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Doctor Re-creates Self-serving Medical Record after Patient Dies

11 Apr 2018 0

$7.5 million in punitive damages awarded in medical malpractice case where doctor destroys original office record and re-creates self-serving medical record after patient dies. Gomez v. Cabatic, 159 A.D.3d 62, 70 N.Y.S.3d 19, 24 (N.Y. App. Div. 2018)

On October 26, 2009, when six year old Claudialee Gomez Nicanor was examined by her pediatrician, a test revealed that her blood had an excessive amount of glucose so she was referred to an endocrinologist Dr. Arlene Basa Mercado.

On October 31, 2009, Dr. Mercado examined Claudialee and diagnosed obesity and impaired tolerance of glucose. She assumed her patient was developing type 2 diabetes but failed to consider it could have been type 1 diabetes. Dr. Mercado determined that she would not respond to the administration of glucose. During the next three months, Claudialee was seen by the two doctors but no further treatment was prescribed.

On January 24, 2010, Claudialee died as a result of diabetic ketoacidosis (a serious complication of diabetes that occurs when one’s body produces high levels of blood acids called ketones).

Claudialee’s family sued malpractice case and presented expert testimony to support their case that had Claudialee’s blood been tested before she died, her type 2 diabetes would have been revealed and insulin would have saved her life.

A Queens County jury found in favor of Claudialee’s family. The jury also awarded punitive damages for Dr. Mercado’s malicious destruction of her original handwritten notes of her office evaluations of Claudialee. Dr. Mercado admitted that she destroyed her handwritten office notes but claimed that they were accurately and fully re-created transcribed before being destroyed.

Commentators have called this a case of first impression because the Appellate Court upheld an award of punitive damages in a medical malpractice case not for the conduct that led to the death, but rather, for the effort to evade liability.