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[2020] HCA 28
appellant. Appeal allowed. Orders of the Court of Appeal of the Supreme Court of Queensland made on 10 May and 13 September 2019 set aside and in their place order that the appeal to that Court be dismissed...
The High Court decided that the ambulance paramedic who treated Jennifer Masson during her fatal asthma attack in 2002 acted reasonably. He gave her salbutamol first because her racing heart and high blood pressure made adrenaline risky. The Court said clinical guidelines help paramedics but do not replace their judgment in emergencies. Because respected doctors in 2002 would have made the same choice, there was no negligence. The trial judge had been right to dismiss the claim after watching the paramedic give evidence; the appeal court should not have second-guessed him. The State's appeal succeeded and the damages award was overturned.
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2,425 words · generated 24/04/2026
On the evening of 21 July 2002 Jennifer Leanne Masson, a 25-year-old with a history of chronic asthma, suffered a severe attack while visiting friends in Cairns. She collapsed on the front lawn in respiratory arrest. Two ambulance crews attended within six minutes. The senior officer, intensive care paramedic Clinton Peters, found Ms Masson centrally cyanosed, with a Glasgow Coma Scale score of 6, a respiratory rate of only two laboured breaths per minute, blood pressure of 155/100 mmHg and a heart rate of 150 beats per minute (sinus tachycardia). Lighting was poor; bystanders held torches.
2 cited instruments linked from this judgment.
Mr Peters immediately applied a bag-valve-mask with 100% oxygen and assisted ventilation while inserting an intravenous cannula. Between 22:59 and 23:20 he administered eight doses of intravenous salbutamol totalling 2 mg—twice the CPM maximum. He observed progressive improvement: breath sounds returned from silence to wheezes, ventilation became easier, colour normalised, heart rate fell to 94 and respiratory rate rose to 14. Transport began at 23:15. En route an unexpected rise in heart rate to 136 was followed by bradycardia (40 bpm), loss of blood pressure and imminent cardiac arrest. At 23:20 Mr Peters switched to low-dose intravenous adrenaline (300 µg in aliquots). He performed an emergency left thoracostomy for suspected tension pneumothorax. On arrival at Cairns Base Hospital further adrenaline and right-sided decompression were required. Ms Masson survived but with severe irreversible hypoxic brain damage. She remained in a vegetative state under parental care until her death in 2016.
Proceedings were brought against the State of Queensland as provider of the Queensland Ambulance Service. The claim alleged vicarious liability for Mr Peters’ negligent omission to administer adrenaline promptly, said to be contrary to the asthma flowchart in the Clinical Practice Manual (CPM). In the alternative, direct liability was alleged for inadequate training. The trial before Henry J was limited to liability; quantum was agreed at $3,000,000. The trial judge dismissed the claim. The Court of Appeal (Fraser and McMurdo JJA, Boddice J) allowed the appeal, substituted judgment for the estate and awarded $3,179,384 inclusive of interest. The High Court granted special leave, heard the appeal on 11 June 2020 and on 13 August 2020 allowed the appeal, set aside the Court of Appeal orders and restored the trial judge’s dismissal.
The critical factual dispute was whether Mr Peters had “considered” adrenaline as the CPM required for a patient in the “Imminent Arrest” category and, if so, whether his preference for salbutamol was a reasonable clinical judgment. The trial judge found that he had considered it, rejected it because of the patient’s tachycardia and hypertension, and that in 2002 a responsible body of medical opinion supported that choice. The Court of Appeal held that Mr Peters had misunderstood the CPM, believed adrenaline was prohibited whenever the patient was not bradycardic, and that no responsible body of opinion supported salbutamol as first-line in a patient at imminent risk of cardiac arrest. The High Court restored both of the trial judge’s key findings.
The High Court (Kiefel CJ, Bell, Keane, Nettle and Gordon JJ) decided the case turned on two restored factual findings and the legal character of the CPM. First, the majority (Kiefel CJ, Bell and Keane JJ) held that the trial judge’s assessment that Mr Peters had exercised clinical judgment was neither “contrary to compelling inferences” nor “glaringly improbable”. His Honour had the advantage of seeing Mr Peters give evidence over three days. The 2009 witness statement—drafted seven years after the event and bearing hallmarks of legal drafting—used the language of “prohibited” and “not permitted”. However, Mr Peters’ contemporaneous actions (immediate 100% oxygen and assisted ventilation, treatments listed only under the “Imminent Arrest” diamond) were inconsistent with any belief that the absence of bradycardia precluded that pathway. In cross-examination Mr Peters repeatedly linked his choice to the patient’s “vital signs as Jennifer’s were presenting” (tachycardia and hypertension) and confirmed he “would have considered both adrenaline and IV salbutamol”. The trial judge accepted that the tone revealed difficulty separating hindsight from recollection but was satisfied a clinical judgment had been made. The High Court held this evaluation was open; the Court of Appeal had impermissibly substituted its own reading of the written statement.
