Crammond v Medway NHS Foundation Trust

In assessing breach of duty in a busy accident and emergency department, the court must consider the operational context and the information reasonably available to the clinician. Triage does not require an exhaustive diagnosis, but an accident and emergency doctor must obtain sufficient history and information before deciding to stream a patient with potentially cardiac chest pain to a same day treatment centre. A normal ECG does not, without more, justify that decision. Where the presentation is suggestive of acute coronary syndrome, relevant history, risk factors and further investigations may be required before streaming is reasonable.

The claimant brought a claim for personal injury and consequential loss arising from treatment at Medway Maritime Hospital in January 2006. After presenting to the accident and emergency department with chest pain, he was assessed by a triage nurse and underwent an essentially normal ECG. An unidentified accident and emergency doctor decided that he should be streamed to a nearby same day treatment centre, where a general practitioner diagnosed gastritis.

In 2010 the claimant was diagnosed with cardiac failure and suffered an ischaemic stroke. The central issue was whether the accident and emergency doctor acted negligently by streaming him without taking a fuller history, identifying cardiac risk factors or arranging immediate investigation.

1. Judgment for the claimant. The claimant’s symptoms, including central chest pain radiating to both arms, were highly suggestive of acute coronary syndrome. The court accepted that symptoms vary between patients and that the whole clinical picture must be considered.

2. The triage nurse acted reasonably. Her role was to obtain a short history and follow the recognised procedure; it was not her responsibility to decide whether the claimant should remain in the accident and emergency department or be streamed.

3. The context identified in Mulholland v Medway NHS Foundation Trust [2015] EWHC 268 (QB) was relevant. Triage in a busy department involves a quick judgment about where the patient should next be seen, rather than an exhaustive diagnosis. That context did not relieve the accident and emergency doctor of the obligation to obtain sufficient information.

4. The doctor attached too much weight to the essentially normal ECG, which all experts regarded as a limited diagnostic tool. A competent doctor would have taken an appropriate history, identified significant risk factors and arranged immediate tests. The decision to stream the claimant without obtaining that information was negligent.

5. The court applied the standard in Bolam v Friern Hospital Management Committee [1957]. On the evidence, no reasonable accident and emergency doctor would have streamed the claimant in the circumstances. Admission and appropriate testing would probably have identified the existing cardiac disease, and timely intervention would have avoided the later severe cardiac difficulties.

6. Streaming to the same day treatment centre was not equivalent to discharge home, but that fact did not answer the breach finding because the claimant required immediate assessment. Judgment was entered for the claimant.

First-instance judgment; no prior appellate decision is stated in the judgment.