FB v Rana & Anor

Clinical negligence is assessed by the standard applicable to the doctor’s role and level of responsibility at the material time. A doctor may reasonably base a working diagnosis on the history obtained and the clinical examination, even where the illness is occult, provided the history-taking and examination meet the applicable professional standard. An inadequate clinical note does not necessarily establish an inadequate examination. For an A&E SHO, the standard is that of a reasonably competent SHO, not that of a consultant or paediatrician. The court must avoid imposing an unrealistically rigorous account of how anxious parents and junior doctors will behave. On causation, a subsequent hospital attendance does not necessarily break the chain where an earlier negligent referral would probably have led to paediatric assessment and effective treatment.

The claimant, a child, claimed damages for alleged clinical negligence arising from treatment during September 2003. She alleged that Dr Rana, an out-of-hours GP, failed to take an adequate history and examine her properly, and that the hospital’s A&E SHO, Dr Rushd, failed to obtain important information, recognise her condition and refer her to paediatricians. The claimant later developed pneumococcal meningitis and sustained irreversible brain damage.

The trial was confined to liability, including breach of duty and causation. The central issues were whether either defendant’s history-taking, examination, clinical records and management fell below the applicable standard, and whether any breach by Dr Rana would have caused the loss despite the later hospital attendance.

1. Claims dismissed. Judgment was entered for both defendants.
2. Applying Bolam v Friern Hospital Management Committee [1957] 1 WLR 583, the standard was that of an ordinary competent doctor exercising the relevant skill. Dr Rana was to be judged as an ordinary GP practising in 2003. Dr Rushd was to be judged as a reasonably competent A&E SHO, taking account of her role and qualifications but not applying the higher standard of an experienced paediatrician.
3. Dr Rana had obtained an adequate history and conducted an adequate examination. Although his note was inadequate as to the history and at best marginally acceptable overall, that did not establish that his examination was inadequate. His assessment of a child who appeared comfortable and not particularly unwell was within acceptable practice. It was not mandatory to assume an occult illness merely because the child had a fever.
4. The court applied the principle in Bolitho v City and Hackney HA [1998] AC 232 when considering whether different information should have produced different decision-making. Dr Rushd conducted a thorough examination and recorded findings that the child appeared alert, active and responsive. Although subtle abnormal state variation was probably present, the evidence did not establish that an A&E SHO’s failure to detect it was sub-standard.
5. The suspected eye-rolling episode was not communicated to Dr Rushd, and she was not negligent in failing to elicit it. The court rejected an excessively logical, hindsight-based analysis of why parents attended A&E at that time. On the history actually obtained and the clinical findings, discharge with safety-netting advice was reasonable.
6. The court considered Wright v Cambridge Medical Group (a Partnership) [2013] QB 312, but held that it did not apply to the suggested causation scenario. Had Dr Rana referred FB, she would probably have been assessed by paediatricians, observed after medication wore off, investigated and treated with intravenous antibiotics. A GP referral motivated by professional concern was materially different from attendance driven only by parental anxiety. The postulated negligence would therefore have been an effective cause, and the later hospital attendance would not have broken causation.

First-instance decision. No prior appellate decision is stated in the judgment.