Qureshi v Royal Brompton & Harefield NHS Trust

Medical negligence is assessed by reference to the information reasonably available to the clinician at the time, rather than by hindsight. The question is whether the treatment fell below the standard of a responsible body of appropriately qualified practitioners. A clinician may balance the risks and benefits of continuing treatment against the risk of an adverse event, including when deciding the timing of follow-up. Where the assessed risk of recurrence is extremely small, a longer review interval may be reasonable, particularly where appropriate advice and access arrangements are provided. A claimant must still prove, on the balance of probabilities, both breach and causation.

The claimant sought damages for severe brain damage following medical treatment after repair of congenital heart disease. After a pericardial effusion had been drained, Dr Redington reviewed her on 31 May 1989, reduced her diuretics and arranged review one month later. A further effusion developed in June and caused cardiac arrest and brain damage.

The claimant alleged that an echocardiogram should have been performed, that the medication should not have been reduced, and that review should have occurred within seven days. The central issues were whether the management was negligent and whether the alleged negligence caused the injury.

1. Judgment for the defendant. The claimant failed to establish that the management on 31 May 1989 was treatment which no responsible body of senior registrars would have adopted on the facts then known.
2. The court found that an echocardiogram had been performed on 31 May and showed that the pericardial effusion had almost resolved. There were no adverse clinical findings, and the residual ventricular septal defect and pulmonary regurgitation did not, without more, indicate cardiac failure.
3. The reduction in diuretics was reasonable. The evidence accepted by the court supported the view that the effusion was associated with post-cardiotomy syndrome rather than cardiac failure. The risk of recurrence was very low, while continuing a high dose without clinical justification carried risks including dehydration and electrolyte loss.
4. The court found that Dr Redington had considered and balanced the risks and benefits. The decision had to be assessed from his perspective on 31 May, not by reference to the later catastrophic event.
5. A one-month review was also reasonable in the circumstances, both in 1989 and at the date of judgment. The assessment that recurrence was extremely unlikely meant that a further appointment within seven days was not required, particularly as the family had been given advice and contact arrangements for deterioration.
6. The court rejected the alleged causal connection between the reduction in diuretics and the later tamponade. The claimant therefore failed on breach and causation. The claim was dismissed, with judgment in favour of the defendant.