Guild Insurance sees many insurance claims which have come about due to poor maintenance of a property.  In too many of these cases, the poor state of the building or its grounds is obvious and it’s quite surprising, as well as disappointing, that repairs haven’t been carried out before an incident has occurred.

What can go wrong?

There are a range of incidents which can occur due to poor maintenance of a property.  Staff can be injured leading to a worker’s compensation claim as well as staff being absent from work for an extended period.  Visitors to the premises, such as customers, clients or contractors, can also suffer injuries leading to public liability claims.  As well as the insurance claims which need to be managed, there’s the added stress of knowing that someone has been injured while at your premises.  Some of these injuries can be very serious and life changing.  Unfortunately, the hazards which lead to these injuries are often not viewed as seriously as they should be.  Yet with appropriate property maintenance many of these injuries could be avoided.

Case 1

A client entered a building and tripped over an edge of carpet which was ripped and curled up.  The client sustained a fractured wrist when they landed.

Case 2

An awning out the front of a building was old and worn out.  During heavy winds it broke off from the building and hit a person walking past at the time.

Case 3

While walking through the carpark of a premises, a staff member has tripped on a large crack in the asphalt which had caused the surface to be uneven.  They fractured their ankle as they fell.

Case 4

Poor maintenance doesn’t just lead to people suffering injuries, it can also lead to further damage to the property.  An old deteriorating roof collapsed when hit by heavy rain as it no longer had the strength to support the weight of this rainfall.  This led to excessive water damage within the building.

Property maintenance tips

• Have a documented maintenance program in place. This requires a schedule for regularly checking the property to identify hazards as well as details on what needs to be serviced, repaired or replaced and when.
• Be aware of the out-of-sight, out-of-mind hazards. Many properties have roofs, guttering and downpipes in poor condition due to a lack of maintenance as no one has thought to get up on the roof and inspect it. Include the less obvious hazards in the maintenance program.
• Have a maintenance budget. Some maintenance work can be planned, other work will come up unexpectedly when something breaks down. You need to be able to find money to fix hazards when identified.
• Be sure to use qualified tradespeople to undertaken maintenance work. While it can be tempting to undertake some DIY and save money, the risk of things not being maintained or repaired correctly will not be worth the savings in the long term.
• If you’re a tenant, be aware of what you’re responsible for maintaining and what’s the responsibility of the landlord. Not all tenancy agreements are the same, so you need to be across the details of your agreement.
• Don’t wait to undertake maintenance till a more convenient time. There are many cases of injuries occurring due to hazards which had been identified but not yet acted upon, usually due to costs, time or not acknowledging the risk of the hazard.
• All staff have a responsibility to create and maintain a safe workspace. Some hazards will be identified through regular property inspections, however, you can’t rely solely on these inspections. Therefore, encourage all staff to continually be on the lookout for hazards and to speak up when they see something.
• Don’t think it won’t happen to you and your property. These incidents are a lot more common that many people realise.

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Medical record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for veterinarians to spend time thinking and talking about. However, it’s incredibly important, and Guild’s claims management experience suggests veterinarians would benefit from learning more about good record keeping.

Records and insurance claims 

Records can impact insurance claims in two ways:

1. Poor records can contribute to a poor or unexpected outcome following treatment, leading to the client complaining and possibly seeking some form of compensation. For example, a dog’s weight was incorrectly recorded in the record due to a simple data entry error. This led to the dog being given a dose of medication which was too high; unfortunately the dog suffered renal damage and died as a result.

2. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence of what took place and why. Poor clinical outcomes and dealing with complaints can be very challenging and confronting. Therefore, understanding how to improve the standard of records really should be a focus.

Why keep detailed records?

1. Continuity of care

It’s not uncommon to hear veterinarians believe they can remember the details of their consultations. However, at Guild we see examples where veterinarians haven’t remembered key aspects of prior consultations and treatment, and this has led to a poor outcome for the animal. It’s therefore imperative to have this information recorded to ensure certainty as to how and why you’ve treated an animal in the past. It’s also important to be sure you refer to the information within the record. Animals can suffer harm when key information is overlooked or forgotten about and they’re therefore not treated accordingly.

2. Regulatory requirement

All State and Territory Veterinary Boards within Australia have some sort of guideline or policy about a veterinarian’s obligations and requirements regarding record keeping. It’s the responsibility of every veterinarian to make themselves aware of and comply with the various codes, guidelines and policies relevant to them. Not knowing is not an excuse for not complying.

If there’s an allegation of wrong doing made against a veterinarian, their records are going to be incredibly important. Those records provide evidence of what took place and why. Without this, the veterinarian will be relying on their memory as a defence. Information recorded at the time of the consultation is going to hold greater weight as a reliable defence than a veterinarian’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

What to record?

A question many veterinarians ask when it comes to record keeping is, ‘How much detail do I need to record?’ Veterinarians should refer to their relevant Veterinary Board’s information to better understand the detail required in a record. Exactly what to include can vary according to the specifics of the animal’s condition and treatment. However, generally records should include, but aren’t limited to:

• client identification
• treatment date
• animal(s) identification
• history
• examination details
• diagnosis
• treatment options offered and given, prescribed, or supplied
• informed consent
• response to treatment
• other records/reports such as imaging reports, laboratory reports or specialist/referral reports
• information provided to the client including post treatment instructions

In some cases, it’s worth noting what didn’t occur as well as what did. For example, if a client has refused to consent to what would be considered the most ideal or obvious treatment option, the record should reflect that it was discussed and declined. If it’s simply left out of the record, it would appear that it wasn’t discussed as an option.

When veterinarians are unsure if they have included enough detail, they should ask themselves whether or not another veterinarian could read the record and understand the full picture of what took place and why, without the treating veterinarian filling in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Records need to always be professional and objective. Criticisms of the client can be included, however this must be professional and only when relevant to the treatment being provided. This may occur in situations where the client isn’t complying with instructions and this is detrimental to the health of their animal. However, it’s important to remember that records can be accessed and read by a number of people, including the client and your regulator, so always be mindful of the language used. The language used should match the professional language a veterinarian would use when speaking to the client during a consultation.

Changes and corrections

If it’s noticed that errors have been made in a record, changes can be made to correct this. However, information should never be deleted. The original information must remain with a note explaining the correction and when the correction was made. Also, if additional information needs to be added to a completed consultation note, it should be done so it’s clear this is additional information and the date it was added.

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