England and Wales Court of Appeal (Civil Division) Decisions
You are here:
BAILII >>
Databases >>
England and Wales Court of Appeal (Civil Division) Decisions >>
Wisniewski (A Minor) v Central Manchester Health Authority [1998] EWCA Civ 596 (1 April 1998)
URL: http://www.bailii.org/ew/cases/EWCA/Civ/1998/596.html
Cite as:
[1998] PIQR P324,
[1998] PIQR 324,
[1998] Lloyd's Rep Med 223,
[1998] EWCA Civ 596
[
New search]
[
Printable RTF version]
[
Help]
IN
THE SUPREME COURT OF JUDICATURE
QBENF
96/0572/CMS1
COURT
OF APPEAL (CIVIL DIVISION)
ON
APPEAL FROM THE HIGH COURT OF JUSTICE
QUEEN'S
BENCH DIVISION
(MR
JUSTICE THOMAS
)
Royal
Courts of Justice
The
Strand
London
Wednesday
1 April 1998
B
e f o r e:
LORD
JUSTICE ROCH
LORD
JUSTICE ALDOUS
and
LORD
JUSTICE BROOKE
B
E T W E E N:
PHILIP
HARRY WISNIEWSKI
Respondent
(A
Minor
)
and
CENTRAL
MANCHESTER HEALTH AUTHORITY
Appellant
_______________
(Computer
Aided Transcription by
Smith
Bernal, 180 Fleet Street, London EC4A 2HD
Telephone
0171 421 4040
Official
Shorthand Writers to the Court)
_______________
MR
S GRIME QC, MR N BRASLAWSKY and MR G FORRESTER (1.4.98) (instructed
by
Hempsons, Manchester M2 3HR) appeared on behalf of THE APPELLANT
MR
M REDFERN QC, MR A LYON and MR P A EDWARDS (1.4.98) (instructed by
Messrs
Alexander Harris, Sale, Cheshire M33 6FX)
_______________
J
U D G M E N T
(As
Approved by the Court
)
_______________
Wednesday
1 April 1998
LORD
JUSTICE BROOKE: This is an appeal by the Defendant health authority from a
judgment of Thomas J sitting at Manchester on 2nd April 1996 when he directed
that judgment be entered for the Plaintiff in this medical negligence action.
Damages were agreed between the parties during the course of the trial, and the
judge was only concerned to decide the question of liability.
At the centre of this litigation is a boy called Philip. He is now 10 years
old. He was born at St Mary’s Hospital Manchester in the early hours of
the morning of 15th January 1988 and he has suffered from athetoid cerebral
palsy from birth. In an admirably clear judgment the judge held that he
suffered irreversible damage to his brain in the 13 minutes immediately prior
to his birth at 5.40 am because as he moved down the birth canal the umbilical
cord was wrapped round his neck and had a knot in it. He was effectively being
strangled. His mother had been admitted to hospital at 2.50 am, less than 3
hours earlier, and the judge held that if her care had not been negligently
mismanaged, a doctor would have carried out an artificial rupture of the
membranes (ARM) shortly after 3.40 am, and such an exercise would inevitably
have disclosed the presence of a substance called meconium. This discovery
would have led to the child being born by caesarean section, thus obviating the
hazards of birth down the birth canal.
The Defendants’ case both at trial and in this court is essentially
that there was a respectable school of medical practitioners who would not have
moved immediately to investigate intervention at the sign of possible trouble
which revealed itself at 3.40 am and that by the time any further trouble signs
appeared it would have been too late to perform a caesarean. It is therefore
said that the judge did what the House of Lords in
Bolitho
v City and Hackney Health Authority
[1997] 3 WLR 1151 has again very recently affirmed that he must not do, which
was to substitute his own assessment of what would have been an appropriate
standard of care for the standard considered appropriate by a responsible body
of skilled medical opinion. There are two further issues in the appeal, one
connected with the judge’s positive finding, in the absence of the
relevant doctor from the trial, as to what he would have done if he had
attended his patient at 3.40 am, and one connected with issues of causation.
Philip’s mother had given birth to her first child, who is a healthy
boy, in 1985. She had been admitted to the same hospital for four days towards
the end of that pregnancy with high blood pressure. A trace of protein in her
urine had indicated pre-eclampsia, but further testing had eliminated this
possibility.
For her second pregnancy, when she was 31 years old, the expected date of
delivery was 7th January 1988. Five days later high blood pressure was
disclosed at a routine check-up and she was admitted to hospital overnight.
This helped her blood pressure to return to normal. The following evening
(14th January) she began to feel mild contractions, and her husband took her to
St Mary’s Hospital in the early hours of 15th January, arriving there at
about 2.50 am. St Mary’s is a major teaching hospital with a specialist
obstetric unit.
The relevant staff on duty that night were Sister Brockbank, the midwife
sister on duty, and Dr Renninson, the resident senior house officer
(“SHO”) on call. No other member of the hospital’s staff
figures in this story until a number of people came on the scene during the
events surrounding Philip’s birth about three hours later. Sister
Brockbank had qualified as a SRN in 1974 and as a midwife in 1978. She had
served on the staff of this hospital since 1979 and was promoted to midwife
sister in 1982. She had had a lot of practical experience as a midwife, since
in an average week the hospital had 40-50 mothers in labour. Dr Renninson, on
the other hand, had qualified as a doctor at Manchester University as recently
as 1985. After obtaining experience at two other local hospitals as a house
physician and house surgeon between August 1985 and July 1986, he had had six
months experience as a SHO in obstetrics and gynaecology at one of those other
hospitals, and had then come to St Mary’s Hospital as a SHO in obstetrics
and gynaecology in February 1987. At the time these events took place,
therefore, he had had 17 months experience in this speciality, which included
11 months experience of managing patients on delivery suites.
The Defendants faced the difficulty that the Plaintiffs’
solicitors’ letter before action was not written until over three years
after Philip was born (9th April 1991), the writ was not served for another 21
months (21st March 1993), and the trial of the action started more than eight
years after Philip’s birth. In those circumstances it is hardly
surprising that Sister Brockbank told the judge that she could not recall what
had happened prior to the actual delivery (although she did remember the
delivery itself because it was so rapid) and Dr Renninson said in a written
statement that he had no independent recollection of his involvement in the
management of this case at all. By the time of the trial Dr Renninson had
obtained an appointment at a cancer centre in Australia, and he did not return
to England to give evidence at the trial, a matter which evoked adverse comment
from the judge to which I will refer in due course. For the events prior to
delivery Sister Brockbank was constrained to try and reconstruct the history of
what had happened from the entries in the admission records and other records
and from her usual practice.
Soon after Mrs Wisniewski was admitted Sister Brockbank carried out an
abdominal examination. She recorded the foetus heart beat as 160 and regular
and the position of the foetus as a cephalic presentation with the head
3-4/5ths palpable. The contractions were noted as irregular. At 3.05 am she
carried out a vaginal examination. She recorded that the cervix was 1-2cm
dilated, that the head was 3cm above the ischial spines, and that it bobbed out
of the pelvis as she was making her vaginal examination. She said she would
not have pushed the foetus: the head, which was in the pelvic rim and not
completely free, would have just moved at her touch. She considered that
Philip’s mother was a normal patient in niggling or early labour and
arranged for her to be taken to the pre-delivery room.
