Recommendations following serious case review

Findings from a recent child safeguarding Serious Case Review

The issues arise from a serious case review last summer and some recommendations to general practice.

The issues are as follows:

1. GPs are strongly recommended to summarise the medical records of all children with particular reference to safeguarding.  Each summary would readily identify chronologies in order to demonstrate safeguarding concerns.

2. Each clinician, administrative staff and others in the practice should ensure good IT governance procedures and, ibn particular, each person with access to the practice IT system should have their own, dedicated log on.  This has not been consistent in some practices in the past.

3. Medical records should be contemporaneous and follow best practise guidelines.  Keeping good medical records in a professional duty as outlined by the GMC in Good Medical Practise, and by the Royal College of General Practitioners in its publication Good Medical Practice for General Practitioners. 

In order to maintain good medical records, it is recommended that each practice undertake a medical records audit every 5 years for each general practitioner.  This would from part of a doctor's annual appraisal and revalidation.

4.  Child protection concerns could be identified from medical notes summarising.  Practices should consider developing a dedicated recording instrument so that concerns can readily be brought to the attention of the practice senior management team.'