West Australian Medical Negligence Law Blog

West Australian Medical Negligence Law Blog

Insights On Medical Negligence Issues From The Perth Area And Throughout Australia

I have been a lawyer for 21 years, during which time I have predominantly represented injured people in pursuing compensation claims. In the last 10 - 15 years, I have focused on medical malpractice / medical negligence law and particularly claims arising from negligent medical care. Read more

Agreeing Quantum in Complex Cases

Posted in Case Summary, damages assessment

Ellis v East Metro Health Service [2018] WADC 91

I read with interest the latest instalment in Judge Gething’s decisions in relation to this contentious birth injury case.  The substantive decision in the plaintiff’s favour is working its way at present to the Court of Appeal.  It will be interesting to see what our CoA makes of the matter and whether some of the more uncertain issues concerning the CLA are clarified.

In this latest decision, Judge Gething dismissed an application by the defendant to amend its defence following judgement.  In essence, the amendment sought to withdraw from an apparent ‘agreement’ in relation to various heads of damage.  Uniquely in my experience, agreement in relation to such heads of damage was given effect by amendments to the statement of claim pleading specific sums for non-pecuniary loss, etc, with admissions of such sums in the defence.

As may have only been appreciated late in the course of the trial, this would cause ‘difficulty’ in the event the trial judge found in the plaintiff’s favour but did not accept the plaintiff’s injuries and disability were all caused by the criticised aspects of management of the infant’s birth.  In other words, an intermediate outcome, between the plaintiff and defendant’s best cases.

It has to be said it is surprising if this was not appreciated earlier, given ‘causation’ was a primary ground for the defence of the claim.  The defendant hospital’s primary case was that the neonatal observations and especially the neuroradiology were inconsistent with a late-labour hypoxic injury as the cause for the plaintiff’s evident disability.

The plaintiff relied upon the ‘face’ of the admissions on the pleadings to assert that if the injuries, in whole or part, were found to have been caused by negligent care, the entirety of the agreed sums should be awarded.  Despite the fact appearances suggest this, it seems very unlikely this was the intended effect of the agreement by the defendant.

As things stand, the point is moot, because Judge Gething in his primary decision found the injuries alleged were indeed ‘all’ caused by negligent care.  This is however squarely the subject matter of the appeal and no doubt the defendant hopes such conclusions will be overturned. 

This will potentially create an awkward result if the pleadings cannot be amended, with, from one side’s perspective at least, a potential “windfall” for the plaintiff.

The decision raises the important practical question of how parties should seek to narrow quantum issues in medical negligence claims.  As here, there is often difficulty in agreeing quantum per se, given the common scope for causation issues and variable conclusions as to the nature and extent of negligently caused loss (as well as issues concerning contingency discounts, etc).

With careful thought, planning and unambiguous execution, narrowing the issues with potentially significant time and costs savings, should still be possible.  Unfortunately, this decision will not encourage defendants and their insurers in this respect.

Spinal Fusion surgery complications case won

Posted in Case Summary, Contemporary Medicine

In the decision Espinos v Popovic published by Judge Braddock on 8 August 2018, the run of successes by plaintiffs in  medical negligence claims continued.  Her Honour awarded damages to Mr Espinos in his claim against deceased neurosurgeon, Emile Popovic, in the sum of $4,817,311.

These are very high damages for a claim for negligent care surrounding a spinal fusion operation for a 55-year-old self-employed man, who, it was conceded, was appropriately advised to undergo a fusion at L5/S1.

The case provides an interesting and helpful summary of technical aspects of performing low back spinal fusion surgery, a common source of complaint and medical negligence claim.

Her Honour was obviously impressed with evidence given by local neurosurgeon, Andrew Miles, concerning appropriate technique intraoperatively and concerning the recurrent issue of malpositioned pedicle screws.