At 3.10 am she started electronic monitoring of the foetal heart rate using
a Corometric monitor. This monitor displayed a digital readout of the foetal
heart beat and recorded both the heart beat and the contractions on a
cardiotachograph (CTG) trace. Between 3.10 am and 3.40 am the trace showed a
foetal heart rate baseline of between 170 beats per minute (bpm) and 175 bpm,
rising to 180 bpm, but not dropping below 160 bpm. The trace showed that the
beat to beat variability was 5 bpm, which was considered to be at the bottom
end of normal.
During this period there were two early decelerations in the foetal heart
rate when the rate fell to 130 bpm (at 3.23 am) and 110 bpm (at 3.40 am)
although it rapidly recovered on both occasions. The Plaintiff’s case
stands or falls by the contention put forward by his expert witnesses that the
early deceleration identified on the CTG trace at 3.40 am called for
investigative intervention at that stage and that to adopt a policy of waiting
to see if there were any further indications of trouble would have been
negligent.
There is a note made by Sister Brockbank in the admission record against the
time of 3.40 am which stated, after noting the CTG readings:
"Dr
Renninson informed. Patient to remain in (central delivery unit) - observe.
Patient
may mobilise."
The judge found that Sister Brockbank went to speak to Dr Renninson at this
time, and that he did not attend Mrs Wisniewski or examine her or see the CTG
trace himself. Instead, he probably assented to Sister Brockbank’s
advice on what to do. Sister Brockbank had told the judge that she had decided
to contact Dr Renninson mainly because of the quick foetal heart beat
(tachycardia) - in 1988 the normal range for a foetal heart rate was considered
to be between 120 bpm and 160 bpm - but also in relation to the deceleration to
110 bpm at 3.40 am. There were some inconsistencies in her evidence, and the
judge eventually held that she had failed to tell Dr Renninson about the
tachycardia, since this was not expressly mentioned in Dr Renninson’s
statement. He went on to hold that the Defendants were negligent in that Dr
Renninson should have attended and examined Mrs Wisniewski at this time. He
found that there was nothing else happening in the hospital that night which
properly prevented the attendance of Dr Renninson or another doctor, or excused
his failure to attend. These findings are not challenged by the Defendants on
this appeal. They understandably take the view that whether this omission was
caused by the midwife not telling the doctor the full story or by the doctor,
on the assumption that he was told the full story, failing to attend, the
result would have been the same and as the responsible health authority they
would be vicariously liable in either event.
The judge also found that it was Sister Brockbank who took the decision to
disconnect the electronic monitor and allow Mrs Wisniewski to walk about the
ward. She said that she might have made this decision, which was the type of
decision midwives often make, of her own motion or in answer to a request to go
to the toilet. The judge also accepted the evidence of Mr and Mrs Wisniewski
that between 3.40 am and 4.20 am, when the monitor was reconnected, Sister
Brockbank did not at any time check the foetal heart rate with a stethoscope or
a sonicaid. But although the judge held that the Defendants were negligent in
failing to ensure continuous electronic monitoring during this period, nothing
now turns on this finding because the judge held that the Plaintiff had not
proved that there was any material difference in the foetal heart rate during
this period, and there is no cross-appeal against this finding. At 4.20 am
Sister Brockbank noted that there were 2 weak contractions every 10 minutes and
that the foetal heart rate was 170 beats per minute and regular. She made no
further notes until 5 am, and the judge accepted the evidence of Mr and Mrs
Wisniewski that Sister Brockbank did not come and look at the trace again after
the CTG was reconnected until Mr Wisniewski went and fetched her when the trace
seemed to be going haywire at 5 am.
The judge found that the earliest time by which delivery by caesarean
section might have been carried out, following investigation at 3.40 am, would
have been 4.00 am, and the latest time 4.30 am, and that if Philip had been
born by that method he would not have encountered the catastrophe which
actually befell him. It was not till 4.50 am, 30 minutes after the trace had
been recommenced, that the judge held that there was again evidence on the CTG
of a deterioration sufficient to warrant intervention in the course of labour
by an ARM. He found that the Plaintiff had failed to prove that it would have
been possible to carry out a caesarean section safely, following a decision to
rupture the membrane after the deceleration observed at 4.50 am, even if the
ARM had been performed without taking a foetal blood sample. In the event
Sister Brockbank performed an ARM at 5.20 am, and events then moved very
swiftly towards the baby’s birth only 20 minutes later.
The result of this appeal therefore turns critically on the findings that
ought to follow the judge’s unchallenged finding that the Defendants were
negligent because Mrs Wisniewski was not examined by the SHO on duty soon after
the early deceleration was noted on the CTG at 3.40 am. In one respect this
court has an advantage not available to the judge, since the decision of the
House of Lords in
Bolitho
was handed down in November 1997, long after the judgment at first instance. I
will first describe the way the judge approached these additional findings
before I go on to consider Mr Grime QC’s criticisms of the approach he
adopted.
The judge set out in his judgment passages from the judgment of Farquharson
LJ (with whom Dillon LJ agreed) in this court in
Bolitho
[1993] PIQR P 334, at p 342 and from the judgments of Hobhouse and Roch LJJ in
Joyce
v Merton, Sutton and Wandsworth HA
[1995] 27 BMLR 124, at pp 155-6 and 145. The judge deduced from these cases
that he had an obligation to make findings as to what Dr Renninson would have
done if he had attended, and what a hypothetical competent doctor would have
done in his place, and also findings as to whether, if Dr Renninson had not
proceeded to rupture the membrane artificially and gone on to decide upon a
caesarean section, this would have been contrary to responsible medical
practice. If Dr Renninson (or a competent substitute) would probably have
performed an ARM soon after 3.40 am, there would be no need to undertake the
second, more complex investigation, since the Plaintiff would have proved as a
fact that but for the Defendant’s negligence an ARM would have been
performed which would have led inevitably to a decision to perform a caesarean
section and would have avoided the hazard that in fact befell him.
On the question of what Dr Renninson himself would have done the judge
adopted the following course. The Defendants’ solicitors had disclosed
on 10th August 1994 a short statement signed by Dr Renninson a week earlier
from an address in Cheshire, in which he made it clear that he had no
recollection of his involvement in the management of this case. Apart from the
question of what happened or did not happen at about 3.40 am, there was never
any suggestion that he was involved again in any way until 5.27 am (13 minutes
before the baby’s birth) when he was told of the presence of
meconium-stained liquor associated with foetal tachycardia and he (and many
others) attended the labour ward immediately. There were hints at the trial,
which he was not present to refute, that he might have been asleep in the room
at the hospital which is made available for this purpose for busy SHOs on call
at night.
