Tips for organising medical files for a medical negligence trial

In a medical neglect case (also known as clinical negligence), the main facts is what is contained inside the contemporaneous clinical files. This is due to the fact medical files are created at the time or close to the time an event happened and therefore should give an accurate understanding of what happened.

Therefore, it is essential, that whenever practitioners report what care and treatment was provided, they do so promptly and file accurately details of their evaluation, what treatment was given, what investigations were performed, what was discussed with the patient and what the plan of care was in going forward. Files should be readable and should contain specifics of who recorded the information in addition to being dated and timed, although this is unfortunately not always true.

From a legal perspective, whenever a solicitor takes instructions on their client’s case, they have to then request ALL clinical files relevant to the treatments they have received. Once received, 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 facts within the notes which will assist your expert in leading them to the relevant notes to enable them to make their report.

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

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

When applying for Doctor files, it is not enough simply to get the computerised records. Full records are essential even if they are not related. Your client may have an underlying condition going back before systems went computerised and it is essential for the lawyer and expert to have the entire picture of the client’s past medical history and family and social history where appropriate.

When getting Dentist records, similarly, both computerised and written records should be provided and radiology should be required for the benefit of completeness.

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

In considering the case thoroughly at the outset and collating all the relevant records will ensure that those issues which your client has instructed you on can be looked into from an early step giving your client the very best prospects of coping with their case thoroughly.

Thorough preparation of clinical records will not only help you, your medical expert, and lawyer you instruct, and the court; it will help your client in making sure no stone is left unturned in the quest for starting a successful case.