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1. Introduction

 

1.1 Cambridge Digital Health collects, holds, processes, and shares personal and sensitive data.

1.2 Every care is taken to protect personal data from accidental or malicious exposure which could compromise security.

1.3 Compromise of information, confidentiality, integrity, or availability may result in harm to individual(s), reputational damage, detrimental effect on service provision, legislative noncompliance, and/or financial costs.

 

2. Purpose and Scope

 

2.1 Cambridge Digital Health is obliged under Data Protection legislation to have a policy and set of procedures in place to ensure the security of all personal data during its lifecycle, including clear lines of responsibility.

2.2 This policy sets out the procedure to be followed to ensure a consistent and effective approach is in place for managing data breach and information security incidents involving data held by Cambridge Digital Health.

2.3 This policy relates to all personal and special categories (sensitive) data held by the Cambridge Digital Health regardless of format.

2.4 This policy applies to all staff employed by Cambridge Digital Health. This includes temporary, casual or agency staff and contractors, consultants, suppliers and data processors working for, or on behalf of Cambridge Digital Health.  The policy also applies to any students or interns that are working on projects with Cambridge Digital Health.

2.5 The objective of this policy is to contain any breaches, to minimise the risk associated with the breach and consider what action is necessary to secure personal data and prevent further breaches.

 

3. Definitions / Types of breach

 

3.1 For the purpose of this policy, data security breaches are defined as confirmed incidents.

3.2 An incident in the context of this policy is an event or action which has compromised the confidentiality, integrity or availability of systems or data, either accidentally or deliberately.

3.3 An incident includes but is not restricted to, the following:

3.3.1 loss or theft of confidential or sensitive data or equipment on which such data is stored (e.g. loss of laptop, USB stick, iPad / tablet device, or paper record);

3.3.2 equipment theft or failure;

3.3.3 system failure; 1 The General Data Protection Regulation (GDPR) and related EU and national legislation  

3.3.4 unauthorised use of, access to or modification of data or information systems;

3.3.5 attempts (failed or successful) to gain unauthorised access to information or IT system(s);

3.3.6 unauthorised disclosure of sensitive / confidential data;

3.3.7 website defacement;

3.3.8 hacking attack;

3.3.9 unforseen circumstances such as a fire or flood;

3.3.10 human error;

3.3.11 ‘blagging’ offences where information is obtained by deceiving the organisation who holds it.

 

4. Reporting an incident

 

4.1 Any individual who accesses, uses or manages information held by Cambridge Digital Health is responsible for reporting data breach and information security incidents immediately to the Data Protection Officer (Dr Oriane Chausiaux, Director).

4.2 If the breach occurs or is discovered outside normal working hours, it must be reported as soon as is practicable.

4.3 When reporting an incident, the individual reporting must include full and accurate details of the incident, when the breach occurred (dates and times), who is reporting it, if the data relates to people, the nature of the information, and how many individuals are involved.

4.4 All staff should be aware that any breach of Data Protection legislation may result in disciplinary action.

 

5. Containment and recovery

 

5.1 The Data Protection Officer (DPO) will firstly determine if the breach is still occurring. If so, the appropriate steps will be taken immediately to minimise the effect of the breach.

5.2 An initial assessment will be made by the DPO in liaison with relevant officer(s) to establish the severity of the breach and who will take the lead investigating the breach, as the Lead Investigation Officer (this will depend on the nature of the breach; in some cases it could be the DPO).

5.3 The Lead Investigation Officer (LIO) will establish whether there is anything that can be done to recover any losses and limit the damage the breach could cause.

5.4 The LIO will establish who may need to be notified as part of the initial containment and will inform the police, where appropriate.

5.5 Advice from external experts may be sought in resolving the incident promptly.

5.6 The LIO, in liaison with the relevant officer(s) will determine the suitable course of action to be taken to ensure a resolution to the incident.

 

6. Investigation and risk assessment

 

6.1 An investigation will be undertaken by the LIO immediately and wherever possible, within 24 hours of the breach being discovered / reported.  

6.2 The LIO will investigate the breach and assess the risks associated with it, for example, the potential adverse consequences for individuals, how serious or substantial those are and how likely they are to occur.

6.3 The investigation will need to take into account the following:

6.3.1 the type of data involved;

6.3.2 its sensitivity;

6.3.3 the protections in place (e.g. encryptions);

6.3.4 what has happened to the data (e.g. has it been lost or stolen);

6.4.5 whether the data could be put to any illegal or inappropriate use;

6.4.6 data subject(s) affected by the breach, number of individuals involved and the potential effects on those data subject(s);

6.4.7 whether there are wider consequences to the breach.

 

7. Notification

 

7.1 The LIO and / or the DPO, in consultation with relevant colleagues will establish whether the Information Commissioner’s Office will need to be notified of the breach, and if so, notify them within 72 hours of becoming aware of the breach, where feasible.

7.2 Every incident will be assessed on a case by case basis; however, the following will need to be considered:

7.2.1 whether the breach is likely to result in a high risk of adversely affecting individuals’ rights and freedoms under Data Protection legislation;

7.2.2 whether notification would assist the individual(s) affected (e.g. could they act on the information to mitigate risks?);

7.2.3 whether notification would help prevent the unauthorised or unlawful use of personal data;

7.2.4 whether there are any legal / contractual notification requirements;

7.2.5 the dangers of over notifying. Not every incident warrants notification and over notification may cause disproportionate enquiries and work.

7.3 Individuals whose personal data has been affected by the incident, and where it has been considered likely to result in a high risk of adversely affecting that individual’s rights and freedoms, will be informed without undue delay. Notification will include a description of how and when the breach occurred and the data involved. Specific and clear advice will be given on what they can do to protect themselves, and include what action has already been taken to reduce the risks associated with the breach. Individuals will also be provided with a way in which they can contact the Cambridge Digital Health for further information or to ask questions on what has occurred.

7.4 The LIO and / or the DPO must consider notifying third parties such as the police, insurers, banks or credit card companies, and trade unions. This would be appropriate where illegal activity is known or is believed to have occurred, or where there is a risk that illegal activity might occur in the future.   

7.5 The LIO and or the DPO will consider whether the Communications Team should be informed regarding a press release and to be ready to handle any incoming press enquiries.

7.6 A record will be kept of any personal data breach, regardless of whether notification was required.

 

8 Evaluation and response

 

8.1 Once the initial incident is contained, the DPO will carry out a full review of the causes of the breach; the effectiveness of the response(s) and whether any changes to systems, policies and procedures should be undertaken.

8.2 Existing controls will be reviewed to determine their adequacy, and whether any corrective action should be taken to minimise the risk of similar incidents occurring.

8.3 The review will consider:

8.3.1 where and how personal data is held and where and how it is stored;

8.3.2 where the biggest risks lie including identifying potential weak points within existing security measures;

8.3.3 whether methods of transmission are secure; sharing minimum amount of data necessary;

8.3.4 staff awareness;

8.3.5 implementing a data breach plan and identifying a group of individuals responsible for reacting to reported breaches of security.

8.4 If deemed necessary, a report recommending any changes to systems, policies and procedures will be considered.

 

9. Policy Review

 

9.1 This policy will be updated as necessary to reflect best practice and to ensure compliance with any changes or amendments to relevant legislation.

9.2 This policy was last reviewed in November 2018.