Negligent Discharge Leads to Damages in Ectopic Pregnancy Case

Hartfield v Calvary Healthcare ACT Ltd (No 4)

Introduction

In this case, Calvary Healthcare ACT Ltd (the Hospital) was found to have been negligent when it discharged a woman with an ectopic pregnancy (Ms Hartfield or the Plaintiff) where:

• she was experiencing significant pain (which was apparent from the notes but was unknown to the discharging doctors);
• the Hospital did not provide her with the opportunity to remain for observation and pain management or with ‘full information’ about her condition and the importance of returning to Hospital.

The Plaintiff was awarded $118,306 in damages.

Background

The key facts of the case are as follows:

• The Plaintiff was a woman who had previously had 2 miscarriages and, in 2015, an ectopic pregnancy. The ectopic pregnancy was treated by removing one of her fallopian tubes. Relevantly, a previous ectopic pregnancy indicates increased risk of subsequent ectopic pregnancies.
• In 2019, the Plaintiff fell pregnant.
• On 30 July 2019, when she was about 5 weeks gestation, the Plaintiff developed abdominal pain, cramping and spotting.
• Fearing she had another ectopic pregnancy, the Plaintiff drove herself to the Hospital on the morning of 31 July 2019. She was admitted into hospital undergoing investigations to determine the cause of the symptoms. During the admission, the Plaintiff’s pain, bleeding and Human Chorionic Gonadotropin (hCG) levels were monitored. The Plaintiff relevantly received Fentanyl as pain relief. The extent of the Plaintiff’s pain was the subject of some dispute at trial. An ultrasound conducted at the Hospital showed no evidence of intra- or extra-uterine gestation.
• The differential diagnosis formulated by the Obstetrics and Gynaecology Registrar included miscarriage, ectopic pregnancy and pregnancy of unknown location (where neither an intrauterine pregnancy nor an ectopic pregnancy is identified by ultrasound).
• On 1 August 2019, the Hospital discharged Ms Hartfield. The opinion of the treating doctors was that the Plaintiff’s diagnosis was a pregnancy of unknown location. The Court found that the Plaintiff was told that an ectopic pregnancy was a possibility and she should return to the Hospital if she had increased bleeding or pain, dizziness or loss of consciousness. However, it found that the Plaintiff was not warned that she ‘remained at real risk’ of an ectopic pregnancy because of her history nor was she warned that any increase in bleeding or pain could be an early indication of the ectopic pregnancy rupturing.
• In the early hours of 2 August 2019, the Plaintiff experienced a sharp, sudden onset of acute pain and vaginal bleeding. For some hours after this, the Plaintiff attempted to go back to sleep before waking her husband to attend the Hospital. The Plaintiff gave evidence that she experienced significant fear during this period and that she felt like she was having an out of body experience.
• The Plaintiff presented to the Emergency Department of the Hospital and was diagnosed with an ectopic pregnancy. She underwent an emergency laparoscopic left salpingectomy (a procedure for the removal of her remaining fallopian tube). As a result, the Plaintiff was no longer able to conceive naturally.

The Plaintiff’s claim

The Plaintiff sued the Hospital in negligence. It was not in dispute that the Hospital owed the Plaintiff a duty of care nor that the Hospital was responsible for the acts and omissions of its staff.

The primary issue was whether the Hospital’s staff had failed to exercise reasonable care. The Plaintiff put forward 2 arguments.

Should a laparoscopy (and salpingostomy) have been performed during the first admission?

The Plaintiff’s primary case alleged that the Hospital should have performed a diagnostic laparoscopy during her initial presentation to the Hospital, a minimally invasive procedure used to visually assess the abdominal and pelvic organs. She submitted that, had this procedure been undertaken, the ectopic pregnancy would have been identified early, enabling only part (rather than the whole) of her fallopian tube to have been removed. According to Ms Hartfield, this would have afforded her a realistic opportunity to maintain her natural fertility and avoided the psychiatric injury that she sustained.

The Plaintiff relied on expert evidence that this was an appropriate course of action because the Plaintiff’s presentation was consistent with ectopic pregnancy (noting her history) and because of the possibility of salvaging the Plaintiff’s fallopian tube.

The Hospital’s experts opined that this was an appropriate course of action because other diagnoses of the Plaintiff’s pain (including miscarriage and the presence of a cyst) could not be excluded and, in that context, the risk of surgical intervention was not justified. It should be remembered that on 31 July 2019, the Plaintiff had undergone an ultrasound that did not show an ectopic pregnancy.

