Obtaining Hospital Files

One of the first things we recommend to a patient and/or their family prior to making a complaint is to seek a copy of the relevant Medical Records. On occasions we would recommend that the person go to their GP to discuss the contents of the records and their concerns. We might also suggest that the person obtain a second opinion on their case if appropriate. The records can be sought in a number of ways as follows:

Administrative Access Requests

As a matter of policy the Health Service Executive supports the right of a patient to see what information is held about him or her within its service. Generally, access to an individual’s own healthcare record should be provided administratively (subject to some exceptions).

An application for administrative access by a patient seeking access to his/her healthcare record should:

  1. Be in writing and sent to the appropriate service manager.
  2. Supply relevant information to enable the institution locate records e.g. Date of Birth.
  3. Be accompanied by appropriate identification.

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Freedom of Information Requests

The Freedom of Information Act confers on all persons the right of access to information held by public bodies, to the greatest extent possible, consistent with the public interest and the right to privacy. The concept of Freedom of Information is derived from the following principles.

i. Records

Every individual has the right:

  • To know what information is held in records about him or her personally (subject to certain exemptions).
  • To have inaccurate material on file corrected (subject to certain exemptions designed to protect the public interest and the right to privacy).

ii. Decisions

Individuals who are affected by decisions of public bodies have the right to know the criteria used in making those decisions.
Decisions by public bodies should be open to public scrutiny, thus providing greater knowledge of the issues involved and public ownership and acceptance of decisions.
Citizens, as shareholders in public bodies, should have the right to examine and review the deliberations and processes of public bodies, subject to the exemptions provided for in the Acts.

iii. Parents, Guardians and Next-of Kin-Rights

Parents, Guardians and Next-of-Kin have been provided with rights of access to reasons for decisions in respect of certain other persons, e.g. children, deceased or disabled persons with a mental incapacity.
Parents or Guardians have also been provided with rights to apply to have personal information of certain other persons e.g. children, deceased or disabled persons with a mental incapacity, amended if they are incomplete, incorrect or misleading.

iv. Making a Freedom of Information request

Freedom of Information requests do have to be in a specific form. A request must:

  1. Be in writing and assistance must be provided for those who require it.
  2. Specify the records required and the manner in which access is sought.
  3. State that the request is made under the Freedom of Information Act.

There are different forms of access to records which may be requested and granted. These are as follows:

  1. Inspect original record.
  2. Obtain copy of the record.
  3. Hear/view audiovisual record.
  4. Obtain a transcript of tape or shorthand.
  5. Obtain a copy of a computer disk or other electronic device.
  6. Shorthand or code must be decoded.

One of the grounds why a request for information may be refused is where the record is of a medical, psychiatric or social work nature relating to the requester concerned and its release, in the opinion of the Decision Maker, might be prejudicial to the physical or mental well-being of the requester. Where the Decision Maker refuses access under this provision, he/she is obliged to offer access through a registered healthcare professional, nominated by the requester, having expertise in the matter concerned.

v. Right of review

A requester, if unhappy with a decision to release records, has the right of review. This includes:

  1. Internal Review
    In most cases the first avenue is for the patient to request an internal review. This is forwarded to the delegated Internal Reviewer (who is normally a more senior member of staff within the healthcare agency). A decision will be made within fifteen days upon receipt of request for an Internal Review.
  2. Information Commissioner Review
    If the requester is unhappy with the decision of the Internal Reviewer he/she may appeal to the Information Commissioner within six months of the date of notification of the agency’s decision. There is a right of appeal to the High Court, on a point of law only, if either the requester or the Healthcare Agency is unhappy with the Commissioner’s decision. The Supreme Court will in turn deal with any further appeal arising out of a High Court decision.

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Private Hospitals

As Private Hospitals are not covered by the FOI Act a patient should write directly to the Hospital concerned for their records.

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GPs

As GPs are also private practitioners the following arrangements apply in respect of obtaining records:

Private Patient:

A patient or their family should contact the GP practice seeking a copy of their records.

Medical Card Patient:

A patient or their family should contact the Local Health Office of the HSE seeking a copy of their records under the Freedom of Information Act. This is necessary as the GP has a contract to provide the services to the patient with the HSE.

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Data Protection Requests

Data Protection (DP) is the safeguarding of the privacy rights of individuals in relation to the processing of their personal data. People supply information about themselves to healthcare organisations and to medical and healthcare professionals. Data Protection law places obligations on such healthcare providers and all staff who keep personal information.

i. Data Protection Rights

Data Protection rights apply whether the information is held:
In electronic format e.g. on computer.
In a manual or paper based form.

ii. Personal Health Information should be:

Obtained and processed fairly; which means that the person providing it must know the purposes for which it will be used and the persons to whom it will be disclosed.

  • Relevant and not excessive.
  • Accurate, complete, up-to-date and well organised.
  • Held no longer than is necessary.
  • Devoid of prejudicial, derogatory, malicious, vexatious or irrelevant statements about the individual.
  • Purpose specific.
  • Held securely.
  • Accessible to the individual or person acting on his or her behalf on a reasonable basis.

iii. Request for access to records made under the Data Protection Act

A request for access to records made under the Data Protection Acts must:

  1. Be in writing.
  2. Be accompanied by a fee (up to and no more than 6.35 Euro [2007]).
  3. Specify the records required and the manner in which access is sought e.g. inspect the original, obtain photocopies etc.
  4. State that the request is being made under the Data Protection Act.
  5. Provide proof of identity.

Many requests may involve the release of documents, which may be accessed without resorting to the Data Protection Acts. A non Data Protection request should usually be made to the local office of the hospital in question. If the information cannot be released routinely the requester will be advised accordingly and informed of his/her rights under the Data Protection Acts.

If a request has already been dealt with under the Freedom of Information Acts it must still be processed separately under the Data Protection process, as if it were a new request.

Personal health information should only be used or disclosed for the purpose for which it was collected or for another directly related purpose. It can be used or disclosed for some other purpose only where:
The patient concerned has explicitly consented to the proposed use or disclosure.

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