England and Wales High Court (Queen's Bench Division) Decisions

IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION

		Royal Courts of Justice Strand, London, WC2A 2LL
		1st August 2012

HHJ Baker :

The Claimant and the Claim

1. Kate Emma Woodward is now 20 years of age. When she was about 8 it was noticed that she was becoming very tall for her age, and by October 2001 concerns were being expressed about her height and about the weight which she was gaining. By September 2005, when she was 13, she was reported as being desperately upset by her weight gain and a diagnosis was made of classic acromegalic gigantism. This was caused by a tumour on her pituitary gland which caused the gland to secrete excessive quantities of growth hormone. Some non-invasive treatment was administered in the form of subcutaneous octreotide as a means of suppressing the secretion of the growth hormone but this was not successful. She reported feeling intermittently ill in November 2005. In March 2006, when Kate was almost 14, she underwent a surgical procedure for the removal of the pituitary tumour, but it was not possible to remove all of it and, as I shall mention in more detail at a later stage in this judgment, there is a risk that the tumour may become aggressive and re-grow.
2. The Claimant alleges, and the Defendant admits, that the Defendant negligently failed to diagnose and then to treat the pituitary tumour for more than three years and that as a result of that failure the Claimant grew both in height and frame to a size which considerably exceeds what would have been expected. It is likely that she would have grown to about 5'9½" but she is now approximately 6'4" to 6'5" in height and she weighs in the region of 24 stones. In addition, the effect of acromegalic gigantism is that she has undergone many bodily changes which affect her life now and which have the potential to affect her life adversely in the future. The Defendant admits that its negligence has caused significant physical effects which the Claimant will have to live with for the remainder of her life, and acknowledges that some of those effects may result in her condition deteriorating in the future. The Defendant admits liability to pay damages to the Claimant, and I have read and heard detailed evidence from a number of sources concerning the quantification of those damages.
3. The Defendant's negligence has resulted in numerous physical consequences which I shall describe. There is some disagreement between the parties as to the severity of those consequences and their effect in terms of their impact upon her life and her future career and the extent to which she will require assistance in the future.

The consequences as described by the Claimant and her parents

4. The Claimant's evidence is primarily to be found in three statements which she has made. In passing I note that her original and signed first statement which she says was made in August 2011 is not contained in the papers available to me or to counsel but I am assured by counsel and by the Claimant that she did sign that statement and no point has been taken by the Defendant that the trial Bundle contains only an unsigned copy.
5. In her first statement the Claimant spoke about the effect upon her of growing at an unusual rate and to an unusual size when she was a child. She suffered some bullying and unkindness at the hands of schoolchildren and although she had been a keen netball player and enjoyed horse-riding she had to give up both of those pastimes. As a result of the many medical examinations and treatments which she underwent she lost some time when she was studying at school as an adolescent and she believes that this had an adverse effect on her A-level results. Notwithstanding that, she has embarked upon a BA degree course at Regent University in London studying Script Writing and Production. She hopes to make a career in that sphere of the entertainment and dramatic arts world. I shall return to that later.
6. She describes in her first statement that she is very self conscious about her height and weight which are considerably in excess of the size of her friends and fellow students. She says, and this is confirmed by her parents, that she tries to disguise her size whenever possible. Her self-consciousness is probably exacerbated by comments, which are at best insensitive and are at worst rude and cruel, which strangers make about her in her earshot. Not surprisingly she finds such comments to be humiliating. It is a sad but perhaps not surprising fact that the Claimant has low self esteem. Paragraphs 19 and 20 of her first statement contain her own description of herself as a cross between a Michelin man and a stretched out doll, and she refers to her footwear as Frankenstein shoes. I accept that the language which is used in those paragraphs truly reflects her own view of some aspects of her physical appearance.
7. The Claimant told the Court that she is not able to control her weight, she becomes tired and short of breath after exertion, and she worries about developing diabetes at some future time.
8. I accept and find that the Claimant has missed out, and will continue to miss out, on many of the pleasurable activities which many young women and many of her own female friends enjoy. For example, going on shopping expeditions for fashionable clothes and shoes or going to nightclubs. She no longer goes swimming because of disfiguring stretchmarks on her body. The Claimant cannot find clothing and footwear in High Street shops except for the occasional pair of trainers (men's size) or perhaps a simple item of very casual clothing or underwear. She derives no enjoyment from shopping for herself, and if she were to accompany her friends on their shopping outings it would only serve to make her disappointment more acute.
9. For some time she was particularly self-conscious about her teeth. Her jaw grew to such an extent that her teeth no longer fitted together but looked far too small for her mouth. She describes how her own teeth looked like the sort of artificial teeth which can be bought in a joke shop. Fortunately this problem has been rectified by some extensive dental work (permanent porcelain veneers in the upper and lower jaws) and are now of satisfactory appearance, but this was another aspect of the serious change of appearance which resulted from the acromegalic gigantism from which she suffers. To maintain the satisfactory appearance she will require replacement of those veneers at periodic intervals and this has been agreed between the parties.
10. A further aspect of her physical appearance which is attributable to her condition and its treatment is that her breasts have not developed normally. This may be a comparatively less serious physical manifestation than some others in this case, but it adds to her unhappiness with her own body and appearance.
11. At the age of 20 the Claimant has not had a serious relationship with a young man. In her first statement she said that she tries to avoid meeting young men in general. She worries that she will not meet anyone because of her appearance. In paragraph 33 of her statement she says that she would never try to form a relationship of her own volition because of how she looks. And in paragraph 63 she says that she has written off her ability to form a relationship with the opposite sex and is concentrating on her work. This again is a reflection of her very subjective view of her own appearance and I accept and find that that is how she feels about herself.
12. One consequence of having grown to such an unusual height and stature is that she finds that she is too large to fit comfortably into almost anything. She cannot comfortably use a conventional domestic bath. She has to crouch when she uses a shower. She has to stoop when she uses the working surfaces and appliances in her kitchen. She cannot fit comfortably in a modest sized car such as a Vauxhall Astra. She is too tall to be able to lie comfortably in a normal sized bed. I accept and find that these are all part of the entire range of consequences which affect her life on a daily basis and which will affect her throughout the remainder of her life.
13. I have heard evidence from Mr and Mrs Woodward who have both described in their statements and their oral evidence how their daughter has a very negative image of her body and how she is very self-conscious. I find that the Claimant's evidence and that of her parents is true and that since these problems started to develop and in particular during her adolescence her relationship with her family has sometimes been strained to a greater extent than is typical of most people's experience of the tensions between adults and their teenage children.

Special Damages: Financial losses incurred prior to the trial

14. In the period between when the cause of action arose and the date of the trial in July 2012 the Claimant's parents provided extensive physical and personal care and psychological support for her which was directly attributable to the condition from which she suffers and the medical treatment which she received for it, and which went beyond that which would have been required if the correct diagnosis had been made and the correct treatment provided in 2002. The parties have agreed that the award of damages should include £15,682 to reflect the extensive additional care which was provided by the Claimant's parents between May 2002 when a correct diagnosis should have been made and the date of the trial. I award that sum.
15. In addition, the Claimant's parents have incurred substantial expense in travelling to and from hospitals, medical and other therapeutic appointments. The parties have agreed that there shall be an award of £2,500 to reflect this additional expense. I award that sum.
16. Interest in the sum of £3,921 shall be added to the damages for the care which has been provided and the cost of travelling.
17. The Claim for pre-trial financial loss, including interest, has been agreed in the total sum of £22,103 and this will form part of the award.

The Claimant's current and future medical condition and its consequences

EVIDENCE FROM THE ORTHOPAEDIC SURGEONS

18. The Court has received evidence from two consultant orthopaedic surgeons, Professor Mulholland and Mr Bradish. Their evidence is now the subject of agreement, which is the basis of my findings, and there is in addition to their own reports a joint statement and a further letter from Professor Mulholland dated 1^st July 2012 and further short joint report from them dated 3^rd July 2012.
19. The Claimant already suffers from painful symptoms of low back pain which affects her after exertion or, for example, after periods of stooping over the kitchen worktops, kitchen sink and appliances in her home. She can alleviate her pain by taking anti-inflammatory tablets and paracetamol but this may not prove to be an effective remedy as time goes by. A major part of this claim is in respect of the extent to which her physical condition will deteriorate during the remainder of her life and the extensive medical treatment which she will require in order to maintain her health and to be able to enjoy those amenities of life which will be available to her.
20. Professor Mulholland and Mr Bradish agree that there is already very severe radiological abnormality throughout the Claimant's spine with disc degeneration at all levels, particularly at the lumbar-thoracic junction. I find this to be a serious condition which affects a woman of only 20 years of age. Further details are contained in the joint report, and are summarised by the experts who say that such changes in such a young woman represent very severe changes and are entirely due to a combination of acromegaly and gigantism. These two conditions, together with damage to the hypothalamus which will lead to obesity, will cause very significant progression in her spinal abnormalities which will inevitably become significantly symptomatic. The two consultant orthopaedic surgeons conclude that by her early forties the Claimant will have a significant spinal problem which may manifest itself in two ways. First, she will probably develop persistent and disabling back pain and restriction of movement. Second there is a more than probable risk that she will develop spinal stenosis (narrowing of the spinal column which puts pressure on the spinal cord) although they cannot estimate with accuracy when that will occur or how severe its symptoms may be but they believe that the risk of it occurring is more than 50%. If it does occur it is likely to affect her lumbar region and there is a risk, although they suggest a lower risk, that it will affect the thoracic region also. Their joint estimate is that if stenosis occurs it is likely to be when she is in her late forties and at that stage she will require surgical treatment. There is little if any medical literature on the subject of stenosis in the case of acromegaly, gigantism and obesity. They jointly observe that what was so disastrous in this case was that the gigantism went undiagnosed in childhood and this led to her developing acromegaly in adulthood. The likely prognosis of symptomatology is that there will be progressive restriction in her walking ability due to leg and back pain and related spinal stenosis. Changes in the thoracic spine may lead to spinal cord compression which would, if untreated, potentially lead to gait disturbance and the risk of bowel and bladder problems. The treatment for spinal stenosis is spinal decompression but if the Claimant's weight is not controlled adequately her obesity would present an obstacle to this type of treatment.
21. The orthopaedic experts jointly report that the Claimant is more than 50% likely to develop premature hip osteoarthritis in her mid 40's which may result in her having to undergo bilateral hip replacements. They believe she is also likely to develop premature knee degeneration in her forties and knee joint replacement surgery may have to be performed.
22. The Claimant is also at risk of developing median nerve injury which would result in pain and disability in the hand and which may require nerve root decompression.
23. Upon the agreed evidence I find that the Claimant is disposed to premature disc degeneration (acromegalic spinal arthropathy) for which no surgery will be available and this will inevitably lead to back pain which will become persistent and require pain relief. By the time she is in her forties she may be 30% - 40% disabled on the Oswestry scale. She already has intermittent discomfort in her back and knees. Mr Bradish says that there is likely to be an acceleration by 10-20 years of osteoarthritic changes in her spine, knees and hips.
24. Professor Mulholland and Mr Bradish have agreed that regular MRI scans on her spine should be carried out every 4-5 years. They agree that eventually she may require the use of a non-motorised wheelchair and a motorised scooter but they do not envisage the need for a motorised wheelchair and a motorised scooter.

The need for Physiotherapy

25. In Professor Mulholland's letter 1^st July 2012 he was asked to comment on certain aspects of physiotherapy treatment which the Claimant will require in the years ahead. It is important to note that in the context of this case the expression "physiotherapy treatment" does not mean gentle massage and manipulation, which is what many people might understand it to mean. It is the application of a number of physical techniques to musculoskeletal disorders, and in this case Professor Mulholland recommends an intensive and active programme of physical rehabilitation and core stability. The purpose of this type of physiotherapy is not only to alleviate acute or chronic pain but also to help to prevent or delay the onset of pain, deformity and disability.
26. I have already mentioned that the Claimant has significant changes in her spine which are modestly symptomatic. The hypothalamic disorder which afflicts her will probably cause her to be obese. She already weighs in excess of 24 stones and is finding it very difficult to control her weight despite being very strict with herself concerning her diet. This is likely to complicate her spinal problem.
27. In Professor Mulholland's opinion it is essential that she commences a fixed programme of intense physiotherapy whilst she is in her twenties for her to maintain spinal mobility and fitness. It is likely that it would also help to alleviate pain in her hips and knees although he envisages that it is certain that at some time in the future she will suffer a failure of her hip joints. He opines that she should commence physiotherapy now. He recommends that a trainer or physiotherapist should be engaged not only to indicate to her what she should be doing but to advise how to adjust the programme if as is likely she experiences pain from her already mildly symptomatic back. Mr Bradish takes the view that because the Claimant has demonstrated that she is motivated by undertaking yoga and by becoming a member of a gymnasium she may have sufficient motivation to carry on with the necessary active forms of physiotherapy which I assume, although the agreed report of 3^rd July 2012 does not specifically say so, would be without the need to engage a personal trainer or physiotherapist on a regular basis.

The cost of future physiotherapy

28. The orthopaedic surgeons recommend weekly, regular and structured physiotherapy and medication to relieve her discomfort in her back, hips and knees. The current cost of this they estimate in their joint report to be not less than £50 per week. In a further joint statement dated 3^rd July 2012 they state that they agree that the Claimant currently requires a regular programme of exercise to help maintain her mobility and core strength.
29. The experts agree and I find that from the age of 35 onwards the Claimant will be at a disadvantage in the labour market and will satisfy the legislative definition of being disabled. In her late thirties she is more likely than not to develop such acute symptoms of pain that she will require not only a weekly session of exercise but two periods each year lasting four weeks when she will require three or four session of physiotherapy every week. The Defendant agrees this. The agreed calculation for this aspect of damages is £50 per week x four weeks x 3.5 sessions per week x twice per annum from age 37 to 50 which according to the Ogden tables produces a multiplier of 7.28 = £10,192.
30. The experts agree and I find that in the Claimant's mid 40's to 50's there will be a significant impact on her domestic activities to the extent that she will require support at home, and in her late 40's to 50's the chronic pain may become so bad that she will require inpatient treatment once or twice a year at a cost estimated to be £2,000 to £3,000. The Defendant agrees with this. Counsel told me that it is agreed that the word "may" in this context of this report of 3^rd July 2012 means "it is more likely than not." The agreed calculation for this aspect of damages (taking the midway point of each bracket as the correct figure) is 1.5 sessions per annum at an estimated cost of £2,500 with an agreed life multiplier of 4.25 from age 50 = £15,938.
31. The cost of regular physiotherapy from now until the deterioration of her condition is not agreed. I have not heard oral evidence from either of the orthopaedic experts and I am invited by the parties to interpret their reports and joint report for myself. The Claimant's counsel submitted that it is likely to be the case that there are times when the Claimant will need the full input from a physiotherapist/trainer and other times when her own efforts will be sufficient. I interpret the joint report as indicating that the Claimant will be likely to benefit from weekly exercise which for the foreseeable future she is capable of motivating herself to engage in, but it is in my view unrealistic to assume that she can carry on with this indefinitely or that her self motivation will be sufficient, and yet it is also unrealistic to conclude that she will have such little motivation that she requires the services of a physiotherapist or trainer every week. In my judgment she should be able to have the assistance of a physiotherapist at an estimated cost of £50 at least once per month so as to monitor her continuing participation in suitable physical exercise and to make sure that her programme of exercise is appropriate for her and to make any necessary adjustments to it. The cost of this will be £600 per annum with a life multiplier of 25.33 = £15,198 plus an additional assessment fee of £68 = £15,266, in addition to the further sums which have already been agreed. This lifetime multiplier, which applies to some other aspects of the damages, is based on the current Ogden tables and reflects the Claimant's life expectancy which has been agreed between the parties.
32. The total amount which I award for the cost of future physiotherapy is £41,396.

