Thinking | 15 September 2019

District Court chips away at discretion for clinical judgement

The District Court of Western Australia has found in favour of patient Sandy Lazarevski and held that the defendant North Metropolitan Health Service (NMHS) breached its duty of care by failing to administer a standard blood test and detect an eventuating heart attack despite finding that the possibility of a heart attack on the patient’s presentation was low.

The 28 year old Mrs Lazarevski presented to the emergency department of Sir Charles Gairdner Hospital with a sudden onset of pain to her chest radiating into her left arm. Ms Lazarevski underwent a chest x-ray, an ECG and blood tests, all of which returned normal results. The only type of blood test that was not ordered was to test her levels of a type of protein called Troponin, which is released in the blood stream when there is damage to the heart. Ms Lazarevski was discharged approximately three hours after her admission. Three days later, the heart attack occurred.

The totality of the expert evidence confirmed that the probability of the patient having an acute coronary syndrome (ACS) was low, given her presentation, age and gender. However, the divergence in the expert evidence boiled down to the issue of whether the omission to order serial Troponin tests represented a departure from widely accepted practice, with Ms Lazarevski’s experts supporting such a contention, and NMHS’s experts supporting the opposing view.

At all material times, NMHS had a clinical guideline the ACS Pathway, which provide for serial troponin blood tests on patients who presented with ‘possible’ ACS. Ultimately, His HonourDistrict Court Judge Troy placed great stock in this guideline in concluding that Ms Lazarevski’s expert evidence, in conjunction with the guidelines, confirmed that widely accepted practice of emergency physicians mandated serial troponin testing on patients who presented with possible ACS, even though the probability of that diagnosis was low, or even unlikely.

His Honour concluded that that it was not possible to completely exclude ACS based on a clinical assessment and an ECG alone and that, given the significant risk of harm of a heart attack, a diagnosis of ACS should have been eliminated. Serial troponin tests were required for all the common risk assessment tools used in practice in Australian emergency departments in 2014, as a simple and practical way to exclude a heart attack, unless the clinician was convinced that ACS was not even a possibility. Further, the burden in taking precautions to avoid such a risk was almost non‑existent, as all that was required would have been to add further instructions to the series of blood tests that was already ordered.

This case, along with the previous decision of Ellis v East Metropolitan Health Service [2018] WADC 36, displays a pattern of reliance that the Court will place on internal clinical guidelines in establishing what would be considered widely accepted practice for health professionals, especially in circumstances where there is a divergence in the expert opinion. His Honour also noted that the guidelines did not provide for any exercise of discretion and no evidence was presented by NMHS on whether there was any latitude for clinicians to depart from the guidelines.

The difficulty that hospitals will face in light of these decisions is that clinical guidelines often represent ‘best practice’ and it would be quite impossible for the clinical guidelines to encompass the vast and varied clinical picture that individual patients may present to clinicians.

This case should cause hospitals to review their internal clinical guidelines to provide for distinctions on what would be considered best practice as opposed to widely accepted practice and provide appropriate leeway for the clinical judgment of individual clinicians, especially in atypical presentations.

Lazarekski v North Metropolitan Health Service [2019] WADC 84