Prehospital Care: Clinical Negligence in Ambulance Service Practice Dr Tim Kilner Senior Lecturer in Paramedic Science Expert Witness in Ambulance and Paramedic Practice Medico-Legal Issues in Emergency Medicine Conference | Dublin | 15 May 2019
When is a paramedic not a paramedic? • RoI • ESW • Intermediate Care Operative • Emergency Care Assistant • Emergency Medical Technician • Student Paramedic • Student Paramedic • Autonomous EMT at threshold • Observer • Emergency Medical Technician • Internship • Registered Paramedic • Paramedic • Critical Care Paramedic • Advanced Paramedic • Community Paramedic • Advanced Paramedic • Specialist Paramedic • Consultant Paramedic
Guidelines
Shared accountability • Shared accountability … or finding someone else to blame. • Duty does not transfer, it duplicates
Patient refusal ‘The patient declined/refused treatment and/or transportation’ ‘The patient took their own discharge’ ‘The patient or their relative signed the disclaimer form’
Disposition decisions • Discharging patients on scene • Persuasion is ‘easy’, doing it safely is infinitely more difficult. • Disclaimer • Adequately informed? • Informed choice • Capacity • Duty to provide adequate information • Safety net • Montgomery v Lanarkshire Health Board • ‘If worried call back’ [2015] SC 11 [2015] 1 AC 1430. • Who? • In what circumstances? • What should they do?
Diagnosis by inclusion • Formulating a diagnosis • Some themes; • Sticking with it at the expense of alternative explanations • Alcohol and alcohol dependence • Age eg. ‘not old enough to have • Constructing the history and heart disease/stroke’ assessment around an assumed diagnosis or explanation • D&V ‘is gastroenteritis’ • Not excluding or being unable to • Reported pain intensity is not actual pain intensity exclude important alternative explanations
History & examination • Narrow focus (assumed diagnosis) • Incomplete • Omission of pertinent negatives • Lack of reasoning • Conflation of history and examination
Clinical records • Sequence of events & timing • Unqualified statements • ‘FROM’ • ‘Has capacity’ • Multiple clinicians • ‘PEEFR within normal limits’ • ‘NAD’ • Mismatch between clinical record and statements • ‘If it isn’t written down it didn’t happen’ • Proximity to events • Not necessarily ... but may be difficult to mount a defense.
Are delays or long response times a breach of duty? ‘… once there are available, both in the form of an ambulance and in the form of manpower, the resources to provide an ambulance on which there are no alternative demands, the ambulance service would be acting perversely ... if it did not make those resources available.’ Lord Woolfe Kent v Griffiths and Others [2000] 2 WLR 1158
Questions Dr Tim Kilner | expert@tmkconsultancy.co.uk
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