As I have said, Dr Renninson did not give evidence at the trial. A Notice
under the Civil Evidence Act 1968 was served on 16th January 1996 seeking to
put his written statement in evidence because he was beyond the seas: the
Plaintiff’s solicitors served a counter-notice on 1st February on the
grounds that he was one of only two material witnesses to the events complained
of, and that the Plaintiff would be severely prejudiced by being deprived of
the opportunity to cross-examine him as to the contents of his statement which
directly contradicted the medical notes. On 8th February 1996 the doctor wrote
a letter, which the Defendants’ solicitor exhibited to an affidavit,
explaining that he was reaching the end of his medical training in
gynaecological cancer surgery at the Women’s Cancer Centre in Sydney,
Australia, and that he did not intend to return to England with his wife and
three children until August 1996 or, possibly, August 1997. The
Plaintiff’s legal advisers then made an unsuccessful application to a
district judge for an order requiring Dr Renninson to return to England to give
evidence at the trial. Nobody seems to have considered the possibility of
arranging for Dr Renninson to give evidence by video-link, although he had said
in his letter he would be happy to help in any way possible from where he was.
At the close of the Defendant’s case at the trial the judge reluctantly
admitted his statement as hearsay evidence although he was not willing to give
its contents much weight.
The reason for this was that the judge took a dim view of Dr
Renninson’s attitude, from which he was willing to make findings adverse
to the Defendants. Two passages in his judgment touch on this point. At p 12
the judge said in relation to the question whether Dr Renninson attended at
3.40 am:
"Dr
Renninson’s evidence was only given by way of a statement. There was no
justifiable reason which explained his non attendance at the trial to give
evidence and be cross-examined on his statement, and no reason why some other
arrangements could not have been made had the defendants so chosen. For this
reason and because his statement was equivocal on whether he attended or not, I
attach little weight to his evidence on this issue. However, his statement,
the circumstances of his non-attendance and the failure to submit his evidence
to cross examination give rise to further consequences to which I refer at page
21"
On p 21, following a heading “What would Dr Renninson have
done?”, the judge said:
"Dr
Renninson’s statement does not mention that he was told of the
tachycardia and I do not accept the evidence of Sister Brockbank that he was.
For the reasons given, I find her an unreliable witness and her evidence as to
why she contacted Dr Renninson was contradictory; she was not sufficiently
concerned about Mrs Wisniewski’s condition to give him a full picture.
As
I have already observed, Dr Renninson’s statement does not deal with what
he might have done if he had had full information and examined the CTG trace
and Mrs Wisniewski. The statement does not seek to answer the serious
criticism made as to what ought to have been done.
It
was submitted by Mr Redfern that I should infer from Dr Renninson’s
failure to attend that he had no answer to the criticism made and that I should
therefore find that he would after examination of Mrs Wisniewski and the CTG
trace have concluded because of the tachycardia and decelerations that it was
necessary to rupture the membrane and concluded it was safe to do so and
thereafter proceeded to a caesarean section; see
Chapman
v Copeland
(1966) 110 SJ 569;
British
Railways Board v Herrington
[1972] AC 877 at p 930. In my judgment this is an inference that I can and
should draw; there was no legitimate reason put forward by Dr Renninson for not
returning to this country for the trial; furthermore there was no explanation
from the defendants for not taking his evidence in Australia on commission or
otherwise so he could have been cross examined and given evidence as to what he
might have done. I conclude that a decision not to call him or to take his
evidence in Australia was made for tactical reasons; the defendants cannot
therefore complain if I draw this adverse inference against them."
If the Plaintiff is able to hold this positive finding on appeal, then there
would be no need to go any further. The judge went on:
"However,
it is rightly pointed out that the evidence of the actual doctor who should
have attended should be treated with a degree of caution, and it is therefore
right that I also find what a competent doctor would have done had he attended."
The judge then reminded himself on the way in which Mr Redfern QC had put
the case for the Plaintiff. He had argued that it was clear that the foetus
was distressed by 3.40 am and that the cause of this was not easy to determine.
There were grave risks in allowing the delivery to continue without
intervention and great benefit in rupturing the membrane and then proceeding to
a caesarean section with only a small risk attached. In these circumstances he
had submitted that it was negligent of a doctor to have run the grave risks
inherent in non-intervention at 3.40 am and not to have ruptured the membrane
and then performed a caesarean section.
The judge said he was satisfied that a competent doctor would have concluded
that an ARM should be performed and that it was safe to do so and that he would
have then proceeded to perform a caesarean section. He said that the only real
risk that was entailed in carrying out an ARM at or shortly after 3.40 am was
the possibility of a cord prolapse; there was no risk of accelerating labour at
that time. Any competent assessment of that risk would have to take into
account an examination to see if the cord could be felt, the position of the
head (which the judge held was not free at that time), and the risk of the head
moving. He said that this risk of movement could have been overcome by
requiring the midwife to push the foetus down, as suggested by Mr Johnson, who
was one of the Plaintiff’s expert witnesses.
Against that risk (which the judge considered to be very low) there was the
evidence of distress to the foetus as evidenced by the CTG trace. The cause of
that distress was not possible to determine, but there was a foreseeable and
likely risk that the cause might well be one that would lead to cerebral damage
(or worse) from hypoxia. It was highly desirable to see if that risk was real
by rupturing the membrane to ascertain whether meconium was present.
The judge said that a competent doctor would balance these risks, and he had
no doubt that the only proper course in the circumstances was to carry out an
ARM.
The judge then went on to consider whether a decision to delay rupturing the
membrane but to continue observation would have been consistent with an
approach that would have been adopted by a responsible body of medical opinion.
On this question he was confronted, as is common in contested litigation of
this type, with a conflict of expert opinion. The Plaintiff’s experts
were Mr Anthony Johnson and Mr G J Jarvis, the Defendants’ experts Mr R R
Macdonald and Professor E J Thomas. The judge was clearly impressed by the
long periods of “hands on” experience in obstetrics and gynaecology
professed by the first three of these witnesses. He described them all as
eminent consultants and impressive witnesses (“most impressive”, so
far as Mr Johnson was concerned), and he dismissed a challenge made by Mr
Redfern to Mr Macdonald’s integrity. In addition to calling Mr Macdonald
an impressive witness, the judge described him as a honest and impartial expert.
Professor Thomas’s experience had been different from the other three.
He had specialised in obstetrics and gynaecology since 1984, and his
“hands on” experience as a consultant was much shorter. He had
first become a consultant at Newcastle General Hospital and a lecturer at
Newcastle University in 1987. At the end of 1990 he had taken up a post as
professor and consultant at Southampton University, and since August 1995 he
had been Dean of Medicine there, so that inevitably much of his time in the
eight months before the trial was taken up in administration. Apart from
making an observation about the shorter length of his experience, the judge was
disposed to find fault with Professor Thomas for being reluctant to criticise
any conduct on the part of the Defendants even where criticism was plainly
merited, and for not being prepared to give straight answers to questions. The
judge described him, nevertheless, as an eminent consultant and rejected the
attack Mr Redfern also made on his integrity.
In his judgment the judge set out the contrasting approaches of the two
pairs of experts.
Mr Johnson and Mr Jarvis both said that if a doctor had assessed the CTG
trace at 3.40 am it would have been important for him to take into account what
was known about Mrs Wisniewski’s condition. She was 31 years old, eight
days post term, and had had high blood pressure during both this and her
earlier pregnancy. Whilst none of this evidence was in itself significant,
when these factors were taken together there was a need for a doctor to be more
alert because they contributed to the risk. They considered Mrs Wisniewski to
be part of the way up the scale of risk, or at the low end of high risk.
