Emergency Medicine (A&E): Common Areas of Clinical Negligence

Emergency departments see more patients, under more time pressure, with less background information than almost any other part of the hospital — and that combination makes A&E one of the fastest-growing sources of clinical negligence claims in England and Wales.

Why Claims Arise in This Area

Emergency medicine claims are shaped as much by system pressure as by any individual clinician's competence: overcrowding, corridor care, and boarding of admitted patients awaiting beds all increase the risk that a deteriorating patient is not reviewed in time. The standard expected is that of a reasonably competent emergency physician working within Royal College of Emergency Medicine (RCEM) and NICE guidance, applied to the information actually available at triage and initial assessment — not to the diagnosis that later became obvious with the benefit of further tests or hindsight.

Common Areas of Negligence

Missed time-critical diagnoses

A recurring pattern in emergency medicine claims is the condition that presents atypically and is filtered out too early. Myocardial infarction is dismissed on the strength of a single normal ECG or troponin without a repeat test at the appropriate interval; pulmonary embolism is not investigated because a formal risk score (such as the Wells score) was never applied; a 'worst headache of my life' is treated as migraine without the CT and, where appropriate, lumbar puncture needed to exclude subarachnoid haemorrhage; and aortic dissection is treated as a straightforward cardiac presentation because the two conditions share overlapping symptoms. In each case, the claim usually turns on whether the recognised diagnostic pathway for that red-flag presentation was actually followed.

Inadequate triage and escalation

Initial triage (commonly the Manchester Triage System or a local equivalent) is designed to identify patients who need to be seen urgently, but it depends on accurate, complete information being captured and correctly interpreted at the point of first contact. Claims frequently arise where a patient is triaged into a lower-acuity category than their presentation warranted, or where a junior doctor's assessment is not escalated to a more senior clinician for a presentation that guidance specifically flags as needing consultant or senior registrar input — a gap that widens considerably during night shifts and periods of high demand.

Failure to act on deteriorating observations

The National Early Warning Score (NEWS2) exists precisely to flag a patient whose physiology is trending in the wrong direction before they reach crisis point. Claims commonly involve a NEWS2 score that was recorded correctly but not escalated in line with the trust's own escalation policy, or observations that were simply not repeated at the frequency the patient's condition required — a particular risk for patients held in corridors or overflow areas awaiting an inpatient bed, where nursing-to-patient ratios and monitoring equipment are often stretched thinnest.

Missed fractures and dislocations on imaging

Certain fracture patterns are notoriously easy to miss on an initial X-ray. Scaphoid fractures often are not visible until repeat imaging at ten to fourteen days, which makes the initial management plan — immobilisation and safety-netted follow-up despite a normal first film — as important as the film itself. Paediatric growth-plate (Salter-Harris) fractures and elderly hip fractures without obvious deformity are similarly prone to being missed, and claims often centre on whether the clinical suspicion justified by the mechanism of injury or examination findings was matched by an appropriate imaging or follow-up plan even when the first X-ray looked normal.

Inadequate discharge and safety-netting

A clinical decision to discharge can be entirely reasonable on the information available, and the claim can still succeed if the safety-netting around that discharge was inadequate — no clear written advice on what symptoms should prompt a return, no follow-up arranged where the presentation warranted it, or discharge information that was not adapted to a patient's ability to understand and act on it. Because the initial assessment is often defensible in isolation, safety-netting failures are one of the more commonly overlooked elements of an A&E claim, and one experienced experts routinely scrutinise closely.

Delayed recognition of sepsis

NICE guidance (NG51) and the 'Sepsis Six' care bundle set out a clear, time-bound pathway once red-flag sepsis features are identified: blood cultures, lactate measurement, oxygen, intravenous fluids, and antibiotics within one hour, with close monitoring of urine output. Claims typically arise where red flags were present in the notes but the bundle was not commenced promptly, or where a patient was reassessed too infrequently to catch the point at which they crossed from at-risk to septic.

What the Law Requires

As with any clinical negligence claim, a bad outcome is not, of itself, evidence of negligence. The legal test of breach asks whether the care fell below that of a reasonably competent clinician practising in the relevant field at the time (Bolam v Friern Hospital Management Committee), and whether that view would withstand logical scrutiny (Bolitho v City and Hackney Health Authority). Where the claim concerns what a patient was told about risks and alternatives before treatment, the test is different: Montgomery v Lanarkshire Health Board requires that a patient be told of any risk to which a reasonable person in their position would attach significance, judged from the patient's perspective rather than a standard clinician's script. On causation, the claimant must generally show that the breach made a material difference to the outcome — though in some multi-cause or cumulative-harm scenarios, a material contribution to the injury can suffice.

What Good Expert Evidence Establishes

Because A&E cases usually hinge on a single moment of clinical decision-making, expert evidence needs to reconstruct precisely what information was available to the treating clinician at the time and what a reasonably competent emergency physician would have done with it. Many claims also require a second expert in whatever specialty the missed condition falls under — a cardiologist for a missed myocardial infarction, or a neurosurgeon for a missed subarachnoid haemorrhage — to address what difference earlier diagnosis would probably have made to the outcome.

Because timing and documentation are so central to these claims, the emergency department records, triage notes, and observation charts typically repay closer scrutiny than the discharge letter alone suggests.