Contemporaneous medical records can be important evidence when investigating a medical negligence claim. They provide a record of what was documented during a patient’s care, including symptoms, clinical findings, investigations, diagnoses, treatment and follow-up.
For a solicitor investigating a potential claim, the records can help establish the sequence of events and identify the information available to healthcare professionals at particular points in time. They may also identify questions that require independent medical expert evidence.
Medical records are not, however, proof of negligence simply because an entry appears in a patient’s file. Their significance depends on the contents of the records, the circumstances in which they were created and the other evidence available. In a clinical negligence case, the records must be considered alongside medical expert opinion and the legal issues arising from the individual circumstances.
What Are Contemporaneous Medical Records?
A contemporaneous medical record is documentation created during or around the time healthcare was provided. It can record what a patient reported, what a healthcare professional observed, what investigations were carried out, the results obtained and what treatment or follow-up was provided.
This timing can be important. A record created during a consultation may document the symptoms and clinical findings known at that point, rather than a later reconstruction of events after a dispute has arisen.
In a medical negligence investigation, this can help establish what happened and, importantly, when it happened.
The distinction is particularly relevant where the allegation concerns a delay. For example, in a delayed cancer diagnosis case, it may be necessary to establish when symptoms were first reported, when investigations were requested, when results became available, whether follow-up occurred and when the diagnosis was eventually made.
Which Medical Records Can Be Relevant to a Medical Negligence Claim?
There is rarely one document that provides the complete clinical history. Relevant evidence may be spread across records held by different healthcare providers.
GP and Primary Care Records
GP records may document:
- symptoms reported by the patient;
- clinical examinations;
- previous medical history;
- diagnoses;
- prescriptions;
- referrals;
- investigations requested;
- follow-up appointments.
Where a patient was treated by both a GP and hospital, the records from each provider may need to be considered together.
Hospital and Emergency Department Records
Hospital records can include doctors’ notes, nursing records, admission documentation, clinical observations, treatment plans, referral information and discharge summaries.
These records can be particularly important where a claim concerns a patient’s presentation to an emergency department or a subsequent deterioration while in hospital.
They may help establish what symptoms were reported, what observations were made, which investigations were undertaken and what decisions followed.
Diagnostic Records
Diagnostic evidence may include:
- blood tests;
- pathology results;
- X-rays;
- CT scans;
- MRI scans;
- ultrasound examinations;
- other imaging;
- diagnostic reports.
The result itself is only part of the evidential picture. The timing can also matter: when was the test requested, when was it performed, when was the result available, who reviewed it and what action followed?
That chronology can be particularly important in claims involving an alleged failure to diagnose or delayed treatment.
Medication and Monitoring Records
Medication records can show what was prescribed, what was administered, dosage changes and whether monitoring was carried out.
Where a medication carries a known risk requiring clinical monitoring, the records may help establish whether the relevant tests or reviews took place and what the results showed.
Surgical, Maternity and Neonatal Records
For surgical and birth injury claims, the relevant records may be more extensive.
They can include:
- pre-operative assessments;
- consent documentation;
- operation notes;
- anaesthetic records;
- theatre records;
- post-operative observations;
- maternity records;
- fetal monitoring;
- delivery records;
- neonatal observations;
- resuscitation records.
These documents can help reconstruct events where the timing of an intervention or deterioration is central to the claim.
How Medical Records Establish the Clinical Timeline
One of the most important uses of medical records is to reconstruct the patient’s clinical chronology.
A medical negligence investigation may need to establish:
symptoms → consultation → examination → investigation → result → diagnosis → treatment → deterioration → referral → outcome
The purpose is not simply to create a list of appointments. The chronology helps identify what information was available at each stage and what happened in response to that information.
Establishing What Was Known at the Time
A key question in many clinical negligence cases is what the treating healthcare professional knew, or should have known, at the relevant time.
A later diagnosis may reveal that a patient had a serious condition, but that does not automatically mean the condition should have been diagnosed earlier.
The records may show what symptoms were present, what examination was undertaken, what investigations were available and what results had been received.
Those facts can then be considered by the appropriate medical experts.
Identifying a Delay in Diagnosis or Treatment
Where delay is alleged, the records can establish the relevant dates.
For example, in a suspected delayed cancer diagnosis, the investigation may need to compare:
- the date symptoms were first recorded;
- subsequent consultations;
- referrals;
- screening or diagnostic tests;
- test results;
- specialist assessment;
- eventual diagnosis.
The same principle can apply to stroke, infection, surgical complications and other conditions where the timing of treatment may affect the outcome.
Recording Changes in a Patient’s Condition
Medical records can also show how a patient’s condition changed.
Entries may document new symptoms, abnormal observations, changes in vital signs, test results or deterioration following treatment.
The important question is then what action followed the change.
A record of deterioration does not itself establish that the response was negligent. It provides part of the factual evidence from which the appropriate medical and legal questions can be assessed.
