Ahmed Oukhellou v Luton And Dunstable Hospital NHS Foundation Trust

A medical practitioner is not negligent merely because another body of medical opinion would have adopted a different course. The question is whether the treatment accorded with a practice accepted as proper by a responsible body of appropriately skilled practitioners. In assessing competing treatment options, the court must consider the clinical evidence and balance the risks of intervention against the risks of non-intervention. Where there are no clinical signs of infection, invasive investigation, antibiotics, blood tests or wound swabs may not be required. A conservative approach may be reasonable, but follow-up must occur within an appropriate period. A breach concerning delayed review does not establish liability without proof of causative loss.

The claimant brought a clinical negligence claim against the defendant hospital trust arising from infection following a total knee replacement. He alleged that, when reviewed on 4 June 2008, the defendant’s registrar should have admitted him for surgical exploration, debridement and antibiotic treatment. The defendant contended that there were no clinical signs of infection at that consultation and that conservative management was reasonable.

The trial concerned liability, including causation. The court also considered whether a retained trocar sheath caused damage and the probable route by which the joint infection developed.

1. Standard of care. The court applied the test stated by McNair J in Bolan v Friern Hospital Management Committee [1957] 1 WLR 583. Negligence was not established merely because another body of medical opinion would have taken a different course.
2. Clinical findings. On the contemporaneous records, the wound was healing apart from a distal area affected by a retained suture. There were no clinical signs of infection, no obvious pus and a range of movement inconsistent with inflammation and infection.
3. Investigations and treatment. A wound swab and blood tests were not indicated. Antibiotics were inappropriate without a clinical reason. Exploratory surgery carried risks, including introducing infection into deeper tissue, and there was no sufficient indication for admission, debridement or aggressive antibiotic treatment.
4. Review. The registrar was not negligent in adopting conservative management. However, review in three months was too long; it should have been arranged within no more than 10 days. That breach caused no loss because the infection had developed by the time a review could have prevented the later consequences.
5. Causation and loss. The probable route of infection was haematogenous spread associated with the claimant’s facial infection, rather than migration through the incompletely healed wound. The retained trocar sheath caused no compensable loss because it was removed during procedures that would in any event have been required.

The claim was dismissed.