Griffiths v The Secretary of State for Health

In a claim involving negligent handling of an acute spinal injury, the conventional but for test governs causation. Evidence that a spinally injured patient was manhandled is insufficient by itself to establish causation where the evidential basis is generic or statistically limited. However, where significant negligent manhandling is proved together with material neurological deterioration occurring afterwards, the court may ordinarily conclude that the deterioration would not have occurred but for the manhandling. The claimant must establish both a level of handling capable of causing further injury and deterioration between the original injury and hospital assessment.

The claimant, a tetraplegic retired veterinary surgeon, suffered a serious cervical spinal injury in a fall at home. An ambulance crew negligently failed to immobilise his neck, assumed that he had suffered a stroke, moved him repeatedly and transported him to hospital without spinal immobilisation.

The defendant admitted negligence but disputed causation. The central issues were whether the handling was liable to cause further spinal-cord injury and whether the claimant’s condition deteriorated between the crew’s arrival and his admission to hospital.

1. Causation. The court applied the conventional but for test. The mere fact of negligent manhandling, even at the scale proved, was insufficient without further evidence to establish on the balance of probabilities that additional injury had occurred.
2. Scientific evidence. The Poonnoose study was too limited to support a generic conclusion that manhandling necessarily caused deterioration. Its small sample, differing delays, differing injuries and lack of sensitivity to the mechanics of handling materially limited its value.
3. Operative inquiry. The relevant questions were whether the negligent handling was at a level liable to cause further spinal-cord injury and whether the claimant’s neurological condition deteriorated between discovery by the ambulance crew and arrival at hospital.
4. The claimant was lifted from a prone position, moved to a sofa, allowed to slump backwards, carried to the ambulance and transported with his neck unrestrained. The court found that this was significant negligent manhandling capable of causing further injury.
5. The court found compelling evidence of deterioration. The claimant had retained residual function before the handling, including movement of his left arm and sufficient truncal function to support himself briefly. On admission he had complete tetraplegia. The deterioration, together with the expert evidence that mishandling is the main cause of neurological deterioration when clearly established, established causation on the balance of probabilities.
6. The claimant’s subsequent good recovery did not disprove additional injury. Additional neuronal damage could reduce the extent of recovery without preventing substantial recovery. The claim therefore succeeded on liability and was to be quantified by agreement or further adjudication, using comparative functional assessments.
7. The court also criticised the excessive trial bundles. Civil Procedure Rules 1998, Practice Direction 39A, paragraph 3.2 identifies limited categories of documents for trial bundles, while CPR 1.3 requires parties to assist the court in furthering the overriding objective. Breach may have adverse costs consequences.