Dr George Fernie, Senior Medicolegal Adviser, introduces this issue’s round-up of case reports
In theory, all doctors are aware of the need to keep accurate and comprehensive medical records. But in busy clinical practice, high standards can sometimes slip as a result of the need to see ever-growing patient numbers. In many of the claims MPS handles, we come across examples of patient notes where there is no record of informed consent being taken; there is no record of discussions around potential postoperative complications; or there is no record of test results being ordered. This can make the job of defending a clinical negligence claim very difficult indeed.
No matter how busy you are, it is important not to underestimate the value of detailed notes. Not only do they help if a clinical negligence claim is brought against you, they are the gold standard of good patient care – leading to better communication between colleagues and smoother handovers.
In “Penetrating the eyeball”, Dr R’s records showed no evidence of discussion of indication, risks or alternatives for Ms J’s periocular injections. No written consent was taken. When a non-standard treatment is offered, a thorough discussion of the indications, risks and alternatives is mandatory and written consent is advisable. As a result, the case was indefensible and was settled for a substantial sum.