Neville Knowles, JNR v South East Regional Health Authority

• Jurisdiction: Jamaica
• Judge: Wint-Blair, J
• Judgment Date: 11 January 2019
• Neutral Citation: [2019] JMSC Civ 3
• Docket Number: CLAIM NO. 2012 HCV 06568
• Court: Supreme Court (Jamaica)
• Date: 11 January 2019

IN THE SUPREME COURT OF JUDICATURE OF JAMAICA

CLAIM NO. 2012 HCV 06568

BETWEEN:

Neville Knowles, JNR (Administrator of the estate of Neville Knowles)

Claimant

and

South East Regional Health Authority

1 ^st Defendant

IN CHAMBERS

Mr. Nigel Jones and Ms. Lianne Chung instructed by Nigel Jones & Co. for the Claimant

Ms. Tamara Dickens instructed by the Director of State Proceedings for the Defendants

NEGLIGENCE - MEDICAL NEGLIGENCE — LAW REFORM (MISCELLANEOUS PROVISIONS) ACT — FATAL ACCIDENTS ACT

Wint-Blair, J

1 This claim has been decided after a considered review of the documents filed by each party, the viva voce evidence and the written submissions of counsel. I am grateful for the industry of counsel appearing in the matter for agreeing all the evidence in the matter, as this assistance has been invaluable. There is certainly no intent to disregard the comprehensive written submissions filed at each and, every point raised has not been reproduced here. This decision does not attempt to capture all that has been presented in the way that it has been and is instead issue based.

2 The claimant is the son of the deceased Neville Knowles. By way of an Amended Claim Form filed on February 26, 2016, the claimant sought;

• a. Damages under the Law Reform ( Miscellaneous Provisions) Act on for the estate of the deceased;

• b. Damages under the Fatal Accidents Act on behalf of the Dependant;

• c. Special damages amounting to in excess of $20,000.00, along with sums spent for funeral expenses.

• d. Interest thereon as at such rate and for such period as may to the Court seem just pursuant to the Law Reform ( Miscellaneous Provisions) Act.

3 In his Amended Particulars of Claim, the Claimant pleaded that Neville Knowles died as a result of the negligence of the Second Defendant as at all material times he was under their care. The Claimant set out particulars of breach of contract and or breach of statutory duty and or negligence as follows:

• - Failing to adopt the correct/ appropriate medical procedure on Neville Knowles in the circumstances;

• - Failing to commence venous thromboembolism prophylaxis on Mr. Knowles upon admission;

• - Failing to realize that the administration of venous thromboembolism prophylaxis may have reduced the possibility of deep venous thrombosis and thereby a fatal pulmonary embolism;

• - Failing to take Neville Knowles' risk factors into consideration in deciding the medical procedure to adopt

• - Failing to realize that Mr. Knowles had the following risk factors: age, comminuted fracture of the femur and a delay between injury and surgical procedure;

• - Failing to provide surgical procedure on the deceased until 11 days after the he received the gunshot;

• - Causing Mr. Neville Knowles to die from pulmonary embolus;

• - Failing generally to provide adequate and reasonable care to Neville Knowles;

• - Failed to advise Mr. Knowles that a delay in the surgery can cause serious complications and can cause him to die;

• - Failed to explain to Mr. Knowles that the he had other risk factors that could cause him to die.

4 Both sides very helpfully agreed all the evidence in this case with brief crossexamination of two witnesses. Both sides also agreed that this case would turn on the applicable law.

5 The claimant gave evidence via live link and said that his father was sixty-three years old and a retired police officer earning a monthly pension of $35,000 per month when he died. Mr. Knowles had been admitted to the Kingston Public Hospital (“KPH”) on November 20, 2009 with a self-inflicted gunshot wound. He was taken into surgery on December 1, 2009 and died on that day at 1:38pm. The agreed post mortem examination report of Dr. Dinesh Rao, Consultant Forensic Pathologist, dated December 10, 2009, under the heading cause of death listed the following;

• I. (a) Acute pulmonary emboli

• (b) Deep vein thrombosis

• (c) Left ventricular hypertrophy

• (d) Chronic ischemic heart disease

• II. (a) Gunshot wound to the leg

• (b) Artherosclerosis

6 The claimant claims that the death of the deceased was caused by the negligence of the first defendant, their servants and or agents in that they failed to provide proper or appropriate treatment to Neville Knowles, which caused his death. The claimant asserts that the recommended protocol for an individual with the deceased's risk factors was to commence venous thromboembolism prophylaxis (“VTEP”) on admission and that this had not been done.

