This question comes from a volunteer with St John Ambulance (NSW) who asks:
I am a St John Ambulance volunteer and also work for a private pre-hospital care service provider here in NSW.
Quite a few times in my career with the private sector as well as on duty with St John I have been in situations where people have attempted to take over or keep me from providing treatment to a patient by proclaiming: “I am a doctor/nurse”.
This has happened in different scenarios for example, coming across an accident and a person in scrubs and with hospital ID to a loud proclamation from a friend of a patient at a party or even just a bystander on a soccer field.
Neither my company nor St John have a clear policy to deal with this nor as far as I understand has any other service. Even ASNSW (upon asking) seem to deal with this case by case.
My question to you would be if there is any legal writings on this scenario at all? You can generally have a good guess at who is actually a doctor/nurse and who isn’t, based on their behaviour but I myself have never been a particular fan of handing over the care of a patient to someone who I cannot identify clearly.
Also I wonder if there are any consequences for those who show up and claim to be health care professionals but aren’t?
There are some important first principles here. The first is that doctors or the medical profession don’t ‘own’ health care, others such as nurses, paramedics and first aiders don’t practice their art at the direction of, or with the permission of doctors (see earlier discussions in ‘Doctors delegating authority to carry drugs’ (20 August 2014) and ‘What is a paramedic’s ‘authority to practice’?’ (19 August 2014)).
Second no-one ‘owns’ the patient. The issue must always be what is in the patient’s best interests or who is best able to provide the care that the person needs.
Let me then turn to the law and let me assume the patient cannot consent (because if they could consent they could chose who they wanted to accept care from). The case about treating those who cannot consent is In Re F [1990] 2 AC 1 where Lord Goff said (emphasis added):
The basic requirements, applicable in these cases of necessity, that, to fall within the principle, not only (1) must there be a necessity to act when it is not practicable to communicate with the assisted person, but also (2) the action taken must be such as a reasonable person would in all the circumstances take, acting in the best interests of the assisted person.
On this statement of principle, I wish to observe that officious intervention cannot be justified by the principle of necessity. So intervention cannot be justified when another more appropriate person is available and willing to act; nor can it be justified when it is contrary to the known wishes of the assisted person, to the extent that he is capable of rationally forming such a wish.
If there is a person who is unconscious, anyone can help and commits no battery if they do help but not if their intervention is officious that is ‘another more appropriate person is available and willing to act’. That begs the question of who is the more appropriate person and I would suggest that is not necessarily a doctor.
If the person is at a public event where the St John Ambulance is in attendance and contracted to provide the health care services, then the St John staff are the appropriate people to help. An off duty doctor or paramedic, or nurse has no right to insist that they hand over care to them and why would they want to? They would then get ‘stuck’ with the person, what are they going to do with them? Assume the person giving care is a paramedic with their ambulance, a doctor isn’t going to want to have to drive the person to hospital; they need to go by ambulance so the ambulance officer is the appropriate person. A position made even clearer by the fact that the state ambulance service is the authority established to provide that purpose (see, for an earlier discussion of the relationship between a doctor and the ambulance service, my article ‘Doctors, the Duty to Rescue and the Ambulance Service‘, (1999) 10 Current Therapeutics 92-95).
Equally however, if a person with first aid training comes across a scene and sees people caring for the injured and the person appears to be a doctor, then they could stop you providing care – just as if you are on St John duty a doctor has no right to push you aside; if a doctor is treating an accident victim, you have no right to push them aside. In short it is not the case that a doctor always is, or is not, the more appropriate person to provide care. It will depend entirely on the circumstances, eg if there is an off duty first aider and an off duty doctor at a car accident then one might expect the doctor to take charge; it would be different if the doctor was off duty at a public event and St John were the contracted first aid providers, and very different if the issue is between a doctor and an ‘on duty’ NSW Ambulance paramedic.
