The Importance Of Medical Records As Evidence In A Personal Injury Claim

Medical records form a key part of evidence in a personal injury claim. A Claimant may not necessarily appreciate the significance of what is written in their medical records in respect of their case and the impact their medical records have on their case.

The accident

Medical records often note the cause of an accident. Although a Claimant’s personal account carries weight as evidence, medical records need to corroborate a Claimant’s version of events. If the medical records state the injuries were sustained due to another cause, a Claimant’s case is likely to fail because causation will not be proven. For example, a Claimant reporting they tripped on pavement and sustained a fracture when the medical records state the injuries were sustained after falling over whilst intoxicated in a nightclub.

The injury

Medical records will accurately note the formal diagnosis following an injury. Sometimes, a Claimant will report sustaining fractures when in reality the injury is limited to soft tissue injury bruising. A Defendant can allege fundamental dishonesty for exaggerating injuries reported at the start of a claim.

In certain instances, a Claimant may report multiple injuries however the injuries reported to the GP or Hospital consultant may be limited to one or couple of injuries. There have also been cases where a Claimant will report injury to the left side of body part to one doctor and then report injury to the other side to another doctor. It is important that a Claimant accurately reports all injuries and symptoms to their doctor or treating consultant. Inconsistencies can have grave consequences for a personal injury claim.

Often a Claimant will be psychologically affected after an accident, however they may not report these symptoms to their GP. Without evidence, a Defendant may question whether genuine psychological symptoms have arisen as a direct result of the accident.

The ongoing symptoms

Claimants are likely to experience ongoing symptoms following an injury which will depend on the nature of the injury and the severity.

It is important for a Claimant to report ongoing symptoms, their impact on activities of daily living and seek medical advice. It is very common for Claimant’s to report that they continue to experience significant pain however at the same time they fail to seek appropriate medical advice and treatment. For example, a Claimant stating they are bedridden due to their injuries but there are also entries in their records reporting a bad back from lifting weights in their local gym after the accident.

A medical expert who prepares a formal report in relation to the accident related injuries is less likely to be persuaded the accident has caused significant issues if the medical records do not make reference to ongoing pain and appropriate treatment for these symptoms.

The Defendant may raise mitigation arguments if the expert concludes that a Claimant may have recovered sooner if they had sought medical advice and treatment for any ongoing symptoms. This can affect the amount of compensation a Claimant might receive.

Losses

A Claimant may not be able to work following an accident or may require care and assistance from family and friends.

The Defendant will often ask for sickness certificates to prove a Claimant was formally assessed to be no fit to work. This is common for self-employed individuals.

If a claim for loss of income is advanced but there is a lack of evidence that a Claimant was not fit to work, the Defendant is likely to challenge a claim for loss of income during the period a Claimant was unable to work.

Past medical history

The Claimant is obligated to disclose any relevant past medical history and accidents as part of their claim. In particular, to the medical expert.

Failure to disclose this information can lead to the Defendant raising credibility concerns and fundamental dishonesty.

For example, if a Claimant fails to disclose they suffered a similar injury in close proximity before their accident related injury for which they are making a claim, then the Defendant may state the Claimant is exaggerating the extent of their symptoms arising from the accident alone.

It is therefore important to be open and honest about all relevant medical history.

Character

Medical records can provide a rich history and insight into a life of any individual.

If a Claimant has a history of poor behaviour towards medical professionals including physical and verbal abuse, this is likely to be noted within their records. Medical records can be disclosed to the Court or the Defendant as part of the claim.

Failing to attend appointments for treatment required for accident related injuries without a reasonable explanation is likely to be frowned upon and may give the Defendant the upper hand in relation to settlement negotiations. A Judge at Court may also see this as a Claimant disregarding valuable NHS money and resources.

Medical records are a core element of personal injury claims and a Solicitor can best advise you in relation to the impact of any records on a Claimant’s personal injury claim.

If you would like to pursue a personal injury claim, please contact our experienced Personal Injury Team on 0808 252 5231 or request a call back.