Medico-legal risk: What neurologists need to know

Know your risk – data by clinical specialty

A patient receiving an MRI head scan.

4 minutes

Published: November 2023

As of the end of 2021, 1,341 CMPA members were neurologists (Type of Work 56). In the recent 5 years (2017 – 2021)1, 17.8% of neurologists were named in one new medico-legal case (legal action, College or hospital complaint), and another 5.6% were named in 2 or more new cases.

Annually, 5.9% of neurologists were named in one new medico-legal case, and an additional 0.7% were named in two or more new cases on average across this 5-year period.

The graphs below compare the 10-year trends in neurologists’ medico-legal experiences with those of the general CMPA membership.

What are the relative risks of a medico-legal case for neurologists?

  •  Neurology, College(n=653)
  •  Neurology, Legal(n=161)
  • All CMPA, College(n=45,421)
  •   All CMPA, Legal(n=13,857)

In the past 10 years, there was not significant difference of College complaint2 rates between neurologists and the general CMPA membership, although rates of neurologists’ College matters fluctuated widely between 2016 and 2020.

In the past 10 years, the risk of civil legal actions for neurologists were similar to that of all CMPA members.

The following sections describe the findings based on the 511 civil legal cases, College, and hospital matters involving neurologists with peer expert criticism that were closed by the CMPA between 2012 and 2021.

What are the most common patient complaints and peer expert criticisms?3 (n=511)

Issue %, Patient allegation %, Peer expert criticism
Deficient assessment 47 8
Diagnostic error 44 17
Unprofessional manner 23 7
Communication breakdown with patient 17 13
Failure to perform test or intervention 14 7
Inadequate monitoring or follow-up 13 4
Inadequate office procedure 11 9
Inadequate documentation 10 14
Inadequate consent process 10 7

Complaints are a reflection of the patient’s perception that a problem occurred during care. They are not always supported by peer expert opinion. Peer experts may not be critical of the care provided, or may have criticisms that are not part of the patient allegation. These complaints might not result in a negative finding by a College or court.

What are the most frequent patient presenting conditions? (n=511)

Episodic and paroxysmal disorders (e.g. migrane, epilepsy, TIA) (16%), Cerebrovascular disease (e.g. cerebral infarction) (9.2%), Dorsopathies (5.9%), Demyelinating diseases of the central nervous system (5.7%), Nerve, nerve root and plexus disorders (4.7%)

  •   Episodic and paroxysmal disorders (e.g. migrane, epilepsy, TIA) (16%)
  •   Cerebrovascular disease (e.g. cerebral infarction) (9.2%)
  •   Dorsopathies (5.9%)
  •   Demyelinating diseases of the central nervous system (5.7%)
  •   Nerve, nerve root and plexus disorders (4.7%)

Frequencies of the presenting conditions among medico-legal cases are likely representative of neurologists’ practice patterns and do not necessarily reflect high-risk conditions.

In the 511 cases, 95 patients experienced a misdiagnosis or delayed diagnosis, often resulting in severe patient harm. For example:

  • Failure to question the initial diagnosis of cerebral vascular accident due to inconclusive imaging results contributed to a delay in diagnosis of a brain tumor.
  • Failure to appreciate the patient’s diminished Glasgow Coma Scale (GCS) contributed to a failure to perform imaging, which would have confirmed a subdural hematoma.
  • A deficient hospital test follow-up system and a physician’s failure to follow-up on a cerebral angiogram contributed to a missed cerebral aneurysm.

What are the top factors associated with severe patient harm4 in medico-legal cases? (n=511)

Factors associated with severe patient harm.

Patient factors5

  • Presenting with myelopathies, myasthenia gravis, or cerebrovascular diseases (e.g. stroke, hemorrhage)

Provider factors6

  • Failure to attend to the patient
  • Failure to perform test or intervention
  • Misinterpretation of test
  • Inappropriate transfer or failure to transfer
  • Premature discharge
  • Deviation from clinical practice guidelines (e.g. failing to adhere to clinical practice stroke guidelines)

System factors6

  • Unavailable or insufficient resources (e.g. lack of imaging services on weekends, lack of neurology beds)
  • Inadequate office system (e.g. test follow-up, appointment scheduling and triage follow-up)

Team factors6

  • Inadequate communication with other healthcare providers (e.g. nurses, pharmacists)

Risk reduction reminders

The following risk management considerations have been identified for neurologists.

  • Gather an appropriate medical history from the patient, including comorbidities and current medications, and conduct a focused physical examination including vital signs.
  • Consider whether additional diagnostic tests or consultations are necessary to establish or confirm the diagnosis. Incorporate clinical pathways, clinical practice guidelines, or decision tools as appropriate.
  • Document discussions, treatment plans, and other clinical issues in patients’ medical records. Clear documentation can improve continuity of care as it provides the rationale for the physician’s clinical decision-making and communicates what took place during the patient encounter to other providers.
  • Thoroughly assess the patient’s fitness for discharge. Inform the patient about symptoms and signs that should alert them to seek further medical attention, and when and whom to consult in the event of complications.
  • Appropriately advocate on behalf of patients to solve issues that arise when limited resources pose an impediment to safe patient care, and document any steps you have taken to attempt to resolve the resource issue within a reasonable timeframe.


The numbers provided in this report are based on CMPA medico-legal data. CMPA medico-legal cases represent a small portion of patient safety incidents. Many factors influence a person’s decision to pursue a case or file a complaint, and these factors vary greatly by context. Thus, while medico-legal cases can be a rich source for important themes, they cannot be considered representative of patient safety incidents overall.

Further, CMPA’s medico-legal cases data focus on provider and team factors. System factors are underrepresented.

Now that you know your risk…

Mitigate your medico-legal risk with CMPA Learning resources.


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  1. It takes an average of 2-3 years for a patient safety incident to progress into a medico-legal case. As a result, newly opened cases may reflect incidents that occurred in previous years.
  2. Physicians voluntarily report College matters to the CMPA. Therefore, these cases do not represent a complete picture of all such cases in Canada.
  3. Peer experts refer to physicians who interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
  4. Severe patient harm includes death, catastrophic injuries, and major disabilities. Healthcare-related harm could arise from risk associated with an investigation, medication, or treatment. It could also result from failure in the process of patient care.
  5. Patient factors include any characteristics or medical conditions that apply to the patient at the time of the medical encounter, or any events that occur during the medical encounter.
  6. Based on peer expert criticism.