They both considered that since by 3.40 am the CTG was still showing a
baseline tachycardia without accelerations, this considerably raised the level
of risk. Baseline tachycardia which continued for more than the 15-20 minutes
that were required to see if it would settle down, was an indication of foetal
distress. The first deceleration at 3.23 am (which the judge held to be an
early, or Type 1 deceleration, connected with a contraction) should have
alerted any doctor to keep a close eye upon the patient. After the second
deceleration, which was also Type 1, at 3.40 am, accompanied as it was by the
observation of baseline tachycardia for 40 minutes and the evidence of the
clinical condition of the mother, they both considered that any competent
obstetrician would have appreciated that the situation was serious because
there were clear indications of deprivation of oxygen (hypoxia) in the blood of
the foetus.
Although common causes of such hypoxia were a cord accident or obstruction,
they said that it was not necessary to try and determine the cause immediately.
The objective was to treat the baby there and then and worry about the cause
later. The next step was therefore to conduct a further vaginal examination
and then to proceed to an ARM. If a vaginal examination had been carried out
at 3.40 am it would have shown it was safe to carry out an ARM since this was
the best way to obtain the further information that was needed.
An ARM would have revealed whether meconium was present in the amniotic
fluid and, if it was, this would be a confirmatory sign of foetal distress.
Meconium is the intestinal waste expelled through the bowel, which is expelled
by a foetus when distressed through anoxia (or during a breech birth, not
relevant in this context). An ARM would also enable a foetal scalp electrode
to be fitted and this would give a better reading of the foetal heart rate.
Mr Johnson and Mr Jarvis both accepted that there are downside risks
involved in carrying out an ARM, particularly the risks of cord prolapse and of
accelerating the labour. They considered that there was very little risk of
accelerating labour in this case, as it had not progressed far by 3.40 am, and
that there was a negligible risk of cord prolapse.
This risk depends in part on the position of the head. If the head is free
and high, the risk is greater. Mr Johnson and Mr Jarvis’s belief that
this risk was negligible was founded on the evidence that the head was engaged
at 3.40 am and was not high in the pelvic area. The fact that Sister Brockbank
had recorded 50 minutes earlier that the head bobbed out of the pelvis did not
mean it was free, and they considered that the relative position of the head to
the ischial spines meant it was not free. If the cord had come down, it would
have been possible to feel it during the earlier vaginal examination. In any
event, if the head was not engaged, Mr Johnson said that, since the
baby’s head was later found to be a small one, the ARM could have been
performed without risk by the midwife pushing down on the foetus, thus
preventing the head from moving and eliminating the risk of cord prolapse.
Mr Johnson and Mr Jarvis went on to express their shared opinion that if an
ARM had been performed, there was a 90-95% chance that meconium would have been
found to be present. They based this belief on their own experience, supported
as it was by the description of the meconium found at 5.20 am and by the
evidence that when Philip was born there was meconium in his trachea and he was
gasping. A caesarean operation would have then followed.
Mr Macdonald and Professor Thomas, on the other hand, were both of the
opinion that no action apart from continued monitoring was required at 3.40 am,
although Mr Macdonald would not have criticised a doctor who took the course
advocated by the Plaintiff’s experts. They acknowledged that the three
points mentioned about Mrs Wisniewski’s clinical condition should have
been borne in mind as indications for closer supervision, although they did not
regard them as significant as Mr Johnson and Mr Jarvis considered to be. The
fact that she was 31 years old did not concern them because this was her second
labour. Since the normal span for delivery was 7 days, she was only one day
late. As her blood pressure was only slightly raised it was not relevant.
There was, in their view, nothing in her clinical condition that was not within
the range of normality, and none of the points that had been raised would have
the effect of limiting foetal reserves.
Mr Macdonald accepted that by 3.40 am the trace was
“suspicious”. He would have concluded that the foetus was being
stressed for some reason and that its reserves were being taken up from the
outset. However, the foetal tachycardia might have been associated with
maternal anxiety, and although he would have noted it, he would not have
considered it a matter of serious concern. After examination he would have
been concerned, but he would have continued observation and seen what further
progress there was in labour. He might have tried moving the mother’s
position to see if that brought out an improvement to the trace. His aim would
have been to try to work out the cause of the tachycardia, difficult though
this might be.
Professor Thomas’s evidence was along the same lines. He considered
that there were signs of stress present, but he said that this was normal in
labour. He did not see any signs of compromise or oxygen deprivation, with the
associated risk of cerebral damage. Things, in his opinion, were normal at
that stage.
Mr Macdonald would not have carried out an ARM in these circumstances. When
asked whether he agreed with Mr Johnson’s view about the small risk of a
cord prolapse he replied:
"No,
I do not. I put more emphasis on that risk, that even if you push the head
into the pelvis in order to rupture the membranes the head will tend to rise
again when the midwife lets go and there is a significant risk that the cord
might come down. But I think my main emphasis is on the point that I would
regard this trace as less serious than he did."
This opinion about the risk that the head would tend to rise again when the
midwife let go was not challenged in cross-examination. He restated his
opinion, even as to the later time of 4.20 am, that the trace did not
demonstrate such a degree of hypoxia at that stage that more than continued
observation was appropriate.
Professor Thomas’s evidence was to the same effect. He was worried
about the risk of a cord prolapse. He had never come across the manoeuvre
mentioned by Mr Johnson. He had never been taught to perform it, he had never
performed it, and he was unaware of it from the text books he used. Although
Mr Johnson’s description of it seemed logical, he was worried that if the
head was unmoulded at this early stage of labour, a midwife might not actually
be able to push it physically into the space that was currently available for
it. This concern was not explored or challenged in cross-examination. The
judge ascribed his approach to “his relatively less experience”,
despite the fact that he had had 11 years experience of obstetrics and
gynaecology. Professor Thomas was of the opinion that on balance he would not
have ruptured the membrane but continued to monitor. If there was a
deterioration, then he would have carried out a rupture of the membrane.
When analysing the effect of this evidence the judge showed that he was
influenced by a passage in the judgment of Sachs LJ in
Hucks
v Cole
[1993] 4 Med LR 393 at p 397 when he had said that a court must be vigilant to
see whether the reasons given for putting a patient at risk were valid in the
light of any well-known advance in medical knowledge, or whether they stemmed
from a residual adherence to out-of-date ideas.
The judge said:
"In
my judgment it is clearly necessary for me to analyse whether the course of
treatment put forward by Mr Macdonald and Professor Thomas put the patient
unnecessarily at risk and was not one that a competent doctor acting with
ordinary skill and care or a responsible body of medical opinion would have
followed; see the judgment of Farquharson LJ in
Bolitho
at p 342. I reject the submission that such an analysis takes a trial judge
into the medical arena; such an analysis of medical evidence given by experts
to see if a view put forward is in fact one that a responsible body of medical
practitioners could hold about a clinical judgment on an individual patient is
no different in this respect to a similar analysis of a judgment by an
accountant, lawyer, underwriter or other professional. A judge has to be
conscious of his own lack of medical knowledge and of the fact that clinical
decisions are often difficult to make. However where an analysis of the expert
evidence on the facts relating to a particular case shows that a decision made
by a doctor and supported by experts cannot be justified as one that a
responsible medical practitioner would have taken, then a judge should not
preclude himself from reaching that conclusion simply because clinical judgment
is involved.
