Request for a child's notes

The scene

A GP received a request for a 14-year old child's records to be disclosed. The request came from the child's father, whom the GP knew to be estranged from the mother. The GP immediately had concerns about complying with the request as the notes contained allegations against the father of past abuse of the child.

The doctor called the MDU for advice. He 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 the parents' marital status, in order to determine 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 married fathers 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 divorce1. The adviser confirmed that under the Data Protection Act 1998, a person with parental responsibility has a right to apply for access to their child's health records.

As the child was 14 years old, the GP should consider whether the child had capacity to decide for himself whether or not the father could see his records. The doctor confirmed that he was confident that the child 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. In determining whether to disclose the records, the GP would also have to consider whether this was in the best interests of the child, even if the child consented, particularly if there was sensitive information about the father in the notes.

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 patient6. 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 that 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. The GP carefully documented the discussion he had had. Before the notes were disclosed, information that had been provided by the child's mother was removed at her request.

Dr Shelagh Turvill
Medico-legal adviser

This page was correct at publication on 04/12/2013. 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.

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Comments

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DR BAJWA

The intention of the father is not mentioned anywhere. Why did he want to see the notes or does it not really matter. If the father was also one of the same surgery patient, the medical record of the father should also have been considered while making the decision that was made in accordance with child's consent and father's parental responsibility.

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