The NSW ambulance paramedic would be in a different position by virtue of the role of the ambulance service and the provisions of s 67J of the Health Services Act 1997 (NSW) which says:
A person must not intentionally obstruct or hinder an ambulance officer when the ambulance officer is providing or attempting to provide ambulance services to another person or persons.
In Western Australia two St John Ambulance officers (remembering that St John provide the ambulance service in that state) attended a call to a person collapsed in a medical centre carpark. On arrival one of the doctors was attending to the patient. In a complaint under the Equal Opportunity Act 1984 (WA) (Zangari and St John Ambulance Service [2010] WASAT 6 (25 January 2010)):
Dr Zangari [said] that on 6 July 2006, the ambulance officers, as employees of SJA, discriminated against her on the grounds of her race when they provided ambulance services to her. She says they dismissed her, ignored her and were rude to her. She relies on an inference that there is no other reasonable basis to explain the ambulance officers’ actions, other than that they had a stereotypical view of who they were dealing with and their stereotypical view was based on race. She says they therefore treated her less favourably than they would have treated someone who was not Italian, and it would seem, particularly a doctor who was not an Italian.
The State Administrative Tribunal of Western Australia found that the Doctor did not have standing to bring the complaint as St John was not providing a service to her, but to the person in need. That’s the technical legal answer but there are some interesting observations relevant to our discussion.
First (at [187]) the tribunal said: ‘Dr Zangari seems to argue that she is in a special position with SJA because she is a medical practitioner. We agree she should be treated with respect and regard should be had for her status as a medical practitioner. But it does not put her in a special or different position when considering the nature of her connection with SJA.’ The Doctor was not a ‘conduit’ between the patient or St John, she was just a bystander who happened to be a doctor. She argued that part of the relationship is that she arranged for the ambulance to be called to ‘have the patient attended to under her supervision and transported to hospital’. The tribunal rejected the idea that the paramedics would treat the patient ‘under her supervision’.
The Tribunal went on to say:
190 … It was acknowledged and we find that on arrival, the ambulance officers are entitled, if not required, to take charge of the situation; which is what the ambulance officers correctly did on arrival at the surgery; they have the primary conduct of patient care and in this case, Ms Howell was the attending paramedic and also the primary person in charge: (see [5] of Ms Howell’s witness statement). The medical practitioner takes a step back once an ambulance arrives, allowing the ambulance officers to attend to the patient and provide what is needed. We have found that this did not happen in this case. The patient becomes SJA’s patient and for the purposes of the particular incident is no longer the medical practitioner’s patient, regardless of the physical location of the patient. For ambulance officers, patient care is their first priority and we find that when the ambulance officers went to the surgery, Mr L was their first priority and they were primarily focused on him and his needs, and accordingly, devoted their attention and skills to him.
191 The role of the medical practitioner is to provide patient and other pertinent information and medical or other assistance if required, by the ambulance officers. It would be good practice if the medical practitioner does what they can to facilitate patient diagnosis and care by the ambulance officers. It would certainly be pertinent and helpful for a doctor present at the scene to identify themselves as such, particularly if they are the patient’s treating doctor. There is no stated policy document or procedure (of which we are aware) that requires ambulance officers to seek out or engage the assistance of a medical practitioner if they are called to provide assistance at a doctor’s surgery (as was the case here), or indeed at any place where a medical practitioner is present. It might be common sense to do so, but it is a discretion exercisable by the ambulance officers based on their appraisal of the situation they are attending and on the needs of the patient, and on the ability of the patient to provide the required information.
