Lessons from the courtroom: Collaborative care


Lessons from the courtroom: A reminder that with collaborative care comes greater individual responsibility

Two recent court decisions have focused on the important role that nurses play within a treatment team, and the corresponding responsibility that this entails.

Case 11

The court had to decide whether an ER physician, a registered psychiatric nurse (“RPN”) and the health authority should be held liable for damages suffered by a patient who attempted suicide one week after his discharge from the emergency room.

The patient went to the emergency room with family members as a result of concerns regarding his mental health. The protocols provided for an initial assessment by an RPN before the assessment by the ER physician. The RPN was advised by the family members that the patient was a skilled manipulator and that in the previous week, he had taken drugs, said that he was being monitored by cameras, and stated that his employer wanted to kill him and use him as a human sacrifice. The RPN did not report this information to the ER physician.

After the ER physician’s assessment, it was concluded that the patient was in need of psychiatric follow-up on an outpatient basis and no hospital admission was necessary. Six days after discharge, before the patient was assessed by a psychiatrist, he attempted to end his life. Given the patient’s loss of blood, he suffered serious and irreparable brain damage.

At trial, the ER physician testified that if she had been informed of the information provided by the family, she would have arranged an immediate psychiatric assessment. The trial judge concluded that timely referral to a psychiatrist would not have prevented the patient’s suicide attempt and, therefore, the physician, RPN, and the health authority could not be held liable. However, the trial judge held that the failure to arrange an immediate assessment by a psychiatrist was not in accordance with the standard of care, and that this was largely attributable to the RPN (80%) who did not report to the ER physician the information obtained from the family. The trial judge considered that the ER physician was partially responsible because, as the person ultimately responsible to recommend a course of treatment, there is an onus on the physician “to ascertain that a complete collateral history is available for the purposes of assessment”.

On appeal, the court revised the trial judge’s finding, in part. The court accepted the trial judge’s finding that an urgent psychiatric consultation would likely not have led to the patient’s immediate admission. The court, however, disagreed with the trial judge’s finding that the physician failed to meet the standard of care. The court said that, absent “red flags,” medical professionals are entitled to assume that other members of the treatment team acting within the scope of their professional obligations have performed their duties competently. The court concluded that since there was no “red flag” that would have triggered a duty on the part of the physician to inquire further about the possibility of additional collateral information, the physician did not have such a duty.

A Court of Appeal’s decision is final unless the Supreme Court of Canada agrees to hear an appeal. On September 28, 2017, the Supreme Court of Canada denied the family’s request to proceed with an appeal.

Case 22

In this case, a 26-year-old pregnant woman presented to the emergency room in the early morning hours and was triaged by a registered nurse. The patient’s reported reason for the visit was increasing neck pain over the last two days, which had become so severe that she had been unable to sleep. The patient wanted to know what pain medication she could take in light of her pregnancy.

The triage nurse (“the RN”) charted that the patient was 28 weeks pregnant, and recorded her temperature, pulse, respiration and oxygen saturation. The RN triaged the patient as “CTAS level 4.” The RN testified at trial that she also measured the patient’s blood pressure but, before she could record it, was called away due to a red alarm for a patient emergency.

Following the unrelated emergency, the RN provided a verbal report to the physician, which included that the patient’s vital signs were normal. The physician did not consider it necessary to review the nursing notes and proceeded to conduct his own assessment of the patient. Based on his assessment, the physician concluded that the patient suffered from a neck sprain and recommended massage and stretches. When recording his notes in the chart, the physician did not notice that the blood pressure was missing.

Before the end of her shift, the RN became concerned that she had not recorded the blood pressure. She discussed this concern with a colleague who suggested that it might still be on the monitor. The RN did not check the monitor or call the patient back to re-measure the blood pressure because she was confident that the reading had been normal.

Two days later, the patient had an eclamptic seizure and was found unconscious by her husband. Upon admission to hospital, her blood pressure was 153/110 with proteinuria at 4+. The baby was born by caesarean section with severe spastic quadriplegic cerebral palsy and cognitive impairment.

The patient and her family later initiated a lawsuit against the RN, the physician, and the hospital claiming that if the patient’s blood pressure had been taken, the adverse outcome could have been prevented.

At trial, the court had to assess contradictory evidence from the patient and the RN as to whether the blood pressure had been taken. The judge concluded that the patient’s blood pressure likely had not been taken. The judge commented that despite the red alarm for the other patient, there would have been time to take the patient’s blood pressure afterwards. Alternatively, when the RN realized that the blood pressure had not been recorded, she could have attempted to locate the patient to re-measure. The court also found that the physician’s assessment was deficient in that he did not realize that the blood pressure had not been recorded, did not take a proper history, and failed to identify the nature of the patient’s complaint as being a headache rather than neck pain.

Notwithstanding the finding that the physician also failed to meet the standard of care, when the court was required to apportion liability, it concluded that the RN made a greater contribution to the damages. The court stated that the RN “set the series of events in play that led ultimately to [the baby’s] brain injury.” The judge specifically considered that the physician would have been able to rely on the information conveyed by the RN that the vital signs were normal except for the fact that the chart did not include any record of blood pressure. The court attributed 70% of the damages to the RN’s omissions and 30% to the physician. This decision was upheld on appeal.

What does this mean for your nursing practice?

  • While court decisions are based on the specific circumstances of each case, the courts have reiterated in a number of decisions that:

    • care is provided as a team;
    • nurses make key contributions to patient care; and
    • other members of the team can rely on a nursing assessment when it falls within the scope of nursing practice, absent any “red flags” that the assessment is inaccurate or incomplete.

  • It is easy to sympathize with the challenges inherent to the practice of nursing, which include managing competing priorities in a complex environment while maintaining clear focus amid multiple interruptions. However, the courts have typically not accepted the realities of a busy nursing practice as a valid defence for an error or omission in the provision of care.

  • It would be prudent for nurses not to assume that any medical assessment, subsequent to their own, would “override” or replace their nursing assessment, including any errors or omissions they may have made in the process.

  • Courts have accepted that a less-than-complete assessment may be consistent with the reasonable exercise of professional judgment if limited information is available or there are other valid impediments to completing the assessment. In such circumstances, it would be prudent to indicate in the record why the assessment is incomplete. An elaborate explanation is not usually required. For example, a court once reviewed the conduct of a nurse who wrote “cry” in a triage record instead of the respiratory rate for an infant. Relying on that word, the court accepted the nurse’s evidence that the child was crying during triage, several years after care was provided. The court also accepted the expert evidence that it is difficult to determine the respiratory rate of a crying child, and concluded that the nurse met the standard of care despite the hospital policy which required nurses to measure vital signs at the time of triage.3

Food for thought...

  • How would you indicate to other team members that you have been unable to collect relevant information so that any gap in information can be adequately addressed?

  • What does this mean for the practice of charting by exception?

 

 

1. Briante v. Vancouver Island Health Authority, 2014 BCSC 1511 (CanLII), 2017 BCCA 148 (CanLII) and 2017 CanLII 63613 (SCC).
2. Pinch (Guardian ad litem of) v. Morwood, 2016 BCSC 938 (CanLII), 2016 BCSC 1907 and 2017 BCCA 234 (CanLII).
3. Latin v. Hospital for Sick Children, 2007 CanLII 34 (ON SC)

 

Published October 2017

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