Medical records and disclosure in clinical negligence cases
Produced in partnership with Andrew Ritchie QC of 9 Gough Chambers

The following PI & Clinical Negligence practice note produced in partnership with Andrew Ritchie QC of 9 Gough Chambers provides comprehensive and up to date legal information covering:

  • Medical records and disclosure in clinical negligence cases
  • The right to obtain disclosure
  • Medical records
  • Hospital records
  • GP records
  • Ownership of medical records
  • Obtaining medical records outside litigation
  • Evidential status
  • Disclosure
  • Inspection
  • More...

Medical records and disclosure in clinical negligence cases

The right to obtain disclosure

The fundamental purpose of disclosure is to further the overriding objective by ensuring parties to litigation are on an equal footing.

The meaning of ‘documents’ is not restricted to paper or writing but extends to anything on which evidence or information is recorded in a manner intelligible to the senses or capable of being made intelligible by the use of equipment. This includes computer databases, microfilms used to keep records, video and audio tapes and discs.

In clinical negligence claims the most important category of document is likely to be the claimant’s medical records. They will provide the most contemporaneous record of the treatment given to a patient and will, in many cases, be the basis of expert opinion that will determine the outcome of the litigation. An early and objective scrutiny of medical records can save a lot of time and expense.

Medical records

Hospital records may include:

  1. clinical records

  2. nursing records

  3. operating notes

  4. discharge sheet

  5. x-rays

  6. magnetic resonance imaging (MRI) scans

  7. ambulance and paramedic notes

GP records may include:

  1. Lloyd George cards

  2. computer summary records

  3. correspondence between professionals

They can come from a wide variety of sources if an individual has been treated by a number of different hospitals or departments within the same hospital. Complete disclosure of an individual’s medical records will reveal their past medical

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