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Thursday, 25 May 2017

Who is liable if a patient leaves A/E after wrong waiting time given?

I don't normally report on specific cases. But the recent Court of Appeal decision in Darnley v Croydon Health Services NHS Trust raises interesting questions about information given by hospital staff in relation to waiting times in A/E
On 17th May 2010 Mr Darnley was the victim of an assault and received a head injury. He was taken by a friend to the A/E Department at May Day Hospital in Croydon. The Receptionist took down his personal details. She also noted that he had had a head injury of about 1.5 hours duration. He reported that he was in severe pain.
The receptionist told him that it would be 4 – 5 hours before he was seen. This was wrong. He would in fact have been seen by a triage nurse within 30 minutes.
Mr Darnley waited for about 19 minutes and then decided to leave the hospital and to take some paracetamol , at home. He did not tell hospital staff that he was leaving. A few minutes later a triage nurse called him but he was no longer there. By 9.42 he had deteriorated and an ambulance was called. He was returned to the May Day. A CT scan revealed a extradural haematoma. He was transferred to St Georges Hospital, London for surgery. He suffered permanent brain damage resulting in severe neurological injury and significant disability.
The case against the hospital was there had been negligent delay in assessing him and also that he had been given wrong information about waiting time.
Guidelines published by NICE in 2007 said –
"1.4.1.6 All patients presenting to an emergency department with a head injury should be assessed by a trained member of staff within a maximum of 15 minutes of arrival at hospital. Part of this assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury, using the guidance on patient selection and urgency for imaging (head and neck cervical spine)."
So it was, understandably, argued that failure to assess him within 15 minutes was negligent. However, it was agreed between the experts that 15 minutes to triage might not always be achievable and that this depended how busy the A/E Department was. They agreed that the department was probably very busy on this particular evening which was a Monday. They agreed that Mr Darnley should have been seen within 30 minutes at the latest. A triage nurse tried to see him within this timescale but he had left. This argument was rejected by the trial judge.
The judge also rejected the claimant’s argument that the receptionist had negligently provided inaccurate information in relation to waiting times. If the claimant had known that he would be seen within 30 minutes he would have stayed. The judge held that there was no duty on the reception staff to provide information about waiting times. It was not ‘fair, just and reasonable’ to impose such a duty. The provision of information by receptionists was a courtesy offered to patients but this was ultimately a matter of clinical judgment. The imposition of a duty of care in these circumstances might lead to a policy of evasive answers.
Even if there was a duty, the provision of inaccurate information did not cause the claimant’s injury. It was caused by his decision to leave.
The claimant appealed.
The Court of Appeal rejected his appeal by a majority of 2 -1. In relation to the duty to triage within 15 minutes Jackson LJ approved the following observation from the trial judge –
"What I am prepared to find is that it seems to me to be extremely unlikely that the triage nurses were not fully engaged that night. The alleged breach of duty is a failure to meet a tight target of 15 minutes by a factor of 4 minutes. I am not prepared to find that this amounts to a breach of a clinical duty of care. It is right that there must be a longstop, or the target becomes meaningless. The consensus of opinion amongst the experts is that the longstop position is 30 minutes. That seems entirely appropriate."
In relation to the provision of wrong information Jackson LJ said –
‘In the present case the gravamen of the claimant's complaint is not failure to inform. It is the giving of incorrect information by the receptionist. I have come to the conclusion that this is not an actionable misstatement. The receptionist took down the claimant's details and, correctly, told him to wait in the waiting area. When she added that he would have to wait for up to 4 or 5 hours, she was not assuming responsibility to the claimant in the sense of accepting responsibility for the catastrophic consequences which he might suffer if he simply walked out of the hospital. Foreseeability alone is not sufficient to give rise to a duty of care.
Nor do I think that it is fair, just and reasonable to impose upon the receptionist (or the defendant acting by the receptionist) a duty not to provide inaccurate information about waiting times. This would add a new layer of responsibility to clerical staff and a new head of liability for NHS health trusts.’
Even if there was a duty to provide accurate information about waiting times, the claim would fail because he had been told to wait and left the building without telling anyone.
At one level it does appear harsh that the severely disabled claimant receives no damages, despite being given wrong information about waiting times. Indeed McCoombe LJ giving the dissenting judgment observed -
'Here the hospital told this claimant that he would receive attention in anything up to four or five hours. That was incomplete and inaccurate information and, in my judgment, imparted negligently. The risks from head injuries were well known within the hospital. Equally, the foreseeability of patients at A & E leaving before being seen (as found by the judge) should equally have been known. It seems to me, therefore, that the reality of the triage system should have been imparted to this claimant in view of his presentation on arrival. The failure to do so was, in my view, on the facts of this case a breach of duty by the hospital.'
So the point is finely balanced. But the position as things stand is that a claim cannot be successfully pursued on the basis of incorrect information provided by non medical hospital staff - particularly where a patient decides not to wait.

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