Davies v Countess of Chester Hospital NHS Foundation Trust

In an emergency clinical negligence claim, the reasonableness of immediate treatment must be assessed in its full medical context. The court should balance the risks of acting immediately against the risks of withholding or delaying treatment. A clinician’s decision is not negligent merely because the treatment carries risks or later proves unsuccessful, provided the decision was reasonably justified on the information available at the time. The claimant must also prove causation. Establishing a serious breach that immediately caused death does not establish recoverable loss where, on the balance of probabilities, the patient would probably have died shortly afterwards in any event.

The claimant, the widow and administratrix of the estate of John Davies, brought a clinical negligence claim against the hospital trust. Mr Davies presented with severe ventricular tachycardia and chest pain. He underwent synchronised cardioversion, which was unsuccessful, and subsequently received an excessive bolus of magnesium that caused cardiac arrest and death.

The issues were whether the decision and manner of commencing cardioversion amounted to a breach of duty and whether Mr Davies would have survived for a substantial period if the excessive magnesium dose had not been administered.

1. The claim was dismissed. The court accepted that administering the excessive magnesium dose was a serious clinical failure and that it was the immediate cause of death. The claimant nevertheless had to establish that Mr Davies would probably have survived for a substantial period without that breach.

2. The court found that cardioversion began after Mr Davies’s blood pressure had seriously deteriorated. That deterioration justified commencing the procedure. The court would have reached the same conclusion even on the alternative chronology contended for by the claimant.

3. The proper approach to the breach issue was to balance the medical risks of immediate cardioversion against the risks of not treating immediately. The relevant circumstances included the very serious ventricular tachycardia, chest pain, profuse sweating, previous myocardial infarction and the risk of imminent ventricular fibrillation, cardiac arrest and death.

4. The risks associated with proceeding without the continuing presence of an anaesthetist or cardiologist were relatively limited on the evidence. Dr Khan was trained and experienced to perform the procedure, and the supporting clinicians were sufficiently competent. Although the shocks initially administered were objectively likely to fail, Dr Khan was acting in accordance with his training and applicable protocol and had no good reason to perceive that risk.

5. The court accepted the interpretation of the relevant clinical guidance that whether a patient was unstable and deteriorating required clinical judgment. The adverse features could reasonably justify immediate cardioversion. Dr Khan’s decision was reasonably justified and did not fall below the standard expected of a competent practitioner.

6. On causation, the court preferred the evidence that Mr Davies’s severe deterioration, underlying cardiac condition, morbid obesity and failure to respond to cardioversion meant that he was unlikely to survive for any significant period, even without the magnesium overdose. The claim therefore failed notwithstanding the serious breach concerning the magnesium.