What a medical records review can and cannot tell you
If you are worried about the care you or a relative received, an independent review of the medical records can explain what happened, before you spend time and money on a legal claim.
What a records review is
A medical records review is a careful reading of the notes, letters, test results, scans and prescriptions from your care, by a doctor who was not involved in it. The reviewer puts the events in order, explains the medical terms in plain language, and points out where the care appears to have followed accepted practice and where questions remain.
The result is usually a written summary with a chronology of your care. Many people find this is the first time the whole story has been set out clearly in one place.
What it can tell you
- What happened and when: a clear timeline of appointments, tests, diagnoses and treatment.
- What the medical terms mean: results, diagnoses and procedures explained in everyday language.
- Where the questions are: delays, missed results, unclear decisions or gaps in the notes that deserve a closer look.
- What is missing: records that should exist but have not been provided, such as observation charts, scan reports or GP notes.
- What to ask your solicitor: the key clinical questions, set out so that a solicitor can understand them quickly.
What it cannot tell you
A private review is a medical opinion for you. It is not a court report, and it does not decide whether you have a legal claim. In England and Wales, a claim for clinical negligence needs two things to be shown: that the care fell below the standard of a responsible body of practitioners in that field (breach of duty), and that this failing caused harm that would otherwise have been avoided (causation). Whether a case meets that test, whether it is worth bringing and how much it may be worth are questions for a solicitor, supported by independent court experts.
A review also cannot fill gaps in records it has not seen. The more complete the records you obtain, the more useful the review will be.
How to get your records
In the UK you have a right to a copy of your own health records under data protection law. You can ask the hospital, GP practice or clinic in writing (a "subject access request"). The organisation should normally respond within one month, and in most cases there is no charge. If you are acting for someone who has died, different rules apply, and the hospital's records team can tell you what they need.
Ask for the complete record for the relevant period, including nursing notes, observation and drug charts, test results, imaging reports and correspondence. A summary or discharge letter alone is rarely enough.
Before or after seeing a solicitor?
Either can work. Some people want to understand what happened before deciding whether to contact a solicitor at all. Others already have a solicitor and want help with a large bundle of records, so they can give clear instructions and ask the right questions. In both cases the legal decisions remain with you and your solicitor.
Time limits matter. Legal claims have strict time limits, often three years in England and Wales and two years in Ireland, and sometimes shorter in other countries. A records review should never delay you from getting legal advice. See our article on time limits for clinical negligence claims.
Independence
If we review your records privately, we will not later act as the independent court expert in the same case. Your solicitor will instruct a separate expert for court, and our review can help you prepare for that.
This article gives general information only. It is not legal advice and does not create a professional relationship. For advice about your own situation, please speak to a solicitor.