Medical Negligence Claim Fails: Court Favours Medical Records

The High Court dismissed a patient’s medical negligence claim, where the doctor’s recollection of a surgery conflicted with the patient’s recollection. The patient had claimed that she reported pain during a surgery and that she requested that the surgery be stopped. Ultimately, the Court accepted the treating team’s version of events over the patient’s account. Our Medical Law team examines how the High Court arrived at this decision and why it felt the defendant’s version of events aligned better with the evidence given at trial.

What you need to know

• In the claim of Tynan v Bon Secours Health System Company Limited by Guarantee and Heiko Kindler[1], the High Court ruled against a patient in a medical negligence claim. The patient alleged inadequate monitoring, anaesthesia and pain management during a cardiac procedure causing her severe pain and psychiatric harm.
• The patient’s version of the events, however, conflicted with the treating team’s position. One of the reasons the Court ruled in favour of the hospital and consultant cardiologist was because the patient’s account of what occurred was not reflected in the records.

A patient lost her High Court medical negligence claim against Bon Secours Hospital and a consultant cardiologist. The patient alleged to have experienced excruciating pain and anxiety during a cardiac procedure. She alleged that she sustained psychiatric injury due to inadequate monitoring and pain management during the operation.

The patient’s claims regarding pain

The patient claimed that:

• She complained of pain during the operation
• She was not properly monitored, and
• She was not provided adequate analgesia and anaesthesia.

She also alleged that she had been crying intensely and shouting to the point of becoming hoarse on foot of the excruciating pain she was experiencing during the operation. Despite receiving local anaesthesia and fentanyl during the procedure for pain relief, she contended that these measures were inadequate and ineffective.

The patient claimed the records were not fully complete. As there were no intraoperative notes to record pain levels, she contended that this suggested that the monitoring was inadequate.

In contrast to the patient’s claim that she repeatedly informed the consultant cardiologist of her pain, the treating team asserted that there was only one instance where the patient voiced discomfort. The treating team stated that additional local anaesthetic and fentanyl were administered at that point.

The treating team gave evidence about when pain would most likely have been experienced during the procedure which did not correlate with the patient’s evidence that she suffered pain throughout the entirety of the procedure.

The inconsistencies in the factual narrative relayed by the patient were highlighted. For example, the patient could complete breathing exercises without difficulty at the conclusion of the operation. Her ability to do so was considered inconsistent with her suffering substantial pain or anxiety. The Court accepted the treating team’s expert evidence that the patient’s report of immediate pain relief after the procedure indicated that adequate anaesthesia had been administered. If it had not been adequate, then the pain would have continued after surgery.

Consent and the patient’s claim that preprocedural sedation should have been administered

The patient alleged that she became anxious when steps were taken to insert a cannula immediately prior to the procedure. She claimed that the consultant cardiologist knew or should have recognised that she was anxious because of this. She claimed this anxiety should have been alleviated through preprocedural sedation, as anxiety can exacerbate pain. The patient’s expert also claimed that preprocedural sedation should have been administered earlier due to her history of anxiety. The patient also asserted that there was a failure to obtain informed consent for procedural sedation as the consultant cardiologist allegedly failed to inform the patient of the option of midazolam.

The Court’s decision

The Court found that the treating team was not aware of her history of anxiety prior to the operation as she did not relay this to the staff. The Court considered the expert evidence and found that it was not a breach of duty that the treating team did not provide the patient with information about preoperative sedation.

The Court also found that the patient had failed to give any evidence that she would likely have opted for sedation had it been offered.

The Court acknowledged that the patient was likely sincere in her belief that she suffered anxiety as a result of a single episode of pain. It also accepted that this anxiety was likely exacerbated by her pre-existing susceptibility to anxiety. However, the Court ruled that the treating team was not aware of her susceptibility to anxiety.

In all the circumstances, the Court dismissed the patient’s claim.

Conclusion

Often in medical negligence claims, a patient’s version of events can conflict with that of the treating medical practitioners. In this case, the patient had maintained that she complained to the treating team about pain on numerous occasions and that the records should have recorded those complaints. However, the Court ruled in favour of the treating team as the patient’s version of the events did not align with what was noted in the records. Similarly, it did not align with the expert evidence and the factual evidence of the five members of the treating team. It cannot be overstated that medical records remain an essential component in defending medical negligence claims, particularly where there is a dispute over what occurred.

For more information and expert advice on navigating clinical negligence claims, please contact a member of our Medical Law team.

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[1] [2025] IEHC 81