EVIDENCE FROM THE CONSULTANT ENDOCRINOLOGISTS

33. The Court received evidence from Dr Stanhope and Dr Wales. They broadly agree with each other both as to the consequences of the Defendant's negligence and as to the nature of the treatment which is likely to be required in the future.
34. I shall set out the key features of Dr Stanhope's evidence, with which Dr Wales broadly agrees because this forms the basis of my findings.
35. First, the tumour on the Claimant's pituitary gland has only been partially resected and it continues to secrete the growth hormone. This can be controlled by the use of octreotide therapy which will be required for the remainder of her life. Octreotide is an inhibitor of the growth hormone. Unfortunately, octreotide creates side effects of its own. It is known to be a cause of gastrointestinal upset, liver disease, gallstones (particularly relevant to this case), pancreatitis, thyroid dysfunction, abnormal blood sugar homeostasis, diabetes and depressive illness. Dr Stanhope told me that the most likely adverse effect will be the development of diabetes mellitus in conjunction with acromegaly and weight gain. Diabetes mellitus can be controlled by self-medication. The Claimant has already suffered the development of gallstones which were very painful and which led to their surgical removal. In his oral evidence Dr Stanhope told the Court, and I accept, that it is likely that the development of bilary stones in the gall bladder was caused by the alteration of her bile salt metabolism as a result of taking octreotide. He told me that as a result of the operation to remove the gallstones and gall bladder there will be scarring to her bilary tract, her bowel and surrounding structures, and it is therefore not surprising that she has continuing pain although he is hopeful that it will settle.
36. Second, she has suffered hypothalmic damage. She will probably feel hot and cold although in a temperate climate such as we have in this country this may not present too much of a problem. It is more likely to be a problem for her if she takes holidays in climates which are markedly different from our own. In the hypothalamus there is what Dr Stanhope referred to as an appetite centre and if this is damaged it can cause hyperphagia which is an abnormally increased appetite for food, which means that the Claimant will have no brake on her appetite. A consequence of this may be future weight gain and obesity unless there is some way of preventing this, either by dieting or by the use of a gastric band or gastric bypass surgery. If such surgery is performed she would probably require vitamin and mineral supplements. If the Claimant continues to increase in weight there is an increased risk that she will develop Type II Diabetes Mellitus, which is capable of being controlled but which carries its own attendant risks to her health and wellbeing. The prospect in future years is that she will have to take more and more medications, some of which are to counteract the effects of some others. I note that the two consultants say that the Claimant probably would have been overweight in adulthood even if she had not suffered the medical complications which have occurred in her life, but they do not say that she would have been excessively overweight. The Claimant told the Court that she is considering having a gastric band fitted. This is a very serious step for a young woman of only 20 to undertake and it would not necessarily result in her losing weight. It would restrict the amount of food which she could ingest, but Dr Stanhope told the Court and I accept that patients who eat great quantities do not necessarily do so because they want to eat but because their bodies crave for calorific intake, and it would be possible to consume vast quantities of calories in a liquid form, eg by drinking calorie saturated soft drinks or even, as Dr Stanhope said, by drinking liquidised Mars Bars. Whilst the Claimant is at present very well motivated to controlling her diet and trying to lose weight it is not clear whether she would be able to retain that resolve and determination if gastric banding or gastric bypass surgery is performed. Dr Stanhope told the Court that the development of Type II diabetes mellitus with all its associated complications is a major risk and that because of the Claimant's acromegaly diabetes would in her case be more difficult to control than it is in the general population.
37. Third, the Claimant is exposed to the risk of cardiovascular disease as a direct consequence of acromegaly and, indirectly, as a consequence of weight gain.
38. Fourth, there may be continuing changes in her soft tissues and there may be a deterioration of spinal arthropathy.
39. Fifth, the Claimant is TSH and TRH deficient and in addition to other medications she has to have thyroxin replacement. Also she is gondotrophin deficient and requires oestrogen and progestogen to complete her sexual maturation. This has an attendant risk of leading to osteoporosis, although Dr Stanhope is unable to quantify that risk. The Claimant also requires vasopressin replacement and regular hydrocortisone therapy.
40. Sixth, there is a risk that the tumour will recur. Dr Stanhope says that this is a major risk. There is not sufficient statistical and historical data for him to quantify this risk. He believes it is likely that it will happen but he is unable to assess that likelihood. He told the Court that the specialist literature reports that this type of tumour behaves aggressively. Dr Wales did not contradict this and there is no evidence to the contrary. I accept Dr Stanhope's opinion. In order to monitor the behaviour of the remnant of the tumour it is necessary to take periodic blood specimens and to examine them but also it is necessary for periodic examination by MRI scans to be carried out. This is because if the tumour re-grows it may not produce the hormones which would be detected in blood tests.
41. It is probable that the Claimant will not grow significantly any more in height. There is some uncertainty about her precise height which may in some circumstances be difficult to measure, but Dr Stanhope and Dr Wales agree that there should be no more significant increase in her height. It there is any it will probably be limited to a few millimetres in her upper body. Dr Stanhope said that we can look to see a little more growth in her, but I find on balance that any such further growth is likely to be minimal.
42. The Claimant also has a problem with excessive perspiration. This is not the result of hypothalamic damage but is a consequence of being acromegalic. The excessive secretion of the growth hormone increases the size of the sweat glands and this causes excessive perspiration. Dr Stanhope told the Court that the Claimant's description of herself in her evidence of having clammy hands is an absolutely classic feature of acromegaly. Most people who have this condition sweat excessively and there can therefore be a tendency to have unwelcome body odour. Dr Stanhope told the Court, and I accept, that he has never met an acromegalic who does not complain of excessive sweating and the social embarrassment which that can cause.
43. Both Dr Stanhope and Dr Wales addressed the subject of gastric banding or gastric by-pass either of which procedures is possible. Either procedure would greatly reduce the pleasure of eating, and probably reduce the pleasure of eating in company with others whose consumption is not restricted. A by-pass operation may have a better outcome than gastric banding both in terms of permitting her to consume more than if she had gastric banding and in terms of reducing although not eliminating the risk of the onset of Type II diabetes. But it requires long term vitamins and mineral supplements and long term monitoring of her mineral uptake. It is therefore an invasive form of surgical treatment which may have some benefits but it can add another dimension to her prescribed medications.
44. The two consultant endocrinologists agree that the Claimant will have to receive growth hormone replacement therapy and must undergo monitoring of the tumour for the remainder of her life. A major issue in this trial has been whether the Claimant may be awarded as damages the cost of receiving such treatment on a privately funded basis even though such treatment is currently available and being provided to her under the NHS.

Private treatment or treatment under the National Health Service

45. The cost of future treatment will be a very substantial sum which the Claimant cannot pay unless she is awarded sufficient damages to enable her to do so. If damages are not awarded to enable her to pay for this treatment privately she will have to rely on the NHS to provide it.
46. The Claimant wants to be able to arrange to have this treatment on a private basis. The law is clear on this. Pursuant to section 2(4) Law Reform (Personal Injuries) Act 1948 there shall be disregarded, in determining the reasonableness of any expenses, the possibility of avoiding those expenses or part of them by taking advantage of facilities available under the National Health Service. The test which I have to apply is whether I am satisfied on the balance of probability that if the Claimant is in a position to pay for this aspect of her treatment privately she will do so.
47. A point against the Claimant's case on this point is the fact that she has thus far received all her treatment under the NHS and since the tumour was diagnosed and treatment was commenced she has been treated very well and she is happy with the care provided by Dr Orme and by her GP and the practice nurses attached to his surgery. The Defendant contends that this pattern of treatment which is serving the Claimant well and which she appears to be happy with is probably an indicator as to the future. However, the mere fact that the treatment up to now has been provided under the NHS is not determinative in my view. This treatment is so expensive that it would have been beyond the Claimant's ability to pay for it up to now. She has not had any choice in the matter. But it is an important point that she has developed a good working relationship with Dr Orme and her GP.
48. On the other hand, the Claimant gave evidence that she has a real fear of the re-growth of the tumour. She says it is constantly on her mind. If it does, she has been informed that surgical excision will probably not be an available option because of the position of the tumour, and the only treatment which may be available will be radiotherapy. She has occasional headaches and worries that they are a symptom of the re-growth of the tumour. She believes that her anxiety about this will never go away. In paragraph 49 of her first statement she says that she is constantly concerned that the treatment which she receives every six weeks (the octreotide injections) maybe withdrawn under the NHS system. She worries about what she would do if this treatment is withdrawn because she cannot afford it from her own means. The injections are crucial to her. She says that the possibility of that treatment not being provided fills her with dread and fear.
49. In paragraphs 28-30 of her second statement (14^th June 2012) she adds that she is concerned and anxious in relation to her future medical treatment. She feels that there is a time-bomb ticking in her head and she wants to have the ability to see an expert whom she trusts as and when it is necessary or required and at a location which is convenient to her. She acknowledges that all the treatment which she has received up to now has been through the NHS but she again expresses a concern that this might not continue. In paragraph 50 of the report of Dr Eileen Bradbury she reports the Claimant as having told her that she has been told that the local GP practice may not continue to fund the injections. The Claimant knows that the purpose of the injections is to control the residual parts of the tumour and knows that the injections are very important, and is very worried that without the injections the tumour will come back. She did not know how she would be able to pay for those injections long term. She is distressed by having been told that if the tumour had been diagnosed and treated appropriately at an early stage it is likely that the entire tumour could have been removed. The Claimant says that if she could see a consultant of her choice and have the assurance of seeing him at agreed times and intervals it would give her considerable reassurance over something which a significant source of worry for her.
50. When she was cross-examined the Claimant said that she has built up a rapport with Dr Orme who she believes has made an exception for her because of the history which gives rise to this claim. She said she is concerned that other doctors may not be as kind to her as Dr Orme. She said that she does not want this treatment to continue under the NHS because "…they lost my trust." When she was questioned more closely about this she agreed that even if she sees a consultant on a private basis there is a risk that the consultant will retire from practice, but she said that this is also a risk if she receives her treatment under the NHS with which there is the additional risk that she may be seen not by the consultant but by another doctor. She said that this has already happened. Dr Wales and Dr Stanhope told me that whilst the treatment which is provided currently under the NHS is qualitatively the same as the treatment which could be obtained on a private basis there can be a difference in terms of the continuity of that treatment. Dr Wales told the court that under a private paying arrangement the patient has almost a guarantee of continuity, ie seeing the same consultant at agreed convenient times whereas under the NHS there can be what he described as the all too common experience of being seen by a Registrar who reads the patient's notes during the consultation. This can be disconcerting for anyone receiving any form of treatment for a serious condition, but for this Claimant who already has had years of anxiety and whose current condition stems not simply from a naturally occurring disease or from an unfortunate accident but from this NHS Defendant's admitted negligence in its treatment of her it would in my judgment be even more disconcerting for her to be at risk of having appointments with a consultant re-arranged to suit the consultant or of having her appointment passed to a junior doctor who may not be familiar with her case.
51. The Claimant intends to settle in London and make her life there. Dr Stanhope told the court that within the NHS the continuity of care may be patchy in some areas of the country although he accepts that both in private practice and in the NHS nurses who work in this field of medicine often stay in that field and in a particular practice or clinic or hospital on a long term basis. In his opinion the NHS would be more likely to provide continuity of care in a provincial town rather than in a large city, and in a city the continuity of care is more likely to be provided on a private basis than under the NHS. He bases this opinion on four decades of experience. Dr Wales did not disagree with this. He told the Court that he would hope that Dr Orme would transfer the claimant's care to a trusted colleague in London but it is not known what arrangements will be made and how satisfactory they will be and what degree of continuity of care they will provide.
52. In my judgment this Claimant has a constant fear about the risk and consequences of the pituitary tumour re-growing. That risk cannot be quantified because the condition is very rare and there is a dearth of statistical data concerning similar cases. But although the risk cannot be quantified it does exist and upon the evidence which I have heard I do not regard it as a fanciful risk. Dr Stanhope told the court that the small amount of medical literature that exists on this subject reports that this type of tumour behaves very aggressively although he acknowledges that this is based on what he described as a handful of cases. For this Claimant it is very important that the state of the tumour is monitored very carefully. Dr Stanhope told the court that if it re-grows the treatment will be very hazardous and the best outcome will be achieved if the re-growth is found at an early stage. I accept that opinion. In my judgment the Claimant is not to be criticised for wanting to do all that she can to ensure that the tumour and the treatment of it are very carefully monitored by a consultant who will have the greater likelihood of providing continuity of care.
53. There is a second area of concern. In some cases a reason for not awarding a claimant the cost of private treatment is because that treatment may not be readily available in the private sector and this gives rise to the prospect that the claimant would revert to the NHS to receive that treatment. This in turn may lead to a court finding in some cases that although a claimant says that he would receive his treatment privately he probably would not do so in fact. That is not this case. At the present time the treatment by way of octreotide injections, twice yearly consultations, blood tests and periodic MRI scans is available to the claimant under the NHS and is also available privately. I accept the evidence of both Dr Stanhope and Dr Wales that this treatment will continue to be available on a private paying basis and that if the Claimant's medical care is transferred to London where she intends to make her life there are specialists in this field of medicine who are amongst the best in the world. The area of concern is not whether the necessary treatment will be available privately but whether it will continue to be available in its current form under the NHS. In an addendum report dated 31^st May 2012 Dr Stanhope stated that in view of the changes which have been made to the structure of the NHS in recent years there is no security in the fundamental structure of the NHS that treatment is provided free at the point of delivery. He observed (although this is a general comment rather than a specific observation on this case) that as the cost of health care rises it may be that the Health Service as it is now becomes unaffordable. He concluded by saying that there is no guarantee that treatment provided free of charge by the NHS will continue in the longer term, particularly over a time-span of the next 40 years. This is a very important consideration because he and Dr Wales agree that the claimant will require lifelong endocrine supervision and treatment of her endocrine condition irrespective of the possibility of a tumour recurrence. She will require endocrine follow-up, octreotide therapy and hypothalamic pituitary MRI scans. Dr Stanhope stated in his recent report that funding of health care in England is through Primary Care Trusts or Commissioning Groups who decide what care will be funded. Certain treatments may be available in one part of England but not in another and this has led to what is sometimes known as "postcode prescribing." In his oral evidence Dr Stanhope repeated that the funding of the health service is in a state of flux and added that as a nation we cannot afford a total healthcare system free of charge. Dr Wales told the Court that he hopes that whatever healthcare system is in place will provide for the Claimant's treatment but he shares Dr Stanhope's unease as to the future.
54. In the light of all that evidence I have to decide if the Claimant would, if able to afford it, arrange for her endocrine treatment to be provided on a private paying basis or whether she would continue to receive it under the NHS. Unfortunately the Court cannot adopt a "wait and see" approach. If the Claimant is not awarded the cost of private treatment now but if she finds at some time in the near, middle or even distant future that her treatment under the NHS is either unsatisfactory because of lack of continuity or because certain parts of the treatment are not funded by the Primary Care Trust or Commissioning Group she would not be able to come back to court to ask for more damages. An award of damages, other than in the exceptional circumstances where provisional damages are awarded, is a one-off lump sum award which has to cater for the many imponderables and contingencies which exist in life.
55. In my judgment the two critical factors are:

i) the Claimant's real anxiety about the recurrence of the tumour and its potential consequences, and her concern that she shall be able to secure continuity of expert care and the provision of necessary medication; she has had so much to contend with during her childhood and adolescence and now in her young adulthood that it would be conducive to her general well being that she should be relieved of this additional anxiety;

ii) the high cost of this treatment which gives rise to an unquantifiable risk that whichever Primary Care Trust or Commissioning Group becomes responsible for overseeing the Claimant's care will restrict the funding which is available. I bear in mind the Defendant's counsel's closing submission that the provision of life preserving treatment would surely be one of the last services to be cut from the NHS, but I also bear in mind the lack of certainty about the treatment being provided in its current form and intensity.

