NHS Digital Data Sharing Remote Audit: University of Cambridge and Cambridge University Hospitals NHS Foundation Trust

Purpose

This report records the key findings of a remote data sharing audit of the School of Medical Science at the University of Cambridge (UoC) and the Cambridge University Hospitals NHS Foundation Trust (CUHFT) between 29 November and 04 December 2021. It provides an evaluation of how the UoC and the CUHFT conform to the requirements of:

• the data sharing framework contracts (DSFC)
  • CON-321529-Q1B0S v2.01 (UoC)
  • CON-314354-C8S4C v2.01 (CUHFT)
• the data sharing agreement (DSA) DARS-NIC24422-R3W3S-v5.9

This DSA covers the provision of the following datasets:

The Joint Controllers are the UoC and the CUHFT.

SIMPLIFIED is a randomised controlled trial which aims to assess the effect of colecalciferol (vitamin D) supplement verses standard healthcare on health outcomes in patients with kidney failure receiving dialysis. Colecalciferol has been used to treat vitamin D deficiency and is cheap and safe, even at high doses. This trial will test the hypothesis that population-wide supplementation with high-dose colecalciferol in patients receiving dialysis will reduce mortality and improve quality of life.

This report also considers whether the UoC School of Medical Science and the CUHFT conform to their own policies, processes and procedures. 

The interviews during the audit were conducted through video conferencing. 

This is an exception report based on the criteria expressed in the NHS Digital Data Sharing Remote Audit Guide version 1.

Audit type and scope

Data recipient’s acceptance statement

The UoC School of Medical Science and the CUHFT has reviewed this report and confirmed that it is accurate. 

Data recipient’s action plan

The UoC School of Medical Science and the CUHFT will establish a corrective action plan to address each finding shown in the findings table below. NHS Digital will validate this plan and the resultant actions at a post audit review with the UoC School of Medical Science and the CUHFT to confirm the findings have been satisfactorily addressed. The post audit review will also consider the outstanding evidence at which point the Audit Team may raise further findings.

The following tables identify 5 agreement nonconformities, 6 opportunities for improvement and 2 points for follow-up raised as part of the audit. 

In addressing a finding the data recipient must take account of any referenced supplementary notes.

One finding has been repeated for both UoC and CUHFT as they are joint Controllers, and the finding applies to both organisations.

Supplementary notes

Note 1 - One option to progress this finding, is for a risk assessment to be completed. The risk assessment shall assess the threats to and the vulnerabilities of the un-encrypted connection and identify the mitigating controls in place. This assessment shall be signed off by the organisation’s Senior Information Risk Officer (or equivalent). If the risk is considered acceptable and all aspects of the connection are inside the area of direct control by the UoC, then the link need not be encrypted. NHS Digital reserves the right to review this assessment.

Use of data

The UoC School of Medical Science and the CUHFT confirmed that the datasets were only being processed and used for the purposes defined in the DSA and were only being linked with those datasets explicitly allowed in the DSA.

Data location

The UoC School of Medical Science and the CUHFT confirmed that processing and storage locations, including disaster recovery and backups, of the datasets were limited to the location shown in the following table. These locations conform with the territory of use defined in clause 2c of the DSA.

Backup retention

The duration for which data may be retained on backup media is:

Note: The backup retention for data held by the CUHFT will be determined during the post audit review.

Good Practice

During the audit, the Audit Team noted the following area of good practice:

• all identifiable data is kept in the UoC Secure Hosting Data Server, which is certified to ISO 27001.

The audit was based upon a sample of the data recipient’s activities, as observed by the Audit Team. The findings detailed in this audit report may not include all possible nonconformities which may exist. In addition, as the audit interviews were conducted through a video conference platform, certain controls that would normally be assessed whilst onsite could not be witnessed.

NHS Digital has prepared this audit report for its own purposes. As a result, NHS Digital does not assume any liability to any person or organisation for any loss or damage suffered or costs incurred by it arising out of, or in connection with, this report, however such loss or damage is caused. NHS Digital does not assume liability for any loss occasioned to any person or organisation acting or refraining from acting as a result of any information contained in this report.