Hospital fabricated my notes. What now?

[FoxyFabrina]

Hi mn. I'm brand new here but really need some advice...

My baby is just over 5 weeks old. I had a fairly awful birth and pregnancy which I don't particularly want to discuss. I'm upset by it and feel let down.

I'm just looking at my purple notes, and realised that the mental health assessment is completely fabricated.

The midwife has ticked 'no' to all of the boxes, so it now shows that I have never had a mental health problem, never had anxiety, never been on medication, never had counselling, and hadn't suffered with anxiety or worry in the two weeks prior to the birth. They also ticked no to whether my partner has mh problems (he hasn't but they don't know thus) and that I have no history of mental health in my family (my mum suffered from PND). This is all incorrect and I actually have a long history of mental health struggles.

It states at the bottom that I might've received support (which I feel I actually needed) had they ticked 'yes'

If they had left the questionnaires blank, I could have forgiven that, but they've just filled it in for me, guessed I have no mental health history, and essentially fabricated my medical records. This has denied me of potential help, and funnily enough, I'm suffering hugely from post natal anxiety and have no idea what to do.

Is this normal? AIBU to be as angry and upset as I am? I've been failed from start to finish and feel that this is just the cherry on top...

That is rough. Speak to your heath visitor or doctor about it? Do you still have the notes?

You need to go and see your GP and speak to your HV. Forget the midwife for now until you are in a better place

@OwlinaTree I have them in front of me. I've only just noticed. I'm definitely going to see my gp when I can, but feel so let down. I think I need to raise this somehow.

Thanks @BonnieandHyde - It's hard to forget. I think I need to raise it for my own sanity...

Hope you get the support you want. Good luck.

The angry and upset is reasonable, you have not been given appropriate medical care based on false records. I'm sorry you have this on top of a new baby.

From what you've said I think you need to raise it to help you move forward. But you need to raise it separately to your current anxiety. I would get help for the anxiety first simply so that that help isn't the 'answer' to your complaint.

It might be helpful to write your own record of everything that has happened to you, if it's written down it might stop going round in your head so much and it's easier to show to someone.

I wouldn't worry too much about this. They might just be basing it on previous notes, which might not be a complete picture. Or it might mean that you haven't needed to access MH services in the time they've been caring for you, or many other form-filling possibilities. Just make sure you raise the issue now with your GP/HV and make sure you get the right support. Good luck and congrats for your newborn baby!

Sue the bastards for every penny.

Thanks everyone. I just really feel like I could use some support.

@flowerpott it's a questionnaire that they are meant to do with you before you leave. I really think this is something to worry about. I imagine the midwife is doing the same with everyone...

How awful, to fabricate answers and not give you the chance to access support you really feel you need.

What's important for right now is you speak to the GP and ask for help, be it CBT, counselling or whatever you need. MH is hard, and anxiety can spiral. (Look into EMDR, some localities provide it on the NHS I had to pay privately but it freed me from the majority of my quite debilitating anxiety, it's very effective with trauma)

And then once you feel up to it, requesting a meeting with a senior midwife to discuss your concerns including the completely false questionnaire. Big hugs xxxx

That's really bad. If you feel up to making a conplaint then please do so - once you've put in place some support for yourself.

Once you feel well enough to do so write and inform either PALS or the head of midwifery about what has happened. Fabricating stuff like this is quite serious, makes you wonder what else they'd be happy to fabricate, BP result, etc?

I have a very similar thing at the moment. I’ve only had my booking appointment and in it I said that I have an anxiety disorder and because I also have a phobia of vomiting it’s been much worse in pregnancy due to morning sickness.

She ticked the box to say I had an anxiety disorder, but when I looked at the notes later she had ticked “no” for “have I been experiencing anxiety in the last two weeks”, “have I been bothered by not being able to stop worrying in the last two weeks”, and “has my anxiety stopped me doing certain things/going to certain places in the last two weeks”. From what I told her she should’ve known the answer to the first one was yes, and if she’d asked me the other two questions she’d have known they were yes as well.

I feel like you, because of my mental health history I know I’m at higher risk of post natal depression and anxiety and I’m so annoyed that after what I said to her she just ticked the box indicating I’d had it in the past and ignored the questions about the current situation. Like in yours, she also ticked no to the questions about my partner and family, even though she did not ask.

I’ll be bringing it up with her at my next appointment, but for you I agree with what JellyBelly has suggested, including the meeting with the senior midwife when you feel up to it. I hope you get some appropriate help and start to feel better soon!

that's awful! If they are doing it routinely for everyone, it could cause a really serious situation - women are being denied an opportunity for access to mental health follow-up at a point when they are incredibly fragile and vulnerable. It's way too easy to slip through the net as it is: this is how mothers and babies die.

Definitely take it up with GP and HV when you can, OP. They need to know for other women's sake as well as your own. I know that's an ask when you are so recently post-partum yourself, but if you feel able to flag it up you really must. If you really wanted to go above and beyond it might be worth notifying the community mental health team, but it might not be appropriate or feasible.

