The basic principle of medical records is that information should be included if it is necessary, important or relevant to healthcare professionals providing clinical care to the patient.

How much information from child protection case conference notes should be stored in the records of family members?

Any case conference reports need to be considered by a GP, who can then decide where to store the information and whether it should be added to the records of the people concerned.

This applies to:

the children who are the subject of the report
any other named patients, such as the parents.

In some cases, a GP may consider it appropriate to add the report to the children's records, but not the parents'. However, every case is different – so a blanket policy of adding/not adding reports to certain records is not advised.

Should child protection information be securely stored separate from the patient records?

If the information is necessary to allow a healthcare practitioner to provide care and treatment, then it needs to be readily accessible.
If you believe there are good reasons not to store child protection information within the main records, make a clear note in the clinical record where this information is kept. Make sure the information is easily available and accessible when needed by a member of the healthcare team.

In its guidance Protecting children and young people: the responsibilities of all doctors, the GMC states:

'You should store information or records from other organisations, such as minutes from child protection conferences, with the child's or young person's medical record, or make sure that this information will be available to clinicians who may take over the care of the child or young person.

'If you provide care for several family members, you should include information about family relationships in their medical records, or links between the records of a child or young person and their parents, siblings or other people they have close contact with.'

Should the records of family members or cohabitees be flagged when a patient presents in certain circumstances?

Information should be recorded where it will help a healthcare practitioner to provide appropriate clinical care and treatment.

For example, if one child in a household has been added to the at-risk register, a GP will need to consider any other children in the household individually when deciding whether it would be appropriate for this to be flagged in their records – that is, whether it is or could be helpful for clinicians caring for the child. We advise against adopting a blanket policy in this regard.

Children's notes already contain a lot of third party information, such as family history, and it's not always practical to seek the consent of every third party referred to in a child's record. What is important is that you can justify holding information because it is necessary for understanding the child's complete medical history and protecting their best interests, including the child's health and general welfare.

How should doctors respond to requests for disclosure of records when these include information about third parties?

In general, if a patient makes a request for disclosure of their notes, they are entitled to receive copies of all information you hold about them in any relevant filing system, including the main notes and other stored information.

However, while data protection law gives patients access to all information held about them there are some exceptions – notably third party information, where a duty of confidentiality exists. The Information Commissioner's Office (ICO) advises that unless you have the consent of the individual(s) concerned, you may not normally disclose the information.

For example, if a child were to request a copy of their notes in adulthood and these contained sensitive information about a third party, such as a sibling, you would probably not be able to disclose the information without the sibling's consent. In such cases, unless the information can be easily anonymised, you may need to explain to the patient making the request that some information has been withheld because it relates to a third party.

In August 2016 the ICO made a finding against a GP practice where information relating to third parties was not removed before disclosure.

It is important that practices have robust systems in place regarding third party information contained within copies of records released.

Storage and disclosure of child protection documents

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