If you are worried about the care you received from the NHS and are considering whether clinical negligence may have occurred, obtaining your medical records is an important first step. These records set out what treatment you had, when and by whom. They form the foundation of any investigation into whether the care you received met the proper standard.
Why Medical Records Matter
Medical records are more than a set of notes. They contain information about:
- Diagnoses, treatment plans and procedures
- Prescriptions and medication history
- Observations and nursing notes
- Referral letters and test results
For patients, these documents provide clarity about what happened. For solicitors, they are essential evidence in assessing whether there may be grounds for a clinical negligence claim. Reviewing the records often reveals where important steps were missed, where care was delayed, or where there are inconsistencies.
Step by Step: Requesting NHS Medical Records
1. Identify the Right NHS Organisation
Records are held by the NHS trust, hospital, GP practice or other provider responsible for your care. If you have received treatment in more than one place, you may need to make separate requests.
2. Make a Subject Access Request (SAR)
Under UK data protection law, patients have the right to see information held about them. This is done through a Subject Access Request.
- You can write to the hospital, trust or GP practice directly.
- Many organisations have a Data Protection Officer or medical records team that handles requests.
- Some will provide a standard form, but a clear written request by letter or email is also acceptable.
Your request should include:
- Your full name, date of birth and address
- Your NHS number, if you have it
- Details of the treatment or time period you are interested in
- Your contact details
3. Provide Proof of Identity
To protect patient confidentiality, the NHS provider will usually ask for ID. A copy of your passport, driving licence or utility bill is normally sufficient.
4. Timescales for a Response
The law requires that providers respond within one month. If the request is particularly complex, they may extend this by a further two months, but they must tell you if they need more time. Records may be supplied electronically or on paper.
5. Review Your Records Carefully
When you receive your records, check them closely. Look for:
- Missing pages or unexplained gaps
- Mistakes or contradictions
- Dates of treatment that do not match your recollection
- References to follow-up care that did not take place
Spotting these details early helps in building a clear picture of the care you received.
Costs of Accessing Records
Under GDPR rules, NHS patients are entitled to a free copy of their medical records. Charges can only be made in limited circumstances, for example if repeated copies are requested or if a request is considered excessive.
What If You Encounter Problems?
If your request is delayed or refused, you are not without options.
- Chase the provider: contact the medical records or data protection team directly.
- Complain: raise a formal complaint through the NHS trust’s complaints process.
- Escalate to the ICO: if necessary, the Information Commissioner’s Office can investigate and enforce your right of access.
Medical Records and Clinical Negligence
Having access to your medical records is vital if you are concerned about possible negligence. They allow you to:
- Confirm what treatment you received
- Identify where care may have fallen below standard
- Highlight omissions, such as delayed referrals or missed test results
- Provide the factual foundation for an expert legal review
Without them, it is difficult to properly assess a potential claim.
Conclusion
Requesting your NHS medical records is a straightforward process, but one that plays a key role in understanding your care. By using a subject access request, you can obtain a full copy of your notes and begin to establish whether the treatment you received was appropriate. For anyone considering a clinical negligence claim, this is an essential first step.
Samuel nurse
Clinical Negligence Paralegal
Samuel Nurse is a clinical negligence paralegal progressing his legal career through the CILEX route. In his role he focuses on developing a strong understanding of complex medical issues, applying analytical skills and attention to detail to support the progression of claims. His earlier experience at a nursing expert witness company gave him valuable exposure to clinical negligence work and the importance of expert evidence in litigation, which now informs his approach as a paralegal.
