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Access to medical records for young people

Since the advent of The Data Protection Act 2018 and GDPR the LMC has received a number of queries regarding access to medical records for children and young. Young people with capacity have the legal right to access their own health records and can allow or prevent access by others, including their parents. In any event you should usually let children access their own health records. No patient should be given access to information that would cause them serious harm, or any information about another person without the other person’s consent. In England, the DPA sets the age of consent for access to medical records as thirteen.

You can let parents access their child’s medical records if the child or young person consents, or lacks capacity, and it does not go against the child’s best interests. If the records contain information given by the child or young person in confidence you should not normally disclose the information without their consent.

Divorce or separation does not affect parental responsibility, unless stated in the terms of the divorce or separation. For children aged under thirteen you should allow both parents reasonable access to their children's health records, unless there is a legal order preventing this.

Patients aged thirteen or older should be asked whether or not they want parents to have access to their medical information. This consent or lack of should be recorded in the medical record.

More detailed guidance is provided by the GMC-

  • Respecting patient confidentiality is an essential part of good care; this applies when the patient is a child or young person as well as when the patient is an adult. Without the trust that confidentiality brings, children and young people might not seek medical care and advice, or they might not tell you all the facts needed to provide good care.
  • The same duties of confidentiality apply when using, sharing or disclosing information about children and young people as about adults. You should:
  1. disclose information that identifies the patient only if this is necessary to achieve the purpose of the disclosure – in all other cases you should anonymise the information before disclosing it
  2. inform the patient about the possible uses of their information, including how it could be used to provide their care and for clinical audit
  3. ask for the patient’s consent before disclosing information that could identify them, if the information is needed for any other purpose, other than in the exceptional circumstances described in this guidance
  4. keep disclosures to the minimum necessary.

Sharing information with the consent of a child or young person

  • Sharing information with the right people can help to protect children and young people from harm and ensure that they get the help they need. It can also reduce the number of times they are asked the same questions by different professionals. By asking for their consent to share relevant information, you are showing them respect and involving them in decisions about their care.
  • If children and young people are able to take part in decision-making, you should explain why you need to share information, and ask for their consent. They will usually be happy for you to talk to their parents and others involved in their care or treatment.

Sharing information without consent

  • If a child or young person does not agree to disclosure there are still circumstances in which you should disclose information:
  1. when there is an overriding public interest in the disclosure
  2. when you judge that the disclosure is in the best interests of a child or young person who does not have the maturity or understanding to make a decision about disclosure
  3. when disclosure is required by law.

Public interest

You can disclose, without consent, information that identifies the child or young person, in the public interest. A disclosure is in the public interest if the benefits which are likely to arise from the release of information outweigh both the child or young person’s interest in keeping the information confidential and society’s interest in maintaining trust between doctors and patients. You must make this judgement case by case, by weighing up the various interests involved.

When considering whether disclosure would be justified you should:

  1. tell the child or young person what you propose to disclose and why, unless that would undermine the purpose or place the child or young person at increased risk of harm
  2. ask for consent to the disclosure, if you judge the young person to be competent to make the decision, unless it is not practical or appropriate to do so. For example it would be inappropriate to ask for consent if you have already decided that a disclosure is likely to be justified in the public interest.

If a child or young person refuses consent, or if it is not practical or appropriate to ask for consent, you should consider the benefits and possible harms that may arise from disclosure. You should consider any views given by the child or young person on why you should not disclose the information. But you should disclose information if this is necessary to protect the child or young person, or someone else, from risk of death or serious harm. Such cases may arise, for example, if:

  1. a child or young person is at risk of neglect or sexual, physical or emotional abuse (see paragraphs 56 to 63)
  2. the information would help in the prevention, detection or prosecution of serious crime, usually crime against the person27
  3. a child or young person is involved in behaviour that might put them or others at risk of serious harm, such as serious addiction, self-harm or joy-riding.

If you judge that disclosure is justified, you should disclose the information promptly to an appropriate person or authority and record your discussions and reasons. If you judge that disclosure is not justified, you should record your reasons for not disclosing.

Disclosures when a child lacks the capacity to consent

Children will usually be accompanied by parents or other adults involved in their care, and you can usually tell if a child agrees to information being shared by their behaviour. Occasionally, children who lack the capacity to consent will share information with you on the understanding that their parents are not informed. You should usually try to persuade the child to involve a parent in such circumstances. If they refuse and you consider it is necessary in the child’s best interests for the information to be shared (for example, to enable a parent to make an important decision, or to provide proper care for the child), you can disclose information to parents or appropriate authorities. You should record your discussions and reasons for sharing the information.

Disclosures required by law

You must disclose information as required by law. You must also disclose information when directed to do so by a court

 

 

 

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