Chappell v Newcastle Upon Tyne Hospitals NHS Foundation Trust

In a clinical negligence claim, the claimant must prove both breach of the standard expected of a reasonably competent practitioner and causation. Compliance or departure from clinical guidelines is relevant but does not itself determine breach. The court must evaluate the evidence as a whole, including expert interpretation of fetal monitoring, fetal blood samples and other clinical indicators.

Where competing medical explanations exist, causation is determined on the balance of probabilities. Evidence inconsistent with the alleged mechanism of injury, together with evidence supporting an alternative cause, may defeat the claim. On the evidence, maternal and neonatal infection was more likely than intrapartum hypoxia to have caused the injury.

The claimant, acting as personal representative of Callum Lee Chappell’s estate, claimed damages from the defendant NHS foundation trust for alleged negligence in the management of her labour at the Royal Victoria Hospital on 4 and 5 March 2000.

The claim concerned alleged failures in the use of Syntocinon, interpretation of cardiotocography, escalation to senior obstetric assistance and timing of delivery. The claimant alleged that these failures caused intrapartum hypoxia and severe cerebral injury. The defendant denied breach and maintained that the injury resulted from infection, including meningitis.

The court therefore had to determine breach of duty and, if breach were established, whether it caused or materially contributed to the injury.

1. Applicable principles. The claimant had to prove that the defendant’s staff acted, or failed to act, in a way in which no reasonably competent obstetrician or midwife would have acted. The claimant also had to prove that the breach caused or materially contributed to the injury. The applicable professional standard was that of a reasonably competent doctor or midwife performing the relevant functions in a hospital delivery suite, applying Bolitho v City & Hackney Health Authority [1998] AC 232 and the principles in Bolam.
2. Breach. The court preferred the defendant’s obstetric evidence, particularly the interpretation of the cardiotocograph. The reduced variability was generally within the normal range, the fetal blood samples at about 01.55 were normal, and continuing accelerations were reassuring. The fetal tachycardia was reasonably attributable to maternal pyrexia. The contraction rate did not establish sustained hyperstimulation, and there was no justification for a further fetal blood sample, earlier caesarean section or compulsory referral to a more senior doctor at 03.00.
3. The clinical team’s management after the fetal blood sample was obtained was of an appropriate standard. Although guidelines informed the assessment, departure from them would not, without more, establish breach. The criticism of the treating registrar was rejected.
4. Causation. The claimant’s hypoxic theory was inconsistent with the normal fetal blood and cord blood results and the absence of convincing cardiotocographic evidence of damaging hypoxia. The court considered it inherently unlikely that severe hypoxia sufficient to cause the injury could have produced profound acidosis which had disappeared within 53 minutes after Syntocinon was stopped.
5. The significantly raised cerebrospinal-fluid white-cell count and the day-thirteen ultrasound findings were strongly suggestive of infection and meningitis. Antibiotic treatment provided a credible explanation for the absence of a cultured organism and the absence of relapse. On the balance of probabilities, infection, not hypoxia, caused the injury. The claim therefore failed.

First-instance decision. No appellate history is stated in the judgment.