May 19, 2010

Altered Pathology Report

A Maryland man has won an $800,600 verdict in a malpractice case against a California surgeon. The award included $300,000 in punitive damages for intentional infliction of emotional distress.

The patient had a small skull based tumor that was threatening his hearing, and went to a doctor to remove the tumor. According to the lawsuit, the doctor removed something but it was not the tumor. The hospital’s pathology report supposedly showed that what was surgically removed was not a tumor. But instead of telling the patient, the lawsuit alleged that the doctor and/or others altered the report to hide from the patient the fact that the tumor actually was not removed. The patient subsequently lost his hearing and filed suit. A copy of an article on the case can be found here.

As an experienced Baltimore, Maryland and Washington, D.C. attorney who handles many medical malpractice and other catastrophic injury cases, I have successfully handled many cases involving important medical records. Clients of mine frequently ask whether there is any way to tell whether medical records have been improperly altered. I always explain that there are ways, such as comparing them to other records, comparing them to records which have been sent to others, and forensic document examination. At times, I have had medical records evaluated by forensic document examiners who can tell, using ink dating analysis or examination under special lighting, that documents have been altered. Computer systems even keep track of alterations of computerized medical records systems. Usually, when I can prove that a medical record was improperly altered, the case settles. To see some of the cases I have handled, click here.

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June 25, 2008

Surgeon Operates on Wrong Part of Body / Altered Medical Records - Medical Malpractice / Medical Negligence / Medical Mistake

A New Jersey doctor's medical license has just been suspended after regulators determined that he performed the wrong surgery on a patient, by removing the wrong lung, then tried to cover up the error. The New Jersey Board found Dr. Santusht Perera removed a portion of the patient's right lung when he should have been removing a tumor in the left lung. According to the Board, the surgeon then told the patient that the right lung contained a life-threatening tumor, though there was no such growth. He also altered the patient's records to show he intended to operate on the right lung. The board determined that Perera's actions constituted gross negligence. A copy of the article regarding the case can be found here.

While most medical care is good, sadly there are significant number of doctors and hospital staff who commit serious medical malpractice / medical mistakes each day. In the case above, the patient's healthy lung was removed while the cancerous lung was left unaltered. As if that is not bad enough, the doctor then tried to cover up his mistake. Like in this case, the doctor usually gets caught.

Unfortunately, I have been involved in a number of cases in which doctors and hospital personnel in the Baltimore, Maryland and Washington area have tried to cover up their medical malpractice / medical negligence / medical mistakes by changing or altering medical records. Surprisingly, it is not always hard to catch these people. After having reviewed hundreds and hundreds and hundreds of medical malpractice cases, I know what to look for in a medical chart, both in terms of what should be in there and what should not be in there. We also have the experience and resources to have a forensic document examiner test a document to determine whether there is anything unusual about the document.

For example, I was involved in one medcial malpractice case in Maryland where a doctor said he told my client to follow-up after an abnormal chest x-ray, but there was no subsequent visit. The doctor even pointed to an entry in his chart that he had written which said that he told the patient to follow-up. This was a critical issue in the case because if the doctor did not tell the patient to follow-up, everyone in the case agreed he would have committed malpractice. If he did tell the patient to follow-up and she didn't, she certainly would have lost the case because the jury would have found her to be guilty of contributory negligence. The client's family was sure that if she had been told to follow-up, she would have. But she was dead and so we couldn't have her deny the doctor's claim. So, I obtained the original medical record and had it tested by a forensic document examiner who was able to prove - by highly magnifying the section where the doctor allegedly told the patient to follow - that the line containing the follow-up recommendation was written with a different pen then the rest of the entry for that day. That was enough to get the case to settle! If necessary, we were prepared to have the ink on the medical record tested to determine the date on which it was written, but that wasn't necessary.

In another Maryland medcial malpractice case, a women died a couple of days after minimally invasive gallbladder surgery (called a laparoscopic cholecystectomy). Strangely to me, the surgeon did not dictate his operative report for months after the surgery. In fact, he waited to dictate it until after the woman's autopsy report came out. The autopsy showed that there had been a leak of bile from the gallbladder's cystic duct after the surgery. When I finally got my client's operative report, it was a full 3 pages long and went on and on about how he carefully did this, and carefully checked that before finishing the surgery. That operative note was suspicious to me because I had seen a number of operative reports from other gallbladder cases I had reviewed and all of those operative reports had been only a paragraph long and certainly no more than one page. When I took the surgeon's deposition, I purposely got him to say that his operative report in my client's case was typical of his operative reports in other gallbladder cases and that he would expect all his other gallbladder operative reports to look virtually the same as my client's. Right after the doctor's deposition, I subpoenaed the last 10 gallbladder operative reports that he generated before and after my client's surgery. When I got those reports, as I had suspected, all 20 were only one paragraph long - which was in stark contrast to our client's 3 page long operative report in which tjhe doctor claimed to check and double-check everything. At trial, the jury hated the doctor for lying under oath during his deposition, and trying to avoid responsibility for killing his patient, and rendered a verdict in excess of $3 million. That is what you can do when you know what to look for!!!!

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