56. In the light of all the evidence which is available I find it is more likely than not that if she has the means to do so the Claimant will obtain her future endocrine treatment on a private basis and will not rely upon the NHS to provide that treatment. There may be many other aspects of her medical condition which she would be content to leave in the hands of the NHS because the need for continuity of care is not as important or because there is no real cause for concern about whether that treatment will be funded by the NHS, but as far as her endocrine treatment is concerned I am satisfied that she will pay for that on a private basis and I award as part of her damages the cost of obtaining it.
57. The growth hormone replacement therapy is administered by injections. Until now these have been administered by a practice nurse at the Claimant's GP's surgery. In addition to these injections the Claimant also needs to have periodic consultations with the consultant endocrinologist who is responsible for this part of her treatment. She also needs periodic blood tests, which ideally should be carried out very shortly before the consultations with the endocrinologist, and periodic MRI scans. The blood tests and MRI scans are for the purpose of monitoring whether there is any evidence of re-growth of the pituitary tumour. Blood tests may reveal if the remnant of the tumour is producing hormones, but it is possible that the tumour could re-grow without hormone markers being revealed. The MRI scan is a second method of monitoring whether the tumour remnant is continuing to grow. It is very important to know if there is any growth of the tumour remnant. If it grows it will be very hazardous to the Claimant's health and because of its position it will be very difficult to remove. I accept that the earlier any re-growth is found the better the outcome is likely to be.

The cost of endocrine treatment and monitoring

58. The injections of octreotide are very expensive. Dr Stanhope has provided a costing, based on the British National Formulary, of £1,062.50 per 30mg vial. If this is administered once every six weeks the annual cost would be £1,062.50 x 52 ÷ 6 = £9,208.33. If this drug is purchased from a pharmacy he estimates that an additional 5% - 10% would be added. The Claimant's counsel has taken a mid point in this range, which may be pragmatic but it is not agreed by the Defendant and any percentage higher than the lowest end of that range (5%) has not been proved to be correct on the balance of probability. If the cost on a six weekly basis is £9,208.33 and if that is increased by 5% the annual cost will be £9,668.75.
59. In addition, he says that the cost of two annual consultations with a consultant endocrinologist would be £400, and the cost of MRI head scanning is £1,200 per scan. In his letter of 12^th June 2012 Mr Stanhope said that the MRI head scanning would need to be undertaken once a year, but in his oral evidence he said that for the first 10 years after surgery (ie until about 2015-2016) he would recommend a head scan every year, and thereafter reducing to every two years. Dr Wales said that after a period of annual scans for the first five years after surgery it would be appropriate for these to be followed by scans every two years which may possibly reduce to a frequency of once every five years. In my judgment, having regard to aggressive nature of this type of tumour and the potentially catastrophic consequences of it re-growing and not being detected timeously the best course, and the course which would give the greatest confidence to the Claimant who already suffers anxiety about the possibility of the tumour re-growing will be for her to be monitored by blood tests and by MRI scans with the frequency which Mr Stanhope has identified. I find that this is a reasonable item of future expense and I prefer Mr Stanhope's opinion to that of Dr Wales on this point. Intervals of five years are, in my judgment, too long for this Claimant to be expected to wait given the history of this case and her understandable anxieties.
60. In my judgment the cost of this aspect of the Claimant's future treatment, if it is paid for privately, is as follows:

Octreotide: £9668.75 per annum (multiplier for life 25.33) = £244,909.

Medical appointments: £400 per annum (multiplier for life at 25.33 years) = £10,132

Blood tests £1,200 per annum (multiplier for life at 25.33 years) = £30,396

MRI scanning (tumour): at a cost of £1,200 once per annum on five occasions until 2016 (ie, until 10 years after the resection surgery) followed by once every second year for the remainder of her life from 2016 with a lifetime multiplier of 14.56 producing a total of £17,477.

That will produce a total sum of £302,914.

61. I am not persuaded that there is a need for the Claimant to require other less expensive injections and medications and the MRI orthopaedic scans for other aspects of her medical treatment to be provided on a privately paying basis. The evidence does not persuade me that these forms of treatment and investigation are likely to be denied to her on the ground of cost, and in any event I am not satisfied that the Claimant would probably opt to pay for this treatment herself. Her major concern is that the tumour must be actively monitored and that the appropriate endocrine treatment for it must be provided so as to allay her fears. But I am not persuaded that the same applies to the other medications and body MRI scans in respect of which I do not make an award of damages for the cost of their private provision.

THE PSYCHOLOGICAL DAMAGE

62. Dr Wales told the Court that the psychological consequences of the Defendant's negligence are devastating. He is not a psychiatrist or a psychologist so I can only regard that piece of evidence as a very general observation but it is a reflection of how from his perspective as an endocrinologist he assesses the psychological effect which the Claimant's condition has upon her.
63. The Court received evidence from Dr Elaine Bradbury who is a chartered health psychologist with extensive experience of assessing and treating people who have developed psychological problems as a result of trauma, disease and problems with physical treatments, and experience of working with children and adolescents who are physically different from their peers. This field of expertise is particularly relevant to this case. She also works with adults and has experience of assessing the long term impact on an individual's development into adulthood. Dr Bradbury reported in June 2011 after seeing the Claimant on 10^th March 2009 a few weeks before the Claimant's 17^th birthday. The Claimant was still attending school at that time and had not taken her A-level examinations. Dr Bradbury reported (in paragraph 87 of her report) that it was difficult in a single assessment session to understand all of the Claimant's problems and how they affect her but she felt able to make a reasonable assessment of her psychological state. She described the Claimant as intelligent and articulate. She reported that part of the Claimant's antipathy to hospitals results from the way in which the diagnosis was disclosed to her on her own and without her parents in attendance when she was 13. She reported that the Claimant felt very distrustful of hospitals and doctors and angry (although I note that the Claimant appears to have developed a satisfactory doctor/patient relationship with Dr Orme).
64. Dr Bradbury reported that in 2009 the Claimant had developed symptoms of panic in public places and felt like a freak. This was consistent with the Claimant's evidence and also that of her mother.
65. I interpose some evidence from the Claimant which to some extent puts this into a different perspective. The Claimant herself told the Court about what she is doing to lead a productive and interesting life. She is in the second year of her degree course and hopes that when she graduates she will be able to gain employment with a broadcasting company such as the BBC or a television or radio production company as a script writer or in the field of production. At University she attends a film club and volunteered and was elected to become the editor of the College newspaper and also to be Vice President of the Students' committee. These activities do not necessarily involve her having to mix with large numbers of fellow students but in my judgment they do indicate a commendable willingness to try to get on with her life as best she can. She has recently undertaken some work experience at a small cinema in Sidmouth as part of her course. She showed initiative by presenting herself and her curriculum vitae to the owner of the cinema. This work involves her interacting with the public in selling tickets, meeting members of the public and their children, serving drinks and snacks, and supervising the auditorium. Sometimes members of the public make comments about her height. In addition to that work she managed to promote herself very briefly into the position of Head Floor Manager at a People's Music Award in London during the summer of 2011. She was in charge of 8 staff and had to organise timings for a lot of guests and co-ordinate as many as 20 musical acts. There were hundreds of people in the audience and the event was broadcast on SKY television. At that event she became the Director's right hand lady (as she put it). She had been taken on as a runner but either had the confidence or at least overcame her self-consciousness to promote herself into the Director's helper. Nevertheless the Claimant is still very self conscious of her appearance.
66. In addition the very unfortunate events giving rise to this claim, and the many difficulties which the Claimant has suffered from and continues to suffer from, have led to unhappy tensions in her family relationships, particularly with her mother.
67. Dr Bradbury reports that the Claimant is very worried about the tumour re-growing and the potential consequences of that. She expresses the opinion that the delay in diagnosis had a catastrophic impact on the Claimant's life.
68. She reports that in 2009 the Claimant had a long-standing moderate depressive disorder which had become worse and a moderate anxiety disorder which she had for about 2 years.
69. Dr Bradbury is of the opinion that the Claimant requires expert and long-term psychological therapy. She recommends 40 sessions in the first two years, and thereafter at up to approximately 10 sessions a year to focus on managing anxiety, stress and coping strategies with regard to current and developing medical problems. She estimates the cost of this therapy to be between £120 and £160 per session. The claim is now calculated on the mid-point of that range. The Defendant does not dispute the cost per session on the basis of £140 and does not dispute the assessment that 40 sessions in two years would be appropriate, but takes issue with the number of sessions which may be necessary in the long term. The Defendant has pointed to the fact that the Claimant has now left school, is leading an independent life at University in London, and has managed to find a short term work experience job by dint of her own initiative. Also, as mentioned already, the Claimant has self-promoted herself into a brief job as a Floor Manager at a musical event, and she has become student Vice President of her college and the editor of her college newspaper. Dr Bradbury accepts that what the Claimant is doing is significant and is of the opinion that it will be of benefit to her, but she regards her as being fragile and vulnerable. The Defendant submits that all of these activities may indicate that the Claimant's need for long term counselling may be less than Dr Bradbury has advised, but there is no evidence from any other source as to what reduced level of counselling she may require. Dr Bradbury told the Court in her oral evidence that her initial estimate may be an underestimate. Whilst the Claimant is doing well at this time what lies ahead will be very difficult for her to deal with. She assesses that in the Claimant's mid to late 40's her physical problems will be significant including increasing physical pain in her back, and she may require knee and hip replacements and may feel there is no alternative to undergoing gastric banding. I bear in mind that the Claimant has a number of other problems: the constant fear of the recurrence of the tumour, the fear of developing cardiovascular disease and diabetes, the under-development of the Claimant's breasts, her infertility, her height, her weight, and her body shape. Any one of these may cause many people without her other difficulties some real concern and anxiety but the Claimant has them all to contend with. Dr Bradbury reported that the Claimant can feel very pessimistic about her future.
70. Dr Bradbury is of the opinion that the Claimant will always be vulnerable due to all that she has been through and that she is likely to have to contend with in the future. She added in her oral evidence that in her opinion the Claimant has been traumatised by the gallstones problem earlier this year which caused severe pain. She remains of the opinion that the Claimant will need help dealing with significant problems to manage high levels of stress and to learn to cope with it. She is of the view that the Claimant will be helped by having clothes she feels good in.
71. I have already mentioned that the Claimant developed gallstones and underwent their removal and the removal of her gall bladder (a laparoscopic cholecystectomy) on 4^th February 2012. This in itself is a serious additional complication which I find to have been caused by having to take octreotide and therefore to have been indirectly caused by the Defendant's negligence. The Claimant suffered severe abdominal pain and an upset stomach, and eventually on 1^st February 2012 her condition was so painful that her mother travelled to London and took her by train to Devon. They did not complete their journey because the Claimant was in such pain that the train manager summoned an ambulance to meet them at Taunton Station and they went to Taunton Hospital immediately and thence to Exeter Hospital where she underwent removal of the gallstones which has resulted in surgical scarring. Her mother told the Court and I accept that she has not returned to the University since then and that her tutor has very helpfully allowed an extension of time in which to submit this year's course work. The Claimant continues to have problems with her diet in that she cannot tolerate spicy food or dairy produce and she often becomes nauseous and suffers an extremely upset stomach. She may have to undergo an endoscopy and the prognosis is as yet uncertain. This has all added another layer of stress upon an already anxious young woman.
72. Having regard to the progress that the Claimant has made thus far, but also having regard to the many difficulties which the Claimant is likely to experience in the future, I do not accept that the estimate of her need for psychological counselling is an underestimate, but on balance I find that Dr Bradbury's original estimate of 10 sessions per annum at £140 per session, starting two years from now, is a realistic assessment of what will be needed in the long term.
73. I award for the next two years £140 x 40 = £5600 and thereafter £1400 per annum commencing in 2014 for the remainder of her life. The application of an appropriate multiplier, as agreed by the parties, produces a total award under this heading in the sum of £38,262.

DENTAL TREATMENT

74. The parties have agreed that a course of dental care will be required in the future and that the appropriate amount of damages to reflect this is in the sum of £68,250. I award that sum as part of the damages. The report from Dr Halpern informs the Court that the porcelain veneers which have been applied to the Claimant's teeth will require replacement at intervals of every ten years, which means that the Claimant will have to undergo this form of orthodontic treatment on at least another three occasions during her life.

ASSISTANCE WITH FERTILITY AND REPRODUCTION

75. The parties have agreed that this is a valid head of claim and that an appropriate amount of damages to reflect this is in the sum of £21,563. I award that sum as part of the damages.

BREAST AUGMENTATION

76. This formed part of the pleaded claim but as Counsel for the Claimant conceded when he opened the case to me there is no evidence in support of it. It has not been pursued. I make no award for it.
77. I come now to consider the claim for future expenses other than the cost of medical treatment and therapy.

