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.
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
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.
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
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
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
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
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.
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
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.
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.
- 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
- 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
Download our factsheet: Discharge from day surgery.
need further guidance, call the Avant Medico-legal Advisory Service on 1800 128 268.
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