For
reasons I have set out in the analysis that a competent doctor should have
undertaken in assessing the risks involved in deciding whether to rupture the
membrane and despite the eminence of Mr Macdonald and Professor Thomas, I
consider on a balance of probabilities that no doctor acting with reasonable
skill and care and no responsible body of medical opinion would have reached
any decision other than to rupture the membrane at or shortly after 3.40 am.
The risks of not acting were too great and the downside very small."
In making this finding the judge did not of course have the advantage of the
guidance now provided by the House of Lords in
Bolitho.
After referring to
Hucks
v Cole
and
Edward
Wong Finance Co Ltd v Johnson Stokes & Master
[1984] AC 296, Lord Browne-Wilkinson said at p 1160A-E:
"These
decisions demonstrate that in cases of diagnosis and treatment there are cases
where, despite a body of professional opinion sanctioning the defendant’s
conduct, the defendant can properly be held liable for negligence (I am not
here considering questions of disclosure of risk). In my judgment that is
because, in some cases, it cannot be demonstrated to the judge’s
satisfaction that the body of opinion relied upon is reasonable or responsible.
In the vast majority of cases the fact that distinguished experts in the field
are of a particular opinion will demonstrate the reasonableness of that
opinion. In particular, where there are question of assessment of the relative
risks and benefits of adopting a particular medical practice, a reasonable view
necessarily presupposes that the relative risks and benefits have been weighed
by the experts in forming their opinions. But if, in a rare case, it can be
demonstrated that the professional opinion is not capable of withstanding
logical analysis, the judge is entitled to hold that the body of opinion is not
reasonable or responsible.
I
emphasise that in my view it will very seldom be right for a judge to reach the
conclusion that views genuinely held by a competent medical expert are
unreasonable. The assessment of medical risks and benefits is a matter of
clinical judgment which a judge would not normally be able to make without
expert evidence. As the quotation from Lord Scarman [in
Maynard
v West Midlands RHA
[1984] 1 WLR 634, 639] makes clear, it would be wrong to allow such assessment
to deteriorate into seeking to persuade the judge to prefer one of two views
both of which are capable of being logically supported. It is only where a
judge can be satisfied that the body of expert opinion cannot be logically
supported at all that such opinion will not provide the bench mark by reference
to which the defendant’s conduct falls to be assessed."
Hucks
v Cole
itself was unquestionably one of the rare cases which Lord Browne-Wilkinson had
in mind. A general practitioner, knowing that his patient had a streptococcal
infection, kept her on a course of drugs which would not kill the organism, and
when that course was over failed to put her on to penicillin. Although four
expert defence witnesses defended his conduct, Sachs LJ said that their reasons
on examination did not really stand up to analysis.
In my judgment the present case falls unquestionably on the other side of
the line, and it is quite impossible for a court to hold that the views
sincerely held by Mr Macdonald (“an eminent consultant and an impressive
witness”) and Professor Thomas cannot logically be supported at all.
These two consultants did not regard Mrs Wisniewski as anything other than a
normal patient. They noted the tachycardia (which Mr Macdonald connected with
the high maternal heart rate noted by Sister Brockbank) and the two early
decelerations, and they both maintained that it would be consistent with an
appropriate standard of care for a doctor to continue observation for the time
being, while seeking to ascertain the cause of the suspicious signs.
It is clear from their evidence that neither of them was willing to discount
entirely the risk of a cord prolapse, which Mr Johnson had described as a
calamitous event if it occurred. Although the baby’s head was not
entirely free, it had moved when Sister Brockbank touched it, and Mr Macdonald
was not convinced that Mr Johnson’s preferred expedient of having the
baby’s head pushed down by the midwife was completely foolproof. He was
not cross-examined about this. Professor Thomas (for all his practical and
academic experience) had never heard of it, and put up theoretical concerns
about it on which he was not challenged in cross-examination, and Mr Jarvis was
not asked about it at all. In those circumstances, in my judgment, the judge
was wrong to have concluded that any reasonably competent doctor would have
resorted to this technique to eliminate the risk of cord prolapse, and the
views expressed by Mr Macdonald and Professor Thomas were views which could be
logically supported and held by responsible doctors. Needless to say, neither
Mr Macdonald nor Professor Thomas would have been willing to countenance a
situation in which no monitoring of any kind would have been conducted for the
next 40 minutes, and the CTG trace would have then remained unwatched for a
further 40, but there is no appeal against the judge’s somewhat benign
finding that even if such monitoring had taken place between 3.40 and 4.20 am
it would not have revealed anything further which would have led a doctor to
perform an ARM. After 4.20 am it was not until 4.50 am that the trace
displayed evidence on which immediate action should have been taken.
I will now turn to consider the judge’s finding that Dr Renninson
himself would have performed an ARM if he had attended Mrs Wisniewski and
conducted a vaginal examination soon after 3.40 am. Mr Grime accepted that
there is a line of authority which shows that if a party does not call a
witness who is not known to be unavailable and/or who has no good reason for
not attending, and if the other side has adduced some evidence on a relevant
matter, then in the absence of that witness a judge is entitled to draw an
inference adverse to that party and to find that matter proved. On this
occasion, however, he says that Dr Renninson was known to be unavailable, and
there was a good reason for his unavailability; the Plaintiff had not adduced
any evidence which tended to show what Dr Renninson would have done if he had
attended; and so far from drawing an adverse inference the judge was willing to
draw a benign inference (in the light of the view he took of the case) that
this negligent doctor would have behaved in a non-negligent way if he had in
fact attended.
The need for the party relying on such an inference to establish a prima
facie case on the matter in question was established in
McQueen
v Great Western Railway Company
(1875) LR 10 QB 569, where it was more likely that a servant of the railway
company (rather than a member of the public) would have stolen the
plaintiff’s goods from a truck in a railway siding to which the public
had access, but the plaintiff did not call any evidence to show that this was
what had in fact happened. In those circumstances, Cockburn CJ said at p 574:
“If
a prima facie case is made out, capable of being displaced, and if the party
against whom it is established might by calling particular witnesses and
producing particular evidence displace that prima facie case, and he omits to
adduce that evidence, then the inference fairly arises, as a matter of
inference for the jury and not a matter of legal presumption, that the absence
of that evidence is to be accounted for by the fact that even if it were
adduced it would not displace the prima facie case. But that always
presupposes that a prima facie case has been established; and unless we can see
our way clearly to the conclusion that a prima facie case has been established,
the omission to call witnesses who might have been called on the part of the
defendant amounts to nothing."