CLOTHING & FOOTWEAR

78. As a result of growing to an unusually large size the Claimant has great difficulty buying clothes and footwear which fit her.
79. A very substantial part of the claim, almost a third of the pleaded value of the claim, is in respect of the cost of buying clothing and footwear during the remainder of the Claimant's life. She would of course have had to buy clothing and footwear even if she had not developed acromegalic gigantism, but she would have been able to buy and replace her wardrobe from time to time from High Street shops or via the internet and in my judgment she would probably have limited her purchasing of very expensive handmade garments to a few special occasions in her life, in the same way that most people do. She and her mother say that she is unable to equip herself from High Street shops and internet outlets because of her height and the size and shape of her frame and the size of her hands and feet.
80. The parties have agreed that because of the size of the Claimant's feet she will require handmade footwear for the remainder of her life and they have agreed that the sum of £88,285 shall be awarded in respect of this.
81. With regard to clothing other than footwear I have heard evidence from the Claimant and her mother and from two witnesses who were called as experts to assist the court with their experience and expertise in clothing, Mr Emanuel Silverman and Miss Lynn Webster. Mr Silverman has very long experience of working in the retail clothing industry. He served an apprenticeship in tailoring and then worked as a tailor for ten years. I bear in mind that Mr Silverman's experience as a craftsman tailor ended about fifty years ago and that thereafter he worked in production design for Moss Bros and in other capacities which did not involve what I might describe as "hands-on tailoring." He has some experience of cutting women's garments but this was around 1950, a very long time ago. He has met the Claimant and discussed her clothing requirements with her.
82. Miss Webster is a senior teaching fellow at Leeds University. She has forty years experience of the clothing industry. She teaches fashion design and garment technology to her students. She told the court that she is a pattern cutter and she teaches pattern cutting to her students every week. She has not met the Claimant and as far as I am aware had never seen her until the trial. She has not discussed with the Claimant the difficulties which she says she has experienced in buying clothes from shops and the internet.
83. The starting point of my consideration of this part of the Claim is the evidence of the Claimant and her mother. They have both told the Court in their written and oral evidence about the difficulties which the Claimant has experienced and continues to experience in buying clothes from High Street shops and via the internet. Having heard their evidence I accept that they have told me truthfully about those difficulties. The Defendant has suggested that there are a number of shops and internet outlets which may be able to supply clothing of a suitable size for the Claimant but she and her mother have both told me of the many unsuccessful efforts which she has made to buy her clothing from such sources. I find upon all the evidence that I have heard that the Claimant is not only a very large size (it is agreed that she is women's size 28) but she has an unusual figuration. As an example of this her nape to waist measurement is significantly longer (by 3" to 4") than a standard size 28. Her upper arms and her thighs are also larger than a standard size 28. Whereas most people may be able to buy a garment which is of their approximate size and have a minor adjustment carried out (eg shortening sleeves or trouser lengths, or letting out or taking in the waistband) the Claimant is unable to do that. It is not possible to lengthen a jacket or the upper part of a ready-made dress. Mr Silverman told the Court, and I accept, that mass produced clothing is "engineered", ie it is made in such a way as to economise on the amount of material which is used, so there is very little spare material built in to garments to enable seams to be let out. Whilst in theory it may be possible for the Claimant to dress herself with size 28 garments from the High Street or from the internet I accept her evidence and her mother's evidence that it has proved extremely difficult to do so, and that such clothing as she is able to acquire from such sources is her underwear and clothes of a very casual type, for example tops, tee shirts, and other loose fitting casual items.
84. My first finding is that for most of the Claimant's clothing requirements, at least in respect of clothes which she will wear to any formal occasions or for work or business and which she will wear when meeting friends socially although informally she will be unable to buy suitable ready made clothes from High Street shops or from the internet. Garments for such occasions and which are of her size and unusual figuration will have to be made to measure. Whether the Claimant's inside leg measurement is 33" or 35", as to which there is some controversy in the evidence, she is at the very upper end of the size of ready made clothing for skirts, trousers, jeans and leggings.
85. During the evidence of the expert witnesses there was some controversy as to what will be required and the type of clothier who may be able to satisfy the Claimant's requirements. A little time was spent in considering what is meant by the term "bespoke tailoring" in relation to women's garments. At the end of all the evidence I have come to the conclusion that it does not really assist me to decide what that term means. It may mean different things to different people. What I am concerned with is:

i) what clothing does the Claimant reasonably require?

ii) who will be capable of making it and at what cost?

iii) what clothing, and at what cost, would the Claimant have required if she had not, as a result of the Defendant's negligence, grown to the size and shape that she is?

iv) how frequently will she have to replace her clothing?

The cost in (iii) above will have to be deducted from the cost in (ii) above so that the Claimant is only compensated for the extra cost over and above what she would have spent in any event.

86. Having heard evidence from the Claimant and from both expert witnesses I find the following facts. First, the Claimant has a reasonable aspiration to dress smartly and with an appropriate degree of style and awareness of current fashions, and in that way she is no different from many people of her age and from her background and whose ambition is to use her academic achievements to enable her to obtain remunerative employment in a sphere in which one might be expected to be of smart and presentable appearance. That would be my view whether the Claimant achieves her ambition of becoming a script writer and producer or not. The styles and fashions which the Claimant would choose for herself will probably not be outlandish or of a type which will draw attention to herself. She is already very self-conscious of her appearance and I do not think she will be likely to accentuate her unusual size and shape by wearing clothes which make her more prominent than she already is. In my view she will choose clothes of a design which is likely to be tasteful and modest whilst at the same time reflecting current styles and trends.
87. Second, it is probable although by no means certain that she will eventually graduate with a BA with Honours in her chosen field of study even if she has a setback which is caused by having had to take time away from her studies this year because of the gallstones complication. It is probable although not certain that she will in the next few years try to embark on a career in script writing and production or, if that is not a success she will probably work in the entertainment media industry in some capacity. I have not been assisted by hearing evidence from any witness about the mode of work or the mode of dress which might be expected if the Claimant fulfils her ambition. I think it is reasonable to anticipate that in that field of work there is likely to be less formality of dress than in some other occupations, for example working as a lawyer or in the commercial world although I do not doubt that there would be occasions when some formality would be appropriate at interviews, meetings and the like, and she will always have a reasonable aspiration to dress smartly and to present herself to her best advantage when attending important meetings. This would have been the case if she had not suffered the problems which she now has and I do not think that she should now be relegated to a world of living in casual and ill-fitting clothes.
88. Third, there are some items of clothing which will have to be handmade in the same way that a man's suits and formal clothing may be made by a craftsman tailor. Measurements will have to be taken, the cloth will have to be cut specifically for her garments, and she will require one or two fittings before the garments are finished. It will probably be necessary to make a toile so that fitting alterations can be made, or copies made of the same garment if she has more than one garment made to the same design. But I do not find that all of her clothing will have to be made in quite such an exacting and time consuming way. I accept the evidence of Miss Webster that some of the Claimant's clothes, the less "structured" and less formal items, will be capable of being made by experienced dressmakers who have experience of making dresses and suits for women of many different shapes and sizes. The Claimant's expert witness Mr Silverman doubts whether there are dressmakers who would be able to cut patterns and make garments suitable for the Claimant, but I accept Miss Webster's evidence that each year students graduate at her University (and there is no reason for me to think that Leeds University is unique) after being taught the skills of pattern cutting, and that there are small dressmaking businesses in which the dressmakers would have the necessary talent to make clothes which are stylish and which are made to the Claimant's own size and figuration. In support of that evidence I think that it would be surprising if dressmakers declined to accept the Claimant as a customer. People come in many different sizes and figurations, and it is known that obesity amongst adults is increasing. It is reasonable to anticipate that dressmakers who are experienced in pattern cutting and garment manufacturing will be very ready to accept business from many customers who are not able to find clothing elsewhere which fits or which can be readily adapted and that the need for such services is likely to increase rather than to diminish in the future.
89. Fourth, because of the very real risk that the Claimant will gain weight in the future there is a real risk that she will find it even more difficult to buy clothes than she does now. This emphasises the need for her to be able to buy clothes which are specifically made for her and increases the likelihood that she will need to replace her clothing more frequently than many people whose weight and figuration remains reasonably constant or which alters gradually.
90. Having set out those preliminary facts which are general considerations I come now to the details of this part of the claim. It is at this point that the evidence from both parties is somewhat unimpressive. The starting point is that the Claimant has provided a list of her clothing requirements to Mr Silverman and he has made some enquiries as to how much it would cost to obtain the items on that list from what he describes as bespoke tailors in the West End of London. The list has also been provided to Miss Webster who has accepted, or at least assumed, that it represents a list of what the Claimant will require and has provided an estimate of the likely cost of obtaining those items. She agrees with Mr Silverman that some items will have to be made by a skilled tailor but she says that some other items could be made by an experienced dressmaker.
91. A more fundamental aspect of this part of the claim is whether the Claimant's list of requirements is, regardless of the cost, a reasonable list. It has been assumed by both Mr Silverman and Miss Webster that it is not only a reasonable list of initial requirements but that the items in the list, whoever they are made by, will all have to be replaced every year. I accept that because of the Claimant's size and her tendency to perspire more than most people (this being a side effect of her acromegaly according to Dr Stanhope) any fabric which is next to her skin is likely to become affected by perspiration. It can damage the fibres of the material and can cause staining. This may lead to the garments having a somewhat shortened lifespan and to a need to have them cleaned more frequently than may otherwise have been the case. Blouses and dresses may be particularly affected in this way. Suits, jackets and, in particular, top coats may be less likely to be so affected because it is unlikely that they will be in direct contact with the Claimant's skin, and they would be more likely to be made with linings and interfacings which I think it is reasonable to believe would provide some protection to the garments. I accept that some of the items may have to be replaced each year and some others may not, but the annual replacement has been accepted by Miss Webster in her report although Miss Pritchard did not concede this point in her closing submissions.
92. The list which the claimant has provided to Mr Silverman has this additional characteristic: it is an entirely subjectively assessed list which has been compiled by the claimant who is still a student and has not yet entered into employment and has not had to start applying for full time jobs or positions. She will therefore not know what range of clothing she will require, for example how much of it needs to be in the style of business suits and how much may be of a more casual type. The Defendant puts in issue the number of suits a young woman will actually require when working in a creative occupation.
93. My assessment of the evidence of the two expert witnesses in this field is that Miss Webster has the more relevant and up to date experience of what garment makers can produce at the current time and what their skills are likely to be. She teaches students who go on to make clothes in a way which is likely to be suitable to the Claimant's needs. Generally, although not in every instance, I find that I prefer the conclusions of Miss Webster to those of Mr Silverman concerning the availability of suitably qualified and experienced dressmakers because of her more recent experience.
94. An unsatisfactory aspect of this part of the claim is that there is no direct evidence concerning the cost of the required garments. Mr Silverman does not say that he knows how much the garments would cost. He has sought some advice from some well known West End of London firms of bespoke tailors and has been provided with some very high figures. He has then sought advice in the less fashionable Shoreditch area of London from a tailor who has given him some estimated prices which appear in Mr Silverman's list. That tailor has not given evidence, and no enquiry appears to have been made as to the basis on which he estimated his prices. For example, what quality of material would be used? I believe that I can take judicial notice that there can be a substantial difference in the cost of a garment depending upon the quality of the material which it is made from. Where Miss Webster has agreed that this type of "bespoke" service would be appropriate she does not appear to have questioned those prices but has adopted them because, as she told the court, "I took Mr Silverman's prices because I was told he had the experience." The Shoreditch tailor has not seen the Claimant and does not know what style of clothing she would want other than she has identified her requirements as if designed by Vivienne Westwood rather than being plain or boring. But I also have to bear in mind that if she did not have the problems which she has, and if she was living an ordinary way of life like many of her contemporaries, she may not have been able to fill her wardrobe with Vivienne Westwood- style clothes rather than what is readily available from chain stores and High Street shops, at least not in her early years of employment.
95. Although I have reservations about the evidence and the way it has been gathered I am going to approach the assessment of this part of the damages on the basis that these are adversarial proceedings and if one party chooses to accept the other party's evidence the court should be slow to intervene unless it is obvious that the evidence is clearly wrong. The Defendant, in Miss Pritchard's closing submissions, conceded on the Defendant's calculation £203,602.54 which, based on a lifetime multiplier of 25.33, appears to represent an annual future expense on clothing of nearly £14,500 less an annual saving of £6,422 (the figure suggested by Miss Pritchard).
96. There is an unsatisfactory aspect to Miss Webster's evidence of the cost of items which she says could be made by a competent dressmaker rather than a bespoke tailor of the type recommended by Mr Silverman. She does not know how much it would cost to make those items so she says she has asked her technician colleagues at the University at Leeds who, she says, make clothes all the time for people. But there is no evidence as to whether the prices which her technician colleagues have proffered represent the price which would be charged by someone doing a job on a one-off basis for a friend, or whether it represents the price which would be charged by someone in business with commercial premises and overheads and, possibly, staff to pay and wanting to make a living at it rather than just make a little extra occasional income. And those technicians of whom she speaks are, I assume in the absence of evidence to the contrary, doing their work in Yorkshire where the price may not be the same as in London. Although it is probably the case that the large multiple stores charge the same for their clothes in London as they charge in Leeds my experience of life leads me to doubt that a small independent craftsman/woman making hand-produced tailor-made garments in London would charge the same as in Yorkshire. The cost of living is more expensive in London and I would expect the cost of hand-made items to reflect that. However, the Claimant has not produced any evidence that Miss Webster's costings are too low on the basis which she has costed them. The Claimant simply relies on Mr Silverman's list which is based on the Shoreditch tailor. Notwithstanding the quality of the evidence the parties have proceeded upon it and they each ask me to draw my own conclusions from it and to do so according to the burden and standard of proof in civil cases.
97. There must, in my view, be an element of making a rough assessment of some parts of this claim. I shall approach this on the basis of looking at each pleaded item individually and then making an overall assessment which will take into account the many variable factors. I think there are probably some items which may not need to be replaced every year, but as against that I think that Miss Webster's costings, which the Claimant has not agreed, for items to be made by a dressmaker are likely to be on the low side for the reasons already stated. Overall it is likely that these deficiencies in the evidence will even themselves out and I will make my assessment on that basis save where I specifically reach a different conclusion.
98. Although it may seem somewhat premature for the Claimant to be purchasing business suits at this time I find that it is reasonable to anticipate that in the near future she will start to have a need for such items, and it is also reasonable to anticipate (as the Defendant's schedule acknowledges) that she will reasonably require other less formal suits.
99. The first items claimed for are five smart, casual and business suits at a cost of £1,750 each. The Defendant proposes two formal bespoke suits and three casual suits made by a dressmaker. In my judgment the Claimant is more likely to have a need for smart and/or business clothes as she proceeds towards trying to embark on a career and then, if she is successful, making her way in that career. I assess her reasonable need as three bespoke suits costing an estimated £1,750 each and two casual suits which I shall accept could be made by a competent dressmaker. At this stage and subject to the caveat which I have already mentioned about the basis of her costings, I shall adopt Miss Webster's of £400 for each dressmaker-made suit, making a total of £6,050. I accept the Claimant's case, although Miss Webster does not agree with it, and I find that these items are likely to require replacement annually. This will probably be necessary because of the problems caused by perspiration and the stress which will be placed on the fabric and the probable changes in her figuration. In the joint experts' report it is stated that the experts agree that the Claimant will need to have many items cleaned and pressed on a weekly basis and Miss Webster is of the opinion that excessive dry cleaning can have an adverse effect in the life of a garment.
100. The next items are three coats which the Defendant agrees are likely to cost £1,000 each. The total of these is £3,000. Although there has been no argument about the frequency of their replacement I do not find that these will all need to be replaced annually. If they are well made outdoor coats, and they are properly made to fit the Claimant, I do not see why they should need to be replaced every year, and I do not think that most people would discard and replace three outdoor top-coats every year or even every other year. In my view the Claimant has not shown that on the balance of probability she will need to replace these every year. I shall award damages on the basis that she needs to buy them now and they will cost £3,000, and it will be necessary to replace them on a two-yearly cycle, resulting in a continuing annual cost as from 2013 in the sum of £1,500. The likely changes in the Claimant's figuration is a relevant factor in my judgment.
101. The Claimant claims for three jackets costing £950 each. I accept and prefer the Miss Webster's evidence that one of these, a casual jacket, could probably be made by a competent dressmaker at a much lower price, and at this stage I shall start by adopting her figure of £250. I accept that there is a reasonable need for these items to be bought now at a cost of £2,150 and that they will probably need to be replaced annually with a recurring cost of £2,150.
102. The Claimant claims for three dresses for daytime and evening wear costing £950 each and one at £1,000, together with three skirts costing £550 each. The Defendant does not dispute the quantity but Miss Webster's costings are substantially lower. I prefer Miss Webster's estimates of the cost of these dresses and skirts in the total sum of £1,300 on an annual basis as from now.
103. The Defendant agrees that four pairs of trousers and 2 pairs of jeans would be appropriate. The claimant claims £3,700 for these items. Miss Webster estimates £600 for the trousers. Again, I prefer her opinion that these could be made for a much lower sum than that claimed by the Claimant, but again this is subject to my reservation about her prices being correct. She says that the jeans could be obtained from a High Street shop or online for £50 per pair. I find that she is probably wrong about that, and that the jeans will also have to be handmade at a cost similar to the trousers, although I think it is reasonable to foresee that anyone attempting to make fashionable jeans will have to put a considerable amount of work into them in order to make them look reasonably authentic and not completely unlike the machine-made jeans that it is likely that most young people will wear. Although the court has not received any direct evidence from a tailor as to how much it would cost to make jeans I will award £250 per pair of jeans because of the attention to detail which will probably be required, and this brings the total for trousers and jeans, even on Miss Webster's costings, to £1,100. In the absence of argument on the frequency of replacement I assess this part of the claim as an annually recurring item.
104. The claimant claims that she will require eight blouses per annum. Again, the Defendant has not disputed that, and again I prefer the evidence of Miss Webster that the likely cost will be substantially below what has been claimed and will be not less than £1,220 per annum, to be replaced annually.
105. The next items claimed for are a silk dressing gown and three pairs of pyjamas. In my view this part of the claim is excessively calculated. I note in the joint report the expert witnesses have agreed that some items, including the dressing gown and pyjamas, should be made of a "silk-type" washable fabric because of perspiration problems. The claimant has not persuaded me that it would be reasonable to require the Defendant to pay more than the sums allowed for by Miss Webster. I will allow for the three pairs of pyjamas each year at a total cost of £300, and a replacement dressing gown once every year at a cost of £150, making £450 per annum for these items.
106. I understood from the evidence that the claimant is able to obtain underwear from shops and these items will to have to be made.
107. A claim is made for four pairs of leather gloves each year at a total cost of £400. I am not satisfied that this is a reasonable claim. I accept the evidence that because of the size of her hands the Claimant will probably require handmade gloves, but a case for four pairs per annum has not been proved to my satisfaction. Even if the Claimant wants to have more than one pair of gloves there seems to me to be no reason why they will have to be replaced every year. I am not persuaded that on an annual and recurring basis it would be reasonable to award more than £200.
108. And finally there is a claim for the extra cost of cleaning and, as the claimant's schedule says, "valeting" her clothes. This, as I understand it, includes the cost of professional cleaning. No alternative figure has been suggested by the Defendant. I think that this item of the claim is excessive. Whilst I accept that the claimant's clothing is likely to require more attention than that of many others, largely because of her perspiration problem, I do not find that she will be spending the equivalent of £30 per week over and above what she would have spent on cleaning her clothes in any event. Some of the clothing can be made from machine washable fabrics including a small proportion of Lycra. Insofar as there will be additional dry cleaning costs I allow £1,000 per annum for this head of claim.
109. Adding all of those items together produces a total of £16,470 initial outlay with replacements on a recurring basis as indicated in respect of each garment. There is inevitably an element of uncertainty about that calculation for the reasons already mentioned. There are many variable factors which may operate in different directions, some pointing perhaps to the replacement intervals being longer than the experts have used as their starting point, and some relating to the basis on which the Shoreditch tailor and the Leeds technicians have provided their estimates. It is surprising that in a claim pleaded in such a large amount neither party has produced more satisfactory evidence. Whilst trying to make an assessment on the basis of the evidence which has been presented, and to avoid resorting to guesswork, I bear in mind the burden of proof and I do the best I can to draw reasonable conclusions from the evidence. I find, looking at the matter broadly, that the figure of £16,470 per annum is within the range of what I would expect this Claimant to have to spend now on clothing which is suitable for her needs and her intended occupation and way of life, and I find that it is reasonable to assess the damages for the cost of future clothing requirements by adopting that figure as a starting point. In the light of my decision relating to the three top coats I find that the annually recurring cost of her clothing will be £14,970 on the basis of the evidence before the court.
110. I do not include in this calculation the list of casual clothing items which include tee shirts, tops, cardigans and joggers. I am not satisfied that these casual items cannot be bought ready made, although it may require some effort to find them. For the same reason that I have not included them as part of the future expenditure I do not add them to the list of costings which are to be deducted from her claim.
111. There must be deducted from this figure the cost which the claimant would probably have incurred in any event for the items which I have considered already because she is only entitled to be awarded the difference. On page 434 of the Trial Bundle there is a list entitled "Comparable units and top prices (taken from web site) if Claimant was able to shop at Reiss". I note that the list is not identical to the list of items in the joint report. For example, it contains only three suits, and it does not include a price for a dressing gown and pyjamas. To that extent the total cost set out in that list may be inappropriately low. On the other hand, if the Claimant had not grown to the size that she is she would probably have bought a mixture of clothing, some of it perhaps from suppliers such as Reiss (which I understand to be not the most expensive store but a little above average High Street prices) but probably some from High Street stores or from internet shops. I bear in mind that the list at page 434 comes to a total of £5,582 which would represent a substantial part of the Claimant's potential net income even if she were to start in employment within the next year. There is in my view a difference between what the Claimant will now have to spend and on the other hand what she probably would have spent if she had not become the size that she is. Like most people of average or modest means she would have had to live within her means. Even though the Claimant wants to be stylish and to dress smartly I am not persuaded that if she had grown to a normal size she would have bought all her clothes from the likes of Reiss or other quite expensive shops. In my view she probably would not have spent much more than about £5,000 per annum on clothing, and even that is probably a considerable overestimate when I consider what her net annual income would be likely to be and what her basic living costs would be (including accommodation, subsistence, and travel).
112. In my judgment there is a serious risk of over-elaborating this entire head of the claim. Trying to work out on a strictly arithmetical approach what the extra cost of clothing will be each year is a task which has so many variables and imponderables in it that it is in my view impossible to arrive with confidence at an accurate answer. Having looked broadly at the figures and having then considered some of them in depth I have come to the conclusion that the difference between what the Claimant will have to spend annually on buying and maintaining her clothing as a result of the Defendant's negligence and what she probably would have spent in any event if the Defendant had not been negligent is approximately £11,470 in the first year (£16,470 less £5,000) and thereafter an annually recurring sum of approximately £9,970 (£14,970 less £5,000) for the remainder of her life. The application of an appropriate multiplier, as agreed by the parties, produces a total sum of £254,040 which I award under this heading.

