Hearne v The Royal Marsden Hospital NHS Foundation Trust

In clinical negligence claims, compliance with a body of medical opinion does not automatically avoid liability. The opinion must have a logical and defensible basis, including proper consideration of competing risks and benefits. Clinical guidelines are not mandatory, but they are important evidence of good practice. Departing from relevant hospital guidelines may require good reason, particularly where they address a high-risk patient group. Where a patient has a high risk of venous thromboembolism and no sufficient contraindication to anticoagulation, failure to assess the risk, obtain appropriate specialist advice where required, and administer prophylactic heparin may constitute a breach of duty. Causation depends on whether prophylaxis would probably have prevented the embolic event at the relevant time.

The claimant sought damages for clinical negligence following treatment at the defendant hospital after chemotherapy. He developed abdominal pain, dehydration and reduced mobility, and was subsequently diagnosed with a pulmonary embolism. The defendant admitted that a venous thromboembolism risk assessment should have been undertaken by 29 June 2010 and that compression stockings should have been provided, but disputed the remaining allegations of breach and causation.

The central issues were whether prophylactic low molecular weight heparin should have been prescribed, whether haematology advice should have been obtained, and whether earlier prophylaxis would probably have prevented the pulmonary embolism.

1. Applicable standard. The court applied the Bolam v Friern Hospital Management Committee test, as qualified by Bolitho v City and Hackney Health Authority. A body of medical opinion must be capable of logical analysis. In particular, experts must have addressed the comparative risks and benefits of the proposed treatment.
2. Guidelines and specialist advice. The NICE guidance and the Royal Marsden Hospital guidelines were not mandatory and did not remove the need for clinical judgment. They were, however, important evidence of good practice. The patient had several VTE risk factors, no active bleeding, and only a remote history of peptic ulcer disease. The Royal Marsden guidance treated complicated cases as requiring haematology advice. If concern about possible gastrointestinal bleeding delayed anticoagulation, the treating team should have consulted a haematologist.
3. Breach. The treating doctors did not undertake or record a competent balancing of the VTE and bleeding risks. On the balance of probabilities, competent assessment and consultation on 29 June would have led to prophylactic heparin being commenced, subject to review after endoscopy. Once the endoscopy showed mild gastritis and duodenitis without active ulceration, the remaining bleeding risk did not justify withholding heparin. Failure to administer it on 29 June, and also after the endoscopy results were available on 30 June, was a breach of duty.
4. Causation. The experts agreed that prophylactic heparin commenced on 29 June would probably have prevented the pulmonary embolism on 2 July. The evidence did not establish that prophylaxis commenced on 30 June would probably have been effective, because the DVT was likely already proximal by then. The claim therefore succeeded on breach and causation in respect of the failure to administer prophylaxis on 29 June.