Mellor v Sheffield Teaching Hospitals NHS Trust & Ors

Professional negligence in diagnosis and treatment is judged by reasonable skill and care in the circumstances. A GP must exercise reasonable care in deciding whether and when to refer possible cardiac symptoms. A cardiologist must exercise reasonable care in deciding whether to discharge a patient or arrange further investigation or treatment.

The mere possibility of cardiac disease does not automatically require referral or invasive investigation. Doctors must weigh the patient’s symptoms, concurrent conditions, absolute and relative risk, the seriousness of possible consequences, and the risks of investigation. They must not generally await a probability of disease before acting. A responsible professional opinion must also withstand logical analysis. In this case, discharge after an inconclusive exercise test was negligent, but causation was not proved.

The claimant, the widower and administrator of Susan Mellor’s estate, brought claims under the Fatal Accidents Act 1976 and the Law Reform (Miscellaneous Provisions) Act 1934, together with a claim for nervous shock. He alleged that two general practitioners had failed to refer Mrs Mellor for suspected ischaemic heart disease and that a cardiologist had negligently discharged her after an exercise tolerance test.

The principal issues were whether the GPs or cardiologist had breached their duties and whether any breach probably caused Mrs Mellor’s death. The cardiologist’s test had reproduced chest pain and breathlessness but was terminated at a very low workload without significant ECG changes.

1. Claims against the GPs. The claim against Dr Groves failed. On the balance of probabilities, he had made the necessary inquiries in 1992, although he should have recorded them. That recording breach was not the gravamen of the claim and did not cause loss. In any event, a referral would probably not have led to a causative intervention.
2. The claim against Dr Richards also failed. In April 1994, the symptoms were sufficiently atypical to justify a GTN trial without immediate referral. A single use of the spray did not make referral mandatory. The 18-month absence of reported use was reasonably reassuring. In November 1995, the reported single use did not require referral, particularly given the serious anaemia and possible cancer. In March 1996, review within three weeks was a reasonable use of time. Any breach would in any event have failed on causation.
3. Applicable legal framework. A GP and cardiologist must exercise the skill and care expected of a reasonably competent practitioner in that field. The task is to distinguish patients who reasonably require referral, investigation or treatment from those who do not. The mere possibility of cardiac disease does not automatically impose a duty to refer or investigate, but a doctor should not generally await a probability of disease. Relevant risks, alternative diagnoses, concurrent complaints and the seriousness of a coronary event must be considered.
4. A GP must make relevant inquiries arising from the history and symptoms and record the inquiries and answers where significant. The duty is not a duty to cross-examine a reticent patient. The assessment is fact-sensitive, hindsight must be excluded, and responsible professional disagreement is permissible. However, under Bolitho v City and Hackney HA [1998] AC 232, professional opinion must withstand logical analysis.
5. Dr West. The exercise tolerance test was inconclusive or equivocal, not properly negative. Mrs Mellor had multiple risk factors, markedly restricted exercise capacity and reproduced chest pain and breathlessness. The absence of ECG changes reduced the probability of significant coronary disease but did not justify ruling it out. Dr West should at least have arranged a thallium scan. His discharge decision therefore breached the duty of care.
6. Causation. The hypothetical pathway would have involved a thallium scan, outpatient review, angiography and, if appropriate, angioplasty. The claimant failed to prove that angiography would probably have occurred before death, that the stenosis was probably proximal, or that angioplasty would probably have prevented death given the significant left ventricular hypertrophy and possible fatal arrhythmia.
7. The claims against all defendants were dismissed. The court recorded quantum conclusions only for completeness.