High Court finds Queensland Ambulance Service not negligent

The High Court of Australia found that a Queensland Ambulance Service (QAS) officer exercised reasonable care in administering salbutamol (rather than adrenaline) in treating a patient having a severe asthma attack. The High Court found that this clinical judgment that was not in contravention of QAS’s clinical practice manual (CPM).

Background

On 21 July 2002 Jennifer Masson, a 25-year-old chronic asthmatic, suffered a severe asthma attack in Cairns, Queensland. The QAS responded to a call for assistance, and officers administered salbutamol with some effect.  Ms Masson was then transported to the Cairns Base Hospital. The officers were not advised, and did not know, that Ms Masson’s previous attacks had successfully been treated with the administration of adrenaline. The two frontline drugs in the treatment of asthma attacks at the time were adrenaline and salbutamol.

Ms Masson sustained severe, irreversible brain damage as a result of oxygen deprivation prior to her arrival at the Cairns Base Hospital. She remained in a vegetative state for several years before her eventual death in 2016. An action was brought before the Supreme Court of Queensland by Ms Masson’s estate alleging negligence against the State (as the provider of ambulance services), who was represented by Crown Law.

Ms Masson’s estate alleged that she would not have suffered catastrophic brain damage if the attending QAS officer had administered adrenaline instead of salbutamol. Alternatively, it was alleged that if the QAS officers themselves were not negligent then the training and instruction given to them (including via the CPM) was inadequate such that the State was liable for their failure to administer adrenaline. The State contended that the administration of salbutamol was a reasonable response to the known circumstances at the time.

Prior Decisions

The trial judge concluded that the treatment administered by the QAS did not fall below the standard of care to be observed by ambulance officers and was not contrary to the CPM. No breach of duty was established and the claim failed. Ms Masson’s estate appealed.

There were two primary issues on appeal including whether ambulance officers ought to have administered adrenaline immediately on attendance (or at least within a couple of minutes); and whether the officers were inadequately trained and instructed by the QAS to respond to emergencies such as this.

The Court of Appeal found that the administration of salbutamol by ambulance officers did not comply with the guidelines in the CPM. As a result, Ms Masson had not been treated in accordance with the CPM, as the use of adrenaline was not relevantly considered as required by the CPM. The Court of Appeal overturned the trial judge’s finding that a reasonable body of medical opinion supported the administration of salbutamol, saying this was not supported by the evidence.

The Court of Appeal unanimously held that the State was vicariously liable for the ambulance officer’s negligence. Damages were agreed at $3M. On 15 November 2019, the State was granted special leave to appeal.

Issues before the High Court

On appeal before the High Court, the State submitted that the Court of Appeal had departed from settled principle by treating the CPM as determinative of the standard of care. The State also contended that the Court of Appeal erred in overturning the trial judge’s findings that the QAS officers “considered” the administration of adrenaline in accordance with the CPM, and in 2002 there was a responsible body of medical opinion to support the administration of salbutamol to patients in Ms Masson’s condition.

Findings of the High Court

In acknowledging the attending QAS officer’s experience and training, the High Court found that the CPM was not expressed to be, and was not, determinative of the range of reasonable responses for an intensive care paramedic in treating an asthmatic patient in imminent arrest.

The High Court also found that there was no basis for concluding that the “consideration” of adrenaline in accordance with the CPM was not to be informed by an officer’s clinical judgment. Therefore, in the subject case where Ms Masson had a high heart rate and high blood pressure (contra-indications of the administration of adrenaline) the administration of salbutamol might have been preferred. The High Court also found that there was ample evidence to support the trial judge’s findings that, in 2002, a responsible body of medical opinion favoured the administration of salbutamol in the initial stage of treatment for a patient in Ms Masson’s condition.

In weighing the above, the High Court found that the QAS officer exercised reasonable care in deciding to administer salbutamol in the circumstances.  It found that the CPM was intended to guide practitioners rather than proscribe decision-making. Further, the flowchart contained in the CPM prompted the consideration of adrenaline but did not require its administration. The decision made by the QAS officer to administer salbutamol was supported by a responsible body of medical opinion.

The High Court  allowed the appeal of the State, and set aside the orders of the Court of Appeal and in their place ordered that the appeal be dismissed with costs.

Implications

This case illustrates the importance of adequate training of paramedics to support their individual clinical judgment about competing treatment options. In this matter, the attending QAS officer was an experienced practitioner who, in weighing the symptomology of the patient, made a clinical judgment under pressure to administer salbutamol (rather than adrenaline), which was in accordance with responsible medical opinion at the time.

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