Medical records are important evidence in a shoulder injury case. But what if the medical records are missing important information?
Mullin v. Secretary of Health and Human Services
Case at a glance:
SYMPTOMS: right shoulder pain, impaired mobility ("couldn't use arm"), sleep disruption
INJURY: right shoulder tendon tears, inflammation, pinching of tissues (impingement)
VACCINE: flu shot (influenza vaccine)
VACCINATION DATE: 11.11.2020
ADMINISTRATOR: pharmacy
INJURY DURATION: over 1.75 years
CASE DURATION: still ongoing since 6.23.2023
OUTCOME: case ongoing
Injured by a flu shot? Click here to learn more.
Ms. Mullin Suffers Immediate Shoulder Pain after a Flu Shot
Ms. Mullin suffered a right shoulder vaccine injury after receiving two vaccinations: a flu shot and a pneumonia shot, in her right shoulder on November 11, 2020. Ms. Mullin noted how high the vaccine was injected on her shoulder, a common phenomena accompanying flu shot shoulder injuries. Prior to the injections, Ms. Mullin had no history of right shoulder pain or impairment.
Ms. Mullin's shoulder symptoms began immediately after the vaccine injection. The symptoms included shoulder pain. She also had impaired range of motion. Together, she complained that she could not even lift her right arm and that she "now cannot use her arm at all." This resulted in symptoms including trouble sleeping and other difficulty with day-to-day activities.
Ms. Mullin called her primary care provider seeking treatment the day after the vaccination. She also sent text messages on that day describing her shoulder pain after the flu shot, and specifically described how she believed her pain and impairments were a reaction to the shot.
Thereafter, Ms. Mullin continued getting treatment for over a year and a half, including multiple rounds of formal physical therapy, an MRI scan, and ultimately two separate shoulder surgeries.
The Flu Shot Medical Record Does Not Say Where the Shot Was Injected
The court addressed a defect in Ms. Mullin's medical records. When a pharmacy administers a flu shot or other vaccination, many states require them to create and keep a vaccine administration record which is supposed to identify the vaccine provided, the date of vaccination, and where the vaccine was injected, among other information. When the pharmacy created Ms. Mullin's vaccination record, they failed to record on it that the vaccine was injected in her right shoulder.
In response to objection from the opposing attorneys, the court reviewed the evidence to determine whether sufficient evidence showed that Ms. Mullin's flu shot was injected in her injured right shoulder.
The judge reviewing the record, noted the many medical records and affidavits which identified Ms. Mullin's right shoulder as the vaccination site. The judge further noted that there was little to no evidence showing the vaccine was injected anywhere else. Finally, the judge observed the very close proximity in time between the flu shot injection and Ms. Mullin's right shoulder injury. On this basis, the judge determined that the majority of evidence weighted in favor of a finding that the vaccine was injected in Ms. Mullin's right shoulder, "albeit barely."
"To rule otherwise, the overall record would need to contain more instances in which the counter situs was suggested or supported." – Chief Special Master Brian H. Corcoran
Thus, the judge found in favor of Ms. Mullin that she was most likely injected in her right shoulder.
TAKEAWAY: Medical Record Deficiencies Can Be Overcome by More Medical Records (and Other Evidence) of a Flu Shot Shoulder Injury
Medical records are very important. Where they are defective, missing some information, it can be a problem for the court. But if there are more records that support one side's position the judge still has a basis to find in a claimant's favor. Still, the judge here noted that the claimant prevailed "barely," so best to get as complete and accurate a medical record as is possible.
Review the full decision here: Mullin v. Secretary of Health and Human Services
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