Raggett, The Executors of the Estate of v Kings College Hospital NHS Foundation Trust & Ors

Clinicians assessing severe lower-limb pain must consider vascular ischaemia, especially where the patient is a known arteriopath or otherwise at high risk of vascular disease. A plausible neuropathic, orthopaedic or rheumatological diagnosis does not remove the duty to investigate more serious vascular causes. Depending on the circumstances, this requires examination of pedal pulses, a vascular history, Doppler or other testing, or referral for specialist assessment. The duty applies to a pain specialist as well as to the clinician responsible for overall care. Where treatment fails and severe pain persists, the original diagnosis must be revisited. A breach of duty is causative where, on the balance of probabilities, earlier investigation would have enabled revascularisation before tissue loss and other irreversible deterioration.

The claim was brought by the executors of John Raggett's estate under the Law Reform (Miscellaneous Provisions) Act 1934. It concerned an above-knee amputation following progressive ischaemia of the deceased's left leg.

The allegations against the treating orthopaedic surgeon, pain specialist, rheumatologist and hospital included failure to consider or investigate a vascular cause for severe pain, and inadequate nursing records. The central issues were breach of duty, the causal effect of any breach, and whether earlier vascular referral would have permitted the leg to be saved.

1. Liability. Judgment was given for the claimant against the second, third and sixth defendants. The claim against BMI Healthcare, the fifth defendant, was dismissed because any inadequacy in nursing records or reporting made no causal contribution to the doctors' failures.
2. Mr Franklin was negligent from the outset. He should have considered and excluded vascular causes, palpated the pedal pulses and referred the deceased for proper vascular investigation. His failure to revisit the diagnosis when unbearable pain persisted was independently negligent.
3. Dr Hanna was negligent. A pain specialist has an independent diagnostic duty. Even if the neuropathic diagnosis was reasonable and the treatment acceptable, vascular ischaemia had to be considered and excluded in this high-risk patient. The duty became especially important when treatment failed and the pain remained out of control.
4. Dr Hussain was negligent. Before injecting the foot, it was mandatory to take a peripheral vascular history and check the pedal pulses. He did neither, thereby depriving himself of the means to identify the ischaemic cause.
5. On the balance of probabilities, there was still arterial run-off before Christmas 2010 and the leg could have been salvaged if any of the three negligent defendants had arranged vascular investigation. The revascularised leg would probably have survived until the deceased's death. In assessing that issue, the court applied the approach in Keefe v Isle of Man Steam Packet Co Ltd [2010] EWCA Civ 683: where important evidence is absent because of defendants' breaches, the claimant's case should be assessed benevolently and the defendants' case critically.

Not an appeal. No earlier decision is stated in the judgment.