How We Analyse Medical Records in a Medical Negligence Claim
At Cian O’Carroll Solicitors, medical records form an important part of investigating the circumstances of a potential medical negligence claim.
The purpose is not simply to collect documents. The records need to be organised and assessed so that the relevant clinical events and potential issues can be identified.
Comparing the Records With the Clinical Standard
The records can establish what treatment or assessment was documented.
Independent medical experts may then be asked to consider whether the care provided was consistent with the appropriate standard in the circumstances.
This distinction is important. A solicitor reviewing a record may identify a potential issue, but whether a particular clinical decision amounted to a breach of the appropriate standard of care is a matter requiring appropriate legal and medical assessment.
Comparing Different Parts of the Medical Record
A patient’s information may appear in several different documents.
For example, a doctor’s note, nursing note, medication chart and investigation report may each record different aspects of the same event.
Where entries appear inconsistent, the discrepancy needs to be investigated rather than automatically treating one record as correct and another as incorrect.
The source of the information, when it was recorded, who created it and the surrounding clinical circumstances may all be relevant.
Reviewing the Timing of Entries
Timing can be particularly important in a delayed-treatment case.
The investigation may need to establish:
- when symptoms were reported;
- when a clinician assessed the patient;
- when an investigation was requested;
- when the result became available;
- when it was reviewed;
- when treatment was started.
A clear chronology can help identify the specific point at which an alleged failure occurred.
What Can Medical Records Establish?
Medical records can provide evidence about factual matters recorded during a patient’s care.
Depending on the circumstances, they may establish:
- symptoms reported by the patient;
- clinical observations;
- examination findings;
- investigations undertaken;
- test and imaging results;
- diagnoses recorded;
- treatment provided;
- medication administered;
- referrals;
- follow-up;
- communications between healthcare providers;
- the timing of clinical events.
This evidence can be highly important when reconstructing what happened.
However, the record must still be interpreted in context.
What Medical Records Do Not Automatically Establish
Medical records do not automatically establish that medical negligence occurred.
For example, a record showing that a diagnosis was made later than expected does not, by itself, establish that the earlier care was negligent.
Similarly, an adverse outcome following surgery does not automatically establish surgical negligence.
A medical negligence claim may require evidence addressing:
- whether the appropriate standard of care was met;
- whether there was a breach of duty;
- whether the breach caused or materially contributed to the injury;
- what injury or loss resulted.
These are separate issues.
The records can provide much of the factual foundation, while independent medical evidence may be required to address the clinical questions.
The Role of Independent Medical Experts
Medical experts can be particularly important because medical records contain clinical information that requires specialist interpretation.
Assessing the Standard of Care
An appropriately qualified expert may be asked to consider whether the treatment, diagnosis, monitoring or other care documented in the records met the appropriate professional standard.
Assessing Causation
Causation can be one of the most difficult issues in a medical negligence claim.
The relevant question may be whether an earlier diagnosis, different treatment or additional monitoring would have changed the patient’s outcome.
For example, where delayed diagnosis is alleged, the medical evidence may need to address whether earlier diagnosis would have resulted in earlier treatment and whether that would have avoided or reduced the injury.
Assessing the Consequences of the Alleged Failure
Medical experts may also be required to address prognosis, ongoing treatment, disability and future medical needs, depending on the circumstances of the claim.
The High Court’s Clinical Negligence List specifically provides for case-management directions concerning the exchange of expert reports and directions relating to expert evidence.
What Happens If Medical Records Are Incomplete or Inconsistent?
Medical records are not necessarily uniform. A patient’s treatment may involve several healthcare professionals and different systems of documentation.
Missing Medical Records
If relevant records are missing, it may be more difficult to reconstruct the clinical chronology.
The investigation may therefore need to consider other available evidence, including records held by another healthcare provider, correspondence, investigation results and witness evidence.
Conflicting Medical Records
Two records may sometimes appear to describe the same event differently.
For example, a doctor’s note may contain different information from a nursing note, or a later discharge summary may not contain the same detail as an earlier clinical entry.
A discrepancy does not automatically establish that a healthcare professional acted negligently.
It should be considered alongside the source of the information, when the entry was made, the circumstances in which it was created and the other available evidence.
Errors in Medical Records
A disputed or inaccurate record can become relevant to a medical negligence investigation, but an error in documentation is not automatically the same as negligent medical treatment.
The important question is how the alleged error relates to the patient’s care and to the issues being investigated.
Can Medical Records Be Used as Evidence in an Irish Medical Negligence Case?
Irish legislation contains provisions dealing with the use of business records as evidence in civil proceedings.
Section 13 of the Civil Law and Criminal Law (Miscellaneous Provisions) Act 2020 provides, subject to the statutory requirements, that certain business records compiled in the ordinary course of business are presumed admissible as evidence of the facts asserted in the document.
