Abstract
Mr Jackson, who was aged 21 years at the time, suffered a serious assault in Bristol city centre at about midnight on Saturday 9 April 2005. He was knocked to the ground and kicked in the head.
PC Rogers was alerted by a member of the public and ran to the scene at 00:10. She asked him if he had been drinking and he replied ‘yes’. Her pocket book entry recorded that Mr Jackson appeared drunk, was very angry, swearing and unsteady on his feet. He could not recount the story of what had happened clearly to his father, when telephoning him, and ‘was talking strange, mumbled and not making sense’.
PC Rogers called an ambulance which arrived at 00:35. One of the crew members, Mr Brown, recalled the Claimant coughing and spitting, but not vomiting. The patient was not complaining of a headache, although he was holding his head which had sustained obvious injuries. He was very uncooperative.
Mr Brown recalled that the patient's presentation and behaviour were consistent both with a brain injury and also with being under the influence of alcohol. In particular, Mr Jackson smelled strongly of alcohol.
The Claimant's parents attended the scene and saw that their son was covered in blood. He was very agitated, angry and confused. He used foul language towards his mother.
The ambulance took him to Bristol Royal Infirmary, arriving at 00:50, and he was transferred to A&E at 01:08.
Triaging was undertaken by Nurse Sully and completed at around 01:25. The nurse recorded: ‘pupils equal and reactive to light and Glasgow Coma Scale 15/15’. The patient continued to be very uncooperative and verbally aggressive, and the nurse assessed him as being under the influence of alcohol. Mr Jackson was allocated a triage category of 4, which meant that he would be seen by a doctor within two hours.
Dr Wilson, a specialist registrar in emergency medicine, first saw Mr Jackson at 02:20. Her note recorded a history of assault and that the patient was complaining of pain in his right hand. Loss of consciousness was queried. Headache was recorded but no diplopia. Vomiting and a feeling of nausea were noted. Dr Wilson also assessed the patient as having a Glasgow Coma Score (GCS) of 15/15. Her plan was to admit him for neurological observation plus analgesia, and for his injured scaphoid to be dealt with in the morning.
In evidence, Dr Wilson said that Mr Jackson was initially verbally aggressive and she had asked him to moderate his language and behaviour. He complied with that request. There were no clinical signs of a head injury at the time of her examination.
Admission arrangements were made at 02:40, and Mr Jackson was transferred to the observation ward at around 03:00. At 03:20, observations were undertaken and the patient was detailed for regular hourly review.
The next note, timed at 04:10, recorded that the patient was agitated and had pulled out a line. There was sudden acute confusion and the GCS was reduced to 11/15. Mr Jackson was taken immediately for resuscitation and an urgent CT scan arranged.
At 04:30, an anaesthetist organized intubation and the CT was performed at 05:00. This revealed a right-sided subdural haematoma, and Mr Jackson was transferred as an emergency to the neurological theatre at Frenchay Hospital. He arrived in theatre at 06:05; at 06:15 he was anaesthetized for surgery; and a large subdural haematoma was evacuated. Effective decompression was achieved by 06:45 at the latest, and probably by 06:35.
Regrettably, despite this emergency action, Mr Jackson is left with significant neurological deficit. From having had a promising career as a printer, winning an apprentice of the year award, he now requires significant ongoing care.
It was alleged that the triage nurse failed to perform a competent assessment, relying too much upon the Claimant's alcohol intake; that Dr Wilson should have ordered an immediate CT scan, again being influenced by the alcohol factor; and that the concerns of the family as to Tony's serious condition were not addressed by the clinicians. It was also claimed that both Glasgow Coma Scores of 15/15 were incorrect.
As to causation, it was claimed that if an urgent CT scan had been ordered, the haematoma would have been diagnosed by no later than 02:07; that surgery would have commenced by about 03:05; and that the haematoma would have been effectively decompressed by 03:38 at the latest, well before the time of the Claimant's coning and collapse, which occurred around 04:30, following the first signs of deterioration at 04:10.
The A&E experts agreed that a relatively thorough triage was performed by Nurse Sully. However, they disagreed as to the correct GCS rating. Dr Campbell-Hewson, for the trust, thought it was reasonable for staff to consider that alcohol, anger and distress were factors in Mr Jackson's behaviour at A&E, and that therefore the appropriate score was 15/15. Ms Peta Longstaff, the Claimant's expert, stated that Mr Jackson's presentation was complex, made up of many elements, which when added together produced a picture that should have raised alarm signals. She considered that the appropriate GCS was 14/15.
The experts also disagreed as to the correct triage category. Dr Campbell-Hewson believed that Nurse Sully had allocated the patient to the correct category, i.e. that he needed assessment by a doctor within 120 minutes. In fact, he was seen within 60 minutes. Ms Longstaff, on the other hand, believed that the patient should have been graded as requiring a doctor's attention within 10 minutes.
