DS v Northern Lincolnshire and Goole NHS Foundation Trust (Rev 1)

Medical negligence requires proof of breach and causation. The standard is that of a reasonably competent practitioner acting prospectively, without hindsight. A professional practice will not satisfy the Bolam test if it lacks a logical basis, applying the qualification in Bolitho. In an apparently normal labour, a foetal heart-rate deceleration may initially be managed by midwives while its cause and persistence are assessed. Once a very low rate has persisted for about three minutes, however, continuous monitoring and obstetric assistance become necessary. A proved delay remains insufficient unless it probably caused injury or made it materially more severe. On the evidence, a three-minute negligent delay occurred, but it was not shown on the balance of probabilities to have materially affected the claimant’s brain damage.

The claimant, a child who developed spastic cerebral palsy following acute hypoxia during an emergency delivery, claimed damages from the defendant NHS Foundation Trust. He alleged negligent monitoring and management by midwives and negligent delay by the obstetrician in deciding to perform an emergency caesarean section.

The Trust denied breach and causation. The principal issues were whether the foetal heart should have been monitored more frequently before 1500, whether the midwives delayed seeking obstetric assistance after a persistent bradycardia, whether the obstetrician acted negligently by taking several minutes to decide the mode of delivery, and whether any proved delay materially reduced the injury.

1. Applicable standard. The court applied the standard of the reasonably competent obstetrician or midwife, assessed prospectively and without hindsight. A professional practice must have a logical basis and, where relevant, must reflect a defensible assessment of comparative risks and benefits.
2. Management before 1500. The claimant failed to prove that the mother was in the second stage of labour before 1500. The decision to defer a routine vaginal examination was reasonable. Monitoring at five-minute intervals was therefore not mandatory, and the omission of a reading at 1457 was not a breach.
3. Midwifery delay. A foetal heart rate of 60 beats per minute at 1500 did not require immediate medical assistance, because decelerations could recover and the midwives could initially reposition the mother, investigate cord prolapse and confirm the rate. Continuous monitoring should nevertheless have begun immediately. By 1504, the failure to establish whether the bradycardia had persisted for at least three minutes, and the further delay until the obstetrician was called at 1507, amounted to a negligent three-minute delay.
4. Obstetric management. The obstetrician acted reasonably in taking a history, examining the patient and deciding whether instrumental delivery was possible. The four-minute period between recognising the bleeding and making the crash-caesarean decision was within the range of reasonable practice. No breach by the obstetrician was established.
5. Causation. The claimant established on the balance of probabilities that a nine-minute earlier delivery would have made a material difference to his cognitive abilities. He failed to establish that a six-minute saving would have materially reduced the injury. In any event, the proved negligent delay was only three minutes, and that delay was not shown to have caused brain damage or made it materially more severe.
6. Disposition. The claim failed because causation was not proved. Consequential applications were to be dealt with administratively if possible.