Walker v Milton Keynes General NHS Trust

In assessing clinical negligence, the court must apply the Bolam standard as qualified by Bolitho. A professional opinion does not satisfy the standard merely because it is held by a responsible body of practitioners; it must also withstand logical analysis. The adequacy of monitoring and treatment must be assessed in the clinical context, including known risk factors and the vulnerability of the patient. Where a failure to monitor deprives the clinical team of information that would probably have led to timely intervention, causation may be established on the balance of probabilities.

Rebecca Walker, born in 1994, suffered dyskinetic cerebral palsy following acute profound hypoxia during labour at Milton Keynes General Hospital. Her claim alleged that the defendant failed to recognise that the pregnancy involved an intra-uterine growth-retarded, high-risk fetus, failed to provide an appropriate induction and monitoring plan, discontinued cardiotocography too early, and failed to deliver her by caesarean section in time.

The trial concerned liability and causation only. The defendant admitted certain breaches, including failures concerning risk assessment, obstetric assistance and the eventual decision to deliver, but disputed the significance of the earlier cardiotocography and whether continued monitoring would probably have avoided the injury.

1. The claim succeeded on liability and causation. The defendant was in breach of its duty of care and the case was to proceed towards a trial on quantum.
2. The pregnancy should have been treated as high risk because the fetus was growth-retarded, small and premature. A clear treatment plan should have identified the need for appropriate monitoring, assessment of fetal well-being and a low threshold for responding to abnormalities.
3. Applying the principles in Bolam v Friern Hospital Management Committee [1957] 1 WLR 482, as qualified by Bolitho v City & Hackney Health Authority [1998] AC 232, the court rejected expert opinions that were not logically supported by the contemporaneous textbooks and clinical evidence. The absence of a detailed plan fell below the required standard.
4. The earlier cardiotocography traces were largely reassuring, but the trace following the second dose of prostaglandin became suspicious. In the context of an intra-uterine growth-retarded fetus, monitoring should have continued after 23.10. Discontinuing it was a breach of duty.
5. Applying Wisniewski v Central Manchester Health Authority [1998] PIQR 324, the court assessed the factual issues in light of the defendant’s failure to call relevant witnesses, while considering all properly available evidence. The court accepted the midwife’s contemporaneous record where it was reliable.
6. Had monitoring continued, the fetal deterioration would probably have been recognised before 02.20, leading to transfer, continuous monitoring and a decision to perform caesarean section by about 02.30 at the latest. Delivery before 03.00 would probably have avoided the brain injury.