March 28, 2019

Consulting a consultant: a doctor’s standalone duty of care

A patient is admitted to the acute assessment unit (AAU) by ambulance following numerous bouts of diarrhoea and vomiting. The junior doctor on duty examines the patient and, after a few hours of observations, sends her home. Before doing so, he speaks with the consultant on call and obtains the necessary authorisation to discharge her.

Does the consultant's authorisation absolve the junior doctor of responsibility?

This was the situation in George Andrews v Greater Glasgow Health Board [2019] CSOH 31. The patient was admitted to hospital by ambulance on 6 January 2013. This followed a visit to hospital on the evening of the previous day. She had presented with reports of vomiting, diarrhoea, and the inability to eat. Dr Izzath conducted his examination and she was placed on observations.

After a number of hours' observations her symptoms had improved. Dr Izzath recorded a clinical impression of likely gastroenteritis. Dr Izzath did not have the authority to discharge a patient. He reported the patient's symptoms and the results of the laboratory tests to the consultant on call. In evidence, the consultant confirmed this would have been a detailed discussion as it was his responsibility to approve the discharge.

The patient was discharged on the evening of 6 January 2013. She had further episodes of diarrhoea and vomiting before being re-admitted to hospital on the evening of 7 January 2013. She underwent a midline laparotomy on 8 January 2013 but died the following day. The deceased's executor brought a claim against the NHS health board as a result of the alleged negligence of Dr Izzath.

The question for the court was whether Dr Izzath was at fault because he neglected to advise the deceased that she should be admitted when he assessed her on 6 January 2013. The expert evidence was that Dr Izzath should have offered the deceased admission to hospital and not to do so would be a departure from normal practice that no ordinarily competent clinician would have made.

Lord Pentland held that Dr Izzath did not offer to admit the deceased and so Dr Izzath was negligent. Lord Pentland concluded that there was a causal link between this negligence and the deceased's death. Appropriate damages were awarded.

An interesting aspect of this case is the court's analysis of Dr Izzath's discussion with the on call consultant. The discussion with a senior colleague was not held to absolve Dr Izzath of liability. The court held that the consultant's authorisation was based upon an inaccurate reporting of the deceased's ability to cope at home. Notwithstanding that, the court affirmed that Dr Izzath owed the deceased a standalone duty of care.

The court referenced the decision of the court of appeal in Wilsher v Essex Health Authority [1987] QB 730 and noted that:

"In general, the principle is that a junior and inexperienced doctor must achieve the same standard of care as a more experienced colleague would be expected to bring to the task in hand."

While health boards and hospital management may find comfort in the implementation of hierarchical systems of decision-making, this does not exonerate a medical professional from the independent duties they owe a patient.

The analogy is made to the case of a learner driver who must show the same standard of care as any other driver. Such an approach may cause some trepidation to medical students and junior doctors, however to proceed otherwise would be to frustrate the Hunter v Hanley test and the focus on ordinary skill and care. To continue the driving analogy: a formula one driver may be able to drive at speeds unimaginable to most, but they must also be able to correctly navigate a roundabout. A learner driver must be able to do the latter but they are not expected to, and would not be criticised for failing to, do the former.