Safeguarding: Children and Storing Information
There is no clear-cut guidance on storing information from third parties e.g. Case Conference reports or MARAC information.
The GMC in, Protecting children and young people - GMC (gmc-uk.org) , states the following:
“You should store information or records from other organisations, such as minutes from child protection conferences, with the child’s or young person’s medical record, or make sure that this information will be available to clinicians who may take over the care of the child or young person. If you provide care for several family members, you should include information about family relationships in their medical records, or links between the records of a child or young person and their parents, siblings or other people they have close contact with.”
The GMC guidance therefore allows both scanning and not scanning of these documents as valid options.
The RCGP Child safeguarding toolkit states:
“The coding and documentation of safeguarding information on a patient’s record is as important as the coding and documentation of any other significant medical issue such as cancer, diabetes, depression or learning disability for example. Safeguarding information needs to be immediately obvious on a patient’s notes to all health practitioners* who may access those medical notes for the purposes of direct patient care.”
Factors to consider as a practice:
- If case conference minutes are scanned into the medical record,
- they then form part of the medical record.
- Would a member of the administrative team who is printing out a complete set of this patient’s notes for an insurance company / solicitor be instantly aware that there is sensitive safeguarding information that needs to be redacted? a. E.g. Child Protection Conference Reports or MARAC information – these DO NOT BELONG TO PRIMARY CARE and therefore primary care do not have authorisation to share these notes with anyone. This also applies to safeguarding information held in consultation notes or 3rd party references
- This can then present the data controller with a very difficult to decision of whether to release or refuse to release or redaction of that part of the medical record.
- The primary data controller is Social Services and they are legally required to keep the records for 75 years.
- If case conference minutes are stored separately from the patient record
- They are still potentially deemed part of the record and there are significant other risks which means this is not a recommended practice:
- They may be unlikely to be accessed in an immediate situation e.g. would a locum, be instantly aware from first glance at the notes/Summary Care Record that there are safeguarding concerns for this child/family/adult?
- If this patient moved practice, would the new primary care team be able to instantly identify from the summary that there are safeguarding concerns?
- They may be unlikely to be sent on to a new GP if the child re-registers elsewhere
- They may become mislaid and cause a serious breach in patient confidentiality
There is a choice for practices and two aspects to consider – the case conference summaries and the more detailed case conference minutes.
Hampshire Social Services have decided to only share a summary of the action plan with GPs (2018) – this makes the situation more straightforward. It is suggested that summaries are scanned on in all cases.
The decision is up to each practice, however, for those with summaries and minutes.
Wessex LMCs would therefore suggest the following approach is reasonable with case conference minutes:
- GP to receive and read the minutes of case conference
- GP to code the Child Protection plan and case conference
- GP to free text summarise the pertinent information
- Details should include the name of Social Services Department (who have to keep the conference minutes and plans for 75 years)
- The read code should also be placed on the other children in the household and the adults named in the report
- Code any decisions made in the conference (e.g. removal from list)
- Case conference minutes to be shredded
When releasing notes:
Remember to check for case conference reports as other previous practices may have opted to scan in these reports. There is no clear national guidance on releasing such reports and we can therefore only advise that practitioners seek advice on each individual case to which this applies. You can seek advice from us or more expert advice from your MDO, your named GPs (https://www.wessexlmcs.com/safeguardingcontactdetails) or the information governance team at the CSU if you are based in Hampshire.
More information can be found on our page Wessex LMCs: Online Access to Medical Records – Safeguarding