The standard of care: clinical judgment in paramedicine

02 September 2020

The High Court overturned the Queensland Court of Appeal’s finding that the State of Queensland was vicariously liable for an ambulance officer’s decision to administer salbutamol (instead of adrenaline) to a patient in respiratory arrest. The High Court found that the decision was not inconsistent with the relevant clinical practice manual and reflected a responsible body of professional opinion.

In Issue

The sole question in issue was whether the State, through the employed QAS paramedic, had breached its duty of care to the patient by failing to promptly administer adrenaline.

Our prior case note, detailing the QCA’s decision is available here: ‘State found liable on appeal for the negligence of a QAS officer’.

The background

Jennifer Masson was a chronic asthmatic. In July 2002 Ms Masson suffered a severe asthma attack. The QAS attended within minutes and found Ms Masson in respiratory arrest.

Four paramedics attended, including Mr Peters, an intensive care paramedic. Mr Peters assessed Ms Masson and found that in addition to being in respiratory arrest, her heart rate was about 150 beats per minute and she had extremely high blood pressure.

Mr Peters inserted an intravenous cannula and administered eight doses of salbutamol – a drug which facilitates breathing by dilating the bronchial passages. Ms Masson’s condition began to improve and transfer to Cairns Base Hospital was arranged.

During transfer to hospital, Ms Masson’s heart rate unexpectedly dropped to 40 beats per minute. Mr Peters administered IV adrenaline with limited effect. On presentation to hospital, Ms Masson was admitted to the intensive care unit.

Ms Masson suffered irreversible hypoxic brain damage and remained incapacitated until her death in 2016. Ms Masson’s Estate alleged that Ms Masson would not have suffered the same damage if adrenaline had been administered instead of salbutamol.

Damages were agreed at $3 million.

The decision at trial

The trial judge found that the treatment did not fall below the standard of care of an ordinary skilled intensive care paramedic. In particular, the decision by the paramedic to administer salbutamol instead of adrenaline was the result of an exercise of clinical judgment, and was supported by a responsible body of medical opinion.

No breach of duty was established and the claim failed.

Appeal to the Queensland Court of Appeal

Ms Masson’s Estate appealed to the Court of Appeal. Two issues were pressed on appeal: whether the ambulance officers ought to have administered adrenaline immediately, or at an earlier time; and whether the QAS provided adequate training and instruction to ambulance officers, and if not, whether this caused the officers’ failure to administer adrenaline at an earlier time.

The Court of Appeal Decision

The Court of Appeal found that administration of salbutamol did not accord with a flowchart in the QAS Clinical Practice Manual (CPM), which instructed paramedics to “consider adrenaline” in the relevant circumstances. The Court of Appeal concluded that the decision to administer salbutamol did not meet the standard of care.

The Court of Appeal relevantly rejected the trial judge’s finding that there was a relevant body of medical opinion supporting the administration of salbutamol on the basis that the evidence that Mr Peters made a clinical judgment based on that body of opinion was not compelling. The Court of Appeal found that the QAS was vicariously liable for the conduct of Mr Peters and, because the CPM set out a reasonable standard of care, not directly liable for any negligence in respect of training and instructing Mr Peters.

Appeal to the HCA

The issues before the High Court, on appeal by the State, were whether the ambulance officers’ decision to administer salbutamol was a clinical judgment and whether the exercise of clinical judgment was consistent with the standard of care expected of a paramedic in 2002.

The HCA’s decision

The majority judgment (Kiefel CJ, Bell and Keane JJ) resolved those issues as follows:

  • An appellate court must respect the advantages of a trial judge when considering witness evidence. The trial judge’s finding that the paramedic made a clinical judgment was neither contrary to compelling inferences nor glaringly improbable and should not have been overturned.
  • The paramedic’s judgment was that the administration of adrenaline was not appropriate because the patient was hypertensive and tachycardic. This was based on his training and all of the components of the CPM.
  • The flowchart in the CPM should not be treated as though it was a statute or legal document. The CPM was intended to guide and assist paramedics, rather than to prescribe decision-making.
  • A decision which is different to that recommended by the CPM but supported by a responsible body of opinion will not necessary fall below the standard of care expected of a skilled paramedic.

In separate reasons, Nettle and Gordon JJ came to the same conclusions. Notably, their Honours concluded:

‘the fact that the majority of specialist emergency practitioners may have chosen adrenaline from the outset does not mean the that the minority who would have chosen salbutamol as a first preference would have been regarded as negligent; still less that an emergency paramedic operating in the field without the assistance and certitude of the facilities of an emergency room would be so regarded’.

Their Honours’ comments allude to another observation that ‘evidence as to common practices or professional opinion among emergency paramedics may have assisted, but such evidence of that kind was scant’.

Unanimous orders were made allowing the State’s appeal and setting aside the orders of the QCA.

Implications for you

From a legal perspective this judgment reinforces the long standing principle that a trial judge is better placed than an appellate court to make assessments of witness evidence, particularly to the extent that they involve credibility or demeanour of a witness.

However, some other principles of interest can also be drawn from the judgment.

Firstly, it is important to choose the right expert. At trial the Estate led expert evidence from emergency medicine specialists criticising the actions of the paramedic involved. The High Court drew the distinction between the standard of care expected of paramedics operating in the field in circumstances of urgency, and that of a specialist emergency physician, who has the benefit of the resources and controlled environment of an emergency department.

Secondly, the role of paramedics, like other health professionals, includes the exercise of clinical judgment. Written guidelines are not necessarily determinative of the standard of care. This decision highlights that the role of a health professional involves bringing training, skills and experience to a situation rather than simply following procedures. This is perhaps even more relevant today given the evolution of paramedicine to a profession, and the high level of education and skill possessed by experienced paramedics.

The paramedic in this case was an Intensive Care Paramedic (the equivalent of today’s Critical Care Paramedics), a more experienced and skilled category of paramedic. This factor was also considered relevant in this case.

Ultimately, the decisions of the trial judge and High Court reinforce the importance of ensuring health practitioners are able to exercise sound clinical judgment and are constantly improving the critical thinking and problem solving skills that are essential to their roles.

Queensland v Masson [2020] HCA 28

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