The case is a bitter reminder of the harm that can be caused by malpositioning of such a screw, even for a relatively short period of time.  In this case, it was ‘only’ 9 days before Dr Popovic repositioned the relevant S1 level screw.  Nonetheless, during such 9 days, it caused damage to Mr Espinos’ nerve causing permanent debilitating right leg pain which persisted even after such screw was repositioned.

The unhappy story for Dr Popovic was made worse by the fact that his initial surgery mistakenly fused the L4/5 level and stabilised the L3 level above.  This was performed despite it being clear the plan, and Mr Espinos’ consent, had been to a fusion at L5/S1.  Not surprisingly, it was admitted that Dr Popovic was negligent in operating at the incorrect level.  It was however denied that such initial surgery had contributed to Mr Espinos’ long-term poor outcome.

The most interesting aspect of the case from my perspective was Dr Miles’ evidence concerning the measures that should be taken intraoperatively and post operatively to avoid a malpositioned pedicle screw.

Her Honour rejected the commonly run argument that malpositioning of a screw is an accepted complication of such surgery and can occur even in the best of hands.  This was rejected because it was accepted that incorrect positioning could occur, but should be appreciated and rectified intraoperatively, particularly given the availability of modern 3D imaging in theatre at the relevant hospital (the Mount) and in any event, very shortly thereafter via appropriate post-operative imaging. 

This goes further than most cases – in which an initial failure to appreciate a malpositioned screw has been accepted as an unfortunate, but not negligent error.

In relation to Dr Miles’ evidence, see, for example, his clear explanation at paragraph 91 concerning the cause for damage to the relevant nerve if a screw is malpositioned in the nerve canal.  Further, in relation to the appropriate intraoperative steps to avoid a malpositioned pedicle screw, see at paragraphs 96 – 99.  He stated: “it is fairly obvious if a screw is badly malpositioned on intraoperative imaging, particularly 3D intraoperative imaging.

In relation to the benefits from intraoperative imaging, the defence neurosurgeon Mr Rogers, quoted at paragraph 128, accepted that the risk of screw malpositioning using traditional intraoperative image guidance varied from 1.6% to 6.4%.  He accepted with that with intraoperative CT imaging the result should be a return to theatre of 0%.

Also importantly, Dr Miles’ view, which Her Honour accepted, was that it was not sufficient, as the defence claimed, for a neurosurgeon to rely upon the assessment of post-operative imaging by the radiologist.  Such radiologist had not reported the malpositioning of the S1 pedicle screw, despite it being clear.

The surgeon was obligated to review the imaging first-hand and to make their own assessment and conclusions concerning the relevant screw’s positioning, et cetera.

Interestingly, it seems no contribution claim had been brought by Dr Popovic against the relevant radiologist for their failure to report the malpositioned L5/S1 pedicle screw.  The absence of such a claim perhaps indicated an acceptance of the attitude expressed by Dr Miles, that a neurosurgeon has primary responsibility to review the relevant imaging in any event, and it was a poor excuse to assert the radiologist’s failure to mention malpositioning had caused a failure to act more quickly.

Nonetheless, given Her Honour’s finding, a contribution would probably have been found against the radiologist, had such claim been made (because had they reported accurately, this would have ‘caught’ Dr Popovic’s error of either not reviewing or in missing the malpositioned screw).

All in all, a favourable decision from the patient’s perspective + confirmation this type of neurosurgical adverse outcome are (and should be) hard to defend.

Bariatric Surgery in UK – different patients, different justification..

Posted in Contemporary Medicine

I recently attended the AvMA conference in the UK.  AvMA is one of the UK’s peak bodies in medical negligence (or clinical negligence as they call it), law.

I would recommend the conference to anyone working in this area on the patient side.  Although there are inevitable differences, there is considerable overlap and perhaps warning in some aspects, as to where we may head.