In
Chapman
v Copeland
(1966) 110 SJ 569 a defendant driver elected to call no evidence in a case
involving a fatal road traffic accident where the plaintiff widow had adduced
evidence of brake and tyre marks made by his car on the road surface, and this
court was willing to infer in his absence that he had been at fault. Salmon LJ
said that:
"....
as the law now stood there was no obligation on the defendant at the end of the
widow’s case to give evidence. However, if he chose not to do so, he
could not complain if, on a very narrow balance of probability, the evidence
justified the court in drawing the inference of negligence against him ...
Where the defendant, quite legitimately, in a case in which there was nothing
but accident mathematics, chose not to give evidence to the contrary, he could
not complain."
In
Herrington
v British Railways Board
[1972] AC 877, the other case cited by the judge, Lord Diplock applied the same
principle when the plaintiffs had adduced evidence that a chainlink fence four
feet high, which ran along the boundary between a railway line equipped with
live electric rail and a public open space where children gathered to play, was
pressed down to a height of no more than ten inches from the ground at a point
where it was approached by a well-trodden path across the meadow. This state
of affair was said to have existed for several weeks before a child suffered an
accident on the line.
Against this background Lord Diplock said at pp 930F-931B:
"The
appellants, who are a public corporation, elected to call no witnesses, thus
depriving the court of any positive evidence as to whether the condition of the
fence and the adjacent terrain had been noticed by any particular servant of
theirs or as to what he or any other of their servants either thought or did
about it. This is a legitimate tactical move under our adversarial system of
litigation. But a defendant who adopts it cannot complain if the court draws
from the facts which have been disclosed all reasonable inferences as to what
are the facts which the defendant has chosen to withhold.
A
court may take judicial notice that railway lines are regularly patrolled by
linesmen and gangers. In the absence of evidence to the contrary, it is
entitled to infer that one or more of them in the course of several weeks
noticed what was plain for all to see. Anyone of common sense would realise
the danger that the state of the fence so close to the live rail created for
little children coming to the meadow to play. As the appellants elected to
call none of the persons who patrolled the line there is nothing to rebut the
inference that they did not lack the common sense to realise the danger. A
court is accordingly entitled to infer from the inaction of the appellants that
one or more of their employees decided to allow the risk to continue of some
child crossing the boundary and being injured or killed by the live rail rather
than to incur the trivial trouble and expense of repairing the gap in the fence."
The need for the party who seeks to rely on an adverse inference to adduce
proof on the matter in issue was repeated by the Supreme Court of Victoria in
O’Donnell
v Reichard
[1975] VR 916 where Gillard J conducted a review of earlier English and
Australian cases and said at p 920:
"Of
course, patently there must be some limitation imposed upon the application of
this rule. For example, any party upon whom the burden of proof on any issue
is imposed must always adduce a prima facie case on such issue to go to the
jury, and the failure of the other party to the litigation to call witnesses
who may be expected to elucidate the matter cannot fill in any gaps in the
proof required (see per Dixon CJ in
Hampton
Court Ltd v Crooks
(1957)
97 CLR 367 at p 371; and
Tyne
v Rutherford
(1963) 36 ALJR 333)."
Gillard J summed up the state of the authorities in these terms at p 921:
"Looking
at the authorities from
Blatch
v Archer
(1774) 1 Cowp 63 right up to
Earle
v Eastbourne District Community Hospital
[1974] VR 722, it may be accepted that the effect of a party failing to call a
witness who would be expected to be available to such party to give evidence
for such party and who in the circumstances would have a close knowledge of the
facts on a particular issue, would be to increase the weight of the proofs
given on such issue by the other party and to reduce the value of the proofs on
such issue given by the party failing to call the witness."
It will be noticed that Gillard J described one effect of drawing an adverse
inference as being “to increase the weight of the proofs” given on
the issue in question by the party in whose favour the inference is being
drawn, and that in
Chapman
v Copeland
this court was willing to uphold the judge even though the plaintiff widow had
been able to adduce very little evidence to support her claim that the
defendant driver had been at fault. The same approach is exemplified by the
unreported case of
Hughes
v Liverpool City Council
(Lexis transcript, 11th March 1988, CA). A tenant had sued her landlords, the
Liverpool City Council, for breach of an implied covenant in her lease because
the gas boiler in her flat had exploded when she tried to light the pilot
light. The only evidence she could adduce to the effect that the council knew
about the defect was the fact that her flat had been inspected by one of its
representatives when she had taken it over two months earlier. The defendants
called no evidence, and while May LJ upheld the judge in finding that the
boiler would have been inspected at that time and that the defect would have
been present then, he was not willing to uphold the judge’s further
inference that as a result of the inspection, the defendants had been put on
inquiry at that time that a repair to the boiler was needed.
He said:
"Although
I have every sympathy with Mrs Hughes, I do not think that that is the correct
approach in law to this matter. The learned judge had to decide this case on
the evidence. He could only draw inferences from the evidence and from his
findings of primary fact on that evidence. He was not, in my opinion, entitled
to draw an inference or inferences from the mere failure to call a witness.
The onus was on the plaintiff to make out her case. If there had been only a
scintilla of evidence called on her behalf tending to support the fourth
inference to which I have referred, then in the absence of any contrary
evidence, because no witness was called for the defendants, the judge would
have been entitled to find even that scintilla sufficient to make out the
plaintiff’s claim."
In
T
C Coombs v IRC
[1991] 2 AC 283 Lord Lowry explained at p 300 the benefit which a court may be
willing to confer on a silent defendant who gives some sort of explanation for
his failure to give evidence, even if it is not a very good one. He said:
"In
our legal system generally, the silence of one party in face of the other
party’s evidence may convert that evidence into proof in relation to
matters which are, or are likely to be, within the knowledge of the silent
party and about which that party could be expected to give evidence. Thus,
depending on the circumstances, a prima facie case may become a strong or even
an overwhelming case. But, if the silent party’s failure to give
evidence (or to give the necessary evidence) can be credibly explained, even if
not entirely justified, the effect of his silence in favour of the other party
may be either reduced or nullified."
From this line of authority I derive the following principles in the context
of the present case:
(1) In
certain circumstances a court may be entitled to draw adverse inferences from
the absence or silence of a witness who might be expected to have material
evidence to give on an issue in an action.
(2) If
a court is willing to draw such inferences they may go to strengthen the
evidence adduced on that issue by the other party or to weaken the evidence, if
any, adduced by the party who might reasonably have been expected to call the
witness.
(3) There
must, however, have been some evidence, however weak, adduced by the former on
the matter in question before the court is entitled to draw the desired
inference: in other words, there must be a case to answer on that issue.
(4) If
the reason for the witness’s absence or silence satisfies the court then
no such adverse inference may be drawn. If, on the other hand, there is some
credible explanation given, even if it is not wholly satisfactory, the
potentially detrimental effect of his/her absence or silence may be reduced or
nullified.
It is therefore necessary to examine with some care the evidence adduced by
the Plaintiff on the issue as to what Dr Renninson would have done if he had
attended Mrs Wisniewski, and examined her, and the circumstances surrounding
his failure to attend the trial to give evidence.
