There may be occasions when the Trust is asked to provide letters, reports, questionnaires or statements about a patient from a clinical perspective from someone involved with the patient's care. These requests may come from solicitors or other organisations (for example the Department of Work and Pensions, DVLA, etc.) on behalf of the patient to assist in legal cases or in relation to benefits or claims.
- These requests may come in directly to the service/team or often via the Access to Records team
- These requests must be handled and responded to directly by the relevant service/team
- They are the responsibility of the patient's clinician/healthcare professional/team and must be completed in a timely manner.
- In line with Data Protection legislation, staff must ensure that there is an appropriate legal basis (such as for the provision of direct healthcare or with the individual's written permission/authority) to share and disclose the requested information.
Please note that these requests are not access to records requests for the Information Governance Team to be dealing with. The Information Governance Team handles requests for copy records and providing copy records in these situations is not an acceptable alternative as it is not what they are asking for and it would be considered excessive, resulting in a breach of Data Protection legislation.
From an Information Governance perspective, responses must be kept factual, pertinent to the questions asked and only provide the minimum necessary information on a strict need-to-know basis in line with the Caldicott Principles. If a question is asked that you do not know the answer to, be truthful and simply inform the requestor that.
The service/team will need to respond directly to such requests, ensuring their response and outcome is appropriately recorded and communicated as per Section 2.17.2 of the Trust's record keeping procedure.
It is also advisable for the service/team to liaise with their Head of Operations regarding any such requests for advice and guidance on how these types of requests should be handled within their service/team.
If clinicians/healthcare professionals do not want to complete these types of requests, then it will need a decision from operational senior management (with input if necessary from Hill Dickinson, the Trust's solicitors) and then the service/team, or the manager, will then need to inform the person/entity making the request of the outcome.
Once completed, the response must be sent securely and confidentially to the requestor, for example by encrypted email or recorded delivery post. A copy of the request and the response must be saved on the patient's record on the relevant Electronic Patient Record (EPR) (as it may be relevant to clinical decision-making).
If it is the clinician's service's/team's standard operating procedure that they do not handle such requests, then they must inform the requestor immediately and save the request and response on the patient's record on the relevant EPR.