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Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report
format and length. Actual reports will vary in format and length appropriate to case type and complexity as
determined by legal nurse consultant and attorney-client.
KM Consulting
Sample Brief Report Personal Injury
Krystal McMahan, RN, BSN, CLNC
KM Consulting
Phone: (254) 405-3562
Email: krystal.kmconsulting@gmail.com
Confidential Attorney Work Product
February 20, 2014
John Smith
Attorney at Law
Best Law Firm, P.C.
1234 Main Street
Sometown, Texas 12345
Re: Amy Johnson case
Dear Mr. Smith:
Pursuant to your request, I have reviewed Amy Johnson’s medical records for the period
5/20/13 – 1/13/14 regarding the incident as well as her 9-month pediatric visit. I have included
my comments and recommendations for your consideration.
Amy Johnson is a 10 month-old white female. In my opinion, this case is meritorious due
to improper installation of the car seat. This resulted in severe brain injury and permanent mental
and physical disabilities.
A state worker named Susan White arrived at the Johnson’s home on 5/20/2013 to
transport Amy for a meeting with her biological mother. The Johnson’s are the child’s foster
parents. Amy was 5 weeks old and weighed 4 lbs. 12 oz. at the time. Ms. White installed Amy’s
car seat in the vehicle, placed the infant in the car seat, and drove to her biological mother’s
house. When they arrived, Ms. White found the infant unconscious and called 911.
The Got-You-Covered EMT service arrived within 5 minutes. In their notes they
described “the car seat had been improperly installed in an upright position instead of at a proper
and safe angle. The infant’s head had flopped forward within the duration of the twelve minute
car ride”. They transported Amy to Little Wonders Children’s Center where she was admitted to
the PICU.

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Confidential Attorney Work Product
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report
format and length. Actual reports will vary in format and length appropriate to case type and complexity as
determined by legal nurse consultant and attorney-client.
Regarding her initial assessment in the PICU, the doctor’s note described that the incident
“resulted in positional asphyxiation including obstruction of the airway, loss of consciousness,
and cardiac arrest.” Multiple cranial ultrasounds were performed during her hospital stay. Amy
remained in the PICU on mechanical ventilation for a period of 3 weeks.
In the history note it was documented that Amy was born prematurely on 4/12/13 at 34
weeks and 6 days at Sunnyside Hospital. Her diagnoses were prematurity and intrauterine growth
restriction (IUGR) weighing in at 3 lbs. and 1.5 oz. She stayed in the NICU for just over 3
weeks.
During Amy’s 9-month check-up it was noted by her pediatrician, Dr. M. Harper, that
Amy had several major developmental delays. Her developmental progress was closer to that of
a 3 month old.
My recommendations are as follows:
 Obtain complete medical records from birth to now including:
o Labor & Delivery, Neonatal ICU, EMT, Pediatric ICU, Pediatric visits
o Cranial ultrasounds, CT scans, and MRIs from NICU stay and PICU stay. These
should be compared by a radiologist.
 Obtain policies and procedures and training requirements from the Division of Youth and
Family Services including:
o Car seat installation
o Transporting a child
 Discover whether Ms. White was CPR certified
o Did she initiate CPR?
o If so, after how long?
o Was her CPR technique up to date and appropriate for a 5 week old infant? If not,
Ms. White as well as the DYFS could be charged with negligence.
 Discover whether the car seat used in transport has a minimum weight requirement of 4 or
5 lbs.
o Many car seats’ minimum weight requirement is 5 lbs. If the DYFS placed Amy in a
5 lbs car seat, then they can be charged with negligence as reports show that she was
only 4 lbs. 12 oz. when she was transported.
o Was this the car seat Amy was discharged from the NICU in? If the NICU discharged
Amy in a 5 lbs car seat when she would have required a 4 lbs car seat, they can be
charged with negligence as well.
 Discover Amy’s family history
o Why was she put up for adoption?
o Was there any substance abuse by the biological mother that would affect Amy’s
development?
o Does Amy have any biological siblings?
o If so, do any siblings have mental deficiencies and/or developmental delays?
 A more detailed report with a comprehensive chronological timeline to assist in developing
this case.
 Locate expert witnesses including:
o Radiologist

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Confidential Attorney Work Product
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report
format and length. Actual reports will vary in format and length appropriate to case type and complexity as
determined by legal nurse consultant and attorney-client.
o Neonatologist
o Life Care Planner
The defense will probably argue that the brain injury was caused by an infection not
improper transportation. However, the state worker neglected to safely install the car seat. This
resulted in permanent injuries. Another defense would be that Amy was born premature,
however being four weeks premature would not account for the severity of her developmental
setbacks.
Thank you for the opportunity to assist in evaluating this case. I will follow up within two
days to answer any questions you may have regarding this case and to determine the next steps
you would like me to take.
Sincerely,
Krystal McMahan, RN, BSN, CLNC