Henderson v The Hillingdon Hospital NHS Foundation Trust

A clinician assessing whether to discharge a patient must consider the totality of the available clinical information, including pre-hospital records and the presenting history. A temporary improvement after short-acting treatment does not, without more, establish that a patient is safe to discharge where the initial presentation involved life-threatening respiratory failure or distress. Expert opinion must represent a responsible body of medical opinion and withstand logical analysis. The court must assess that issue itself and prospectively, without hindsight. Where the cause of a serious episode remains inadequately explained and there is a significant risk of recurrence, inpatient admission and monitoring may be required.

The claimant brought a fatal clinical negligence claim as administratrix of Dennis Robert Bolton’s estate and on behalf of his dependants under the Law Reform (Miscellaneous Provisions) Act 1934 and the Fatal Accidents Act 1976. Mr Bolton attended the defendant’s emergency department after paramedics recorded respiratory distress, hypoxia, wheeze and respiratory failure. His condition improved after nebulised Salbutamol and oxygen. He was discharged with antibiotics but suffered fatal airway obstruction and cardiac arrest several hours later.

Quantum was agreed at £75,000, subject to liability, and causation was conceded if admission would have occurred. The central issue was whether the defendant breached its duty by failing to admit and monitor Mr Bolton, and by discharging him when it did.

1. Applicable standard. The court applied the Bolam test: the clinician had to act in accordance with a responsible body of medical opinion. Under Bolitho, the court had to determine for itself whether the opinion relied upon was responsible and capable of withstanding logical analysis. The assessment had to be made prospectively, without the benefit of hindsight.
2. Clinical information and diagnosis. The relevant history included the Patient Report Form, triage records and observations before hospital assessment. The most significant features were the life-threatening respiratory distress and respiratory failure, wheeze, abnormal oxygen saturations and dramatic improvement after Salbutamol. Neither pharyngitis nor a lower respiratory tract infection adequately explained the total presentation. The appropriate clinical concept was reversible airways disease or a reversible airways episode, regardless of whether the precise label was asthma or COPD.
3. Failure to assess risk. The judge found that Dr Rosales had not taken the pre-hospital and triage information into account. His assessment and diagnosis were therefore inadequate. A single oxygen saturation reading of 95 per cent on air did not establish stabilisation, particularly where the duration and effect of monitoring were unclear and Salbutamol had a short duration of action. The risk of recurrent deterioration had to be considered against discharge, especially because the treatment could not be administered at home.
4. Conclusion. The responsible and logical assessment required admission, observation, monitoring and treatment if deterioration occurred. Mr Bolton met the criteria for being kept in hospital. The defendant was in breach of duty because he was discharged rather than admitted. Judgment was entered for the claimant in the agreed sum of £75,000.