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From the case files - September 2013

Dr Alison Metcalfe, Head of Medical Services, introduces this issue’s round-up of case reports

All doctors are aware of the need to keep accurate and comprehensive medical records. But in busy clinical practice, standards can sometimes slip as a result of the need to meet ever increasing service demands. 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 tests being ordered or results being followed up. This can make 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 fundamental to 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. Additionally 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. The case was indefensible and settled for a substantial sum.

Good record-keeping means not only recording consent taken and treatments offered, but doing so contemporaneously. In “Rash decisions”, Dr P made notes retrospectively after Mr M rang the surgery with swelling, throat discomfort and difficulty breathing after he had been taking allopurinol and steroids for severe foot pain. Remember that alteration of records is a probity issue. Any alterations or retrospective entries should be clearly marked and dated according to when they are entered in the record.

Good record-keeping also means recording accurately the results of observation and monitoring. In “A brain-damaged baby”, experts were critical of the monitoring of the fetal heart rate both during Mrs N’s induction phase with prostaglandin, as well as during labour. Poor monitoring and incorrect interpretation of the CTGs, compounded by poor documentation on the CTGs, with a failure to record the date and time, meant that labour was allowed to continue in place of a caesarean section, resulting in intrapartum asphyxia. The case could not be defended.