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Clinical Records Given More Weight Than A Medical-Legal Report

In Hatchard v Sulzle 2014 BCSC 2135 the BC supreme court compared a family doctor’s clinical records to his medical-legal report and found some significant inconsistencies. The claim arose as the result of a low-velocity collision after which the plaintiff went to hospital and stayed for three and a half hours. The plaintiff sought $50,000 for chronic pain or alternatively $20,000 for a soft tissue injury of 13 months’ duration.

At trial the plaintiff relied heavily on his family doctor’s medical-legal report. The court was concerned about that doctor’s opinion that the plaintiff’s chronic pain was due to the MVA and to a prior workplace accident. The report did not record any facts in support of these opinions. Statements in the report did not correlate with the clinical records. For example, the notes of five consecutive appointments contained no mention of the accident, but the doctor reported that the visits related to the MVA injuries. The clinical records did not evidence any particular injury caused by the accident.

The court was satisfied that the clinical records were complete but inconsistent with the report, and consequently concluded that the report had little value and gave it very little evidentiary weight.

The court dismissed the plaintiff’s claim because the lack of a complete and accurate medical record, combined with the plaintiff’s own testimony, failed established that he incurred any injury as a result of the collision.

Case law update by: Trevor Morley