Journal of Travel Medicine, 2016, 1–3
doi: 10.1093/jtm/taw048
Perspective
Medico-legal risk, clinical negligence and the practice of
travel medicine
Kieran M. Kennedy1,* and Gerard T. Flaherty1,2
1
Department of Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland and 2School of
Medicine, International Medical University, Kuala Lumpur, Malaysia
*To whom correspondence should be addressed. Email: kieran.kennedy@nuigalway.ie
Submitted 8 April 2016; revised 27 May 2016; Accepted 17 June 2016
Traditionally a small number of clinical specialties, such as ob-
stetrics and gynaecology, have been regarded as particularly
high-risk areas of medical practice in terms of medical negli-
gence litigation. Increasing evidence is emerging to substantiate
the view that clinical negligence litigation is becoming prevalent
in primary and ambulatory care settings.1–3 In common with
other specialist areas of clinical practice, travel medicine
presents medico-legal risks. The potential for unrecognised
medico-legal risk and a lack of risk management practices in
travel medicine merit consideration.
In order for an allegation of negligence to be proven, four
principle facts must be individually established.4 In the first in-
stance, the travel health professional must have a duty of care to
the patient. Second, that professional must have failed to reach
an accepted standard of practice in the course of providing that
care. Third, the patient must have suffered physical, financial,
psychological and/or another form of loss. Finally, the loss must
have been legally caused by the failure to provide an accepted
standard of care. The onus is upon the plaintiff (i.e. the patient)
to prove that negligence has occurred, and unless evidence of all
four aspects is accepted by the court, the allegation of negligence
will not be upheld.
Travel health professionals owe a duty of care to any patient
who consults them. Within that duty of care, there is an obliga-
tion to provide a standard of care that must be approved by a
reputable body of opinion within the specialist area of practice.
In this way, variation in clinical practice and differences in opin-
ion between practitioners are taken into account. If there is a
reasonable body of opinion to support the course of action
taken, then the professional will likely be considered to have
provided an appropriate standard of care. Duty of care begins at
the commencement of the first consultation with the patient.
Deficient doctor–patient communication is well recognised as a
major contributor to clinical negligence,5,6 yet the consultation
time available for performing a comprehensive pre-travel risk
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Perspective
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assessment is very limited. Within that consultation, it is incum-
bent upon the travel health professional to discuss the proposed
travel itinerary and fully elucidate all travel health risks that
need to be addressed prior to departure. Failure to do so could
result in inadequate provision of pre-travel advice, failure to ap-
propriately vaccinate and/or provision of inappropriate vaccina-
tions. The past medical history and current medications must be
carefully explored. This is of special importance now that more
individuals with multiple co-morbidities are actively engaging in
international travel.7 Previous vaccination history must be es-
tablished in order to ensure unnecessary vaccinations are not ad-
ministered. Prior to administration of vaccines, any history of
allergy must be confirmed, with special regard to egg allergy,
for example, in the case of yellow fever vaccination.
There are numerous medico-legal risks associated with the
administration of travel vaccinations. The travel health profes-
sional should have a well-formulated consent process that en-
deavours to promote fully informed consent. Discussion of the
risks and benefits of vaccination may need to be supplemented
by the provision of reading material and time for the patient to
make an informed decision. It may, in some cases, be necessary
to defer vaccination to a subsequent consultation to allow the
patient sufficient time to consider the options available. While
the use of consent forms is recommended, a signed consent form
does not automatically imply that informed consent was ob-
tained.8 Careful documentation of the patient’s decision-making
process is recommended. This is especially important where a
patient declines to have vaccinations or other treatments that
the travel health professional considers necessary. The extent to
which pre-existing medical conditions are considered, in light of
vaccination decision making, is of concern. Failure to consider
an immuno-compromising condition, for example, prior to yel-
low fever vaccination, could have serious consequences and
would likely be considered, on the balance of probabilities, to
constitute negligent practice should an adverse patient outcome
2 Journal of Travel Medicine, 2016, Vol. 23, No. 5
arise. Pregnancy status should be queried and/or actually
checked in female travellers before vaccine administration
where doubt exists. Management of the breast-feeding traveller
also poses potential medico-legal risk, particularly with respect
to failure to vaccinate owing to concerns about safety of vac-
cines for the breastfed infant. It is generally accepted that breast
feeding is not a contraindication to vaccination, except in the
case of smallpox vaccine.9
When administering travel vaccinations, standardized proce-
dures are necessary to avoid errors such as administration of an
incorrect or expired vaccine. Strict hygiene standards are essen-
tial to help avoid injection site infection. The travel health pro-
fessional must have up-to-date training in the management of
anaphylaxis and ready access to necessary resuscitation equip-
ment and medication although it would also be inappropriate to
withhold recommended travel vaccines in a controlled clinical
setting because of an undue fear of hypersensitivity reactions.10
In many clinical settings, the practice nurse administers travel
vaccinations. Travel health professionals should be aware of the
principle of vicarious liability, whereby the employer (e.g. the
general practitioner) holds responsibility for the negligent ac-
tions of the employees. In such a scenario, general practitioners
must ensure that they are actively involved in clinical decision
making and that their employee is competent in the practice of
travel medicine. Inadequate physician oversight may addition-
ally expose nurses to criminal proceedings, such as in the case
reported by Lin and Wang involving the death of a baby follow-
ing administration of a vaccine by a public health nurse in the
absence of a doctor’s prescription.11
Travel medicine is a truly multidisciplinary specialism and
the extent to which non-clinical agents, including commercial
airlines and travel agencies, may be responsible for the provision
of pre-travel health advice has previously been highlighted.12
A paucity of legislation currently exists in this area. Physicians
who render medical assistance in unconventional non-clinical
arenas such as aboard a commercial aircraft or cruise ship
should be cognisant of the potential legal risks of associated
with care in these settings.13,14 In the case of inflight medical
emergencies, the country in with the aircraft is registered deter-
mines jurisdiction for civil proceedings. Some European coun-
tries impose a legal obligation on doctors to provide medical
assistance in the event of a medical emergency during air travel.