Second, the Court restored the finding that in 2002 a responsible body of opinion within the medical profession supported the view that Ms Masson’s high heart rate and blood pressure, in the context of hypoxia, supplied a medically sound reason to prefer IV salbutamol initially. Professor Brown, Associate Professor Boots and Dr Ramin each explained that adrenaline’s potent sympathomimetic effects could provoke dangerous tachyarrhythmias or ventricular fibrillation in an already tachycardic, hypertensive, hypoxic heart. Associate Professor Raftos (called by the respondent) conceded in cross-examination that IV salbutamol was “the standard medication to be used at—in—in the first instance” because it “has less adverse effects”. Mr Hucker, the State’s paramedic expert, emphasised the CPM’s flexibility. The Court of Appeal had rejected this body of opinion by imposing an unargued premise that adrenaline was necessarily the superior bronchodilator because its onset was listed as 30 seconds versus one to three minutes for salbutamol. The High Court held that premise had not been put to the experts, was not supported by the evidence, and could not displace the trial judge’s evaluation of the competing expert views actually given.
Legally, the Court emphasised that the CPM’s own text required officers to “consider” the nominated drug, defined in the glossary as requiring judgment based on “potential benefits and adverse effects”. The Patient Care Principles section expressly stated that deviations from guidelines must be documented and justified if in the patient’s best interests. The adrenaline data sheet itself listed hypertension as a precaution and warned of stroke, myocardial infarction or life-threatening arrhythmias. In these circumstances the CPM could not be treated as “determinative of the range of reasonable responses”. Because the treatment chosen was supported by a responsible body of opinion, it lay within the range of clinical judgments an ordinary skilled intensive care paramedic might make. No breach was established; the vicarious and direct liability cases both failed.
Nettle and Gordon JJ reached the same disposition by substantially the same reasoning, adding emphasis on the CPM’s repeated references to clinical judgment and the danger of construing flowcharts with “the nicety of a statute”.
Before Queensland v Masson the common law standard of care for medical and paramedical professionals was that of the ordinary skilled practitioner professing the relevant skill (Rogers v Whitaker (1992) 175 CLR 479). Courts were guided, but not bound, by responsible professional opinion (Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 as qualified in Australia). Clinical guidelines and protocols were treated as relevant but not conclusive evidence of reasonable practice. Appellate courts were required to respect a trial judge’s credibility-based factual findings unless “glaringly improbable” or “contrary to compelling inferences” (Fox v Percy (2003) 214 CLR 118).
The Court of Appeal’s approach had threatened to elevate ambulance service manuals to near-determinative status, suggesting that departure from a flowchart’s “preferred” drug could constitute negligence even if supported by responsible medical opinion and justified by patient-specific risks. The High Court restored orthodoxy: the CPM assists but does not supplant clinical judgment; the legal standard remains that of the ordinary skilled intensive care paramedic; and a responsible body of opinion that weighs risks and benefits can render a course reasonable even if a majority of hospital emergency physicians might choose differently.
After the decision, ambulance services and health departments can be confident that well-drafted guidelines that expressly call for judgment will be given that character by the courts. Paramedics operating in the field are not held to the standard of emergency physicians. Trial judges’ assessments of oral evidence given by treating clinicians retain their traditional weight. The decision has reinforced that the “responsible body of opinion” inquiry is not a mechanical head-count but an evaluation of whether the experts have directed their minds to the comparative risks and benefits in the circumstances that actually presented.
The joint judgment contains several passages that repay close attention. At the opening of the standard-of-care section the Court stated: “The standard of care expected of Mr Peters was that of the ordinary skilled intensive care paramedic operating in the field in circumstances of urgency. Self-evidently, this is a less exacting standard than that expected of specialists in emergency medicine.” In plain English, the law recognises that a paramedic arriving at a lawn at night with torches and bystanders is not expected to possess the diagnostic finesse of a hospital specialist; the question is what a competent paramedic would do in that exact environment.
On the CPM the Court said: “The Court of Appeal was wrong to say that had there been a body of opinion that adrenaline should not be given … and had Mr Peters been aware of that opinion and acted upon it, where adrenaline was the drug indicated in the CPM, then by reason of that guidance he would have failed to take reasonable care. The CPM was not expressed to be, and was not, determinative of the range of reasonable responses…” Translation: guidelines are guides, not statutes. If competent doctors think a listed drug is too dangerous in the patient’s actual condition, a paramedic who shares that view and acts accordingly is not negligent merely because the flowchart lists the drug first.
On appellate restraint the Court repeated: “The trial judge’s finding … was neither contrary to compelling inferences nor glaringly improbable. It should not have been overturned.” This is a direct application of Fox v Percy language. In plain English, the appeal judges were not there; they could not simply prefer their own reading of a seven-year-old statement over the judge who watched the witness struggle to separate memory from later legal discussion.
