The scene
An estranged father requested access to his 14-year old child’s medical records. The GP who received the request immediately had concerns about complying as the records contained allegations of child abuse against the father.
The doctor called the MDU for advice and wanted to know whether he was obliged to disclose the child's notes to the father, and if so, whether they could be redacted before sending.
MDU advice
The MDU adviser firstly asked about parental responsibility. The parents had been married, the GP said, but were now divorced. The GMC's 0-18 years (2007) guidance explains that parental responsibility relates to the rights and duties that parents and guardians have by law for their child and is defined in the Children Act 1989.
Mothers and fathers named on the birth certificate (irrespective of marital status) generally have parental responsibility unless this has been removed by the court. In this case, the father appeared to have parental responsibility as it had not been removed and it is not affected by divorce. The adviser confirmed that under the Data Protection Act 2018, a person with parental responsibility has a right to apply for access to their child's health records.
The adviser explained that no information should be disclosed, if disclosure could be contrary to the child’s best interests.
In addition, as the child was 14 years old, the GP should consider whether the child had capacity to decide whether or not the father could see his records. The doctor thought that the child probably had capacity and the adviser suggested he involve the child in the decision.
The adviser suggested the GP see the child on his own to discuss the disclosure of the records to his father. This would determine whether the child had enough maturity and understanding to make his own disclosure decision, and to consider whether disclosure might go against the child’s best interests.
The adviser also suggested the GP check the records for third-party information, which generally should not be disclosed without appropriate consent. This would not apply where the third party was another health professional who has compiled or contributed to the health record or has been involved in the care of the patient.
The records should also be checked to ensure that disclosure of all or part of them would not cause serious harm to the physical or mental health of the child or any other person.
Outcome
The GP confirmed the father did have parental responsibility for the child and also discussed the disclosure with him. The child was aware of the reference to child abuse and consented to the release of his records to his father, explaining that his father already knew about the allegations so the disclosure would not affect their relationship.
The GP carefully documented the discussion. Before the notes were disclosed, references to the child's mother were removed, along with her address.
This is a fictionalised case compiled from actual MDU case files.
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This page was correct at publication on 18/12/2023. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.