This question came from regular correspondent, Dodge, who asks for my ‘…input into this article that has appeared in the UK press – Ian Johnston, ‘Ambulance staff told to leave patients at A&E departments if they have not been admitted after 45 minutes’, The Independent (Online) 18 January 2015.
To my way of thinking if something went wrong and the receiving hospital was not willing to accept care for whatever reason would this be considered abandonment and if anything happened to the patient who would be held responsible.
The question of ‘abandonment’ has come up in an earlier post (see Physical restraint of patients by paramedics (February 14, 2014)). I said there:
Abandonment is not a term that I am familiar with in Australian law but I have heard of it in US law (see Curt Varone, Fire Law Blog: Abandonment Issue Raised in Asiana Crash Case) but even there it does not sound like a well accepted principle.
‘Abandonment’ is still not a term that arises in Australian law so I will address this question based on the principles of negligence law and as if this article were referring to Australia rather than the UK.
Let me assume that in any case a patient is seen by the relevant triage nurse or other health professional. I assume that where the paramedics arrive at hospital with a patient in cardiac arrest or needing urgent resuscitation they are not left for 45 minutes. If they are that is a bigger issue for the health service and not one I’m addressing here. I assume here that the person is seen and having determined their injuries are not life threatening they are then left on the ambulance bed in the company of the treating paramedics. If that’s the case then one has to ask both ‘what is the reasonable response’ and ‘what is the professional role of paramedics?’
If paramedics are unskilled automatons, whose only job is to provide care in accordance with pre-set protocols but to exercise no judgement, then it may be appropriate to require them to wait until a real health professional can take over. But surely that is not the case.
If paramedics are members of the professional health team then they can and should be able to make informed clinical decisions (for a related discussion see‘Transport everyone or act as a professional? A question for paramedics’ (6 May 2013) and ‘Do paramedics have to transport everyone?‘ (February 3, 2014)). So the first decision they need to make is are they, by their presence, advancing the patient’s interests in a clinically significant way. If, for example, the patient is being given IV medication, is being monitored and will get worse if they are left alone, then it would seem reasonable for the paramedics to stay and continue to provide that care. If, on the other hand, the person fell during sport and has been transported as there is a question mark over whether they have sprained or fractured their ankle, then one might make a clinical decision that they could wait on the waiting room chairs as well as on the stretcher and they don’t need a paramedic to talk to them and bring them a cup of tea, when other patients who have made their own way to hospital do not get such a service. In that case it may be reasonable to put the patient on the chair, let the triage nurse know and go.
The question is always about duty and what does one’s duty require. A paramedic owes a duty of care to the person in their care, the ambulance service may owe a duty of care to a person that then rings triple zero but individual paramedics do not. How the reasonable ambulance service responds to that call requires consideration of the resources available, no emergency service can be resourced to meet every contingency so there will be occasions where demand exceeds supply. What this means is that there is a certain amount of ‘first come first served’. Where a person is being treated by a paramedic that paramedic has a duty to act in their interest. They cannot just leave them because other people are ringing for an ambulance. There is no way of knowing whether the next patient is in a worse, or better, condition than the patient already being treated.
Because of that I would suggest that a blanket rule – leave your patient after 45 minutes, could not be reasonable. But a rule that says ‘you can leave your patient at the hospital if there is no value in staying in order to reasonably free up resources for others’ would be fine.
Naturally any ambulance service that wanted to implement such a rule would need, as always, to think about in what circumstances is it ok to leave the person and that, in turn requires a risk assessment (see Wyong Shire v Shirt (1980) 146 CLR 40 (Mason J)). Questions like what might happen if they are left? How likely is any adverse event? (And remember we’re talking about a person being left in a hospital and presumably the hospital has some system in place to reassess a triage assessment of people waiting in the waiting room). What are the conflicting obligations? (This raises the obligations to others who need an ambulance).
To answer the question ‘if anything happened to the patient who would be held responsible?’ requires consideration of what it is that happens and who could do something about it. If the person is left in reasonable condition but then deteriorates then the issue would also be, as it would be with anyone who is waiting but gets worse, what system did the hospital have in place to monitor people before they get seen and to reassess their triage? If the issue is that the person needs paramedic care and the delay is because there is a high demand on the hospital’s resources, then the issue will be that the person approached the health system that started their care, and one part of the health system (the ambulance service) can’t abandon them because another part (the hospital) is busy, or worse, to make the political point that A&E departments are overwhelmed or inefficient.
The tort of abandonment is not part of Australian law. The issue will be judged by the law of negligence. A rule that says ‘leave your patient after 45 minutes’ could not meet the test of ‘reasonableness’ required by law as it in no way invites consideration of the particular circumstances. A rule that says patient’s may be left in particular circumstances and identifies issues of risk and clinical practice, could well be ‘reasonable’.
Who would be responsible if something went wrong would, as it always must, depend on the facts and what it is that went wrong. An adverse event however does not prove negligence even if the risk of that event was foreseen.