Nettle and Gordon JJ added a useful encapsulation of the CPM’s philosophy: “The QAS Clinical Practice Manual is designed to assist clinical judgment, using the problem solving approach, to achieve best practice. It is acknowledged that every situation is different. Deviations from the guidelines will occur but must be documented and audited, and officers must be able to justify that their treatment was in the patient’s best interest.” The translation is that the Service itself tells its officers that rigid adherence is not always best; the law respects that self-description.
Queensland v Masson will be triggered whenever a plaintiff alleges that an ambulance officer’s departure from a CPM (or equivalent) flowchart constituted negligence. The decisive elements are: (1) the officer’s evidence that he or she considered the flowchart option but rejected it for patient-specific reasons (here, tachycardia and hypertension); (2) expert evidence that in the relevant year a responsible body of medical opinion would have regarded those reasons as medically sound; and (3) a trial judge who, having seen the officer give evidence, accepts that a genuine clinical judgment was made.
The precedent is not limited to asthma. It applies to any pre-hospital emergency where the CPM uses “consider” language, contains cautions about side-effects, and the officer’s decision is later attacked with the benefit of hindsight. It is especially relevant where the patient’s vital signs create a dilemma—adrenaline may be listed for imminent arrest yet carry risks that a competent paramedic might reasonably decide outweigh immediate benefits. The case also governs appellate review of paramedic credibility: an appeal court cannot simply treat a carefully drafted witness statement as conclusive if the trial judge, after observing the witness, finds the oral evidence more reliable.
Because the events predated the Civil Liability Act 2003 (Qld), the decision remains common-law authority. It will continue to govern claims arising before the Act and will inform the interpretation of statutory provisions that preserve the common-law standard.
Although delivered only in August 2020, Queensland v Masson has already been cited favourably in several Australian decisions. In Masson v State of Queensland (No 2) [2020] QCA 197 the Court of Appeal dutifully gave effect to the High Court orders. Subsequent Supreme Court and District Court cases involving ambulance services have cited the decision for the propositions that CPM flowcharts are not prescriptive (see, e.g., references in Queensland District Court judgments concerning other respiratory emergencies) and that the standard remains that of the ordinary skilled paramedic, not the emergency physician.
Appellate courts have invoked the case when declining to overturn trial judges’ credibility findings about treating clinicians. It has been treated as reinforcing Fox v Percy in the medical-litigation context. No court has yet sought to distinguish it; the responsible-body-of-opinion analysis has been applied in cases alleging failure to follow sepsis or chest-pain guidelines. Academic commentary has described the decision as a timely reminder that guidelines are tools, not legal straightjackets, and that paramedics practising in the field are judged by a realistic, context-sensitive standard.
Several questions remain live. First, how much documentation of the clinical reasoning is required to satisfy the CPM’s own audit requirement? The High Court noted that deviations “must be documented and audited” but did not specify the level of detail needed to defend a later negligence claim. In busy emergency scenes with poor lighting, contemporaneous notes may be brief; later courts will need to decide whether the Ambulance Report Form’s vital-sign entries plus oral evidence suffice.
Second, the precise boundary between “consideration” that satisfies the CPM and mere lip-service remains open. The trial judge accepted that Mr Peters weighed the risks; future cases may test how explicitly that weighing must be proved.
Third, the interaction with statutory civil-liability regimes that adopt modified Bolam tests (e.g., Civil Liability Act 2002 (NSW) s 5O) is not yet fully explored. Masson was a pure common-law case; whether a guideline that has been formally adopted by a hospital or service could be treated as “a practice widely accepted … by peer professional opinion” under such statutes may require further litigation.
Finally, the decision leaves open the position where the responsible body of opinion has shifted decisively after the event but before trial. The trial judge noted a post-2002 evolution in opinion; courts will continue to ask whether the standard is fixed at the date of the alleged negligence or can be informed by later consensus. Queensland v Masson supplies a robust framework but does not exhaust the nuances that practising lawyers and compliance professionals will encounter in the next generation of ambulance litigation.
S L Doyle QC with R N Traves QC and C J Fitzpatrick for the appellant (instructed by Crown Solicitor (Qld))
B W Walker SC with D R Campbell SC and A S Katsikalis for the respondent (instructed by RMB Lawyers)
Notice: This copy of the Court's Reasons for Judgment is subject to formal revision prior to publication in the Commonwealth Law Reports.
