Garcia v East Lancashire Hospitals NHS Trust

In a clinical negligence claim, the claimant must prove on the balance of probabilities that the defendant’s breach caused the injury. Abnormal cardiotocograph findings may justify delivery prospectively, but they do not necessarily establish the underlying cause retrospectively. An association between neonatal stroke and hypoxia does not, without an established mechanism or other sufficient evidence, prove that hypoxia caused the stroke in an individual case. Where the evidence is more consistent with a pre-existing stroke than chronic hypoxia, and the stroke explains the abnormal monitoring, the claimant fails to establish that earlier delivery would have avoided the injury.

The defendant admitted that it had been in breach of duty by failing to deliver Amelia Garcia by 2130 hours on 7 August 1998, approximately 26¼ hours before her actual delivery by emergency caesarean section. The issue at this split trial was causation.

The claimant suffered a major right middle cerebral artery stroke and severe disabilities. She contended that chronic partial hypoxia caused by placental insufficiency had developed before delivery and that the stroke or additional hypoxic-ischaemic injury occurred after the time when she should have been delivered. The defendant contended that the stroke had occurred earlier and that the abnormal cardiotocograph traces and subsequent disabilities were attributable to the stroke alone.

The claim failed on causation.

1. The claimant bore the burden of proving, on the balance of probabilities, that the admitted breach caused her injury. She therefore had to establish that the stroke or relevant damaging hypoxia occurred after 2130 hours on 7 August 1998.
2. Viewed prospectively, the cardiotocograph traces reasonably justified concern about fetal wellbeing and delivery. Retrospectively, however, the relative improvement in the traces during increased uterine activity was inconsistent with the expected deterioration of a chronically hypoxic fetus. The evidence did not establish that the abnormalities were caused by chronic hypoxia.
3. The evidence showed an association between stroke and hypoxia or hypoxic-ischaemia, but no established causative mechanism. That association could not, in an individual case, prove that hypoxia caused the stroke.
4. The claimant’s condition at birth and in the neonatal period was more consistent with stroke alone than with prolonged damaging hypoxia. There was no convincing evidence of placental insufficiency, significant growth restriction, multi-organ damage or hypoxic-ischaemic brain injury. The radiological evidence overwhelmingly indicated that the damage shown on scanning was caused by the right-sided stroke.
5. The abnormal cardiotocograph trace on 7 August was determinative of timing. Since hypoxia had not been proved, the changes between the normal trace on 4 August and the abnormal trace on 7 August were most probably caused by the stroke, rather than by an implausible coincidental mechanism. The stroke therefore occurred before 1330 hours on 7 August.

It followed that the stroke occurred before the admitted breach-related delivery time of 2130 hours. The claimant had not proved that earlier delivery would have avoided the injury. The claim was dismissed on the issue of causation.