THE COST OF FUTURE CARE, AIDS AND EQUIPMENT

113. The Court heard evidence from a registered nurse, Mrs Sally Plumb, and an Occupational Therapist, Mr Apurba Chakraborty. Both of these witnesses have relevant experience and knowledge which equips them to assist the Court in understanding and assessing the value of the care and assistance which the Claimant is likely to need in the future, and in particular when she starts to develop more serious physical problems in her back, hips and knees. The controversial part of this aspect of the claim concerns such aids and equipment as the Claimant needs now or is likely to require during the remainder of her life.

Care and Assistance which will be required after the trial.

114. The parties have agreed that the Claimant will require assistance in the future with some aspects of her daily personal and domestic activities and they have agreed the value of such care and assistance if it is rendered by her family when practicable and by a cleaner and by a gardener/handyman. The parties also agree that provision should be made for the likely cost of engaging a paid carer at times in the future when she is likely to require more intensive assistance, for example if she is recovering from any surgical treatment. The court is relieved from the task of assessing the cost of this future care because the parties have agreed that an appropriate amount to be awarded is £85,000. The extent of the care which will be required is relevant to the assessment of damages for pain, suffering and loss of amenity of life.

Appliances, Aids and Equipment

115. There are a number of items upon which the parties are not agreed either as to the need for them to be provided or as to their likely cost or replacement intervals.

Walk-in bath, Wet Room and Shower Cubicle

116. The Claimant is too large to fit comfortably into a conventional bath. She is too tall to be able to be comfortable standing in a conventional shower cubicle. It is agreed by the parties that she will require bathing and/or showering facilities which are much larger than would be found in the average residence. Mrs Plumb has recommended that the Claimant should be compensated so as to enable her to equip herself with a Pegasus Zeus two-person bath and a wet-room. Mr Chakraborty is of the opinion that her needs could be satisfied by an extra large bath and a large shower enclosure.
117. In my view it is necessary to keep a sense of perspective and to try to make a realistic assessment of the type of accommodation which the Claimant is likely to have. Because of the increasing problems which she is likely to experience in her back, hips and knees, which to some extent she is already noticing, it is recommended that she should obtain single storey accommodation at ground floor level, ie a ground floor flat or, when she may be able to afford it, a bungalow. She proposes to live and work in London where property is known to be far more expensive than the national average. Whilst she may eventually become able to purchase a large property if she succeeds in the career which she hopes to follow she is likely to be limited in the foreseeable future to accommodation which is adequate for her needs but which will not be particularly spacious. I am not persuaded that it is likely that she will in the foreseeable future have the means with which to acquire a property which is large enough to install an extra large bath and a wet-room. I think that realistically the award of damages should reflect that she will require one or other of these facilities but that it is unlikely that she will have the space to install both. The Court heard, and I accept, that the Claimant has a preference for showering rather than bathing. In my judgment the damages should be sufficient to enable her to install a wet-room facility so as to give her the most convenient method of regular showering without having to clamber into and out of a shower cubicle. Although a large shower cubicle is suggested by the Defendant as a practical option I find that it would probably be awkward for the Claimant to use one and I am satisfied that her reasonable requirement is for a wet-room.
118. The cost of a wet-room has not been provided by a bathroom supplier and fitter, and the evidence from both parties is deficient and unsatisfactory. The Claimant's father told the court that he and his family installed a wet-room at their family home in Yorkshire some years ago and this proved to be satisfactory. He said that it cost several thousand pounds but was not more specific. Mrs Plumb is of the opinion that the cost may be in the region of £3,500. I accept this evidence as the best evidence which is available to me in respect of this item. Installing a wet-room would necessarily involve the removal of existing bathing and/or showering facilities, installing the new plumbing fittings, making the entire floor area of that room impervious to water, installing drainage and tiling the walls. This will inevitably take a tradesman a number of days. Applying what I believe is likely to be common a experience in respect of engaging tradesmen to carry out what would be quite a substantial job I find that £3,500 is a figure which will be within the range of what it would be likely to cost to install a wet-room, and it is likely to be a conservative figure. I also accept and find that the Claimant will probably make her first purchase of a wet-room when she is approximately 25 years of age. I find it is unlikely that she will move her home as often as many other people do. Her increasing physical disability will in my view be likely to inhibit her inclination to endure the difficulties of moving home more than is necessary. Looking at it broadly, and after hearing submissions from both parties, I am persuaded that it is reasonable to expect that the Claimant will probably have two further moves in her life at approximately fifteen year intervals, ie once when she is about 40 and once when she is about 55.
119. The damages will therefore reflect the cost of a wet-room at £3,500 when she is 25 and again at the ages of 40 and 55, and an appropriate multiplier and discount must be applied in order to calculate the damages on that basis. The parties have agreed that the appropriate multiplier is 1.92, which produces a total of £6,704.
120. Insofar as it is suggested that the cost of installing a wet-room in each property could be off-set by the notional cost which the Claimant would have incurred if she had chosen to replace whatever bathroom facilities exist in each property which she moves into I find that to be too speculative to amount to a relevant consideration at this stage. Unless a bathroom is dilapidated it is entirely a matter of personal choice whether an existing bathroom is retained or replaced, and I do not have any evidence which would lead me to conclude that whether or not she had suffered the consequences of the Defendant's negligence she would have been more likely than not to replace bathroom equipment just for aesthetic reasons or just for the sake of doing it.