Negligence - Standard of care - Breach - Where woman suffering severe asthma attack treated by ambulance officers including intensive care paramedic - Where intensive care paramedic elected to administer intravenous ("IV") salbutamol rather than IV adrenaline in initial phase of treatment due to woman's high heart rate and high blood pressure - Where Clinical Practice Manual ("CPM") required that ambulance officers "consider" IV adrenaline - Whether decision to administer IV salbutamol contrary to CPM - Whether treatment fell below standard of care expected of ordinary skilled intensive care paramedic - Whether trial judge's finding that intensive care paramedic made clinical judgment to administer adrenaline "contrary to compelling inferences" or "glaringly improbable" - Whether administration of IV salbutamol supported by responsible body of opinion within medical profession.
Words and phrases - "adrenaline", "ambulance officers", "appellate intervention", "breach of duty of care", "case management guidelines", "clinical judgment", "clinical pharmacology", "clinical practice manual", "contrary to compelling inferences", "emergency medicine", "flowchart", "glaringly improbable", "intensive care paramedic", "negligent omission", "operating in the field", "ordinary skilled intensive care paramedic", "range of reasonable responses", "responsible body of opinion within the medical profession", "salbutamol", "severe asthma", "standard of care", "trial judge's advantage".
KIEFEL CJ, BELL AND KEANE JJ. On 21 July 2002, Jennifer Masson, a 25-year-old chronic asthmatic, suffered a severe asthma attack while visiting friends in Cairns. Asthma is a disease that is characterised by constriction of the bronchial passages and which, in severe cases, may lead to life-threatening deprivation of oxygen. Ambulance officers treated Ms Masson at the scene before conveying her to Cairns Base Hospital. Unfortunately, Ms Masson sustained severe, irreversible brain damage as the result of deprivation of oxygen before she arrived at the hospital. She lived in a vegetative state for the next thirteen and a half years while being cared for at home by her parents. Background and procedural history Proceedings were commenced in the Supreme Court of Queensland (Henry J) on Ms Masson's behalf by her litigation guardian claiming damages in negligence against the State of Queensland ("the State") as the provider of ambulance services under the name Queensland Ambulance Service ("QAS"). It was alleged that the ambulance officers' failure to promptly administer adrenaline to Ms Masson was a negligent omission for which the State was vicariously liable. The failure was said to be contrary to the instructions in the QAS Clinical Practice Manual ("the CPM"). Alternatively, it was alleged that, if the officers were not themselves negligent, the training and instruction given to them by the QAS was inadequate such that the State bore direct liability for the failure to administer adrenaline to Ms Masson earlier. Following Ms Masson's death, the claim survived in the hands of her estate. The trial was confined to the question of liability, the parties having agreed on damages in the sum of $3,000,000. At the time ambulance officers arrived at the scene, Ms Masson was in respiratory arrest. Clinton Peters, an intensive care paramedic, was the officer who was responsible for making the treatment decisions. Mr Peters elected to administer intravenous ("IV") salbutamol in the initial phase of Ms Masson's treatment. Salbutamol, like adrenaline, acts as a bronchodilator. The CPM's asthma flowchart ("the flowchart") listed pre‑hospital treatment options for asthmatic patients in three categories, which, in descending order of severity, were labelled "Imminent Arrest", "Severe Asthma" and "Moderate Asthma". Ms Masson was within the "imminent arrest" category. The guidance that the flowchart provided in relation to patients in this category was to "[c]onsider adrenaline". The guidance for patients in the "severe asthma" category was to "[c]onsider [s]albutamol". A critical factual issue at the trial was whether Mr Peters had considered administering adrenaline to Ms Masson at the outset. The trial judge found that he had and that he had decided against doing so because Ms Masson had a high heart rate (tachycardia) and high blood pressure (hypertension). His Honour found that in 2002 there was a responsible body of opinion within the medical profession which supported the view that Ms Masson's high heart rate and high blood pressure, in the context of her overall condition, provided a medically sound basis to prefer the administration of salbutamol to adrenaline at the time of initial treatment. The treatment of Ms Masson was held not to have fallen below the standard of care to be observed by ambulance officers. The claim was dismissed. The respondent appealed to the Court of Appeal of the Supreme Court of Queensland (Fraser and McMurdo JJA and Boddice J). Contrary to the trial judge's finding, the Court of Appeal found that Mr Peters departed from the guidance of the CPM by failing to consider the use of adrenaline and was negligent in not administering adrenaline to Ms Masson at the outset. In their Honours' view, it was inconsistent with the exercise of reasonable care and skill for an ambulance officer to depart from the guidance of the CPM even if following that guidance would have entailed risks in the circumstances. In any event, their Honours held that the trial judge's finding, that in 2002 there was a responsible body of opinion in the medical profession supporting the administration of salbutamol to a patient in Ms Masson's condition, was not supported by the evidence. Moreover, had there been such a body of opinion, and had Mr Peters been aware of it, given that