Oral Records – Not Worth the Paper They Are Written On!

The first of today’s cases includes a young woman who died of Ischemic Colitis (death of the bowel) due to abuse of cocaine.

The fact that she had taken cocaine was accepted, but the junior staff stated that any abdominal pain would clear up and discharged her. Unfortunately, the patient died, and in his evidence, the junior doctor indicated that he looked in her eyes with a torch and found the pupils were normal and reacting to light (in a patient with acute intoxication with cocaine, the pupils would be dilated). He also stated that he “definitely would have informed his consultant”, but there was no indication in the written record that he did either of these actions.

In the second case, a young lady was admitted to hospital with a diagnosis of acute Appendicitis.  She was seen by a junior doctor, who concurred with the diagnosis in the record but did not prescribe antibiotics, nor did he tell senior staff. In his evidence, he stated that he would always have prescribed antibiotics, and he could not understand why they had not been given. The patient deteriorated over the next 24 hours, and by the time she was taken to the operating room, the appendix had perforated and there was severe peritonitis. In his evidence, the junior member of staff also stated that he had informed the specialist registrar and had expected they would attend the patient. The specialist registrar indicated that she did not know about the case until the following morning.

Both of these cases were the subject of medical negligence litigation, and in both cases, the evidence of the staff concerned was dismissed on the grounds that there was no written record to back up such important details.

Evidence in court must be credible. Any oral evidence must be consistent with the facts of the case and are usually contained in accurate, contemporaneous note-keeping in the record, in order that such evidence may be asserted confidently in court proceedings. In the absence of clear and contemporaneous note-keeping, apparently contradictory oral evidence is likely to be dismissed.

MDU figures for 2020 show that fewer than one in six actions in medical negligence actually succeed, with the vast majority failing on the grounds of causation. It must be remembered that subsequence is not the same as consequence.

Initial screening is therefore essential to manage client expectations at an early stage. This avoids unnecessary effort and costs for all concerned. Too many cases are taken to court with no chance of success. This is stressful for both the client and their legal adviser, and indeed for the medical personnel involved.

For fast and effective screening of all potential medical negligence cases, contact Peyton Medico Legal Services now on +44 (0)28 87724177, or email rpeyton@rpeyton.com

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