In a recent judgment[1] of the High Court, Ms Justice Leonie Reynolds was satisfied that the defendant acted in accordance with the standard of care expected in her capacity as a GP. The Court made reference to the defendant’s contemporaneous notes, which were an important factor in the Court accepting the defendant’s evidence and ultimately dismissing the plaintiff’s claim for compensation for personal injuries.

Background

The proceedings were issued in 2021 by the plaintiff’s mother when the plaintiff was a minor.

The plaintiff had been brought to the defendant’s clinic in December 2017 feeling unwell for a day or so. At consultation Dr F took a history of symptoms, the plaintiff was examined and a diagnosis of likely gastroenteritis was made. The plaintiff’s mother was concerned that her then eleven year old daughter may be suffering from appendicitis and claimed that she was “falsely reassured”. Dr F provided a hospital referral letter for use should the plaintiff’s condition deteriorate.

The plaintiff’s condition did deteriorate over the following days and due to the alleged delay in diagnosis, she suffered serious medical complications due to the perforation of her appendix including a prolonged hospital stay, surgical intervention and wound infection.

The contemporaneous medical notes

Dr F stated that having considered the triage notes documenting the plaintiff’s symptoms (“unable to stand up with abdominal pain”), she commenced her assessment by observing the plaintiff as she walked to the consultation room and concluded that she was able to stand up straight. Thereafter, she requested the plaintiff to get up on the examination couch unaided (“the bed test”) and documented in her contemporaneous notes that the plaintiff “looks well able to get on couch.” This was in direct contrast with the evidence given by the plaintiff and her mother who stated that the plaintiff was bent over with pain and needed assistance to get on the couch.

Ms Justice Reynolds found this to be quite important. In circumstances where Dr F had sight of triage notes in advance of the consultation which noted the plaintiff’s difficulty standing up, commenced her assessment by observing the plaintiff walking from the waiting room to her consultation room, and her contemporaneous notes confirmed the plaintiff’s ability to get on the couch unaided, Ms Justice Reynolds attached significant weight to that evidence. She felt that Dr F clearly had concerns about the plaintiff’s mobility and the only plausible explanation for the reference in her notes was to document her clinical findings in that regard.

The other key issues in dispute between the parties included whether Dr F dismissed concern about appendicitis or kept it as a differential diagnosis and the extent of “red flag” advice given by Dr F.

Ms Justice Reynolds was satisfied that when the plaintiff presented, Dr F used her clinical acumen and experience to carefully assess her complaints and carried out a thorough physical examination as documented in her contemporaneous notes. Based on the plaintiff’s history and the absence of an acute abdomen together with other clinical findings, she made a diagnosis of “likely gastroenteritis” and managed the plaintiff accordingly by providing a handwritten note, red flag advice, and a hospital referral letter. Dr F kept appendicitis in her differential diagnosis as evidenced by her contemporaneous notes (hospital referral letter with “Cave appendicitis”).

Conclusion

Ms Justice Reynolds held that the primary diagnosis of gastroenteritis was reasonable and that Dr F’s management and advice to the plaintiff and her mother was in accordance with the expected standard and she dismissed the plaintiff’s claim. The existence of a contemporaneous note which documented the GP’s findings and the content of the letter of referral were important factors in the Court’s deliberations.

It is notable that the compilation of a joint expert report by the opposing parties’ GP experts assisted in narrowing the issues in advance of the hearing. The Court ultimately favoured the “watchful waiting” approach put forward by the defendant’s GP expert in respect of suspected appendicitis rather than the “mandatory referral” approach advocated by the plaintiff’s GP expert.

[1] Afolabi v Southdoc Services Limited & Anor [2026] IEHC 110