Info Commissioner's decision over amending medical record is quashed
High Court reporters
The High Court has quashed a decision of the Information Commissioner to refuse a woman's request to amend her deceased's partner's medical record that he drank some 40 units of alcohol a week when he was younger.
Her partner, who suffered from liver cirrhosis, died on September 28th, 2017.
In January 2020, she made an application to St James’s Hospital in Dublin for amendments of what she described as inaccurate and misleading information in his records.
She said some records incorrectly included a reference to excess alcohol intake by her partner and in particular to him “itting” to a doctor to an alcohol excess of about 40 units per week over a 15-year period in his younger years.
She claimed there were other records disputing this. These included a referral letter from the man’s GP in August 2014 that mentioned that the deceased mother, who was a teetotaller, had a history of cirrhosis of the liver.
No history of excess alcohol
There was further information from the GP that he had no history of excess alcohol. There was also another letter to a doctor which referred to his weekly alcohol intake being between 12 – 20 units and was 14 units prior to him becoming abstinent.
St James's refused her request, and it was also rejected after going through the hospital's internal appeals system.
She then appealed the decision to the Information Commissioner saying her partner's file was misleading, incomplete and inaccurate.
Her appeal essentially related to a request that there should be an addendum to a letter in her partner's file, of March 2015 making the 40 units a week assertion. She said this was starkly at odds with his GP's August 2014 referral letter.
The Commissioner rejected her appeal. He concluded that she had not shown on the balance of probabilities that the information she sought to have amended was incomplete, incorrect or misleading. The hospital was justified in refusing to amend the record, he said.
Addendum
The Commissioner also tried to facilitate a settlement of the matter whereby an addendum would be added to the file acknowledging the letter was incomplete, incorrect, and misleading because it did not reflect all of the information available to the hospital at the time. The hospital refused to agree to this.
The woman appealed to the High Court seeking the setting aside of the Commissioner's decision.
She requested that the court send the matter to mediation claiming there was no serious attempt by the Commissioner to effect a settlement. The Commissioner denied the claim and said he saw no benefit in mediation in circumstances where the hospital had already refused to amend the records.
The woman argued the Commissioner had failed to supply her, as part of the investigation, with a copy of a February 26, 2021, letter from St James's which she said was substantially different to the explanations given by the hospital previously.
In that letter, the hospital said the deceased's consultant stood by the 40 units of alcohol consumption information as it was provided by the patient on different attendance dates and that it would be incorrect and inappropriate to alter the clinical record.
The hospital said it would not amend the record. But it added: "To try and provide some comfort and reassurance to (the woman) the medical file is closed and would not be opened again for any future purposes"..
In a judgment quashing the Information Commissioner's decision, Ms Justice Niamh Hyland said she only needed to deal with the alleged failure of the Commissioner to supply the woman with a copy of that letter and the separate failure to take it (the letter) into in his decision.
The judge found the Commissioner ought to have conveyed the substance of the letter to the woman to obtain her views on it and ought to have taken that explanation into when adjudicating on the appeal.
"By failing to observe fair procedures and by failing to take into material information, the Commissioner erred in law", she said.
