Intended for healthcare professionals


When patients are victims: access to online records and medical misconduct

BMJ 2022; 379 doi: (Published 09 December 2022) Cite this as: BMJ 2022;379:o2968

Linked Opinion

US experience with transparent medical records should reassure doctors

Linked Editorial

Patient access to full general practice health records

  1. Charlotte Blease, research affiliate
  1. Digital Psychiatry, Division of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, USA
  2. Department of Women’s and Children’s Health, Uppsala University, Sweden
  3. @crblease on Twitter

Greater transparency can help patients and clinicians to identify and raise concerns, says Charlotte Blease

A review into the records of 44 patients who died while under the care of former Belfast Trust neurologist Michael Watt was published on 29 November 2022.1 In 2018, concerns about the quality of Watt’s care led to one of the biggest patient recalls in NHS history, and the largest ever in Northern Ireland. The review identified numerous concerns, including lack of proper clinical investigation, inaccurate diagnoses, poor prescribing practices, poor recording keeping, lack of openness and effective communication, inappropriate treatment, and the risks of clinicians working in isolation.

Conducted by the Royal College of Physicians with the involvement of patients’ families, the review was commissioned by the independent Regulation and Quality Improvement Authority (RQIA). Although the report examined only a small sample of patients, potentially thousands may have been affected.

A central theme of the report was that Watt’s clinical records and documentation tended to be brief and lacking explanation of clinical decisions. Important information was omitted, and there was a “lack of openness” about patients’ diagnoses. Families reported witnessing the neurologist regularly writing clinical records on “scraps” of paper. Watt also failed to answer requests for information from other clinicians. The treatments he prescribed in many cases were “unnecessary and invasive.”

Watt’s patients and their families were kept in the dark about their diagnosis and the rationale behind their care. Meanwhile, coinciding with the RQIA report, NHS England further extended the 30 November deadline for giving all patients online access to their general practice records by default.2

More eyes

Patients worldwide are increasingly being invited to access their full electronic health records online. Much attention has been paid to easing doctors’ anxieties about the potential risks of increased litigation after shared access 34Considerably less thought has been devoted to whether online record access might protect victims from medical negligence or intentional wrongdoing. This propensity to focus on doctors’ legal woes rather than patients is telling. Greater transparency and more eyes on the charts can help support patients and clinicians, especially when medical procedures are inconsistent, unnecessary, or when clinical documentation is at odds with expected practice.

Although cases such as that of Michael Watt are extremely rare, research from the US shows that serious ethical violations, improper prescribing of controlled substances, sexual impropriety, and unnecessary invasive procedures, occur more often than might be assumed.5For example, a review in the US found that the annual rate of major disciplinary action in medicine resulting in revocation, suspension, or surrender of licences, was one per 1000 doctors.6 Moreover, just as the report found in the case of Michael Watt, serious ethical violations are more likely to arise when doctors work in isolation and unchecked.5

We can’t know for sure whether open online record access would have helped the victims of Michael Watt. However, online transparency could have made it easier for patients, and families, to understand their diagnoses and seek second opinions. Evidence of what was documented, or omitted, might have helped strengthen their voice when raising doubts about their care to other clinicians. This, in turn, could have empowered other doctors to raise the red flag and act.

Transparency strengthens trust.7In the UK, online record access has already helped victims of medical misconduct. In 2000, Amir Hannan accepted a position at the family practice of the most prolific serial killer of the modern age, Harold Shipman. On 31 January 2000, Shipman was convicted of murdering 15 patients by administering lethal injections of morphine. The tally of victims, mostly women aged 60 or older, is believed to be more than 250. Hannan’s job was to restore trust among the patient community left traumatised, confused, and distrustful of doctors. Patient access to their electronic health records was one tool Hannan used to show his patients that he had nothing to hide.8That’s the point: openness signals professional honesty.

Access to online records won’t solve every case of medical misconduct, but it could help protect some patients and their families. It can also assist the vast majority of good doctors to better protect victims too.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I served on the ethics advisory group for the Regulation and Quality Improvement Authority’s expert review of records of deceased patients of Dr Watt.

  • Provenance and peer review: Commissioned; not externally peer reviewed.