192 We have found, on the facts, that the ambulance officers did not require information or assistance from Dr Zangari because they gathered adequate and appropriate information from the patient as was the correct procedure in this particular situation; in the third, fourth and fifth allegations, Dr Zangari is critical of the ambulance officers for not ‘engaging’ her ‘assistance’ at various times throughout the period they were attending to Mr L in the car park. But she offers no detail of what ‘assistance’ she could have given or should have been allowed to give nor does she explain how the ambulance officers, acting on a priority one callout, could have ‘engaged her assistance’. The ambulance officers did not require assistance from Dr Zangari as they concluded either that they did not need any assistance or that Dr Zangari was incapable of providing any sensible assistance because she was emotive and panicstriken. Dr Zangari did not provide any convincing evidence of what assistance she could have provided to the ambulance officers or Mr L if requested by the ambulance officers…
That’s not a binding precedent but it appears to be a sensible approach, whether the person providing care is a St John volunteer at a public event or a paramedic responding to a triple zero call.
Having said that no-one should stand mute if the person giving care is going to make a mistake. A doctor should intervene if the first aider or paramedic is going to harm the patient and equally a paramedic or first aider should intervene if a person who claims to be a doctor is clearly going to harm the patient. Professional modesty should not stand in the way of protecting a person against poor care.
Are any consequences for those who show up and claim to be health care professionals but aren’t? Absolutely. A person who steps out of the crowd in order to assist may want to rely on the good Samaritan provisions in the Civil Liability Act 2002 (NSW). Section 57 says:
A good samaritan does not incur any personal civil liability in respect of any act or omission done or made by the good samaritan in an emergency when assisting a person who is apparently injured or at risk of being injured.
Section 58(3) goes onto say (emphasis added):
This Part does not confer protection from personal liability on a person in respect of any act or omission done or made while the person is impersonating a health care or emergency services worker or a police officer or is otherwise falsely representing that the person has skills or expertise in connection with the rendering of emergency assistance.
If they are sued then, as the High Court said in Rogers v Whitaker (1992) 175 CLR 479 ‘The standard of reasonable care and skill required is that of the ordinary skilled person exercising and professing to have that special skill’. So if a person claims to be a medical practitioner and they are not, they get no protection from s 57 and if they were sued the question would be ‘did they act as the reasonable medical practitioner’ because that is the skill they ‘professed’ to have.
Australian Emergency Law 
Good discussion topic on liability.
A couple of years ago (maybe 3) I was walking home from work in the evening; when a driver rolled her car on the off ramp for the ICB in Brisbane; just 300m South of the largest Hospital in Brisbane. She was still in the inverted car, alive and able to carry a conversation. The inverted car was on a blind exit off ramp, with oil and petrol over the ground and dripping over her and the car.
Surprisingly there was enough power in my almost flat mobile for one 000 call.
My choice was the fire brigade.
The passenger had gotten out, and I suggested he help extract her.
There was nothing I could do for her so my choice was to flag down any cars coming off the bypass before they crashed into them. That included the fire brigade too. When it looked like there was a clear gap on the freeway a minute or so later; I ducked back to check she was out and not on fire. Two persons who acted professionally and identified them selves as doctors had showed up and where providing medical assistance until someone arrived. I went back to flagging down cars entering the off ramp and then left just after the fire brigade arrived.
Despite several decades of First Aid Training, if someone else looks like they can handle it, they are welcome to help.
The original contributor has added:
If your employer has hired your company to provide patient care, you simply can’t hand over that responsibility to a doctor whether your sure they are one or not. Doctor’s don’t outrank other health professionals, they’re just different health professionals. If your service is contracted to provide the care and you are treating a person then you are responsible for the care provided. As the care coordinators you may well ask others to assist, so if a person identifies themselves as a doctor and can help with the care there is no harm in taking their assistance, but even if they are largely running the care, your service is still there, you can’t ‘hand over’ in the sense of abrogating any care or responsibility.
It begs the question of why would you want to, and why would any doctor want to take on that care? You hand over when you are delivering the patient to someone else, perhaps the ambulance crew to transport to hospital or mum or dad to take them home.
