When a child’s birth takes an unexpected turn, the medical record can provide important details about what happened during labor and delivery. A fetal monitor may have malfunctioned, a delivery device may have been used incorrectly or staff may have missed signs of fetal distress. In these situations, preserving the medical records and equipment data early can help establish what occurred and whether the care fell below the required standard.
Request the records tied to the delivery
Illinois law allows patients and authorized representatives to inspect and obtain copies of medical records. Under 735 ILCS 5/8-2001, a hospital generally must respond to a written, signed and HIPAA-compliant request within 30 days. Parents should request records for both the mother and child when a birth injury may have occurred.
A request should cover more than the final hospital summary. Depending on the circumstances, these records may be important:
- Labor and delivery records, including fetal monitoring strips, vital signs, medication records and nursing notes
- Continuous fetal heart rate tracings and any raw digital fetal monitoring or telemetry data
- Doctor and specialist notes about changes in the mother’s or baby’s condition
- Records showing fetal monitor alarms, staff responses and major interventions
- Device details, including the model and serial number of equipment used during delivery
- Records about complications, emergency procedures and neonatal care
Some fetal monitoring data may exist outside the standard electronic medical record. Parents should specifically ask the hospital about the location and retention of fetal heart rate tracings and related digital data.
Know what may require an attorney
Not every record connected to a medical device will appear in a patient’s chart. Internal maintenance logs, inspection records, calibration histories and biomedical engineering reports may remain part of the hospital’s internal records.
Parents can ask the hospital about these materials and tell their attorney about any device involved in the delivery. An attorney may then send a formal preservation letter, sometimes called a spoliation notice, to request that the hospital preserve relevant device data and other evidence. If necessary, an attorney may seek those materials through the legal discovery process.
Parents should also be careful when speaking with hospital risk management personnel. Avoid guessing about what caused an injury or stating that a particular person was at fault. Parents should not sign statements, releases or other documents about a possible claim without first having them reviewed by an attorney.
Preserve the evidence as soon as possible
Medical records, fetal monitoring data and other delivery records can help piece together what happened during a complicated birth. Acting early can also help protect information that may not remain available forever.
An Illinois medical malpractice attorney can review the records, identify missing evidence and explain the steps for seeking additional information. Legal guidance can help a family protect its rights while caring for a child who may have suffered a birth injury.