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Court dealt with history-taking in ED

25 May 2017

Ed Madden

Ed Madden, BL, looks at a recent England and Wales Court of Appeal case that considered the standard of care expected of doctors in history-taking in emergency departments

In May 2017, the England and Wales Court of Appeal delivered its judgment in a case in which the mother of a teenage girl brought an appeal on her behalf against a decision of the High Court dismissing a claim for negligence against an NHS Trust. The appeal concerned a hospital A&E (or emergency department) consultation that took place in September 2003, when the girl was 13 months old.

When the matter came on for hearing, the Court was told that shortly after 4am on Monday, September 29, 2003, the child’s mother telephoned an out-of-hours service where she spoke to the triage nurse.

The nurse called the ambulance service and told them that the child was presenting with a “temperature… up to 40 she is rolling her eyes and her breathing is a little bit erratic”.

That information was confirmed by the mother when she spoke directly to ambulance control. An ambulance was dispatched immediately. Having arrived at the home, the paramedics recorded that “Mum says patient v lethargic. O/E patient eyes rolling not coordinated”.

When the ambulance arrived at the nearby hospital the child, having been triaged, was seen in the A&E Department by a Senior House Officer. The consultation, which was attended by the parents, lasted about 25 minutes.

In her detailed note of the consultation, the doctor recorded that on examination: the child looked well; was alert and active; and was responsive and aware of her surroundings.

She made the following entry: “Impression-Upper Respiratory Tract Infection”.

Before discharging the child shortly before 6am, she advised the use of Calpol and Nurofen to keep her temperature under control. The parents were advised to return to the hospital with the child if she started vomiting, could not tolerate oral fluids, or developed a non-blanching rash.

That afternoon, the child’s condition worsened and the mother contacted her GP. Having conducted an examination, she immediately called an emergency ambulance. The child was taken back to the hospital where she was seen by a triage nurse and referred directly to the paediatric team. They conducted an examination and administered antibiotics.

Pneumococcal meningitis
The child was transferred to Great Ormond Street Children’s Hospital on October 1, 2003, where a diagnosis was made of pneumococcal meningitis and multiple brain infarcts. Sadly, she sustained permanent brain damage and is profoundly deaf.

The appeal centred on whether the SHO had taken an adequate history during the consultation in A&E, when the child was first taken to hospital.

Apparently, while it was normal practice for the ambulance and paramedic records to be attached to the triage nurse’s notes, that did not occur on this occasion.

It was not in dispute that the SHO had not recorded the reason why the parents had brought their child to hospital at 4.30am.

The High Court found that it was “the eye-rolling episode” that precipitated the emergency call and the summoning of the ambulance. However, the trial judge found that while a consultant would be expected to elicit that information from the parents, it was not substandard practice for the SHO to have failed to do so.

Giving her judgment in the Court of Appeal, Lady Justice Thirlwall said the fact that most children who are brought to A&E “are not really unwell” is not an answer to a failure to elicit information that leads to the identification of the unwell child.

There was “nothing overly rigorous or inordinately logical” in the proposition that in the absence of special circumstances, it is the duty of an A&E doctor to elicit the reason why a child is brought to A&E in the early hours of the morning. On the contrary, that is a basic requirement of the history-taker.

The view of the trial judge that in matters of history-taking, there was a lower standard of care for an SHO than a consultant, was unsupported by evidence and could not be upheld.

Junior doctors
Lord Justice Jackson agreed with the judgment of his colleague. History-taking is a basic skill that doctors at all levels are expected to possess. However, he wished to acknowledge that junior hospital doctors work long hours under considerable pressure, and are often involved in life and death decisions.

The pressures can be even greater when they are “working all night”, as was the position in the present case. When mistakes are made, it can be devastating for patients and expensive for the NHS.

He concluded his judgment as follows: “Doctors, however, are human. Even good and conscientious doctors may, from time to time, fall short. That is not a reason to lose heart or (even worse) to abandon medical practice. Those who have learnt from past mistakes often have even more to offer.”

Reference: [2017] EWCA Civ 334.

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