Jones v North West Strategic Health Authority

Medical negligence is assessed by the Bolam standard, subject to the requirement that expert opinion have a logical and defensible basis. In cases concerning advice about alternative medical courses, the duty to warn depends on whether the risk would be significant to a reasonable patient; it is not determined merely by customary medical practice or by what treatment is clinically preferred. The court must decide significance, assisted but not bound by expert evidence. A breach of duty must also be shown to have caused the claimant’s loss. In an obstetric emergency, a sequence of conventional manoeuvres is not negligent merely because, with hindsight, another manoeuvre might have been preferable, provided the chosen approach was supported by a responsible and logically defensible body of professional opinion.

The claimant, who suffered cerebral palsy after shoulder dystocia during his birth, alleged that the defendant’s antenatal care was negligent because his mother was not referred for appropriate advice about the risk of shoulder dystocia and the alternative of elective caesarean section. He also alleged negligence in the management of the delivery, including delay and the selection and sequence of obstetric manoeuvres.

The court tried liability, causation and the extent of any injury as preliminary issues. The central questions were whether the antenatal advice was inadequate, whether the delivery was managed below the required standard, and whether any breach caused the claimant’s injuries.

1. Antenatal advice. The relevant risk factors, particularly the previous shoulder dystocia, maternal obesity and the size of the previous babies, should have led to an earlier consultant consultation. However, the failure to arrange an ultrasound scan at 36 weeks was not negligent. There was a responsible and logically defensible body of medical opinion that would not have undertaken such a scan in 1992.
2. Applying Pearce, the issue was whether vaginal delivery carried a significant risk, not whether it remained the best or usual method of delivery. The risk of shoulder dystocia and consequent injury, together with the potentially traumatic emergency it created, was significant. Mrs Jones should therefore have been told of the risk and of the alternative of caesarean section.
3. The breach was not causative. On the balance of probabilities, Mrs Jones would have followed Dr Railton’s reasonable advice to proceed with vaginal delivery. Her strong objection to blood transfusions, the increased risks of caesarean section, and the ordinary deference patients showed to medical advice in 1992 supported that conclusion. Hindsight was disregarded.
4. Management of the delivery. Applying Bolam, qualified by Bolitho, the court found no negligence in trying lithotomy before McRoberts, attempting McRoberts before internal manipulation, administering syntocinon, or allowing the senior registrar to undertake the initial internal manoeuvre. Each step had a rational clinical basis and was supported by expert evidence. The fact that McRoberts is now preferred did not make its earlier use mandatory.
5. The 15-minute interval was not itself negligent. The manoeuvres were conventional, each had some prospect of success, and the timing was affected by the contractions and the difficulty of internal manipulation. The claim was dismissed and the defendant was held not liable.

Not stated in the judgment.