Kitchen adaptations

121. The Claimant is too large to be able to make comfortable use of kitchen fittings which are designed for use by people of about average height and build. Because she is very tall she has to stoop over her kitchen worktops and the kitchen sink. Her back is already somewhat symptomatic. The Defendant accepts that the Claimant will probably need to adapt the kitchen of any property which she acquires. The parties do not agree on what needs to be done nor at what cost, and again the evidence on this is unsatisfactory. No estimates have been obtained from a kitchen fitter or from a builder or joiner or other tradesmen. It is in my judgment unlikely that there will be any need for kitchen fittings, ie cupboards and appliances, to be specially made for the Claimant, but it will be necessary to have everything raised to a height which will be more comfortable for her to use. This could be achieved by creating a plinth or platform on which all the floor-based cupboards and appliances would sit, and then raising the height of the wall cupboards commensurately. This would enable the Claimant to work in her kitchen without constantly having to stoop and bend. In principle I find this to be practicable and necessary and I am satisfied that the Claimant should be awarded damages to reflect this type of adaptation which will have to be undertaken each time she moves her home which, as I have already found, is likely to be when she is about 25 and again at about 40 and 55.
122. The cost of doing that work has not been researched thoroughly and is unclear. Neither party has obtained a trademan's estimate or the opinion of a suitably qualified surveyor or kitchen fitter. In the joint report Mrs Plumb stated that she would defer on this to an accommodation expert or kitchen designer. Mr Chakraborty suggested that this could be done at a cost of £1,000. In her oral evidence when she was cross-examined Mrs Plumb said that she is not familiar with the cost of designing a kitchen and she had not costed this item of the claim. She was quite clear that she could not give a figure for this and that insofar as she had stated in her first report (in paragraph 3.12) that she had recently seen (presumably in another case) a quotation in the sum of £10,000 from a firm named Howdens in respect of raising worktops and some associated works, she said that she had included that in her report merely as an illustration but she is unable to say what the cost will be which this Claimant will incur. Mr Chakraborty's allowance of £1,000 is said to have been arrived at after consulting Disabled Supplies Limited in Hampshire and a company which advertises on the internet (see paragraph 8.9 of his first report). It is not known precisely what the £1,000 would cover. Neither counsel asked him, and in any event it is not his field.
123. In my judgment neither of these experts has been able to provide the court with as much assistance as I would have liked to have in order to enable me to make an accurate assessment of the potential cost of doing this work which I do find to be necessary to assist the Claimant.
124. The burden of proof of each contested part of the claim rests upon the Claimant. She has not proved that it is likely that the cost of doing this necessary work will be £10,000. But on the other hand I find that it will inevitably involve some considerable expense and it is very highly improbable that a firm of builders or joiners or kitchen fitters would raise the working level of a fitted kitchen by 3" to 6" for only £1,000. I believe it is reasonable to anticipate that even in a relatively modest sized kitchen it would take a skilled person several days to remove the kitchen fittings and appliances carefully, build an appropriate plinth or platform, re-install the units and appliances and do all the necessary plumbing and electrical alterations and probably tiling which would accompany that work. This is all work which would have to be done to an acceptable standard and in my view it would have to be done by a skilled tradesmen or a number of tradesmen and not by a local handyman. It is in my view entirely unrealistic to think that this could be done for £1,000 or anything like it. In my view, which reflects in part such knowledge as I have gleaned over the years in the context of trying minor building work cases and such knowledge as I have absorbed in the same way that most people absorb it (ie by a mixture of personal experience, anecdotal evidence and a general awareness of the cost of tradesman in a variety of trades) the cost of doing this work is highly likely to be at the very least £5,000 but I am unable to make a more specific finding than that. It may well cost more, but to the extent that it may cost more it has not been proved to my satisfaction. I am satisfied that it will not cost less than that. I award £5,000 for this item at age 25 and again at age 40 and 55. The appropriate and agreed multiplier is 1.92 which produces a total of £9,578 under this heading.

Furniture

125. The parties have agreed a single payment in the sum of £10,000 to reflect the additional cost of acquiring suitable furniture throughout the Claimant's lifetime. I award that agreed sum.

Household appliances and equipment

126. There is in my judgment a need for the Claimant to have some items of household equipment which she probably would not have needed but for the Defendant's negligence. This is a relatively minor part of the claim but again there is disagreement between the parties and their expert witnesses.
127. Having read the reports and the joint report from Mrs Plumb and Mr Chakraborty and having heard their oral evidence I make these findings based upon my own assessment of the Claimant's reasonable needs after taking into account the conflicting views of the experts.
128. The Claimant has in my judgment established a reasonable need for a wall mounted ironing board at a cost of £248 and a perching stool at a cost of £37.95 and a trolley at a cost of £18 which will all, in my view, need to be replaced at intervals of about 10 years. In my view she has a reasonable need for these items now and should not have to wait until she is 25 before they are provided. An appropriate and agreed multiplier is 2.24 and this produces a total of £985.
129. I am not persuaded that she has or will have a reasonable requirement for a lightweight iron and I do not add the cost of this to the award of damages.
130. I am also not persuaded that the need for a robotic floor washing machine is established by the evidence and I do not add this to the award of damages, but I do accept Mr Chakraborty's evidence that the Claimant does need a lightweight vacuum cleaner now at a cost of £79.99 which he says will need to be replaced every five years. An appropriate and agreed multiplier is 4.78 and this produces a total of £462.

Equipment which the Claimant will require at later stages of her life

131. I am satisfied upon the evidence of the orthopaedic experts that the Claimant will require both a non-motorised wheelchair and a motorised electric scooter from about the age of 45.
132. The Claimant is likely to struggle to maintain her current weight and in my view there is, I regret to say, a greater likelihood that her weight will increase rather than decrease. Even if her weight remains about the same as it is now I find that when the time comes for her to need a wheelchair it will have to be what is known as a bariatric wheelchair which will be suitable for someone of her likely weight and size.
133. Mrs Plumb and Mr Charkraborty did not agree on the likely cost of such a wheelchair. Mrs Plumb estimates that the cost would be a little short of £4,000 for an Eclipse Bariatric Wheelchair. Mr Chakraborty's contribution to the joint report did not suggest a figure because he did not understand that a wheelchair will be required. To be fair to both him and Mrs Plumb the evidence concerning the need for a wheelchair only became clearer when the orthopaedic experts were asked to consider this at a late stage in the proceedings. In his oral evidence Mr Chakraborty suggested a figure of £1,400 to £1,500 which is based on the cost of a Karma Bariatric Wheelchair. There are, as I know from other cases, many suppliers of wheelchairs which come in many different specifications. Some are bigger than others. Some are sturdier than others. Some are lighter in weight and more easily collapsible than others. And some are much more expensive than others. Mrs Plumb did not particularly endorse or recommend the Eclipse brand, and Mr Chakraborty did not particularly endorse or recommend the Karma brand. I have no evidence as to their respective characteristics and qualities, save that each expert says that the one which he or she has suggested would be suitable for a person of greater weight than the Claimant's current weight. I suspect that this item is one in respect of which it would be possible to obtain a wide range of prices which may reflect the popularity of a trade name and market conditions at the time of purchase and do not necessarily reflect any or much material difference in quality. I have no way of knowing which manufacturers will be in existence or of renown in 25 years time or what the relative qualities of their products may then be. At this stage I shall take a broad brush approach and award damages on the basis that a reasonable cost of buying a suitable bariatric wheelchair now, with the addition of Value Added Tax, would probably be in the region of £2,500 which happens to be not far from the middle point of the range suggested by the evidence of Mrs Plumb and Mr Chakraborty. I formed the view that Mrs Plumb's estimate was very much at the top end of the range of options and that Mr Chakraborty's figure was a somewhat last-minute afterthought which he had not fully researched.
134. As far as the replacement interval is concerned Mrs Plumb has suggested every five years. However, this is not a case in which it is envisaged that the Claimant will become wheelchair-bound or will have to make almost constant use of a wheelchair. It is envisaged that she will still have the use of a car and, for short journeys to the shops and local facilities she will have a motorised scooter. It probably will be necessary to replace the wheelchair at some stage because nothing lasts indefinitely, but I do not accept that an item which is made for the purpose of carrying someone of substantial weight should require replacement after a period of only five years. In my judgment ten years would be a reasonable replacement interval and the award will be for the cost of a wheelchair in the sum of £2,500 at ages 45 and 55. An appropriate and agreed multiplier is 0.96 and this produces a total of £2,402.
135. In addition there will be a need for a motorised scooter. The need for this is supported by the evidence of the orthopaedic surgeons. The only figure which has been supplied to the court is in the joint report from Mrs Plumb and Mr Chakraborty. Mrs Plumb suggested £4,399. Mr Chakraborty did not suggest any figure. The only evidence before the court is the figure of £4,399 and in the absence of any other evidence on this point I find that this is an appropriate figure. I do, however, find that this is likely to require more frequent replacement than the wheelchair. The wheelchair is more likely to be used indoors that outdoors, whereas the motorised scooter is by its nature an outdoor means of transport. I accept Mrs Plumb's evidence that it is likely to be required at age 45 and then to require replacement at five yearly intervals. An appropriate and agreed multiplier is 1.81 and this produces a total of £7,962. There will in addition be the cost of insuring and servicing it. The figure estimated by Mrs Plumb for insurance (£60 per annum) seems to me to be reasonable and is not challenged by the Defendant. Her figure in respect of servicing (£450 per annum) seems to me to be unrealistically high. The scooter will not be likely to undergo excessive use, and it will have an electric motor not a combustion engine. In my view the Claimant's counsel's closing written submission that the annual cost of insurance and servicing will be £155 in total is far more likely to be correct, and I award that sum on an annual basis from age 45 onwards. An appropriate and agreed multiplier is 7.22 and this produces a total of £1,119.
136. In addition, there will be awarded a single additional expense of a scooter store in the estimated sum of £1,995. It is likely that the scooter will need to be stored. I cannot predict that the Claimant will acquire a property which is sufficiently large for her to store it inside her house or flat. It will probably need to be stored outdoors. If the Claimant has a home with a garage it is reasonable to assume that she would keep her car in the garage, so I am satisfied that it is reasonable for her to require a scooter store at age 45. If she moves house at the age of say 55 there is no evidence before me to establish that the scooter store could not be moved to the new accommodation. Therefore I award this as a one-off item at age 45. An appropriate and agreed multiplier is 0.54 and this produces a total of £1,076.

THE FUTURE ADDITIONAL COST OF TRANSPORT AND TRAVEL

Motor car

137. The Claimant already has the use of a car, a Vauxhall Astra. This is suitable for the journeys which she makes but is not really suitable for her. It is a modest sized car. The Claimant needs a car with much greater headroom and leg room than most people need, and with a sufficiently wide and supportive driver's seat. She also needs a car with an adjustable steering column and one in which, having regard to her size, she will be able to have a good view without her line of vision being obstructed by pillars, A-frames and the windscreen frame. This combination of requirements inevitably limits the range of available options.
138. The Claimant has apparently expressed the view (reported at page 482 of the Trial Bundle, paragraph 9.3) that she does not particularly want a Vauxhall Insignia or some other types of vehicle because she regards them as being more suitable for older people rather than a young woman of only 20. I can understand her view about that, but I do not find that it would be reasonable to limit the range of available options on the basis of a car's image. Provided the car meets her physical needs and is manufactured by a reputable manufacturer and is of a current and contemporary design it is my view that the Claimant, just like most other people, will have to sacrifice image for practicality. I find that a Vauxhall Insignia is a car of a type which is likely to satisfy the Claimant's practical requirements.
139. As far as the cost is concerned this is another area of the case in which the evidence is unsatisfactory. The evidence from both sides is indirect (ie not from a motor dealer with direct knowledge of makes, models, specifications, prices, depreciation costs and the like) and comes from Mrs Plumb, Mr Chakraborty and some figures which have been produced from (I believe) the current edition of "Facts and Figures" which is a very helpful compendium of useful data but none of it is specific to the facts of this case.
140. In short, the Claimant contends that the sort of car which she will require will cost in the region of £20,000 whereas the Defendant contends that a suitable vehicle could be bought for as little as £12,000. The Defendant concedes that the range may go up to about £16,000. Although the Court has not heard evidence from a motor dealer there is before the Court a list of about forty cars in part L4 of the current edition of "Facts and Figures". This is not an indication of what car may be suitable for the Claimant but it is a useful list in that it indicates the new prices of cars in 2011 in different categories of size and model ranging from Mini to Medium and all the way up to Prestige and Luxury. I have a fair idea of the general size and standard of many of the cars in that list and I have formed the view that because of the Claimant's size she is likely to require a car which is no smaller than those which are identified as "Medium" and she may even require one which is categorised as "Executive" although that name often implies a level of extras, trim, gadgets and cosmetic modifications which, however welcome they may be to the Claimant, would be surplus to her reasonable requirements and beyond what it would be reasonable to charge to the Defendant. There is a wide range of prices even within the "Medium" sector and an even wider range in the "Executive" sector. In fact, as most motorists will know, two cars which are very similar may be sold for considerably different prices. The price of a car will often reflect the renown of the name of the manufacturer and may not reflect a material difference in the build quality or longevity of the vehicle.
141. Most of the cars in the "Medium" cars list appear to cost in the region of £18,000 to £20,000.
142. Although the quality of the evidence from both parties on this aspect of the case is not very impressive I am satisfied on such evidence and data as have been provided that the sort of vehicle which will be suitable for the Claimant's requirements will probably cost in the region of £18,000 new, for example a Vauxhall Insignia.
143. It has been agreed between the parties that if the Claimant was not suffering from the acromegalic gigantism she would have required and owned a car in any event, and they have further agreed that she would probably have owned cars costing in the region of £7,000 which might be the cost of a suitable second hand car. It has been conceded by the Defendant that because of the Claimant's need for a reliable vehicle it is reasonable to assess this part of the damages on the basis of the difference between the cost of a new car (£18,000 in my judgment) and the notional value of whatever other car the Claimant may have owned in any event (£7,000) ie £11,000 and that this will recur on a four yearly cycle which will result in the damages reflecting the depreciation which might be expected in a £18,000 vehicle over that period. I enquired of Miss Pritchard if the Defendant contends that the damages should reflect the fact that a £7,000 second-hand car would also be likely to depreciate over the same period although to a lesser extent, but the Defendant declined to include that in the calculation.
144. My assessment of damages in respect of the cost of purchasing a car results in an award of £11,000 in respect of the first car, and then replacing it every four years. During the evidence from Mrs Plumb it emerged that the annual depreciation on a £20,000 car would be £2,463 which over four years amounts to £9,852. This represents about half the car's new cost. The depreciation figure is likely to be slightly less on a car which costs £18,000, although the rate of depreciation often depends on the make and model rather than the actual condition of the car. The data contained in "Facts and Figures" suggests a depreciation of 64% over four years. Whilst it is not a very satisfactory method of assessing this part of the claim I am persuaded that the statistical data which has been compiled in "Facts and Figures", whose editors have drawn data from "Parker's Car Price Guide" which is almost universally used in the motor trade in this country, is probably a more reliable guide than the evidence of either Mrs Plumb or Mr Chakraborty neither of whom appears to have done much research into this subject and neither of whom claims to have any expertise in this specific area of the case.
145. My award of damages will be based on the cost of a new car now in the sum of £11,000 (ie the difference between £18,000 and £7,000) and its replacement on a four yearly cycle after suffering a 64% depreciation over the four years. The total period will be for 36 years. The parties have agreed that on that basis the total sum under this heading will be £11,000 + £42,559 = £53,559.
146. The running of a car which will be larger than would otherwise have been needed and probably larger than the Claimant would have chosen if she were not affected by acromegalic gigantism will inevitably be somewhat higher than the cost of running a smaller car. There is likely to be a difference in the cost of motor insurance and probably some extra cost for petrol or diesel. Mrs Plumb and Mr Chakraborty have agreed that an appropriate allowance (at least on a car costing up to £16,000) would be £214.60 per annum. This may in fact be a very conservative figure and lower than the actual difference in cost, but it is a figure which the Claimant's counsel has contended for on the basis of the available evidence and it has not been challenged by the Defendant. I award that sum as from now on the basis of it being a recurring cost over the next 36 years. The multiplier is 25.33. The total sum is £5,436.
147. I do not find that the evidence supports the contention that from the age of about forty the Claimant will incur even greater cost in running her car. That claim is predicated upon the basis that at about the age of forty the Claimant will undertake many more journeys by car because she will be unable to undertake them on foot. I am not persuaded that prior to the age of forty the Claimant will be undertaking many journeys on foot which she would then replace by using her car when she attains forty. I suspect that she, like a great many other people, will find that the convenience of having and using a car at her current age will outweigh the attraction or potential benefit of walking. I remind myself that the Claimant already suffers from symptoms of discomfort in her back and this is likely to become worse with the passage of time, and that insofar as she sees the benefit of taking regular exercise she is likely to take it in a gymnasium rather than walking any great distances.
148. I do not award anything in respect of car valeting services. It has not been proved that it is likely that the Claimant will incur any expense over and above what she probably would have incurred in any event, ie the periodic use of a car washing machine or hand-wash service. I am not persuaded that if she did not have acromegalic gigantism she would have been regularly washing and polishing her own car.

