G v Central & North West London Mental Health NHS Trust

In a clinical negligence claim, the court must assess the treatment decision by reference to the information reasonably available when it was made, without hindsight. A doctor is not negligent merely because the outcome was adverse or because another competent practitioner would have assessed the risks differently.

The professional practice relied upon must be accepted as proper by a responsible body of practitioners. However, the court may reject professional opinion that cannot withstand logical analysis. In psychiatric care, decisions about patient leave require a clinical balancing of the risks of self-harm against the therapeutic and rehabilitative benefits of leave. A reasonable difference of professional judgment does not establish negligence.

The claimant sought damages for orthopaedic and psychological injuries sustained after she left the defendant’s psychiatric unit and went onto railway tracks. She alleged that the defendant negligently permitted unescorted leave despite her fluctuating mood, suicidal ideation, previous suicidal behaviour and poor sleep. She also alleged negligent management based on an asserted misdiagnosis or treatment of personality disorder.

The defendant denied negligence. The central issues were whether the claimant’s management was unreasonable and whether the decisions to grant and continue unescorted leave fell below the standard of a reasonably competent psychiatrist.

1. Applicable clinical negligence principles. The court applied the principles in Bolam v Friern Hospital Management Committee [1957] 1 WLR 583, Maynard v West Midlands Regional Health Authority [1984] 1 WLR 634 and Bolitho v City and Hackney Health Authority [1998] AC 232. The question was whether the decisions departed from the ordinary skill of a reasonably competent practitioner applying the standards prevailing at the time. The court had to consider the information then available and avoid hindsight. A decision was negligent only if no reasonable, well-informed and competent practitioner could have taken it.
2. A body of professional opinion will ordinarily provide the benchmark, but it must be capable of logical analysis. The court was not required to accept an opinion merely because it was professionally held, although it would rarely be appropriate to reject genuinely held expert opinion on the assessment of medical risks and benefits.
3. The defendant’s management of the claimant’s abnormal behaviour was reasonable. The evidence did not establish that the claimant was being treated as suffering from personality disorder. The claimant presented a mixed and difficult clinical picture, and encouraging her to take responsibility for her conduct was not, in the circumstances, negligent. Any unsympathetic treatment by nursing staff was peripheral and temporary.
4. The decisions concerning leave involved balancing the risks of self-harm against the benefits of rehabilitation, contact with family and avoiding excessive restriction. The decisions on 1 February and subsequently to permit short periods of unescorted leave in the hospital grounds were not illogical or unreasonable. Other reasonable consultant psychiatrists might have taken the same course, notwithstanding the claimant’s fluctuating mood, suicidal thoughts, poor sleep and earlier departure from the hospital grounds.
5. The claimant’s case on liability therefore failed. No findings on quantum were made.