Background
Scope of Review
Preliminary Matters
Analysis and Findings
Decision

Whether CHI was justified in refusing access, under section 15(1)(a) of the FOI Act, to handwritten notes of a multidisciplinary team meeting about the applicant's son on the basis that the records do not exist or cannot be found after all reasonable steps to ascertain their whereabouts have been taken

29 May 2024

Background

In a request dated 10 May 2023, the applicant sought access to handwritten notes from a multidisciplinary team (MDT) meeting about his son that was held in Crumlin Hospital on 29 September 2021. In his request, the applicant noted the names of a number of staff that were present at the meeting. In a decision dated 8 November 2023, CHI refused access to handwritten notes from the MDT meeting under section 15(1)(a) of the FOI Act on the ground that the records do not exist or cannot be found. On 13 November 2023, the applicant sought an internal review of CHI's decision. On 4 December 2023, CHI affirmed its original decision. CHI said that the relevant MDT meeting notes were entered into the Paediatric Intensive Care Unit (PICU) electronic system by a named doctor. (As noted below, I understand the applicant has a copy of the typed note of the meeting.) CHI also said that it confirmed with the relevant nursing team that their practice, if asked to take notes for a patient's MDT meeting is to enter those notes in real-time directly into the patient's healthcare record as opposed to taking any handwritten notes in a separate location for transcription later. On 8 December 2023, the applicant applied to this Office for a review of CHI's decision.

During the course of this review, the Investigating Officer provided the applicant with details of CHI's submissions wherein it outlined the searches undertaken to locate the records sought and its reasons for concluding that no records related to his request exist or can be found. The Investigating Officer invited the applicant to make submissions on the matter. To date, no such response has been received.

I have now completed my review in accordance with section 22(2) of the FOI Act. In carrying out my review, I have had regard to the correspondence as outlined above. I have decided to conclude this review by way of a formal, binding decision.

Scope of Review

CHI's position is that a typed note of the MDT meeting was entered into its PICU electronic system and that no handwritten notes of the meeting exist or can be found. Accordingly, this review is concerned solely with whether CHI was justified, under section 15(1)(a) of the FOI Act, in refusing access to any handwritten notes of the meeting that took place on 29 September 2021 on the ground that no such records exist or can be found.

Preliminary Matters

Before I address the substantive issue in this case, it is important to note that this Office has no remit to investigate complaints, to adjudicate on how FOI bodies perform their functions generally, or to act as an alternative dispute resolution mechanism with respect to actions taken by FOI bodies.

Furthermore, I wish to note that section 13(4) of the Act provides that, subject to the FOI Act, in deciding whether to grant or refuse an FOI request, any reason that the requester gives for the request and any belief or opinion of the FOI body as to the reasons for the request shall be disregarded. While I acknowledge the importance of the records to the applicant, as noted above, this review is solely concerned with whether CHI was justified in refusing access to the handwritten notes of the meeting on the basis that they do not exist or cannot be found.

Analysis and Findings

Section 15(1)(a) of the FOI Act provides for the refusal of a request where the records sought do not exist or cannot be found after all reasonable steps to ascertain their whereabouts have been taken. Our role in a case such as this is to review the decision of the FOI body and to decide whether that decision was justified. This means that I must have regard to the evidence available to the decision maker and the reasoning used by the decision maker in arriving at his/her decision and also must assess the adequacy of the searches conducted by the FOI body in looking for relevant records. The evidence in "search" cases generally consists of the steps actually taken to search for the records along with miscellaneous and other information about the record management practices of the FOI body, insofar as those practices relate to the records in question.

CHI's Submission

As I have outlined above, CHI provided this Office with details of its reasons for concluding that the records sought by the applicant do not exist or cannot be found, details of which have been provided to the applicant. While I do not propose to repeat those details in full here, I confirm that I have had regard to them for the purpose of this review.

In its submission, CHI stated that it searched the healthcare record (the HCR) of the applicant's son for all entries made in relation to the MDT meeting held on the date in question. It said that no nursing notes were documented into the paper HCR in relation to the MDT meeting, which it said is where an entry would have been made if the named nurse who attended the meeting had been taking notes for the Respiratory Team. CHI said in its submissions that it was unable to contact the named nurse as part of processing the applicant's request as she is on extended leave. CHI said, however, that it consulted the nurse's co-workers in order to determine whether any relevant records were held or would have been held and in relation to their record-keeping practices. It said that team stated that they do not keep records of medical notes in their office nor do they retain their own documentation. CHI said that all notes are handwritten into the paper HCR directly if the team is required to make a note.