The Evidence

7 Mr. Knowles was examined at approximately 8:30pm on November 20, 2009 by Dr. Jason Copeland, junior surgical resident, orthopaedic rotation. The significant clinical findings upon examination revealed:

“His scrotum was swollen and tender with blood oozing from two wounds to his scrotum; the wound to the left half of the scrotum a likely entry wound and to[sic] one to the right half a likely exit wound. Two wounds were noted to the right thigh; one to the upper medial third a likely exit wound. Two wounds were noted to the right thigh; one to the upper medial third a likely entry wound and another to the medical[sic] aspect of the proximal right knee a likely exit wound. These wounds were also noted to be oozing blood a non-expanding haematoma was appreciated around the wound to the upper right thigh…

…His admitting blood results were: haemoglobin of 13.8g/dl, a white blood cell count of 6.0 and a platelet count of 179. The follow up complete blood count revealed a fall in his haemoglobin level to 11.7g/dl confirming the loss of blood from his injuries.”

8 The following morning, Mr. Knowles was seen by Dr. Melton Douglas, orthopaedic consultant. Dr. Copeland reviewed his findings with his senior, Dr Douglas. The decision was taken not to commence the administration of anticoagulant drugs to include Heparin as they are contraindicated in a trauma patient with ongoing blood loss.

9 The agreed medical report of Dr. Melton Douglas, orthopaedic consultant, dated December 30, 2009, stated that Neville Knowles was admitted to the Steventon Ward of the KPH on November 20, 2009 following a gunshot wound. The salient portions are as follows:

“The bullet went through the scrotum before entering the right lower thigh. …Entry and exit wounds were noted to the scrotum and right thigh and were also swollen…X-ray of the right thigh confirmed a comminuted fracture of the right lower third of the femur. Mr. Knowles is a known hypertensive on medication…

His blood studies showed Hb = 13.8, WBC = 6, Platelet 179 on November 20, 2009. The repeat blood test done the following day showed a Hb of 11.7. He was prescribed antibiotic Rocephin for 3 days, Voltaren and Panadol for pain, Enalapril for his blood pressure, and Federgel as a replacement for Zantac that was unavailable. He was not on Heparin.

The life threatening injuries done on the emergency list would make it impossible to have his surgery done on the emergency list on the day of admission.

Skeletal traction was applied through a tiabial[sic] pin that was inserted on November 20, 2009. Mr. Knowles was taken to the Operating Theatre on November 22, 2009 by Dr. Dunbar, the Urologist and under general anaesthesia had the left testes removed. His orthopaedic surgery could not be done at the same sitting because the locked intramedullary nails costing over one hundred thousand dollars are not available in the hospital for routine use. They would have to be acquired through the hospital procurement procedure or by the relatives.

He was advised surgery to the right femur. A retrograde locked intramedullary nail was needed for the surgery to fix his fractured femur. The request was sent to the procurement office of the KPH. The relatives and the procurement officer met and the nail was made available. His ECG was done on November 26, 2009 Mr Knowles was schedule[sic] for surgery on November 27, 2009 but the operating time was exceeded before we could get to him. He was rescheduled for December 1, 2009.

He was taken to the Operating Theatre on December 1, 2009 at 11:30am. and under general anaesthesia had a retro=grade[sic] locked intramedullary nail inserted. The blood loss was relatively low. Near to the end of the surgery the anesthetist expressed concern over his unstable vital signs. The surgery was completed while the anesthetists were assessing and treating him. The details would be best reported by the anesthetist, but in essence had a fall in blood pressure and a suspicion of pulmonary embolism made. Attempts at resuscitation with a full complement of anesthetic[sic] consultant[sic] and staff and the Orthopaedic team failed to resuscitate him. Drugs, deffrillator[sic], cardiac massage, were all utilized in his resuscitation. The resuscitation went on for 30 minutes but failed. He was pronounced dead at 1:38p.m. on December 1, 2009.

A post mortem was requested to confirm the cause of death.”

10 The claimant relied on the expert evidence of Dr. Christopher Rose, consultant orthopaedic surgeon, who produced a medical report dated December 16, 2010. In his report, Dr. Rose set out the medical history of the patient pertinent to his admission at the KPH and that he had reviewed the report of Dr. Melton Douglas. The report authored by Dr. Rose significantly stated that:

“On admission, appropriate blood investigations were requested and he was placed on parenteral Rocephin for three days as well as analgesics. No venous thromboembolism prophylaxis was commenced according to the medical report submitted by Dr. Melton Douglas.”

TREATMENT

… The post mortem revealed a thrombus in the posterior tibial vessel and thromboemboli in the pulmonary artery of the right lung. The cause of death as stated in the post mortem report was a pulmonary embolus.

COMMENT

Venous thromboembolic disease is a leading cause of death and morbidity (1,2). For the orthopaedic surgeon this disease has...