The Importance of Medical Record Review and Analysis in Wrongful Death Claims

Defending against a wrongful death claim can prove challenging. Often, the “blame” is directed at the last place the deceased received care, although myriad factors may have contributed to the cause of death. To be successful, the plaintiff must first prove that an event or injury occurred as a result of negligence. Then it must be proven that the event or injury proximately caused or contributed to cause of death. Even with a death certificate, the cause of death can remain uncertain, so an accurate and detailed medical record review is vital. Here are a few recommendations to consider:

1. Know the medical record in detail.

The old adage “the devil is in the details” couldn’t be more appropriate when reviewing medical records for a wrongful death claim. There are 3 key time periods in which crucial details can be found – before, during, and after their hospitalization or nursing home residency.

Medical records are extremely helpful in multiple ways. Records that precede admission provide context for the hospitalization or skilled nursing facility placement. In addition, they serve as excellent sources of information about co-morbidities and baseline functional status. Since the event or injury leading to the alleged wrongful death likely occurred during a hospital or nursing home stay, the need to review records during that period is obvious. Finally, if there are medical records following discharge or transfer from the hospital or nursing home, reviewing these records will assist in proximate cause and damage determinations. For example, if the alleged cause of death is sepsis from a urinary tract infection, medical records that reflect a history of urinary tract infections preceding admission to the hospital or nursing home will be critical. Also, records describing continued urinary tract infections after being discharged or transferred from the hospital or nursing home may support an argument that the infections were more likely due to an underlying co-morbidity or condition, as opposed to any negligence on the part of the facility staff. Additionally, if the death occurred many months to even years after the alleged event or injury, proximate cause becomes more dubious.

2. Remember to consider the other possible causes.

A detailed medical record review can shed light on other issues that could have caused or contributed to the patient/resident’s death—beyond what is alleged by the plaintiff or stated on the death certificate. These factors include co-morbidities, pre-existing risk factors, and non-compliance. Co-morbidities such as congestive heart failure, COPD, and chronic infections could arguably have caused more debility than an alleged pressure ulcer, for instance. Risk factors like Alzheimer’s disease and other forms of dementia can have a dramatic impact as well. As the disease progresses, individuals forget how to do basic activities of daily living such as walking or eating. They may also become non-compliant with recommended treatments, safety measures, or medications—and their refusals must be respected. For these individuals, outcomes such as falls, pressure ulcers, or malnutrition may be unavoidable despite all efforts made by the facility staff to prevent them. In those cases, even if the event or injury was the ultimate cause of death, there exists no negligence.

3. Do not presume the death certificate is accurate.

In some cases, the death certificate may be completed and signed by someone who barely knew the resident. Those authorized to sign a death certificate vary by state, but often include any physician, medical examiner, nurse practitioner, forensic pathologist, or coroner. As such, the death certificate may be completed and signed by a professional who had little to no knowledge of the events leading up to the resident’s death, much less their progressive decline over a period of months or years. Coroners and medical examiners will often review the medical records when making a cause of death determination, however rarely do they perform autopsies on individuals who were of advanced age or resided in a nursing home. In some cases, challenges to the death certificate may require testimony from a medical expert, and having a firm grasp of the details will be essential.

Navigating a medical record to extract all the relevant information is no easy task. Luckily, there are experts who know exactly what to do. Click here for more information.