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12 Oct 2023

Court of Appeal Clarifies Position on Discovery of Post Accident Medical Records

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Litigation and Dispute Resolution

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In Egan v Castlerea Co-operative Livestock Mart Limited [2023] IECA 240, the Court of Appeal has upheld a High Court order for discovery in personal injury proceedings, which directed disclosure of the plaintiff’s post-accident medical records.

The Underlying Proceedings

The plaintiff issued proceedings in respect of an injury suffered in a livestock mart when a bullock collided with his left leg. The plaintiff allegedly sustained a soft tissue injury and experienced difficulty standing, climbing stairs and walking.

Updated particulars were subsequently delivered which suggested that the plaintiff had suffered a more complex injury, with his ongoing complaints possibly due to a combination of his leg injury and a pre-existing back problem, which may or may not have been re-activated by the accident.

The defendant disputes the claim in its entirety. It put causation in issue, requiring the plaintiff to prove that the injuries complained of are attributable to the accident and not caused by any prior accident or medical condition.

Discovery Dispute

While the discovery of certain documents was agreed before the contested motion was heard, including pre-accident medical records for a period of 5 years and the plaintiff’s initial medical attendance post-accident, the plaintiff maintained a refusal to provide the balance of post-accident medical records, which had been sought for a 5-month period post-accident.

High Court Decision

The High Court ordered that the discovery sought by the defendant be provided. It noted that post-accident records are more likely to be relevant to the proceedings than pre-accident medical records and they are the best evidence of the plaintiff’s medical condition The court held that such records in this case were particularly relevant given the possible overlap between the complaint of leg pain arising from the accident and the plaintiff’s pre-existing back problem.

Court of Appeal Decision

The Court of Appeal found that while there is no general prohibition on the discovery of post-accident medical records, it does not follow that such an order should be made in every case. It has to be considered whether the documents are relevant to the dispute and if discovery of the documents is necessary for disposing fairly of the case or for the saving of costs.

In this instance, the court noted that the relevance of the documents was established by the pleadings themselves, which outline the overlap between the injuries sustained by the plaintiff and his pre-existing medical condition. Given that the documents were relevant, there existed a presumption that the documents were also necessary, with the onus for rebuttal on the plaintiff.

The court outlined possible arguments that could establish that the documents were not necessary, including evidencing that other equally effectual means of establishing the truth were available or if it could be shown that the cost and administrative burden to prepare the discovery would be disproportionate to the likely benefit of the documents being available. In this regard, the court can consider the volume of documentation and the fact that the resources of parties to bear such a burden may not be equal.

It was noted that the plaintiff in this case did not reply to the request for voluntary discovery nor did he file an affidavit in response to the motion and as such, certain arguments made by the plaintiff were without evidential foundation, including an argument on the burden posed by the requirement for redaction.

The Court of Appeal held that the letter seeking voluntary discovery established a sufficient basis for the court to be satisfied that discovery was necessary, namely the defendant’s need to establish the extent of the overlap between the injuries and a pre-existing medical condition, as well as facilitating a comprehensive medical examination of the plaintiff on behalf of the defendant. The Court of Appeal did, however, reject the contention that the necessity for discovery of medical records needs to be based on the view of a medical expert.

While it was noted that a court should exercise a certain degree of caution in the discovery of medical records that are _prima facie_confidential, the detail in this instance was at the less sensitive end of spectrum.

Conclusion

The Court of Appeal held that there is no distinction in principle between pre and post accident medical records unless and until the records overlap with legally privileged medical material. The standard principles for determining whether documents should be subject to discovery, namely relevance, necessity and proportionality, are also applied to this class of medical records.

DISCLAIMER: This document is for information purposes only and does not purport to represent legal advice. If you have any queries or would like further information relating to any of the above matters, please refer to the contacts above or your usual contact in Dillon Eustace.


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