# FORMAL COMPLAINT ABOUT MISSING AND INACCURATE MEDICAL RECORDS
## Scope of this worked example
This fictional letter is a complaint to an NHS trust in England about the accuracy, completeness, access history and clinical effect of a patient's records. It is not a diagnosis, a request for a clinician to alter a professional opinion to match a patient's view, or legal advice. A health record may properly contain a clinician's opinion, and a correction must distinguish an objective error from a disputed account. The trust must apply the UK General Data Protection Regulation, the Data Protection Act 2018, NHS records requirements, confidentiality rules, safeguarding duties and its current complaints policy. The English complaints route is governed by the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, as amended, and the NHS trust's procedure: normally the patient first complains to the provider, then may ask the Parliamentary and Health Service Ombudsman to review the final response. The Information Commissioner's Office can consider data-protection concerns, but it does not ordinarily award clinical compensation or order a trust to rewrite a clinical opinion. The names, NHS number, dates and addresses below are fictional.
Date: 6 October 2027
By recorded post and secure email
To: Complaints Manager, West Mercia University Hospitals NHS Trust, County General Hospital, 4 St Anne's Way, Hereford HR1 2QJ
Secure complaints email: complaints@westmercia.example.test
Copy for support only: PALS, pals@westmercia.example.test
From: Harriet Louise Bowen, 22 Meadowbank Close, Hereford HR2 7LF
Email: harriet.bowen@example.test
Telephone: 01432 555 184
NHS number: 943 771 6284
Trust complaint reference requested: HLB-WMUH-2027-06
Subject: Formal complaint about missing, inaccurate and inaccessible records following treatment on 18 April 2027
Dear Complaints Manager,
Please register this as a formal complaint under the Trust's complaints procedure. I consent to the Trust using the information in this letter to investigate my care and records. My preferred contact is secure email, but please do not include my full medical history in an ordinary unencrypted message. I ask the Trust to confirm the complaint reference, investigator, expected response date and any required consent or identity verification.
## 1. Treatment and chronology
I attended the County General Hospital urgent treatment unit on 18 April 2027 at 19:10 with right-sided abdominal pain, vomiting and a temperature. The triage entry I was shown in the patient portal records arrival at 19:18 and describes the pain as “mild”. That is inaccurate. I told the triage nurse that the pain had begun at 14:30, had reached 8 out of 10 by 18:00 and was accompanied by three episodes of vomiting. My sister, Amelia Bowen, was with me from arrival until 22:40 and can confirm what I said.
The portal shows a clinical assessment at 20:05 but no corresponding clinician's note, examination findings, observation chart or safety-netting advice. At 23:10 I was discharged with a printed note saying “abdominal pain, cause unclear; return if worse”. The printed note does not record the blood pressure, pulse, temperature, blood-test results, urine result, medication administered, differential diagnosis or the name of the clinician who made the discharge decision.
On 19 April at 08:45 I telephoned my GP because the pain had increased. The GP record says that I reported being discharged without a clear explanation and that the hospital blood test was “normal”. I was admitted to Riverbank Hospital on 20 April with acute appendicitis and underwent surgery that evening. Riverbank's discharge summary dated 24 April says that the CT scan showed perforation and a localised abscess. I am not asking West Mercia to adopt Riverbank's clinical conclusions without investigation. I am asking it to locate the records of what happened at West Mercia and explain the impact of any missing or inaccurate entry on the information available to staff and to me.
## 2. Records concerned and corrections requested
On 3 May 2027 I made a subject access request to the Trust's data-protection team. The response dated 31 May supplied the triage screen, a partial pathology report and the discharge note, but said that no observation chart, medication administration record, clinician assessment, imaging request or audit history could be located. The response also states that I “declined further investigation”. I did not decline further investigation. I said at 23:00 that I was tired and wanted to understand the discharge plan; I was not asked to sign a refusal form.
Please investigate and, where an objective error is established, correct the following data. First, amend the triage entry to record the history I gave, or attach a clear supplementary statement if the original entry cannot be overwritten. Secondly, correct “declined further investigation” to record that I did not decline an offered investigation, or explain the evidence for that wording. Thirdly, add the missing medication, observation and assessment records if they exist. If the Trust cannot establish what occurred, annotate the record with the fact that the entries are missing and with my dated correction statement, rather than creating a retrospective clinical note that pretends to be contemporaneous.
I understand that I cannot require a clinician to change a genuinely held professional opinion merely because I disagree with it. If the Trust considers that “mild pain” or “normal blood test” records a contemporaneous opinion rather than an objective transcription error, please identify it as a disputed statement, attach this complaint and explain who made the entry, when, and what source information was used. Please preserve the original audit trail and record the date, author and reason for every amendment. Do not delete an original entry in a way that prevents an authorised reviewer from seeing the history.
