Zhang v Homerton University Hospitals NHS Foundation Trust

A specialist registrar must exercise the skill and care expected of a reasonably competent doctor performing the relevant specialist function. During caesarean delivery of a deeply impacted foetal head, deliberately rotating the head or applying excessive lateral force to disimpact it is negligent where the manoeuvre is inappropriate, dangerous and unnecessary. The risk of injury must be assessed in the circumstances known to the doctor, including the degree of impaction and the lack of available space. A recognised risk of injury does not prevent a finding of negligence where the injury resulted from an avoidable use of excessive force.

The claimant suffered permanent brain damage during his delivery by caesarean section. His head was deeply impacted in his mother’s pelvis. The defendant accepted that the skull fracture, intracranial bleeding and subgaleal haemorrhage occurred during attempts to disimpact the head, but denied that the force used was negligent.

The claim was confined to whether the obstetric registrar had used excessive force, including by rotating the impacted head, deliberately moving it laterally, or creating excessive lateral force through the wedge effect of inserting her hand.

1. Standard of care. The applicable standard was that of a reasonably competent doctor carrying out the functions expected of a specialist registrar in the delivery suite of a district general hospital, applying the approach in Bolitho v City & Hackney Health Authority [1998] AC 232.
2. Rotation. The court found that Dr Gupta attempted to rotate the claimant’s head while it remained firmly impacted. The contemporaneous operation note, investigation statement, Midwife Harling’s recollection that Dr Gupta said she had difficulty rotating the head, and subsequent correspondence and pleadings supported that conclusion. Rotation of an impacted head was inappropriate and dangerous, could not assist disimpaction, and constituted a breach of duty.
3. Lateral movement. Dr Gupta deliberately and discretely moved the head laterally in an attempt to create room to insert her hand and flex the head. The defendant accepted that this manoeuvre was inappropriate, dangerous and a breach of duty.
4. Alternative wedge-effect finding. Even without a separate deliberate lateral movement, the court would have found negligence because the lateral force produced by inserting the hand was excessive, unnecessary and dangerous. Dr Gupta knew that there was essentially no available space, and ought to have foreseen a substantial risk of skull fracture and intracranial injury.
5. Causation and outcome. The attempted rotation caused the subgaleal haemorrhage. The lateral movement caused the depressed right parietal fracture and consequent intracranial haemorrhage. Liability was established and judgment was ordered for the claimant on the issue of liability.

Not stated in the judgment.