Dr E was alarmed when in late February she received a letter from a law firm requesting a copy of the medical records of the child. She pulled out the patient’s file and found her scribbled notes and began transcribing them into the file. When she was done, she threw out the scribble notes, made a certified copy of the file and sent it to the attorneys. She also sent a copy to the pediatrician, with a note thanking her for the referral and attaching “consult/follow-up visit notes.”

Before long, Dr E was sued for medical malpractice and wrongful death by the child’s grieving parents. At trial, medical experts for the plaintiff faulted Dr E for not considering that the child had type 1 rather than type 2 diabetes, for not educating the parents about the symptoms of diabetes, and for not recommending that the family perform home testing of the child’s blood sugar and ketones. 

During her testimony, Dr E was asked about the notes in the chart, and she was forced to admit that she transcribed the scribble notes into the patient’s record after the patient died and she had been contacted by the plaintiff’s law firm asking for the records. Dr E was asked whether she retained the original scribble notes, and she admitted that she had thrown them out after transcribing them. She testified that this was her standard practice.

In addition, she was questioned about the content of the notes, particularly the one from mid-December where Dr E claimed she wrote that the next visit should record random blood glucose both fasting and 2-hour post meal, and that the child should return in 4 weeks. Yet the parents had an appointment card indicating that the child was to return in 2 months. When questioned about this discrepancy, Dr E had no explanation.

The jury found that Dr E had departed from the accepted standard of medical care in the treatment of the child, and that this was a substantial factor in the child’s death. The jury awarded damages in the amount of $500,000 for the child’s pain and suffering, and also awarded $7.5 million in punitive damages against Dr E. The physician appealed the punitive damages award, claiming that her destruction of the original records did not contribute to causing the child’s death and did not prevent the child’s family from successfully suing. The appeals court disagreed.