Buxton v Abertawe Bro Morgannwg University Local Health Board

In a medical negligence claim, the question is not whether treatment involved clinical judgment, but whether the particular decision fell outside the range open to a reasonably competent practitioner.

Where two conditions coexist and treatment for one may worsen the other, the practitioner must assess and balance the relevant risks, the seriousness of possible outcomes, and the consequences of withholding or delaying treatment. The court will not impose an absolute rule that corticosteroids can never be prescribed for stromal or disciform keratitis while a dendritic ulcer remains incompletely healed.

Causation must be proved on the balance of probabilities. A temporal sequence alone does not establish that treatment caused a later condition, particularly where the later condition lacks the expected clinical features.

The claimant suffered herpes simplex disease affecting his right eye. He was diagnosed with a healing dendritic ulcer, disciform keratitis and iritis. A hospital doctor prescribed Prednisolone Forte for the stromal condition while epithelial defects remained.

The claimant alleged that prescribing a corticosteroid before complete healing of the dendritic ulcer was negligent and that the steroid caused a subsequent epithelial ulceration. The defendant contended that the prescription was a matter of clinical judgment and that the later ulceration was not proved to have been steroid-induced.

The issues were whether the prescription fell below the required professional standard and whether it caused the subsequent ulceration.

1. Liability. The action was dismissed. The relevant question was whether no reasonably competent ophthalmologist could have prescribed a corticosteroid in the circumstances. The description of the decision as an exercise in clinical judgment did not answer that question; the particular judgment remained open to examination.
2. The claimant’s eye showed a dendritic ulcer which had almost, but not completely, healed, together with stromal or disciform keratitis. There was no absolute rule requiring treatment of one condition to be postponed until the other had completely resolved. A reasonably competent ophthalmologist could assess which condition required priority and weigh the advantages and disadvantages of available treatments.
3. That assessment included the risk that corticosteroids might aggravate viral ulceration, the availability and relative effectiveness of non-steroidal treatment, the greater risk to sight presented by stromal keratitis, and the seriousness of the possible consequences if either condition was inadequately treated. On the evidence, the doctor’s decision could not be characterised as one which no reasonably competent ophthalmologist could have made.
4. Causation. The claimant had to prove that the Prednisolone Forte caused the ulceration identified on 2 October 2005. The medical evidence did not establish that conclusion. The ulcer was not described in the geographical form expected of a classical steroid-aggravated herpes simplex ulcer. The temporal connection was no more than post hoc reasoning and did not satisfy the balance of probabilities.
5. The claim therefore failed and was dismissed. The judge recorded that, had damages been necessary, general damages would have been assessed at £15,000, with a further £5,000 for disadvantage on the open labour market and specified special damages.