How do I gain access to my birth notes?
If you have questions about your traumatic birth, your birth notes should be able to provide some answers. Anna Vroobel, a senior associate medical negligence solicitor at Irwin Mitchell, one of our trusted legal partners, explains how to ask for them
After a traumatic birth, you may have questions about your pregnancy or birth – either because you need more information about what happened, or because you want to know why the medical professionals made certain decisions or took the actions that they did.
The best place to start is by looking at your medical records. Everyone has the right to apply for access to their own medical records, a right that is protected by the General Data Protection Regulation (GDPR) in conjunction with the Data Protection Act 2018.
How do I request my records?
You must make your request in writing directly to the healthcare provider – either your GP practice or the hospital that looked after you during pregnancy and birth. Any records to do with appointments in hospital or with the community midwifery team will be kept by the hospital, while records associated with GP appointments during pregnancy will be held by the GP practice. To request your records:
From a hospital. Make the request to the records manager or patient services manager at the hospital trust or board (for NHS care) or hospital group (for private medical care). You should be able to find the email address on the trust website. If your pregnancy was managed at one hospital but you gave birth at another hospital, you will need to contact both hospitals in order to obtain your full set of records
From a GP surgery. Make the request to the surgery’s practice manager. Again, the email address should be on the surgery’s website.
The hospital or GP website will have details of how to make the request. Some healthcare providers will have a request form that you need to fill out, and they may also ask to see documents to prove your identity.
When you make a request for your records, you should specify whether you would like copies of all or part of your medical records. If there are any records that you particularly want to see, such as scan pictures or blood test results, you should mention this in your request. Make sure you also ask to see copies of your baby’s records if there are aspects of their care that you are interested in.
If you’re making the request via a form, there is often a box where you can select whether you want the records to be provided as a hard copy or an electronic download. If you don’t specify a preference, the healthcare provider will send the records in its preferred format.
Your healthcare provider is legally obliged to provide your medical records free of charge. The only exception is if the request is “manifestly unfounded or excessive”. There is very little guidance on this but the assumption is that the threshold set here is fairly high and will hardly ever apply in practice.
How long does it take?
You are entitled to receive a response from the healthcare provider no later than 28 days after they have received your request. Sometimes, they might ask for additional information before sending the copies. In such cases, the 28-day time limit will begin as soon as they have received the additional information.
The 28-day time-limit can be extended for two months for complex or numerous requests where the medical record provider needs more time to collate and supply the data. They should inform you about this within 28 days of the initial request and provide you with an explanation of why the extension is necessary.
If you don't receive your requested medical records within 28 days, you should first contact the organisation that holds the records and inquire about the delay. If you are dissatisfied with their response, you can make a complaint to Information Commissioner’s Office (ICO).
Hospitals will not keep your pregnancy and birth records indefinitely, but they have a legal obligation to keep them for a period of 25 years after you gave birth.
What should I do if I receive my medical records and I think something is missing?
If you receive your medical records and believe that certain records are missing, you should contact the healthcare provider (your GP surgery or the hospital which that managed your pregnancy and birth care) to let them know. It is helpful to identify exactly which records you believe are missing, to assist the healthcare provider in their search.
If the healthcare provider refuses to supply you with your medical records without good reason, you can make a complaint to the ICO. In some circumstances you may be able to apply to Court for an order to obtain the missing medical records but it’s best to seek legal advice if you wish to take this step.
What should I do if I find inaccurate information in my medical records?
If the information within your medical records is inaccurate, you can ask for that information to be corrected or deleted. For example, there might be a note in your medical records saying that you have high blood pressure when your blood pressure readings have always been within normal range. This is the sort of note which you can ask to be corrected.
If you think that any information in your medical records is inaccurate, it’s best to talk to the health professional looking after you in the first instance. You should explain clearly what you believe is inaccurate or incomplete, how you believe the medical record should be corrected and, if possible, provide evidence of the inaccuracy.
You can make the request to correct your medical records either orally or in writing but if you do make an oral request, it’s best to follow it up with a written one so that you have a record of your request. If you are unhappy with how the healthcare provider has handled your request, you should first make a formal complaint directly to the person that you have been corresponding with. If you remain dissatisfied with the healthcare provider’s response, you can make a complaint to the ICO.
There are some circumstances in which a healthcare provider is unlikely to amend your medical records, despite your request to do so. Whilst an incorrect factual statement will often be corrected, a healthcare provider is unlikely to agree to amend notes which relating to a doctor’s medical opinion.
There may also be a situation where an initial diagnosis has been found to be incorrect once further tests and investigations have been undertaken. In these circumstances the healthcare provider is likely to maintain that reference to both the initial incorrect diagnosis and the final correct diagnosis need to be included in your medical records. Although an initial diagnosis may later be found to be wrong, a note will be kept in your medical records because it shows the thinking of your treating medical professionals at the time before the final correct diagnosis was arrived at.
You can find out more about our legal partners at: https://www.birthtraumaassociation.org/trusted-legal-partners