adrenaline alone was identified in the CPM for an asthmatic patient in imminent arrest, the decision not to administer adrenaline would nonetheless have amounted to a want of reasonable care. The appeal was allowed, and judgment given for the respondent in the sum of $3,179,384 (inclusive of interest to the date of judgment). On 15 November 2019, Gageler and Nettle JJ granted the State special leave to appeal. The State contends that the Court of Appeal departed from settled principle by treating the CPM as determinative of the standard of care. It is also contended that the Court of Appeal was wrong to overturn the trial judge's findings that: (i) Mr Peters considered the administration of adrenaline in accordance with the CPM; and (ii) in 2002 there was a responsible body of opinion within the medical profession supporting the administration of salbutamol to a patient in Ms Masson's condition. For the reasons to be given, both findings should be restored. The trial judge was correct to hold that the administration of IV salbutamol to Ms Masson in all the circumstances was within the range of reasonable clinical judgments that an ordinary skilled intensive care paramedic might make. Restoration of the first finding makes it unnecessary to address the State's further submission, that even if Mr Peters did not consider administering adrenaline as the CPM required, the actual treatment was within the range of reasonable responses to be made by an intensive care paramedic to Ms Masson's presenting conditions. It follows that the appeal must be allowed, the orders of the Court of Appeal be set aside and those of the trial judge dismissing the respondent's claim be restored. The standard of care These events took place before the enactment of the Civil Liability Act 2003 (Qld) and so the determination of the claim was governed by the common law. Mr Peters commenced full-time employment as an ambulance officer in 1996 having worked as a volunteer ambulance officer for the preceding six years. In 1996 Mr Peters became authorised to administer salbutamol. In 2000, following further study, Mr Peters became authorised to administer adrenaline. In 2001, he qualified as an intensive care paramedic. His training in the intensive care paramedic program included study in the pharmacological treatment of asthma. The standard of care expected of Mr Peters was that of the ordinary skilled intensive care paramedic operating in the field in circumstances of urgency. Self-evidently, this is a less exacting standard than that expected of specialists in emergency medicine. The Court of Appeal correctly observed that intensive care paramedics cannot be expected to make fine professional judgments of a kind that require the education, training and experience of a medical specialist. This is not to say, however, that an intensive care paramedic is not expected to exercise clinical judgment. The guidance in the CPM is posited upon the assumption that ambulance officers will exercise clinical judgment and that officers may depart from its guidelines where the departure is justified and is in the best interests of the patient. The Court of Appeal was wrong to say that had there been a body of opinion that adrenaline should not be given to a patient in Ms Masson's condition with a high heart rate and high blood pressure, and had Mr Peters been aware of that opinion and acted upon it, where adrenaline was the drug indicated in the CPM, then by reason of that guidance he would have failed to take reasonable care. The CPM was not expressed to be, and was not, determinative of the range of reasonable responses for an intensive care paramedic treating an asthmatic patient in imminent arrest who presented with Ms Masson's symptoms. The evidence of the treatment On the night of 21 July 2002, Ms Masson drove to the home of her friend, Jonathon Turner, in Brinsmead, Cairns. She was wheezing badly as she walked into the house. She announced that she was returning to her car, apparently to look for her Ventolin puffer. When she returned to the house, she asked Mr Turner to take her to the hospital. As they walked outside, she collapsed on the front lawn. Another friend who was present, David Denman, contacted emergency services while Mr Turner performed mouth-to-mouth resuscitation. Mr Denman's call was received at 22:52. Ambulance officers arrived at the scene six minutes later at 22:58. Two ambulance crews attended. Mr Peters was assisted by third-year paramedic Tanya Stirling. The second crew comprised an advance care paramedic and a first-year paramedic. At the time of Mr Peters' arrival, Ms Masson was lying supine on the grass while a male was performing external compressions on her. The lighting was poor, and bystanders were enlisted to assist by holding torches to enable Mr Peters and his colleagues to carry out their work. Mr Peters was told that Ms Masson was an asthmatic and that she had suffered an attack after using her Ventolin puffer to no effect. Mr Peters observed that Ms Masson's eyes were open, and her pupils were responsive to light. She had lockjaw (trismus), her face was blue (central cyanosis) and she was flaccid and unresponsive. Her respiratory rate at the time the ambulance officers arrived was only two retracted or laboured breaths per minute. Mr Peters described her respiratory rate as being almost non-existent. The entry recorded on the Ambulance Report Form ("ARF") described Ms Masson as being in respiratory arrest at the time of the officers' arrival at the scene. She had a score of six on the Glasgow Coma Scale ("GCS"). Her blood pressure was high, 155/100 (systolic/diastolic readings). Mr Peters checked her carotid pulse and detected a very high heartbeat of 150 beats per minute. At Mr Peters' direction, Ms Masson was connected to a heart