Thursday, 17 December 2015

Relying on Medical Records

"The Judge won't believe me. He'll believe what's in the notes".

I have heard that said by many clients who are contemplating bringing a clinical negligence claim. But it is not true. Judges take into account all the evidence. Whilst it is true to say that contemporaneous notes made by a medical professional will ordinarily carry great weight at court, where there is a conflict between a patient's recollection and what was recorded contemporaneously by their doctor, the court is not bound to find that the record is accurate and the recollection unreliable. That has been confirmed by the Court of Appeal decision in Synclair v East Lancashire Hospitals NHS Trust [2015] EWCA Civ 1283

Just as patients sometimes believe that the courts are bound to accept the truth of something recorded in the medical notes, so healthcare professionals are sometimes taught that "if it isn't recorded, it didn't happen". That is equally untrue.

It always depends on the circumstances. 

If three independent medical practitioners all separately record that the patient reported no pain, but the patient says that they told them they were in pain, the court may struggle to find that "on the balance of probabilities" the patient reported that he was in pain.

If a patient and two relatives recall that he told Dr X that he was in pain, and Dr X' cannot recall the consultation but his junior doctor recorded "All fine" and nothing more, perhaps the court will be more likely to find that the patient did report that he was in pain.

A record of a consultation cannot be a word for word account. On the other hand a doctor who does not note a matter of potential significance, even if the finding was "normal", e.g. there were no red flag signs of cauda equina syndrome, may regret having failed to do so. When asked at court why they did not check for red flag signs, a reply that "they would have done so" carries much less weight than a contemporaneous record that they had done so and there had been no such signs.

I cannot recall seeing medical records counter-signed as accurate by a patient. Consent forms are of course signed but not other records. Patients tend not to make and keep notes themselves. There is no reason why they should not do so.

Sometimes patients are convinced that a medical record has been tampered with or "doctored" (pun intended). It has been known. But the court will need to be presented with cogent and compelling evidence before it can find that medical records have been concocted or dishonestly altered after the event.

The Court of Appeal in Synclair has reviewed guidance on these sorts of issues, providing a very helpful source for clinical negligence practitioners. Tomlinson LJ said:

  1. We were shown, in chronological order: the well-known remarks of Lord Pearce in his dissenting speech inOnassis & Calogeropoulos v Vergottis [1968] 2 Lloyds Rep 403 at p 431; the guidance given by Lord Goff of Chieveley giving the opinion of the Judicial Committee of the Privy Council in Grace Shipping v Sharp & Co [1987] 1 Lloyd's Rep 207 at 215-6, in particular founding upon his own judgment in the earlier decision of the Court of Appeal in Armagas Ltd v Mundogas SA (The Ocean Frost) [1985] 1 Lloyd's Rep 1 when he said, at page 57:-

  2. "Speaking from my own experience, I have found it essential in cases of fraud, when considering the credibility of witnesses, always to test their veracity by reference to the objective facts proved independently of their testimony, in particular by reference to the documents in the case, and also to pay particular regard to their motives and to the overall probabilities. It is frequently very difficult to tell whether a witness is telling the truth or not; and where there is a conflict of evidence such as there was in the present case, reference to the objective facts and documents, to the witnesses' motives, and to the overall probabilities, can be of very great assistance to a Judge in ascertaining the truth."
    In Grace Shipping Lord Goff noted that his earlier observation was, in their Lordships' opinion "equally apposite in a case where the evidence of the witnesses is likely to be unreliable; and it is to be remembered that in commercial cases, such as the present, there is usually a substantial body of contemporary documentary evidence." We were reminded too that in "The Business of Judging", Oxford, 2000, Lord Bingham of Cornhill observed that:-
    "In many cases, letters or minutes written well before there was any breath of dispute between parties may throw a very clear light on their knowledge and intentions at a particular time."
    The essential thrust of this learning is the unsurprising proposition that when assessing the evidence of witnesses about what they said, or what was said to them, or what they saw or heard, it is essential to test their veracity or reliability by reference to the objective facts proved independently of their testimony, in particular by reference to contemporary documentary evidence.

    He noted that:

    1. In the present case it is plain that the judge recognised that the evidence of the Claimant had to be assessed in the light of the apparently contemporaneous clinical note. Indeed that note was doubly important. Not only did the Claimant's evidence fall to be evaluated in the light of it, the note also represented the full and entire extent of the evidence which Mr Zafar could give as to what was said and observed on his ward round, as he had no recollection as to what had transpired independent of what was written in the note.
    2. However it is too obvious to need stating that simply because a document is apparently contemporary does not absolve the court of deciding whether it is a reliable record and what weight can be given to it. Some documents are by their nature likely to be reliable, and medical records ordinarily fall into that category. Other documents may be less obviously reliable, as when written by a person with imperfect understanding of the issues under discussion, or with an axe to grind. I would commend the approach of His Honour Judge Collender QC, sitting as a judge of the High Court, in EW v Johnson [2015] EWHC 276 (QB) where he said, at paragraph 71 of his judgment:-

    3. "I turn to the evidence of Dr Johnson. He did not purport to have a clear recollection of the consultation but depended heavily upon his clinical note of the consultation, and his standard practice. As a contemporaneous record that Dr Johnson was duty bound to make, that record is obviously worthy of careful consideration. However, that record must be judged alongside the other evidence in the action. The circumstances in which it was created do not of themselves prevent it being established by other evidence that that record is in fact inaccurate."
      Dr Johnson, a GP, had made his own note of a consultation at an out of hours walk-in centre at a hospital. After a careful evaluation of all the evidence in the case, the judge found that Dr Johnson's oral account in evidence, based on his contemporaneous note, was reliable. In Welch v Waterworth [2015] EWCA Civ 11 a surgeon was unsuccessful in persuading the court that his own notes of a surgical procedure which he had performed, one a manuscript note written very shortly after the operation and another a typewritten note made later in the day at home, did not accurately record the order in which he had carried out the constituent parts of the relevant procedure.

    4. The real difficulty which the judge faced in the present case was that he had no evidence of the circumstances in which the relevant clinical note had been made, and no evidence from the maker of the note, who was not Mr Zafar but Dr Dal Bianco. Furthermore, it was unclear whether Dr Dal Bianco had been present when Mr Zafar spoke to and examined the Claimant at 08.10 and unclear when precisely he prepared the note relating to that ward round.
The Trust submitted that medical records carry great weight because doctors have a professional duty to provide an ongoing record and could risk professional sanctions for failing in that duty. The Court held that whilst in many cases the inherent reliability of medical records would carry the day, it all depended on the circumstances in the individual case.

The trial judge had approached the finding of fact exercise in a proper manner and his finding that the facts were other than as recorded in the contemporaneous medical record was upheld.

1 comment:

  1. I have heard that said by many clients who are contemplating bringing a clinical negligence claim. But it is not true. Judges take into account all the evidence. Physician Assistant vs Nurse Practitioner