Roughton v Weston Area Health Authority & Ors

In medical-negligence causation cases, the likely effect and timing of treatment must be assessed by reference both to the individual facts and to the available medical knowledge. General medical literature cannot be relegated until after a conclusion has been reached from the final hours of the illness. Where treatment is said to have controlled a rare and potentially fatal condition, subsequent stability and the absence of further deterioration may be important evidence, even if immediate improvement preceded the period in which the treatment was expected to take effect. A court must not assume that early stability was permanent. If the trial judge has failed to identify the relevant form of disease, assess material expert evidence, or consider the subsequent course, the causation issue may require retrial while unchallenged findings remain undisturbed.

The claimant suffered severe and permanent brain damage after an episode of cerebral vasculitis. Two general practitioners admitted that earlier treatment should have occurred, but causation remained in issue. The High Court held that the claimant had not proved that treatment with steroids and cyclophosphamide, if started two or three days earlier, would have prevented the major deterioration on 27 April 1998.

The claimant appealed. The central question was whether, on the balance of probabilities, earlier administration of the drugs would have prevented that deterioration, having regard to the nature of the disease, the expected timing and effectiveness of the treatment, the medical literature, and the claimant’s subsequent stability.

1. Appeal allowed and causation remitted. The Court of Appeal held that the causation issue alone had to be retried. The trial judge’s unchallenged findings on other issues stood. The respondents were ordered to pay the appellant’s costs.
2. The likely effects and timing of a drug must be assessed in the context of both the particular illness and the relevant medical knowledge. In this case cerebral vasculitis was rare, the experts had limited direct experience, and the evidence was necessarily incomplete. That made the medical literature and professional opinion especially relevant; they could not be treated as a matter for consideration only after the judge had concluded that the claimant’s stabilisation was spontaneous.
3. The judge had focused on the improvement or stabilisation achieved by midnight on 27 April. That did not establish that cyclophosphamide could not have produced a beneficial effect later, including by preventing further deterioration. The subsequent absence of neurological deterioration was relevant. Nor could the stability achieved on that date be assumed to be permanent, because earlier stability between 22 and 27 April had not proved permanent.
4. The evidence required assessment against the distinction between the aggressive or primary form of the disease and the benign form. The judge had not made a clear finding on that issue. He had also failed adequately to consider whether the combination of steroids and cyclophosphamide had controlled a serious form of illness which, on the medical evidence, was normally fatal without treatment.
5. Lord Justice Jonathan Parker agreed with Pill LJ’s reasons and with Hooper LJ’s observations. Hooper LJ emphasised that the judge had to decide whether the drugs were generally effective for the relevant form of vasculitis and, if so, within what period. The events after 27 April were relevant, although not necessarily decisive.

• Court of Appeal (Civil Division): [2004] EWCA Civ 1509. Appeal allowed. The causation issue was remitted to the lower court for rehearing; other unchallenged findings stood.
• High Court, Queen’s Bench Division: Mr Justice Owen dismissed the claimant’s damages claim in a judgment dated 17 November 2003.