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Accident & Emergency: Common Sense or Clinical Care?

09 Feb 2016

The public perception of A&E departments across the UK is generally one of inefficiency, pandemonium and long waits. Undoubtedly there is persistent pressure on resources and staffing, but are the systems in place ensuring patients in need are assessed quickly and effectively? A recent case played out the struggle between patient emergencies and staff competency.

On 31st July 2015, Judge Robinson handed down a judgment from the Queen’s Bench Division in the case of Darnley v Croydon Health Services NHS Trust. The case considered an amalgamation of issues including patient responsibility, duty of care, clinical negligence and the job description of an A&E receptionist. The judgment acted as the catalyst to a wave of debate regarding the role played by non-medical staff in a clinical environment and appropriate categorisation of patients’ conditions.

The Facts

In May 2010 the Claimant, who had suffered a head injury, presented at Croydon University Hospital’s A&E department, whereby he was booked in by the A&E receptionist. The claimant was advised (incorrectly) by the receptionist that the wait to be seen would be around 4 to 5 hours. The claimant proceeded to wait for 19 minutes before returning home through a reluctance to linger in A&E for such a long period of time. Tragically his condition deteriorated and an ambulance was called to his home almost an hour later. He was returned to A&E where a CT scan revealed an extradural haematoma and following surgery he was diagnosed with a left hemiplegia (permanent paralysis of the left side of the body).

The Claim

Had the claimant remained at the hospital, in reality, he  would have been assessed within20-30 minutes.  The Claimant alleged that had he been given an accurate waiting time he would have remained in A&E where he would have received urgent treatment within a clinical setting preventing neurological injury. Secondly, he stated that there was a failure by the receptionist to communicate to clinicians his status for ‘priority triage’. The triage process is the system whereby patients are categorised according to the severity of their condition. Individuals presenting with urgent complaints are given precedence and reviewed by medical staff sooner than patients with minor illnesses or injuries. The Claimant contended that the receptionist should have recognised the seriousness of his head injury and called for urgent assistance.

The Decision

The judge dismissed the claim.

Whilst the judge accepted that it was foreseeable for the claimant to leave A&E after being advised of a four hour + waiting time, there was no duty on the part of the receptionist to prevent further injury to a patient, even if this harm could have been avoided through the provision of accurate information. The judge, citing the NICE guidelines (National Institute for Health and Care Excellence), found that the triage of a patient with a head injury should take place within 15 minutes. However, A&E expert opinion advised that these guidelines should not be considered in the abstract, but instead applied in the context of a busy emergency department. As such, a period of 30 minutes for triage to occur was found to be reasonable. The claimant left A&E after 19 minutes which contributed to a finding of no breach of duty, despite the considerable discrepancy between the actual likely waiting time (30 minutes max) and the advice given by the receptionist of 4 to 5 hours.

In any event, the judge ruled that it would not have been just, fair and reasonable to find the Defendant liable for information given by the receptionist. At this point the judge, assisted by A&E experts, considered the role and remit of administrative staff in a medical context. The judge reflected upon the balance between receptionists refraining from offering medical advice, whilst remaining informative and helpful. Importantly, it was found that the provision of information on waiting times was a courtesy and not a mandatory service that could be relied upon by patients. Ultimately, the judge held that the expectation to be applied to non- clinical staff is ‘the standard of a member of the public exercising common sense’. The judge applied public policy reasoning in that it would be detrimental to reduce a receptionist’s role to completing forms and being forced to tread carefully whenever a patient requested information. The preservation of good old fashioned manners succeeded over the stringent imposition of legal liability.

The judge found that the claimant had to take responsibility for his decision to leave A&E and suggested this was an age where individuals were progressively reluctant to take personal responsibility for their own actions.

The Consequences

Whilst it is difficult to disagree with the logic of the judge, it could be suggested that the standard of expectation applied to an A&E receptionist should be higher, given that in reality they will possess far greater expertise than a member of the public. However, more pertinently this case sparked a wider concern that non-clinical staff were playing a major role in the triage process and ultimately patient welfare.

The judge placed importance on the presentation of the claimant, who was alert and conscious, and suggested this was not a situation where a ‘member of the public’, and equally a receptionist, would refer the patient for immediate triage. This aspect of the pre-triage process exposes the integral part played by non-clinical individuals in vital medical assessments. Ultimately, receptionists are the first stage in a system which involves critical decision-making and where each minute can be of the upmost importance in affecting the end result. Undoubtedly resources are stretched and in an era when A&E waiting times are a serious challenge to the efficiency of the NHS, the role played by non-clinical individuals in a medical context could become increasingly prominent.

For further information or advice, please contact Helen Morland

Call: 0191 232 8345

Email: Helen.Morland@hay-kilner.co.uk

Please note: This article is not legal advice; it is intended to provide information of general interest about current legal issues. Please contact us to discuss how the contents of the article may affect you.