Leggett v Norfolk, Suffolk & Cambridgshire Strategic Health Authority

Medical negligence is assessed by reference to the practice accepted as proper by a responsible body of practitioners, provided that the opinion has a logical basis and has addressed relevant comparative risks and benefits. A difference of professional opinion does not itself establish breach. Where evidence shows varying local practices and no national standard, the claimant must prove that the practice relied on falls outside the range of responsible clinical judgment. Causation remains a separate question. The claimant must prove that proper care would probably have prevented the injury. In this case, the evidence did not establish breach in the clinical monitoring or treatment decisions, and the laboratory’s failure to communicate a bilirubin result did not probably cause the injury.

The claimant, a severely disabled young man, alleged that negligent neonatal care in March 1990 caused bilirubin encephalopathy (kernicterus), resulting in cerebral palsy and other disabilities. The claim originally concerned hypoglycaemia and was later amended following a diagnosis of possible kernicterus.

By order of Master Ungley dated 25 September 2005, the court determined liability and causation. The principal issues were the bilirubin levels known to the treating staff, the appropriate thresholds for phototherapy and exchange transfusion, whether the laboratory should have telephoned a split bilirubin result, and whether any breach probably caused the injury.

1. Standard of care. The court applied the principles in Bolam v Friern Barnet Hospital Management [1957] 2 All ER 118, as qualified by Bolitho v City and Hackney Health Authority [1998] AC 222. A responsible body of medical opinion must have a logical basis, including proper consideration of comparative risks and benefits.
2. The evidence established substantial variation in neonatal practice and no national standard for exchange transfusion. The defendant’s approach, including use of a threshold of 330 mmol/l for a healthy premature baby and the possible deduction of conjugated bilirubin, fell within the range of responsible professional judgment in 1990. The claimant failed to prove that the doctors should have ordered blood or performed an exchange transfusion when the ward reading was 267.
3. The laboratory should have telephoned the split bilirubin result of 321 mmol/l during the morning. However, the evidence did not establish what a repeat test would have shown, whether the level was still rising, or that the doctors would probably have undertaken an exchange transfusion in time. The treating doctors’ proposed monitoring and re-testing were within the range of professionally acceptable decisions.
4. On causation, the court accepted that neurological damage was present by about 10.45 am on 19 March 1990. The balance of probabilities did not establish that later care could have prevented the kernicterus. The laboratory breach therefore made no difference to the outcome.
5. The claim was dismissed.

This was a first-instance liability and causation decision. The judgment records that Master Ungley directed determination of those issues by order dated 25 September 2005.