, would be the norm if someone is admitted to hospital, as pain is a common symptom when someone is unwell or injured ? Does she think she has been offered stronger pain killers since the injury that happened since admission ? Has she had an increase in pain and requested stronger pain medication ?
Have you been able to visit your Mum whilst she has been in ? The ward manager should be able to answer the questions you are asking, so what pain medication is prescribed and what the incident log relating to the injury says. If you are not able to get in to the ward then you could ask them to phone you, as long as your Mum gives consent for them to discuss things with you. If you aren't able to get any joy that way, you can contact PAL's in the hospital and they should be able to help.
Hope your Mum feels better soon

The notes on the bed frame are not medical notes. They are observation charts / food fluid charts etc.

@DealOrNoelsDeal not true at all. I've worked in hospitals for 20 years - not a nurse. Nurses do not sit around on their phones ignoring the phone. That's just plain bitchy and uncalled for. Unless you are a nurse and your saying that's what you do at work? Do you work in hospital?

I’m a hospital doctor. You can request to see the notes but they may not be released unless she is in for a very long time.
Injury should have been documented but may be done in an unstructured way simply as a note by either the doctor and or nurse who examined and treated her.
A datix or Lern form ( formal) may have been done . Usually if a staff member thought that there were learning points. They are not mandated.
It is easy enough to ask the nurse about your medication and they shops tell you if a datix or lern form was completed. The duty of candour means that we should also document that the staff have explained to you what happened and what was done about it.

Apologies if someone has already said this up thread. You need to do a subject access request to see the notes. Perhaps ask to speak to PALS in the hospital. The fact you are doing a SAR may well assist the medical team in just providing some facts to you and talking you and your mum through what has happened. Sounds like you should do a SAR for her medical notes before anything goes awol.

Get her to contact PALS, they will tell her

If its from a fall then a note and indication that she's had a fall should be in the notes. It sounds like from you're possibly saying you/she feels that the injury was caused by a staff member? Has she broken a bone?

As you are saying she is of sound mind I don't understand why she's not just saying either (for example)
'Is the fact I slipped going to the bathroom on my own down in the notes'
''Is the fact I fell in the bathroom when the nurse was helping me shower in the notes"

to answer those questions, yes i have been with my mum every permitted visiting hour, no one will say anything. nurses say they are not allowed to answer her queries only doctors and there is never a doctor available during visiting hours, nurses cant give xray results or discuss anything, my mum is not being told anything whilst I am not there either. I understand the PALS procedure but wanted to find out here if there is any option to avoid that so her treatment is not impacted by involving PALS. However it appears there is no form she can sign that would allow her to see her notes. they removed the notes from her ward, others remain due to her asking to see them. Which is concerning as now she cant see if they are logging obs.

Have you asked to meet with her consultant? What injury does she have and how did it occur?
What outcome are you looking for, are you just wanting to know as its unsettling for her or are you planning formal complaint/gathering information to sue?

What do you mean by her treatment being impacted by involving PAL's ?

You need to ask to speak to the ward manager OP, there are clearly some communication issues which sound as though they could be easily resolved if someone spoke with you and your Mum.

I have no plan of outcome or formal complaint at this point. just want her to be able to see the notes (now hers have been removed) more so she can see why they are so desperate that she doesnt see them. not sure if it is standard that nurse couldnt say xray is fine for example. i thought nurses would be able to speak to patients and would be doing a lot of jobs doctors used to do so am very surprised at the lack of authority. obviously asked for doctor each day as anyone would if injured and awaiting xray and then xray result!

They won't have been removed they'll be out near the nurses station where we can check other patients and their visitors don't have a nosey through other people's notes as that can happen.
Have you/your mum said to a nurse 'what painkillers are being prescribed/how is my leg injury recorded in the notes' and they have said 'We can't tell you' ?

When did she have the x-ray ? I am suprised that the nurse couldn't tell her if the x-ray confirmed an injury, or if there is no fracture, if the x-ray was a couple of days ago. The x-ray wouldn't tell you if she had soft tissue injury and she could have quite spectacular bruising if she is elderly and on any blood thinners ?