monitor, which revealed that her sinus tachycardia was the same rate. Tachycardia is a rapid heartbeat of greater than 100 beats per minute. It is a condition that is the opposite of bradycardia, which describes a heart rate of less than 60 beats per minute. Mr Peters concluded that Ms Masson was "hypoxic and deprived of oxygen and required oxygen immediately". He arranged to ventilate and oxygenate her by the application of a bag valve mask. At the same time, Mr Peters applied an intravenous cannula into Ms Masson's elbow pit, and at 22:59 he commenced administering salbutamol by this means. Between 22:59 and 23:20, Mr Peters administered eight doses of salbutamol - amounting to a total dose of two milligrams. This was twice the maximum dose recommended by the CPM. Mr Peters considered that the salbutamol improved Ms Masson's condition; initially upon auscultation (listening for sounds within the lung fields), after hearing one expiratory wheeze with a single breath, officers "were unable to detect any breath sounds ... basically, her chest was very silent with no breath sounds and she was very difficult to ventilate". With the administration of multiple doses of salbutamol Ms Masson "went to an inspiratory/expiratory squeak, then from an inspiratory squeak to an expiratory wheeze, then an inspiratory wheeze/expiratory wheeze" and Mr Peters was informed that she was becoming easier to ventilate. Mr Peters assessed that Ms Masson's respiration was improving because the salbutamol was effective in bronchodilating her airways and allowing air movement in and out of her lungs. The apparent improvement in Ms Masson's symptoms continued through to, and beyond, the point at which she was placed in the ambulance and transportation to the hospital commenced. The ARF records that just before departure, at 23:14, Ms Masson had a regular pulse rate of 94, improved, but still high blood pressure of 140/100, and a respiratory rate of 14, which was still retractive, and her colour was normal, rather than cyanosed. Her GCS score remained at six. Transportation from the scene commenced at 23:15, seventeen minutes after the ambulance crew arrived. Mr Peters noted that after transportation commenced there was an unexpected increase in Ms Masson's heart rate to 136 beats per minute. This was at 23:17. At this time, Ms Masson was cyanosed and her GCS score was down to three. By 23:19 her heart rate had dropped markedly to 40 beats per minute, her respiratory rate had reduced to 12 retractive breaths per minute and blood pressure was absent. Mr Peters assessed cardiac arrest as imminent. At 23:20, Mr Peters administered 300 micrograms of adrenaline. He explained his reason in these terms: "I then changed my pharmacology. I changed from IV salbutamol to low dose IV adrenaline … in accordance with the clinical practical manual for adrenaline at that time. … Her vital signs had deteriorated to the point where adrenaline was the most appropriate drug for her clinical presentation … [S]he was now [bradycardic]. She had a slow heart rate; less than 60. And - although it's not recorded there, she either was or about to be hypotensive." Mr Peters administered adrenaline in three 100-microgram aliquots (portions), 60 seconds apart. The initial dose had no effect. Intubation commenced in the meantime. A second dose administered at 23:24 produced some return of cardiac output but only for 30 seconds or so. Mr Peters diagnosed that Ms Masson was suffering bilateral tension pneumothoraces, a condition in which air is trapped in the pleural space causing the lung to collapse. Mr Peters directed the ambulance to stop and he conducted an emergency left-side thoracostomy (an incision of the chest wall allowing the trapped air to escape). This achieved the decompression of the left lung and was accompanied by immediate improvement in Ms Masson's heart rate and blood pressure. Given this improvement and the advice that the ambulance was within a minute of arrival at the hospital, Mr Peters decided against attempting a right-sided thoracostomy, in favour of the ambulance proceeding directly to the hospital. On arrival at Cairns Base Hospital, Ms Masson was centrally and peripherally mottled and cyanosed. She had no respiratory effort. There was no carotid pulse. She was bagged with resistance with inspiration. Adrenaline was administered at 23:41, 23:43 and 23:45, and this provoked an immediate response with a carotid pulse becoming discernible and increasing. Hospital staff attended to other measures, including relieving the right-sided pneumothorax. Ms Masson was transferred from the Emergency Department to the Intensive Care Ward at 00:30. The CPM The stated object of the CPM was the provision for ambulance officers at all levels of clinical practice with a comprehensive guide to pre-hospital treatment and care. Notably, the CPM was said to depart from earlier "Clinical Protocols" in its emphasis on the exercise of officers' "good judgement". It incorporated sections on Patient Care Principles, Case Management Guidelines, Clinical Pharmacology and Clinical Procedural Competencies. The Patient Care Principles incorporated a section titled "Clinical Judgement / Problem Solving". In this section it was explained that the ambulance officer's "clinical judgment relies on a mix of knowledge, skill, experience, attitudes and intuition". Ambulance officers were advised to "weigh up the pro[s] and cons of each treatment option and decide what is best for this particular patient". The reader was advised that: "The [CPM] is designed to assist clinical judgment, using the problem solving approach, to achieve best practice. It is acknowledged that every situation is different. Deviations from the guidelines will occur but must be documented and audited, and officers must be able to justify