Ratcliffe v Plymouth & Torbay Health Authority & Anor

In medical negligence claims, res ipsa loquitur is a convenient description of facts capable of supporting a prima facie inference of negligence. It is not a rule of law or a presumption, and the legal burden remains on the claimant throughout.

At trial, the court must assess all the evidence and decide whether negligence and causation are proved on the balance of probabilities. The defendant may rebut the inference by providing a plausible non-negligent explanation or by proving that reasonable care was exercised. In complex medical cases, expert evidence will usually be required. Once competing factual and expert evidence has been called, the maxim normally adds little.

The claimant suffered permanent neurological injury after a spinal anaesthetic administered during surgery on his ankle. He alleged that the needle had been inserted at the wrong spinal level and into the spinal cord. The defendants contended that the injection was correctly administered and that the injury resulted from an unexplained pre-existing or latent condition.

Mantell J rejected the claimant’s principal neurological theory, found that the injection had been administered at L3/L4 with due care, and dismissed the negligence claim. The claimant appealed, arguing that the unexplained injury raised an unrebutted inference of negligence under res ipsa loquitur.

1. Appeal dismissed. The claimant’s permanent neurological deficit did not, by itself, establish negligence.
2. Res ipsa loquitur is no more than a convenient description of facts sufficient to support a prima facie inference of negligence. The formal burden of proving negligence and causation remains on the claimant throughout the trial. At the conclusion of the evidence, the judge must decide the case on the balance of probabilities.
3. The defendant may answer a prima facie case by showing that the inference is not justified on closer examination of the evidence, by providing a plausible explanation consistent with the absence of negligence, or by proving that reasonable care was exercised. A merely theoretical possibility will ordinarily be insufficient, but the defendant need not prove that its explanation is more likely than every alternative.
4. In simple medical cases, ordinary experience may support an inference without expert evidence. In most contested medical negligence cases, expert evidence will be needed to establish that the outcome ordinarily would not occur without negligence. Once both sides have called factual and expert evidence, the maxim normally has no independent work to perform.
5. The judge was entitled to reject the alleged elongated spinal-cord lesion, find that the injection was administered at L3/L4, and accept the evidence that appropriate care had been taken. The accepted evidence also established that a rare neurological deficit could follow a properly administered spinal block without negligence. Those findings removed any residual inference of negligence.
6. The appeal was dismissed with costs. An order nisi was made against the Legal Aid Board, with legal aid taxation of the appellant’s costs. Leave to appeal to the House of Lords was refused.

• Court of Appeal (Civil Division): Appeal from Mantell J’s judgment dismissing the negligence claim. Appeal dismissed with costs.
• High Court of Justice: Mantell J dismissed the claimant’s claim for damages after finding that the spinal injection was administered at L3/L4 with appropriate care.