Taxi fares

149. In addition to the cost of purchasing and periodically replacing a new car the Claimant is likely to incur some additional travelling expenses as a result of her condition. There will be some journeys which she would not make in her known car and which she will feel uncomfortable making by public transport in and around London where many local residents make much use of the bus service and the Underground. Mr Chakraborty has recognised, and so do I, the psychological problem which the Claimant has in using public transport. The Claimant prefers the anonymity of a private vehicle. That is understandable in my view. The Claimant herself has not made any detailed prediction of her prospective use of taxis in the next year or thereafter. Mrs Plumb and Mr Chakraborty have acknowledged in their joint report that there may be some additional reliance on taxis for some time, although they disagree on the details. In my judgment the claim for £2,400 for the next twelve months, which represents the cost of taxi fares over and above what would have been incurred in any event, is unrealistically high. I understand that the Claimant intends to bring her car to London when she is 21, ie in April 2013. That is now only about eight months away. However, as anyone who regularly or occasionally uses London taxis will know the cost of a fare can very soon mount up and it would not take many journeys of relatively short distances to amount to a considerable sum each week. Bearing in mind that the Claimant will soon be commencing her University summer vacation and in all likelihood spending some of that time at her family home in Devon, I find that a sum which would be a reasonable reflection of the additional taxi fares which she will incur in London between now and April 2013 is £1,000 which is very roughly £30 per week. The sum of £1,000 will be added to the award of damages.
150. As from April 2013 onwards in my view there will be less need for her to take additional taxi journeys. She will have her own car with her by then. Her extra use of taxis would be likely to be limited to such journeys as she may make when going out socially, and whereas if she did not have acromegalic gigantism she may have been able to use public transport she will now be much more comfortable using a taxi. But this will in my view be only occasional use of taxis over and above what would have been incurred in any event. In my judgment the way the claim is formulated in Mrs Plumb's contribution to the joint report is too speculative. It is not known where in the Greater London area the Claimant will choose to live or where she may have to commute to or how often. I am not persuaded that Mrs Plumb's calculation of the future additional cost of taxi fares in the sum of £1,200 per annum is made out. I do, however, think it is reasonable to anticipate that she will probably have to take some additional taxi journeys which she would not otherwise have taken, and a fairly conservative estimate of a return journey to and from anywhere beyond comfortable walking distance is likely to be in the region of £750 per annum (which is approximately £15 per week) from April 2013 for the remainder of her life to reflect this. The multiplier is 25.33. The total sum is £18,247.

Train fares

151. In addition to the cost of taxis and increased personal car mileage costs the Claimant also claims for the potential extra cost of using the railways from time to time. If she does travel by train she would probably be more comfortable in first class accommodation rather than in standard class, but such accommodation tends to be available only on long-distance inter-city journeys. I accept that if she lives in London she will be likely to want to visit her family home in Devon insofar as that fits in with her working commitments and other activities. There will probably be first class accommodation on the trains to and from Devon. It is reasonable to make some allowance for this, and I note that in the joint report Mrs Plumb and Mr Chakraborty agree that between now and when the Claimant is 21 a sum of £600 would adequately reflect this. The Defendant has agreed this figure and I award it as part of the total amount of damages but the Defendant contends that after the age of 21, by when the Claimant will have her car with her in London, there is insufficient evidence to justify a continuing claim. There is no evidence before the court as to how frequently the Claimant will want to travel to Devon or be able to do so, nor whether she would choose to use the train rather than have the "door to door" convenience of using her own car, nor is there any evidence as to what the difference in cost will be between a discount-price first class ticket booked in advance and the cost of using her own car. In my judgment this is an aspect of the claim which is too vague and speculative as to enable me to make a proper assessment that any future loss beyond April 2013 will be sustained. I have had to adopt what I regard as a broad brush approach on many aspects of this claim, but this is an aspect of the claim on which in my view I cannot make a positive finding on the balance of probability. I award £600 under this heading.
152. The parties have agreed that in the light of my findings under this heading relating to travelling the application of appropriate multipliers to the various items produces a total of £78,842 which will be awarded to the Claimant.

THE COST OF FUTURE NECESSARY SERVICES

153. The Claimant makes a claim for some future expenses which she is likely to incur in redecorating her home, and claims that this is over and above what she would have had to spend if she did not suffer from acromegalic gigantism and all its associated and likely future problems. The parties have agreed that there will be an annual additional cost of £576.64, and that the appropriate multiplier from age 25 is 20.83, producing a total of £12,011. I award this sum as part of the damages.

THE EXTRA COSTS INCURRED IN FUTURE HOLIDAYS

154. The parties have agreed that in addition to the cost of holiday travel which the Claimant is likely to have incurred in any event she will probably incur extra expenditure by reason of her condition. They have agreed a sum of £26,000 to reflect this, and I add that to the award of damages.

LOSS OF EARNING CAPACITY

155. This is an aspect of the case which is not supported by any specific evidence. The Court has not heard evidence from an employment consultant or from anyone within the entertainment and media industry who could provide any assistance with what field of work the Claimant may be able to enter, what field or fields she may find beyond her ability to enter, what the career path will be if she does become a script writer or producer, what income she might hope to earn, and whether she would be likely to spend long periods or short periods or no periods at all when she is not working and therefore not receiving an income. There is no evidence as to whether in her chosen field of work she would be likely to be employed by a media company (whether the BBC or any others) or whether she would be exposed to the uncertainties of being self-employed in what I suspect is a very competitive world. Mrs Plumb states in section 8 of her report (page 409 of the Trial Bundle) that this is outside her area of expertise. Mr Chakraborty identifies this aspect of the claim in his report but does not make any assessment of any potential loss because the Claimant is keen to pursue her chosen career and is motivated to do so and subject to her health he sees no reason why she should not do so.
156. When she was a child the Claimant had an ambition to be performer. Insofar as her condition renders that an unrealistic ambition it is most unfortunate. But I do not think it can be reflected in an award of damages for future loss of earnings or disadvantage on the labour market. Acting and performing is notoriously one of the most precarious occupations. Many young and talented actors and performers find it very difficult to earn a reasonable living and find that they have to resort to other work, often of a very unstimulating nature, to eke out a living.
157. The submission is made on her behalf that it is reasonable to think that but for her condition she would have attained better school results. It is possible that that is so, and I do not doubt and I hope I do not underestimate the difficulties which she went through between the age of 13 and 18. It may be that she did not achieve the success which she might otherwise have hoped for, but there is insufficient evidence to enable me to reach the conclusion that her career prospects have been measurably damaged. She attained A-level passes. She has embarked on a course of study which she enjoys and which it is hoped will equip her for the type of work which she would like to do. That is very much to her credit and I accept that she is doing her utmost to overcome her difficulties.
158. Counsel for the Claimant submitted that the Court can make use of the current Ogden Tables and adapt one of the examples contained in them and make a sensible projection of what income the Claimant will lose during her working life because of her condition which has been caused by the Defendant's negligence.
159. The Defendant's counsel submitted that there is no evidence on which I could make such a projection and that any award which I might make would have to be on the basis of the broad brush approach of which the decision in the case of Blamire v South Cumbria Health Authority was an example.
160. In my judgment, because there is no evidence before the Court as to what the Claimant's actual earning capacity now is and how it may differ from what her earning capacity would have been if she were not afflicted by her condition, and there is no evidence that she will suffer a loss of earnings whilst she is physically able to work and not restricted by increasing pain and disability, it is impossible for me to make an arithmetical calculation of a future loss of earnings claim in the conventional way of identifying an annual multiplicand and applying an appropriate multiplier to it to reflect a loss during her working life. There are, as Balcombe LJ said in Blamire "… far too many imponderables here …" for me to take the conventional approach. A different approach was adopted in Van Wees v. Z. Karkour, A. Walsh [2007] EWHC 165 (QB). Langstaff J in that case preferred to come to a broad assessment of earnings loss. He distinguished between plucking a figure from the air and reaching an informed assessment of a lump sum which properly balanced between the various possibilities, probabilities and chances as he saw them in the light of the evidence called before him. There is a considerable difference between that case and the facts of the case which I am trying. In Van Wees the Claimant was in her mid thirties when she was injured and in her early forties when damages were assessed. She had an established and profitable working history and although there were many imponderables as to the future, such as to deter Langstaff J from adopting what is now the conventional approach to calculating future loss of earnings, he had a sufficient body of evidence from which he could draw inferences as to what the future was likely to hold, at least on a broad brush approach. But in Miss Woodward's case she has not yet embarked on her chosen career and it is not certain that she will, and there is no evidence and no data other than that which is contained in "Facts and Figures" which cast any light on what she might earn. Even that information is extremely imprecise. The Office for National Statistics data for female full-time employees in the United Kingdom in 2011 indicates that for those engaged in writing the mean of incomes was £35,205 gross, and for those in acting and entertainment it was £29,837. Those figures do not reveal the high and low points of the range, nor the age at which a female might achieve the mean income figure. Those figures create nothing more than a snapshot which provides little assistance to the Court.
161. In my judgment the Claimant has failed to establish that she will suffer any loss of earnings prior to when she may have to take time off work because of her progressively disabling condition. That is not likely to occur until she is in her late thirties when she may require intensive physiotherapy for up to about 8 weeks a year, and then matters may deteriorate further in her late forties or early fifties (approximately twenty five to thirty years hence) when she will probably develop chronic pain and severe problems with her mobility and is likely to require intensive hydrotherapy and physiotherapy including periods when she has to be admitted to a hospital or clinic for that therapy to be provided. There is the prospect that from her late thirties, and more particularly from her late forties, she will have to take time from work at least for a few weeks each year. It is probable that the Claimant will suffer many other health problems, and may require treatment for diabetes, spinal stenosis, median nerve damage and there is a likelihood that she will require hip and knee joint replacements at some time. All of those problems would inevitably involve her from being absent from work for potentially long periods whilst she receives the appropriate treatment and recuperates from it. If these problems start to have a serious impact on her life, as they probably will, from her late thirties onwards, when she would have a reasonable expectation of at least another 17 or 18 years of working life ahead of her, it is not difficult to foresee that even if she only has to take on average a month away from work for treatment and recuperation each year for ten years between her late thirties and late forties and two months each year from her late forties to her mid fifties (and those are probably very conservative estimates) she has the prospect of losing, over a period of time, at least two years' income whilst she is absent during those last 17 or 18 years of her likely working life. It is inconceivable that she will ever be able to take out any self-employed person's ill health insurance and I cannot safely assume that any future employer will pay her salary during prolonged periods of absence.
162. Doing the best that I can with the very limited information which is available, and trying to make a sensible appraisal of what will happen in the future, I am satisfied that by her late thirties, and probably long before that, she will have become established in her working life, and on even the most conservative approach it is very probable that the Claimant will lose in total at least two years' net pay in those later years of her working life.
163. As to what her net pay would be at that stage is extremely difficult to assess. The ONS figures give only a glimpse of what will be a very patchy employment market for "authors and writers." At this stage I do not think that the information before the Court justifies a finding that the Claimant would be likely to have an income which, in current values, exceeds the national average income which is currently in the region of £25,000 gross and this is probably the equivalent of about £20,000 after tax and national insurance contributions are taken into account.
164. I have considered very carefully whether this is all sheer speculation which would not justify any award of damages for future potential loss of income, or whether it is a reasonable appraisal of what is known and what can be predicted about her future medical condition and a reasonably realistic, albeit conservative, projection of at least some of the financial disadvantage which she will suffer in the later years of her working life. I have come to the conclusion there is sufficient medical evidence to justify my findings as to the likelihood of having to take time off work because of increasing disability, and my inference as to the amount of time which she is likely to lose from work and I believe that there is just enough publicly available data which enables me to identify a basic and minimum level of earnings which I am confident the Claimant would achieve by that time.
165. In the light of all those considerations I award a round sum of £40,000 to reflect her financial disadvantage in the sense of likely loss of earnings due to ill health, commencing from her late 30's which I shall specify for the avoidance of doubt as age 37. The parties have agreed that in the light of my findings under this heading the damages to be awarded under this heading will be £26,288.
166. The total sum which I award in respect of future losses is £1,082,539.

THE CLAIM FOR PROVISIONAL DAMAGES

167. The Claimant claims provisional damages. She wishes to reserve the right to bring the matter before the court again at any time during the remainder of her life to ask for a further award of damages if the event which she fears and dreads occurs, namely the enlargement or spread of the pituitary tumour which causes a significant increase in the Claimant's symptoms or a requirement for further medical treatment.
168. Helpful guidance on the circumstances for awarding provisional damages is to be found in Kotula v EDF Networks (EPN) PLC and others [2011] EWHC 1546 (QB). Irwin J considered the decision of Scott Baker J in Willson v Ministry of Defence [1991] 1 All ER 638 in which a number of criteria were identified. First, there must be a clear and severable risk of a significant medical problem occurring, which was also described as a clear-cut event, rather than a continuing deterioration such as the progression of osteoarthritis. Second, the court must consider the degree of risk and the consequences of the risk.
169. In Curi v Colina [1998] Court of Appeal (unreported) the court agreed with the conclusion that the chance concerned must be more than merely fanciful. It must be measurable rather than fanciful.
170. Applying those criteria to the facts of this case I am satisfied that there is a future risk that the pituitary tumour will re-grow and, if it does, it will cause a significant increase in the Claimant's symptoms which will probably then not be treatable by surgery but will only be treatable by radiotherapy. If this happens it will probably be catastrophic for this Claimant.
171. I have to consider whether the risk of that happening is either so large that it should be reflected in a final award of damages at this stage, or so small as to be minimal or fanciful and not feature much in a final award now and not result in an award of provisional damages, or whether although the risk is not measureable it is a real risk rather than fanciful and should permit an award of provisional damages to be made.
172. I have regard to the evidence of Dr Stanhope and Dr Wales which I have already referred to at some length earlier in this judgment. I have no doubt in my mind that the risk of the tumour re-growing and requiring extensive medical treatment is a real risk. This type of tumour is said by Dr Stanhope to behave aggressively. The fact that the Claimant's condition is rare and that as a result of that there is little statistical data or clinical experience which would enable Dr Stanhope to assess or measure the risk does not in my view mean that the risk is not present or that it is negligible, minimal or fanciful. In my judgment there is a real risk that the tumour will re-grow with disastrous and life-threatening consequences.
173. If I take that chance, small though it may be, into account now in assessing damages for pain, suffering and loss of amenity of life and if that clear-cut trigger event occurs the Claimant would be substantially under compensated because she would not be able to claim an appropriate amount if that trigger event does occur.
174. I echo the words of Irwin J in the Kotula case in which he said (paragraph 48 of the judgment) that there is a desirability of finality of awards but that must be set against the potentially enormous inadequacy of an award in the very small but (in that case) measurable group of patients who go on to develop really significant medical problems resulting from their relevant illness. Irwin J said that it is precisely that kind of rare but highly damaging contingency which Parliament must be taken to have had in mind when permitting damages to be provisional.
175. For those reasons this Claimant will be permitted to treat her lump sum award as being provisional and she will have the right to seek further damages if there occurs the enlargement or spread of the pituitary tumour which causes a significant increase in the Claimant's symptoms or a requirement for further medical treatment.

