We continue to receive variations on this query, which can range from forged prescriptions and genuine sick notes that have been altered to prolong the duration of the patient's sick leave, through to more elaborate letters that have been created entirely from scratch.

With editing software freely available it has become increasingly easy to make a convincing copy of a practice's headed notepaper. There are even various sites online that offer advice on how to convincingly forge a sick note or that allow you to buy replica NHS sick notes.

In situations such as this the MDU advises that it's not a breach of confidentiality if you simply confirm that you didn't create the document, or that any altered documents aren't as they were when you originally signed them. However, no other information should be given about whether the patient is actually registered at the practice or if any of the medical information is correct.

When faced with seemingly fraudulent documents doctors often feel understandably aggrieved and ask if they should involve the police or remove the patient from the practice list. But although you might be left feeling that there's been a breach of trust, removing the patient from the list without a prior warning could leave the practice vulnerable to criticism.

The letter of the law

The General Medical Services contract suggests that doctors can remove a patient from their list if they have reasonable grounds. However, except in specific circumstances, it is expected that the patient would have been given a warning in the preceding 12 months explaining they are at risk of removal and why. The contractor would need to be able to justify such a decision. A patient can also be removed from a list with immediate effect if they have been violent and the incident has been reported to the police.

It is also helpful to consider the GMC's guidance 'Ending your professional relationship with a patient' (2013), which indicates some examples of how the relationship with a patient may break down, including if the patient has 'persistently acted inconsiderately or unreasonably'. However the guidance also advises that doctors should not only have warned the patient but done what they can to restore the relationship and explored alternatives to ending it, which should be a last resort.

Bearing this guidance in mind, it is often helpful to ask the patient in to discuss the letter or form in question and to make a judgment after that discussion as to the best way forward.

Disclosure decisions

In situations such as this, where there is no legal obligation to disclose the patient's actions and where patient consent to do so would be unlikely to be forthcoming, you would need to consider whether disclosure could be justified in the public interest. This decision is essentially a balancing act between the benefits to an individual or society of disclosing versus the harms of disclosure.

Disclosure in the public interest without consent, or after refusal of consent, may be justified if failure to make the disclosure could expose others to a risk of serious harm or death. This could arise where disclosure might assist in the prevention, detection or prosecution of a serious crime, as outlined in paragraphs 51-56 of the GMC's 'Confidentiality' guidance (2009).

This guidance does not provide a specific definition of 'serious crime', but on page 35 of the Department of Health guidance 'Confidentiality: NHS Code of Practice' (2003) the examples listed are murder, manslaughter, rape, child abuse, substantial financial gain/loss and risk of state security/public order. Theft, fraud and property damage where loss would be less substantial are not thought to constitute a serious crime.