Guidance for Access to Health Records Request v6 October 2015
Accessing Health Records under the Access to Health Records Act 1990
The Data Protection Act 1998 does not have any provision for access to health records of
the deceased. Access under these circumstances is governed by the Access to Health
Records Act 1990.
Under the Access to Health Records Act 1990, the representative of the deceased can
access information from the records. It should be noted that a deceased person’s next of
kin is not necessarily the deceased person’s representative.
If a will is made, then it is the executor of the will who is the lawful personal
representative. If there is no will and the deceased died intestate, it is at this stage that
the closest “next of kin” can apply, through a solicitor for a Letter of Administration to
handle the deceased affairs.

The patient’s personal representative or someone applying on their behalf e.g.
executor or administrator can apply for access to the health records. Legal
documentation will be required as proof of appointment to this role.

It is any person who may have a claim arising out of a patient’s death or someone
applying on their behalf can apply for access to the health records. Information,
which is not directly relevant to the claim, will be withheld.

Information may be withheld if the patient previously gave the information on the
understanding that it would remain confidential. Similarly, no results of
examinations or investigations which the patient thought would be confidential at
the time they were carried out can be disclosed. No information can be revealed if
the patient requested non-disclosure.
We are not obliged to comply with the access request unless we have sufficient
information to identify you and to locate the information. Once we receive all relevant
information we will inform you of specific costs in order that you can arrange payment.
Our Trust aims to complete your request within 21 days on receipt of all information.
However, this timescale is determined, by the detail and volume of the request. The Data
Protection Act 1998 states all subject access requests should be completed within 40
days. In exceptional circumstances, where it is not possible to comply within this period
you will be informed of the delay and given a timescale for when your request is likely to
be met.
In some circumstances, the Act permits the Trust to withhold information held in your
health record. This information will be redacted:

where it has been judged that supplying you with the information is likely to cause
serious harm to the physical or mental health or condition of you, or any other
person

where providing you with access would disclose information relating to or provided
by a third person who had not consented to the disclosure, this exemption does not
apply where that third person is a health professional involved in your care.
Guidance for Access to Health Records Request v6 October 2015
When making your request for access, it would be helpful if you could provide specific
details of the periods and parts of your health record you require. Although this is optional,
it will help save time and resources.
Payment details
Payment can be made by credit card, cheque, etc. Details will be outlined on the invoice
you will receive prior to the information you have requested being released.
If you are using an authorised representative, you need to be aware that in doing so they
may gain access to all health records concerning you, which may not be relevant. If this is
a concern, you should inform your representative of what information you wish them to
specifically request when they are applying for access.
If you have any queries relating to any aspect of your request to obtain access to your
health records, please contact:
Access to Health Team Contact Details:
Telephone Numbers:
0191 3332978
0191 3332088
0191 3332075
0191 3332191
0191 3332464
Fax: 0191 3332731
Email: cdda-tr.accesstohealth@nhs.net
Post: Access to Health Department
University Hospital of North Durham
East Wing Corridor
North Road
Durham
DH1 5TW
Please complete the following forms and send to the address or email above.
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Access to Deceased Patients Health Records under the Access to Health Records Act
1990
(Please print all details and use dark ink)
To: (please provide details of the patients GP name and address or consultant name and
hospital department here)
Identity of individual about whom information is requested
Full Name
Former name(s)
Address
Former addresses (with dates of change)
Date of birth
NHS Number (if known)
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Requestor information (tick as applicable)? In doing so you understand you may
have to pay a fee for access or copies of the records.
I am the deceased persons representative applying to access their health records
I have a claim arising from the death of a deceased person and require access to
their records
Details of person requesting the information
Surname…………………………………………………………………….
Forename(s)…………………………………………………………………
Address………………………………………………………………………
………………………………………………………………………………..
………………………………………………………………………………..
………………………………………………………………………………..
Telephone number…………………………………………………………
Relationship to patient…………………………………………………….
I am the deceased person’s personal representative and attach a copy of confirmation of
my appointment:
o Grant of Probate
o Letter of Administration
o Patients Will
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I have a claim arising from the patient’s death (please provide details of this claim
below and provide documentary evidence):
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
……………………………………………………………………………………………………
What is being applied for (tick if applicable)? In doing so you understand you may
have to pay a fee for access or copies of the record.
I am applying for access to view paper health records in paper format (Monday to
Friday 8am – 5pm)
I am applying for access to view health records online in electronic format
(Monday to Friday 8am – 5pm)
I am applying for copies of health records (including black and white copies of any
photographs)
Please tick all relevant boxes to indicate the types of records you wish to access
Clinical Records (Inpatient and Outpatient)

