How organising medical files & good preparation is important to your medical negligence trial

In a clinical negligence case (also known as medical negligence, the principle source of evidence is what is contained within the contemporaneous medical records. This is due to the fact medical files are created at the time or near to the time that an event happened and therefore should give a precise understanding of what took place.

It is therefore essential, that when health professionals record what care and treatment was provided, they do so quickly and file accurately details of their assessment, what treatment was given, what investigations were performed, what was discussed with the patient and what the plan of care was in moving forward. Records must be readable and should include specifics of who recorded the information as well as being dated and timed, although this is unfortunately not always the case.

From a legal perspective, when a solicitor takes instructions on their client’s case, they have to then apply for ALL medical records relevant to the treatment they received. Once obtained, these may then be sorted into a rational format and indexed into sections and page numbered accordingly. This allows those working on the case to navigate the records with ease. A chronology will pinpoint the salient facts within the records which will assist your expert in directing them to the relevant notes to enable them to make their report.

When indexing the medical files, it is important to put the details which will fundamentally contain the main substance of your client’s care & treatment towards the front of the bundle (medical records, nursing evaluation notes and medical correspondence). This ensures that when arranging a chronology, the details can be pulled out of the medical bundle at an early stage and all other elements of care and treatment then be added and padded around the case, like microbiology or radiology results or information on problems with consent to operations.

Having the medical records organised like this prior to commencing substantive investigations will also mean that any records which appear to be missing can be obtained and put into the bundle and all radiology may be checked off against what’s indicated within the records and what is provided for on disc by the treating hospital or dentistry surgery.

When getting Doctor files, it is not sufficient simply to get hold of the computerised records. Complete records are essential even if they’re not relevant. Your client may have an underlying condition going back before systems went computerised and it is important for the expert and solicitor to have the complete picture of the client’s past history and family and social history where relevant.

When getting Dental records, similarly, both computerised and written records must be provided and radiology should be required for the sake of completeness.

Hospital records must also be obtained in their entirety where it relates to a birth injury, both mother & baby documents should be requested. Further, where out-patient care is arranged by a hospital, such as physiotherapy treatment or district nurse care, these records also need to be obtained so that both solicitor and expert have a total & detailed understanding of the followup care setup and or given. Where a patient has passed away while in care, pathology reports and the post mortem report should be acquired. When a complaint has been made, all complaints reports as well as correspondence should be provided. Where protocols are referred to within the records, these need to be obtained as these can help in assessing the standard of care expected and whether treatment and care has fallen below those standards.

In preparing the case thoroughly at the beginning and collating all the relevant records will make sure that those issues which your client has instructed you on can be explored from an early stage giving your client the very best prospects of dealing with their case thoroughly.

Thorough preparation of medical records will not only help you, your medical expert, and lawyer you instruct, as well as the court; it will help your client in making certain no stone is left unturned in the pursuit of establishing a successful case.