The Plaintiff adduced evidence to the effect that Dr Renninson was the duty
doctor on call that night, and that if he had attended Mrs Wisniewski when
Sister Brockbank told him about her, he would have seen the CTG trace which
would have shown him that there had been flat baseline foetal tachycardia for
40 minutes and that there had been two early Type 1 decelerations and no
accelerations. He would have also noted the other features of his
patient’s history which I have mentioned in this judgment.
Mr Johnson told the judge, when asked what the doctor should have done, that
if Dr Renninson had attended, then after absorbing all this evidence he would
have told Mrs Wisniewski that he wanted to examine her abdomen and that he
would then have told her he wanted to do a vaginal examination and to rupture
the membranes, if appropriate. This was the standard he would expect of a
reasonably competent SHO. It was not very complicated obstetrics: it was
simple stuff. He would know enough to know that he needed to rupture the
membranes. This was standard practice, which he would have expected on the
signs and appearances he had described. Indeed, Mr Johnson went so far as to
describe it as mandatory. Towards the end of his evidence he said that the
care he was describing was the big typed stuff in the books we read: not
something in obscure journals.
Mr Jarvis, who agreed with Mr Johnson’s evidence, spoke to the judge
in terms of a doctor’s duty to obtain more information in these
circumstances.
In addition to this evidence, which spoke in terms of mandatory obligations,
or duties, the judge was shown two textbooks which reflected the proper
approach to the situation which would have confronted Dr Renninson if he had
attended his patient at 3.40 am. The first of these text books,
A
Textbook for Midwives
by Margaret F Myles, was unequivocal in its advice to midwives. After
describing how foetal distress occurs when the foetus suffers oxygen
deprivation and becomes hypoxic, the 1989 edition reads at p 174:
"Signs
of foetal distress. Any or all of the following may be present:
foetal
tachycardia which is an early sign of oxygen deprivation
foetal
tachycardia or foetal heart rate decelerations related to uterine contractions
passage
of meconium-stained fluid.
Management
of foetal distress. When signs of foetal distress occur the midwife must call
a doctor..."
The earlier, 1964, edition had said at p 421 that a foetal heart rate of
over 160 should give rise to concern and that when the rate decreases by 20
beats this indicates severe oxygen lack and is a serious sign of foetal distress.
The other textbook was called
Foetal
Monitoring in Practice
(Gibb and
Arulkumaran
1992). The passage from that book at p 16 which the judge quoted in his
judgment was not wholly apt for the circumstances of the present case, because
the suggested causes of a high foetal baseline heart rate of 150-160 bpm were
absent here, and it was common ground that in 1988 there was not the same
degree of concern about a foetal heart rate below 160 bpm. Nevertheless the
text contains the same general message as
Myles,
and the Defendants did not adduce any textbook reference which might tend to
suggest that the seriousness with which Mr Johnson and Mr Jarvis were disposed
to regard the situation as shown by the CTG trace at 3.40 am was misplaced.
When I turn to consider the pre-trial development of the Plaintiff’s
case, the Statement of Claim, served on 25th March, concentrated its fire
particularly on the alleged failings at 3.40 am. In particular it was said
that a vaginal examination should have been carried out at or about that time,
and that if that had been done the membranes would have been ruptured and
meconium would have shown demonstrating foetal distress and the need for a
caesarean section, which should have been carried out. In the Defence, served
on 15th July 1993, it was admitted and averred that the CTG was normal and
demonstrated good baseline variability with occasional decelerations and that
at about 3.40 am irregular contractions were noted, the CTG scan then
demonstrating a rate of 160 to 170 bpm with satisfactory baseline variability
and shallow decelerations. There was a general traverse of the allegations of
negligence. In May 1994 the Plaintiff furnished further particulars of his
claim, which included the allegation that there was a significant episode of
deceleration on the trace at 3.40 am.
The Defendants were very slow in furnishing their witness statements, for
which an “unless” order eventually had to be sought.
Bolitho
had been decided in this court by the time Dr Renninson’s statement
eventually appeared (see [1993] PIQR P 334) so that the Defendants’
solicitors would or should have known that a likely issue in the case was what
Dr Renninson would probably have done if he had attended his patient at 3.40
am, read her notes and seen the CTG trace (see Farquharson LJ, with whom Dillon
LJ agreed, at p 342).
Dr Renninson’s statement is completely silent on this issue. He does
not say whether he was told of the long period of tachycardia in the foetal
heart rate, and he could not remember if he in fact saw the patient. He says
that he gave instructions that the patient should remain on the labour ward and
that observation should continue but that the patient could mobilise for a
while. He also comments in retrospect that he would have been satisfied, if
the CTG was discontinued, if the midwife had continued monitoring with a
Pinnards stethoscope. But he nowhere says what he would have done if he had
attended his patient.
The experts’ reports were exchanged soon after the witness statements
were exchanged. The Defendants’ solicitors would by now have known of
the uncompromising terms in which Mr Johnson and Mr Jarvis were expressing
their opinion. Mr Johnson said that failure to carry out a vaginal examination
and an ARM was well below accepted standards of care. Mr Jarvis said that he
believed that the latest time that ARM should have taken place was 3.40 am, and
he was equally outspoken about the standards of care Mrs Wisniewski in fact
received (“I cannot believe that there is any reasonable body of clinical
opinion who would have ceased monitoring at this point given the information
already available”). Before the action came on for trial at the end of
February 1996 the decision of this court in
Joyce
v Merton, Sutton and Wandsworth Health Authority
[1995] 27 BMLR 124 had also been reported. Hobhouse LJ, with whom Nourse LJ
agreed, made it clear in his judgment at pp 155-6 that the plaintiff could now
win a case like this if he satisfied the court that the doctor who failed to
attend would probably have taken the requisite action if he had attended
(although he would not have been at fault if he did not). What Dr Renninson
would have done if he had attended was therefore now an even more central issue
in the case.
I have recited earlier in this judgment how the Defendants’
solicitors, well outside the time allowed by Order 38 Rule 21(1), served a
notice under the Civil Evidence Act in relation to his statement, and what the
Plaintiff’s solicitors’ reaction was to this belated notice.
Because the trial went short, after quantum had been agreed, and because
Professor Thomas could not attend until what would normally have been the
eighth day of evidence, there was in fact a six-day break in the hearing
between 28th February and 6th March. Just before this break the judge made it
very clear to the Defendants that he would be likely to draw an adverse
inference if Dr Renninson did not give evidence.
Mr Grime has explained to us that during the course of his discussion with
the judge at that time, he believed that the effect of Farquharson LJ’s
judgment in
Bolitho
was that the Plaintiff not only had to prove what Dr Renninson would have done
if he had attended but also that he would have been negligent if he had not
done it. The judge told him he wanted to indicate that he had never come
across a case before where a person had chosen not to come to defend his
clinical judgment. At that stage he had not been shown Dr Renninson’s
letter, but he made it very clear that unless he was shown evidence that it had
been rendered impossible for Dr Renninson to attend, he would be liable to draw
an adverse inference.
Although they had been given this warning, the Defendants placed no further
evidence about Dr Renninson’s non-appearance (other than his letter)
before the judge when the trial resumed nearly a week later. So far as the
judge was aware, although damages had now been agreed at £900,000, the
Defendants made no effort during the break in the hearing to see if Dr
Renninson could after all fly to England to give evidence or if he could give
evidence by videolink from Sydney (there is a reference to the protocol which
is available as a guide to the use of video-conferencing equipment in civil
proceedings in the High Court in the notes to Order 38 Rule 3 in Volume 1 of
the White Book).
