Jaciubek v Gulati & Anor

Clinical negligence is assessed against the information reasonably available to the practitioner at the time, not with hindsight. A sudden, severe headache, particularly one reaching maximum intensity rapidly and accompanied by relevant symptoms, may be a warning sign requiring further investigation. The court should, however, avoid rigid distinctions based on precise seconds and minutes. A triage nurse makes a rapid judgment about where the patient should next be sent; the nurse’s brief notes should not be subjected to the same detailed analysis as a full clinical consultation. Even if triage was negligent, liability requires proof that the error had causative significance. Where the patient’s presentation did not reliably disclose the relevant warning signs, and the evidence did not establish that further questioning or a more senior clinician would probably have led to investigation, the negligence claim fails.

The claimant alleged that Dr Rajeev Gulati, a general practitioner, Dr Karen Shepherd, an A&E doctor, and Mr Timmy O’Donoghue, an emergency-department triage nurse, negligently failed to recognise symptoms of subarachnoid haemorrhage or arrange further investigation. She had experienced episodes of headache, neck pain and other symptoms in June and July 2010, and suffered a serious subarachnoid haemorrhage in Canada on 9 July 2010.

The claim concerned liability only. The claimant contended that proper history-taking would have revealed sudden severe headaches and other warning signs requiring brain imaging. The defendants disputed what had been communicated and relied on the recorded presentations, examinations and the resolution of several symptoms by the time the claimant was assessed. The central questions were whether any defendant had acted below the required standard and, if so, whether that breach had caused a different outcome.

1. Claim dismissed. The claimant failed to establish that Dr Gulati, Dr Shepherd or Mr O’Donoghue had breached their duties of care.
2. A sudden onset of severe headache was the recognised warning sign requiring further investigation where an intracranial event could not be excluded. The court accepted that “sudden” should not be applied with an entirely rigid distinction between precise periods such as 60 and 75 seconds. Nevertheless, where the history reasonably suggested that the headache took materially longer to reach maximum intensity, the level of suspicion could properly be reduced.
3. The evidence did not establish that Dr Gulati had failed to ask about the speed of onset or had been told that the headache was instantaneous or developed within a minute or so. His recorded history suggested neck pain radiating into the head, an intense headache lasting several hours, vomiting and subsequent improvement. His examination was detailed, and the overall diagnosis was reasonably open to him on the presentation as he understood it.
4. Dr Shepherd was also likely to have asked about the headache and its onset. The evidence indicated that the claimant presented principally with recurring neck pain, while double vision and paraesthesia had resolved. The court was not satisfied that she had conveyed a sudden, severe headache on either occasion. The possible attribution of temporary double vision to cervical problems did not make the decision negligent where an intracranial cause had not reasonably been raised.
5. As to triage, the task was a rapid judgment about where the patient should next be sent. The court adopted the approach stated in Mullholland v Medway NHS Foundation Trust [2015] EWHC 268 (QB). Even if the claimant had been wrongly placed in the lowest priority category, the error would not have caused loss because a more senior clinician would not, on the balance of probabilities, have obtained a history leading to CT scanning.
6. The court’s overall assessment was reinforced by the claimant’s retrospective and inconsistent accounts, the absence of recorded warning signs in the records of several practitioners, and the possibility that the episodes involved small bleeds without the classical presentation of subarachnoid haemorrhage.