Speech & Language Therapy

Accident and Emergency Records

Podiatry

Physiotherapy Records/Orthotics Records*

Dietician

Urgent Care /Out of Hours/Minor Injury Records

Genitourinary Medicine and Sexual Health

X-Rays

Audiology/Ophthalmology*

Colour Clinical Photographs

Community Records Midwife/
Health Visitor/School Nurse*
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To provide you with a copy of your health record the costs are:
Copies of any record held electronically
£10.00
Colour Clinical Photographs (per A4 sheet)
£2.00
Copies of paper records - Up to 20 copies
£15.00
Copies of paper records - 21 to 100 copies
£30.00
Copies of paper records - Over 100 copies
£40.00
X-Rays
£10.00
To view your records:
Paper Copy Admin Fee
£10.00
Online Electronic Access Admin Fee
£0.00
There will be no fee to view a paper copy of health records if entries have been made to
the records within 40 days of application
All charges include postage and packaging.
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To help the NHS save time and resources, it would be helpful if you could provide details
below, informing us of periods and parts of the health record you require, along with
details which you may feel have relevance i.e. consultant name, location, written
diagnosis and reports, etc. Please use the space below to document and continue on
another page if necessary:
Dates and types of records:
Declaration: I declare that the information given by me is correct to the best of my
knowledge and that I am entitled to apply for the access to the health records
referred to in this request, under the terms of the Access to Health Records Act
1990.
Signature of applicant…………………………………………………………..
Print Name………………………………………………………………………..
Date………………………………………………………………………………..
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We would appreciate feedback on how satisfied you were with this process
PLEASE TICK ONE BOX FOR EACH QUESTION:
1) It was easy to locate this booklet to request the information.
Strongly Agree
Agree
Neither Disagree/Agree
Disagree
Strongly Disagree
Disagree
Strongly Disagree
2) The charging structure for receiving the information is clear
Strongly Agree
Agree
Neither Disagree/Agree
3) It is easy to indicate what information I require from the different types of records
Strongly Agree
Agree
Neither Disagree/Agree
Disagree
Strongly Disagree
4) I felt confident and was treated with respect and dignity by the Access to Health Team when I contacted
them.
Strongly Agree
Agree
Neither Disagree/Agree
Disagree
Strongly Disagree
Please make sure you have:
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


