Care files: sensitivity and openness needed when compiling and sharing records

By David Riley

Julie Levitt’s recent blog on reading the social services file on her time in care highlighted the need to record information with care and sensitivity. Perhaps few working in social care would have thought their recording of information – the way in which it was recorded, the language used, etc – could be accessible to the people it concerned some years after it was actually written. Even now, with the ever-growing demands of the job and the rush to complete tasks, how much thought is given to what and how we record, taking on board that it may be read by the person it is about?

The Data Protection Act enables individuals to apply to see the information an organisation holds about them, known as a subject access request. Although this is potentially a very time-consuming task, it can bring benefits to the person seeking information and understanding about their past, and can be challenging and thought-provoking in the decisions to be made about the disclosure of information. Drawing on my experience as the social worker charged with addressing a council’s subject access requests until earlier this year, there are a number of lessons and tips for good practice I’d like to suggest:

1. There can be a conflict of loyalties, and a temptation to avoid the disclosure of information that may be uncomfortable – for the worker as well as for the data subject. Material that does not reflect favourably on the agency may be contained within the recording. There may be documents which show that procedures had not been followed, or information which may cause offence and/or upset to the data subject. However, this has to be disclosed.
2. Social care files will contain a great deal of information, not only about the person who the records are about but about others linked in some way or other to that individual. The aim is to release as much information as possible to the person making the request. However, generally only personal information relating to the person making the request can be disclosed. Redaction is common to remove or conceal information about third parties, so that we don’t disclose personal data about other people. Everybody should be allowed respect for confidentiality and privacy in their lives, and this extends to the deceased.
3. Adopt reflective and anti-oppressive practice. For example, in progressing subject access requests I had separate phone conversations with two women who as children were looked after. Each remarked on how “strange” it felt for them that somebody they’d never met was actually going through their records. How might women who have been the victims of abuse at the hands of men feel about a male social worker working through recordings of their experience of abuse and sharing these recordings with those same women? We may become desensitised to the fact that each record is very personal and unique to each individual. Good practice should involve a face-to-face meeting between the person undertaking the file redaction and the person requesting the information, and consideration of issues of gender.
4. Try to make the records truly accessible. It shouldn’t just be a case of despatching an absolute mass of ill-organised written material. The records need to be legible and well-arranged. For example, K had extensive social care involvement over the course of her childhood, including experience of being looked after. There were extensive paper records. She remarked that “10 folders were sent in all. I get what you mean with the handwriting, it is very difficult to work out, but my partner has proven to have a dab hand in reading messy writing so that’s good”.
5. Avoid using social work jargon when recording information. As social workers we will be familiar with the meaning of CPC, Strategy Meeting, a section 47, etc, but these may not have any meaning to those requesting access to their records.
6. Be careful about using negative and emotive terminology. For example, J’s records variously described him as “of low average intelligence… a lonely, confused, maladjusted boy”, and there were references to his mother as a “psychopathic personality” – this may not have been positive for J to read and dwell upon.

David Riley is a registered social worker. His previous work has included addressing subject access requests from those who had contact with a local authority social care department.