This month we look at the interesting question of whether a plaintiff in a malpractice lawsuit against a clinician may recover punitive damages when the clinician destroys or changes medical records in an attempt to avoid malpractice liability.

The case involved a 6-year old girl, Miss C, whose mother took her to a new pediatrician, Dr P, in mid-October. The pediatrician recommended that Miss C see a pediatric endocrinologist because the child’s blood sugar level was high. The girl’s mother asked Dr P for a referral and the pediatrician recommended Dr E.

Dr E, the endocrinologist, worked from a private office in the basement of her home. Her sister served as her office manager, and her two nephews helped with billing and appointment scheduling. The office was low-tech, and Dr E had a habit of using what she called “scribble notes” during exams and then typing the notes into the medical record at some later point in time.

Dr E saw the patient a total of 3 times – in late October, in mid-November, and in mid-December. Meanwhile, the patient’s pediatrician also saw her again in late November, and then early January.

The endocrinologist concluded that the child was obese and developing type 2 diabetes. At the conclusion of the mid-December office visit, the child’s mother was given an appointment card for an appointment two months later, in mid-February.

Tragically, the child never made that appointment. In late January, Miss C came home from school complaining of lethargy and that she wasn’t feeling well. She brought home a note from the school nurse describing her symptoms. That evening the child had a stomachache and vomited. The next day, the mother tried to have the child seen by the pediatrician, but she was not available, so the mother took Miss C to the hospital. The child remained in the hospital until her death, 3 days later. 

The final autopsy report revealed the cause of death to be attributable to “bilateral cerebellar tonsillar herniation secondary to cerebral edema following diabetic ketoacidosis.”