Jones v Portsmouth Hospitals NHS Trust

In assessing alleged clinical negligence, the court applies the Bolam standard prospectively. A doctor is not negligent where the treatment accords with a practice accepted as proper by a responsible body of suitably skilled medical opinion. The court must not prefer one professionally respectable body of opinion merely because it considers that view better. Nor may subsequent events be used to judge the reasonableness of an earlier decision retrospectively.

On the evidence, the defendant’s clinicians acted within an accepted range of medical practice in diagnosing and treating a rare condition, timing the operations, retaining muscle judged capable of recovery, and advising on reconstructive options. The claim therefore failed.

The claimant developed severe necrotising myositis in her right thigh following infection with Group A streptococcus. She alleged that the defendant NHS trust was negligent in delaying surgery, performing inadequate remedial surgery, and advising her to undergo a through-knee amputation rather than pursuing limb salvage.

The court determined issues of breach of duty, causation and the extent of injury. By trial, the allegation that amputation was itself an unreasonable recommendation had been abandoned. The remaining questions concerned the timing and nature of the treatment, and whether the claimant had been properly informed about the available reconstructive options.

1. Applicable standard. The court applied the Bolam test: a doctor is not negligent if acting in accordance with a practice accepted as proper by a responsible body of medical opinion skilled in the relevant field. The test is applied prospectively. Later events cannot establish negligence merely because they show that a different course might have produced a better result.
2. Delay and diagnosis. The clinical notes were accepted as reliable on the disputed issues of weight-bearing and the history of a sore throat. The court found that compartment syndrome was not actually diagnosed until approximately 2245hrs on 20 July and was not established in fact until Mr Richards examined the claimant at about 0200hrs on 21 July. The agreed emergency medicine and orthopaedic evidence supported the conclusion that the referrals, observation and timing of decompression were reasonable in light of the rarity and initially unclear presentation.
3. Operations. At the first operation, the muscle was judged to be dubious rather than obviously dead. In those circumstances, retaining it was reasonable because apparently non-viable muscle might recover after decompression. The second operation involved appropriate debridement, and the decision to stabilise the claimant before further surgery, together with the timing of that surgery, was reasonable.
4. Reconstructive options and consent. The multidisciplinary team reasonably considered limb salvage and through-knee amputation. The court accepted that the claimant was properly and fully informed of the options on 4 August, when she was sufficiently lucid to understand them, and consented to amputation. The exposed femoral vessels and bone made reconstruction urgent.
5. Disposition. There was no negligent delay, inadequate remedial surgery or negligent advice. The claim failed.