A. This case is being determined by a judge. What type of law is created by judges and decisions madein the courts?

B Whatis the name given to a case in law that is a judgement or decision of a court that is cited in a similar dispute or court case, to justify or support deciding on a similar case?

Please ensure you answer both of these questions.

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Case Study 2-Wang v Central Sydney Area Health Service [2000] NSWSC 515. Supreme Court NSW

In the NSW case, Wang v Central Sydney Area Health Service, the court found the health service negligent in failing to provide appropriate advice to a young man with a head injury who decided to leave an emergency department waiting room without waiting to be seen by a doctor.

This matter dealt with the duty of care involving staff, particularly nursing staff, dealing with people attending the emergency department of hospitals.

In this civil case, the court found Central Sydney Area Health Service liable for Mr Wang's damage because of the actions of the relevant nursing staff in the Emergency Department of Royal Prince Alfred Hospital.

Facts

The plaintiff, Sha Cheng Wang, was left seriously and permanently disabled by irreversible brain damage as a result of an assault perpetrated upon him in April 1988 as he was walking from the railway station to his home. He was struck from behind by a heavy object and fell to the ground and may have been unconscious for a short period. He managed to walk to his home, and two of his friends theN took him by taxi to Royal Prince Alfred Hospital at Camperdown. They waited for some time in the Emergency Department, where they were joined by other friends of Mr Wang.

Mr Wang had come to the Emergency Department at 9.25 p.m. At 11.00 p.m., and before Mr Wang had been treated, they left and went to the city Superclinic, which was then on Broadway near Railway Square. There, Mr Wang was treated by Dr Andrew Katelaris and returned home. In the small hours of the following morning his condition deteriorated and he was taken back to Royal Prince Alfred Hospital by ambulance. It seems that his skull was fractured. He was suffering from extra Dural haemorrhage, and surgical intervention at that stage was unable to prevent irreversible brain damage.The reason Mr Wang left the Emergency Department and went elsewhere is because he and his friends became upset and impatient that he was not seen by a doctor within a short time of his arrival at the Emergency Department. They were worried about his condition, he was bleeding from his head wound and very pale, but conscious.

Treatment at Royal Prince Alfred Hospital

Mr Wang was seen on arrival by the triage nurse, Registered Nurse Carruthers, who obtained a brief history and undertook a brief physical examination of him. Her entry in the patient notes read simply 'assaulted? LOC' and she explained that the expression '? LOC' meant a possible loss of consciousness. There was no other notation made of any other neurological observations undertaken by Nurse Carruthers, although she gave evidence that, as part of her initial examination of Mr Wang 'he walked into her office unaided and appeared to be alert. She had him squeeze her fingers to test his hand grip, which she found to be firm and equal. She checked his pupils by having him close his eyes and open them quickly, and they appeared to be equal and reacting to light'. It should be noted at this point that the judge hearing the matter concluded that he found the evidence of Nurse Carruthers 'unreliable in certain respects'.

Nurse Carruthers advised Mr Wang and his companions that the Emergency Department was busy and they would have to wait. There was evidence that Mr Wang's companions later approached Nurse Carruthers on two occasions expressing their concern about him.

At about 10.00 p.m., Nurse Carruthers was relieved by Registered Nurse Jennifer Smith. Evidence was given that one of Mr Wang's companions subsequently approached Nurse Smith to enquire how much longer Mr Wang would have to wait to be treated. He was told that the department was busy and that a lot of people were waiting. About 15 minutes later he asked her if they could go somewhere else for treatment, perhaps at a private hospital, and she said that they were free to do so. As he put it, she said that 'we can do whatever we want to'.

A decision was taken to leave the hospital and seek treatment elsewhere. Mr Wang and his friends left about 11.00 p.m. and Nurse Smith wrote in the notes 'Did not wait to be seen'.

Events after Leaving the Hospital

When Mr Wang and his friends arrived at the Superclinic he was immediately seen by Dr Katelaris. There was no criticism or adverse finding as to the treatment given by Dr Katelaris to Mr Wang as recorded by his clinical notes at the time. That is:

• Dr Katelaris obtained a full history of the assault.
• He examined Mr Wang and took the full range of neurological tests. He found no abnormal signs.
• He examined, cleaned and sutured the head wound and administered a tetanus toxoid injection.
• He advised Mr Wang he should return to the hospital for an X-ray. This was rejected because of the displeasure at what had occurred earlier.
• Dr Katelaris gave them a 'head injury advice form' and went on to explain what it said, using gestures to ensure that he was understood. He said that an ambulance should be called immediately in the event of vomiting or convulsion, if the plaintiff became drowsy or unrouseable, or if they observed weakness in one or more of his limbs or inequality in the size of his pupils. He told them that the plaintiff should not be left alone. He advised them to take him to a Chinese-speaking doctor the next morning to arrange for an X-ray and for any ongoing care which might be necessary.