The US congress enacted legislation, known as the Aviation
Medical Assistance Act,15 which provides greater immunity
against civil litigation in such scenarios, with the exception of
gross negligence or intentional harm. A physician passenger on
an aircraft would be considered grossly negligent by treating a
patient while intoxicated, for example. The physician should be
aware of the need for careful documentation of the medical inci-
dent16 and the requirement to balance doctor–patient confiden-
tiality against the responsibility to contribute to decision
making in relation to continued passage of the flight.17
A failure to counsel travellers about relevant travel precautions
could be considered negligent. Provision of anti-malarial medica-
tion without discussion of practical measures to avoid mosquito
bites, for example, would be considered unacceptable. Similarly,
provision of pre-exposure rabies prophylaxis without advice on
what action to take if bitten would be considered substandard
care. Consideration of long haul flight risk for deep venous
thrombosis, as a further example, should result in provision of ad-
equate preventive advice. Travel itinerary uncertainty has been
demonstrated to be a common phenomenon that challenges travel
health professionals in the provision of the most suitable advice
possible.18 While it is common practice for travel health profes-
sionals to advise travellers about personal safety and security mea-
sures, it is unlikely that a court would consider a failure to do so
as clinical negligence given that the capacity to mitigate these risks
is not dependent upon specialist medical expertise but rather is of
a general nature. Keeping abreast of recent global events, such as
natural disasters, terrorist threats and the risk of sexual violence19,
is, however, consistent with best practice. There is certainly an
onus upon the practitioner to maintain awareness of emerging
travel-related health risks. At the present time, for example, pre-
travel advice in relation to pregnancy risk is considered essential
for females intending to travel to Zika-infected Latin American
countries.20 Referring patients to websites such as the Centre for
Disease Control, the World Health Organization and relevant con-
sulates is a useful way of practically empowering patients to fur-
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ther their knowledge and to mitigate against potential failure to
provide comprehensive advice in a dynamic outbreak situation.
Caring for patients who are travelling when they become ill
overseas and the ill-returned traveller are a further source of
medico-legal risk. Where travel health professionals undertake
to consult, perhaps by telephone or email, with a traveller, a
duty of care still exists. The travel health professional should be
cognisant of the limitations associated with a consultation that
does not allow for face-to-face interview and physical examina-
tion. Caution must be exercised in remote telemedicine consul-
tations. Referral to a local health care provider, where possible,
may be the preferred option. Most clinical negligence litigation
cases involve either a failure to diagnose or a delay in diagnosis.
This is especially relevant to the care of the returned traveller.
Depending on the travel itinerary, it may be essential to ensure
that the patient is warned, prior to travel, to seek medical atten-
tion should they become ill upon their return.21
Travel health professionals have a duty to participate in con-
tinuing professional development. They must maintain their
knowledge of the most current clinical guidelines and they
should complete a recognised postgraduate programme in travel
R
medicine and obtain the Certificate of KnowledgeV of the
International Society of Travel Medicine.22 Furthermore, it is
important to be mindful of the scope of one’s abilities and when
referral to a more specialised practitioner is appropriate.
Queries in relation to high altitude or diving medicine, for ex-
ample, often necessitate expert sub-specialist input. As travel
medicine becomes more specialised, clinicians who have not
participated in continuing professional development activities
should avoid practising outside of their domain of expertise. All
travel health professionals should ensure that they possess ade-
quate medical indemnity and that their insurance provider is
fully aware of the scope of their clinical practice.
Awareness of medico-legal risk helps to promote high stan-
dards of clinical practice. A careful approach to informed con-
sent, rigorous clinical note-keeping and engagement with
continuing professional development are key recommendations
in the mitigation of clinical negligence risk. Adoption of these
medico-legal recommendations will improve patient safety and
optimise standards of care.
Journal of Travel Medicine, 2016, Vol. 23, No. 5
Conflict of interest: None declared.
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