Quando la cartella clinica diventa una prova: la Cassazione e il nesso causale nella responsabilità sanitaria

In its Order No. 4704 of 2 March 2026, the Italian Supreme Court of Cassation, Third Civil Section, addressed the relationship between medical liability, incomplete medical records and the burden of proof. The Court reaffirmed that deficiencies in medical documentation cannot operate to the detriment of the patient from an evidentiary standpoint. Where direct evidence has become unavailable precisely because of inadequate documentation by the party responsible for keeping the medical records, the patient may rely on circumstantial evidence, in accordance with the principle of proximity of evidence. The decision is also relevant to the assessment of causation: merely classifying an adverse outcome as a “complication” does not, in itself, establish that the event was unavoidable or exclude medical liability. The ruling therefore highlights the dual function of medical records as both clinical documentation and evidentiary material, while reaffirming the importance of the proximity-of-evidence principle in medical liability litigation.