Accident & emergency negligence
Negligence in the area of A&E or emergency medicine is a growing problem in Ireland.
Between the years of 2010 and 2014 the number of reported ‘clinical incidents’ in emergency medicine rose by over 50%. The term ‘clinical incident’ is used by our health service to describe when things go wrong in public hospitals. This cold term can mask the devastating nature of the injuries that often result from from such clinical incidents - some of which will be entirely avoidable and due to negligence.
Emergency medicine is one of the most common specialities likely to give rise to a medical negligence case against the State.
This article provides an overview of some of the most common issues in our experience that have arisen in the context of emergency medicine negligence.
Between the years of 2010 and 2014 the number of reported ‘clinical incidents’ in emergency medicine rose by over 50%. The term ‘clinical incident’ is used by our health service to describe when things go wrong in public hospitals. This cold term can mask the devastating nature of the injuries that often result from from such clinical incidents - some of which will be entirely avoidable and due to negligence.
Emergency medicine is one of the most common specialities likely to give rise to a medical negligence case against the State.
This article provides an overview of some of the most common issues in our experience that have arisen in the context of emergency medicine negligence.
- The first part of this article discusses the setting in which emergency medicine takes place and the typical complaints that patients present with.
- The second part of the article below talks about the typical process when a patient presents to a hospital accident and emergency department.
- The third part of the article looks at the situations in which emergency medicine negligence typically arises.
- We then turn to a discussion of the types of injury or damage that can result from such negligent treatment.
- At the conclusion of the article, we illustrate the process of assisting victims of this negligence with a case study. The case study sets out the timeline of a recent case from its commencement up to the time of its successful conclusion.
1. Accident & Emergency negligence: the typical setting and presenting complaints
Emergency medicine is the medical speciality concerned with the care of acutely ill or injured patients who need immediate medical attention.
Various healthcare professionals work under the umbrella of emergency medicine, including doctors, nurses, psychiatric nurses and paramedics.
The practice of emergency medicine may take place in a number of different settings, such as emergency medical response vehicles, at accident sites, via telemedicine and most typically in accident and emergency departments in hospitals, often referred to as ‘A & E’.
Patients with acute illness or injury can present to A & E around the clock and across the age spectrum.
Patients may arrive to A & E departments by ambulance or make their own way, as a walk-in, with or without a GP referral or an appointment.
Patients typically present in an emergency setting with a broad range of complaints:
Various healthcare professionals work under the umbrella of emergency medicine, including doctors, nurses, psychiatric nurses and paramedics.
The practice of emergency medicine may take place in a number of different settings, such as emergency medical response vehicles, at accident sites, via telemedicine and most typically in accident and emergency departments in hospitals, often referred to as ‘A & E’.
Patients with acute illness or injury can present to A & E around the clock and across the age spectrum.
Patients may arrive to A & E departments by ambulance or make their own way, as a walk-in, with or without a GP referral or an appointment.
Patients typically present in an emergency setting with a broad range of complaints:
- Loss of consciousness;
- Headaches;
- Altered vision or loss of sight;
- Eye injuries;
- Aneurysms;
- Wounds, bites and abscesses;
- Seizures or convulsions;
- Chest pain;
- Rash;
- Dislocated joints or fractures;
- Breathing difficulties;
- Bleeding;
- Allergic reactions;
- Burns or scalds; and
- Major trauma (serious life-threatening or disabling injury).
2. The normal process when a patient presents to A & E
Generally, there are various stages to the care received by patients in A & E departments, broken down as follows:
Reception: A set of medical records is assembled and an identification bracelet is provided.
Triage: This is the process of determining the priority of a patient’s treatment by the severity of their condition. The first stage on arrival at the emergency department is assessment by a hospital triage nurse. The patient is given a priority rating and the nurse will assess whether pain relief is required. Patients who arrive by ambulance are taken to a receiving bay and will be triaged from there.
Treatment: Following triage, patients may be seen by a doctor and referred for treatment such diagnostic testing, lab tests, blood and urine analysis, ultrasound, CT or MRI. Appropriate medication may be needed. Prompt treatment, such as suturing for lacerations may be required. The patient may be admitted to hospital for treatment by specialists or for urgent treatment, referred to another hospital or a GP, given an appointment to attend a clinic at a later date, or simply sent home (discharged).
Chest pain: Patients attending an A & E department with chest pain will be evaluated by an emergency department consultant, sometimes with input from a cardiology advanced nurse practitioner and usually with direct access to cardiology team on call.
Resuscitation: For critically ill patients, this is a key area in most A & E departments. It contains all of the equipment needed to treat immediately life-threatening illnesses and injuries and is staffed by specialists.
Reception: A set of medical records is assembled and an identification bracelet is provided.
