Access to deceased records

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Access to a deceased patient’s medical or dental records can be requested for a number of reasons. This advice addresses some of the most common queries, together with appropriate suggested responses.

Reasons to request access

• Those close to the patient wish to look into the care and treatment in the lead up to death.
  The General Medical Council advises doctors that they should disclose relevant information where a partner, close relative or friend seeks information about the circumstances of the death, if it will assist them in coming to terms with their loss. However, this must be considered within the context that the deceased retains the right to confidentiality even after death, especially where they have explicitly requested that specific information remains confidential, or that it would be obvious to the healthcare professional that this should be the case. The same criteria would apply where a relative wishes to check for specific genetic or family risk of illness following the death of a patient. All releases of information should be dealt with by considering: whether the disclosure is likely to be of benefit, whether it includes third-party information, and whether the information requested is already public knowledge.

• The patient's personal representative
  The Access to Health Records Act allows a deceased patient’s representative access to their records. The personal representative would usually be the executor or appointed administrator of the patient’s estate. Information should not be disclosed where it is likely to cause serious harm to the physical or mental health of any individual, where it relates to an individual other than the patient or where the information was provided by the patient in the expectation that it would not be disclosed.

Common pitfalls

• Seriously harmful and other confidential third-party information is disclosed because adequate checks and redactions have not been carried out before release of the medical records.
• Specific requests that certain information remains confidential after death have not been recorded in the patient’s health record.
• Failing to comply with a lawful request to release health records to a procurator fiscal or coroner investigating the death of a patient.
• Providing confidential or other sensitive information in response to general “fishing exercises” driven by curiosity.

Key points

• Always consider the ongoing right to confidentiality after death before disclosing any patient information.
• Check and confirm identities of persons requesting access to the health information of deceased patients.
• Carefully consider how much information needs to be disclosed, dependent on the circumstances
• Ensure that all staff with a responsibility for processing patient information are appropriately trained and understand the potential risks associated with disclosing and/or sharing such information.
• Seek further advice from MDDUS before disclosing if you are unsure.

Further guidance

• Access to Health Records Act 1990
• General Medical Council. Confidentiality: Good practice in handling patient information (paragraphs 134-138)
• General Dental Council. Focus on standards. Principle 4 Maintain and protect patients’ information

This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.