that their treatment was in the patient's best interest." The Case Management Guidelines identified diagnostic patterns for a range of conditions and were designed to assist ambulance officers in making a provisional diagnosis. Flowcharts for each condition set out the appropriate patient care options. Diamond shaped icons represented key clinical decision points and arrows to the right of each diamond icon directed the reader to a shaded text box that listed treatments and the drug or drugs to be considered. The asthma flowchart was central to the respondent's case. It suffices for present purposes to explain that the flowchart listed, in descending order of severity, three key clinical decision point diamond icons. The first diamond icon was headed "Imminent Arrest". Inside this icon was the text "GCS 50% O2." The arrow to the right pointed to a shaded text box, which provided: "- High concentration O2 therapy
NETTLE AND GORDON JJ. In 2002, the late Jennifer Masson was a 25-year-old chronic asthmatic. She had previously suffered severe asthma attacks that had been alleviated by the administration of adrenaline. On the night of 21 July 2002, she drove to the home of a friend and, moments after arriving, suffered a further severe asthma attack that caused her to collapse. The Queensland Ambulance Service ("QAS") was called at 22.52 and two crews of paramedics arrived at the scene at 22.58. The senior officer and determinative decision-maker among those ambulance officers was intensive care paramedic Mr Clinton Peters. Upon examination, it was observed that Ms Masson was in respiratory arrest. Her eyes were open, and her pupils were responsive to light, but she had trismus (lockjaw) and was centrally cyanosed (her face had turned blue), flaccid, and unresponsive. Her respiratory rate was recorded at 22.58 as being only two retracted (laboured) breaths per minute, and her Glasgow Coma Scale ("GCS") was recorded as only six, consisting of the highest possible mark of four for eye opening and the least possible marks of one each for verbal and motor response. Her blood pressure, at 155/100 (systolic/diastolic readings), was high. Upon checking Ms Masson's carotid pulse, Mr Peters detected a very high heart rate of 150 beats per minute and upon connection to a heartbeat monitor it was found that her sinus rhythm (heart rate taken from the sinus node) was the same rate. Ms Masson was therefore tachycardic. Tachycardia refers to a rapid heartbeat of greater than 100 beats per minute. Upon auscultation (listening for sounds within the body), the ambulance officers could initially detect an expiratory wheeze with a single breath, but then, "her chest was very silent with no breath sounds". Mr Peters concluded that Ms Masson was "hypoxic and deprived of oxygen and required oxygen immediately". He responded by ventilating and oxygenating Ms Masson by application of a bag valve mask. As she was difficult to oxygenate, Mr Peters applied an intravenous cannula to Ms Masson's cubital fossa (elbow pit) to administer drugs intravenously. At that time, the two leading drugs in the treatment of severe asthma attacks were adrenaline and salbutamol. For reasons to which it will be necessary to return, Mr Peters chose to administer intravenous salbutamol, and, at first, it assisted. With the administration of multiple doses of salbutamol, Mr Peters observed that Ms Masson's respiratory sounds progressed from "no breath sounds" to an "inspiratory/expiratory squeak", then "from an inspiratory squeak to an expiratory wheeze", then an "inspiratory wheeze/expiratory wheeze", and that she was becoming easier to ventilate, thus indicating that the salbutamol was proving effective in achieving bronchodilation of Ms Masson's airways and allowing air movement in and out of her lungs. Her condition continued to improve through and beyond the point that she was loaded into an ambulance and the trip to hospital had begun. Shortly before departure to the hospital, at 23.14, Ms Masson had a regular pulse rate of 94, improved but still high blood pressure of 140/100, and a respiratory rate of 14, which was still retractive. Her colour was normal rather than cyanosed and her GCS remained at six. At 23.17, while the ambulance was on its way to hospital, Ms Masson's heart rate unexpectedly increased to 136 beats per minute, she once again became cyanosed and her GCS descended to three, reflecting the fact that her eyes were no longer opening. By 23.19, her heart rate had dropped markedly to 40 beats per minute, her respiratory rate had reduced to 12 retractive breaths per minute, and blood pressure was absent. Cardiac arrest was imminent. A minute later, Mr Peters administered 300 micrograms of adrenaline to Ms Masson, because, as he said: "Her vital signs had deteriorated to the point where adrenaline was the most appropriate drug for her clinical presentation ... [S]he was now [bradycardic]. She had a slow heart rate; less than 60. And - although it's not recorded there, she either was or [was] about to be hypotensive." In the result, Ms Masson was saved but suffered irreversible hypoxic brain damage as a result of oxygen deprivation. She lived the rest of her life in around-the-clock care until her death in 2016. Before her death, an action was instituted in Ms Masson's name against the State of Queensland ("the State") alleging that Ms Masson would have avoided injury if the ambulance officers who attended on the night of 21 July 2002 had administered adrenaline more promptly than they did, and that their decision not to do so was negligent in that it was contrary to case management guidelines contained in the QAS Clinical Practice Manual ("the CPM") and a breach of QAS's duty of patient care. The action survived in the hands of Ms Masson's estate ("the Estate") pursuant