In addition to Dr Renninson’s absence, there was also a deafening
silence from the other members of the relevant medical team at the hospital.
Neither the registrar who had been on call that night nor the consultant with
overall responsibility for the team attended to tell the judge what the
practice at that hospital was for handling situations like the one that
presented itself at 3.40 am. If such evidence had tended to show that the
doctors at that hospital would be likely to adopt a “wait and see”
approach, it would have been much more difficult for the judge to make a
finding that Dr Renninson would have adopted a different course if he had in
fact attended.
In all the circumstances, in my judgment the judge was entitled to adopt the
course he chose to adopt. The Plaintiff had established a prima facie, if
weak, case that a doctor who attended Mrs Wisniewski at 3.40 am would probably
have adopted the course which the Plaintiff’s expert witnesses had told
him it was his duty to adopt, and the judge was entitled to treat Dr
Renninson’s absence, in the face of a charge that his negligence had been
causative of the catastrophe that befell Philip, as strengthening the case
against him on that issue. It must be remembered that the first limb of the
Bolitho
test, as it has now been explained by Lord Browne-Wilkinson, does not require a
court to make a finding of fact as to what a doctor actually did, but as to
what a doctor would have done in the hypothetical situation the court is
required to envisage. In those circumstances it may be easier for the
Plaintiff to set up an affirmative case on that issue which is liable to be
strengthened if for no good reason the doctor is unwilling to submit
him/herself to questioning before the judge as to what he/she would probably
have done. And in these days of videolink technology it may no longer be
sufficient for defendants to rely on a doctor’s absence abroad to avoid
calling him/her to give evidence.
In future it would, in my judgment, be very much better in this type of case
for the Statement of Claim to include a positive averment that if the
defendants had not been negligent in failing to take the action alleged, the
relevant member of their staff would have acted in the manner which the
plaintiff contends would have represented appropriate non-negligent practice,
so that that issue is fairly and squarely on the pleadings for the defendants
to answer. However, as the law was developing during the passage of this
litigation, I would not discharge the judge’s finding on that account,
since both
Bolitho
(in the Court of Appeal) and
Joyce
had been decided before the trial took place, and it would not have been
difficult to infer how the Plaintiff would be putting his case: indeed, the
Defendants were given the windfall of six extra days to think about how to
defend themselves successfully while the trial was going on.
Mr Grime’s third challenge to the judgment related to causation. Put
shortly, he argued that the harm which befell Philip during his passage down
his mother’s birth canal (in effect, strangulation because the umbilical
cord was looped round his neck and had a knot in it which gradually tightened)
was quite different from the harm to which the health authority’s breach
of duty had wrongfully exposed him (the risk of damage by oxygen starvation
within the womb). He cited to us a number of well-known authorities on issues
of causation, culminating in a passage from the speech of Lord Hoffmann in
Banque
Bruxelles SA v Eagle Star Insurance Company Ltd
[1997] AC 191 at p 213C:
"Rules
which make the wrongdoer liable for all the consequences of his wrongful
conduct are exceptional and need to be justified by some special policy.
Normally the law limits liability to those consequences which are attributable
to that which made the act wrongful."
Some of the earlier cases to which Mr Grime referred us were reviewed by
Glidewell LJ in
Galoo
Ltd v Bright Grahame Murray
(1994) 1 WLR 1360 at pp 1369-1374, and culminated with this passage which
starts at p 1374G:
"The
passages which I have cited from speeches in
Monarch
Steamship Co Ltd v Karlshamns Oljefabriker A/B
[1949] AC 196 make it clear that if a breach of contract by a defendant is to
be held to entitle the plaintiff to claim damages, it must first be held to
have been an ‘effective’ or ‘dominant’ cause of his
loss. The test in
Quinn
v Burch Bros (Builders) Ltd
[1966] 2 QB 370 that it is necessary to distinguish between a breach of
contract which causes a loss to the plaintiff and one which merely gives the
opportunity for him to sustain the loss, is helpful but still leaves the
question to be answered ‘How does the court decide whether the breach of
duty was the cause of the loss or merely the occasion for the loss?’.
The
answer in my judgment is supplied by the Australian decisions to which I have
referred, which I hold to represent the law of England as well as of Australia,
in relation to a breach of a duty imposed on a defendant whether by contract or
in tort in a situation analogous to breach of contract. The answer in the end
is ‘By the application of the court’s common sense’."
The
Australian decisions to which Glidewell LJ referred went back to dicta by Dixon
CJ, Fullagar and Kitto JJ in
Fitzgerald
v Penn
(1954)
91 CLR 268 at p 277:
"It
is all ultimately a matter of common sense .... In truth the conception in
question is not susceptible of reduction to a satisfactory formula."
The
judge dealt with this issue quite briefly at the end of his judgment:
"It
is clear that the actual mechanism that led to the hypoxia - the true knot in
the cord wrapped around the neck - could not have been foreseen. A true knot
in a cord is a very rare happening - perhaps 1 to 2 a year in a busy teaching
hospital, although the cord being looped around the neck is much more common.
Thus the particular mechanism that brought about the injury could not have been
foreseen.
Mr
Grime accordingly argues that even if Sister Brockbank and Dr Renninson had
been negligent, no foreseeable damage occurred.
I
am however satisfied that there clearly was a foreseeable risk of damage by
hypoxia to Philip. The damage that occurred was caused by hypoxia and of the
kind that was foreseeable; as the damage was of the kind foreseeable, it makes
no difference that the precise mechanism by which the hypoxia arose was not
foreseeable."
I can find no fault with this approach, and it would in my judgment be
regarded as an affront to common sense, and the law would look an ass, if we
reached any different conclusion. As the judge concluded, the risk to which
the Defendants’ breach of duty exposed Philip was the risk of damage by
hypoxia. For all we know, the harm which was showing up on the CTG was being
caused by a cord accident or obstruction connected with the presence of a cord
which was shortened by the presence of a loose knot and looped round his neck,
and it was this harm which the Defendants should have taken steps to address.
As the judge said, it makes no difference in these circumstances that the
precise mechanism by which the later, much more serious hypoxia arose was not
foreseeable. This was not a case of novus actus interveniens and the
Defendants’ breach of duty was indeed properly categorised as the
effective cause of the Plaintiff’s damage.
For these reasons I would dismiss this appeal.
LORD
JUSTICE ALDOUS: I agree.
LORD
JUSTICE ROCH:
I
also agree.
ORDER
(Not part of judgment):
Appeal
dismissed; respondent to have costs of appeal; legal aid taxation of
respondent's costs; money in court (£315,000) to remain in court; balance
of agreed damages (ie balance of £585,000) to be paid into court together
with interest on that sum from 2 April 1996; monies in court to be transferred
to the higher interest account; the question of a structured settlement to be
listed as soon as is convenient before Thomas J; leave to appeal refused; case
to be given its full title.
________________________________________