John v Central Manchester and Manchester Children's University Hospitals NHS Foundation Trust

In a medical negligence claim, the Bolam standard remains subject to the court’s assessment of whether the supporting professional opinion has a logical basis. Causation may be established by proving that negligent conduct made a material contribution to injury, including where several negligent and non-negligent factors operate successively or cumulatively. The material-contribution approach is not confined to single-agency cases. Where medical evidence makes it impossible, rather than merely difficult, to attribute particular loss to particular causes, damages should not be apportioned between those causes. The claimant may recover for the entirety of the injury once material contribution is established.

The claimant, a general practitioner, suffered a serious head injury after falling down stairs. He alleged that the defendant hospital negligently delayed a CT brain scan and later delayed arranging an ambulance transfer to a neurosurgical hospital. He sustained permanent cognitive and neuropsychological impairment. The defendant disputed breach, causation and the extent of recoverable damages, relying on the initial trauma and a later post-operative infection as non-tortious causes.

The central issues were whether the hospital was negligent, whether the claimant suffered damaging raised intracranial pressure during the relevant delays, whether that pressure materially contributed to his injury, and whether damages should be apportioned.

1. Breach of duty. The applicable standard was that in Bolam, qualified by the requirement in Bolitho that professional opinion must withstand logical analysis. The defendant was negligent in failing to ensure that the CT brain scan was performed by about 10.00 am. It was also negligent in failing to request a second ambulance soon after the claimant had been stabilised and was ready for transfer.
2. Raised intracranial pressure. On the balance of probabilities, the claimant was suffering damaging raised intracranial pressure from at least about 12.15 pm, and in any event from the time of his seizure. The operative findings and evidence of the neurosurgeon who saw the claimant’s brain were preferred to the limited indications on the earlier CT scan.
3. Factual causation. Without the CT delay, the claimant would probably have been transferred and operated upon before his seizure, avoiding several hours of damaging pressure. The ambulance delay would separately have postponed surgery by about one hour.
4. Legal causation. The material-contribution approach applied even though the initial trauma and later infection were additional causes. The authorities did not confine that approach to single-agency cases. The negligent pressure made an unquantifiable but more than negligible contribution to the claimant’s cognitive and neuropsychological impairment.
5. Apportionment. Apportionment was inappropriate because the evidence made it impossible, rather than merely difficult, to attribute particular loss to particular causes. The claimant was therefore entitled to recover without deduction.
6. Disposition. Judgment was entered for the claimant in the total sum of £454,858.65, inclusive of interest.