Patient's condition deteriorated after she was discharged from the hospital
In a recent case, the Ontario Superior Court has absolved two emergency department doctors from liability for the death of a 26-year-old patient.
Ashly Coville visited the Hamilton General Hospital Emergency Department feeling ill on December 24, 2012. Dr. Ian Laidley and Dr. Catherine Sellens treated her and eventually discharged her. However, she returned the next day with worsened symptoms. Tragically, her condition deteriorated, and she passed away on December 26 due to complications from bacterial pneumonia.
Coville's family filed a lawsuit against Drs. Laidley and Sellens, arguing that the doctors failed to investigate Coville properly for pneumonia and breached the standard of care, resulting in her death. The plaintffs contended that the applicable standard of care required the two doctors to consider and investigate Coville for pneumonia by ordering a chest x-ray and bloodwork.
Dr. Laidley is a senior resident, and Dr. Sellens is an emergency medicine specialist. They asserted that they acted reasonably in Coville's care and that her bacterial pneumonia developed rapidly and could not have been reasonably foreseen.
Factual findings
The parties brought the matter to the Ontario Superior Court of Justice to determine the applicable standard of care, whether the doctors breached it on December 24, and if this breach caused Coville's death.
After carefully examining and weighing the evidence on the balance of probabilities, the court accepted the evidence pointing to the fact that Coville was "non-distressed while at the emergency department on December 24 and that she was not in respiratory distress. Her respiratory triage was considered to be within the normal level. The court also said no credible and reliable evidence established that Coville was having breathing problems or shortness of breath while at the emergency department on December 24.
The court noted that Coville's condition improved after receiving treatment in the emergency department, and her heart rate decreased. The court found that Coville's condition remained "essentially unchanged" from when she was discharged and returned home in the afternoon of December 24 until the afternoon of December 25, a short time before she returned to the emergency department that day. Witnesses observed that something went "really wrong," "she started coughing and gasping for air," "she was panicked," and "she couldn't catch her breath."
Overall, 75 per cent of nurses and 69 per cent of doctors intend on leaving the industry in the next 12 months, found an earlier report.
Standard of care
The court acknowledged that the standard of care required of Dr. Laidley and Dr. Sellens is "of a normal, competent, and prudent emergency medicine physician, practising in the emergency department of an urban community in 2012."
The court noted that in assessing whether there has been a breach of the required standard of care, the physician's conduct must be judged in light of the knowledge that should have been reasonably within their possession at the relevant time. The court also took note of the well-established principle that "an error in judgment does not amount to negligence where the physician appropriately exercises clinical judgment."
The court stressed that Drs. Laidley and Sellens can only make their clinical judgments based on the information they know at the time of their assessment and treatment of Coville.
The court disagreed with the plaintiff's position that the applicable standard of care required Drs. Laidley and Sellens have ordered a chest X-ray and bloodwork on December 24 to investigate the differential diagnosis of pneumonia. The court noted that Coville's respiratory status on December 24 was normal and not indicative of possible pneumonia. Although ill, no apparent signs or symptoms indicated an infection or pneumonia. Her presenting symptoms were not more severe than those of a viral illness.
The court was not persuaded that Drs. Laidley and Sellens failed to meet the standard of care. Instead, the court found that Coville's vital signs, appearance, and existing physical conditions on December 24 were more compatible with the experts' opinion that it was reasonable to diagnose Coville with a viral illness that day and that her presentation did not raise a concern for pneumonia, and so a chest X-ray and bloodwork were not clinically required.
The court accepted that the clinical judgment of Drs. Laidley and Sellens were that there were no indications in Coville's presentation on December 24 that suggested bloodwork and a chest X-ray were required. The court found that this judgment was reasonable in the circumstances. The court acknowledged that it is not standard practice for an emergency department physician to order routine chest X-rays and bloodwork to rule out pneumonia in patients complaining of cough and fever.
Accordingly, the court was satisfied that the defendant doctors did not fall below the applicable standard of care by not ordering a chest X-ray and bloodwork for Coville on December 24.
Furthermore, the court found that Drs. Laidley and Selles were not faced with any indication that pneumonia was a real possibility on December 24. The court was also satisfied that given Coville's vital signs, observed symptoms and improvement with treatment on December 24, there was no indication of a risk of infection or pneumonia that day. The court concluded that the defendant doctors' care and treatment of Coville and their diagnosis of viral illness did not fall below the applicable standard of care.
Causation
The plaintiffs argued that Coville had treatable pneumonia when she presented at the emergency department on December 24, which progressed and ultimately caused her death.
After carefully reviewing the witness testimonies, the court concluded that "it is more likely than not that Ms. Coville did not have bacterial pneumonia on December 24, 2012." The court accepted the expert evidence pointing to the fact that Coville developed a rapid fulminant bacterial pneumonia sometime during the afternoon of December 25, a few hours before she went to the emergency department that day.
Furthermore, the court found that a chest X-ray and bloodwork would not have revealed bacterial pneumonia in Coville on December 24 and would not have resulted in treatment for that pneumonia. Finally, the court said it had not been established that Coville's death would have been prevented with earlier treatment.
The court ultimately ruled that the plaintiffs have failed to prove on a balance of probabilities that Dr. Laidley and Dr. Sellens breached the standard of care, except for Dr. Laidley's failure to chart the results of Coville's physical, respiratory examination. The court further ruled that the plaintiffs failed to prove that any breach in the standard of care by Dr. Laidley and Dr. Sellens caused Coville's death.
