Confidentiality and disclosure of information

Picture the scene. In the middle of a busy ward round, you are asked to speak to a social worker who has contacted the ward by telephone. The social worker tells you that concerns have been raised by a relative of Mrs Smith, an elderly patient admitted from home with dehydration and widespread bruising. You are asked to disclose information about the patient’s medical history.

On your way back to the ward, you are stopped by the daughter of another patient, Mr Jones, who wishes to discuss her father's recent diagnosis of disseminated colonic carcinoma.Relatives will often ask you for information about a patient, but what if the request comes from the police, social services or another third party? Dr James Lucas, medico-legal adviser, explains when it may or may not be justifiable to disclose confidential information.Confidentiality is central to the bond of trust between doctor and patient. Respecting patients' rights to confidentiality is one of the duties of a doctor registered with the General Medical Council.All information about a patient should be considered confidential, including their personal details, records of admission to hospital or attendances at clinics, and the very fact that a person is or was your patient.Consent is the foundation stone of disclosure, although there may be certain circumstances in which it is appropriate to disclose confidential information in the absence of consent (or even against the patient's wishes).The GMC makes clear in Confidentiality (2009) that asking a patient for their consent to disclose confidential information demonstrates respect and is part of effective communication with a patient.

Disclosures to family members

You should not assume that a patient will agree to disclosure simply because they have a close personal relationship with the person seeking information. The patient's express consent should be obtained

... there are circumstances in which you are legally obliged to provide confidential information...

Difficulties may arise when a patient lacks capacity to consent to disclosure, for example, when a patient is admitted in an unconscious state, or suffers from cognitive impairment secondary to a neuro-degenerative illness. Paragraphs 59 and 60 of Confidentiality (2009) contain guidance relevant to this scenario, emphasising that you must respect the patient's dignity and privacy.

In order to assess a patient's best interests, it may be necessary to share confidential information with someone close to them but that does not equate to a general right of access to the patient's clinical records. And in these circumstances, you should only share relevant information.

Considerations in cases where the patient lacks capacity to consent:

  • Is the patient's lack of capacity permanent or temporary?  If temporary, can the decision to disclose reasonably wait until they have recovered capacity?
  • Has the patient previously expressed any preferences?
  • Has the patient asked you to consult anyone or is there someone with legal authority to make decisions on their behalf?
  • Have you considered the views of people who are close to the patient? For example, do they consider the proposed disclosure to be in the patient's best interests?
  • What do you and the healthcare team know about the patient's wishes, feelings, beliefs and values?

Examples of disclosures that are required by law

  1. Following an order made by a judge or presiding officer of a court.
  2. In certain cases of communicable disease, when you must inform the proper officer of your local authority.
  3. Preventing the commission of an act of terrorism.
  4. To comply with a statutory request made by a regulatory body such as the GMC.

Disclosures to social workers, police and others

From time to time you may have to share confidential information with an agency providing social care. It is important that the patient is aware of this and consents. You should only disclose the minimum information necessary and take care not to breach another person's confidentiality.

If you believe that a patient is being neglected, or physically, sexually or emotionally abused, and the patient lacks the capacity to consent to disclosure, you must inform an appropriate responsible person or statutory agency.

Confidentiality (2009) makes clear that you must not disclose personal information to a third party, such as solicitor or police officer, without the patient's express consent, unless it is required by law or can be justified in the public interest. However, there are circumstances in which you are legally obliged to provide confidential information to the authorities. Patient consent is not necessary in these circumstances, but it is good practice to notify the patient, where practicable, unless to do so would undermine the purpose of the disclosure.

Gunshot wounds and wounds caused by a blade or sharp instrument are considered to represent a special category of injury, and doctors working in emergency settings are advised to be familiar with the GMC's supplementary guidance on disclosure in these circumstances.

The decision to disclose confidential information in the public interest can sometimes be finely balanced.

There may also be cases where the public interest overrides doctor/patient confidentiality, for example if failure to make the disclosure could expose others to a risk of serious harm or death. But doctors should remember that there is also a public interest in the provision of a confidential medical service. You must balance the potential harm to the patient’s interests and the overall trust between the profession and the public, against the benefits to be gained from releasing the information. You should still ordinarily seek your patient's consent unless to do so would be impracticable, would put you or others at risk of harm, or would prejudice the purpose of the disclosure.

The decision to disclose confidential information in the public interest can sometimes be finely balanced. A detailed note should be made in the patient's clinical record and doctors should always be prepared to justify their decisions. We encourage doctors in training grades to discuss these cases with a senior colleague, preferably the consultant in charge of the patient’s care, if they are available.

Occasionally, it may be necessary to seek input from your trust's Caldicott Guardian or legal department. If you do have concerns, don't hesitate to seek guidance from one of our medico-legal advisers via the MDU's 24-hour advisory helpline.

Outcome

At the conclusion of the ward round, you discuss the social worker's request for information about Mrs Smith with your consultant and the rest of the clinical team. You establish from a GP referral letter that Mrs Smith is on warfarin. The district nurses have had difficulty obtaining blood from her due to the condition of her peripheral veins, and this had led to the development of bruising on her upper limbs. Mrs Smith is drowsy and unable to participate in any meaningful discussion, however, your consultant expects her to recover with fluid replacement within 24 hours. The team agrees that the decision to disclose information to social services could reasonably wait for Mrs Smith to regain capacity. The social worker is informed of the decision.

You then speak with Mr Jones, who is very keen for information to be shared with his daughter. However, he would like to participate in the discussion and you arrange for a private room, out of earshot of the ward, to be made available for a meeting.

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This guidance was correct at publication . It 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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