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Psychiatrist’s $64,000 discharge error

A court has found a psychiatrist breached their duty of care to a patient for the injuries she sustained in a car accident while driving home following discharge from the hospital.

The patient alleged that at the time of her discharge, she was excessively tired and/or sedated and should not have been permitted to drive home. She claimed the psychiatrist and admitting hospital’s negligent conduct had caused her to lose control of the car and sustain personal injuries.

In reaching its decision, the court considered a range of evidence from the psychiatrist, hospital, witnesses, experts, as well as medical notes and letters.

Ultimately, the court found the psychiatrist and the hospital each liable for negligence, and apportioned responsibility between them. The hospital and the psychiatrist were ordered to pay the patient $32,167 and $64,333, respectively, plus costs.

The case highlights the risks when discharging patients potentially under the influence of sedating and psychoactive agents, and the importance of conducting and documenting a careful assessment before allowing any unattended patient to drive home.

Car accident following discharge

The patient was a woman with a background as a registered nurse, who had been terminated from her job due to absences because of back pain following a work accident. She visited her GP complaining of depression and feeling suicidal, and was admitted to an acute hospital’s mental health unit for about a month. She was then admitted as a voluntary inpatient, to a private hospital under the psychiatrist.

During her admission, which lasted another month, she suffered both insomnia and daytime tiredness. She was taking multiple psychoactive drugs including antidepressants, opiates and other strong analgesics as well as Stilnox at night.

During a consultation the day prior to the patient’s discharge, the psychiatrist assessed her readiness for discharge in relation to her mental state. The patient was able to assure the psychiatrist she was no longer suicidal and the psychiatrist authorised discharge for the next day.

On the morning of discharge, the patient took her regularly prescribed OxyContin. Prior to discharging her in the afternoon, a nurse completed a driving risk assessment and then returned the patient’s car keys so she could drive the 50 kilometre journey home. Unfortunately, the patient drove off the road and into a wall, quite close to home.

She was taken by ambulance and treated at an acute hospital for her injuries, including pain in her neck, head, shoulder, lower back and leg. She was then re-admitted to the private hospital under the original psychiatrist, where she remained for another month.

Court’s findings

The court heard in the days prior to discharge, the patient was often excessively drowsy and would fall asleep even while sitting eating meals. On the day of discharge, the patient had again fallen asleep over breakfast. Nursing staff had tried to wake her on several occasions, but she kept falling back asleep.

The court noted medical records from the hospital in which staff had reported the patient appeared over-sedated and drowsy. The nurse’s risk assessment completed at the time of discharge, also stated, “reports tiredness lately – Psych aware”.

Given the “overwhelming evidence”, the court found the patient was tired, drowsy and sedated upon discharge.

“I find she was not in a fit state to make a decision about her capacity to drive and find that she relied upon her carers to advise as to whether or not it was safe for her to drive herself home and warn her of the risks of drowsiness,” the court said.

The court concluded the car accident occurred as a result of the patient falling asleep due to tiredness, fatigue or excessive sedation.

Psychiatrist’s grounds for negligence

While the psychiatrist conceded the scope of their duty of care extended to reasonable care of treatment, they sought to deflect liability on the basis of s50 of the Civil Liability Act (CLA), claiming they had acted in a manner which at the time was widely accepted in Australia by peer professional opinion as competent professional practise.

In determining the psychiatrist had breached their duty of care to the patient, the court noted they had granted the patient permission to drive her car and was the sole person with control over whether the patient drove. Based on hospital protocol, staff could only give the keys to the patient with the psychiatrist’s permission.

The court accepted the patient’s evidence she had expressed concern to the psychiatrist about driving due to drowsiness, to which the psychiatrist had responded, “you should be fine to drive.”

The court found that at no stage during the consultation before her discharge, did the psychiatrist discuss how she would travel home. Furthermore, the psychiatrist admitted they left the decision up to the patient as to whether she was fit to drive.

“To leave it up to a psychiatric patient who suffered from pain, fatigue and sedation, which would vary from day to day, to decide whether to she was fit to drive at the time of discharge, is a complete abrogation of the psychiatrist’s duty of care and responsibility,” the court said.

The psychiatrist was also found negligent by failing to review the patient or enquire about her condition on the actual day of discharge, despite her observations of the patient the day before discharge and personal knowledge of the patient’s sedation, as evident in the records and other correspondence.

In a letter to the patient’s insurer, the psychiatrist had reported increased sedation over the last week which the introduction of OxyContin may have caused. Another letter to a neurologist said in the three days prior to discharge, the patient was “excessively sedated” and had some semi-falls.

The court accepted expert opinion that in allowing the patient in such a state to drive unattended, the psychiatrist and hospital breached accepted professional standards, and had not acted in a manner which would be widely accepted by peer professional opinion.

Hospital breaches duty of care

The hospital argued they had relied upon the fact the psychiatrist had authorised the patient to drive, as well as the patient’s own assessment of her capacity to drive and knowledge of the effects of the medication, given she was a registered nurse. The court rejected these defences.

The hospital was found to have breached its duty of care to the patient for permitting her to drive following discharge in circumstances where she was unfit to drive.

No basis for patient’s contributory negligence

The court rejected claims made by the hospital and psychiatrist against the patient that her actions constituted “contributory negligence”, by failing to take reasonable precautions against her risk of harm. The court found the sedating effects of the medications impeded her ability to make a responsible decision in the circumstances.

Key lessons

  • Doctors and hospitals have a responsibility to carefully assess the safety of their patients being discharged from their care. This includes identifying suitable arrangements for transport home and may require prolonging admission if no arrangements can be organised.
  • Doctors should remain aware of the risk of excessive sedation of patients taking psychoactive agents, especially in combination, and carefully assess their risk for harms. In preparing patients for discharge it is good practice to carefully review their use of sedating medications and other risky agents warranting special advice. This of course extends to showing caution when prescribing sedating medication in the community including sleeping tablets, strong analgesics and psychoactive agents, and adequately warning of the risks.
  • Doctors should always carefully document their assessments of patients, especially in higher-risk contexts such as transitioning from care. It is important to record the relevant positive and negative findings which would justify discharge and to outline the discussed options and agreed plan.

This article was originally published by Avant Mutual. You can access the original here.