Ms X and St Vincent's University Hospital

• Judge: Senior Investigator
• Judgment Date: 18 May 2020
• Case Outcome: The Senior Investigator affirmed the Hospital?s decision to refuse access to the additional records sought under section 15(1)(a) of the FOI Act on the ground that no further records exist or can be found.
• Court: Information Commission
• Record Number: OIC-60060-K3F7X0
• Respondent: St Vincent's University Hospital

Whether the Hospital was justified in its decision to refuse the applicant’s request for access to certain additional medical records relating to her late mother from May and June 2017 other than those already released to her on the ground that no further relevant records exist or can be found

18 May 2020

Background

On 20 June 2019, the applicant submitted a request to the Hospital for certain information relating to the records of her late mother. Specifically, she sought access to

1. The audit trail for the electronic glucometer for May and June 2017, and

2. All diabetes nursing management screening tools, all nursing management diabetes care plans and all diabetes variance sheets for the May and June 2017 episodes of care.

On 25 June 2019, she submitted an amendment to her request. She also sought access to

3. All nursing handover sheets for her mother for May and June 2017

The Hospital’s FOI Coordinator sought to discuss the request with the applicant and the parties exchanged a number of emails on that matter.

On 9 July 2019, the applicant submitted a further amendment to her request. She said she was also seeking access to

4. The revision history for the electronic glucometer

On 11 July 2019, the FOI Coordinator emailed the applicant and said that all medical records relating to her late mother, including all nursing documentation, had been released to her on 18 December 2018. He also asked the applicant to clarify what she meant by “audit trail” and “revision history”, in order to identify the records sought.

In her response on the same date, the applicant said that the records previously released did not include the diabetic nursing screening tools/care plans and variance sheets for May and June 2017 or the nursing handover sheets that are completed at the beginning and end of each shift, for the period in question. She also explained that “electronic health record technology creates chronological logs and data versions for documents”.

On 2 August 2019, the applicant wrote to the Hospital requesting an internal review of the FOI Coordinator’s “decision not to grant access to the records requested”. She referred to the Coordinator’s email of 11 July 2019 and said the email did not set out whether the Hospital’s position was that it did not hold or could not find the records sought or that the request related to records already released.

She further explained that all electronic health records generate security relevant chronological log that authenticates the accuracy, completeness and reliability of the electronic glucometer health record that was released on 18 December 2018. She said the audit log provides documentary evidence of, among other events, who accessed the EMR; from which location and exactly what actions were taken (queries, print, copy, entry of new data, changes to existing data, deletions etc). She said the revision history is a chronological listing that saves the data versions that was changed.

On 6 August 2019, the Hospital issued a decision on the amended request. It provided a copy of a Quality Control Audit Trail for the glucometers used. While it refused access to diabetes nursing screening tools, care plans and variance sheets under section 15(1)(i) of the Act, which provides for the refusal of a request where the records sought was previously released, it also said that no such records exist apart from the records released. It also refused access to the nursing handover sheets under section 15(1)(i). It said the sheets are filed in the nursing notes section of the current healthcare record. Finally, it refused the revision history sought under section 15(1)(b) on the ground that the applicant had not provided sufficient details to enable the records sought to be identified by the taking of reasonable steps.

On 19 August 2019, the applicant sought an internal review of the Hospital’s decision of 6 August 2019. She argued that there were express references in the records previously released to the existence of diabetes nursing screening tools, care plans and variance sheets and that the nursing handover sheets were missing from the records previously released. She further argued that the audit record released was not the audit trail/log and revision history for the electronic glucometer that is uploaded onto the Hospital’s data management system.

On 9 September 2019, the Hospital issued its internal review decision, wherein it varied its original decision. In relation to part 1, it released a PDF document of an audit log/trail, which it described as containing the chronological log of blood glucose/ketones results...