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Safeguarding: Filing of Child Protection Documents

Updated on Friday, 23 June 2017, 1885 views

The LMC has decided to issue a more detailed position on this area.

The GMC 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.

There are two aspects to consider – the case conference summaries and the more detailed case conference minutes.

Factors to consider as a practice:

This is very important information and health care professionals involved in caring for individuals need to know relevant information.

This information is highly sensitive.

If case conference minutes are scanned into the medical record – they then form part of the medical record. This means that future requests for copies of the medical records eg insurance/ lawyers technically include these as well. 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. There is no clear national guidance on the release of such documents as part of the GP medical record and we can therefore only advise that practitioners seek advice on each individual case to which this applies where they feel uncertain. You can seek advice from us or more expert advice from your MDO, your named GPs (https://www.wessexlmcs.com/safeguardingchildrencontactdetails) or the information governance team at the CSU if you are based in Hampshire.

If case conference minutes are stored separately from the Lloyd George file they are still potentially deemed part of the record and there are significant other risks which means this is not a recommended practice:

They are unlikely to be accessed in an immediate situation
They are 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

We recognise that there is national guidance from the RCGP which says as below. Guidance is just that - there is therefore a choice for practices but once scanned in the report is then deemed part of the medical record for posterity. If you do this then you need to highlight that third party information is included so this can be easily identified and removed prior to sharing the record.

RCGP advice

“Case conference minutes frequently raise concerns because of their size and the content

(much of it about third parties). They should be processed and stored in the following way:

 

Read Code significant details

Scan Summary/Plan

 Scan Full Report

Subject child

Yes

Yes

Yes*

other children in household

Yes

Yes

No

Adults Named in Report

Yes

Yes

No

Table extracted from Safeguarding Children & Young People - A Toolkit for General Practice, RCGP & NSPCC 2011.  

*The minutes should be read by the relevant GP. The GP should identify any pertinent information in the minutes. If the minutes contain a majority of pertinent information that other professionals are likely to need to know, particularly where they are taking the case on cold (such as a locum, or GP receiving the patient on a transfer) then the full minutes can be scanned. If there is little pertinent information this should be entered as free text notes on the child’s record. Following either the scanning, or entry of pertinent information, the paper copy should be securely disposed of (i.e. shredded)”

Hampshire Social Services have decided to only a summary of the action plan with GPs (2018) – this makes the situation more straightforward. As you can see 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 (8CM6) and case conference (further read codes can be found here)

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/safeguardingchildrencontactdetails) or the information governance team at the CSU if you are based in Hampshire.

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