By e mail
LRF/NG/LMS/FOI
16th April 2013
Ms S Davis
Dear Ms Davis
I refer to your request for information under the provisions of the Freedom of Information Act 2000.
You requested the following information relating to Hospital Chaplaincy :
Do policies or procedures exist to:
a. establish whether a patient admitted to any hospitals does or does not wish to receive contact from a hospital chaplain
Nursing Admission Procedures request information about the Religious Affiliation of patients on admission to hospital. Currently there is no specific question, as part of that documentation, about whether or not the patient would like a visit from a Chaplain.If, however, a patient as a result of the question about their religious affiliation requests a visit from a chaplain or makes it clear that they do not want to see a Chaplain that information is passed to the Chaplaincy Department.
All patients are asked by nursing staff on a weekly basis if they wish to see a Chaplain or attend an act of worship in the Chapel. Requests are then passed to the Chaplaincy Department. Any patient or relative who specifically requests no contact with a Chaplain can make their views known and again this will be passed onto the Chaplains.
b. ensure that patients (or their visitors, next-of-kin etc.) do not receive unsolicited contact from chaplains
All Chaplains work within the remit of:
1) UK Board for Healthcare Chaplains Code of Conduct for HealthcareChaplains
2) NHS Chaplaincy Meeting the Religious and Spiritual Needs of Patientsand Staff Guidance for managers and those involved in the provision of chaplaincyspiritual care
3) UK Board for Health Care Chaplaincy - Spiritual and Religious Care Capabilities and Competences for Healthcare Chaplains
Part of the role of the Chaplain identified in these standards and codes of practice is to protect patients and staff from any unwanted visits from members of faith communities, this includes Chaplains.Chaplains work with a referral system. Referrals come directly from patients and their families, through multidisciplinary teams and through community contacts. Verbal consent is taken from all patients, visitors and next of kin before proceeding with any interaction. Whilst visiting wards or departments to follow up referrals conversations frequently occur with other patients and families. Any contact is only made with their consent.
Chaplains always check with ward staff to ensure that if any one has made a clear request not to meet a Chaplain their wishes are acknowledged and respected.
c. safeguard patients’ personal and medical data such that hospital chaplains by default do not have access to it
Chaplains arerecognised as an integral part of the professional multi disciplinary team in the Trust, and are bound by the same protocols and policies concerning confidentiality as any other member of staff.
Confidentiality and Security (Data Accreditation)
Information Governance Policy
The Data Protection Act allows Chaplains to access data on a need to know basis and with the consent of the person involved. The Trust’s electronic record system does not directly provide Chaplains with information about Religious Affiliation (deemed sensitive information). Access to data is limited to that needed for a Chaplain to meet the spiritual and religious needs of patients as part of the multi-disciplinary team caring for a patient.
d. ensure that hospital chaplains, when given access to patient data, do not share any of it with third parties
Chaplains arerecognised as an integral part of the professional multi disciplinary team in the Trust, and are bound by the same protocols and policies concerning confidentiality as any other member of staff. No information is shared with third parties. There are occasions when patients will ask a Chaplain to contact their Faith Community on their behalf. This is only done with their express consent.
Outline the approach for monitoring adherence to the policies and procedures above.
All Chaplains undertake mandatory training each year and have an annual appraisal. Data Protection is part of the Trust mandatory training and details of participation is recorded centrally.
The Trust’s electronic record system can identify unauthorised access to patient records and any unauthorised access is reported to and acted on by Trust management.Compliance is also monitored through the Trust’s complaints procedure.
A summary of the results of this monitoring for the last five years, including rates of compliance with the policies and procedures, and severity of any non-compliance events. Provide me with details of any action taken in respect of any non-compliance identified (e.g. tightening of procedures, disciplinary action – in the latter case, taking care not to disclose any personal information).
There has been no recorded non compliance during the period.
I trust this information is useful. The information supplied to you continues to be protected by the Copyright, Designs and Patents Act 1988. You are free to use it for your own purposes, including any noncommercial research you are doing and for the purposes of news reporting. Any other reuse, for example commercial publication, would require the permission of the copyright holder. Many documents supplied by the Newcastle upon Tyne Hospitals NHS Foundation Trust may have been produced by government officials and will be Crown Copyright. You can find details on the arrangements for re-using Crown Copyright on HMS Online at:
Information you receive which is not subject to Crown Copyright continues to be protected by the copyright of the person, or organisation, from which the information originated. You must ensure that you gain their permission before reproducing any third party (non Crown Copyright) information.
If you have any queries about this letter, please contact Mrs Summers, Patient Relations Administrator, on 0191 2231382.
If you are unhappy with the service you have received in relation to your request and wish to make a complaint or request a review of our decision, you should write to The Patient Relations Manager, Patient Relations Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, The Freeman Hospital, Newcastle upon Tyne, NE7 7DN.
If you are not content with the outcome of your complaint, you may apply directly to the Information Commissioner for a decision. Generally, the ICO cannot make a decision unless you have exhausted the complaints procedure provided by the Patient Relations Department. The Information Commissioner can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.
Yours faithfully
Sir Leonard Fenwick CBE