Mr Wang went home to the flat that he shared with his friends. During the night Mr Wang started vomiting and convulsing and became unconscious. An ambulance was called and Mr Wang arrived back at Royal Prince Alfred Hospital by 4.00 a.m. and underwent surgery, but was left with irreversible brain damage.

Further discussion and information from this case

Nurse Carruthers' examination was inadequate and superficial and that no notice was taken of his friends' insistence that Mr Wang needed urgent attention, so that Mr Wang was not afforded the priority for care which he deserved. Alternatively, accepting that his priority was appropriately assessed, Nurse Carruthers should have consulted a doctor about him before she went off duty and Nurse Smith should have done so before the plaintiff left the hospital. In either event, some attempt should have been made to dissuade Mr Wang from leaving before he had been seen by a doctor.

It is clear that Nurse Carruthers gave an oral report to Nurse Smith at the end of her shift. Mr Wang's friends continued to request that he be seen by a doctor only to be met by the statement from Nurse Carruthers and Nurse Smith that the Emergency Department was busy and they would have to wait. Eventually one of Mr Wang's friends, a Mr Ng, enquired as to whether they should seek treatment elsewhere.

Should hospital staff have attempted to dissuade the plaintiff from leaving? The enquiry was directed to Sister Smith and that she did not advise them to wait. It is true that some further time elapsed before they left, and counsel for the hospital submitted that the staff might have not been aware of their departure. However, if appropriate observation of the plaintiff in the waiting area were being maintained, they should have been.

It was common ground that the plaintiff was free to leave and the hospital staff had no power to restrain him. Expert witnesses gave information about how the situation should have been handled.

• Ms Fares said that normally staff would attempt to persuade a patient from leaving and would find out how soon a doctor might be available, informing the medical staff that the patient was becoming restless.
• Another expert witness stated ... when patients decide to leave an emergency department without treatment, staff should attempt to discourage them from doing so. Failing that, they should try to ensure that they seek alternative medical care. The practice in the hospital where he worked was that, if it was clear that a patient could not be persuaded to wait, he or she would be given the names of medical clinics in the area ... the approach of staff to the situation must be flexible and would depend on a number of variables, including the clinical presentation of the patient, where the patient intended to go upon leaving, the demands upon the resources of the department at the time, the availability of other medical services in the area and their capacity to deal with the patient's condition.

In considering the circumstances in which Mr Wang left the Emergency Department, the judge came to the conclusion that the Central Sydney Area Health Service was liable for Mr Wang's permanent damage, because of the failure of the triage nurses in Royal Prince Alfred Hospital to properly observe him and advise him against leaving the hospital. Given the unpredictable effects of head injuries, it was clearly in the plaintiff's best interests to remain at the hospital, where there were the resources to observe and respond to any deterioration of his condition. I am satisfied that, if he had, he would not be in his present predicament.

Sister Smith did not ask Mr Ng where they intended to go, and did not offer any advice about alternative sources of treatment suitable for the plaintiff's condition, should it deteriorate. Indeed there is no evidence that there was any suitable source at that time of night other than a public hospital. Sister Smith should have counselled the plaintiff to remain at the hospital, explaining why it was in his interests to do so.

The Central Sydney Area Health Service, which administers the hospital, is a statutory authority whose duty was to take reasonable care for the plaintiff's wellbeing in the circumstances, within the limits of its resources. In my view, that duty extended to furnishing the plaintiff with appropriate advice when it was intimated that he might leave the hospital. The hospital failed to discharge that duty, and the plaintiff's present condition is attributable to that failure.

The question as to whether Mr Wang and his friends would have accepted the advice to remain at the hospital if spoken to in those terms had to be determined. Mr Wang was unable to say because of his incapacity. The judge did consider the evidence of his friends who were with him on the night in question and came to the view, on that evidence, that he would have.

 

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