If you are considering making a complaint against a healthcare professional and/or bringing a clinical negligence claim, it is essential that you have sight of your medical records. The records compiled by the practitioner against whom you have a complaint will be critical in establishing what treatment was provided to you and whether that treatment was negligent and are evidence in support of your claim.

Is there a fee for obtaining my records ?

Under the Data Protection Act 1998 a fee of up to £50.00 is payable to each healthcare professional or body providing notes. On each occasion that updating records are requested, a further fee of £50.00 may be charged.

Under the Access to Health Records Act 1990, there is no limit on the fee that can be charged but we would request that the fee kept to a reasonable limit.

In any event, we will pay these fees for you and recover them either from your opponent on successful conclusion of your claim or from your After the Event Insurer if your case concludes unsuccessfully.

What should the medical records contain?

Your medical records should contain all written notes made by your treating healthcare professionals, all test results, all correspondence they have entered into with you and other parties concerning your healthcare, all scans, x-rays and any reports or investigations into your treatment that may have been carried out by the institution or healthcare professional who has compiled these records.

Who holds the records?

In the case of private practitioners such as physiotherapists, counsellors, osteopaths and privately consulted doctors, the records will be held by the institution or the NHS Trust where you receive the treatment.

If you receive treatment from the NHS at X NHS Trust, to gain access to those records we would write to the Medical Records Officer at the NHS Trust with responsibility for the running of all hospitals within that Trust. If you receive treatment privately from Dr Z, to gain access to your records he or she holds we would write directly to Dr Z requesting copies.

Common difficulties in accessing records

Frequently healthcare practitioners refuse to provide copies of your notes and records to individuals if they think it is in connection with a complaint, and will offer such excuses as “we only release them to your doctor”. But in order to make a complaint or to assess whether you have cause to make a complaint, you need to obtain the medical records first.

Practitioners should not be refusing to provide medical records unless they believe that provision of the information that is contained within those notes would cause injury to you or other people. They should state that when refusing to provide the records. Generally if the records are requested by a solicitor instructed by you, the request is complied with promptly.

However, if your records are requested by a solicitor then any complaints process you are pursuing will be brought to an immediate end. For that reason many patients request their records themselves so that they can pursue a complaint before considering whether they wish to consider pursuing a clinical negligence claim.

What if you want to make a request for another living person’s records?

Generally you cannot make a request for disclosure of another person’s records unless you are their guardian, parent, or litigation friend of the person whose records you are requesting. Therefore parents of children who are minors or under a disability can make a request on behalf of their children for disclosure of their child’s medical records.

What if the person whose records you are requesting has died?

Where a person has died, and you are seeking their medical records you apply for sight of their records under the Access to Health Records Act 1990. The personal representative (an Executor or Administrator of the estate of the deceased) or any person who may have a legal claim arising out of the patient’s death may apply for access. You are only entitled to records made after 1 November 1991 unless it is necessary to see those made earlier in order to understand the treatment that followed. You must make the application in writing and you should be provided with the notes within 21 days. You can be charged a fee for providing and copying the notes and there is no restriction on the amount that may be charged.

How long should it take the Hospital/Doctors to provide you with your records?

Your records should be provided to us within 40 working days of the request being made.

For further information please feel free to call our Medical Negligence team on 0844 800 9860. They will be happy to provide you with as much help as possible.