Holt v Edge

In a clinical negligence claim, an admitted breach does not establish causation unless the claimant proves what information competent further inquiries would probably have obtained and that it would have led to earlier treatment. Where the evidence does not establish symptoms requiring immediate referral, the alleged breach does not cause the claimed loss. A doctor may be at fault for failing to investigate a symptom specifically recorded in the practice notes, but the claim still fails if the evidence cannot establish that the answer would have required referral or changed the outcome.

The claimant suffered a subarachnoid haemorrhage after slipping in the shower. She was diagnosed and operated on several days later, sustaining a stroke during surgery and permanent disability. She sued her general practitioner and the practice, alleging that earlier medical inquiries and referral would have led to earlier diagnosis and surgery.

The High Court dismissed the claim, finding no negligence by the treating general practitioner and, in any event, no causative difference to the eventual outcome. On appeal, the claimant relied on the failure to conduct an initial telephone triage and the failure to ask directly about vomiting during a later visit. It was no longer alleged that earlier treatment would have avoided the stroke or disability. The central issue was whether the breaches caused any legally compensable loss.

Scott Baker LJ gave the judgment of the court. Ward and Wilson LJJ agreed. The appeal was dismissed.

1. The failure to conduct a telephone triage was an admitted breach of duty. However, the evidence did not establish that a competent telephone triage would have elicited pounding headaches, vomiting or other information requiring immediate hospital referral. The later examining doctor had not diagnosed subarachnoid haemorrhage, and the judge was entitled to find that the telephone triage would have made no difference.

2. The third ground succeeded on breach. The practice nurse’s note specifically recorded vomiting, which should have put the visiting doctor on notice of the need to ask Mrs Holt about it directly. The doctor could therefore be criticised for failing to make that inquiry, even though he had discussed whether she felt sick.

3. The breach did not establish causation. The judge had made no finding of persistent vomiting and had rejected the evidence relied on to establish its frequency. The hospital records were inconsistent, and none of their makers gave evidence. It was therefore impossible to conclude, on the balance of probabilities, that an answer to the omitted question would have required immediate referral. The available information did not dictate referral.

4. By way of obiter observation, had negligence and causation been established, the appropriate damages for the additional two or three days of illness, anxiety and altered loss of amenity would not have exceeded £750. The court noted the disproportion between such an award and the costs of the litigation, but did not determine any costs issue.

• Court of Appeal (Civil Division): Appeal dismissed. [2007] EWCA Civ 602.
• High Court, Queen’s Bench Division: His Honour Judge Richard Seymour Q.C., sitting as a High Court judge, dismissed the negligence claim on 26 July 2006.