3. legal ethical issues - nhs . legal ethical آ legal & ethical issues of patient transfers
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Legal & Ethical Issues of Patient
• Scott a 30yr old is in the ED with meningococcal meningitis; he is very sick and requires Intensive Care.
• The hospital’s ICU is full although there are some stable patients but they still require critical care.
• The nearest ICU bed is 50 miles away
� Evidence shows that premature discharges from ICU increase mortality (Goldfrad & Rowan 2000; Blunt & Burchett 2001 etc,
� However non-clinical transfers increase morbidity (Kollef et al.1997; Duke & Green 2001; Durai et al. 2003; Welch, Harrison & Rowan 2008)
• Mr Keith Abel (retired surgeon) sustained a cerebral haemorrhage whilst being driven to High Wycombe hospital.
• He was unconscious, intubated and ventilated and required immediate neurosurgery but there were no neurocritical care beds available & considerable time was spent trying to locate one.
• Mr. Keith Abel: Death in hospital (Hansard, 14 February 1995).
Duty of Care
• Health professionals in an ICU have a duty of care to their patients and must act in their patients’ best interests.
• Consider the difficulty in making a decision that is not entirely in this patient’s best interest.
• Does the intensive care team also have a duty of care to a patient who is currently physically elsewhere in the hospital but who is in need of intensive care treatment?
Duty of Care
• Who has this duty during a transfer?
• Consultant in charge
• The transferring team
• The receiving unit
• Many staff however are unsure of their roles and responsibilities in their interactions with the legal system.
• This is not surprising, given the increased requirements imposed on practitioners by legislation, regulations and guidelines.
• The first duty of a doctor must be to ensure the wellbeing of patients and to protect them from harm (this responsibility lies at the heart of the medical profession)
• Nurses must protect and promote the health and wellbeing of those in your care, their families and carers (Code of conduct).
• Patients expect staff to be technically competent, open and honest, and to show them respect.
� Critical care is in an emerging crisis of conflict
between what individuals expect and the
economic burden society and government are
prepared to provide
�Demand exceeds capacity
�Pressure of targets
�GP OOH contracts
�Junior doctors hours
Risks of Transfer
� How good is the care patients receive during interhospital transfer?
� Adverse events occur in about one-third of cases.
� Half the time this can be related to not following advice from the receiving centre.
� Of these events, 70% are probably avoidable and 30% are related to technical problems (Ligtenburg et al. 2005).
How to make things
• Essentially, why you are here today…….: – Training.
– Equipment safety.
– Publication of European Standards for ambulance vehicles, i.e. (CEN 1789) compliance
• Noncompliance will technically invalidate any EU ambulance's motor insurance policy.
– Each hospital must nominate a specialist with responsibility for critical care received during transfer.
• They would then be responsible for guidelines, training and equipment.
– Adverse events can then be fed back immediately so they can be acted upon.
“We must take reasonable care to avoid acts and omissions which you can reasonably foresee would be likely to injure your neighbour ...”
Lord Atkin in Donoghue v Stevenson (1932)
• If a patient is not treated with the proper amount of care, resulting in an injury or death, medical negligence has been committed (by the physician or any the relating staff members).
• Requirements for proving negligence: – Duty of Care
Doctors charged with manslaughter in the
course of medical practice, 1795–2005
Who should transfer?
• Is inexperience a defence?
Inexperience as a
• “In my view, the law requires the trainee or learner to be judged by the same standard as his more experienced colleagues. If it did not, inexperience would frequently be urged as a defence to an action for professional negligence.”
• LJ Glidewell (Wilsher v Essex AHA 1987)
Inexperience as a
• Two SHOs were convicted of manslaughter by
gross negligence, following the death of 31yr old
– He developed toxic shock syndrome, which the two
doctors were accused of failing to treat, and died four
• Earlier this year a doctor was convicted of
manslaughter after her ICU patient died
– She failed to gain advice of seniors and gave adrenaline after ignoring the advice of colleagues.
Staying out of trouble
• Effective communication with patients, their families and other healthcare providers
• Staying up-to-date clinically
• Realising and practising within the limits of your skills, knowledge and experience.
• Utilise published guidelines
• In 1993 Professor Ian Kennedy commented that:
“the role of protocols and guidelines will become more and more important”.
• His words remain apt, although in England and Wales clinical practice guidelines do not yet constitute legally binding standards of care, nor have they replaced expert testimony.
• In the case of Early v Newham HA, the 13yr old claimant recovered consciousness while still paralysed from an unsuccessful attempt to intubate her in preparation for appendix surgery. – She panicked and was in great distress until she had
• The anaesthetic SHO had followed the health authority’s written “Failed Intubation Procedure’’ correctly. – The guideline had been drawn up by the hospital’s
division of anaesthesia, which included eight consultant anaesthetists
• The claimant sued the health authority, claiming that the doctor was incompetent and negligent, and that the guidelines he followed were faulty and flawed.
• The claim failed. • Bennett QC concluded that the small risk of
transient consciousness was far outweighed by the avoidance of the far greater risk of injury due to hypoxia.
• He also found the guidelines to be reasonable in that ‘a reasonably competent medical authority would have adopted them for their use’.
“Where clinical guidelines have been developed in a robust manner, which reflects wide consultation and best
practice, then it is unlikely that a health professional who follows such guidelines
would be held to be negligent for the outcome of the treatment or process
Code of Ethics
• Professional responsibilities • duties and obligations
• Professional relationships • professional behaviour
• good communication
• Four Major Bioethical Principles in Healthcare
– The Principle of Autonomy
– The Principle of Non-Maleficence
– The Principle of Beneficence
– The Principle of Justice
• Article 2 - Right to life
• “Treatment that could prolong life may sometimes be withheld on the grounds of scarce resources.”
• “The court is unlikely to interfere in a particular case with a Health Authority's decisions on allocation of resources.”