Case Note: Medical Negligence and Organisational Clinical Guidelines

Medical Negligence Organisational Clinical Guidelines

Further update:  We note that this case was recently the subject of an appeal.  On 10 May 2019 the appeal was allowed, with the court noting that the finding of the trial judge that 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 heartrate and blood pressure was not supported by the evidence.  A more detailed update on the appeal will be provided soon.

Masson v State of Queensland [2018] QSC 162

Introduction

The case concerned an allegation of negligent care provided by an ambulance service crew to Ms Masson (the Plaintiff) for a life-threatening asthma attack. At trial, the care provided by the paramedics and the content of the Queensland Ambulance Service Clinical Practice Manual (Clinical Manual) were assessed, specifically in relation to the management suggested in the Clinical Manual, and the drugs that were administered.

Ultimately, it was found that Queensland Ambulance Service (QAS) had not been negligent, and the care provided was consistent with the recommendations in the Clinical Manual.

Facts

The Plaintiff who was 25 years old at the time and a known asthmatic had suffered a life-threatening asthma attack at a private home in 2002. She had suffered serious attacks responding to administration of adrenaline before, but this was not made known to the paramedics. In spite of the care provided by the QAS crew and subsequently at Cairns Base Hospital, the Plaintiff suffered severe hypoxic brain injury as a result of the incident, leaving her completely care-dependent for fourteen years before she passed away. Following her death, the action for negligence against QAS survived in the hands of her estate, with quantum agreed in the amount of $3 million prior to the trial.

At trial, the Plaintiff’s allegation of negligence centred on the QAS paramedics’ initial choice of intravenous salbutamol over adrenaline for an asthmatic patient presenting with extreme dypnoea and bradypnoea, but also with hypertension and tachycardia. Adrenaline was only administered shortly thereafter when the Plaintiff became bradycardic with no measurable blood pressure.

It was also suggested by the Plaintiff that the care provided was inconsistent with the QAS Clinical Manual.

Issues

Generally, the court articulated that the appropriate standard of care was based on pre-hospital care provided by paramedics in an emergency. Three issues as set out below were identified as relevant to the potential breach of a duty of care owed to the Plaintiff by QAS.

Was adrenaline the preferred drug to administer in a life-threatening asthma attack in 2002?

Considering the expert evidence, the Judge concluded that at the relevant time, most likely the predominant view of the medical profession was that adrenaline would have been the preferred drug to administer to an asthmatic patient suffering a life-threatening attack. However, this depended on the specific clinical presentation of the patient, there would also have been credible views favouring salbutamol under such circumstances, and such clinical preferences were at any rate subject to a lack of relevant scientific evidence supporting one treatment over the other.

Did the plaintiff’s condition make salbutamol a choice that was equally acceptable or preferable to adrenaline?

Considering the expert evidence, the Judge assessed that given the Plaintiff’s clinical presentation, namely the initial hypertension and tachycardia, there was a reasonable body of opinion in the medical profession that held that under the initial circumstances, salbutamol was preferable to adrenaline to administer, as done by the paramedics.

Was the choice against adrenaline for the initial treatment contrary to the Clinical Manual?

QAS at the relevant time provided its staff with the Clinical Manual which included a section on the pre-hospital treatment of asthmatic patients. The Clinical Manual was explicitly intended to not be proscriptive, but rather to guide and assist patient diagnosis and management.

In assessing what the Clinical Manual required of paramedics in the management of a patient with life-threatening asthma, the Court cautioned against seeking to interpret the Clinical Manual, including a relevant flowchart, in the manner of a statute or contract. Rather, the Clinical Manual should be understood in the way that it would be read by the paramedics using it in their daily practice, and the relevant evidence as to its meaning was therefore that of the paramedic experts. Evidence about the use and suggested interpretation of the Clinical Manual in QAS’s teaching for paramedical staff would also have been relevant, but only very general evidence was offered in this respect.

The Court found that 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.

On the accepted evidence of one of the paramedics, he had considered (but decided against) the initial administration of adrenaline, which was consistent with the management as suggested in the Clinical Manual.

Compliance Impact

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.

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