Baynham v Royal Wolverhampton Hospitals NHS Trust

Medical negligence and causation are separate questions. A clinician’s conduct is assessed by reference to practice accepted as proper by a responsible body of professional medical opinion. Where negligence caused a delay in treatment, the claimant must still establish on the balance of probabilities that the delay materially caused or contributed to the injury claimed. In a complex medical case involving competing possible causes, the court must assess the totality of the evidence objectively. The existence of a possible additional injury is insufficient. Causation fails where the evidence does not establish that the negligent period probably produced an additional injury beyond the damage that would have occurred in any event.

The claimant, a child born prematurely after a concealed placental abruption, brought a claim for damages arising from alleged negligent delay in performing an emergency caesarean section. The defendant accepted a systems delay of 25 minutes but disputed a further alleged delay caused by the examining registrar.

The court had to determine when delivery should reasonably have occurred and whether the negligent delay materially contributed to the claimant’s cerebral palsy, cognitive impairment and other disabilities. The central causation issue was whether the additional period of hypoxia-ischaemia caused further brain injury, or whether the claimant’s disabilities were wholly attributable to the abruption and subsequent hypoxia-reperfusion injury.

1. Negligence. The registrar had to assess the history, symptoms, fetal heart rate and examination findings before deciding on emergency delivery. Applying the established medical-negligence test in Bolam v Friern Hospital Management Committee [1957] 2 All E R 118, the court accepted that the decision could not reasonably have been made within one minute. It should, however, have been made within 10 minutes, by 23.40 hours.
2. The claimant should therefore have been delivered by 00.10 hours. The actual delivery at 00.40 hours involved 30 minutes of negligent delay.
3. Causation. The claimant had suffered a placental abruption, fetal bradycardia and a subsequent hypoxia-reperfusion injury resulting in complicated, high-grade bilateral germinal-matrix and intraventricular haemorrhage. That injury was capable of accounting for the whole of the claimant’s disabilities.
4. The claimant did not establish on the balance of probabilities that the additional 30 minutes caused a separate or additional ischaemic insult. The relevant evidence included the stable fetal heart rate, the absence of evidence of deterioration after admission, reasonable renal function, relative ease of resuscitation, stable neonatal blood pressure, absence of microcephaly and the marked asymmetry of the injury. These features were consistent with injury caused by the haemorrhages rather than a further time-related hypoxic-ischaemic injury.
5. The court rejected the suggested analogy that the injury increased in proportion to the duration of the hypoxic episode. The expert evidence and available literature did not establish that the size or consequences of the haemorrhage were time-related in the circumstances of this case. Possibility was insufficient to prove material causation.
6. The claim was dismissed.