Suspected medical malpractice: documents for a legal consultation

A difficult medical experience may leave questions about treatment, information and its consequences. Preparing for a legal consultation starts with organising facts, not assuming fault. An unfavourable outcome does not by itself establish malpractice, and a lawyer does not replace a medical specialist’s assessment.

Build a treatment chronology

Record consultations, investigations, admissions and procedures with their dates. Identify the provider and available records for each event. Include subsequent developments, recommendations and requests for clarification.

Separate personal recollection from what the records say. Mark uncertain dates or explanations. A concise chronology can orient the discussion more effectively than a large collection of unsorted files.

Make an inventory of available records

Keep originals and prepare readable copies. Do not alter records or reconstruct a missing medical entry from memory. List documents you believe are missing and their likely source so that the next steps can be discussed.

• Discharge summaries, medical letters and recommendations.
• Investigation results and available treatment records.
• Consent forms and information provided.
• Correspondence with the provider and official responses.
• Documents concerning relevant subsequent assessments or treatment.

Document the consequences separately

Keep invoices and receipts with an explanation of their connection to the matter. If you describe effects on work or daily life, identify concrete changes and supporting documents. A personal estimate is not an established compensation entitlement.

The malpractice liability framework concerns professional error and harm, and requires more than dissatisfaction with an outcome. Legal assessment and technical medical findings have different functions. Initial review may identify questions for a specialist without anticipating that specialist’s conclusions.

Explain earlier complaints and correspondence

Identify requests to the provider, complaints already made and replies received. Bring copies and evidence of submission. Flag any judgment or document mentioning a deadline at first contact.

Different procedures may have different objectives, conditions and time limits. The appropriate course must be discussed against the circumstances. A general guide cannot establish the deadline applicable to your matter, and examples from another case may not apply.

Agree how documents will be shared

Do not publish medical records in comments or send the complete file through a public enquiry form. The initial message can briefly identify the issue and request a consultation. Documents should then be shared through the channel agreed with the lawyer.

Before the engagement, clarify the scope of the initial review, possible further work and how any specialist assessment costs would be discussed. Neither a compensation amount nor the duration of proceedings can be guaranteed from a short account. The objective of preparation is a clearer assessment, not a predetermined conclusion.

Medical malpractice legal assessment in Bucharest

Source: Romanian Constitutional Court Decision 43/2024 on malpractice liability