## 3. Access audit and security investigation
Please provide, or make available through a secure process, an explanation of the access audit for my electronic record from 18 April to 30 June 2027. I request the date, time, staff role or department and purpose of access, subject to lawful redaction of information about other people and security-sensitive details. In particular, please investigate access by urgent treatment unit staff, the records team, the complaints team and any external processor. Please confirm whether the missing documents were never created, were created and later deleted, were stored in a different system, were not transferred from paper, or are unavailable for another stated reason.
This request includes the data used to respond to my access request, the search terms and systems searched, the retention or deletion rule relied on, and the identity of the person who approved the 31 May response. I am not asking for another person's confidential record. I will complete a reasonable identity check using the Trust's secure portal. Please do not require me to send a full passport scan to an unverified email address.
## 4. Treatment impact and remedy requested
The missing or inaccurate entries affected my ability to understand what was tested, what remained uncertain and why I was discharged. At my GP appointment on 19 April, the description that the hospital blood test was “normal” contributed to the conversation about whether urgent reassessment was necessary. I cannot prove from my records alone that an earlier diagnosis would have avoided perforation, and I do not ask the complaints investigator to assume that result. I do ask for a clinical review of whether the absent observations, inaccurate history and unavailable test information created a material communication or safety risk. Please explain any clinical conclusion in plain language and identify any learning or safety action.
I ask for these remedies: a written apology for any established administrative or communication failure; correction or a supplementary statement for objective inaccuracies; preservation of the audit trail; a secure copy of the complete records that can lawfully be disclosed; a reasoned explanation for every withheld or unavailable item; a review by a clinician independent of the original discharge decision; and a meeting with me and, if I agree, Amelia Bowen. Please tell me whether the Trust will reimburse reasonable copying or travel costs and how I can submit any separate claim for treatment injury. This letter does not quantify a damages claim or waive any legal right.
## 5. Procedure and routes
PALS may help me understand appointments and the local process, but copying PALS is not a substitute for registering this formal complaint. Please treat the Trust's complaints team as the decision-maker. I request acknowledgement within three working days and a written response under the Trust's published timescale, with notice if the investigation needs longer and an explanation of the revised date. If the final response does not resolve the complaint, please explain how I may approach the Parliamentary and Health Service Ombudsman and any time limit that applies.
The records and access aspects are also data-protection matters. I reserve the right to ask the Trust's Data Protection Officer for an internal review and to complain to the Information Commissioner's Office if I remain concerned about accuracy, access, audit or the handling of my request. I understand that the ICO may investigate compliance and issue regulatory advice or enforcement where its powers permit, but it does not decide clinical negligence, award compensation for distress or order a particular damages payment. I will not represent this letter as an ICO decision. If the investigation identifies a concern about an individual doctor's professional conduct, honesty, competence or fitness to practise, I may separately raise that concern with the General Medical Council through its current concerns process. The GMC is not a substitute for this NHS complaint, does not determine a compensation claim and may decide that a concern is outside its remit.
Please preserve the relevant electronic audit logs, scanned forms, observation charts, medication records, telephone recordings, portal messages and complaint records while this matter is investigated. Please tell me if any record has been destroyed under a routine policy, when that occurred and what the policy was. A routine retention policy does not answer whether a litigation hold, complaint preservation step or safeguarding requirement applied; please ask the appropriate information-governance officer to consider that question.
## 6. Service and signature
I send this letter by recorded post to County General Hospital and by secure email to complaints@westmercia.example.test. I request written confirmation of receipt and will retain the postal and secure-email records. Whether and when it is legally served is governed by the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009, as amended, the Trust's complaints process and any other applicable rule; this paragraph does not set the legal time of receipt. The PALS copy is for practical support and does not alter the formal registration of the complaint. The law and jurisdiction relevant to the Trust's handling of this complaint are the law of England, subject to that English NHS complaints process and any mandatory statutory route.
Please acknowledge this letter and confirm whether you need a signed authority for Amelia Bowen to attend a meeting. I will cooperate with a reasonable clinical or identity check, but I ask that the investigation remain focused on the stated records and treatment impact.
Yours faithfully,
Harriet Louise Bowen
Signature: __________________________
Date: 6 October 2027
## Schedule 1 — documents enclosed or available securely
The documents are the 3 May subject access request, the Trust response dated 31 May, the portal screenshots downloaded on 2 June, the 18 April discharge note, the GP record extract dated 19 April, Riverbank Hospital discharge summary dated 24 April, operation summary, my contemporaneous symptom diary and Amelia Bowen's signed witness account dated 28 September. The originals remain available for inspection. The screenshots show what was visible to me and are not claimed to be the Trust's complete system record.
## Schedule 2 — requested response headings
Please answer separately: what records were created; what records were searched for; what is missing and why; which factual entries will be corrected or annotated; what the access audit shows; what clinical impact was considered; what learning or remedy is offered; what data-protection explanation is given; and what review or escalation route remains. A clear answer to each heading will avoid treating a PALS conversation as a final complaint response.