Published Thu, 2010-10-21 17:24; updated 1 year ago.
This page tells you how to get hold of the records of the care you received during pregnancy, birth and afterwards.
It explains where to go and what to say or write. You have legal rights about obtaining your notes, and these are also explained, but you may be charged for the administration and copying of the notes.
Many of the women who want to know about getting hold of their maternity records are thinking about questioning or complaining about a part of their care.
You do not have to disclose the reason why you want your notes. You have a legal right to obtain copies of your records (subject to certain exemptions) and they can be very helpful should you wish to write a complaint.
However, getting the notes can take time and cost you money.
You may feel that a meeting with maternity staff or a complaint letter setting out your specific anxieties is a better option for you. (Your letter should be sent to the Complaints Manager or Chief Executive of the hospital where your baby was born or where you were treated.)
The NHS is obliged to respond to complaints within 20 working days of receipt.
You might also contact the Patient Advice and Liaison Service (PALS) at your hospital or Primary Care Trust (PCT) who concentrate on explaining and resolving concerns over treatment raised by patients and carers, and ensuring that organisations learn from feedback.
You have a legal right to be sent a copy of your case notes and your baby’s case notes, on written request, under the Data Protection Act 1998.
Most organisations have an application form for you to request access to your records. Contact the Data Protection Officer or Health Records Manager at the hospital where your baby was born or where you were treated and ask them to send you the form (see sample letter overleaf).
If you had a home birth, contact the hospital where the midwives who cared for you are employed – this is likely to be the hospital nearest you.
The contact details for the Health Records’ Department will be on the hospital’s website. You may even be able to download the application form from the hospital’s website. The telephone numbers and addresses of all NHS Hopital Trusts are also in the phone book.
The form will ask for relevant details to ensure that the right information is sent out to you to protect patient confidentiality.
You may also be asked for some form of proof of identity such as a utility bill or copy of your passport or driving licence or be asked to get the form signed by a witness. This form should also explain any charges that will be made and how they are calculated (see overleaf).
If the hospital does not have a specific form for you to use, write to them asking for a full copy of all your notes (including computerised records) and your baby’s notes too.
Ask them to include all relevant attached documents such as letters, X-rays and laboratory result sheets. If you or your baby have been treated at more than one hospital you will need to apply to each hospital.
This is because each hospital keeps its own separate set of notes. Please note that medical records are not kept indefinitely and different organisations may have different retention periods.
If you want the notes your GP (family doctor) holds, write to the practice manager at the practice you attend.
For the health visitor’s notes apply to the Primary Care Trust, Local Health Board or Health and Social Services Trust which employs your health visitor.
Telephone numbers and addresses of NHS Hospital Trusts and PCTs, LHBs and HSS Trusts are in the phone book or you can look at www.nhs.uk.
If you have been involved with social services you may also want their notes about you.
Apply to the social services department for these; they are obliged to supply them to you and can be contacted through your local council.
Sometimes the hospital will suggest you come to look at your notes rather than be sent a copy. This is your choice, and could save you time and money, particularly if there are lots of pages.
You can still have a copy of those notes you wish to keep photocopied, should you wish, although there is a charge (see below).
The hospital will probably insist that you are supervised when viewing the notes, just to ensure that no changes are made and they stay complete.
Sometimes the hospital may suggest that you meet with them to discuss the notes – this can save time and enable you to have an explanation of some of the entries, but you may like to have time to read and absorb the notes before the discussion.
How much can you be charged for asking to see your notes?
Under the Data Protection Act you are entitled to view your records for free within 40 days of the last entry in them.
To get a copy of your notes after having viewed them you would have to pay a fee (see below). If you wish to view your records after the 40 days then an access fee of £10 may be charged.
To get a copy of your notes at that stage you would still have to pay a fee but the £10 access fee would be deducted from the final amount.
NHS organisations are allowed to charge up to £50 for administration/photocopying of notes, usually with a per-page fee, although most hospitals charge a flat administration fee of around £10-25, or £50 if X-rays are also requested since these are expensive to copy.
If you have any difficulties getting a copy of your notes contact the Chief Executive at the organisation concerned and explain the problem. If you still have difficulty you can write to:
- In England The Information Commissioner Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF Tel: 01625 545745
- In Wales Information Commissioner’s Office – Wales 2 Alexandra Gate, Ffordd Pengam, Cardiff CF24 2SA Tel: 02920 894929
- In Scotland Information Commissioner’s Office – Scotland 28 Thistle Street, Edinburgh EH2 1EN Tel: 0131 225 6341
- In Northern Ireland Information Commissioner’s Office – Northern Ireland Room 101, Regus House, 33 Clarendon Dock, Laganside, Belfast BT1 3BG Tel: 028 9051 1270
Your notes must be sent to you within 40 days of your asking for them.
Usually they will be sent sooner. It is wise to keep a dated copy of your request letter, so that you can prove when you asked for your notes if there is a disagreement about this later.
The 40 day stopclock starts when the record holder receives the fee (if appropriate) and enough written information to help locate the records you seek.
Your medical notes make interesting reading and may give you a different perspective on the birth of your baby. You may find the staff had good reasons for their actions, or that there are further issues about which you want to complain.
If you find that the notes are factually incorrect you have the right to have them corrected, or a note from you inserted, putting your version of the events. Sometimes the photocopies are unclear, or times and dates are missing from the edges of the paper – if this happens, ask for a better copy.
If there are things in your notes that you do not understand, you could ask your local NCT antenatal teacher for help, or you could contact the PALS service at the hospital where your baby was born or where you were treated, or your PCT, LHB or HSS Trust, or AIMS (Action on Improvement in Maternity Services) on 0870 765 1433.
Content provided and copyright by NCT, the UK’s largest parenting charity. We support parents through pregnancy, birth and the early days of parenthood through our antenatal and postnatal courses, local support and reliable information.