Westcott v Minister for Health [2015] WADC 122 outlines a claim alleging delayed diagnosis and treatment of appendicitis. The claimant succeeded and damages were assessed.

Of broader interest may be the court’s discussion of medical note-taking at [295] ff. Of one of the doctors it was said that he “virtually never makes notes” and that the notes of another were informed by the author’s perception of what is necessary to record or report. Accordingly at [300] – [301]:

“These note-taking practices present forensic difficulties because one cannot know if something was missed or, alternatively, was taken into account but not recorded. The court is left to an inferential process as to what happened and what people thought, said and did.

The practice is also fraught from a clinical point of view – the better the note-keeping, the better the care….”

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