HOW CLINICAL RECORDS WILL BE CONSIDERED BY A COURT IN A CLAIM FOR COMPENSATION ARISING OUT OF MEDICAL NEGLIGENCE

On the 1st April 2014, Ms. Justice Irvine handed down her decision in the case of Gerry Foley-v- Bon Secours Hospital & Anor. It has become apparent to those practicing in the Medical Negligence field that a significant number of the compensation claims brought arise out of deficiencies in post-operative care. In Mr. Foley’s case, the failure to diagnose and treat a post-operative “leak” led to emergency operative intervention for him and subsequent adverse sequelae.

Both the Clinical and Nursing Notes were reviewed in detail during the course of the hearing. The Patient’s file was reviewed by the Judge in a chronological manner and the level of importance placed on the Clinical and Nursing Notes was significant. The Judge was critical of the shortcomings in the Clinical Notes (these are the treating doctor’s notes on the patient file). On this occasion, however, he found the standard of the Nursing Notes to be of a high calibre to the extent that Mr. Foley’s outcome was not adversely affected by the failure of the Doctor to keep notes of an acceptable standard.

The outcome of the case which saw substantial compensation paid to Mr. Foley ultimately turned on the failure to diagnose his post-operative condition and to treat same properly.

The Court concluded that:

– The treating doctor should have recognised a significant deterioration in Mr. Foley’s condition and should have managed him on the basis that the deterioration might have been due to a leak from an astomosis that had been carried out the previous Monday. The doctor ought to have carried out immediate blood tests. The doctor ought to have advised his Consultant Superior of the patient’s deterioration. The care afforded to Mr. Foley fell short of acceptable standards. The delay in diagnosis led to what would have otherwise been unnecessary Lifesaving surgery. The delay in remedying the situation led to adverse physical sequelae for Mr. Foley.

What is clear from this and other cases is that the post-operative period is one where particular vigilance is necessary.

In contentious business a Solicitor may not calculate fees or other charges as a percentage or proportion of any award or settlement.

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