PAIN SUFFERING AND LOSS OF AMENITY

176. Finally, I deal with the award of general damages for pain, suffering and loss of amenity of life. I have left it to the end of this judgment because it has been necessary at many junctures to identify what medical and other evidence the Court has heard and accepted in connection with the claims for many forms of financial loss. It is in the light of all that evidence and the findings which I have made upon it that I now assess the general damages under this heading.
177. The Claimant has submitted that an appropriate award for pain, suffering and loss of amenities of life should be in the region of £150,000. The Defendant contends for a figure of around £100,000. It is clear that both parties recognise that the consequences of the Defendant's admitted negligence have been profound and life-changing, and that the Claimant will suffer a loss of enjoyment of many aspects of the life which she might otherwise and reasonably have expected to enjoy.
178. I do not intend to repeat at great length the numerous aspects of the evidence to which I have already referred in this judgment, but I think that it is necessary to draw the major points together so as to present a composite picture of the consequences of the Defendant's negligence upon this Claimant.
179. As a result of the Defendant's negligence the Claimant:

i) has grown to a height and size which are quite abnormally large and which cause her to be very self-conscious and to have a very poor self-image. She has already undergone more than six years of medical treatment and will have to undergo various forms of treatment (probably by surgery, medication, physiotherapy and psychological therapy) and medical examinations for the remainder of her life. She will never recover from her condition in the sense of getting to the point where her condition stabilises to the extent that she will not require continuing active treatment, and of course she will always be a woman of exceptionally large size who will feel literally too big for most of what surrounds her.

ii) is constantly worried that the tumour will re-grow. She dreads the thought of it and worries each time she has a headache that the tumour may be re-growing. She also worries about the risk of developing diabetes. It is probable that these fears will never leave her.

iii) is already suffering significant radiological abnormality in her spine with disc degeneration at all levels, and she experiences back pain at the young age of 20. She is likely to have a progressively worsening back condition throughout the remainder of her life. From her mid thirties she will be at some disadvantage in the employment market and this is likely to become worse with the passage of time. In about another twenty years from now she is likely to be significantly disabled by pain and she faces the likelihood of having to undergo joint arthroplasty in her hips and in her knees in her mid forties. She worries about the risk of becoming wheelchair-bound and even if that fear does not materialise there is the likelihood of having to use a wheelchair and an electric scooter from about her mid forties. There is also a real risk that she will develop spinal stenosis in her lumbar and thoracic spine by her late forties which may cause bowel and bladder problems and which may require a surgical operation, and a risk that she will develop median nerve damage which will also require an operation to correct.

iv) cannot control her weight in the same way that most people would be capable of doing, and faces the prospect of bariatric surgery by gastric banding or gastric by-passing which will diminish her enjoyment of eating, which is something which most people take for granted.

v) assesses her chance of finding a male partner for life as being very unlikely because of her unusual size and because of her own perception of herself. If she tries to conceive a child she will require intensive fertility treatment which carries no guarantee of success. I take into account that even if all these problems had not occurred it would not have been certain that she would have been able to conceive children at all or without medical intervention, but it is an admitted fact that her actual infertility problems have been caused by the Defendant's negligence.

vi) has already suffered a moderate depressive illness and moderate anxiety disorder. She will require psychological counselling, increasingly intensive physiotherapy and treatment with many different drugs throughout the remainder of her life some of which create the risk of her developing known side effects including gastrointestinal upset, liver disease, pancreatitis, thyroid dysfunction, diabetes and osteoporosis, and she is also at risk of developing cardiovascular disease and a depressive illness.

vii) has undergone extensive dental treatment and, as the substantial agreed award for future dental care indicates, she will require extensive dental work periodically throughout the remainder of her life.

viii) cannot lead a normal life which for most people of her age involves the ability to use public transport without giving a second thought to it, to go shopping for clothing and footwear as a pleasurable activity, to go swimming and to play team sports.

ix) is not only very tall and of large frame but has other features caused by acromegaly including thickened facial soft tissues, an enlarged tongue, and an enlarged facial skeleton, and she has permanent clicking in her tempero-mandibular joints (as described by a consultant maxillo-facial surgeon Mr Hodge).

180. The starting point is to consider the guidance which is contained in the Judicial Studies Board "Guidelines for the Assessment of General Damages in Personal Injury Cases" currently in its 10^th edition. The Claimant's case is certainly very rare. Because of its rarity it does not fit comfortably within any single area of guidance in the Guidelines. Neither I nor any of the three very experienced counsel who have conducted this case before me have been able to find in the Law Reports or practitioners' textbooks any case in which a claimant has been awarded damages for suffering acromegalic gigantism and its lifetime consequences. Counsel have submitted two different approaches. The first, as submitted on behalf of the Claimant, is to conclude that her life has been ruined, and whilst her case is not as catastrophic as those which would attract awards at the very highest end of the current scale of general damages for pain and suffering (up to about £265,000) the effect on her life has been and will be so profound that she should be awarded damages which broadly equate to those which would be awarded to claimants who suffer ruination of their lives in some other but lesser ways.
181. The Defendant recognises that a very substantial award would be appropriate but has approached the assessment from a different direction. Miss Pritchard has identified what she submits are the most significant individual aspects of the claimant's condition at this time and, as far as the medical evidence permits, in the future, and she has used the Guidelines to identify either a figure or a range appropriate to each of those individual aspects, and has then aggregated them in the usual way which necessarily involves some rounding down of each sum or the total sum when different amounts are added to each other.
182. The current Guidelines indicate that the sum of £150,000 is towards the lower end of the range (although slightly above the lowest point in the range) for claimants who suffer either paraplegia, or moderately severe brain injury associated with very serious disability and dependence on others and a need for constant professional or other care. The figure is slightly above the top of the range for claimants who suffer moderate brain damage where there is moderate to severe intellectual deficit, a personality change, an effect on sight, speech and senses with a significant risk of epilepsy and no prospect of employment. It has not been submitted that this Claimant's case involves any of those catastrophic features, but the thrust of the submissions on her behalf is that when all of the consequences of the Defendant's admitted negligence are taken into account, and when each facet of the effect on her life is considered separately and then looked at cumulatively her life has been ruined and she should be entitled to an award of damages in the region of £150,000.
183. Miss Pritchard submitted for the Defendant that a starting point may be the obvious physical effect of the Claimant's condition, ie her unusually large size, and her own perception of her appearance. The Guidelines range of damages for a different type of disfigurement namely very severe facial scarring to a relatively young woman where the cosmetic effect is very disfiguring and the psychological reaction is severe is between £31,750 and £64,000. In addition there will be progressively worsening back problems which Miss Pritchard submitted may be broadly similar to the range of symptoms and potential disability similar to those identified in parts of section B(b)(i) of the Guidelines relating to back injuries, where the range of damages is £18,250 to £25,500. The Defendant's submission is that when those two major components of the claim for damages for pain, suffering and loss of amenity are considered together, and when account is also taken of the problems relating to the gall bladder, weight control and the possible need for bariatric surgery, fertility issues and the risk of surgery to the Claimant's hips and knees, and when an appropriate adjustment is made by way of rounding down because these numerous components of the claim overlap each other to some extent, a total award of £100,000 would be appropriate.
184. In theory there is no reason why the two approaches submitted by counsel should not result in broadly the same outcome, and there is an advantage in having two different approaches because the result of using one method may provide a valid means of cross-checking the result of using the other method.
185. My assessment is that the Claimant's life has undoubtedly been severely affected to a very great extent and will always be very different from what she might otherwise reasonably have expected to look forward to. That will result in a substantial award. I do not in any way diminish the range and the breadth of ways in which her life has been altered but I must keep a sense of perspective. This claimant has the use of all her limbs and all five physical senses. She is intellectually capable of undertaking a full time undergraduate course studying for an Honours degree which she hopes will lead her into employment or self employment in the creative world of script writing. She shows initiative and determination and has the impetus to seek opportunities for herself. She is motivated to enter into a career, and to maintain as far as she can some control over her weight by a combination of strict dieting and taking exercise. She has a circle of friends and a modest social life. She is able to drive a car. She envisages making her life in London where there may be the greatest range of opportunities within the world of writing for the entertainment media. She hopes, in the next ten years or so, to be able (after necessary fertility treatment) to have one or two children. Whether that will be possible or not will depend upon many factors which I cannot predict, but I can take note of the fact that that is what she would like to do. When I balance the many adverse consequences (past, present and future) against those positive aspects of her life I do not find that the effect of her condition is or will be as catastrophic as that which is associated with awards of damages in the region of £150,000.
186. In my view it is helpful to approach the assessment of damages by starting with Miss Pritchard's approach. She started with the most obvious physical manifestation of the Claimant's condition, her height, frame and figuration. The Claimant has undergone a permanent and major physical change in her appearance which is plain to be seen and which she cannot disguise. In her own words the Claimant feels like "a freak." There is of course nothing which she can do about this and there is a real risk that her size and weight, although not her height, will continue to increase despite her efforts to restrict it. In her own perception she feels that bodily she is very disfigured. Her condition has already resulted in a moderate psychological reaction and moderate depressive illness. Even if the Claimant did not have all of the other problems to contend with now and in the future the measure of damages for the excessive growth which she has experienced and the permanent and irreversible disfigurement of her body and appearance which she genuinely perceives she suffers from would be £55,000.
187. A major consequence of the Claimant's condition is the damaging effect on her spine and the long term pain which she will suffer and the increasing level of disability and restriction of her mobility. She has not suffered an acute injury to her back of the types which may be contemplated by sections B(a)(ii) and (iii) of the Guidelines relating to back injuries but she suffers and will suffer many of the consequential problems which are identified in those sections. In my judgment the continuing and future symptoms and disability in the Claimant's back is more consistent with the range of damages identified in B(a)(iii) than the range identified in B(b)(i) which Miss Pritchard has invited me to adopt. The Claimant's back condition is already symptomatic and is likely to deteriorate during the remainder of her life and will require a very prolonged and increasingly intensive amount of physiotherapy. It will, in conjunction with other physical problems, become progressively disabling. If this aspect of her claim stood alone I would award £35,000.
188. Another major consideration is that it is likely that when she is in her mid forties the Claimant will require hip and knee joint replacements. Each of these procedures requires a major surgical operation which will inevitably result in many weeks of recuperation and rehabilitation. Insofar as guidance can be obtained from the Guidelines relating to leg injuries I have noted the nature of the injuries and the consequential disabilities and treatments in L(b)(iii) and (iv), and with regard to knee injuries M(a)(ii) and (iii) although the figures in those categories must be discounted because the Claimant has not suffered a direct injury to her hips or knees and because the seriously disabling progression of her symptoms and the need for arthroplasty will not occur for many years. The need for joint replacements will be the result of osteoarthritis which will result from her condition. The likelihood that she will have to have her hip joints and knee joints replaced, with all the attendant disruption which those operations will cause to her, is a very serious albeit distant prospect to face at this time. If these consequences stood together with each other but without all the other complications I would award not less than £30,000 general damages in respect of them.
189. I have also consulted the Guidelines in relation to bowel and bladder problems which the Claimant is at risk of suffering from if she develops spinal stenosis. There are the other risks to her health associated with taking octreotide, and there is the major risk that she will develop diabetes. In addition there are the problems with infertility (which the Claimant hopes to overcome with appropriate treatment) and future dental treatment. These aspects of the case are all to a greater or lesser extent related to other aspects which I have already referred to and I accept that there must not be an element of double counting.
190. Having considered the matter in that way, if damages were to be assessed for each individual aspect of injury and actual or potential disability and each amount was to be added to all the others the resulting figure would in my view be in the region of £140,000 to £150,000 but that is not how damages are conventionally calculated. Whilst some of the consequences may not develop to their fullest extent for many years some of the major problems already exist and are being suffered simultaneously.
191. I also think it is instructive to look at the assessment from the perspective of considering how badly this Claimant's life is and will be affected by her condition in comparison to the extent to which the lives of claimants are damaged or ruined in cases in which the Guidelines suggest an award in the region of £150,000. It is impossible to draw a very meaningful comparison between this case and cases involving paraplegia in which constant care will be required, or to cases involving moderately severe brain injury or moderate brain damage where there is no prospect of employment, but to the extent that it is possible to compare the life shattering consequences of such conditions with the seriously life changing consequences of acromegalic gigantism it is my view that the damages in this case should reflect that there is a significant difference between them.
192. Having approached the matter from those different perspectives I assess the general damages for pain, suffering and loss of amenity of life in the sum of £120,000. Excluded from this is the risk that the tumour will re-grow because this is the subject of the order for provisional damages. There will be interest added in the sum of £3,000.

THE TOTAL AMOUNT AWARDED

193. Appended to this judgment is a schedule which sets out the amount of damages which I award now under each heading. The total sum, inclusive of interest, is £1,228,242 and this sum is awarded as provisional damages.
JUDGMENT SUMMARY (calculated to 1.8.12)

HEAD OF DAMAGE	AWARD
General Damages	£120,000
Interest on General Damages (2.34%)	£3,000
TOTAL GENERAL DAMAGES + INTEREST	£123,000
PAST LOSSES :
Care	£15,682
Miscellaneous	£2,500
Interest on past losses (21.55%)	£3,921
TOTAL PAST LOSSES + INTEREST	£22,103
FUTURE LOSSES :
Care	£85,000
Dental	£68,250
Assisted Reproductive Therapy	£21,563
Psychological Treatment	£38,262
Physiotherapy	£41,396
Hormone replacement therapy / MRI	£302,914
Aids and Equipment	£40,288
Travel	£78,842
Services	£12,011
Holidays	£26,000
Footwear	£88,285
Clothing	£254,040
Loss of earnings	£26,288
TOTAL FUTURE LOSSES	£1,083,139
TOTAL	£1,228,242