C v North Cumbria University Hospitals NHS Trust

Clinical negligence is assessed under the Bolam v Friern Hospital Management Committee test [1957] 1 WLR 583, as refined by Bolitho v City and Hackney Health Authority [1997] UKHL 46; [1998] AC 232. A claimant must show that the treatment fell outside the range of reasonable professional responses. A responsible body of expert opinion is important, but the court retains responsibility for the decision and may reject an opinion that lacks logical support. Approved clinical guidance supports reasonableness but is not conclusive if incomplete. A highly cautious approach need not be the only reasonable approach. The tragic outcome and hindsight do not convert a decision involving an exceptionally low risk into negligence.

The claimant, a child represented by his father, brought a clinical-negligence claim against the defendant NHS Trust. The claim concerned the administration of a second 3mg dose of Prostin during induction of the claimant’s birth in December 2002.

The Trust admitted liability for the mother’s death from negligent post-natal care and accepted that the claimant’s condition resulted from the second dose. It disputed that administering that dose, or failing to obtain a further obstetric opinion, fell below the standard reasonably expected of a midwife. The central issue was whether the decision at 19.00 was negligent in the circumstances.

The claim did not succeed. The court held that the midwife’s administration of the second dose of Prostin was within the bounds of reasonable professional judgment.

1. Applicable standard. The Bolam v Friern Hospital Management Committee test [1957] 1 WLR 583 was reformulated as asking whether no reasonably competent midwife would have acted and exercised judgment in the way the defendant’s midwife had done. A claimant cannot establish negligence merely by showing that another competent body of opinion would have acted differently. The court applied the logical-analysis qualification in Bolitho v City and Hackney Health Authority [1997] UKHL 46; [1998] AC 232. The court must decide the standard itself and need not accept expert opinion that cannot be logically supported.
2. Assessment of expert evidence. The court should consider whether expert evidence is given in good faith and whether the expert is competent, responsible and respectable. The most important consideration is whether the opinion is logical and consistent with the evidence, including the clinical notes, CTG traces, relevant guidance, and the evidence as it develops at trial. The court must not delegate its decision to experts.
3. Guidance and risk. The Prostin Data Sheet and BNF permitted a second 3mg dose after 6–8 hours where labour was not established. The midwife administered the dose 7½ hours after the first and labour had not been established. Compliance with the guidance was a factor against negligence, but was not conclusive because the guidance was incomplete and the wider circumstances still required assessment. The risk of uterine rupture was exceptionally low, and the mother had no scarred uterus or other listed high-risk feature.
4. Application. The decision required an overall assessment of uterine activity, maternal pain or discomfort, fetal heart rate, abdominal and vaginal examination, and the mother’s obstetric history. The relevant observations did not identify an unacceptable risk requiring the highly precautionary approach advanced by the claimant’s experts. That approach could reasonably have been adopted, but it was not the only reasonable response. The later catastrophic consequences could not be used with hindsight to establish breach.
5. Second opinion. In the alternative, the court held that the hypothetical advice of an obstetrician had to be assessed objectively by asking what a reasonable obstetrician would have advised, rather than what the particular Registrar would have said. Advice to administer the dose immediately, or after a short delay, would not have been negligent. The failure to seek a second opinion was therefore not negligent.