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Lack of objective assessment and communication to hospital staff (99HDC02269)

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(99HDC02269, 12 July 2000)

Ambulance officer ~ Senior house officer ~ Emergency Department ~ Standard of care ~ Professional standards ~ Communication ~ Back pain ~ Septicaemia ~ Rights 4(1), 4(2), 4(5)

A woman complained that ambulance staff failed to treat her partner with appropriate respect when attending him at his home, and did not pass on to the hospital information she provided to them about her partner's condition, instead advising the hospital that his condition was psychosomatic. In addition, she complained that medical staff at the hospital failed to appropriately examine him and diagnose his systemic illness.

The 47-year-old man awoke with severe back pain, which intensified during the course of the day. He took Voltaren to ease the pain, and several hours later began vomiting and complained to his partner that he was feeling hot. His feverish symptoms continued throughout the night, and he lost control of his bowels. His partner telephoned an ambulance, and informed one of the officers of her partner's symptoms. The officer noted that the man was having difficulty getting comfortable but did not appear to be in pain. He appeared lucid and alert but seemed to avoid answering questions, and the officer wondered whether there might be an emotional element to the problem. The officer decided to transport the man to the Accident and Emergency Department at a nearby hospital. On arrival, the officer spoke to two nurses and passed on his report, which stated "Back pain/?Psychosomatic", described the patient's history, and commented that he was "making the most of the situation (hard to tell if genuine)".

A senior house officer examined the man and diagnosed a muscular strain and muscular spasms of the back. He was administered Voltaren, pethidine and Maxolon, which provided some relief, although he still complained of back pain. The house officer asked whether he felt well enough to return home, and the man agreed that he could. He was able to walk to the taxi himself, but his partner reported that when he arrived home he required assistance, and felt that his condition had been "dismissed" at the hospital. Shortly after arriving home he collapsed and was unable to be revived. A pathology report concluded that the man died of septicaemia, and suggested that the portal of entry may have been a wound noted on his left forearm.

It was held that the ambulance officer breached Right 4(2) in inappropriately forming an early opinion that the man's condition was psychosomatic. The officer's assumption interfered with his ability to assess the man in an objective and professional manner, and may have contributed to him playing down or negating the information provided by the man's partner - information that was vital in providing clues to the systemic nature of the problem. Further, in recording his subjective judgement on the patient report form, he may have contributed to medical and nursing staff providing less than satisfactory treatment.

The ambulance officer was also held to have breached Right 4(5) in not ensuring continuity of care in his handover to Emergency Department staff. Staff were not sufficiently informed of the man's clinical signs and symptoms, such as his hypothermia, low blood pressure, and his agitation and confusion, and there was inadequate reference to these symptoms on his report form.

The senior house officer was held to have breached Right 4(1) in failing to properly examine, diagnose and treat the man. She targeted her examination to the man's main complaint (his back) and failed to undertake a systems review and a general physical review. Given the atypical nature of the man's presentation, such an examination would have been appropriate to exclude other possible causes for his back pain. In addition, having been given pethidine for pain relief, the patient should have been observed, monitored and reassessed prior to discharge.