Mulholland v Medway NHS Foundation Trust

The standard of care in a busy A&E department must reflect its time pressures and collective decision-making structure. A triage nurse is ordinarily required to assess symptoms sufficiently to stream the patient, not to make a full diagnosis. An A&E doctor may ordinarily rely on the assessment of other competent professionals, including a specialist stroke team, unless that assessment is obviously wrong. The doctor is not required to identify every specialised possible diagnosis or investigate illicit drug supply in detail. Where symptoms are confusing and non-specific, a provisional drug-related impression, coupled with advice to abstain and obtain prompt general-practitioner review, may be reasonable. Negligence was not established merely because the patient was later found to have a serious neurological condition.

The claimant developed symptoms caused by an undiagnosed brain tumour. He attended the defendant’s A&E department on 11 and 12 January 2010. On the first occasion, a triage nurse streamed him to a hospital GP, who attributed the symptoms to anxiety or cannabis use. On the second occasion, ambulance staff recorded right-sided weakness and the claimant was assessed by a specialist stroke team, which found that the presentation was not suggestive of TIA or CVA. An A&E doctor then conducted a neurological assessment, considered the symptoms likely to be cannabis-related, discussed the case with a Registrar, and discharged the claimant with advice to stop cannabis and consult his GP if symptoms persisted.

The claimant alleged that the defendant was negligent in failing to make an urgent neurological referral or arrange a CT scan, and in failing to investigate his drug history more fully. The claim concerning the triage nurse was abandoned during the trial.

1. Disposition. The claim was dismissed. The claimant failed to establish breach of duty by either the triage nurse or the A&E doctor.
2. Triage. In a busy A&E department, a triage nurse’s function is ordinarily to take a limited history, record symptoms and perform the assessment needed to decide the appropriate care pathway. The nurse is not required to make the full diagnosis which is the responsibility of the doctor or specialist to whom the patient is streamed. Following a negative FAST test, referral to a hospital GP rather than the stroke team was reasonable.
3. Reliance on other professionals. An A&E doctor may prima facie rely on previous assessments, including a specialist stroke-team assessment, and on advice from a Registrar. That reliance is not blind or slavish. If the earlier assessment is obviously wrong, the doctor may need to verify and correct it. This was not such a case: the symptoms were confusing and non-textbook, and the specialist assessment was not challenged as negligent.
4. Clinical judgment in A&E. The standard of care must reflect the time constraints and practical conditions of emergency medicine. The doctor was not negligent for failing to identify a specialised possibility such as a Jacksonian seizure. The mixed symptoms, cannabis history, hallucinations, anxiety and spasms provided a reasonable basis for treating cannabis use as a possible cause, particularly because drug use could mask other symptoms.
5. Drug history and provisional diagnosis. The doctor was not required to investigate drug supply arrangements or obtain more detailed information than she had concerning the claimant’s long-term use, frequency, strength and recent consumption. Her conclusion was provisional. Advising abstinence for three days, followed by GP review if symptoms persisted, was a reasonable care pathway. The evidence did not establish the combination of clear non-drug causation, a clearly neurological condition and such urgency that immediate specialist referral or CT scanning was required.
6. Expert evidence and causation. The court applied the Bolam and Bolitho principles. A responsible body of expert opinion is important, but the court must assess the opinion itself, including its logic and consistency with the evidence. The court’s observations on causation were unnecessary to the result. Had breach been established, some loss of medical advantage from later surgery might have been compensable, but the alleged post-operative deficits were not shown to result from the delay.