Case Study: Venepuncture Expert Witness and the Absence of Contemporaneous Clinical Documentation

In clinical negligence litigation, the contemporaneous medical record is often the "silent witness" that determines the outcome of a claim. It provides an objective anchor against which the recollections of both the claimant and the defendant are measured. However, what happens when that anchor is missing?

At Apex Experts, our panel is frequently instructed to navigate cases where the central clinical event has left no paper trail. This case study examines a common yet complex scenario: a routine venepuncture procedure that allegedly led to lasting injury, but which was never recorded in the clinician’s notes.

The Anatomy of the Claim: A Routine Procedure Gone Wrong

The case involved a patient who attended a Genitourinary Medicine (GUM) clinic for a routine blood test. According to the claimant, the procedure was fraught with immediate complications. He reported experiencing sharp, radiating pain the moment the needle was inserted, followed by rapid swelling and the development of a significant "lump" at the site of the draw.

The patient’s journey through the healthcare system following this event was documented in fragments:

• Immediate Review: The patient alleged that a doctor reviewed the site in the clinic and advised on pressure.

• Reattendance: Within the hour, the patient returned to the clinic, distressed by the worsening symptoms, and was reviewed by a second nurse.

• Secondary Care: He was advised to attend A&E, which he did later that day.

• Primary Care: GP records from several days later confirmed "local venepuncture damage" and persistent arm pain.

Despite this clear sequence of events, there was a glaring omission: the GUM clinic had no record whatsoever of the initial appointment or the venepuncture procedure itself.

The Role of the Venepuncture Expert Witness: Finding the Breach

A venepuncture expert witness was instructed to assess the liability. In cases of "missing" evidence, the expert’s role shifts. They cannot speculate on whether the nurse used the correct angle of insertion or the right gauge of needle, as there is no evidence to review. Instead, the focus must sharpen on the professional standards of record-keeping.

The expert concluded that while the clinical *response* to the patient’s pain (the reviews and the advice to attend A&E) appeared appropriate based on the patient's account, the failure to create a clinical note was an indefensible breach of nursing standards.

What the Expert Witness Seeks in the Records

When complications arise from the most common invasive procedure in healthcare - venepuncture - a nursing expert looks for a specific "gold standard" of documentation. This isn't about bureaucracy; it is about patient safety and professional accountability.

In a standard, defensible clinical interaction, the expert expects to find:

1. Technique and Site Selection: Documentation of which vein was used and whether any difficulties were encountered (e.g., "difficult access, second attempt successful").

2. Patient Feedback: A note of the patient’s tolerance. If a patient cries out in pain, this must be recorded alongside the clinician’s immediate response (e.g., "procedure halted, needle withdrawn").

3. Post-Procedural Management: If a haematoma or swelling occurs, the note should reflect the advice given - such as limb elevation, the use of cold packs, or "safety netting" instructions on when to seek emergency care.

4. Incident Reporting: For any procedure resulting in injury, an internal incident report (such as a Datix) should be generated to ensure the event is audited.

In this case, the total absence of these markers left the healthcare provider in a position where they could not prove that care was delivered to a reasonable standard.

The "Non-Negotiable" Nature of Clinical Notes

The Apex expert was clear in their educational takeaway: the standard for documenting invasive procedures is non-negotiable. Whether a clinic is overstretched or an appointment is viewed as "routine," the duty to record the interaction remains a pillar of the Nursing and Midwifery Council (NMC) Code.

From a legal perspective, the lack of documentation creates a "speculation vacuum." Without a note, the court is often left with only the claimant’s version of the events. While the claimant’s reported pain and the subsequent GP findings suggested "local venepuncture damage," the nursing expert could not definitively comment on the *cause* of that damage (causation) without knowing the technique used. However, they could - and did - confirm that the record-keeping was a breach of duty.

The Interdisciplinary Challenge: Causation vs. Breach

This case highlights why a multi-disciplinary approach is often required in medico-legal claims. While our nursing expert identified a clear breach in professional standards, the question of "Causation" (whether the breach actually caused the long-term pain) remained complex.

To prove a claim, a solicitor must show that the breach directly led to the injury. In this instance:

• The Nursing Expert identifies the breach in record-keeping and procedural standards.

• The Vascular or Neurological Expert may be required to assess whether the physical damage (numbness or chronic pain) was a result of a direct nerve strike or a secondary complication like a haematoma.

The absence of the initial GUM note made the job of the causation expert significantly harder. It created a "missing link" in the medical history that forced the experts to rely on secondary evidence, such as the A&E blood results and subsequent GP entries.

Educational Lessons for the Legal and Medical Communities

For solicitors, this case serves as a reminder that a breach of duty can be established through the "absence" of action just as easily as through a "wrong" action. When documentation is missing, the focus of the instruction should be on the standards of professional practice.

For clinicians, the lesson is a "human" one. We understand that in a busy GUM clinic, the pressure to see the next patient is immense. However, the five minutes taken to document a procedure are the only five minutes that protect the clinician in the years that follow a claim.

As our Apex expert noted: "If it isn’t written down, it didn’t happen."

Conclusion: Relying on the Apex Standard

At Apex Experts, we don't just provide a medical opinion; we provide a bridge of understanding. This case demonstrates how our experts apply their deep clinical knowledge to the legal framework, ensuring that even when the evidence is sparse, the standards of the profession remain clear.

By focusing on what should have happened according to the NMC Code and standard venepuncture protocols, our expert provided the instructing solicitor with a solid foundation for the breach of duty argument. We move beyond the "speculation" of what might have occurred and stick to the "facts" of what professional standards require.