High Court Examines Paramedic’s Standard of Care

State of Queensland v Masson [2020] HCA 28

Introduction

In State of Queensland v Masson [2020] HCA 28, the High Court overturned a medical negligence finding from the Queensland Court of Appeal where the State of Queensland had been found to be vicariously negligent in relation to the care provided by a Queensland Ambulance Service (QAS) crew to Ms Masson following a life-threatening asthma attack (the subject of a previous Case Law Update). The Court of Appeal had reversed the original ‘not negligent’ finding from the Queensland Supreme Court, however, the High Court ultimately agreed with the first instance trial judge that the paramedics had not been negligent in their treatment of Ms Masson as detailed below.

Facts

On 21 July 2002, Jennifer Masson, a 25- year-old chronic asthmatic, suffered a severe asthma attack while visiting friends in Cairns. Ambulance officers treated Ms Masson at the scene before taking her to Cairns Base Hospital. She had suffered serious attacks requiring and responding to administration of adrenaline before, but this was not known to the ambulance crew. Based on her clinical presentation, Ms Masson initially received multiple doses of intravenous salbutamol, with adrenaline only being administered later. In spite of the care provided QAS and subsequently at Cairns Base Hospital, Ms Masson suffered a severe hypoxic brain injury as a result of the incident, leaving her completely care-dependent for fourteen years before she passed away.

First instance decision

At the first instance trial in the Supreme Court of Queensland, the allegations of negligence centred on the senior QAS paramedic’s initial choice of intravenous salbutamol over adrenaline for an asthmatic patient presenting with extreme dyspnoea (shortness of breath) and bradypnoea (slow rate of breathing), but also with hypertension (increased blood pressure) and tachycardia (fast heart rate). Adrenaline was only administered later when Masson became bradycardic (slow heart rate) with no measurable blood pressure. The care provided was assessed in view of the content and requirements of the Queensland Ambulance Service Clinical Practice Manual (Clinical Manual).

In assessing what the Clinical Manual required in the management of a patient with life-threatening asthma, the Court cautioned against seeking to interpret the Clinical Manual in the manner of a statute or contract. Rather, the Court found that the manual should be understood in the way that it would be read by the ambulance officers using it in their daily practice, and the relevant evidence as to its meaning was therefore that of members of that profession.

The Clinical Manual provided for the consideration, but not necessarily administration, of adrenaline in the pre-hospital treatment of an asthma attack with imminent arrest. The care provided by the ambulance officers had been consistent with this. QAS was therefore held to not be liable in negligence.

First appeal

At the first appeal in the Queensland Court of Appeal, the allegations of negligence were based upon a claim that QAS had not adequately trained their staff to deal with emergencies such as the present case, with the consequence that the administration of the adrenaline was delayed.

The Court of Appeal commented that where ambulance officers are provided with guidance, such as a Clinical Manual, divergence from what is required under such guidance would be inconsistent with the exercise of reasonable care and skill by an ambulance officer.

In the first appeal, the ambulance officer was found to not have considered the administration of adrenaline in the manner required by the Clinical Manual. Specifically, the ambulance officer was found to have rejected the administration of adrenaline, not because of clinical considerations, but because he believed that adrenaline was prohibited by the Clinical Manual under the relevant clinical circumstances (namely the patient not being bradycardic at the relevant time). The Judge also noted that the ambulance officer had acted inconsistently with the contents of the Clinical Manual, in relation to the recommended dosages of salbutamol which had been administered to Ms Masson.

Further, the Judge rejected the finding at the first instance trial that evidence, including expert evidence, provided that at the relevant time, “there was a responsible body of opinion in the medical profession to support the administration of salbutamol to a patient with Ms Masson’s high heart rate and blood pressure”.

Ultimately, the Court of Appeal found that care provided by QAS through the ambulance officer had been negligent, as it had not been provided in accordance with the Clinical Manual.

Issues on High Court appeal

The State of Queensland was granted special leave to appeal to the High Court. The appeal centred on whether the senior paramedic’s administration of salbutamol instead of adrenaline was reasonable in light of the interpretation of the Clinical Manual, the state of medical opinion at the time and witness evidence from the paramedic.

Specifically, the State contended that:

  • the Court of Appeal departed from settled principle by treating the Clinical Manual as determinative of the standard of care; and
  • the Court of Appeal was wrong to overturn the trial judge’s findings that:
    • the Senior QAS paramedic considered the administration of adrenaline in accordance with the Clinical Manual; and
    • in 2002, there was a responsible body of opinion within the medical profession supporting the administration of salbutamol to a patient in Masson’s condition.

Ultimately, the High Court found that both findings should be restored. The majority held that the trial judge was correct to hold that the administration of salbutamol to Ms Masson in all the circumstances was within the range of reasonable clinical judgments that an ordinary skilled intensive care paramedic might make. We outline the Court’s reasoning below.

