Halifax Medical Malpractice Lawyer Blog

I get several calls a week from patients, of family members of patients, who are concerned about the care that they, or their family member, have received from their doctor or hospital.

In most cases, a careful investigation of the facts reveals that there are no grounds for a medical malpractice claim (in other words, the doctor or hospital wasn’t negligent) or that there may have been negligence in the patient’s care, but the cost of filing a lawsuit would be more than the potential recovery.

Explaining these facts to my clients is one of the more frustrating aspects of being a medical malpractice lawyer. I hate telling patients that I believe there was negligence in the care they received but that I don't think they should pursue a compensation claim.

My colleague Ches Crosbie has posted about this problem at the Newfoundland Injury Law Blog. Ches is one of Newfoundland and Labrador’s finest medical malpractice lawyers. He points out that the decision to accept or reject a client who has a medical malpractice claim is always difficult.

College of Physicians and Surgeons

However, if you are not satisfied with the care that you or your family has received, you can file a complaint with the College of Physicians and Surgeons. Each province has a College of Physicians and Surgeons that is made up of a panel of doctors and lay persons (non doctors) who are responsible for hearing complaints about doctor’s conduct and administering discipline.

Discipline can range from something as simple as giving the doctor a warning to as serious as suspending the doctor’s license or taking away the doctor’s license to practice medicine in that province.

File a Complaint About the Doctor!

I encourage patients and family members who are concerned about a doctor’s conduct to contact the College of Physicians and Surgeons to express their concerns. Often the patients don’t follow through with the complaint. I think this is a real mistake.

There are certain doctors who I regularly receive calls about. However, if the patients don’t file a complaint with the College of Physicians and Surgeons, there is no way for the College to know about any potential concerns about the doctor’s conduct.

When a patient finally files a complaint the College may not take the complaint seriously because it is the first complaint received about a particular doctor. The Board members' reasoning may be something like: “Well, we have only received one complaint about his/ her conduct. Lets give the doctor a warning to make sure it doesn’t happen again”.

On the other hand, if the College has received a half dozen or more complaints about the same doctor they will be far more likely to take the complaint seriously and more likely to administer more severe discipline to the doctor.

Ches gives some good advice about what type of information should be contained in a complaint to the College of Physicians and Surgeons. I would recommend anyone considering filing a complaint to take a look at his post.

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Altering medical records does not happen as often as it appears to happen on television or in the movies. However, it happens enough that experienced medical malpractice lawyers develop a sense of when further investigation into the legitimacy of a medical record or chart is warranted.

One of my favourite movies of all times is The Verdict with Paul Newman. I love the scene where he finally realizes that he can prove that the defendant doctor altered the medical files of the woman who was left in a coma because of the doctor’s negligence.

Lessons Learned From Past Cases:

Over the past 18 years, I have learned some lessons about when to suspect that a medical file may have been altered.

Notes on one report, not on another:

In one case I was involved in the specialist’s report that was received by my client’s family physician did not have (exculpatory) handwritten notes that appeared in the report in the specialist’s file.

Lesson:
Look for all copies of the record and compare them.

Different Versions of reports:

In one case the surgeon dictated three different versions of the operative report. The family doctor received the first version days after my client’s surgery. After my client’s condition deteriorated, he dictated a second version (which was found in the Hospital chart). After my client became comatose and was transferred to another hospital for corrective surgery he dictated a third version of the report which was in his office copy of my client’s chart.

Lesson:
Get the records, and get them fast.

Were they working?

In a claim involving allegations of nursing negligence, the nursing notes contained statements that the patient’s condition had been communicated to the attending physician. However the date of the entry was for a day that the nurse in question wasn’t working!

Lesson:
Compare staffing sheets/time cards with the medical chart to detect entries/notes by staff members that were not present/on duty that day.

Medication Errors:

Medication errors are a common mistake among nurses who are overworked or inexperienced.

In a claim involving a fatal overdose, the nursing notes indicated that the deceased had received the proper dosage of medication. However, the medication administration records, which were not supplied by the hospital when the chart was originally requested, showed that the medication had been administered to the patient twice.

Lesson:
Compare the medication administration records with the nursing notes and physicians orders.

Destroying Records:

In an anesthesia negligence claim the anesthesiologist tore up the original anesthesia record and prepared a new record with different data. One of the nurses involved in the operation retrieved the original record and scotch taped it together.

Lesson:
Interview everyone, including retired employees.

White out = Suspicious Records

In a birth injury claim two of the babies APGAR scores had been whited out and changed from a 0 to a 2 (normal).

Change the Numbers - Change the Result:

In a fatality claim the deceased’s blood pressure reading had been changed from 170/90 to 120/80 by using a different colour pen to alter the numbers 7 and 9. The change couldn’t been seen on the photocopy of the patient’s chart, but was reasonably obvious on examination of the original chart.

Lesson:
Whenever I have a reasonable suspicion that the medical files have been altered, I make an appointment to attend at the Hospital or the doctor’s office to view the original chart.

What to Look For:

Some “red flags” that I look for, based on past experience, that may indicate the possibility of altered medical records are:

• Crowding or squeezing entries above a signature, or between lines;
• Erasures, crossed out entries or white-out corrections;
• Changes in slant of handwriting;
• Using different pens or computer typeface to write one entry;
• Notes on different dates in the same colour ink from same pen;
• Notes in different colour ink (different pen) in the same chart note;
• A typed entry following handwritten entries, or vice versa;
• Missing original records that have replaced by photocopies;
• Entries that are self-serving;
• Half sheets instead of the standard size page (page cut in half);
• Additional notes on the original document, not on copies received by client;
• An unusually late date of dictation of a consult report;
• Any handwritten entry made by someone who erred significantly in treatment.

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