Being on the receiving end of a claim, or receiving a request for records from attorneys who are investigating a potential claim, can be extremely unnerving and worrying.
You have a dedicated team at Medical Protection that can support you through what can be a difficult time. And to ensure we are best placed to offer that support, here are some ways you can help us to help you.
Don’t delay!
Notify us immediately if you receive:
- A request from a patient, or attorneys on their behalf, requesting the patient’s records.
- A letter of demand or summons/court proceedings. There is a ten-day deadline for responding to a summons at court – after which, the patient’s attorneys can apply for judgment against you.
- Invitations to attend a pre-mediation meeting or participate in a mediation process. We have experienced cases where members have joined a mediation process without having notified Medical Protection and, without having had our support, they have been poorly advised.
Your written statement
When you receive a request for records, letter of demand or a summons, one of the first steps you need to take is write a report or statement, detailing your involvement and treatment. Medical Protection will send you guidance on how to write a report, whenever you request assistance for a claim or potential claim.
Your written report should:
- Be written in the first person throughout, rather than in the passive voice: “I intubated the patient at 1200 hours” rather than “the patient was intubated at 1200 hours”.
- Include an overview of your experience, qualifications (including dates), current role, your role at the time if it was different, and time in post.
- Provide the dates of your first and last contact with the patient, your membership grade and specialism during the period of your involvement.
- For all key interactions with the patient, provide a chronological account specifying:
- The date of the interaction
- Full details of the history taken, including any negative findings
- The extent of any examination of the patient, including any negative findings
- The relevant observations, eg, pulse, blood pressure, if taken during your examination
- Your immediate differential diagnosis, the management plan and instructions to the patient and/or any other medical practitioners
- A detailed description of your operative/surgical technique (where applicable).
- If applicable, clarify if the risks of the treatment you provided were fully explained to the patient. If so, specify the risks you discussed and whether your discussion with the patient was documented.
- Provide the names and areas of specialism of any other healthcare professionals (if known) involved in the treatment of the patient.
- Where allegations of negligence or a demand for compensation has been made by the patient, provide your comments on each allegation. Include your views on any areas where you consider you may be vulnerable or open to criticism.
- Specify whether your report has been prepared on the basis of contemporaneous medical records or recollection alone.
We need the complete patient file
At the outset of a claim/potential claim, we will request your complete patient file. Please do
not send your original file or any original documents; these should be securely retained by you.
A common cause of delay here is when the complete patient file isn’t provided. You are under a duty to disclose complete records, which should include:
- The front and back cover of the patient file (inside and out)
- Clinical notes (handwritten and typed) – you should provide an exact typed transcript of your clinical notes, which should not be edited or amended. You may provide explanatory notes on a separate sheet. Please do not be tempted to amplify your notes, or create notes.
- Every document, letter, memorandum (including emails, text messages, WhatsApp messages)
- Referral letters
- Special investigation reports, test results, pathology reports, radiology reports, laboratory reports
- Consent forms and notes recording discussions about consent
- Operation notes/reports
- X-rays/radiology, ECG traces, CTG traces
- All drawings and images/photographs/videos
- Clinical research and clinical trial details
- Insurance forms and disability assessments
- Death certificates and autopsy reports.