A court in a medical negligence case has decided that non-clinical hospital staff, as well as the clinicians, owe a duty of care to patients. The case – which involved a patient attending at a hospital's A&E department - emphasises the wide interpretation the courts will apply to the duty of care in personal injury claims involving medical negligence.
A unanimous Supreme Court judgment (Darnley v Croydon Health Services NHS Trust [2018] UKSC 50) sets out that once a patient has presented at A&E requesting medical attention, part of the duty of care which non-medics owe to patients includes providing them with accurate information on waiting times.
The facts
Mr Darnley was assaulted by a blow to the head on the afternoon of 17 May 2010. Later that day he attended the A&E department at Mayday Hospital, Croydon with a worsening headache. On arrival Mr Darnley was advised by a receptionist that he may have to wait four or five hours before being seen. Mr Darnley said he couldn't wait that long, as he felt he was just about to collapse. The receptionist replied that if he were to collapse, that would be treated as an emergency.
In actual fact, the hospital's policy was for all head injury patients to be seen by the triage nurse within 30 minutes of their arrival at A&E. The information provided to Mr Darnley was wrong. He would have in fact been seen within the first half hour of his arrival.
Mr Darnley stayed at the hospital for just 19 minutes as he felt too unwell to stay, and wanted to go home to take some paracetamol. Less than an hour after leaving the hospital, Mr Darnley's condition deteriorated and he collapsed. He was transported by ambulance back to A&E at Mayfield Hospital where a CT scan identified a large extra-dural haematoma which required surgery. Mr Darnley was left with permanent brain damage as a result.
It was found that had the correct information been provided to Mr Darnley, he would have waited to be seen. Had Mr Darnley waited at reception and suffered his collapse in the hospital, he would have had his surgery hours earlier, and would have made a much better recovery.
The claim
Mr Darnley raised an action against the NHS Trust. He alleged that, firstly, the non-medical reception staff had breached their duty of care towards him by giving him wrong information about how long he would have to wait, and secondly, that he should have been seen by the triage nurse as a priority.
The court's decision
At the High Court, the judge found Mr Darnley did not present in such a way that should have made his case a priority for triage. The judge also held it would not be fair, just and reasonable to hold hospitals liable for the harm suffered as a result of reception staff failing to give the correct information to patients about waiting times. The court did say it was reasonably foreseeable that someone who believes there may be a wait of several hours before they are seen would leave. However, A&E receptionists do not have a duty to protect patients against the consequences of failing to wait to be seen. This was even where the harm could have been prevented by providing accurate information about waiting times.
Ultimately, the court decided that the link between the incorrect information and the harm Mr Darnley suffered was broken as it was his decision to leave the hospital.
On appeal, a majority of judges at the Court of Appeal dismissed Mr Darnley's appeal on the basis that (a) neither the reception staff nor the NHS Trust acting through the reception staff owed a duty to advise waiting times accurately, (b) the damage was outside the scope of any duty they did owe to Mr Darnley, and (c) by leaving the hospital on his own accord, Mr Darnley had broken the chain of causation between any breach of duty and the eventual injury.
The Court of Appeal were concerned that if they found in favour of Mr Darnley, a new head of liability for NHS Trusts would be created, and that there could be unwanted social consequences.
The Supreme Court
i) Duty of Care
The Supreme Court upheld Mr Darnley's appeal.
The judges said the Court of Appeal's approach to duty of care was flawed. There was no basis in law for the idea that this would be a new type of liability for NHS Trusts. The court referred to previous cases that conclude casualty departments have the duty to take reasonable care not to cause physical injury to the patient. As soon as Mr Darnley had checked into A&E, the relationship of patient and health care provider had been established: this is a distinct and recognisable situation in which a duty of care arises. The Court referred to a similar case, involving an ambulance provider who had been liable for injuries suffered by a patient as a result of actions taken after having been erroneously assured by the clerical call handler that they would wait only a short time for an ambulance.
The court held that the NHS Trust's duty of care should be considered holistically: it is not appropriate to distinguish between medical and non-medical staff when considering the duty of care owed. The NHS Trust had delegated responsibility for providing accurate information to its reception staff, and they should carry out that role with reasonable skill and care.
ii) Causation
The Supreme Court said that the Court of Appeal had also erred in its reasoning on the point of causation. The Court of Appeal had set out that Mr Darnley should take responsibility for his own actions, and in doing so the court had failed to consider the effect of the incorrect information on his decisions. Their decision had been incompatible with the findings of fact in the case. Given it was reasonably foreseeable that a patient provided with the incorrect information as to waiting times would leave the hospital, and this decision was made on the basis of inaccurate information provided by the NHS Trust, the Supreme Court decided Mr Darnley's decision to leave the hospital did not break the chain of causation.
Conclusion
This case emphasises the wide interpretation the courts will apply to include every staff member working for an NHS Trust and providing patient care when assessing a breach of the duty of care. This decision will likely encourage clearer guidelines on waiting times, provision of relevant paperwork to patients upon arrival at hospital and further training of non-medical and medical staff alike within the NHS.
It also has the potential to go beyond the A&E receptionist and include those working in GP Practices as well as other health care facilities who, although not providing medical care, are providing information to patients that could impact upon a medical condition.
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