Mary O’Rourke, QC

The Following article is reproduced with kind permission of the League Medical Association (LMedA) 

Ask even those who barely follow football this question and they will probably look at you as if you have lost your mind and say “what a silly question – the manager of course!”

In the case of tactical substitutions that answer will of course be correct. But in the case of injury substitutions that answer – certainly in terms of issues of medical ethics and legal responsibility – will be very wrong, though many in the game (and particularly some medical staff) do not fully understand that this is so or more importantly the legal and indemnity implications of it. This article seeks to address the misconceptions where potential substitutions are injury related.

The recent “concussion” cases of Hugo Lloris of Spurs (at Goodison Park at the beginning of November) and then very shortly thereafter of Nemanja Vidic brought the ethical and medical questions to the fore and prompted significant media debate.

Whilst many supporters think they can influence substitutions – injury or tactical – (why else do they waste their time chanting the names of players on the bench in a blatant attempt to influence the manager and coaching staff or applaud the “brave” player trying to “run it off” and “carry on”) there is no doubt that save in very exceptional circumstances (the under pressure and possibly weak manager courting popularity) the fans really have no say and cannot dictate changes in on field players or formations (though they may get it right in terms of calling for a substitution which was about to happen anyway and thus claiming credit for it).

Some Chairmen/ owners or Chief Execs will also believe that substitutions are matters on which they can (and should) be heard and will voice their opinions to their managers (including on the timing of the substitution during the match since substitutions before the 60th minute cost the club more in terms of match bonuses than those after that time as a result of specific clauses in the standard PFA player contract – so “let him carry on if he can run it off” or “don’t make your tactical swap yet”) – but again, unless the manager is exceptionally vulnerable or weak or under extreme pressure at the time – this really won’t be the case and their influence will be more imagined or indirect.

Therefore not the fans and not the owners – so some might say the only other “interested party” is the player himself – and we can all think of examples of players unwilling to come off or pointedly and blatantly refusing to come off (in injury situations) and unhappy about being taken off in other tactical or personnel situations. Certainly many managers in injury cases are quick to give players a say in whether they are “ok to carry on” or “can run off the injury” and whether they “should see how they go” – especially with a star player. The question is whether they should do so and whether the player should be allowed to have any say in the matter or even more importantly, whether in the case of injury or suspected injury the manager himself should have any say or actually has anything to contribute.

The ordinary match going supporter who would express surprise at the question who decides as to a substitution would probably be equally surprised at the answer I would give on whether the player or manager should have any say – that in the case of injury or suspected injury the decision should primarily (if not exclusively) be one reserved to the medical team – the (pitch side) team doctor or physio. My answer is not given as a 20 year plus season ticket holder at a major Premier League club – but as a 30 year qualified lawyer with some expertise in sports medico-legal work. That puts me in conflict with supporters sitting around me when the issue presents on the pitch as it has in several significant instances.

The key question is (and ought to be) whether a player should have had any right to a say in the decision. It is one thing for the medical team to assess the player and determine that medically he appears fit to continue and then to check with the player that he does want to continue if and when the staff are satisfied of fitness. It must also be correct that any on-pitch medical assessment (where the means of assessment especially in head injury cases is limited for the medics with no scanning facilities on the pitch) how the player says he is and feels and what his attitude is will necessarily form part of the appropriate medical assessment of fitness to continue.

However the danger for the medical staff is in letting the player’s wishes and own assessment or statements as to fitness to influence the healthcare professional’s objective decision (or indeed dominate it). The healthcare professional needs not only to resist the player’s “agenda” (whatever it might be) but also any baying from the crowd for the player to get up and carry on or entreaties from the manager that he does not want to make a substitution. The situation will be even more acute if towards the end of the match and all 3 substitutions have already taken place such that removal of the injured player will reduce his team to 10 men.

It is not just a question of attracting comment in the media after such an event that should be of concern to the healthcare professional – but rather what else might happen.

In the last 15 years I have been involved in at least 2 medico-legal cases which serve to illustrate the risks to the Club medical staff.

The first involved an Australian semi-pro rugby league player in the south east of England (Greater London area). He sustained a head injury in a match and the evidence was he was “knocked out” for maybe a minute or so. Back when this happened the relevant rules required all games to have a medical officer in attendance – but there were no rules as to what discipline that medical officer should be or what training (s)he should have.

The doctor in question for the relevant match was a Consultant Obstetrician and Gynaecologist and was roped in as she was the wife of one of the home team players 9 and the home team bore the obligation to provide the medical officer). She allowed the player to “play on” despite rugby rules requiring 21 days away from play after a concussion head injury which involved a loss of consciousness. The referee (despite rugby rules requiring him to ensure the withdrawal of a concussed player) deferred to the medical opinion and the player’s wishes (he was a star import and the game an important one).

12 hours post match he attended a DGH A & E to be diagnosed with a subdural haematoma (and Glasgow Coma scale score of 8/15) and was rushed in a blue light ambulance to central London and a major neurological centre where after operation he was left with permanent left sided hemi-plegia and lost his career in rugby and in computers. He sought my advice as to who he could sue.

The other case is a current one (due for hearing in the London High Court towards the end of 2014). It relates to club doctors and physios being involved in the care of a player in 2005/2006. In this case – brought on behalf of the player (he has no capacity himself) – the Club has already joined as parties (what are called Third Parties) to the proceedings the Club doctors of the time (and are seeking to pass liability to them) and it seems consideration may be given to also joining in the physios involved in the player’s care on behalf of the Club and when employed by the Club.

Lessons to be learned as the healthcare professional from these 2 examples:-

  1. The player staying on the field and telling you, the healthcare professional, he is ok to do so is no bar to him subsequently seeking to sue you and claiming how would he know what was in his best interests medically and it was your job to make an assessment and look after his longer term health and foresee what potential consequences or repercussions there might be for him – and that you breached your duty of care to him and he suffered injury and loss as a consequence!
  2. That your Club employer (despite anything said by the manager or other executives or despite their own roles and failings in the incident) will and can turn on you and blame you when the big claim presents (especially if you have moved on in the meantime as is the situation in my current case) and you will then need your own indemnity and representation.

Finally the referee and FA. In my rugby case there were questions of suing the RFL and / or the referee – for the rules not protecting players and the referee not taking the decision away from the player and club provided doctor.

So – what do you do and what is the answer to the question posed in my title? You tell the player and manager (and anyone else who asks!!) that you owe a duty to the player as to his (health) best interests and the decision whether he is fit to continue is therefore yours and yours alone. And you make sure you have appropriate indemnity cover and access to a good lawyer!!

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