Ironically, while our Civil Liability legislation continues to cause confusion about the role and meaning of peer practice standards (hopefully addressed by the High Court soon, noting Sparks v Hobson‘s special leave application is soon to be heard), the UK has moved away from peer standards (Bolam) in relation to advice/explanation obligations, following its leading case of Montgomery.  This essentially adopts our Rogers v Whitaker approach to advice/warning cases.  Understandably, a reasonable chunk of the conference was grappling with this change.

The conference was an excellent blend of legal v medical talks.

Amongst the excellent medical presentations, I enjoyed a talk by a bariatric (metabolic) surgeon who seemed generally surprised when I discussed with him following his talk, the range of candidates now undergoing bariatric surgery in Australia for ‘lifestyle’ reasons.

As his talk well demonstrated, there are compelling population-based advantages of bariatric surgery in those with significant comorbidities, particularly diabetes. The “bad rap” this form of surgery has in Australia, at least amongst lawyers, is in this sense unfair. There are great public health benefits from such surgery, provided the appropriate patient population are selected.  This is a big proviso…

Interestingly, he indicated that pre-surgery psychological workup, an essential part of appropriate practice in the UK, filtered out approximately 20% of candidates as unsuitable for such form of surgery.  I would be interested to know whether this is similar to the rate in Australia..  My impression (no more than this) is that this very rarely leads to rejection of an offer of surgery.

Forget CSI … the humble smartphone: the medical lawyers new best friend!

Posted in Contemporary Medicine, Our Cases

It is an old saying that a picture is worth a thousand words.

In the last week or so I have been reminded of this and the forensic usefulness of the modern era of smartphones and particularly phone cameras.

In the last week, on 2 entirely separate substantial claims we are investigating, smartphone-based photographs provide compelling evidence as to the condition of the relevant patients, not otherwise evident from the relevant medical records.

In the first case, the photographs taken by the parents of their newborn, including video footage, clearly demonstrates the child suffering seizures during the 1st and 2nd days of life, wrongly discounted as unconcerning “twitches” by the midwifery staff at the relevant country hospital.

In the 2nd, unrelated case, photographs taken by our client’s wife whilst he was a patient at hospital clearly demonstrate the patient’s appearance and grossly disturbed mental state, unrecognised and undocumented in the hospital records. He subsequently suffered a fall while unsupervised (falls remain, as they have been for 20+ years, the most common cause for potential medical negligence claims!).

In both of these cases, this recorded evidence (time and date stamped) may well be the difference between a claim being possible or not.

Traditionally, many, many cases could not be pursued because even though a patient’s claims would justify it, the relevant features were not noted in the medical records and because of the weight likely to be attached to the contemporaneous medical records.. This has been frustrating and unfair – the same reason worrying features may not have been documented after all being potentially the same reason they were not acted upon (ie they were not considered important).

In this context, all praise the smartphone (apple or android, we’re smartphone agnostic!), now 1 of the plaintiff medical negligence claimant and their lawyers best friends!

The Costs of Medical Tourism

Posted in Cosmetic Surgery (and Other Treatment), Our Cases, Uncategorized

I noticed with interest and some concern, recent media attention (see for example and a Herald Sun story in mid-May) concerning the number of Australians travelling to Asia to undergo cosmetic surgery.  According to a recent report, this may be 15,000 patients a year.

Concerns have arisen at the costs then borne by Medicare for remedial treatment for patients suffering complications of the procedure overseas.  According to a Monash Uni study, this is almost $13,000 per patient undergoing such treatment. This is a lot.  $13,000 involves a lot more than simple infection treatment etc.

This in combination with concerns from a public health and safety perspective about such completely unregulated and possibly unregulatable industry is obviously of significant concern.

Action against the surgeon/provider of sub-standard medical treatment overseas (noting “sub-standard” meaning below the standards that would be expected in Australia), will depend upon the law of the place in which such treatment is provided.  Even if, through ingenuity, claim could be brought against the surgeon/service provider in Australia, in the absence of any likely insurance, recovering any loss or compensation from a surgeon or clinic overseas would be problematic.

