From Monday 1 August 2022, GP practices are required to respond to Access to Health Records Act (AHRA) requests for individuals who have passed away however, PCSE will process the Access to Health Records request if:
The ethical obligation to respect a patient’s confidentiality extends beyond them passing away. The Access to Health Records Act 1990 (AHRA) provides a small amount of people with the right to access this information:
Please note: Only information directly relevant to a claim will be disclosed.
All applicants will need to provide some documents to be able to access the records.
On behalf of NHS England, the NHS GP Practice medical records for patients who have passed away should include information about:
Sometimes these records don’t always contain a full medical history.
PCSE will process this request, please complete this form (for the below questions please enter the provided answers).
GPs are legally obliged to follow the Access to Health Records Act 1990, as the GP is the record holder as per s3(2) of the Act. If a practice refused to process the request, the requestor should complain to the GP practice and/or raise the issue with NHS England, please see NHS England » Complaining to NHS England.
Deceased patient records no longer need to be printed and sent to PCSE. However, PCSE will still continue to collect any legacy paper Lloyd George records.
If you work at a Practice and are unsure of what steps to take, please contact your ICB / Commissioner regarding the recent GP contract changes.
You remain responsible for the AHRA request but will need to contact PCSE to request the records using our Contact Us form and selecting Subject Access Request and then ‘Information Services Request’.
From 1 August 2022, you only need to provide a statement confirming that you have undertaken the necessary ID checks. Where completing the online form, please attach this statement in place of the verification documents.
PCSE will process this request as before, please complete this form (for the below questions please enter the provided answers as shown).
PCSE will process this request for you as before via our Contact Us form and selecting Subject Access Request.
Please note however, PCSE do not have access to the patient’s digital record and can only provide copies of a Health Record which we hold in storage.
There may be instances where parts of a person’s medical record may be held with Hospital, Community or Mental Health trusts, as well as any previous primary care practice(s). PCSE cannot provide access to these records, and you may wish to make a separate application to the relevant Health Organisation
Primary Care Support England does not store:
· X-rays/transparencies – these will remain with the relevant NHS trust
· digital records
· hospital records – apply to the NHS trust
· private clinic records – available from the clinic concerned.
From Monday 1 August, GP practices are required to respond to Access to Health Records Act (AHRA) requests for deceased patients however, PCSE will process the Access to Health Records request if:
In these circumstances, if the request for a medical record is under the Access to Health Records Act 1990, PCSE will process the access application within 40 days.
In certain circumstances, this may not be possible (for example, where the record cannot be traced, or is held by a third party storage provider outside of the control of PCSE.)
PCSE will update the applicant on likely timescales.
A record may not always contain the patient's full medical history.
PCSE can only provide you with the information we hold.
If there are missing years, please contact the GP Practice where the patient was registered during the period you are missing the information.
To appeal a decision on disclosure please email firstname.lastname@example.org
Please ensure to include a statement as to why you wish to appeal the decision.
If your appeal is accepted, it will be passed to the NHS England Redaction team to review the initial decision.
The personal representative/executor of the estate of a deceased patient has the right to apply for access to that patient's records.
However, the NHS Health Professional, when making their decision on disclosure, may limit the disclosure of the records if sufficient information regarding the reason the record are required has not been provided.
Exemptions to disclosures of information relating to deceased patients
If the deceased person had indicated that they did not wish information to be disclosed, or the record contains information that the deceased person expected to remain confidential, then it should remain so unless there is an overriding public interest in disclosing.
In addition, the record holder has the right to deny or restrict access to the record if it is felt that:
This may happen if the NHSE Health Professional, in the process of disclosing the records, finds that the records are either incomplete or contain illegible notes.
This is because PCSE do not hold the notes in question and they are still retained with the last practice. You would need to direct the request to the last registered practice for the missing/illegible notes.
As the GDPR/DPA only applies to living individuals, the concept of a data controller does not apply to records for the deceased.
NHSE/PCSE would become the record holder of the deceased’s records at the point at which we physically take possession.
Practices remain legally responsible for copies of records retained on local systems. Where a practice retains a copy (be it paper or electronic) of a deceased patient’s record, they are legally obliged to consider it under AHRA. They may choose to direct applicants to PCSE, but must also be prepared to respond directly if an applicant insists on accessing data retained by the practice.
PCSE will consult an appropriate health professional who will review the records and decide which records may be released.
There are certain circumstances in which the health professional may deny access to the complete records or to certain parts of the record:
It is no longer a requirement for GP practices to print off the electronic/digital patient record for a deceased patient. GP Practices can still return the legacy paper Lloyd George medical record (if one exists) to PCSE and PCSE will store it on behalf of the Practice. Should a Practice require an electronic copy of the Lloyd George record to respond to an Access to Health Record application you can request this from PCSE using the online form.
No, 'suspended records' is the term used to describe the medical records of live patients who are not currently registered with a GP Practice. For example, they may have moved to live abroad. Paper records for suspended patients are stored by PCSE on behalf of NHSE and PCSE manage Subject Access Requests relating to these records.
Following a review of NHS England's policies and responsibilities, it was identified that NHSE are not the record holder for the purposes of the Access to Health Records Act 1990 in a number of scenarios. The Access to Health Records Act 1990 is legislation and any application made should be considered in line with the Act. PCSE will process applications where the patient's last GP practice has closed, all other applications should be made to the most recent GP as the 'record holder'.
The term 'record holder' is a legal term used in the Access to Health Records Act and does not relate to the organisation who stores the records.
The Access to Health Records Act 1990 states that the medical records should be reviewed and if necessary redacted by the most appropriate healthcare professional before release. In most cases the appropriate healthcare professional is the most recent GP. The healthcare professional is responsible for deciding whether access should be allowed, which records are appropriate for release and if any redaction is required. There is further guidance around the redaction of records here.
Under the Access to Health Records Act 1990 the most recent GP is the 'record holder' of a deceased patient's medical record. They are the most appropriate healthcare professional to review the medical records in line with any application to access the records. The term 'record holder' is a legal term used in the Access to Health Records Act and does not relate to the organisation who stores the records.
The Application should provide a signed authority for the application setting out whether they are the personal representative or, if not, state the basis under which their application is made e.g. they are the parent, sibling, etc of the deceased and have a claim as a dependent under the Fatal Accidents Act 1976.
If a solicitor is acting on a requester's behalf, it is the solicitor's responsibility to verify that the requester is the legitimate personal representative of the deceased or has a legitimate claim arising from the patient's death. The record holder can accept the solictor's statement that they have done the necessary checks, provided that they submit it to the record holder in writing by letter or email.
If there has been a practice merger since the patient has died, the practice that holds the contract with local commissioners to provide primary care medical services is the responsible record holder.
Documents requested from PCSE will be sent to the GP in PDF format. GPs can upload all documents, including PDF documents, into the record attachments section of the electronic patient record.
Practices may have access to redact patient records using internal software, e.g. in SystmOne called Subject Access Requests. Where electronic redaction software is being used and a patient record has been deducted when the user accesses the record, there will be a prompt to add data, then confirm YES and this allow them to override and add additional information/attachments.
Alternatively, Practices may choose to use third-party software such as IGPR or Adobe Acrobat Pro.