Sibaweih v Bedford

A general practitioner examining an injured knee must consider the possibility of fracture where the mechanism of injury reasonably raises it. The examination must be sufficiently thorough to identify relevant tenderness, and the patient should be referred for an X-ray where fracture cannot be excluded. A negligent delay in diagnosis is causative only of damage proved on the balance of probabilities. Where pre-existing conditions, an unrelated later injury and the negligence operate concurrently, the court must distinguish the additional symptoms attributable to the negligence and assess the likely period of acceleration or contribution. Lifelong disability cannot be awarded without evidence establishing that consequence.

The claimant sued her general practitioner after a fall inside a London Underground station. She alleged that the defendant negligently examined her knee eleven days later, failed to detect a fracture of the head of the fibula and thereby caused prolonged knee pain, impaired mobility, back pain and consequential care and treatment costs.

The defendant disputed breach, causation and loss. The claimant had a substantial history of knee, back, fibromyalgia, chronic fatigue and other medical problems. The central issues were whether the fracture should have been detected and referred for imaging, what symptoms and losses were caused or materially contributed to by the delay, and how far those losses were separable from pre-existing conditions and an unrelated disc prolapse.

1. Breach of duty. The claimant’s fall, involving a flexed and twisted knee, was capable of causing the fracture. Proper examination required palpation of the head of the fibula. The court found that the defendant had not palpated that area. A reasonably competent general practitioner would have considered fracture and referred the claimant for an X-ray if it could not be excluded. The failure to examine the fracture properly fell below the required standard of care.
2. Causation. The fracture remained symptomatic for approximately six months, with particularly significant pain during the first three or four months. The additional pain caused by the unsplinted fracture materially increased the claimant’s immobility and use of a stick. That abnormal gait was a significant cause of additional back pain, although the claimant’s pre-existing conditions remained concurrent causes.
3. The acute disc prolapse and sciatica arising in July 2009 were unrelated to the fall and negligent delay. The court separated their effects from the additional symptoms attributable to the negligence. The evidence did not establish that the negligence caused lifelong disability. The most likely period of accelerated back symptoms was assessed at 12 to 18 months, with the court awarding for approximately 18 months to two years of additional pain.
4. General damages for pain, suffering and loss of amenity were assessed at £6,000. The court awarded £2,000 for past gratuitous care and £980 for private treatment. Counsel were asked to draw a draft order including interest.

Not stated in the judgment.