Coakley v Rosie

A general practitioner is negligent where a patient presents with signs and symptoms warranting a diagnosis of meningitis, creating a strong suspicion of it, or making it impossible reasonably to exclude. The practitioner must administer penicillin and arrange urgent hospital admission. The applicable standard is that of the ordinary competent general practitioner, assessed by a responsible body of medical opinion, subject to the court’s assessment of whether that opinion has logical force. In causation, unusual injury does not prevent recovery where the claimant proves that earlier treatment would probably have avoided it. Where medical science cannot establish that but for the breach the injury would have been avoided, a material contribution approach may apply if the negligent delay contributed more than negligibly.

The claimant developed meningococcal meningitis after a nine-day illness. She attended the defendant general practitioner with headache, neck stiffness and rashes, but was diagnosed with a respiratory infection and sent home without antibiotics or urgent referral. She later became unconscious, suffered seizures, and was admitted to hospital with severe meningococcal disease. She sustained blindness, deafness and other neurological injury.

The parties agreed the damages payable if breach and causation were established. The trial therefore concerned whether the defendant had breached her duty of care and whether earlier penicillin and hospital treatment would probably have prevented, or materially reduced, the injuries.

1. Breach of duty. The court applied the standard stated in Bolam v Friern Hospital Management Committee [1957] 1 WLR 582, as qualified by Bolitho v City & Hackney Health Authority [1998] A.C. 232. A general practitioner must exercise the ordinary skill of an ordinary competent practitioner, but the court is not bound by professional opinion lacking logical force.
2. Where meningitis is diagnosed, strongly suspected, or cannot reasonably be excluded, the practitioner must administer penicillin and arrange urgent hospital admission. The claimant’s purpuric and petechial rashes, severe pressure headache and neck stiffness were characteristic of meningococcal meningitis. The defendant failed properly to examine the rashes or neck, misidentified the rash as urticarial, and failed to suspect, exclude or treat meningitis. She was therefore negligent.
3. Causation. The claimant was neurologically intact when examined. The accepted evidence showed that meningococcal disease was progressive, that earlier effective treatment generally produced a better outcome, and that treatment at the consultation would probably have prevented the neurological damage. The Aronin evidence supported the conclusion that allowing progression from the least severe prognostic stage to the most severe stage materially worsened the outcome.
4. The unusual nature of blindness did not defeat causation. The injuries resulted from the untreated infection and its inflammatory consequences, and there was no evidence that the claimant had an exceptional susceptibility which made earlier treatment ineffective.
5. Had the primary but-for conclusion not been reached, the court would have applied the material-contribution approach in Bailey v Ministry of Defence [2008] EWCA Civ 882, because medical science could not identify a precise point at which treatment ceased to be effective and the delay would nevertheless have contributed more than negligibly to the injury.
6. The claimant succeeded on both breach and causation. Damages had been agreed, and the parties were invited to agree the form of order.

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