Worcestershire Acute Hospitals NHS Trust

3. Mr N complains about the Trust’s record keeping of his medical records between February 2004 and April 2005. Specifically, records relating to how he obtained his HIV infection. That is, whether he obtained HIV from a blood transfusion in 1995 or through sexual contact.

4. Mr N says Dr D, an infectious diseases consultant recorded incorrect details and made false, misleading statements relating to his sexual interactions, past travel history and past transfusions in his medical records. He says this has only come to light very recently after the Infected Blood Inquiry published its report in May 2024.

5. Mr N says the errors and falsehoods within his medical records are continuing to damage his reputation and are causing damage to his mental health. He says he is suffering ongoing anxiety and distress for over a year, and this has considerably impacted the quality of his life and is also having a financial impact.

6. Mr N is seeking an apology from the Trust, an opportunity to collaborate with the Trust to remove, redact and amend inaccurate records and statements and financial remedy.

7. In 1995 Mr N received a blood transfusion during an operation. In 2004, following a preimmigration medical check Dr D diagnosed Mr N with HIV.

8. Following publication of the Infected Blood Inquiry report in May 2024, Mr N believes he received contaminated blood during the transfusion. Mr N requested copies of his medical records from his GP surgery and from the Trust to pursue a clinical negligence claim.

9. In June 2024, Mr N noted what he considered inaccuracies and false statements made by Dr D in his medical records for the period between February 2004 to April 2005. Specifically, records relating to how he obtained his HIV infection. That is, whether he obtained HIV from a blood transfusion in 1995 or through sexual contact.

10. Following a consultation in February 2004, Mr N says Dr D recorded the following inaccuracies in his post consultation letter sent to his GP:

• Mr N had a transfusion in his operation in 1998 • Mr N says this is inaccurate and Dr D should have noted it as occurring in 1995 - Mr N says this should be removed or redacted.

• Mr N had six heterosexual partners, after his first sexual encounter in a named country in Africa, where he used a condom • Mr N says this is inaccurate and Dr D should have noted Mr N received a total of six oral sex encounters whilst always wearing a condom from girlfriends between 1998-2000 who were two white heterosexual English females from around his local area - Mr N says this should be removed or redacted.

• Mr N went back to a named country in Africa in April 1996 • Mr N says this is inaccurate and Dr D should have noted Mr N only went to a named country in Africa once in July 1995 and nearing the end of his second visit in November 1995 he had a single event of receiving heterosexual oral sex wearing a condom with a white heterosexual female - Mr N says this should be removed or redacted.

11. Mr N further says, in his undated report to Australian Immigration, Dr D recorded Mr N had oral sex or vaginal sex protected with a condom. Mr N says this is inaccurate and that the latter part of this statement is false, misleading and very damaging. Mr N says this statement should be completely erased as it is no longer relevant to his medical treatment. He says this information ceased to be relevant when he was refused entry to Australia due to his HIV diagnosis.

12. Mr N says Dr D continued to make factual errors in his medical records up until they left their employment at the Trust in April 2005.

15. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there is an organisation that is better placed to deal with the concerns. Some complaints can be looked at by us, and by other organisations. We have considered whether another organisation is better suited to giving an answer to the complaint and whether it can provide the outcome Mr N seeks.

16. In January 2025, Mr N complained to the Trust. It investigated his concerns and issued a final response in April 2025. The Trust confirmed it had no new clinical evidence to change the medical records, as it had no evidence that the information was recorded incorrectly at the time.

17. The Trust confirmed it was unable to change Mr N’s medical records. It offered to add a statement to his notes outlining the points he disputes in his complaint letter. Mr N told us he did not believe this was enough. He seeks an opportunity to collaborate with the Trust to remove, redact and amend inaccurate records and statements he says Dr D made. We are unable to change medical records as they are a legal document. An addendum can only be added as the Trust has offered.

18. According to the ICO’s Outcomes, the ICO can make recommendations to organisations to put things right or to improve their practices. It lists the following as potential outcomes it can achieve that we believe are applicable in this case. The ICO can:

• tell the organisation to do more work to help resolve the complaint or explain its position more clearly to the person complaining - this could mean getting the organisation to provide the complainant with their information or correct any inaccuracies • make recommendations to the organisation about how it can improve its information rights practices - this can include asking the organisation to review its policies or procedures, guidance or standards.

19. While the ICO cannot achieve his other outcomes, we saw a reason for us to wait for the outcome of ICO’s work first and not consider Mr N’s complaint now. Potentially, Mr N could approach us after the ICO’s investigations to achieve his other outcomes. This includes an apology and financial remedy.

20. We have decided it is appropriate this happens after the ICO’s investigations. The ICO’s findings may be helpful if we do work later. If the ICO does ask the Trust to do further work, it is possible Mr N may achieve his other outcomes as a by-product. For example, if the ICO deems there are inaccuracies, the Trust might apologise.

21. This means we consider it is appropriate to wait and see what the outcome of the ICO’s work is. For this reason, we have decided not to consider Mr N’s complaint further.

22. We recognise Mr N approached us hoping we would consider his complaint now, and it is likely to come as a disappointment to him we have decided not to. We hope we have clearly explained why we are not considering it further at this stage.

1. We have carefully considered Mr N’s complaint about Worcestershire Acute Hospitals NHS Trust (the Trust). We are very sorry to hear Mr N was dissatisfied with the Trust’s record keeping of his medical records. We do not underestimate the impact he told us this experience has had on his mental health and quality of life.

2. We have decided not to consider the complaint further as the Information Commissioner’s Office (ICO) is best placed to consider Mr N’s complaint in the first instance. The ICO is currently considering his complaint. We consider it is appropriate to await the outcome of the ICO’s investigation before we look at Mr N’s concerns. We explain our reasoning in more detail below.