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Spoliation Of Evidence: Nurse Threw Away Her Notes After Writing Her Incident Report.
Legal Eagle Eye Newsletter for the Nursing Profession
Spoliation of evidence refers to destruction of or failure to preserve evidence relevant to pending or potential litigation, particularly evidence that would be damaging to the legal position of the party who committed the spoliation.
The court can impose sanctions at trial on a party that has engaged in spoliation of the evidence. Sanctions can include an instruction to the jury that the evidence would have been detrimental to the party who destroyed it and helpful to the other side if the jury was able to hear it.
Spoliation only occurs when the party who destroyed or failed to preserve evidence knew at the time of an actual or potential legal claim and the relevance of the evidence to the legal claim. In this case the clinic had not been notified of a legal claim when the nurse threw out her notes, but she and other key individuals knew that a legal claim was likely. The nursing supervisor and a risk manager had completed their reports before the patient’s nurse completed her report and then threw out her notes.
UNITED STATES DISTRICT COURT PUERTO RICO March 21, 2018Soon after the patient completed his dialysis around 10:00 p.m. he stood up, fell to the floor, assumed a fetal position and appeared to be having a seizure. It happened as his nurse was throwing away the used pad and gauzes in the biohazard container next to his chair. His nurse and her coworkers checked the patient’s vital signs and tended to the new lesion on his scalp. The nursing supervisor phoned a physician who said he should be taken to a hospital. Paramedics came at 11:10 p.m. and transported the patient to an emergency room.
The next morning at 8:00 a.m. the nurse’s supervisor phoned her to come in right away, hours before her 2:00 p.m. shift started, to fill out an incident report. To prepare her incident report the nurse relied on her handwritten notes from the night before. She had jotted down the patient’s vital signs before and after he seized as well as the timing of various steps she took in performing the dialysis. After she finished the incident report for her supervisor the nurse threw away her handwritten notes.
The US District Court for the District of Puerto Rico ruled the patient will be entitled to an instruction from the judge to the jury that the handwritten notes the nurse threw away must have contained information that supported the patient’s case and compromised the clinic’s defense. The nurse knew from the urgency of her supervisor’s need for an incident report that the clinic was deeply concerned about legal liability. The nurse also should have known that legal complications can result from a patient falling, sustaining a head wound and being transported to the emergency room. In fact, the nursing supervisor and a risk manager had already investigated and prepared detailed reports before the nurse completed her incident report.
Vargas Alicea v. Company, 2018 WL 1441229 (D. Puerto Rico, March 21, 2018).More references from nursinglaw.com
http://www.nursinglaw.com/monitor.htm
http://www.nursinglaw.com/spoliation5.pdf
http://www.nursinglaw.com/spoliation7.pdf
http://www.nursinglaw.com/spoliation1.htm