OIA 20127 supplementary response.pdf

Provider Healthcare Services
North Shore Hospital Campus
Shakespeare Road, Takapuna

Private Bag 93-503, Takapuna

Auckland 0740

Telephone:  09 489 0527
Facsimile:   09 486 8339

25 September 2020

Amy S Van Wey Lovatt
[FYI request #12531 email]

RE: OIA request – Policies relating to the storage of human tissue

Dear Ms Van Wey Lovatt

Thank you for your Official Information Act request received 29 August 2020 seeking information from
Waitematā DHB about the long-term storage of human tissue.

We provided a response to your request on 15 September. You contacted us on 16 September with the
following request:

I request all documents held by Waitematā DHB that show that the location in which human tissue is
stored at Waitematā DHB is a ‘secure archival room’ (for instance, the check list provided by
International Accreditation New Zealand (IANZ) and the documentation of approval

The policy relating to the storage of human tissue was provided in an earlier OIA response sent to you
on 21 May 2020. We have included this policy again for your reference – Attachment 1. IANZ does not
provide a checklist or a document of approval for a secure archival room. IANZ accreditation documents
were provided in another earlier OIA response sent to you on 23 June 2020, which confirms Waitematā
DHB’s surgical pathology accreditation status.

…as well as policies which describe which employees may access, handle and store the tissue and
when it is permitted for employees to store the tissue in locations outside the ‘secure archival room’.

All surgical pathology staff members have access to the secure archival room. At times, archival tissue
may be removed from the archival room when additional ancillary testing is requested. The tissue block
would be re-archived on completion of testing.

I trust that this information is helpful.

Waitematā DHB supports the open disclosure of information to assist community understanding of how
we are delivering publicly funded healthcare. This includes the proactive publication of anonymised
Official Information Act responses on our website from 10 working days after they have been released.

If you consider there are good reasons why this response should not be made publicly available, we will
be happy to consider your views.

Yours sincerely

Mark Shepherd
Director Provider Healthcare Services
Waitematā District Health Board

Attachment 1
SPU QM, Retention of laboratory records and samples 9808S
Supersedes 26 April 2018
Issued 08 April 2020
Retention of laboratory records and samples
The department is electronically secured with access available to authorised personnel only.
All records are secure, identifiable, and legible and stored in readily retrievable form. Electronic records may be stored in place of
hard copies.
All records containing patient information requiring disposal are to be placed in confidential rubbish.
Retention Times are based on the NPAAC 2018 Guidelines, and local policy.
Reference
General
Minimum Retention
Storage
Disposal
Time
NPAAC 2.1.2
Assessments
4 years
Quality Manager, Medialab,
Destroy
Systems, compliance,
IANZ
environment, quality
Both internal and external
NPAAC 2.1.2
Quality
4 years
Quality Manager, Medialab,
Destroy
MRM minutes, meeting
IANZ
minutes
Quality Improvement projects
Incident reports
NPAAC 2.1.4
Operating Procedures
Retain historical
Medialab,
versions
Network Folder
EQA assessment records
4 years
Quality Manager,
Destroy
Medialab
Local SPU Policy
Complaints and Actions
15 years
Unit Manager Office
Destroy
NPAAC 2.1.1
Personnel Records
Employment + 4 years
Personnel Files
Destroy
NPAAC 2.1.3
Equipment Maintenance
Life span of equipment
Network Equipment Folder
Archive
Records
+ 4 years
Local SPU Policy
Accession Log Books
Indefinite
Cut Up, Cytology
Local SPU Policy
Laboratory Workbooks
4 years
Cut Up
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  Authority to Issue SPU Quality Manager

SPU QM, Retention of laboratory records and samples 9808S
Supersedes 26 April 2018
Issued 08 April 2020
Retention of laboratory records and samples
Reference
Specimen and Patient
Minimum Retention
Storage
Disposal
material
Time
NPAAC 2.1.5
Laboratory Request Forms
4 years
SPU Records Room
Destroy
NPAAC 2.2.3
and digital images of
specimens
NPAAC 2.2.1
Reports, copy of original,
10 years
1984-95; SPU Records Room
Local SPU Policy
or ability to reprint an
7 years from the age
1995-1999 APS
original report
of majority for minors
27 10 1999-Present DAP
NPAAC 2.2.4
Paraffin blocks
10 years
Retained indefinitely
Local SPU Policy
7 years from the age
of majority for minors
NSH blocks1984-2017; Crown
Storage
2017-Present;
SPU Storage Room
Medlab blocks 1995-1999; APS
NPAAC 2.2.2
Histology Slides; sections
10 years
Slides prior to 2002; Destroyed
Discard
of fixed tissue preserved in
2003-2017; Crown Storage
mounting medium
2018-Present; SPU Storage
Rooms
NPAAC 2.2.5
Frozen Section Slides
10 years
Slides prior to 2002; Destroyed
Frozen section blocks
2003-2017; Crown Storage
processed to paraffin
2018-Present; SPU Storage
Residual tissue processed
Rooms
to paraffin
Blocks retained indefinitely
Page 2 of 3
  Authority to Issue SPU Quality Manager

SPU QM, Retention of laboratory records and samples 9808S
Supersedes 26 April 2018
Issued 08 April 2020
Retention of laboratory records and samples
Reference
Specimen and Patient
Minimum Retention
Storage
Disposal
material
Time
NPAAC 2.2.7
Wet Specimens
1 month from date of
Stored for 8 weeks post reporting
Discard
issue of report
in specimen filing room
Wet specimens may be retained
for a longer time period at the
request of the reporting pathologist
depending on complexity and
reporting TAT.
NPAAC 2.2.7
Containers with no
1 month from date of
Stored for 4 weeks in dated bags
Discard
residual tissues
issue of report
NPAAC 2.2.2
Cytology Slides
10 years
1999-2009; Crown Storage
2010-Present; SPU storage room
NPAAC 2.1.7
Cytology Specimens
7 days from receipt or
Discard
2 days after final
Prep Room for 7 days
report (whichever is
longest)
Reference
Bio-banking
Retention Time
Storage
ARB
Samples of specimens
Indefinitely at -80oC
Retained indefinitely at the WDHB
MOH Guidelines for the
that have been consented
Bio bank space permitting before
use of Human Tissue for
for bio banking
transfer to
future unspecified
ARB Auckland Regional Bio bank
research purposes 2007
at Auckland University
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  Authority to Issue SPU Quality Manager