As an NHS nurse manager I speak for myself, I would give verbal information to your mum from her notes, this all sounds very strange, I would go to through her prescription chart and tell her if an incident form had been completed. If results are straight forward generally a nurse can tell the patients.

As said up thread your mum can do a SAR now to access her notes but it's unlikely she will see them before discharge, there is a time frame they have to work to, to allow your mum to see her notes. Most trusts do not charge for this service now.

Did your mum fall? The trust does have a duty of candour to the patients when harm has occurred, this includes an apology and explanation of what has happened, how it will be prevented again and what your mum can expect now.

If I were you I would firstly advise your mum to ask to speak to the ward manager, failing that the matron for that area, failing that PALS. This will not affect your mum's care, she has a right to all of this information. You can of course take this on with your mum's consent, you say your mum has capacity, might be worth her writing down that she gives you permission.
I hope your mum gets some answers, this is not acceptable.

said you need to speak to a doctor and there is none of the ward whenever anything is asked, even fairly simple requests. Yes of course records have not been removed from ward and are on nurses desk but it means obs are not recorded as carried out which gives more chance of errors.

Last time I checked legally most of what has been written here is wrong.

The patient has a right to see any notes there and then provided there us nothing in them that is considered to be of harm to the patient.

The patient can delegate to a third party.

A subject access request is only necessary if you actually want a copy. It's lazy nursing to restrict access this way

If it is a matter of looking at what information is available to nurses at the time legally you have a right.

No nurses cannot comment on results of diagnostic tests, that is a Dr's job. Patients in hospital will be seen by a consultant led team daily on ward round so this morning she needs to ask them directly what the xray results were of her leg. Her obs will definitely be recorded, they will have moved them to the nurses station. In the hospital I work in, no patient notes are on the ends of beds anymore as it is legal protocol for patients to not have automatic access to their own records (I do find the process unnecessary and think there should be a form to fill in).

I haven't worked on the wards for a while now, but even several years ago the observations were recorded on a computer and not paper copies at the end of the bed.
Paper work at the end of the bed tended to be fluid balance charts, nutrition charts, repositioning charts, that sort of thing.
Honestly ask to speak to the ward manager, I am sure they will be able to give you the information you need.

icedlatte - thank you for this as this is what i had previously understood from viewing my own hospital notes. i have been permitted to view them in hospital records office or on the ward and in GP surgery and the 40 day timescale was only if you want the hospital/GP to photocopy them for you. However everyone is posting otherwise here including those stating they work in hospitals. Do you have any links to where it might state this right to view?

It's data protection. Yes notes can contain nothing more than bare medical facts, but if there are safeguarding/sensitive issues this is all logged there. Notes cannot just be read even by the patient they are about without this being screened due to confidentiality of all parties.

And I'm a student nurse. I'd bloody love to sit around on my mobile instead of running round like a blue arsed fly for 13 hours at a time.

i think this lack of trust/openess about treatments is where UK really differs with countries who work with the patients with great healthcare. Unfortunately in UK I havent met anyone who has ever accessed their notes via records office request and not found important mistakes or omissions. By working together records could be correct which would reduce mistakes in treatment. It is a very strange attitude that people shouldnt be allowed to see/know.

Tbf it was about 5 years ago but I did actually speak to a lawyer on this. It was a matter where a medical professional said they had a piece of evidence in file here, i asked to look at it and they refused (because they hadnt done it) saying it had to be a subject access report. She got very uppitty when i said i would take it further. the lawyer confirmed if they can look at it, you can look at it but you can't remove it essentially.

So it might have changed since, but given the medical professionals response on here states data protection legislation prior to this date I suspect not.

A verbal subject access request has the same weight as a written SAR. You have the right to see what is written about you. The attitude of the staff rings alarm bells.

Make a SAR for the hospital notes but make a parallel request for GP notes. I did this and found letters which had been deliberately held back from me by the hospital which were very concerning.