The only remaining option if a serious complication or other sub-standard outcome occurs, is to make claim against the local Australian promoter and facilitator for the overseas medical care.  A quick google search will net a whole bevvy of such ‘health travel agents’ with a flashy website promising a ‘Kardashian like outcome’ at a bargain basement cost (with a holiday thrown in!).

This is the avenue we have pursued on behalf of clients, with some, but not complete, success.  Such claims are essentially misrepresentation and misleading and deceptive conduct cases against the website operator.

Whilst ideally this sort of promotion would not be permitted or would be tightly regulated to ensure responsible and accurate statements about the risks and a fair evidence-based comparison between services provided overseas and those with a registered and insured local provider, in the absence of this, such mode of claim seems the best likely to be available, for now at least.

 

Case Review: 10 important medical cases since Jan 16

Posted in Uncategorized

I today presented a paper at conference providing a review of 10 recent Australian medical law cases since January 2016, which I found interesting.

Cases reviewed were: Coote, Bigg, Morocz, Westcott, Martin, Pierce, Sorbello, McManus and Stefanyszyn and Wright.

Although only a single Judge decision, I particularly noted the WA District Court Judge Sweeney’s decision in Wright v Minister for Health [2016] WADC 93, which is an interesting [if long] read as to the approach in considering a peer defence, under the Civil Liability legislation.

Apart from this case, I have not seen a case discussing what sort of evidence should be lead to establish a relevant practice is ‘widely accepted by the health professional’s peers as competent professional practice‘ (section 5PB(1)).

It supports my view that this should require more than : (A) an expert saying they think they know what their peers ‘widely accept;’ or (B) an expert saying he has asked a few colleagues and they agree that what was done was competent practice!

Anyone who would like a copy of the article, email me at julianj[at]jjlaw.com.au

Public Hospital Restructure (again!)

Posted in Contemporary Medicine, Our Cases

It is no doubt my age..  but I have an acute sense of deja vu!

As from 1 July 2016, we have ‘reverted’ to the old scheme of Boards of Management running our major hospitals (and geographic areas).  See the Health Services Act 2016 + the 30 June 16 Government Gazette.

The consequence, if I am right, is that the Minister for Health (not in this context the MP, but the entity incorporated as the relevant hospital board), was abolished and from 1 July 2016, any existing liability has transferred to the ‘new’ Board.  Strictly speaking, this should require an application to add/substitute the ‘new’ defendant.  I understand RiskCover are taking a pragmatic approach, to existing proceedings (provided served).

Anyone needing help with such an application, how to plead the transmission, let me know.. happy to help (I’ve been here before!)

Ian Harris’ book: whistle blown and common unnecessary operations listed

Posted in Contemporary Medicine, Our Cases

I read with interest the article in last weekend’s Sydney Morning Herald concerning Ian Harris’s recent book.

In the interests of full disclosure, Ian is an orthopaedic surgeon from whom we commonly seek advice, as an independent expert to review and comment on orthopaedic cases we are investigating. He strikes me as a sensible and “down-to-earth” expert.

I was intrigued at the list of operations which apparently his book confirms are commonly performed but objectively of questionable benefit. In the orthopaedic/spinal area, 3 of these particularly resonated, being spinal fusion operations, arthroscopies and epidural steroid injections.

Each of these are procedures we are regularly instructed to investigate. We presently handle a series of cases in which catastrophic outcomes have followed these initiatives.

I was particularly interested to read the sevenfold variation in the rate of knee arthroscopy surgery between different regions across Australia, which speaks volumes as to diverging views as to its usefulness.

We have handled 2 or 3 cases in the last couple of years in which patients have developed serious infection following such primarily investigative procedure, despite the fact it is I think fairly understood to be relatively low risk. One such case, which is not yet resolved, involves damages > $1M.

