Guidance

Accessing your medical records

You are entitled to copies of your medical records, which are held by your GP, hospital and anyone that has provided you with medical treatment.

You can make a request to see copies of your medical records to your healthcare provider either verbally or in writing and no fee will be charged to you under normal circumstances.

How do I request copies of my records?

There is no formal process for requesting your medical records, and you can make your request verbally or in writing. This can be made during an appointment, over the telephone, via email or letter to your healthcare provider. Of course, when requesting your records during an appointment or a consultation, you will need to bear in mind the time constraints that doctors and clinicians have during appointments to deal with your request.

When making your request, you may wish to specify which records you wish to review, for example, your computer and paper records, correspondence, test results, schedules of x-rays/scans and continuous CTG traces, if applicable. You can also request a copy of any complaint and internal investigation documentation.

 

How much does it cost?

There will be no fee charged to you for requesting a copy of your medical records. A ‘reasonable fee’ of the administration costs may be charged if your request is clearly unsupported or excessive, or if you wish to request further copies of your records.

How long will it take?

Your medical records should be provided to you within one month of the date of receipt of your request.

This time may be extended by a further two months if the request is complex, or if you have submitted a number of requests. If this is the case, your healthcare provider should inform you of the extended time limit within one month of receiving your request, and explain why the extension is necessary.

Can you apply for someone else’s records?

Yes, you can apply for someone else, if:

  • They are a child and you have parental responsibility;
  • They have died and you are the personal representative or executor of their estate or are someone who has a claim resulting from their death (although different rules apply - see below);
  • You have a power of attorney for them.

How do I apply for a Deceased’s person’s records?

The process is exactly the same as it would be for a living patient, but the request is to be dealt with within the following timescales:

  • Where the medical records were made less than 40 days preceding the date of application, they should be provided within 21 days; or
  • Where the medical records were made more than 40 days preceding the date of application, they should be provided within 40 days.

If the healthcare provider considers that they have not received enough information to enable them to identify the patient, or to satisfy themselves that you are entitled to make the application, they may request any further information they require from you within 14 days.

If further information is requested from you, the time within which your request is to be dealt with starts on the day the healthcare provider has received sufficient information to process your request.

Help with obtaining your medical records

We are very happy to help you obtain your medical records and consider them with you. Following our review we will be able to advise you as to whether there are any concerns regarding the medical treatment or care provided to you that could lead to a clinical negligence claim.

Healthcare Complaints

If you are concerned or unhappy about medical treatment or care provided to you or a loved one, you have the right to complain about it. We have detailed the process below and some tips on how a complaint is best managed.

You can request that your concerns are investigated and that you receive a response providing answers to the questions that you have.

The benefit of pursuing a complaint includes trying to understand what has gone wrong and why.  Many clients who approach us after pursuing a complaint report being frustrated by the process but we can guide you through this.

If you wish you can investigate a potential claim at the same time as pursuing a complaint, you do not need to pursue a complaint first.  We can advise you - at no cost  - on whether pursuing a complaint is the most appropriate step for you to take.

Who can complain?

You can make a complaint on your own behalf relating to treatment you received.  You can also make a complaint on behalf of someone else if:

  • They are a child but only if they are not able to make the complaint themselves;
  • They have died and you are the next of kin;
  • They do not have the mental or physical capacity to do so and you are the next of kin; or
  • They have specifically asked you to deal with the complaint on their behalf.

We recommend that you make your complaint in writing.

You should provide a brief background to the medical treatment that you have received:

  • Where you received the treatment;
  • When you received it;
  • Which clinicians provided the medical treatment;
  • You should try and be as succinct as possible;
  • You should explain why you are concerned about the medical treatment that you received;
  • You should request an acknowledgement to your letter of complaint; and
  • Request that your concerns are dealt with in line with the NHS Complaints procedure.

Who should you write to?

It depends on where you received the medical treatment:

  • Hospitals - The Chief Executive of the NHS Trust responsible for the hospital;
  • GPs and Health Centre - The Practice Manager.
  • A private health provider will have their own complaints process and you can request details of this.

Is there a time limit?

Ideally, you should complain as soon as possible, whilst it is fresh in yours and the clinicians’ minds, so that they are best able to deal with your concerns.

However, in the NHS you have 12 months from the date of the incident to make a complaint.  This can be extended but that is up to the hospital Trust/clinician involved.    

The process

  • In the NHS, you should receive an acknowledgement to your complaint within 3 working days;
  • There will be an investigation into your concerns;
  • After conducting the investigation, you will receive a response letter addressing your concerns;
  • If you wish, you can request a meeting, or this may be offered to you, to discuss the findings of the investigation.
  • If a meeting takes place, ensure that you take someone with you and that a note of the meeting is clearly recorded by the healthcare provider.  You can request that a copy of the meeting notes are sent to you afterwards.

How long will it take?

Unfortunately, there are no time limits for how long it can take to deal with your complaint.  However, it would usually take at least 2 months.

Who can help you make a complaint?

We are very happy to guide you on whether or not to pursue a complaint, the process, help you draft your letter of complaint and deal with the response.

The Patient Advice and Liaison Service (PALS), which is a service found in most hospitals that advice, support and information.

If you are not happy with the response

Our team are very happy to talk you through your options following receipt of the response including whether advice on whether you have a potential clinical negligence claim for which compensation should be paid;

You can take your complaint to the Parliamentary and Health Service Ombudsman.  This must be done within 12 months of the incident.  The investigation is usually lengthy and considers whether the complaint has been deal with satisfactorily by the Trust.

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