Organising clinical files for your medical negligence case

In a clinical negligence case (otherwise known as medical negligence, the principle source of evidence is what is contained inside the contemporaneous clinical files. This is because medical records are written at the time or close to the time an event occurred and therefore should give an accurate understanding of what happened.

Therefore, it is essential, that whenever practitioners document what treatment and care was provided, they do so quickly and record precisely specifics of their assessment, what investigations were carried out, what was reviewed with the individual, what treatment was given and what the plan of care was in going forward. Records must be readable and should contain specifics of who recorded the information as well as being dated and timed, although this is regrettably not always true.

From a legal perspective, when a solicitor takes instructions on their client’s case, they have to then request ALL clinical records related to the treatments they have received. Once obtained, these can then be organised into a rational format and indexed into sections and page numbered accordingly. This lets those working on the case to navigate the records without difficulty. A chronology will focus on the salient information within the records which will assist your medical expert in leading them to the relevant notes to enable them to make their report.

Whenever indexing the clinical records, it is very important put the details which will essentially include the main substance of your client’s treatment & care towards the top of the bundle (medical records, nursing evaluation notes and medical correspondence). This makes sure that when arranging a chronology, the information can be pulled out of the medical bundle at an early stage and all other aspects of care and treatment then be added and padded around the case, for example microbiology or radiology results or details of problems with consent to operations.

Having the medical files sorted this way before starting substantive investigations will mean that any details which are missing can be obtained and added to the bundle and all radiology can be checked off against what is indicated within the records and what’s provided for on disc by the treating clinic or dentistry surgery.

When applying for General Practitioner files, it is not enough simply to obtain the computerised records. Complete records are needed even if they are not relevant. Your client may have an underlying condition going back before systems went computerised and it is crucial for the expert and solicitor to have the full picture of the client’s past medical history and family and social history where appropriate.

When applying for Dentist records, similarly, both computerised and records must be provided and radiology should be required for the sake of completeness.

Hospital files must also be acquired in their entirety where it relates to a birth injury, both baby and mother records need to be asked for. Further, where out-patient care is arranged by a hospital, for instance physiotherapy treatment or district nurse care, these records should also be obtained in order that both Lawyer and medical expert have a full and detailed understanding of the followup care setup and or provided. Where a patient has passed away whilst in care, pathology reports and the post mortem report needs to be obtained. Where a complaint has been made, all complaints correspondence and reports should be obtained. Where protocols are referred to inside the records, these need to be obtained as these can be helpful in evaluating the level of care expected and whether treatment & care has fallen below those standards.

In preparing the case thoroughly at the outset and collating all the relevant records will make sure that those issues which your client has instructed you on can be looked into from an early step giving your client the best possible prospects of managing their case thoroughly.

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