I think a hospital made a serious mistake. What should I prepare before speaking to a lawyer?

How to use this guide

You do not need a perfect record set before asking for advice. A time-sensitive matter should be triaged while requests continue, particularly where treatment occurred at a public hospital, a patient has died, important records may be lost or someone is being asked to sign a release or settlement.

Write the one-page case summary

State why the care is being questioned in factual terms. Name the treatment episode, the particular decision or omission that needs investigation, the condition or injury that followed and the outcome sought from the consultation. Keep the suspected breach separate from the harm and do not write that one caused the other unless that conclusion already has an appropriate evidential basis.

At the top, record:

• patient and requester identity, including authority if different;
• facility, department and treatment dates;
• current medical needs and ongoing care;
• the source-supported event causing concern;
• later diagnosis, injury or financial effect;
• public or private provider status if known; and
• every complaint, notice, request or legal date already mentioned.

If a fact is uncertain, say so. The lawyer needs an accurate problem statement, not a polished accusation.

Build a clinical chronology and record index

Start before admission with relevant symptoms, referrals and known history. Continue through triage, tests, medicines, procedures, monitoring, discharge, return visits and later treatment. For each entry, cite a page, result, message or personal recollection. Keep source documents unchanged and use a separate copy for annotations.

Index clinical notes, nursing observations, medication charts, results, consent material, theatre and anaesthetic records, referrals, discharge instructions and follow-up records according to relevance. Add a table of missing categories, the date each was requested and the response. A discharge summary alone rarely represents the complete evidential record.

Show the harm without estimating the case value

Collect evidence of additional treatment, rehabilitation, medication, care needs, expenses, absence from work and functional change. Keep invoices, receipts, medical-scheme statements, employer records and later clinical reports. If a family member provided care or paid costs, record who, what, when and the supporting source.

Do not calculate a guaranteed payout or treat every expense after treatment as caused by the suspected error. The link between conduct and harm requires clinical and legal assessment, while recoverable loss needs its own proof.

Identify the likely provider and route

Bring admission documents, account information and correspondence that show which hospital, practice or public department provided the care. More than one practitioner or organisation may have been involved, but inclusion in the record does not automatically make each one liable.

List any internal facility complaint, Health Ombud submission, HPCSA or SANC complaint and response. Explain what result you want: access to records, an explanation, professional accountability, service correction or compensation. These routes have different purposes and should not be treated as substitutes for one another.

Put deadline questions before merits perfection

Record the treatment date, later discovery dates, the date harm became known, every complaint submission and any formal response. Ask the lawyer to assess prescription from the actual knowledge facts rather than relying on a universal three-year slogan. The Constitutional Court’s Links decision shows why the knowledge inquiry can be important in medical-negligence matters.

Where a provincial health department or another organ of state may be implicated, ask separately about the statutory notice regime. A complaint or records request should not be assumed to interrupt prescription or satisfy that notice. The first consultation may need to prioritise deadline protection before a full expert opinion is obtained.

Prepare authority and a secure sharing plan

If the patient will not attend the consultation, place the requester’s authority in a separate section. That may mean the patient’s written authority, proof of parental or guardianship status for a child, documents relevant to a deceased estate, or the instrument under which another adult may lawfully act. Do not assume that being the account payer, spouse or closest relative automatically answers the authority question. Flag uncertainty so that the lawyer can identify what is needed before confidential information is requested or disclosed.

Create a clean working bundle rather than forwarding an entire phone or email account. Give each document a descriptive filename, keep the original download or scan, and use a password-protected or otherwise controlled channel agreed with the lawyer. Remove unrelated third-party information from a consultation copy only after retaining the complete original securely. Record who has received the file, because clinical and identity material may later be shared with experts or another authorised professional for a defined purpose.

Turn the chronology into focused consultation questions

Write down the questions that the present evidence cannot answer. Which professional discipline should assess the decision being challenged? What alternative clinical explanations need to be tested? Which event is said to have caused which injury, and what record is missing from that link? Which hospital, practitioner or employing body may hold the relevant evidence? What immediate step is required to protect a time-sensitive position?

Also ask the lawyer to distinguish factual investigation from legal conclusions. The first review may identify a plausible issue without establishing a breach, causation or recoverable harm. Request a list of assumptions that remain unverified and the evidence that could confirm or disprove each one. This makes the consultation useful even if the responsible provider, appropriate expert or correct complaint route is not yet clear.

Ask for a staged evidence plan

The lawyer should explain what the current file can and cannot establish, which record gaps matter and whether an expert is justified. Ask which discipline would answer the alleged standard-of-care issue and whether a different discipline may be needed for causation or future harm. Do not commission a generic medico-legal report merely because the dispute involves treatment.

Request written scope for the first phase, including files reviewed, deliverable, fee, disbursements, complaint work and the event requiring new authority. A sensible stopping point may be a records and deadline assessment before expensive expert work.

Related preparation resources

• Medical negligence information: Review the practice-area overview.
• Hospital records request guide: Request the clinical source file.
• Hospital timeline guide: Prepare a source-linked chronology.
• Medical evidence preparation resource: Organise the wider evidence pack.

What preparation cannot establish

An organised consultation pack improves triage but does not prove that care was negligent, that an act or omission caused the harm, that a particular provider is liable or that compensation will follow. It also does not calculate prescription, state-notice or complaint periods. Those matters require current, fact-specific legal and clinical analysis.

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