Triage: This is the process of determining the priority of a patient’s treatment by the severity of their condition. The first stage on arrival at the emergency department is assessment by a hospital triage nurse. The patient is given a priority rating and the nurse will assess whether pain relief is required. Patients who arrive by ambulance are taken to a receiving bay and will be triaged from there.
Treatment: Following triage, patients may be seen by a doctor and referred for treatment such diagnostic testing, lab tests, blood and urine analysis, ultrasound, CT or MRI. Appropriate medication may be needed. Prompt treatment, such as suturing for lacerations may be required. The patient may be admitted to hospital for treatment by specialists or for urgent treatment, referred to another hospital or a GP, given an appointment to attend a clinic at a later date, or simply sent home (discharged).
Chest pain: Patients attending an A & E department with chest pain will be evaluated by an emergency department consultant, sometimes with input from a cardiology advanced nurse practitioner and usually with direct access to cardiology team on call.
Resuscitation: For critically ill patients, this is a key area in most A & E departments. It contains all of the equipment needed to treat immediately life-threatening illnesses and injuries and is staffed by specialists.
3. Situations in which negligence in emergency medicine typically arises:
Medical negligence occurs where the care a patient receives has fallen below an acceptable standard and they have suffered injury as a result.
There are articles elsewhere on this website which explain in more detail the ‘test’ applied by the Courts for determining whether the medical negligence has occurred [link].
Of the legal cases arising from A & E negligence that were settled by the State in recent years, more than half were diagnosis related. The vast majority of these cases related to failure to diagnose, delay in diagnosis or failure to treat. Of these negligent diagnoses, three quarters were fracture and musculo-skeletal injury related.
Patients attending A & E are most often seen for assessment by junior doctors. Senior House Officers (SHOs) are the grade of doctor most likely to be involved in an instance of medical negligence in the emergency setting. SHOs rank below Consultants and Registrars in the hierarchy of clinicians.
According to the State Authorities, the most common types of negligence in the emergency medicine setting include:
There are articles elsewhere on this website which explain in more detail the ‘test’ applied by the Courts for determining whether the medical negligence has occurred [link].
Of the legal cases arising from A & E negligence that were settled by the State in recent years, more than half were diagnosis related. The vast majority of these cases related to failure to diagnose, delay in diagnosis or failure to treat. Of these negligent diagnoses, three quarters were fracture and musculo-skeletal injury related.
Patients attending A & E are most often seen for assessment by junior doctors. Senior House Officers (SHOs) are the grade of doctor most likely to be involved in an instance of medical negligence in the emergency setting. SHOs rank below Consultants and Registrars in the hierarchy of clinicians.
According to the State Authorities, the most common types of negligence in the emergency medicine setting include:
- Foreign body left in situ;
- Failure / difficulty performing a procedure;
- Unexpected complications during a procedure;
- Incorrect data (mix up of patient identity or records)
- Allergic reaction to a known allergen.
- Failure to check a patient’s medical history properly;
- Premature discharge from hospital;
- Discharging a patient without proper treatment, referral or advice about what to do if their condition continues or deteriorates;
- Failure by a junior doctor to seek assistance of senior or specialist doctor;
- Failure to recognise an acute condition such as appendicitis or meningitis;
- Negligently misdiagnosis of cardiac event, stroke or embolism.
4. The types of adverse outcomes which arise in cases of surgical negligence:
Surgical negligence may give rise to devastating, life altering injuries and catastrophic outcomes, such as:
- Amputation;
- Paralysis;
- Organ damage;
- Reduced heart function;
- Pain;
- Brain damage;
- Prolonged in-patient hospital stay, possibly in intensive care;
- May require a lifetime of surveillance and a lifetime of follow up due to the possibility of late, life threatening complications for the rest of life;
- Psychological trauma, stress and distress, post-traumatic stress disorder, sleep disturbance, clinical depression, a risk of further more serious psychological illness in future, poor concentration and memory, lack of libido and the patient may require anti-depressants, sleeping pills or other medication and counselling;
- Inability to return to full time work or at all;
- Inability to care for children or dependents; and
- Loss of life expectancy.
5. Accident and emergency negligence - Case Study:In this section, we set out a case study of the journey of a typical victim of negligence in the Accident & Emergency Department.
