Trail of Deception: Legal Nurse Consultant Unveils Altered and Missing Records in a Fatal Medical Malpractice Lawsuit

Introduction: This case study delves into a medical malpractice lawsuit where a legal nurse consultant  played a pivotal role in assisting the attorney in securing a successful outcome for the plaintiff. The case  revolves around the tragic death of a patent, Mrs. Emily Watson, who was discharged from the  emergency room with a misdiagnosis and later died. The legal nurse consultant’s expertise in forensic  clinical documentation analysis was instrumental in exposing altered and missing medical records. 

Case Background: Mrs. Emily Watson, a 58-year-old woman with a history of respiratory issues, sought  care at Mercy Regional Hospital’s Emergency Room (ER) with severe shortness of breath, high fever, and  exhaustion. She had been diagnosed with pneumonia by her primary care physician the day before her  ER visit. Mrs. Watson’s vital signs upon admission to the ER were alarming: a temperature of 102 degrees  Fahrenheit, a heart rate ranging from 117 to 137 beats per minute, a respiratory rate of 26 breaths per  minute, and an elevated white blood cell count of 21,000. 

The Legal Nurse Consultant’s Role: Attorney Daniel Foster, representing Mrs. Watson’s family,  recognized the need for an expert in clinical documentation and engaged the services of Michelle Harris,  a legal nurse consultant with extensive experience in forensic clinical documentation analysis. Michelle  played a crucial role in building the case: 

1. Medical Record Review: Michelle conducted a comprehensive review of Mrs. Watson’s medical  records, focusing on the initial evaluation, diagnostic decisions, and the subsequent decision to  discharge her. 
2. Audit Trail Request: Suspecting potential foul play, Michelle advised Attorney Foster to request  an audit trail of the medical records to track any unauthorized changes or deletions. 
3. Forensic Clinical Documentation Analysis: Michelle conducted an in-depth forensic analysis of  the medical records, comparing the audit trail with the original records. She identified gaps and  inconsistencies in the documentation. 
4. Expert Witness Selection: She collaborated with Attorney Foster to identify expert witnesses in  healthcare informatics and clinical documentation who could testify about the authenticity of  the medical records and the implications of missing or altered information. 

Legal Strategy: Attorney Daniel Foster built his case on the following key arguments: 

1. Misdiagnosis and Premature Discharge: The ER staff failed to accurately diagnose Mrs. Watson’s condition and discharged her too early, despite her alarming vital signs and elevated white blood cell count. 
2. Altered and Missing Records: The plaintiff’s team argued that the altered and missing medical  records were indicative of a cover-up attempt and raised questions about the true extent of the  negligence and its impact on Mrs. Watson’s condition. 

Outcome: During the trial, Michelle Harris’s forensic clinical documentation analysis played a pivotal  role. The expert witnesses testified convincingly about the irregularities in the medical records and the implications for Mrs. Watson’s care. They confirmed that there were indeed missing records and  evidence of tampering with existing records. 

The jury found in favor of Mrs. Watson’s family, holding the hospital and medical staff accountable for  their negligence and the manipulation of medical records. The substantial compensation awarded to  Mrs. Watson’s family reflected the severity of the case. 

Furthermore, the hospital faced regulatory scrutiny and was required to implement enhanced record keeping and auditing procedures to prevent similar issues in the future. 

Conclusion: This case study illustrates how a legal nurse consultant, with expertise in forensic clinical  documentation analysis, played a pivotal role in uncovering the truth behind altered and missing medical  records. Michelle Harris’s meticulous examination and analysis of the records, along with expert witness  testimony, were instrumental in securing justice for Mrs. Watson’s family. This victory not only provided  closure and financial relief but also prompted positive changes in the hospital’s documentation and  record-keeping practices to safeguard patient care and legal accountability.

LORNA TAYLOR