Meiklejohn v St George's Healthcare NHS Trust

A clinician assessing a rare disorder is judged prospectively by the standard of a responsible specialist practising in the relevant clinical setting. Later scientific knowledge and retrospective features cannot, without more, establish that the clinician should have suspected an alternative diagnosis. Where the clinical presentation and history do not provide sufficient indicators, there is no duty to delay treatment to obtain research testing or to pursue an expedited result. A responsible body of medical opinion may reasonably decide that a very remote treatment risk need not be disclosed, provided that view is logically defensible. The absence of breach also prevents a remedy based on informed choice.

The claimant alleged clinical negligence in the diagnosis and treatment of aplastic anaemia at St George’s Hospital in 2003. He contended that the defendant’s clinician should have suspected dyskeratosis congenita, expedited analysis of a blood sample sent to a specialist researcher, discussed Oxymetholone as an alternative to anti-lymphocyte globulin, and warned of the risk of avascular necrosis from Prednisolone.

The court determined the factual nature of the 2003 consultation, the purpose of the blood sample, the availability of testing, the appropriate treatment advice, and whether the failure to warn or discuss alternatives constituted negligence.

1. Claim dismissed. Judgment was entered for the defendant.

2. The court assessed the diagnosis prospectively, by reference to what an appropriate UK specialist in aplastic anaemia could reasonably have concluded in March 2003. The claimant’s physical presentation and clinical history did not provide enough to put Professor Marsh on alert to dyskeratosis congenita. Retrospective knowledge that some features were consistent with that diagnosis did not alter that conclusion.

3. The claimant had given verbal consent for blood to be sent to Professor Dokal for research. The sample was not submitted through an established diagnostic screening service. Professor Dokal’s laboratory could attempt to expedite testing when specifically asked, but there was no reason to make such a request because the presentation did not justify suspicion of constitutional aplastic anaemia.

4. On the diagnosis reasonably made, treatment with anti-lymphocyte globulin and Prednisolone was appropriate. There was no obligation to delay treatment pending further testing or to discuss Oxymetholone as an alternative. The court nevertheless found that, had a TERC mutation been identified before treatment, Professor Marsh would probably have followed Professor Dokal’s recommendation of Oxymetholone.

5. The failure to warn about avascular necrosis was not negligent. The risk was extremely remote in the low-dose regimen used at St George’s Hospital, and the supporting medical opinion was not logically indefensible within the approach in Bolitho v City & Hackney Health Authority [1998] AC 232. The informed-choice reasoning in Chester v Afshar [2004] UKHL 41, [2005] 1 AC 134 could not provide a remedy because no breach of duty had been established. The court likewise did not accept the reliance on Birch v University College London Hospital NHS Foundation Trust [2008] EWHC 2237 (QB) as establishing liability on these facts.

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