FB v Princess Alexandra Hospital NHS Trust

A hospital doctor’s inexperience does not reduce the standard of care required in tort. A doctor is judged by the standard of a reasonably competent practitioner occupying the relevant post and performing the task in question.

Taking a patient’s history is a basic clinical skill. An accident and emergency doctor must use appropriate techniques to elicit why a patient, particularly a young child, has been brought to hospital at that time. The precise technique may vary with the patient and context, but the standard of care does not vary according to the doctor’s seniority. Failure to elicit the precipitating event may constitute negligence even where many comparable patients are not seriously ill.

The appellant, a young child, suffered permanent brain damage and profound deafness following pneumococcal meningitis. Her claim concerned the care provided by a senior house officer in the respondent hospital’s accident and emergency department. The doctor diagnosed an upper respiratory tract infection and discharged her without discovering that an alarming episode involving her eyes had precipitated the emergency attendance.

Following a trial on liability, Jay J dismissed the negligence claim against the hospital: [2015] EWHC 1536. The judge found no breach in either the physical examination or the taking of the history. It was agreed that timely referral to the paediatric team would have led to antibiotics which would have prevented the injury.

The central issue on appeal was whether the judge had wrongly applied a lower standard of care to history-taking by a senior house officer than would apply to a consultant.

1. Appeal allowed unanimously. Thirlwall LJ, with whom King LJ and Jackson LJ agreed, held that the doctor’s history-taking fell below the standard required of a competent senior house officer. Breach of duty and negligence were therefore established.

2. In a clinical negligence claim, the relevant conduct must be assessed by reference to the particular task being performed. Although a task’s complexity may correlate with the seniority of the doctor ordinarily performing it, a doctor who undertakes the task must exercise the skill required for it. The required standard is not reduced merely because the doctor is junior or inexperienced.

3. History-taking is a basic clinical skill expected of hospital doctors at every level. Its technique is context-sensitive and need not follow prescribed questions. Nevertheless, an accident and emergency doctor must use appropriate techniques to discover why the patient has presented at that particular time. Where the patient is a young child brought by anxious parents during the early morning, the precipitating reason is a fundamental part of the history.

4. The trial judge erred by reasoning that an experienced consultant would have pursued the inquiry but a senior house officer was not negligent for failing to do so. There was no evidence that the necessary inquiry was beyond a senior house officer’s competence. The fact that many children attend accident and emergency without a clear precipitating event did not answer the failure to discover one where it existed and the parents would have disclosed it if asked.

5. Jackson LJ added that the governing standard in tort was that of a reasonably competent senior house officer occupying the relevant post. The doctor’s youth and relative inexperience did not lower that standard, while her previous paediatric experience did not raise it. The health trust was liable where the doctor placed in the post failed to exercise the requisite skill for the task.

6. Because breach was established through inadequate history-taking, the court found it unnecessary to determine the remaining grounds concerning the examination.

1. Court of Appeal (Civil Division): The hospital appeal was allowed unanimously. The court held that the senior house officer’s history-taking was negligent and that breach of duty was established: [2017] EWCA Civ 334.
2. High Court: Jay J dismissed the negligence claim against the hospital following a trial on liability, finding no breach in either history-taking or examination: [2015] EWHC 1536.