As to Dr Wilson's examination and treatment plan, Dr Campbell-Hewson's opinion was that her decision to admit Mr Jackson to the observation unit was the correct one. Ms Longstaff, in contrast, considered that the correct GCS of 14/15, associated with other symptoms including headache, rapid pulse and multiple haematoma of the scalp, indicated a need for immediate scanning.
The expert neurosurgeons were largely in agreement. They considered that vomiting was a common sequel to trauma, and may or may not be associated with brain injury. Perceived aggression and lack of cooperation could be a consequence of head injury, but could occur for other reasons. Contusions to the head, such as those sustained by the Claimant, might or might not be associated with brain injury. Conversely, severe brain injury can occur without any external evidence of trauma.
The judge noted that the NICE guidelines, published in June 2003, were based on the best evidence then available worldwide. They did not mandate an immediate CT scan by virtue of the symptoms exhibited by the Claimant.
Held: There was no doubt that the family had a total conviction that Tony did not receive the standard of care which he was entitled to expect. Their evidence was honestly given, but they were demonstrably wrong regarding their contention that the first consultation with Dr Wilson was prior to 02:20. Other aspects of their evidence also cast doubt upon its accuracy. Furthermore, the independent lay evidence did not support the picture presented by the family. For example, the notes of PC Rogers did not support the picture of persisting confusion and disorientation presented by the family. To her, as to the clinicians, Mr Jackson appeared drunk.
As to the actions of Nurse Sully, his triage was undertaken within 15 minutes of admission which was in accordance with guidelines. It was alleged that his notes did not contain evidence to support a GCS of 15/15, but it was undeniable that the Claimant had been drinking and that his breath smelled strongly of alcohol. Mr Jackson had been able to walk to the X-ray department and to cooperate to enable diagnostic X-rays of his wrist to be performed. He was also able to draw attention to the condition of his right hand and to complain of pain in his nose. These indications pointed to his being orientated rather than confused.
Nurse Sully gave a favourable impression in the witness box. He was not in the least evasive or defensive. The picture he presented was of an experienced, competent and careful triage nurse.
Even if Nurse Sully had assessed Mr Jackson's GCS score at 14/15, good practice at the time required that CT scanning of the head should be requested at 2 hours after the injury, owing to the fact that there was often a recovery from initial confusion by concussion. Hence, Mr Jackson would not have had a CT scan before 02:00 anyway.
Turning to the actions of Dr Wilson, the family maintained that she was dismissive of their concerns. It could well be understood that even in a caring and conscientious doctor, the early hours of the morning in A&E on a Saturday night in a big city meant that the caring, solicitous bedside manner of a doctor in less-pressured circumstances might not be evident.
Dr Wilson had also created a favourable impression in the witness box. She gave her evidence in a balanced, straight-forward way and was neither evasive nor defensive. She wrote a full and comprehensive note, in itself evidence of a careful assessment. The fact was that she did not dismiss Mr Jackson as yet another drunk young man involved in a fight and send him home, but insisted (against his wishes) that he remain in hospital for observation.
Her warning as to zero tolerance of inappropriate behaviour was reasonable. Mr Jackson had been verbally aggressive and was using foul language. It was appropriate for the doctor to take charge and establish the parameters at the outset.
Dr Wilson did not have a closed mind to the risk of serious brain injury. She took the appropriate course in admitting Mr Jackson for neurological observation.
As between the accident and emergency experts, the views of Dr Campbell-Hewson were to be preferred. Ms Longstaff ‘was inconsistent in her evidence in significant respects and at times trespassed upon becoming an advocate rather than expert’. She was inconsistent during cross-examination and her report did not refer specifically to the relevant guidelines.
Overall, there was no basis for a finding that a CT scan should have been requested sooner than was the case. The Defendant was, therefore, not in breach of duty, and was under no liability to the Claimant.
Jane Tracy Forster (instructed by David Gist) appeared for the Claimant. John Whitting (instructed by Barlow, Lyde and Gilbert) appeared for the Trust.
Comment
The clinicians in this case were faced with an all-too-familiar picture for an A&E department in a large city on a Saturday night. However, rather than dismissing the Claimant as being yet another drunk, and sending him home to sober up, they admitted him for observation. They complied with appropriate professional practice at the time, and indeed with the prevailing NICE guidelines. Understandably, the family were distraught at events but an objective analysis of the evidence supported what the clinicians had done. While it was exceptionally unfortunate that the Claimant suffered a profound neurological deterioration while he was at hospital, the question of legal liability should not be viewed from that perspective. Rather, the trust had been able to demonstrate that their staff acted in accordance with a reasonable body of professional opinion at the time. Consequently, although this was a tragic case, legal liability had not been made out.