Barnett v Medway NHS Foundation Trust

In a complex medical negligence claim, breach of duty may be established where a basic and essential investigation is omitted, even though causation remains unproven. Stopping antibiotics may be reasonable on the clinical evidence, but exceptionally high inflammatory markers can require close monitoring. Good practice or a helpful step, such as consulting a microbiologist, does not necessarily amount to a legal duty. The claimant must prove causation on the balance of probabilities. Where the evidence leaves the timing of an infection, the likely result of investigations, or the effect of treatment materially uncertain, the causation claim fails.

Barnett v Medway NHS Foundation Trust concerned a claim for damages arising from treatment at Medway Maritime Hospital. The claimant, who had hypophosphatasia and a history of fractures, was admitted in October 2009 with severe pain, fever and a very high CRP. Antibiotics were given and then stopped. Blood cultures were not taken before treatment, inflammatory markers were not closely monitored, and the claimant was later discharged.

He subsequently developed spinal infection, abscesses and spinal cord infarction causing permanent paraplegia. The issues included breach in failing to take blood cultures, stopping antibiotics, monitoring inflammatory markers and consulting a microbiologist, together with whether any breach caused the subsequent injury.

1. The claim was dismissed. Judgment was entered for the Defendant.
2. The failure to take blood cultures before commencing antibiotics was a breach of duty. The procedure was basic, essential, simple and directed to identifying infection.
3. Stopping the antibiotics was reasonable in the circumstances. However, a reasonably prudent doctor with full knowledge of the claimant’s background should have arranged close monitoring of the CRP and white-cell findings, given the exceptionally high inflammatory markers.
4. The failure to consult a microbiologist was not a breach of duty. Consultation might have been helpful or good practice, but the evidence did not establish that it was legally required.
5. The claimant failed to prove on the balance of probabilities that blood cultures would have been positive, that monitoring would have led to spinal imaging, or that earlier or recommenced antibiotics would have avoided spinal cord infarction. The evidence concerning the onset and progression of the infection and the effect of treatment was materially uncertain.
6. Accordingly, although breaches of duty were established, the claimant did not establish that they caused the consequences alleged. The court also observed that the diagnosis of spinal infection is particularly difficult where co-pathologies exist.