How paper trail works in medical negligence cases

A recent Punjab State Consumer Commission decision underscores the evidentiary value of medical records. Records from the hospital where the patient was later admitted helped the hospital where the patient was first admitted in a medical negligence case.

The patient was admitted with a severe proximal tibial plateau fracture and compartment syndrome after a road accident. The surgical team performed a double-incision fasciotomy and fracture fixation, followed by regular monitoring, aseptic dressings, and specialist consultation. The patient was discharged after two weeks with explicit instructions for strict bed rest, non-weight-bearing status, and a ten-day follow-up. Instead of returning for follow-up, the patient sought treatment at another hospital three days later, walking against medical advice. He developed complications and required prolonged treatment.

The patient approached the court alleging negligence by the first hospital. One notable defence taken by the hospital was that the patient was discharged with the advice “strict bed rest and not weight bearing till further orders”, but three days later, when he approached the other hospital, the chief complaint recorded was “Pt unable to bear weight and walk properly.” The inference that could be drawn from this was that the patient did not comply with the medical advice.

The court found this defence plausible. Further, the patient failed to produce any evidence of medical negligence. “The mere fact that the patient subsequently developed complications cannot, by itself, be treated as proof of negligence,” the court observed.

Hospitals and doctors must ensure that medical records, especially admission notes, surgical notes, specialist consultations, and discharge summaries, are written clearly. These records are vital not only for continuity of care but also for medical negligence cases. They may be helpful to you and, at times, to other hospitals and doctors as well!