Gardner v Northampton General Hospital NHS Trust

A competent emergency physician must consider infection where a patient presents with unusual, severe or disproportionate symptoms, even where the suspected condition is rare. Clinical assessment must take account of the patient’s individual history and circumstances; general sepsis indicators are not an inflexible checklist.

For causation, a claimant may succeed by proving that non-negligent treatment would probably have avoided the outcome, or that the defendant’s negligence made more than a negligible contribution to it. On the evidence, earlier assessment, sepsis treatment and surgery would probably have saved the patient’s life.

Mrs Gardner attended the defendant hospital’s accident and emergency department with severe limb pain, swelling, discolouration and blisters. She was taking immunosuppressant medication and had recently grazed her elbow. Necrotising fasciitis was not diagnosed until it was too late for life-saving surgery.

The defendant admitted several breaches of duty but disputed whether earlier competent treatment would have led to timely surgery and survival. The principal issues were the treatment that a competent medical team should have provided and whether the admitted and established breaches caused Mrs Gardner’s death.

1. Breach of duty. A reasonably competent emergency physician should have addressed the possibility of infection at an early stage. The rarity of necrotising fasciitis did not justify failing to consider infection where the symptoms were unusual, severe and out of proportion to the apparent cause. The patient’s recent injury, immunosuppressant medication, blisters, discolouration and swelling away from the joints were important features pointing away from rheumatoid arthritis and towards infection.
2. The eight general factors relevant to sepsis assessment were low systolic blood pressure, raised pulse, raised temperature, altered mental state, raised respiratory rate, an abnormal white cell count, raised C-reactive protein and elevated lactate. That list was not exhaustive or inflexible. The circumstances of the individual patient had to be taken into account.
3. On the hypothetical timeline, a doctor should have assessed Mrs Gardner by 01.34 with appropriate observations. Blood testing should have confirmed infection by approximately 02.45–03.15. The sepsis protocol should then have been implemented, reviewed after about an hour and followed by consultation with a microbiologist by approximately 04.30–05.00. A competent microbiologist would have diagnosed necrotising fasciitis and emphasised the need for urgent surgery. With proper urgency, preparation and resuscitation, the patient could have been ready for surgery by approximately 05.40–06.10.
4. The court preferred Professor Winslet’s evidence and found that surgery begun by 07.30 would probably have enabled survival. The defendant’s negligence caused the delay which allowed the infection to progress beyond the point at which surgery could avert death.
5. The claimant succeeded under either causation approach identified in Bailey v Ministry of Defence [2009] 1 WLR 1052: the patient would probably have survived but for the negligent delay, and the negligence in any event made a material contribution to her death. The material contribution had to be more than de minimis or negligible, consistently with Bonnington Castings Ltd v Wardlaw [1956] AC 613.

The claimant therefore succeeded on liability. Mrs Gardner would probably have survived an emergency bilateral amputation and debridement for which she should have been ready no later than 06.10.