1. RECORD KEEPING A Barrister's view Laura McMahon BL

2. When might we meet? Civil claims Criminal cases Inquests Inquiries NMC hearing

3. What documents will I ask for? All midwives notes, however recorded All medical notes GP notes All administrative correspondence Notes from other patients being cared for at the same time/within same timeframe All computer held notes Woman-held notes Personnel files as relevant, e.g. previous disciplinary Midwife expert reports Letters of complaint relating to similar treatment and/or the same midwife Notes of all meetings with woman/family with any and all healthcare professional Supervision notes

4. Midwifery training: Compassionate Caring Patient centred Empathic Professional Accountable Hierarchical

5. Barrister training: Detached Individualistic Objective Analytical Adversarial Inquisitorial Forensic

6. What I look for in notes: Chronological order for all actions Referrals – not clearly indicated, reviewed and documented Inconsistency – within midwifery notes and other professional notes Failure to cite facts to support statements/findings and care plans Failure to give conclusions or base conclusions on the evidence Failure to document the name of doctor informed of patient condition Opinion without facts Supposition/assumptions without facts or action Failure to follow a logical order "Wait and see" Absence of evidence that info has been given/risks explained Absence of woman's signature around info/risks/consent

7. Remember: Protect your patient AND your practice Assume everything you write or document in any format will be accessed by someone at some stage If in doubt, always seek advice within line management or among other healthcare professionals involved in patient care. If it’s not recorded it’s not done If it's not signed/witnessed it's not done Ensure issues around risk and consent are recorded