Orwell v Salford Royal NHS Trust Foundation

In a clinical negligence claim, the claimant must prove both breach of duty and causation of loss on the balance of probabilities. Where compartment syndrome is a time-critical possibility, clinicians should consider it alongside other plausible diagnoses, such as deep-vein thrombosis or pulmonary embolism. They should not delay investigation of compartment syndrome until those alternatives have been excluded where delay risks irreversible injury.

However, an admitted breach does not establish liability unless the breach caused the claimed damage. The claim fails where the evidence shows that the relevant muscle damage had already occurred before the treatment that reasonable care required.

Mr David Orwell developed compartment syndrome after lengthy colorectal surgery in the Lloyd Davies position. A fasciotomy was performed approximately 50 hours after the original operation, by which time extensive muscle necrosis had occurred and he suffered permanent disability.

His executrix claimed damages, alleging that the NHS Trust negligently delayed recognising and treating compartment syndrome. The Trust admitted breaches of duty, including failures to consider compartment syndrome and to obtain timely pressure measurements. The central issues were when the syndrome began, when reasonable care required a fasciotomy, and whether the delay caused the muscle damage.

1. Disposition. The claim was dismissed. Although the NHS Trust was in breach of its duty of care, the breaches did not cause the claimed muscle damage.
2. The claimant had to establish breach and causation on the balance of probabilities. A doctor is judged by the reasonable care and skill expected of a reasonable, prudent and competent doctor. A doctor does not act in breach merely because another body of medical opinion takes a different view.
3. It was reasonable initially to consider deep-vein thrombosis or pulmonary embolism as possible diagnoses. Compartment syndrome should nevertheless have been considered by about 0600 hours on 20 December 2007. It was not reasonable to exclude those alternative diagnoses before investigating compartment syndrome, given the time-critical nature of treatment.
4. If reasonable care had been provided, a fasciotomy would have taken place between 0600 and 1200 hours. The medical evidence and contemporaneous records established, however, that compartment syndrome had begun shortly after the original operation on 18 December 2007. The pain, inability to bear weight, later findings and extent of necrotic muscle supported that conclusion.
5. The muscle damage had therefore already occurred before the fasciotomy should have been performed. The admitted breaches consequently caused no recoverable loss on the issues before the court.