I was also interested to read in relation to epidural steroid injections, which are commonly performed upon patients complaining of back or leg pain, that the published literature shows no better relief from such steroid injections than a placebo saline injection. We are presently investigating one case in which a patient (our client) suffered profound permanent neurological injury from such an injection.

All credit to Prof Harris for his refreshingly questioning of professional practices in this area.

Quite apart from the unjustified drain upon the public purse, my observation would be that such questionable interventions are especially hard to justify when the outcome can be as catastrophic as we have seen, even if this is a small minority.

Fatal Accidents (which aren’t accidents) : the ‘missing’ claim

Posted in damages assessment, Our Cases

Coincidentally, in month or so before Christmas I have handled pre-trial settlement negotiations in relation to 2 similar cases, in the sense they both involved negligence allegations which it was claimed had led to the death of my clients life partners (in old fashioned speech: wives..).

Although the background and issues with the medical care were entirely different, the first thing that was notable in each case was the rawness and severity of their persisting anger and grief, despite the period that has elapsed (5 and nearly 10 years respectively) since my clients’ respective wives died.

As we negotiated in each case, there was an air of unreality. In particular, what was highlighted is the disconnect between the most profound aspect of loss suffered by my clients and the loss the Law is interested in and prepared to compensate.

In both case, my clients overwhelming concern and loss was the loss of their life partner and the dramatic change in their life’s trajectory because of this. In each case my clients were in early middle age with teenage children. Their predominant perceived loss was the negligently caused loss of their loving partner.

In contrast, the Law, when assessing compensation confined (it may be said distorted), the loss of such partner into 2 aspects:

• an evaluation of the replaceable services the deceased wife would have provided, essentially as unpaid child care worker and domestic servant.

• Insofar as my clients grief and suffering, the extent such suffering passes into the pathological and so can be labelled (at least according to traditional legal theory) a diagnosable psychiatric ‘injury’ (most commonly depression, anxiety or in some cases, post-traumatic stress disorder).

No compensation is paid for the ‘core’ loss they have (and other comparable claimants suffer) experienced in the loss of their life-partner (or parent), due to negligent medical care.
Whilst I understand the policy arguments for limiting recovery in psychological/emotional distress cases, the disconnect between the law and “reality” was highlighted by the totally independent incredulity expressed by each of these clients during this process seeking to negotiate resolution of their claims.

An example of the dangers of self-representation

Posted in Case Summary

My impression is that there has been an increase in recent times of cases presented before our District Court in which claimants have represented themselves, without a lawyer.

A sobering example of the dangers of this course, is the New South Wales Supreme Court’s recent decision in Fan -v- South Eastern Sydney Local Health District (No. 3) [2015] NSWSC 1620.

In this decision by Justice Harrison, the court dealt with the legal costs following failure of Mr Fan’s medical negligence claim.  Mr Fan parted company with his lawyers in May 2013, two years before trial. He was “assisted” in presenting his case by his son who it appears was a law student. Trial took 10 days in March and May 2015.

Justice Harrison ordered that Mr Fan pay the health service’s legal costs of the claim in the sum of $250,000. In part this followed the fact the defendant, it was disclosed, had made 3 separate settlement offers over the course of the proceedings, including offers to pay $100,000 and later $250,000 in settlement of Mr Fan’s claim, which offers had been rejected.

This must have added insult to injury for Mr Fan.  Not only did he lose his claim, but he did so having rejected such settlement offers from the defence.

As stated earlier, this seems to be a growing trend for plaintiffs, for whatever reason, to seek to present their own cases at trial. Whilst presenting the case in person avoids costs of the plaintiff’s own legal representation, as this case clearly demonstrates, the plaintiff nonetheless still faces the risk of being ordered to pay a very substantial sum to the defendant if the claim does not succeed.

Note as a measure of the costs expended, the $250,000 is actually slightly less than 1/2 the total legal costs incurred by the defendant in relation to the case which was stated as $512,250.83…