Self-help guide
Name of Records Manager
Address
Dear Sir/Madam
Application for records under the Access to Health Records Act 1990
Full name of the deceased – last address – NHS number – hospital number, if applicable
Please supply the data about [Name of deceased person] that I am entitled to under data protection law relating to:
- their medical records held by you.
[Avma’s note to reader: include the date range you are requesting records for
If you wish to access a deceased persons GP records be aware that when a person dies, their GP health records will be passed to Primary Care Support England so they can be stored for up to 10 years after the death. To access a deceased’s records, you must apply to the records manager in the relevant local area. You can ask your GP for details on who you should contact.
Hospital records will be kept by the records manager at the hospital the deceased attended. Fees may apply for accessing these records. You can apply to the hospital trust’s records department]
- any specific records you are seeking [e.g. x-rays or real-time imaging such as ultrasound].
[Avma note to reader: Be as specific as possible about the records which are required for an initial investigation of the claim. For example, if the events leading up to the alleged negligence included an admission to hospital by way of the Accident and Emergency (A&E) department, immediately after which the deceased person underwent surgery, then developed an infection in the post-operative period and died, the medical records you would probably need to request include: the A&E records (including nursing and clinical notes); operating records; anaesthetic records; daily nursing records including temperature, pulse and respiration charts and fluid balance charts; any laboratory reports, X-rays etc available in relation to the infection etc.]
- any investigation reports [such as root cause analysis, serious investigation report or serious case report] which have been compiled regarding [date and nature of the incident].
- a request for any relevant guidelines, protocols, policies in place at the time you were treated.
- I also request an explanation of any medical terms or abbreviations which might be unintelligible to me.
[Avma note to reader: you should also consider requesting any updates to those guidelines, protocols, policies especially if the allegation of negligence took place some time prior to your making a request for the medical records]
Authority to request these records:
Please find enclosed Grant of probate/Grant letters of administration.
[Avma note to reader: You will only be able to obtain the medical records of someone who has died if you are either a personal representative (the executor or administrator of the deceased’s estate) or someone who has a claim resulting from the death (this could be a relative or someone else). You may find our leaflet on Grant of probate helpful: www.avma.org.uk/guides
You should make your relationship to the deceased clear along with the nature of the claim (see section on details about the incident below) when requesting the records.]
Details about the incident
[Avma note to reader: Under this heading you should set out brief information about the events you are concerned about to alert the healthcare provider to where an adverse outcome has been serious or has had serious consequences or may constitute a notifiable safety incident.]
Copies of medical records
If you need any more data from me, or a fee, please let me know as soon as possible. It may be helpful for you to know that data protection law requires you to respond to a request for data within one calendar month. If you are unable to process this application within that time, then please write to me and let me know when I can expect to receive copies of these records.
If you do not normally deal with these requests, please pass this letter to your Data Protection Officer, or relevant staff member.
Yours faithfully
[Signature]
Name