A decision of the Queensland Court of Appeal has reversed a decision of the Supreme Court and found the Queensland Ambulance Service vicariously liable for a failure by an ambulance officer to give adrenaline, as soon as possible, to a patient suffering as asthma attack.
The 25-year-old patient was a chronic asthmatic, with a lifelong history of severe asthma. She had previously been admitted to hospital many times for asthma. She used a Ventolin salbutamol puffer and carried an EpiPen of adrenaline in case of sudden or severe asthma attacks. The EpiPen had previously been effective when she suffered such attacks. Adrenaline and salbutamol help to facilitate breathing where a person’s airway is constricted by an asthma attack. However, adrenaline can also cause a person’s heart rate to spike.
In 2002, the patient was at her friend’s house in Cairns, when she suffered a severe asthma attack. The patient was having extreme difficulty breathing, used her salbutamol puffer to no effect, and deteriorated quickly. The patient told her friends to take her to the hospital. She collapsed on the front lawn and stopped breathing. Her friends performed CPR and called for an ambulance at 10:51pm.
The ambulance officers arrived seven minutes later and were told that the patient had a history of severe asthma, had suffered an attack and had unsuccessfully used her puffer. They were also advised that the patient had asked to be taken to hospital, collapsed, and stopped breathing. The ambulance officers were not told that adrenaline had previously been an effective treatment.
The principal ambulance officer saw that the patient was blue in the face, only breathing twice a minute, and was effectively unconscious. She had high blood pressure and a very high heart rate of 150 beats per minute. He continued to monitor her vitals signs.
The patient was ventilated but proved difficult to oxygenate with a mask. A cannula was inserted into her elbow to allow access to administer intravenous drugs.
At 10:59pm, the principal ambulance officer began administering salbutamol through the cannula, in an attempt to relax the patient’s airways and allow her to breathe. Her condition neither markedly improved nor deteriorated. At 11:15pm, she was moved to the ambulance.
At 11:17pm, the patient’s eyes were no longer opening. Two minutes later, her heart rate dropped to 40 beats per minute. At 11:20pm, the patient was given adrenaline for the first time to try and avoid “imminent arrest”; either cardiac or respiratory. By then the patient had been given 2mg of salbutamol, which was twice the recommended dose from the Ambulance Service manual.
Tragically, by the time the patient arrived at the hospital she had suffered irreversible brain damage due to oxygen deprivation. She was not breathing, had no pulse, and was blue in the face. She was given three further doses of adrenaline, which provoked an immediate increase in her pulse, but her condition did not improve.
After ten days in the Cairns Intensive Care Unit, the patient was transported to the New South Wales South Coast. For the next fourteen years, the patient lived in a vegetative state. She was cared for 24 hours a day by her parents. She died in 2016.
The patient, and later her estate, claimed damages against the State of Queensland as the provider of the Ambulance Service. Damages were agreed at $3 million.
The issue at trial was liability for negligence. There were multiple allegations of negligence at trial, but only two were pressed on appeal. It was alleged that the ambulance officers were negligent for not administering adrenaline as soon as possible, rather than 20 minutes after arriving. It was further alleged that the Ambulance Service was negligent for failing to adequately train its officers, such that they did not give the adrenaline earlier.
The principal ambulance officer gave evidence at the trial and described in detail the extremely high-pressure situation that occurred that night. He provided his interpretation of the Ambulance Service manual and the reasons for his decisions and actions.
The eight expert witnesses were divided in their opinions at trial. The patient’s experts provided that in her case, adrenaline was superior to salbutamol, and should have been given as soon as possible, especially when salbutamol proved ineffective. The opposing experts maintained that salbutamol was appropriate in the circumstances.
The learned trial judge found a causal link that if adrenaline had been administered immediately, the patient would not have suffered brain damage. However, his Honour held that the ambulance officers had not been negligent in their delay in administering adrenaline, and also that they had been properly trained. Therefore, the Ambulance Service was not held liable.
On appeal, that decision was reversed. Justice McMurdo, with whom Justice Fraser and Justice Boddice agreed, found that this was a case of “imminent arrest” per the Ambulance Service manual. That meant that the ambulance officers should have considered and administered adrenaline as a first priority.
Justice McMurdo found that the patient should not have been given a double dose of salbutamol. The ambulance officer misunderstood the manual by thinking that adrenaline should never be given to a patient with a high heart rate. He had not considered the use of adrenaline as required by the manual, and had doubled the dose of salbutamol in the hope that this would be as effective as the administration of adrenaline. The manual did not suggest salbutamol as an alternative to adrenaline and the manual was not ambiguous.
The relevant standard of care was that of an ambulance officer. By acting the way he did, and not following the manual, the ambulance officer had not acted with reasonable care and skill. He was therefore negligent in not administering adrenaline at the outset. Further, the patient would not have suffered brain damage if she had been given adrenaline immediately. Therefore, the Ambulance Service was vicariously liable for the ambulance officer’s negligence. The patient’s estate was entitled to the agreed $3 million damages.
This decision highlights the crucial decision-making of emergency healthcare professionals in the discharge of their duties, the importance of training alongside clear and unambiguous manuals, and the inescapable tragic consequences of human error.