Section 14 sets out the general conditions for admissibility and specifically refers to a record by a registered medical practitioner of an examination of a living or deceased person.
However, admissibility and evidential weight are not the same issue.
Under section 16, the Court can consider whether information should be admitted in the interests of justice and may consider matters including the reliability and authenticity of the information. The section also provides that the weight given to admissible information depends on the circumstances relevant to its accuracy.
There are also procedural requirements concerning notice and service of documents where the statutory business-record provisions are relied upon.
For that reason, it would be incorrect to say that every medical record is automatically decisive in a medical negligence case.
How Patients Can Access Their Medical Records in Ireland
Patients may need access to their medical records when investigating their treatment or discussing a potential medical negligence claim.
The HSE states that, under GDPR, service users have a right to request access to their personal data, including medical information. Its guidance also explains that, in appropriate circumstances, healthcare staff should facilitate access to information held in a care setting.
Medical information may be held by more than one provider. Depending on the circumstances, relevant records could include information held by:
- a GP;
- a public hospital;
- a private hospital;
- a consultant;
- a diagnostic service;
- a maternity hospital;
- a specialist clinic.
Obtaining the relevant records can therefore be an important early step when reconstructing a patient’s treatment history.
How Medical Records Are Used in Different Medical Negligence Claims
The importance of particular records depends on the type of clinical negligence being investigated.
Delayed Cancer Diagnosis
Records may establish symptoms, referrals, screening or diagnostic investigations, pathology, follow-up and the date on which cancer was diagnosed.
The evidence may then be assessed to determine whether an earlier diagnosis should reasonably have occurred and what effect, if any, the alleged delay had on treatment and outcome.
Stroke Diagnosis and Treatment
Relevant evidence can include symptoms, neurological observations, imaging, scan interpretation, treatment decisions and the timing of intervention.
The chronology may be particularly important where the allegation concerns a failure to recognise or treat a stroke promptly.
Birth Injury and Maternity Negligence
Maternity records may include antenatal care, labour records, fetal monitoring, delivery documentation and neonatal observations.
In a birth injury claim, the timing and sequence of events can be central to the medical assessment of what occurred and whether an alleged delay or failure caused the injury.
Surgical Negligence
Surgical cases may require review of pre-operative assessments, consent records, operation notes, anaesthetic documentation and post-operative observations.
If a complication subsequently developed, the records can help establish when it became apparent and what treatment followed.
Why Medical Records Must Be Considered With the Full Evidence
Medical records are one part of a medical negligence investigation.
Other evidence may include the patient’s account, family evidence, correspondence, witness evidence and independent medical reports.
The records may establish what was documented, but they do not necessarily explain every decision or resolve every medical question.
That is why a clinical negligence investigation needs to consider the evidence as a whole.
At Cian O’Carroll Solicitors, our medical negligence work includes complex cases involving diagnosis, treatment, hospital care, cancer, stroke, childbirth injuries and neonatal care. The firm’s case experience demonstrates the importance of establishing the clinical sequence and obtaining appropriate medical evidence when investigating alleged failures in care.
Frequently Asked Questions About Medical Records in Medical Negligence Cases
What are contemporaneous medical records?
Contemporaneous medical records are records created during or around the time healthcare was provided. They can document symptoms, clinical findings, investigations, treatment, monitoring and follow-up.
Why are medical records important in a medical negligence claim?
They can help establish the clinical chronology and show what was recorded about the patient’s condition, investigations, treatment and response to care. They can also help identify issues requiring independent medical expert assessment.
Can medical records prove medical negligence?
Medical records can provide important evidence, but they do not automatically prove negligence. A claim may also require evidence concerning the appropriate standard of care, breach and causation.
Can I request my medical records in Ireland?
Yes. The HSE states that service users have a right under GDPR to request access to their personal data, including medical information. The appropriate process can depend on where the records are held.
What if I believe my medical records contain an error?
An apparent error should be considered in context. It does not automatically establish negligent treatment. If the accuracy of a record is relevant to a potential claim, it may need to be considered alongside other records and evidence.
Are medical experts involved in reviewing medical records?
They may be. In a medical negligence claim, appropriately qualified independent experts can be asked to assess the standard of care, causation and other medical issues arising from the records.
Discuss Your Medical Negligence Case With Cian O’Carroll Solicitors
Medical records can provide an important factual foundation when investigating a potential medical negligence claim. The significance of those records, however, depends on the individual circumstances and the wider medical and legal evidence.
At Cian O’Carroll Solicitors, we act in medical negligence cases involving cancer misdiagnosis, delayed diagnosis, stroke care, surgical negligence, childbirth injuries and neonatal care. We can review the circumstances of a potential claim and advise on the evidence and legal issues that may need to be examined.
Contact Cian O’Carroll Solicitors to discuss your circumstances.