Audit trail
Dear Department of Health and Social Care,
Please will you clarify the Department of Health and Social Care’s position regarding a patient’s legal entitlement to an audit trail in respect of his or her medical records?
In the event that the medical records in question belong to a deceased person, how can the deceased’s executor enforce any entitlement to an audit trail?
Yours faithfully,
Julia Rees
Dear Department of Health and Social Care,
I am writing to request an internal review, as, by law, you should have responded to my FOIA request by now.
Yours faithfully,
Julia Rees
Dear Ms Rees,
Thank you for your email.
The Freedom of Information Act 2000 (FOIA) applies only to recorded information, such as paper or electronic archive material. As your original correspondence asked for general information, rather than requesting specific recorded information or documentation, it did not fall under the provisions of the FOIA. It was therefore not processed as a Freedom of Information (FOI) request and was passed to the Department of Health and Social Care's Public Enquiries Team to be answered as general correspondence.
We apologise that you were not informed about the handling of your request and that you have not yet received a response from the Public Enquiries Team. The team have been notified of your recent correspondence and you should expect to receive a response directly from [email address].
As your correspondence was not handled as an FOI request, we will not be conducting an internal review, but the Department will aim to respond to your original query as soon as possible. Please accept our sincere apologies for the long delay.
Yours sincerely,
Freedom of Information Team
Department of Health and Social Care
Dear Freedom of information team,
Thank you for your reply.
However, please clarify whether or not you are in possession of any recorded information relating to my request.
As I have not received a response from the public enquiries team, please could you clarify the address to which they have responded or will be responding?
It would obviously be helpful if their response could be copied to department of health and social care and posted here in response to my FOIA request, given the department’s interest in ensuring the veracity of the public’s medical records.
Yours faithfully,
Julia Rees
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Our ref: DE-1491235
Dear Ms Rees,
Thank you for your correspondence of 15 November about access to health
records. I have been asked to reply, and I apologise for the delay in
doing so.
This reply presumes that an audit trail refers to a history of who has
seen your medical records.
Confidential patient information is never made available to anyone other
than those who need to see it for the provision of care; for example,
clinicians and their support staff, which can include clerks and other
people responsible for managing data, typing up notes and issuing referral
letters or the results of tests. There is a longstanding legal and ethical
duty of confidentiality that limits disclosure of a patient's
information.
Everyone has a legal right to access the information held about them by
health and care organisations, which would include information on who has
accessed records where it is recorded. Information on making a Subject
Access Request can be found at
[1]transform.england.nhs.uk/information-governance/guidance/subject-access-requests/.
However, the provision of direct care can involve a number of people
seeing a medical record – for example, members of a multi-disciplinary
team – without this being recorded.
Access to GP records – for example, through the NHS App – may also show
information relating to who has accessed them, but systematic information
on who has accessed your electronic records throughout the NHS is not yet
available online.
There are routes for accessing a deceased person’s confidential patient
information, in certain circumstances and where appropriate. Guidance on
this can be found at
[2]transform.england.nhs.uk/information-governance/guidance/access-to-the-health-and-care-records-of-deceased-people/.
I hope this reply is helpful.
Yours sincerely,
K Jarvis
Ministerial Correspondence and Public Enquiries
Department of Health and Social Care
Dear Department of Health and Social Care,
Thank you for your reply.
However, I can find no information at the link provided in relation to the enforcement of access rights under AHRA, or, indeed, the full extent of these access rights.
It may help if I clarify that I have been sent medical records pursuant to AHRA 1990, but they are incomplete, and appear to have been doctored, which is why I require the audit trail. The audit trail should tell me who has accessed the medical records, when, and for what purpose.
In the circumstances, could the Department of Health and Social Care kindly direct me to where I may find this information? (I am aware that some health authorities do supply audit trails, but I require clarification of the precise extent of my entitlement).
Thank you.
Yours faithfully,
Julia Rees
Dear Ms Rees,
Please find attached the Department of Health and Social Care's response
to your FOI request (our ref: FOI-1494750).
Yours sincerely,
Freedom of Information Team
Department of Health and Social Care
Dear Department of Health and Social Care,
Thank you for your reply.
However, unfortunately, the link provided doesn’t work.
Please could you clarify what information you hold regarding a person’s right to access an audit trail in respect of medical records to which he or she has a right of access under the Access to Health Records Act 1990.
For the avoidance of doubt, my request relates to a case where the medical records of a deceased person appear to have been improperly accessed and edited by a hospital employee. However, because the person whose records have been improperly accessed is deceased, the ICO has no remit.
Yours faithfully,
Julia Rees
Dear Ms Rees,
Please find attached the Department of Health and Social Care's response
to your FOI requests (our ref: FOI-1498203 & FOI-1499789).
Yours sincerely,
Freedom of Information Team
Department of Health and Social Care
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