Wednesday, January 06, 2010

A Brush with the Law

It was a tragedy. It caused huge grief and distress, made much worse by lawyers.

One Thursday afternoon was on the ward. I had an urgent call to casualty. I was not the physician on call, but I was there.

The emergency ambulance had been brought a 12 years old boy in cardiac arrest.
His class was at the swimming pool. He was in a group of boys who urged each other on to race across the pool, underwater. He reached the far side, began to pull himself out of the water, then gave a cry and fell back in.
He was quickly rescued; he was unconscious, breathing, but no pulse and no heart beat. A teacher and the pool attendant gave external cardiac massage, then mouth-to-mouth became necessary.
An ambulance arrived within minutes. The paramedics continued resuscitation during the journey to hospital. He arrived there maybe 20 minutes after the incident began.

The casualty doctors intubated him, and gave oxygen. There was no heartbeat; an ECG showed no electrical signals from the heart, the condition of asystole. Drugs and electrical shocks failed to start the heart. After 40 minutes increasingly desperate effort the boy's pupils were fixed and dilated; there were no signs of life.

They needed a consultant to declare the boy dead. This was my responsibility, and my duty. I remember a student nurse pulled her apron over her face, and ran out.

I spoke to the teacher who had given first aid. She was in her 30's, I guess, shocked and distressed in the office. I told her the bad news. I reassured her she had done skilfully everything that could be done; it was a rare catastrophe, which could not have been foreseen; in no way should she consider herself at fault.

Some weeks later I was notified the date of the inquest into the death of the boy. The casualty officer was required to attend, I was not. Nevertheless I told the coroner's officer that I would be there.

I drove to the place of the inquest in a neighbouring small town. I noticed a large, dark-blue Rolls-Royce car in the parking area. A warning bell rang in my head.
The inquest was conducted without a jury by the coroner, a gentle, elderly doctor of many years' experience. The boy's parents had briefed a Queen's Councillor, a senior barrister. He was a big, heavy, dominating figure in a lawyer's suit - black jacket and waistcoat, striped trousers, white shirt.
No one else was legally represented.
It is important to remember that an English inquest is to determine cause of death. It is not an adversarial institution. It is not there to apportion guilt or blame.

The facts of the event were quickly established. The casualty officer attested that similar cases had occurred, and are described in the medical literature, but they are very rare.
The theory is that excited boys overbreathe before the dive, in the belief they will have more oxygen, and increase their duration underwater. But in so doing they can substantially reduce blood carbon dioxide concentration, which is the main driver of respiration. In such circumstances vigorous exercise may deplete blood oxygen dangerously, before carbon dioxide has increased enough to make respiration feel urgent. Cardiac arrest is a recognised hazard in this condition.

Then the barrister stood up, and began a sustained attack on everyone concerned with the case. He criticised the manager of the pool: the water temperature was 72 degrees Fahrenheit, too cold for safety, he asserted. He criticised the local authority: they had ordered the pool to be run at this temperature to save money. He criticised the casualty officer for not persisting longer with resuscitation.
Worst of all, he laid into the two women teachers. They should not have taken the class swimming when the water was so cold. They should not have allowed the boys to swim under water. Their negligence had caused this tragedy. He reduced them to tears. I was appalled.
He finished and sat down. The court room was silent.

After a few seconds the coroner asked if I would comment on the way the event had been handled by the teachers. I used words such as exemplary; I stressed they were no way to blame. The QC rose and demanded that I agree that swimming under water is inherently dangerous: I said that crossing the road and riding a bicycle were dangerous, if that standard was right. Did I think it was a duty of teachers to stop boys swimming underwater: I had boys of my own, I had no worries about them swimming underwater, and in any case, boys are boys, how do you stop them?

The coroner asked me if a pool at 72 degrees was too cold for children to swim. No; this is normal summer sea temperature around Britain, it was a temperature for comfortable swimming. The QC challenged me again: the death of this boy was evidence the water was too cold. I rebutted that: I nearly said 'rubbish'. Surely the local authority should now run the pool warmer; no again.
I kept my cool with difficulty. He glared at me and sat down.

He did not challenge the coroner's summing up and verdict of accidental death. The coroner repeated to the teachers that they had done all they could, and were in no way to blame for the death. The QC, the instructing solicitor, and the boy's parents walked out. I saw the QC drive off in the Rolls Royce.

I spent a few minutes comforting the teachers again. I went home outraged.

Never will I pardon that QC. An honourable professional would have advised this was not a case for him. I wonder how much he charged the parents.
I suspect a tougher coroner would have controlled him. Much blame must go to the instructing solicitor: if the parents had requested a legal representation he should have acted himself; bringing in a pit-bull barrister was cruel and wrong.

Physicians and lawyers have a difficult relationship. Physicians must manage the health problems of individuals, often in distressing circumstances, and often must decide despite incomplete information. Medical practice is degraded if physicians worry about possible judgements of lawyers blessed with hindsight, taking one side of the case, in comfortable offices, months later.
Physicians and lawyers share one proverb, to often forgotten in these days of compensation culture.

Bad cases make bad practice.

Barristers, I'm told, have an unofficial motto: "It pays to be a bastard".

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