Was the administration of salbutamol reasonable?

The Clinical Manual

The High Court agreed with the State that the Clinical Manual should not be determinative of the standard of care for paramedics, drawing attention to a prominent section of the Clinical Manual titled ‘Patient Care Principles’ that incorporated a section covering “Clinical Judgement / Problem Solving”. In this section it was explained that:

“The [CPM] is designed to assist clinical judgment, using the problem solving approach, to achieve best practice. It is acknowledged that every situation is different. Deviations from the guidelines will occur but must be documented and audited, and officers must be able to justify that their treatment was in the patient’s best interest.”

Further, as to the question of adherence to the Clinical Manual, the High Court commented that the Court of Appeal had erroneously treated the Clinical Manual as though it were a legal document or statute which was incorrect. The correct approach was that adopted by the trial judge who commented that the Clinical Manual was “intended to guide and assist rather than to proscribe decision making”.

Did the paramedic exercise clinical judgement?

The representatives for Ms Masson argued that the paramedic misinterpreted the Clinical Manual and believed he was precluded from administering adrenaline and it was therefore not a clinical judgement. However, the High Court disagreed and confirmed that the paramedic had in fact considered the use of adrenaline before choosing to administer salbutamol, stating:

“As the primary judge reasoned in effect, the curious and, in one sense, erroneous reference to the guideline not permitting the administration of adrenaline was not inconsistent with Mr Peters having considered that the administration of adrenaline was too risky by reason of Ms Masson’s tachycardia and hypertension. That was confirmed by his statement in the extract that “I therefore elected to administer intravenous salbutamol”; since an election necessarily implies a choice.”

Therefore, the High Court agreed with the trial judge’s finding that the paramedic’s decision not to administer adrenaline to Ms Masson was a clinical judgment and did not proceed from a mistaken understanding of the Clinical Manual.

State of Medical Opinion

During the first two proceedings, each party led opinion evidence from three specialists in emergency medicine and an expert paramedic. As the Court of Appeal observed, there was a marked division of opinion between witnesses as to whether salbutamol was an appropriate drug to administer in Ms Masson’s condition.

Given the High Court’s finding that the Clinical Manual allowed for clinical judgements, the pertinent question at hand was whether the election to administer salbutamol and not adrenaline was within the range of clinical judgments that an ordinary skilled intensive care paramedic might make. Evidence of a responsible body of medical opinion approving the use of salbutamol would support this.

Ultimately, the High Court agreed with the first instance decision. His Honour in the Supreme Court found that in 2002 a responsible body of opinion within the medical profession supported the view that, in the context of Ms Masson’s overall condition (i.e. her high heart rate and high blood pressure) there was a medically sound basis to prefer salbutamol to adrenaline at the time of her initial treatment.

Accordingly, the decision to administer salbutamol to Ms Masson in the initial phase of her treatment was not considered contrary to the Clinical Manual.

The paramedic’s witness statement

Similarly to how the Court of Appeal interpreted the Clinical Manual as a legal document, there was contention in both the Court of Appeal and the High Court’s judgments about the paramedic’s written statement prepared seven years following the events in 2002 and the use of the phrase “not permitted”.

This written evidence was used to show that the paramedic had not considered the use of adrenaline and believed the Clinical Manual prevented him from doing so. However, the High Court dismissed this claim. Kiefel CJ, Bell and Keane JJ drew attention to the paramedic’s evidence in chief as being persuasive and not inconsistent with his written evidence while noting that the statement had the “hallmarks of professional drafting”.

Further, Nettle and Gordon JJ also stated that:

“It is neither surprising nor at all unlikely that a paramedic whose day-to-day business is one of making life and death decisions should conceive and speak of a “not recommended” or “not appropriate” course of initial treatment as one that is “not permitted”. Common sense and ordinary experience dictate that, just as a paramedic’s initial treatment must be immediate and unhesitating, a paramedic is likely to be inclined to conceive and speak of actions in perfunctory and unqualified terms. Of course, exceptionally, such a person might be so particular in his or her choice of language as to convey that, by stating that something is “not permitted”, he or she means that all choice is excluded.”

Compliance Impact

While the State of Queensland was ultimately found to be not negligent in this case, the twice reversed decision serves as an important warning for health services to be as clear as possible when drafting clinical guidelines.

Entities that provide their own clinical guidelines to their staff should ensure that such guidelines are current and based on scientific evidence and/or expert consensus as much as possible. They should also ensure that such guidelines are drafted in an unambiguous manner, including any graphic representations, and that they indicate the extent, and any limits, of clinical discretion that is appropriate in applying the guidelines.

Staff continuing education should reference such organisational guidelines and provide clear and consistent messaging around the interpretation and expected use of such guidelines.


Contact

For further information please contact the Law Compliance team:

Phone: 1300 862 667

Email: info@lawcompliance.com.au

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