Court quashes decision to refuse request to amend medical record on deceased man’s alcohol intake

The High Court has quashed a decision of the Information Commissioner to refuse a woman’s request to amend part of her deceased partner’s medical record stating that he drank some 40 units of alcohol a week when he was younger.

The man, who suffered from liver cirrhosis, died in September 2017.

Ms Justice Niamh Hyland found the commissioner should have conveyed to the woman the substance of a February 2021 letter from the hospital to obtain her views on it and should have taken that explanation into account when adjudicating on the appeal.

“By failing to observe fair procedures and by failing to take into account material information, the commissioner erred in law,” the judge said.

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The woman had made an application in January 2020 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 “admitting” 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’s mother, who was a teetotaller, had a history of cirrhosis of the liver.

There was further information from the GP that he had no history of excessive alcohol intake. There was also another letter to a doctor which referred to his weekly alcohol intake being between 12 to 20 units and was 14 units prior to him becoming abstinent.

St James’s Hospital refused her request and it was also rejected after going through the hospital’s internal appeals system. The woman then appealed the decision to the commissioner, saying her partner’s file was misleading, incomplete and inaccurate.

At odds

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.

The commissioner also tried to facilitate a settlement of the matter whereby an addendum would be added to the file acknowledging that 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 asked the court to 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.

Failed to supply letter

The woman argued that the commissioner had failed to supply her, as part of the investigation, with a copy of a February 26th, 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. “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 purpose,” it added.

In her judgment quashing the commissioner’s decision, Ms Justice 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 the letter into account in his decision.