I just can’t imagine why two contracted ALS paramedics would ever ‘let a doctor take over patient care’ whether you knew they were a doctor or not. You would let the doctor assist you if they could and if the assistance was helpful. If the doctor is the patient’s friend and is going to take them home, then they’re looking after their friend, because they are a friend, not because they are a doctor.
You and your employer simply cannot abrogate one’s responsibilities like that. If you let someone who claims to be a doctor ‘take over’ the patient care, whether they are or not, and there is an adverse outcome questions will be asked but whether that equates to liability would depend on the circumstances.
I received this further comment by email:
My advice would not be any different in Queensland. I can’t imagine that QAS or first aiders on duty would ever accept someone, no matter who they are, telling them the person is dead and leaving it at that. They would have to make their own assessment. All the Australian states (other than WA) have adopted a uniform definition of death. The definition is for the purpose of transplant procedures but is, of general application. In Queensland the Transplantation and Anatomy Act 1979, s 45 says:
One can’t be sure that either (a) or (b) are true unless one checks and people who appear dead (eg in cardiac arrest) are not in fact dead if their circulation can be restored by appropriate care, care best provided at the road side by an advanced life support paramedic and, pending their arrival, by someone doing CPR. That does not mean one has to attempt resuscitation on everyone and ambulance services have their protocols on when resuscitation may be withheld; but it is not up to a doctor, or anyone, to tell the paramedics – “this trauma victim is dead; take my word for it”. (The situation may be different if the person is being treated by the doctor at the end of a terminal illness, but in that case why are the paramedics there?)
The same is true for first aiders on public duty. They are the ones charged with providing immediate care, the appropriate response is to thank the doctor, ask them to step aside, examine the patient and decide whether your treatment protocols call for resuscitation or not.
As for a doctor (assuming they really are a medical doctor) taking the lead again one has to wonder how or when that might happen. It should not happen when the ‘less qualified’ person is from the state ambulance service, unless the doctor is going to transport the person to hospital they’re going to have to let the ambulance service officers take the lead, so as in Western Australia the expectation is that the doctor should step back and offer to assist.
That would also be true at a public event when the first aiders attend.
The real issue is the patient’s best interests. A person may be a doctor but they may be next to useless or worse, dangerous. If they, like Dr Zangari in Western Australia are not coping with the situation and making the matters worse, a trained first aider, and ambulance paramedics, could and would be justified in trying to get them away from the scene. On the other hand if a trained first aid or off duty paramedic appears at a car accident and there is a person who is competently managing the patient care you would expect the first aider/paramedic to identify themselves and offer to assist, just as you would expect a doctor to do if the first aider or paramedic was first on scene. It’s a matter of trying to work out, in the ‘heat of battle’ who is who and what people can offer. It should never come down to people pushing others out of the way in the rush to get to the patient except where the people doing the ‘pushing’ are the on duty state ambulance officers with the statutory authority and obligation, as well as the practical obligation, to take control as they ultimately have to put the person in the ambulance and take them to hospital. As the State Administrative Tribunal of Western Australia said “It was acknowledged and we find that on arrival, the ambulance officers are entitled, if not required, to take charge of the situation…” Whether the person is an on or off duty first aider, an off duty paramedic or a doctor, when the ambulance service turns up, they have to be prepared to ‘hand over’ to that service but those officers can take whatever assistance is offered if it will help.
In Queensland that position is reinforced by the Ambulance Service Act 1991 (Qld) s 38 which gives special powers to Queensland ambulance officers including the power to ‘request any person to take all reasonable measures to assist the authorised officer’ which presumably could be to step aside, or hold the drip in order to stop them doing something less useful. Further s 46 makes it an offence to ‘willfully obstruct or hinder any person acting under the authority of this Act’.
Your correspondant is incorrect. All ambulance services in Australia have policies and procedures for dealing with other health professionals (Doctors Nurses and others) who offer or even demand to be part of the care of a patient.
It is often a difficult situation
Thanks Malcolm, I wonder if you can point to any relevant policy, perhaps NT has one online?