This case study involves our client who is a child and suffered horrific injuries arising from a delay in diagnosing acute appendicitis. She had been referred by her GP to the A & E department in her local hospital with abdominal pain in the peri-umbilical area (behind her bellybutton). The A & E doctor incorrectly made a diagnosis of a respiratory tract infection and sent her home with advice to take antibiotics and child’s cough bottle. Following discharge, her symptoms of abdominal pain worsened. She was readmitted to A & E a couple of days later and upon diagnosis with appendicitis required an open appendectomy. Her appendix had ruptured by this time and the surgery was a much more serious operation than ought to have been required. She required intravenous antibiotics and a period of convalescence in a specialist children’s hospital unit, before being discharged back to her local hospital. She suffered severe, puckered scarring. She later learned that she was at risk of complications later in her life, including bowel obstruction. She was also subsequently advised that she had been left with a significantly elevated risk of infertility due to the prolonged period of time that her reproductive organs had been exposed to a toxic infective abnormal environment. Drains were required. |
Her father contacted our office as he was concerned that his daughter had been left with such a poor outcome. We obtained a copy of her medical records and asked a leading, independent, UK based expert to review the records and give an assessment of what had gone wrong and what the effect had been on her outcome.
Although we instruct the expert to assist us in our investigations, it must be stressed that the expert’s primary duty is to assist the Court and to provide an unbiased, independent opinion. Many of our clients take comfort in having their suspicions vindicated by an independent review of their circumstances, finding this acknowledgment to be an important part of the healing process. They will often have been told by their treating doctors that nothing untoward occurred and that there was no negligence.
The UK expert in this case reported that there had been failures of care during the initial attendance in A & E.
The expert criticised the failure recognise the classic presentation of early acute appendicitis.
The expert criticised the failure to arrange an ultrasound scan or refer her to the surgical team on call.
The expert concluded that if the appropriate care had been provided during the initial attendance at A & E, then the patient would most likely have had less invasive, keyhole surgery rather than open surgery and she would have avoided the complications that she had suffered. The rupture of the appendix was entirely avoidable.
Having learned that his daughter had suffered a complexly avoidable injury, our client instructed us to sue the responsible parties in the High Court. This involves preparing a document which sets out what happened and lists out all the errors made by the hospital and the effect this had on the patient’s outcome.
This case was filed with the High Court, formally commencing the process against the defendants, the treating surgeon and hospital. Although they eventually conceded that the surgery had been negligent, they still fought the case on the grounds that they denied that the outcome had been caused by the negligent surgery.
It is quite common for defendants in cases like this to deny culpability by insisting that the patient would have ended up in a bad way, regardless of any wrongdoing on their part.
In total, seven expert reports were obtained by our office, to ensure that no stone was left unturned in investigating the case. This included including reports which quantified the cost of future treatment, such as treatment to improve the appearance of the scar.
Shortly before the trial was due to commence in the High Court the case settled for a substantial six figure sum. Most cases settle on the day of the hearing or shortly after that.
The hospital also apologised to our client, stating that the staff were truly sorry. Many clients find that an apology can be helpful in enabling them to move on.
The defendant’s insurers were also required to pay all of our client’s legal costs, in addition to the settlement sum.
Although we instruct the expert to assist us in our investigations, it must be stressed that the expert’s primary duty is to assist the Court and to provide an unbiased, independent opinion. Many of our clients take comfort in having their suspicions vindicated by an independent review of their circumstances, finding this acknowledgment to be an important part of the healing process. They will often have been told by their treating doctors that nothing untoward occurred and that there was no negligence.
The UK expert in this case reported that there had been failures of care during the initial attendance in A & E.
The expert criticised the failure recognise the classic presentation of early acute appendicitis.
The expert criticised the failure to arrange an ultrasound scan or refer her to the surgical team on call.
The expert concluded that if the appropriate care had been provided during the initial attendance at A & E, then the patient would most likely have had less invasive, keyhole surgery rather than open surgery and she would have avoided the complications that she had suffered. The rupture of the appendix was entirely avoidable.
Having learned that his daughter had suffered a complexly avoidable injury, our client instructed us to sue the responsible parties in the High Court. This involves preparing a document which sets out what happened and lists out all the errors made by the hospital and the effect this had on the patient’s outcome.
This case was filed with the High Court, formally commencing the process against the defendants, the treating surgeon and hospital. Although they eventually conceded that the surgery had been negligent, they still fought the case on the grounds that they denied that the outcome had been caused by the negligent surgery.
It is quite common for defendants in cases like this to deny culpability by insisting that the patient would have ended up in a bad way, regardless of any wrongdoing on their part.
In total, seven expert reports were obtained by our office, to ensure that no stone was left unturned in investigating the case. This included including reports which quantified the cost of future treatment, such as treatment to improve the appearance of the scar.
Shortly before the trial was due to commence in the High Court the case settled for a substantial six figure sum. Most cases settle on the day of the hearing or shortly after that.
The hospital also apologised to our client, stating that the staff were truly sorry. Many clients find that an apology can be helpful in enabling them to move on.
The defendant’s insurers were also required to pay all of our client’s legal costs, in addition to the settlement sum.
LocationIndaville, Boherclogh, Cashel, Co. Tipperary, E25 V448
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