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Practice dilemma: Declaring a medical history

In completing a report for a patient who wants to join the police, you note joint stiffness and that his mother has rheumatoid arthritis - but she objects to the release of this information. What should you do? Our legal expert gives advice.

In completing a report for a patient who wants to join the police, you note joint stiffness and that his mother has rheumatoid arthritis - but she objects to the release of this information. What should you do? Our legal expert gives advice.

Firstly you should determine from the mother what information she objects to being disclosed. It may be the reference to her having rheumatoid arthritis, or the reference you have made to her son's history of six months of joint stiffness. Under the terms of The Data Protection Act (1998) you are prohibited from processing (ie disclosing) identifiable personal sensitive information without consent from the data subject.

You are also obliged by the GMC (Good Medical Practice, paragraph 63) to provide a factually accurate report which is not misleading in any way.

If the mother's objection relates to the reference to her illness, then you should amend the report so that she is not identifiable, but its factual accuracy is still preserved.

This could be done by altering the report along the following lines – ‘The applicant has informed me that he has a close family history of rheumatoid arthritis.'

If however she is objecting to the inclusion of information about her son's joint stiffness, you should explain that as she is not the data subject, she does not have authority to request this amendment regarding her son's personal data, and that you are obliged to ensure that any report you prepare is factually correct.

Finally, before sending the amended report to the police, ensure that you have your patient's consent to do so, in accordance with requirements of The Access to Medical Reports Act 1988.

Richard Dempster is a senior medicolegal adviser at the Medical Protection Society

Richard Dempster

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