Missing Medical Records – What can you do?
Clinical Negligence solicitors have an onerous job as it is to satisfy both that the clinician has been negligent and that the client has suffered, additionally, because of this negligence. This task is made even more difficult if the medical records are incomplete and the missing records, on many occasions, are the exact records that are of most interest and pertinent to the client’s case.
Obtaining medical records from the various clinicians, be it GP’s, Hospitals, Physiotherapists etc can be a challenge. Some health boards, clinicians etc are very organised and helpful and comply with s29 of The Data Protection Act 1998. Other must be, shall we say, encouraged to comply by way of emails, telephone calls, letters and even court applications. And when they finally do comply the records are incomplete.
Discovering that the provided medical records are incomplete is often overlooked or not identified due to the vast amount of records which often arrive in a totally disordered mess. We often wonder, if negligent cases are caused by the disorganised mess that is the client’s clinical records, or, are the records provided in such a mess to enable paginating companies such as us to make a living! Do we have contacts or family in the medical records department of all the health boards and a conspiracy is at work!
The only way to be sure that all the client’s medical records have been presented is to ensure that the disordered mess is properly sorted into a manageable and comprehendible form. This can be a very costly and time-consuming activity if done, in-house, by a fee earner or paralegal.
Missing records can include clinical notes, investigation results, radiology reports and films, which is less than ideal because the experts cannot review the originals and original operation notes. ITU and A&E notes are problematic because they are often not added to the patient’s main hospital notes when the patient is discharged, and so separate searches will need to be made to find them and it is worth being persistent with the Trust. Sexual health clinic notes are the same, as they are nearly always (if not always) kept separate from the patient’s main hospital notes.
Many clinical negligence solicitors are unaware that “non-clinical” notes such as internal adverse event investigations, serious incident reports, root cause analysis reports, comprehensive internal inquiries, they have a number of different names, are also potentially hugely important and need to be disclosed. Trusts are usually not difficult about disclosing the final report but they are often less forthcoming when it comes to disclosing documents generated during the investigation process, such as witness statements, emails, memoranda, etc. Therefore, these types of document need to be asked for specifically and there should be no let-up in chasing them down.
Clinical Negligence solicitors should be aware that almost every set of records will be missing something, but it is not always relevant or pertinent to the issues in the case. However, it is critical to establish whether a record that is relevant is missing and to pursue the finding and disclosure of it vigorously, including with pre-action disclosure or specific disclosure proceedings when necessary. It is important to know what the Trust has done to find the document, what searches, where, when, by whom, etc.
It is well known that finding that key piece of information can turn a case: it is therefore important to push hard for it and, just occasionally, it will magically appear!
Do you, the busy clinical negligence solicitor, with targets to meet and costs to save, have the time, funds, and sometime, the inclination to;
1 Sort out your client’s medical records into a comprehensible format,
2 Analyse the records to identify missing documents.
3 Chase the health board or clinician for the missing records.
You don’t?
We do!
Instructing Professional Paginating Services to undertake all the above onerous tasks will not only save you time but also increase your profit costs. Find out more here.
We will make a nuisance of ourselves, be a terrier, and won’t be easily brushed aside and do not give up until we are satisfied that any document really is no longer in existence, anywhere!
Call Professional Paginating Services now, 01495 370288, let us take away the stress and chase those missing records for you!
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