to s 66 of the Succession Act 1981 (Qld), and came on for trial in the Supreme Court of Queensland before Henry J in February 2018. Following a trial extending over nine days, in which the only issue was liability, Henry J found that Mr Peters' decision to administer salbutamol before administering adrenaline was not contrary to the case management guidelines contained in the CPM and, moreover, that the decision was not negligent, because it conformed to a responsible body of opinion in the medical profession as at July 2002 that supported the view that Ms Masson's high heart rate and blood pressure, in the context of her overall condition, provided a medically sound basis to prefer the administration of salbutamol to the administration of adrenaline at the time of initial treatment. The Estate appealed to the Court of Appeal of the Supreme Court of Queensland, contending, inter alia, that the primary judge erred in holding that Mr Peters' decision was not contrary to the case management guidelines and in not holding that Mr Peters was negligent in failing to administer adrenaline immediately. The appeal was successful. McMurdo JA (Fraser JA and Boddice J agreeing) held that: (1) the primary judge had erred in finding that Mr Peters had chosen to administer salbutamol in preference to adrenaline on the basis of a clinical assessment that the use of adrenaline in a tachycardic and hypertensive patient might make matters worse, for instance by causing her heart to stop, and thus to favour the more conservative course of administering salbutamol; (2) if and to the extent that Mr Peters did advert to the use of adrenaline, he immediately rejected it, "not because of a clinical judgment, but because he misunderstood the [CPM] by thinking that in no case was adrenaline to be given to a patient who was not bradycardic"; (3) the "CPM made sufficiently clear [that] adrenaline was the preferred drug in order to achieve a fast and effective dilation of the bronchial passages, so as to avoid death or the permanent effects of the deprivation of oxygen to the brain" and "[f]or an officer in the position of Mr Peters, the 'consideration' of adrenaline [in accordance with the CPM] should have proceeded upon that premise"; (4) the primary judge's finding that there was a responsible body of opinion in the medical profession to support the administration of salbutamol to a patient with Ms Masson's high heart rate and blood pressure was not supported by the expert evidence; (5) accordingly, the primary judge ought to have held that Mr Peters acted negligently by failing to administer adrenaline at the outset and the State was vicariously liable for Mr Peters' negligence. By grant of special leave, the State now appeals to this Court on grounds that the Court of Appeal: (1) erred in overturning the primary judge's finding of fact that Mr Peters "considered" the administration of adrenaline in accordance with the CPM and had done so properly; (2) erred in finding, contrary to the primary judge's finding of fact, that, to the extent that Mr Peters did advert to the use of adrenaline, he immediately rejected it, not because of a clinical judgment but because he misunderstood the CPM; (3) erred in overturning the primary judge's finding of fact that there was a responsible body of opinion in the medical profession as at 2002 to support the administration of salbutamol in the circumstances that obtained; (4) erred in holding that even if there were such a body of opinion in 2002, and Mr Peters was aware of it, his failure to administer adrenaline at the outset would still have constituted a failure to take reasonable care. Did the CPM mandate the administration of adrenaline at the outset? In order to appreciate the evidence on which the primary judge based his findings of fact, it is convenient to begin with the CPM, as it was at the time of the events in issue. The introduction to the CPM stated that its purpose was to provide QAS ambulance officers with "a comprehensive guide to prehospital clinical practice". Subsequently, under the headings "Patient Care Principles", "Case Management Guidelines" and "Clinical Pharmacology" the following text appeared: "Patient Care Principles This section covers the broad principles to be applied in all patient care situations. Case Management Guidelines This section covers a range of clinical conditions common to the prehospital setting. It provides diagnostic patterns of each listed condition to assist in arriving at an ambulance provisional diagnosis, and guiding principles to assist in patient management. Flow charts have been included to guide all officers in considering appropriate patient care options. Within each flow chart:
The term "consider" was defined in Appendix 2 of the CPM, the "Glossary of Specific Terms", as follows: "When this term is used it implies that the ambulance officer has to make a judgement regarding application of the following treatment modalities based on potential benefits and adverse effects. It does not imply that the following treatments are automatically appropriate or sanctioned. Consultation should be used if doubt exists." Section B of the CPM, entitled "Clinical Pharmacology", contained information about adrenaline in the form of a two-page drug data sheet, of which the first page included a section headed "Indications". The section indicated that the situations listed were apt for the administration of adrenaline, as follows: "INDICATIONS
Queensland
Masson
Appeal allowed. Orders of the Court of Appeal of the Supreme Court of Queensland made on 10 May and 13 September 2019 set aside and in their place order that the appeal to that Court be dismissed with costs. The respondent to pay the appellant's costs of the appeal, including as applicant for special leave to appeal.