Access to the health and care records of deceased people guidance for health and care professionals

When a patient or service user dies, you may be asked for a copy of, or access to, their record. A family member, for example, might ask to see the record.

These requests will need to be considered carefully. Records related to deceased patients remain subject to a duty of confidentiality, however, it is usually possible to agree to such requests in the appropriate circumstances.

In NHS organisations there will usually be someone who is responsible for dealing with access requests. You should inform the relevant individual or team as quickly as possible of the request, or let the requester know who to contact, depending on your local policy. For requests to access health records, your organisation needs to respond to the request within a set time limit (see the information governance (IG) professionals section for further information about time limits).

There is no equivalent right of access to social care records, so you should check with senior staff whether access should be granted (see the guidance for IG professionals for further information).

You may need to provide information to support those dealing with the request. For example, you may be asked:

• if you are aware of any wishes (written or verbal) of the deceased individual relating to their information being shared
• information about those who have been closely involved in the care of the deceased individual which may inform who records are shared with
• if there is anything in the record which would either cause distress to the family or benefit them to know (Also see the guidance for Information governance (IG) professionals sharing information with family members or individuals close to the deceased)
• if there is any third-party information in the record; for example, information about other family members
• if there is anything in the record which if disclosed might cause harm to another person
• to explain any clinical abbreviations or terminology in the record to help the person who has asked for a copy of the record understand it

You should provide those dealing with the request with the required information or record so that they can facilitate access to the requester.

In cases of uncertainty, you should follow your internal process which will usually involve informing the Caldicott Guardian, so that they can make recommendations about whether information should be disclosed.

If you are a health and care professional who is responsible for making a decision about access, refer to the IG professional section. The British Medical Association (BMA), General Medical Council (GMC) and Medical Defence Union (MDU) have provided further guidance for doctors on requests to access records.