And I hope you yourself are doing OK. Congratulations on your new baby.

You can talk to a midwife at the hospital who'll take you through the birth, too, when you're ready. I know women who say it's been an incredible help.

@MeredithGrey1 those are the exact same questions that are on mine and I've got 'no' ticked in the boxes. To be honest I don't know many pregnant women who didn't feel anxious in the last couple of weeks of pregnancy!!

How awful, I really hope you get the support you need.

I've spoken to PALS who is going to get the midwife to contact me. To be honest, I don't want to get people in trouble, I'm not one for making complaints, I just want my notes rectified (and it would also be nice to know I may prevent this from happening to other people...)

You're not at all wrong to be upset by that.

The best way to follow it up is through PALS (patient liaison and advice service) at the hospital, by dropping them an email setting out what you've said here. In my experience, raising stuff through PALS tends to get it taken quite seriously, and they force departments to attend to it quickly.

That form is there for a good reason, and if one midwife is completing on automatic without asking women for the answers, that's putting people at risk of not receiving support in a timely fashion.

Most importantly, do prioritise seeing the HV or GP to make sure you get support for your mental health now.

You're not alone, they did the same with me! In my case it was in terms of breastfeeding support, which was totally made up!!!

We ended up in hospital just a couple of days after returning home because my son had lost too much of his birthweight. Which might have been caught had they been more cognizant of the breastfeeding difficulties we were having.

They also never weighed him before we left the hospital, even though we were there for 2 days following his birth as I recovered from a c-section.

I also had a really disappointing experience. I'm really sorry, it sucks!

FoxyFabrina your post struck a chord with me. I agree with others that there are two separate but related issues. Firstly, your mental health now and secondly the fabricated assessment.

I think you're absolutely right to have contacted PALS. I'll spare you the details but I had something fairly similar after one of my births and PALS being involved promoted VERY prompt action from clinical staff.

Your notes should be rectified and you're right to say that there is a bigger issue about the midwife - to put it bluntly - lying. Medical notes are legal records and it's incredibly unprofessional and dangerous to complete an assessment without speaking to the patient and without noting that you didn't bother actually asking the patient, but just made a load of assumptions.

If no-one gets back to you quickly, might I suggest that you state your problem in writing to PALS as this tends to galvanise action. Like you, I didn't want to get anyone into trouble or create problems, but failure to complete forms correctly and a refusal to chase up something that had been lost in the post (but I knew had been sent) was really damaging to my post-natal mental health.

In the meantime, speak to your GP surgery and be as open as you can about your anxiety with the receptionist so that they offer you a quick appointment. Post natal anxiety and illness can escalate really quickly with sleep deprivation, so don't delay.

If you feel able to, have a look at the PANDAs website, that has lots of useful information. www.pandasfoundation.org.uk/

Best of health to you.

As a nurse I feel this is appalling. I would speak to the Midwife's manager. And actually consider a formal writtwn complaint. Maternal mental health is a serious issue. By all means mention to the GP and Health Visitor but they won't be the people who can address this person's practice.

Go to PALS (patient liason service), they will guide you.

Yes, there are two separate issues, and OP does need to focus on her mental health now via the GP/HV.

Hopefully, PALS will promote some action from the midwifery team, but I agree with you that it's appalling not to mention unlawful.

Cardio sent me a copy of their assessment which states I consume 10 units of alcohol a week. The most I drink is 2 units over 2 days ( bottle of wine shared with others with a meal). Some weeks none at all. The perception of how much a patient drinks can have implications for treatment if alcohol is thought to be a problem.
I shall certainly be challenging this when I return for further assessments shortly.
Never occurred to me in the past to check reports for accuracy.

OP, I had a similar experience, however it wasn't with a midwife, but my local MH team.

They had a questionnaire, one for me and one for the doctor. Mine had questions such as 'Do you have anxiety?' and the doctors had 'Do you have reason to believe the patient suffers with anxiety?' I ticked 'yes' on the questions, but the doctor ticked 'no'. In fact, the doctor ticked 'no' on every single question.

I struggled for 7 years just to get an appointment there, to be told 'Well, you have no kids and the doctor said 'no', so you can't have any diagnosis/treatment' and simply discharged me.

I'm in the same position 3 years later. I don't want to go back there, GP has sent repeated referrals that they don't respond to and i'm not allowed to be referred elsewhere due to where I live.

Congratulations on your baby and I really hope you get the support you need!

have a look at www.birthtraumaassociation.org.uk/

I felt massively let down by my birth experience and unfortunately I found these people a bit too late, but they might well be able to offer some support for what to do next.

I'm so sorry for you that you have been let down in this way.

It's not about getting people in trouble. It's about getting this midwife corrected on a very important procedure. You won't be the only this has happened to with her. I'm astonished actually. Post-natal mental health issues are so widely known that anyone would do this is so upsetting. She really needs retraining at best