I have previously emphasized how important it is for a medico-legal expert to demonstrate objectivity and diligence. These qualities are indispensable especially in compiling and reviewing the available documentation pertinent to a particular claim.
Clinical records can often be the central piece in a case, steering the outcome in one direction or another. NHS Resolution provides actionable guidelines for clinicians regarding good record keeping practices and pitfalls to avoid. GMC guidance instructs that good records should be detailed and contemporaneous—meticulously recording all decisions as they occur.
From an expert’s perspective, any piece of information contained within the records could prove fundamental to the case. For this reason, it is important for an expert to have a solid understanding of what good record-keeping ought to look like before beginning their review of available documentation. Sometimes, the decisive information on a claim is that a crucial piece of information was not recorded. Such a lapse in documentation on the clinician’s part could severely weaken the defense of a case and its absence should definitely be noted by the expert.
The clinical information gleaned through a meticulous review of existing records pertaining to a claim should help an expert to asses whether, in their opinion, the standard of care was met. For example, if a misdiagnosis is alleged but the records show that the attending physician followed all recommended guidelines (as indicated at the time of treatment) and requested all necessary investigations to be carried out, that may lead the expert to conclude that the clinician was acting to the best of his or her ability considering the information they had.
To this end, contemporaneous records can often offer a fuller picture of the context in which a patient was treated. Events and actions recalled from memory may not be as reliable. This is why information gathered post-factum may hold less sway in the eyes of the court. That said, I’d like to once again highlight an expert’s commitment to impartiality. It is not within the expert’s purview to decide the veracity of conflicting information. If a doctor’s notes provide a different account of events from that of, for example, a witness statement provided at a later date, the expert’s job is to assess the implications of both and give clear and concise opinions to the court on all evidence provided.
In the end, it is the expert’s job to make sense of the available records and help build a coherent timeline and infer a reasonable course of action based on the evidence at hand. Ultimately, as underscored in previous posts, it is up to the court to draw conclusions after being equipped with an expert’s report.