CHI said that it also contacted the patient's Respiratory Consultant, as the nurse in question would have been attending the MDT meeting as part of the Consultant's team. CHI said the Consultant confirmed that she is not aware of the existence of any handwritten notes in relation to this MDT meeting. CHI also said that if non-Paediatric Intensive Care Unit (PICU) staff attending the MDT meeting were requested to write a record into the paper HCR, they would do so in real time, handwriting directly into the paper HCR.

CHI said it located the typed notes from the MDT meeting, which were held on the PICU electronic system, and are printed and filed into the paper HCR. It said these notes were made by another named doctor, who is a PICU Intensivist. CHI said that if a PICU staff member is required to make a record, they do so directly after the meeting into the electronic system. CHI said that the doctor who typed the note of the meeting confirmed that she does not request anyone to take handwritten notes on her behalf, and that she advised that she would only write down on note paper who the main attendees were at the meeting and would then enter the record of the discussion into the electronic system from memory directly after the meeting. CHI said that this doctor advised it that the handwritten note of attendees was destroyed after the electronic entry was created.

CHI said that, as the applicant's son was admitted to the PICU ward during the date of this MDT meeting, the PICU staff were the staff members documenting the daily records in relation to the patient. It said that PICU staff document their notes on the PICU electronic system, and these electronic records are printed and filed in the paper HCR along with any handwritten notes that are to be retained, documented in chronological order. CHI said that it located an electronic note entered by a staff nurse that contained a reference to the fact an MDT meeting had taken place on the specified date. CHI said that this note contained no details of the meeting itself and directs the reader to the typed note of the meeting for details of the discussion. It said this nursing note was also printed and filed in the paper HCR. CHI said that due to the electronic nature of this note, there was no original handwritten note.

CHI said that the applicant had been previously provided with a copy of the paper HCR and should therefore have access both to the typed note created following the MDT meeting and the PICU nurse's note that the meeting took place. CHI said that these were the only records located in the course of its searches that are relevant to the applicant's FOI request.

In short, CHI's position is that if any notes were made about the MDT meeting of 29 September 2021, they would be held on the electronic PICU system, and/or in the paper HCR. It said that any handwritten notes if they existed would be placed in the paper HCR and not held in a separate location such as a nursing office. It said that as no further records were located in the course of searches, it concluded that no handwritten notes existed or could be found.

Analysis

As noted above, the Investigating Officer provided the applicant with details of the searches carried out by CHI and its reasons for concluding that no records exist or can be found and invited the applicant to make submissions if he wished. To date, we have received no response from the applicant.

On the matter of whether CHI holds relevant records, it is important to note that where an FOI body refuses a request for records under section 15(1)(a) of the FOI Act, the question we must consider is whether the body has taken all reasonable steps to ascertain the whereabouts of relevant records. We do not generally expect FOI bodies to carry out extensive or indefinite general searches for records simply because an applicant asserts that more records should or might exist, or rejects an FOI body's explanation of why a record does not exist or cannot be found.

Having considered the information before this Office in this case and in the absence of evidence to suggest that further searches should have been undertaken, I am satisfied that CHI has undertaken all reasonable steps to locate the records sought by the applicant. While I appreciate that the applicant will be very disappointed by my decision, I find that CHI was justified in refusing access to handwritten notes from the MDT meeting about his son, under section 15(1)(a) of the FOI Act, on the ground that no such records exist or can be found after all reasonable steps to ascertain their whereabouts have been taken.

Decision

Having carried out a review under section 22(2) of the FOI Act, I hereby affirm CHI's decision to refuse access to the records sought by the applicant under section 15(1)(a) of the FOI Act.

Right of Appeal

Section 24 of the FOI Act sets out detailed provisions for an appeal to the High Court by a party to a review, or any other person affected by the decision. In summary, such an appeal, normally on a point of law, must be initiated not later than four weeks after notice of the decision was given to the person bringing the appeal.

Richard Crowley, Investigator

Irish Information Commissioner's Decisions

Mr. Y and Children's Health Ireland