Webb v Liverpool Womens' NHS Foundation Trust

In clinical negligence, a defendant escapes liability under the Bolam test only where the professional practice relied upon is supported by a responsible body of medical opinion with a logical basis. The court must assess the practice by reference to knowledge and standards at the relevant time, while avoiding substitution of judicial preference for expert opinion.

In an induced labour involving secondary arrest, hyperstimulation, a large fetus and other recognised risk factors, continuing maximal oxytocin and relying on intrauterine pressure monitoring lacked logical force. A Caesarean section was therefore required. However, the evidence did not establish negligent management of the subsequent shoulder dystocia or that excessive traction or fundal pressure had been used.

The claimant suffered a brachial plexus injury and Erb’s palsy during vaginal delivery following induced labour. She alleged that the defendant was negligent in failing to proceed to Caesarean section at several stages, and that the shoulder dystocia was subsequently mishandled.

The liability trial concerned whether Caesarean section should have been undertaken at 13.50, 15.00, 15.30 or 16.15, whether any such breach caused the injury, and whether the delivery was negligently managed by failing to achieve the McRoberts position, applying excessive traction or using fundal pressure.

1. Clinical negligence test. The court applied the Bolam test as qualified by Bolitho. A professional practice does not provide a defence merely because experts honestly support it. The supporting opinion must have sufficient logical force. The court must assess the practice in 1999, not by hindsight or current standards, and must avoid choosing between competing views merely because one is preferred.
2. Failure to undertake Caesarean section at 13.50. At that time the claimant was in dysfunctional labour and secondary arrest, had been receiving maximal or near-maximal Syntocinon, was experiencing hyperstimulation, and had the recognised risk factors for shoulder dystocia, including induced and prolonged labour, obesity, oxytocin augmentation and a large fetus. The fetus was optimally positioned and cephalopelvic disproportion was the probable explanation for the failure of progress. Continuing oxytocin and inserting an intrauterine pressure catheter did not have a logical basis. The failure to proceed to Caesarean section was negligent. Causation was established because a decision at 13.50 would probably have resulted in Caesarean delivery.
3. Later decisions. The claimant did not establish causation in relation to the alleged failures at 15.00, 15.30 or 16.15. At the later stages the court could not conclude that a reasonable obstetrician would necessarily have proceeded to Caesarean section when the cervix was near full dilation and the fetus was at the spines. The judge nevertheless considered that a vaginal examination at about 15.00 would have been logically justified to assess whether dilation was continuing.
4. Management of shoulder dystocia. McRoberts was attempted but could not be fully achieved because of the claimant’s habitus. That did not establish negligence. There was no evidence of fundal pressure; the notes recorded suprapubic pressure. The claimant also failed to prove that excessive traction was applied or that it caused the injury. Maternal propulsive forces remained a possible cause of the brachial plexus injury.
5. Disposition. Judgment was entered for the claimant on the 13.50 Caesarean-section allegation. Liability was not established on the other allegations.