CONTEMPORARY DOCUMENTS: CLINICAL NEGLIGENCE AND MEDICAL NOTES

The judgment of Mrs Justice McGowan today in FE -v- St George’s Hospitals NHS Trust [2016] EWHC 533 (QB) highlights the importance of contemporary documents. It also shows the dangers of the subsequent alteration of notes. There is no suggestion that this was done deliberately. However the poor standard of records served to undermine many of the defendant’s witnesses.

(It is also the first time I have seen the word “shambolic” in a judgment, although this is a apt description of the notes in question).

“The shambolic state of the theatre records show that timings have been altered and no signatures or initials have been applied, so no explanations can be given for the appalling state of record keeping …”

THE CASE

The claimant brought an action alleging clinical negligence in the period living up to his birth.

THE JUDGE’S OBSERVATIONS ABOUT THE MEDICAL NOTES

1. It is an unsatisfactory feature of this case that the recording of events was generally unreliable. The CTG monitor that was used to observe and record the baby’s heart rate and contractions was running on the wrong time for a considerable part of labour. The machine did not permit notes of events to be written against the time on the paper as it passed through the machine, although it might have been possible to mark the paper at the correct time and fill in details later that procedure does not seem to have been followed. At one stage the evidence was that events, such as an examination, are recorded on the trace before the paper went through the machine and before they were carried out, at another time the evidence was that the notes were added after the paper had been through the machine. The names of medical personnel are inaccurately recorded, sometimes but not always corrected later. Theatre notes have been altered by over writing without authorship. Some important events, if they occurred, have not been recorded at all, in particular the stopping of the administration of Syntoconin to JE. It is hoped that these failings have been remedied in the time since 2001.

1. The records of the time of arrivals and departures in and out of theatre have been written over and in general terms are wholly unreliable…

2. The shambolic state of the theatre records show that timings have been altered and no signatures or initials have been applied, so no explanations can be given for the appalling state of record keeping when it was obvious to all by 03.16 that the events of the night and their precise timing would be of great significance. It would be difficult not to be somewhat cynical about the nature of that piece of record keeping were it not for the fact that it is so generally awful.

3. Dr Hussain had compiled notes of the events of the shift at different times and on occasions she would record the fact that they were made up in retrospect but not necessarily every time that was the case. It is difficult to place much confidence in her note recording. She could not be certain whether she stayed with patient X until all the surgery was concluded, including the cutaneous suturing which could have taken up to 10 minutes, or not.

THE JUDGE’S CONCLUSIONS

The judge found that the defendant had been negligent. She observed:-

“iii) That the standard of record keeping was unsatisfactory, notwithstanding the workload.

a) All notes should have been acknowledged by signature or initial at the very least.

b) Theatre records should not have been altered without acknowledgment.

c) There should have been a method by which notes could be matched to the timing of an event on the CTC trace.

d) If a time recording device is capable of going wrong then there should have been an adequate means of regular checks.

e) It is unacceptable that the administration of oxytocin is not properly recorded; the doctors should not be working on the presumption that it had been stopped simply because they would have expected it to be stopped.”