Ratcliffe v Plymouth & Torbay Health Authority & Anor

In medical negligence claims, res ipsa loquitur is a convenient description of an inference from proved facts, not a rule shifting the legal burden of proof. The claimant retains the burden of proving negligence and causation on the balance of probabilities.

An inference may arise where the event ordinarily would not occur without negligence. The defendant may rebut it by providing a plausible non-negligent explanation or by proving that reasonable care was exercised. In complex medical cases involving full factual and expert evidence, the judge should determine the issue on the evidence as a whole. An unexplained injury following treatment does not itself establish negligence.

The claimant suffered permanent neurological symptoms after a spinal anaesthetic administered during surgery. He alleged that the needle had been inserted at the wrong spinal level and caused a spinal cord lesion.

Mantell J rejected that case. He found that the injection was administered at L3/L4 with proper care, that the claimant's symptoms were consistent with a patchy lesion, and that an unexplained neurological complication could occur without negligence. The claimant appealed, principally arguing that res ipsa loquitur required the defendants to rebut an inference of negligence.

The central issue was how the inference operates where a medical procedure is followed by serious injury but the court has heard extensive factual and expert evidence.

1. Appeal dismissed. Mantell J was entitled to find that the spinal injection was administered at L3/L4, that Dr Boaden exercised proper care, and that the claimant had not established that the injury resulted from negligent insertion of the needle.
2. Res ipsa loquitur is not a doctrine or presumption which transfers the legal burden of proof. It describes facts capable of supporting a prima facie inference of negligence. The claimant retains the legal burden throughout and must satisfy the court, on the balance of probabilities, that the defendant was negligent and caused the injury.
3. The inference may arise from ordinary experience, without expert evidence, in simple cases such as operating on the wrong limb or leaving a swab in the operation site. In most medical negligence cases, however, expert evidence is required to show that the event ordinarily would not occur with proper care.
4. After a prima facie inference has arisen, the defendant may rebut it by showing that the inference is unjustified on closer examination, by providing a plausible explanation consistent with the absence of negligence, or by proving that reasonable care was exercised. A merely theoretical possibility is insufficient where the defendant relies solely on an alternative explanation, but the defendant need not prove that its explanation is more likely than every other possibility.
5. Once both parties have called factual and expert evidence, the judge must decide the case on all the evidence. The usefulness of the Latin phrase will normally have been exhausted. A serious or unexplained outcome following treatment does not by itself justify an inference of negligent treatment where the evidence establishes that proper care was taken and the outcome can occur without negligence.
6. The judge accepted the defendants' evidence, including the contemporaneous record of clear cerebrospinal fluid and the evidence of the anaesthetist and supporting witnesses. Those findings defeated the claimant's remaining inference of negligence. The appeal was dismissed with costs; the order nisi was made against the Legal Aid Board, and leave to appeal to the House of Lords was refused.

• Court of Appeal (Civil Division): Ratcliffe v Plymouth & Torbay Health Authority & Anor, [1998] EWCA Civ 206. Appeal from the judgment of Mantell J dismissing the negligence claim; appeal dismissed with costs.
• High Court: Mantell J dismissed the claimant's claim for damages after finding that the spinal injection was administered at L3/L4 with proper care.