It is very unusual for a clinical negligence claim to reach the highest reaches of the court system. Rarer still are cases involving non-clinical staff such as receptionists. Dr James Lucas, medicolegal consultant, discusses such a case that was recently considered by the Supreme Court and extracts potential learning points for practices.1
Mr Darnley, aged 26, sustained a blow to the back of the head during an assault late one afternoon. He telephoned his friend, Mr Tubman, to explain what had happened, adding that he had a headache that was getting worse. Mr Tubman drove his friend to the local Emergency Department (ED). Mr Darnley was noted to have attended at 20:26 hours.
Mr Tubman was a witness to the conversation between Mr Darnley and the ED receptionist, and became involved in the discussion. On Mr Tubman’s account, the background to Mr Darnley’s attendance was explained to the receptionist. She was informed by both men that they were worried that Mr Darnley had sustained a head injury and needed urgent attention. According to Mr Tubman, the receptionist told Mr Darnley that he would have to sit in the waiting room, for up to four to five hours, before somebody looked at him. Mr Tubman said that Mr Darnley explained to the receptionist that he could not wait that long as he felt that he was about to collapse, and that the receptionist replied that if the appellant did collapse, he would be treated as an emergency.
The two receptionists on duty that evening gave evidence in court about their usual practice, in circumstances where they were unable to recollect a conversation with Mr Darnley. One receptionist indicated that she would have mentioned an assessment by a triage nurse within 30 minutes of arrival; the other said that she would inform a patient that they would be seen by a triage nurse as soon as possible.
Mr Darnley sat down with Mr Tubman in the ED waiting area but he left shortly thereafter because he felt too unwell to remain, and he wanted to go home to take some analgesia. Neither Mr Darnley nor Mr Tubman informed the receptionist or anyone else about their intention to leave the ED; however, both of the receptionists on duty noticed that the men had left, and notified the receptionist taking over on the next shift to look out for Mr Darnley.
Mr Darnley was driven to his mother’s house and went to bed. He became distressed a short time later and an ambulance was called. He was taken to hospital where a CT scan demonstrated a large left temporal/inferior parietal extradural haematoma with marked midline shift. Despite neurosurgical intervention to remove the extradural blood clot, Mr Darnley suffered permanent neurological impairment in the form of a severe and very disabling left hemiplegia.
In the context of his claim against the NHS Trust, Mr Darnley included an allegation of breach of duty by the reception staff. This related to the information provided about the time that he would have to wait before being seen by a clinician and also alleging a failure to assess him for priority triage.
The High Court judge concluded that the harm suffered by Mr Darnley was outside the scope of any duty or obligation owed by the Trust or its reception staff. The judge said that the connection between the alleged inadequacies of the information provided and the harm suffered was broken because the decision to leave was one that was ultimately the decision of Mr Darnley.
Mr Darnley appealed the High Court’s decision. The appeal was dismissed by a majority at the Court of Appeal. Lord Justice Jackson’s judgment included a comment that imposing a duty on the receptionist would add a new layer of responsibility to clerical staff. The judge said that Mr Darnley should accept responsibility for his own actions with regards to his having walked out of the department without telling staff that he was about to leave.
The Supreme Court’s analysis
The Supreme Court Justices considered that the case fell within an established category in which the law imposes a duty of care. As soon as Mr Darnley had attended the Emergency Department, provided the information requested by the receptionist and had been ‘booked in’, he was accepted into the system and entered into a relationship with the NHS Trust. It was not appropriate to distinguish between medical and non-medical staff with regards to the duty of care. The NHS Trust in this instance had charged its non-medically qualified staff with the role of being the first point of contact with persons seeking medical assistance and, as a result, with the responsibility for providing accurate information about its availability.
Having established this, the Justices went on to say that, whilst acknowledging the enormous pressures on staff, it is not unreasonable to require receptionists to take reasonable care not to provide misleading information about the likely availability of medical assistance.
The standard required is that of an averagely competent and well-informed person performing the function of a receptionist at a department providing emergency care.
The Justices held that Mr Darnley had been misinformed by the receptionist about the true position with regards to triaging and, as a result, misled about the availability of medical assistance. The Justices referred to the critical finding of the trial judge, namely that it was reasonably foreseeable that a person who believes that it may be four or five hours before he will be seen by a doctor may decide to leave.
The provision of misleading information by the receptionist was therefore found to be negligent. Causation was also established on a number of grounds. Importantly, the Justices referred to the trial judge’s findings that, if Mr Darnley had collapsed whilst at the NHS Trust, he would have been transferred earlier for neurosurgery with the result that he would have made a very near full recovery.
Mr Darnley’s appeal was allowed by the Supreme Court.
This case related to care in an Emergency Department. However, there is nothing to indicate that a different approach would be taken by the courts when considering out-of-hospital settings. This is particularly relevant in the context of ‘open surgeries’ or ‘walk-in centres’ providing primary care, where patients may have to wait to be assessed. Practices might therefore consider the following guidance on foot of the judgment:
- The development of a protocol is critical in terms of defining the roles and responsibilities of non-clinical staff on the ‘frontline’ of a clinical service. Protocols should encompass issues such as:
- Dealing with special patient groups, for example children and those with special needs.
- Clearly understood thresholds for alerting clinical staff to the presence of a patient who may require prompt attention, eg patients presenting with time-sensitive complaints such as chest pain.
- Expectations with regards to documenting patient encounters.
- Communicating with patients when the waiting time significantly increases, eg because of a medical emergency or staff illness.
- Appropriate training of non-clinical staff with patient-facing roles is essential. The training needs of temporary/agency staff should be considered as part of induction processes at the practice. In the case of established administrative staff, refresher training should be considered. It is important to retain training materials and logs.
- The present case could be used as an illustration of the role of administrative staff in providing clear information to patients when they present for clinical assessment and the risks of patient harm, and costly litigation, when the duty of care is breached.
- Consideration could be given to an agreed ‘script’ or form of words to be used when explaining the system in operation at the practice. Patients should understand what they should do if they believe that their condition is deteriorating whilst waiting for clinical assessment.
- Written information relating to triage procedures/waiting times, including patient information leaflets and signage within the practice, might be helpful in supplementing verbal explanations and demonstrating that clear guidance has been provided to patients.
In conclusion, it is important to reassure non-clinical staff that the judgment does not impose highly unrealistic expectations in relation to the standards of communication with patients. Neither does it impose responsibility with regards to the design of the system in operation at the practice or the fact that some patients will have to wait to be assessed, as a consequence of the resource constraints within healthcare. In Medical Protection’s experience, it is extremely rare for allegations of breach of duty to be directed towards practice receptionists or other administrative staff and we expect this to remain the case.
- Darnley (Appellant) v Croyden Health Services NHS Trust (Respondent)  UKSC 50
Published as Supreme Court judgement
in our print publication, Practice Matters.