Record retention

Please see below for a number of frequently asked questions from a specific category. Simply select one of the questions of interest, the answer will then appear below. For the complete list of categories please visit the main FAQs page [1].

What type of records enable traceability?

Traceability refers to the completeness of auditable information about every step in the pathway for the use of relevant material, from consent through to disposal or use of the tissue to extinction. Documented records are used by licensed and unlicensed establishments to evidence traceability and ensure a robust audit trail. The actual types of records that enable traceability may vary from establishment to establishment, depending on what kinds of records are created during the licensed activity.

In what format should traceability records be retained?

Records may be in various formats, including paper, electronic, or stored on recordable media such as CD-ROM or DVD. It is up to each establishment to determine the best storage method for their records.

How long do traceability records need to be retained?

With the exception of the human application sector, the HTA is not prescriptive about the length of time for which traceability records should be retained. In other sectors, additional bodies may have specific requirements for the retention of records. Additional guidance for each of the sectors is provided below.

What are the requirements for the human application sector?

Establishments in the human application sector should refer to the HTA’s Guide to Quality and Safety Assurance for Tissues and Cells for Patient Treatment [2] for specific requirements for record retention.

What do NHS Trusts need to be aware of with regards to retention of traceability records?

HTA-licensed NHS Trusts should adhere to the two-part document Records Management: NHS Code of Practice, available on the Department of Health’s website, as this sets out the requirements for retention of all NHS records. The current position is that all NHS records created as a result of work taking place in accordance with the Human Tissue Act 2004 are to be retained for 30 years.

What do staff at establishments in the post mortem sector need to be aware of with regards to retention of traceability records?

Staff at HTA-licensed establishments should refer to the HTA’s code of practice on Post-mortem examination [3], paying particular attention to the Records Management section of the code.

The HTA endorses the most up to date guidance from the Royal College of Pathologists, The retention and storage of pathological records and specimens. This document is available on the Royal College of Pathologists’ website [4].

Additionally, where HTA-licensed post mortem establishments are part of an NHS Trust, consideration should be given to the above general advice for NHS Trusts.

What do staff at establishments in the research sector need to be aware of with regards to retention of traceability records?

Records that enable traceability must be maintained at least until the tissue has been disposed of, used to extinction or otherwise brought outside of the regulatory framework, or will never be used again in research. Licensed research establishments should refer to the Governance and Quality Systems section of the HTA’s code of practice on Research [5]. Staff at licensed establishments should also adhere to any relevant organisational/committee policies and procedures for records management e.g. NHS Trust requirements (see above), Medical Research Council requirements etc.

What do staff at establishments in the anatomy sector need to be aware of with regards to retention of traceability records?

Records that enable traceability must be maintained at least until the tissue has been disposed of. Staff at HTA-licensed establishments should refer to the Documentation and Record Keeping section of the HTA’s code of practice on Anatomical examination [6].

What do staff at establishments in the public display sector need to be aware of with regards to retention of traceability records?

Records that enable traceability must be maintained until the tissue has been disposed or reaches an age when it falls outside the Human Tissue Act 2004 (i.e. more than 100 years old). For temporary exhibitions where relevant material will be exported rather than disposed of, it is acceptable that traceability records are exported with the exhibition once the HTA licences have been revoked.

Staff at HTA-licensed establishments in the public display sector should refer to the Governance and Quality Systems section of the HTA’s code of practice on Public display [7].

Additionally, museums and other public display establishments should refer to the Guidance for the Care of Human Remains in Museums, published in the Department for Culture, Media and Sport’s website [8].

What do we do if our establishment does not have a policy or procedure that covers retention of traceability records?

If there is no overarching records retention policy in place at the establishment, the Designated Individual should ensure that relevant policies and procedures are put in place. These should be in line with the establishment’s own internal requirements. Retention schedules are to be made available to the HTA on inspection or as otherwise requested in writing or by Directions.

The DI should consider undertaking a documented risk assessment of retaining/disposing of each type of record to enable a robust and appropriate records management policy to be established.
The DI may wish to consider good practice examples from other similar organisations.
The DI should ensure that the records retention policy considers the storage of documents beyond the minimum requirements e.g. if the establishment were to shut down.

What do we need to consider in relation to the Data Protection Act 1998?

Staff at Establishments that store records containing personal data for tissue which has been taken from the living need to consider that ‘Personal data processed for any purpose or purposes shall not be kept for longer than is necessary for that purpose or those purposes’.

The Data Protection Act 1998 does not apply to personal records relating to the deceased; these are covered by common law and confidentiality.

We want to revoke our licence. What do we need to consider about retaining traceability records?

Any establishment that intends to revoke their licence should retain traceability records in accordance with their documented record retention requirements in place during the period of licensing. Particular things to consider are:
a) If any relevant material is being transferred to alternative licensed premises, the records to enable traceability should be transferred to those premises also.
b) If the licence to be revoked is associated with other licensed premises e.g. where a satellite licence is being revoked but the hub is remaining licensed, the records should be transferred to the associated licensed premises (in this case, the hub).
c) If there is no alternative site that the records could be transferred to (e.g. a private organisation which has gone out of business), it is good practice to retain those records and provide the HTA with contact details.

What do we need to consider when disposing of traceability records?

The disposal of traceability records should be carried out in such a way that the confidentiality of the data is maintained. For more information please refer to the Information Commissioner’s Office [9].