Reviewing Slip-and-Fall Records for Causation

The Slip-and-Fall Causation Challenge

Slip-and-fall cases are everywhere. Grocery stores, parking lots, stairwells, sidewalks. The plaintiff claims an injury. The defendant claims pre-existing conditions or alternative causes.

Your job as an IME physician: Determine causation. Is the current condition related to the fall?

This is harder than it looks. Slip-and-fall records often lack:

• Clear mechanism documentation
• Immediate medical attention
• Objective findings
• Consistent reporting

This post shows you how to review slip-and-fall records for causation — what to look for, what to question, and how to render a defensible opinion.

The Causation Framework

Step 1: Establish the Mechanism

What you need:

• Date, time, and location of the fall
• Description of how the fall occurred
• What the plaintiff landed on
• Whether there was loss of consciousness

Where to find it:

• Incident reports (if available)
• ER records
• First medical visit notes
• Plaintiff's deposition (if available)

Questions to ask:

• Is the mechanism described consistently across records?
• Does the mechanism plausibly explain the claimed injuries?
• Are there inconsistencies in the plaintiff's account?

Red flags:

• Mechanism changes over time
• Mechanism doesn't match the injuries
• No contemporaneous documentation of the fall

Step 2: Identify the Immediate Injuries

What you need:

• Chief complaint at first medical visit
• Objective findings (imaging, physical exam)
• Diagnosis at first visit

Where to find it:

• ER records
• Urgent care records
• First family doctor visit

Questions to ask:

• What did the plaintiff report immediately after the fall?
• What did the physical exam show?
• What did imaging show?
• Was there a delay in seeking treatment? If so, why?

Red flags:

• Delay in seeking treatment without explanation
• Chief complaint doesn't match mechanism
• No objective findings

Step 3: Review Pre-Existing Conditions

What you need:

• Past medical history
• Prior imaging
• Prior treatment for similar complaints

Where to find it:

• Family doctor notes (often include past medical history)
• Specialist consults
• Prior imaging reports
• Plaintiff's deposition

Questions to ask:

• Did the plaintiff have prior complaints in the same body part?
• Did the plaintiff have prior imaging? What did it show?
• Did the plaintiff have prior treatment? For what?
• Is there a pre-existing condition that explains the current findings?

Red flags:

• Prior imaging shows the same findings
• Prior treatment for the same complaint
• Pre-existing condition not disclosed

Step 4: Assess Treatment Trajectory

What you need:

• Timeline of treatment
• Response to treatment
• Objective measures over time (ROM, strength, pain scores)

Where to find it:

• Progress notes
• Physiotherapy notes
• Specialist consults

Questions to ask:

• Did the plaintiff follow the treatment plan?
• Did the plaintiff improve with treatment?
• Are there objective measures of improvement?
• Is the treatment trajectory consistent with the claimed injury?

Red flags:

• Non-compliance with treatment
• No improvement despite treatment
• Treatment extended beyond expected duration without objective justification

Step 5: Evaluate Subjective vs. Objective Findings

What you need:

• Plaintiff's self-reported symptoms
• Objective findings (imaging, physical exam, functional testing)

Where to find it:

• Progress notes
• Physiotherapy notes
• IME examination findings

Questions to ask:

• Do subjective complaints match objective findings?
• Are there inconsistencies between self-report and observed function?
• Are there signs of symptom magnification?

Red flags:

• Subjective complaints far exceed objective findings
• Inconsistencies between self-report and observed function
• Non-organic findings (e.g., Waddell signs)

Common Slip-and-Fall Scenarios

Scenario 1: Soft Tissue Injury with No Imaging Findings

The claim: Plaintiff fell, landed on their back, and now has chronic low back pain.

The records:

• ER visit: "Low back pain, no radiculopathy. X-ray negative."
• Family doctor: "Mechanical low back pain. Prescribed NSAIDs and physiotherapy."
• Physiotherapy: "Lumbar strain. Treated for 12 weeks."
• Current: "Chronic low back pain, pain 6/10, unable to work."

Causation analysis:

• Mechanism: Fall onto back. Plausible for lumbar strain.
• Immediate injury: Low back pain, negative X-ray. Consistent with soft tissue injury.
• Pre-existing conditions: Need to check prior records. Any prior low back pain?
• Treatment trajectory: 12 weeks of physiotherapy. Did they improve? If not, why?
• Subjective vs. objective: Pain 6/10, but what does physical exam show? Any objective findings?

Opinion:

• If no pre-existing conditions and treatment trajectory is consistent: "More likely than not, the current low back pain is causally related to the fall."
• If pre-existing conditions: "The fall may have aggravated a pre-existing condition. Further review of prior records is needed."

Scenario 2: Fracture with Prior Imaging

The claim: Plaintiff fell, landed on their wrist, and has a distal radius fracture.

The records:

• ER visit: "Fall onto outstretched hand. X-ray shows distal radius fracture."
• Prior imaging (from 2 years ago): "Distal radius fracture, healed."

Causation analysis:

• Mechanism: Fall onto outstretched hand. Plausible for distal radius fracture.
• Immediate injury: X-ray shows fracture. But is it a new fracture or the old one?
• Pre-existing conditions: Prior fracture in the same location.
• Need to compare: Is the current fracture in the same location as the prior fracture? Is there evidence of new trauma?

Opinion:

• If the current fracture is in a different location: "More likely than not, the current fracture is causally related to the fall."
• If the current fracture is in the same location: "Comparison with prior imaging is needed to determine if this is a new fracture or a re-injury."

Scenario 3: Delayed Treatment

The claim: Plaintiff fell in a grocery store, didn't seek medical attention for 2 weeks, and now claims a shoulder injury.

The records:

• No ER visit.
• First medical visit (2 weeks after fall): "Shoulder pain. Started after a fall 2 weeks ago."
• MRI (3 weeks after fall): "Rotator cuff tear."

Causation analysis:

• Mechanism: Fall. But no contemporaneous documentation.
• Immediate injury: No immediate medical attention. Why?
• Pre-existing conditions: Need to check prior records. Any prior shoulder complaints?
• Delayed treatment: Why did the plaintiff wait 2 weeks? Is there an explanation?

Opinion:

• If no explanation for delay and no prior complaints: "The temporal relationship suggests causation, but the delay in treatment raises questions about the mechanism and severity."
• If prior shoulder complaints: "The rotator cuff tear may be pre-existing. Further review of prior records is needed."

Key Takeaways

1. Establish the mechanism. Is it consistent and plausible?
2. Identify immediate injuries. What did the plaintiff report and what did objective findings show?
3. Review pre-existing conditions. Is there a prior history of the same complaint?
4. Assess treatment trajectory. Did the plaintiff improve? Is the trajectory consistent?
5. Evaluate subjective vs. objective findings. Are there inconsistencies?
6. Render a defensible opinion. State what you know, what you don't know, and what you need to know.

What's Next?

In our next post, we'll tackle "Workplace Injury Files: What Adjudicators Look For" — the second in our case-type series.

This post is part of our series on medical record review for IME physicians. For more, see our 60 AI Prompts for IME Physicians Reviewing Medical Records.

Questions for Readers:

• What's the most challenging slip-and-fall case you've reviewed?
• How do you handle delayed treatment in causation analysis?
• What red flags do you look for in slip-and-fall records?