Completed this form in full
Signed the declaration above
Enclose the relevant proof of identity
If applying on behalf of another person, their permission together with any
authorities to act on their behalf
Completed the quick feedback section
Send the completed form and enclosures to:
Access to Health Department
University Hospital of North Durham
East Wing Corridor
North Road
Durham
DH1 5TW
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Frequently Asked Questions
Q
Do I have to use an Act to apply for access to health information?
A
The Access to Health Records Act 1990 (AHRA) provides a statutory right of
access to information, NHS organisations can chose to disclose information to
individuals outside of provisions of these Acts, subject to confidentiality
considerations.
Q
Can information about third parties be disclosed within a health record?
A
Careful consideration should be made before disclosing third party information, and
consent should normally be sought before disclosure. Where it can be
demonstrated that consent is not practicable, the NHS organisation should weigh
up whether the third party information should be fully released or removed. All
disclosures of information about third parties need to be considered on a case-bycase basis, and decisions about disclosures should be fully documented.
Q
Can information within a health record which identifies health professionals
be disclosed to a patient?
A
Information about health professionals is not normally considered as ‘third party’
information, and as such should normally be disclosed as part of a request unless
disclosure would put any person at risk of harm.
Q
Should individuals be informed if information is withheld from a request?
A
NHS bodies should normally inform patients if information is withheld from them
during an access request, unless doing so would put any person at risk, or would
disclose information or inappropriately identify a third party.
Q
Do researchers have a right to access information from patient health
records when they are unable to gain consent?
A
Research using health information can provide many potential benefits.
Researchers wishing to access information should follow NHS Research
Governance processes and in most cases where access to identifiable information
is sought they should obtain approval from the Health Research Authority (HRA).
Q
Can MPs have access to health information about their constituents?
A
The term ‘elected representative’ covers Members of Parliament (UK, Scotland,
Wales, Northern Ireland and EU), local authority councillors and mayors (and their
equivalents in the developed countries). Specific legislation under the Statutory
Instrument, 2002, No. Representative) Order 2002 enables information to be
disclosed to elected representatives without contravening the Data Protection Act
1998. However, it does not remove the constraints of the common law duty of
confidentiality and as such the common law should still be satisfied (normally be
consent) before information is disclosed.1
1
Section 13 of Model B3 in Confidentiality: NHS Code of Practice (DH 2003) provides more information
about disclosures to MPs
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Q
Should all information available be disclosed to a LSCB when investigating a
child’s death?
A
Local Safeguarding Children’s Boards may require access to health records
relevant to a deceased child from an NHS body to conduct an investigation/inquiry.
It is highly likely that the public interest served by this process warrants full
disclosure of all relevant information within the child’s own records. However, in
some circumstances the LSCB may also require access to information about third
parties (e.g. members of the child’s immediate family or carers). In all cases the
LSCB should explain why it believes information about third parties is relevant to its
enquiries, and you should use this to consider whether or not there is an overriding
public interest to justify the disclosure of the information requested. In cases where
you determine disclosure to be in the public interest you must ensure that any
information you disclose about a third party is both necessary and proportionate.
Q
Should all information requested be disclosed to Coroners for the purpose of
carrying out an inquiry?2
A
It is the Department of Health’s view that the public interest served by Coroners’
inquiries will outweigh considerations of confidentiality unless exceptional
circumstances apply.
When an NHS organisation feels that there are reasons why full disclosure is not
appropriate, e.g. due to confidentiality obligations or Human Rights considerations,
the following steps should be taken:
a)
the Coroner should be informed about the existence of information
relevant to an inquiry in all cases;
b)
the concern about disclosure should be discussed with the Coroner and
attempts made to reach agreement on the confidential handling of
records or partial redaction of record content;
c)
where agreement cannot be reached the issue will need to be
considered by an administrative court.
Q
Should consideration be given to surviving family members when disclosing
information about deceased patients?
A
NHS bodies should have consideration to the potential harm or distress to the
requester or other individuals either through supplying or withholding information.
Where information is disclosed the amount of information provided should be
proportional to the need. Requesters should be sensitively informed where the
decision is taken to withhold information.
Coroners’ inquiries are an important part of determining cause of death in a huge number of cases in
the UK. Prompt access to confidential information regarding patients and others involved in an
investigation is often vital to the reliability of the outcome of an inquiry.
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2
Q
How do Independent Mental Health Advocates (IMHAs) and The Mental
Health Act 2007 apply to access to health records?
A
Under the 2007 Act, certain people (“qualifying patients”) are entitled to support
from an IMHA. Subject to certain conditions, schedule 10 and section 8 (1) (30) ac.
Mental Health Act 2007
http://www.legislation.gov.uk/ukpga/2007/12/pdfs/ukpga_20070012_en.pdf
Q
How do Deputies and Lasting Powers of Attorney and The Mental Capacity
Act 2007 (MCA) apply to access to health records?
A
The MCA generally only affects people aged 16 or over. The Act provides a
statutory framework to empower and protect people who may lack capacity to
make some decisions. The MCA set up a new Court of Protection, which is
permitted to appoint a deputy, to deal with property and affairs and/or personal
welfare decisions. People whilst they have capacity can appoint a Lasting Power of
Attorney, also either for property and affairs and/or personal welfare decisions.
Personal welfare deputies and attorneys can ask to see information concerning the
person they are representing as long as the information applies to decisions they
have the legal right to make.3
Q
Can NHS bodies disclose information in response to allegations made about
the operation and conduct of its staff?
A
Where allegations are made against a NHS body in the media by patients or
relatives the NHS body may wish to respond in order to maintain the reputation of
the NHS. However, in doing so, NHS body should not disclose further confidential
information and the level of disclosure should be proportionate to the need, with
strong considerations on the impact of possible harm caused to others.
Q
How long should health records be kept for?
A
NHS organisations should retain records in accordance with the retention
schedules outlined in the Department of Health Records Management NHS Code
of Practice before determining whether they should be archived or destroyed.4
Where records are to be archived they should be transferred to a designated local
Place of Deposit (POD) or the National Archives. The Code is available from the
following link:
https://www.gov.uk/government/publications/records-management-nhs-code-ofpractice
The Department of Health, in partnership with the Welsh Assembly Government and the Social Care
Institute for Excellence has published a range of materials including training materials to support the
implementation of the MCA.
3
The Department of Health’s Records Management: NHS Code of Practice provides best practice guidance
on records management issues and includes a retention schedule for various categories of records.
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Q
What if records are stored at an archive?
A
Archives may also receive requests for deceased health information from
individuals and may consider the use of this guidance as a framework on decisions
for disclosure.
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