In that context, the Court accepted that it was reasonable not to have performed a laparoscopy. It rejected the Plaintiff’s primary case on negligence.

Was it negligent to discharge the Plaintiff on 1 August 2019?

The Plaintiff’s alternative case alleged that the Hospital was negligent by discharging her on 1 August 2019 in circumstances where:

• an ectopic pregnancy had not been ruled out,
• she continued to suffer significant pain, and
• she was not given adequate warnings about the increased risk of an ectopic pregnancy (which was heightened by virtue of her history) and importance of presenting to Hospital immediately where her condition worsened.

She contended that, had she remained in the Hospital, she would have been there when her symptoms deteriorated later that evening, at which point a salpingostomy could still have been successfully performed. Alternatively, she claimed that she would have avoided the psychological harm, specifically Post-Traumatic Stress Disorder, that she said arose from the distress and fear experienced in the hours leading up to the emergency surgery performed on 2 August 2019.

A key factual issue on this aspect of the case was whether the Plaintiff had been experiencing ‘really significant’ pain that was obvious to the observer at the time of discharge (as she contended) or whether there was ‘no pain’ (as the Hospital contended). The Court found that the true position was somewhere between these 2 poles because the Plaintiff had reported ‘6 out of 10 pain’ to a nurse less than 90 minutes prior to the discharge decision being made.

Having made that factual finding, the Court found that the decision to discharge the Plaintiff was negligent based on expert evidence, including from the Hospital’s witnesses, that the presence of pain would have tipped the balance of risk in favour of admission or further examination and offering the Plaintiff a choice whether to remain in Hospital.

It should be noted that:

• the Court was able to reject the Hospital’s experts’ evidence that discharge was defensible on the basis that it assumed that the Plaintiff had ‘no pain’ (which was found not to be correct);
• the Plaintiff’s treating consultants each acknowledged that they were not aware of the Plaintiff’s report of 6 out of 10 pain and that had they known it was ‘unlikely’ that the Plaintiff would have been discharged.

Ultimately the Court found that the Hospital had breached its duty of care by:

not discussing whether she wished to remain for observation and pain management, and without providing her with appropriate information concerning the likelihood of an ectopic pregnancy, the significance of increased pain and bleeding in that connection, and the need to return to hospital immediately in the event of an increase in pain and/or bleeding.

Having found that the Hospital was negligent, the Court went on to find that:

• the Plaintiff would have elected to stay in the Hospital (if she had been given the option);
• the ectopic pregnancy would have been detected on the evening of 31 July 2019;
• the prospects of a successful salpingostomy (which would have had some prospect of preserving the Plaintiff’s fertility) were negligible – it followed that the claim for the injury of the loss of fertility was rejected;
• however, had the Plaintiff remained in the Hospital, her pain would have been managed, she would have proceeded to surgery calmly and she would not have suffered psychiatric harm (or at least not to the same extent as she did from being rushed to emergency surgery).

Damages

The Court found that the Hospital was liable to the Plaintiff for significant physical pain she experienced between 1 August and her emergency surgery on 2 August 2019. Her Honour accepted that she developed a psychiatric condition comprising depression, anxiety and post-traumatic symptoms. The Court awarded general damages of $100,000 to compensate her for the physical and psychological harm it found to have occurred (which included disturbed sleep and recurrent nightmares).

Importantly, the Court declined to award damages for the asserted emotional harm associated with the awareness that her remaining fallopian tube was rupturing, as that category of loss required proof that a salpingostomy could probably have been successfully performed even if she had remained in Hospital, something Ms Hartfield did not establish. For the same reasons, the Court rejected an argument that the Hospital should have been liable for the Plaintiff’s proposed IVF treatment.

Otherwise, the Court awarded an additional $18,306 in interest, past and future economic loss and past future psychological treatment. The total sum awarded to Ms Hartfield was $118,306.

Compliance Impact

Discharge decisions can be a key risk area. Here, the decision to discharge was found to have proceeded on incomplete information – as it was unknown that the Plaintiff had reported ‘6 out of 10’ pain – and without adequate warning the Plaintiff about the need for a return to the emergency department if her condition worsened. The case provides a timely opportunity to consider discharge decision-making processes.