An interesting point arose in the case of William Lees v
North Lanarkshire Council heard by Lord Bracadale in January
of this year in relation to where information recorded in ambulance
and hospital records had actually come from.
By way of background Mr Lees had fallen and broken his ankle
whilst walking along a footpath near his house in February 2005. He
raised an action for personal injury against the defenders North
Lanarkshire Council on the basis that they were responsible for
maintaining the pavement. Mr Lees alleged that he fell because the
pavement had been in a poor state of repair.
Unfortunately for Mr Lees the patient form completed by the
ambulance crew who attended to him had at the history section
"fall, patient slipped on ice, went over left ankle". He
was taken by ambulance to the local hospital where two doctors who
saw him that day recorded in their notes respectively "slipped
on ice this morning and fell" and "slipped on ice at 9am
this morning". There were apparently other similar
descriptions at various points later in the medical notes.
When he gave evidence Mr Lees specifically denied that he had
slipped on ice and insisted that his fall had been caused by the
poor condition of the pavements. His evidence about the absence of
snow and ice at the point where he fell was supported by his wife
and a neighbour both of whom attended to him prior to the arrival
of the paramedics and ambulance.
The pursuer's wife and the neighbour both gave evidence to the
effect that the paramedic who was the first to arrive said to the
pursuer "what's the matter big man, did you slip on ice?".
The pursuer was described by his wife and neighbour as being
incoherent and in agony at this stage and unable to answer the
paramedic's question. His personal details were given by his wife.
The paramedic was then overheard saying to the ambulance crew who
were next to arrive, "he has broken his leg, he slipped on
ice".
The paramedic in his evidence accepted that "did you slip on
the ice big man?" was something that he may well have said.
Although he suggested that he wouldn't have made reference to ice
if it hadn't been there he accepted that on the patient report form
he had filled out there was no mention of ice. He also accepted
that he might well have said to the ambulance crew when they
arrived "I think he slipped on ice and maybe broke his
ankle".
The court also heard from one of the ambulance crew who was
asked about the record card that he had filled out which included
reference to the pursuer slipping on ice. The ambulance man
explained that that information was probably received from the
pursuer but could also have been received from witnesses,
neighbours or indeed the paramedics. It was confirmed that where
the paramedic is first on scene he will normally give the ambulance
crew a short briefing when they arrive. The ambulance man thus
accepted it would be in accordance with normal practice if the
paramedic had given him the information about slipping on ice.
The doctor who had first seen the pursuer when he was admitted
to the local accident and emergency department also had a hand
written note which made reference to the pursuer slipping on ice.
Initially he suggested that the information must have come from the
pursuer but on cross examination he conceded that the pursuer would
have been in great pain and that the note was possibly a
combination of the pursuer indicating that he had fallen and the
report from the ambulance team, which the doctor would also have
seen at that time, suggesting that he had slipped on ice.
Lastly the court heard from the doctor who was in charge of the
orthopaedic department at the hospital where the pursuer was
admitted after his initial assessment at accident and emergency.
Again he had his own hand written note which made reference to the
pursuer slipping on ice. Again his initial feeling was that the
information must have come from the pursuer but he accepted the
pursuer was in great pain and the medical records confirmed that he
had had two doses of morphine on arriving at the hospital which
would have made him drowsy and less able to give an accurate
history on questioning. The orthopaedic doctor also accepted that
he would have spoken to the doctor who had first seen the pursuer
at the accident and emergency department and would also have seen
that doctor's notes which made reference to slipping on ice before
he saw the pursuer himself.
Perhaps not surprisingly none of the medical witnesses could
recall the incident in any detail and they were all primarily
relying on the notes they had made at the time.
Having heard all the evidence Lord Bracadale decided that the
original source of the suggestion of slipping on ice was in fact
the paramedic rather than the pursuer. Although subsequently the
ambulance team and doctors had all spoken to the pursuer he thought
the reference in their written records to slipping on ice had most
likely come from the information initially supplied by the
paramedic. Lord Bracadale accepted that the pursuer would have been
in great pain, had been medicated and would not have been terribly
communicative. He also pointed out that the doctors were primarily
interested in the way in which the pursuer had fallen and that the
cause of the fall was of little importance to them in terms of
diagnosis and treatment of the injury.
Overall Lord Bracadale preferred the pursuer's version of events
supported by his wife and neighbour and found that the fall was
caused by a defect in the path for which the Council were
responsible. That said he also found the pursuer 40% to blame for
what happened on the basis that he was very familiar with the path,
knew that the defect existed and could easily have walked around it
as there was plenty of room.
Versions of events given by pursuers during post accident
medical treatment are often an extremely good source of information
to challenge or cross check what may emerge later after the pursuer
has had time to reflect and perhaps take legal advice. Although we
think this case is an extreme example if you are going to challenge
a pursuer on the basis of conflicting entries in the medical
records bear in mind that the pursuer may have been in significant
pain and affected by medication when being spoken to by the doctors
and that the doctors main focus does tend to be finding out how
rather than why the accident occurred. Try insofar as possible to
find out if the critical information can only have come from the
pursuer rather than a jovial good samaritan.