Arkless v Betsi Cadwaladr University Local Health Board

Under the Bolam test, clinical negligence is assessed by reference to the practice accepted by a responsible body of medical opinion. In suspected scaphoid fracture cases, reasonable medical practice required examination for anatomical snuff box tenderness, scaphoid tubercle tenderness and pain on axial compression of the thumb. Although a combination of tests might leave a very small number of fractures undiagnosed, that possibility did not justify omitting any test. Failure to administer and elicit results for all three tests constituted a breach of duty. A potentially acceptable examination technique was not, in itself, negligent where the breach arose from its incompetent execution.

The claimant sustained a wrist injury while playing football and attended hospital the following day. The defendant’s doctor diagnosed a sprain, performed some examination and obtained non-specific wrist X-rays, but the claimant’s scaphoid fracture was not diagnosed. The fracture failed to unite and caused continuing injury. Damages of £39,000 were agreed, leaving breach of duty and causation for determination.

The central issue was whether the examination and treatment provided on the claimant’s initial attendance met the standard required by the Bolam test.

1. Liability established. The claimant proved that she had sustained a scaphoid fracture when she attended hospital. Judgment was entered for her for the agreed damages of £39,000.
2. The applicable standard was the Bolam test, as stated in Bolam v Friern Hospital Management Committee (1957) 1 WLR 582 and distilled in Sidaway v The Governors of Bethlem Royal Hospital (1985) AC 871.
3. The College of Emergency Medicine Guidelines and the medical literature established that reasonable practice required three separate clinical examinations: anatomical snuff box tenderness, scaphoid tubercle tenderness and tenderness on axial compression of the thumb. The possibility that a very small number of fractures might produce negative results did not justify adjusting that approach.
4. On the balance of probabilities, the doctor had not competently administered and elicited results for all three tests. In particular, the contemporaneous notes did not record a separate scaphoid tubercle test. The examination therefore fell below the required standard of care.
5. The court did not need to decide whether the doctor’s combined technique, using the thumb to test the anatomical snuff box and scaphoid tubercle, was itself contrary to reasonable medical practice. The technique was not condemned in principle; the breach consisted in the failure to carry out the examination competently on this occasion.