Tippett v Guy's & St Thomas' Hospital NHS Foundation Trust

A claimant in clinical negligence must prove, on the balance of probabilities, both breach of duty and causation of loss. A midwife is judged by the care and skill expected of a reasonable, prudent and competent midwife. The proper interpretation of a clinical guideline depends on its wording, even though the guideline is intended for clinical rather than legal use. A trace may be unsatisfactory without being pathological or showing decelerations requiring urgent intervention. Where continued monitoring would probably have led to review and further monitoring, but not to delivery before the causative event, causation is not established.

The claimant, a child with cerebral palsy and other serious disabilities, brought a trial liability claim against the defendant NHS Trust. The claim concerned antenatal CTG monitoring on 8 November 2005, before his emergency caesarean delivery.

The claimant alleged that the CTG trace showed decelerations requiring medical review, that monitoring should have continued, and that earlier delivery would have avoided the brain injury. The Trust disputed who disconnected the trace, the interpretation of the trace, the appropriate clinical response, and whether earlier monitoring would have resulted in delivery before the umbilical cord compression that caused the injury.

1. Applicable principles. The claimant bore the burden of proving, on the balance of probabilities, both breach of duty and causation. The Trust was vicariously liable for the relevant midwives. The standard was the reasonable care and skill expected of a reasonable, prudent and competent midwife. Acting in accordance with a proper and responsible practice did not constitute breach merely because another body of opinion took a contrary view.
2. Disconnection and reconnection. The court found that the claimant’s mother removed the CTG trace at 1155 hours and that Midwife Nanseera reconnected it at 1331 hours. The witnesses’ recollections about the earlier disconnection were unreliable, while the midwife’s consistent evidence and the contemporaneous records supported those findings.
3. Interpretation of the CTG guidance. The NICE definition of a deceleration required slowing of the fetal heart rate below the baseline by more than 15 bpm lasting 15 seconds or more. The court accepted the interpretation that the slowing itself, rather than the period before return to baseline, had to last 15 seconds. The trace between 1108 and 1155 hours therefore showed no decelerations. There was no obligation to seek medical review at 1155 hours or to tell the mother that the trace was not yet reassuring.
4. Causation. If monitoring had continued, the trace would probably have remained unsatisfactory and prompted medical review by about 1220 hours. The likely response would have been further CTG monitoring, followed, if necessary, by induction of labour, perhaps after a scan. The trace was unsatisfactory but neither pathological nor sinister, and contained no decelerations requiring an urgent caesarean. Earlier monitoring would therefore not probably have resulted in delivery before the umbilical cord compression at 1353 hours.
5. Disposition. The claimant failed to establish breach causing loss. The claim was dismissed.