Casebook Vol. 18 no. 2 - May 2010
On the case
Head of Medical Services (Leeds) Dr Nick Clements introduces this issue’s round-up of case reports, which focus on the need for accurate record-keeping
Good record-keeping is essential in all medical specialties. Documenting relevant conversations is always good practice and accurate records are vital for defending a complaint or clinical negligence claim; they provide a window on the clinical judgment being exercised at the time.
In “Unrealistic expectations” and “Casting stones”, both cases were successfully defended as a result of good record-keeping. The orthopaedic consultant in “Unrealistic expectations” documented the explanations given to Miss D at the time of the informed consent and a description of the steps taken to minimise scarring.
As well as the consent process, it is good practice to document any discussions or explanations given, including any alternatives and commonly occurring and significant potential complications.
In “Tunnel vision”, expert opinion was supportive of the clinical decisions made, but the case could not be defended due to deficiencies in the recording of consent. Claims such as this that cannot be defended are increasingly being settled for higher sums. MPS claims experience has increased year on year, due to the significant costs of ongoing care and the fact that those who need care are living longer as a result of improvements in medical treatment.
Changes in the legal guidelines relating to settlements are also having an effect.
The amount for which claims settle is not related in any way to the nature or extent of any negligence. It is based on the nature and extent of the harm suffered by the patient, and on factors such as their care needs, loss of earnings and whether they have any dependants.
About these case reports: Casebook publishes medicolegal reports as an educational aid to MPS members and to act as a risk-management tool. The reports are based on issues arising in MPS cases from around the world. Facts have been altered to preserve confidentiality.