CONTEMPORARY DOCUMENTS: CLINICAL NEGLIGENCE AND MEDICAL NOTES
The judgment of Mrs Justice McGowan today in FE -v- St George’s Hospitals NHS Trust  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 claimant brought an action alleging clinical negligence in the period living up to his birth.
THE JUDGE’S OBSERVATIONS ABOUT THE MEDICAL NOTES
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.
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.
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.