Velarde v Guy's & St Thomas NHS Foundation Trust

Clinical negligence is assessed by reference to the individual patient and the circumstances known to the treating clinician at the time. A treatment choice is not negligent merely because another unit would adopt a more cautious or liberal approach. The court must ask whether a responsible body of clinicians could support the decision and, applying Bolitho v City and Hackney Health Authority, whether that clinical approach withstands logical analysis. Protocols cannot be applied slavishly. Relevant risks must be balanced holistically, including the patient’s clinical presentation, trends in measurements and the purpose of the treatment. On the evidence, neither the rate of Captopril escalation nor the restriction of fluids fell below the required standard.

The claimant, born prematurely with multiple ventricular septal defects, developed cerebral venous sinus thrombosis and peri-ventricular leukomalacia after treatment at the defendant hospital in September 2005. He alleged that negligent fluid restriction caused dehydration and clot formation, and that Captopril was increased too quickly, causing hypotension and impaired cerebral perfusion.

The court examined the clinical records, expert evidence, the timing and interpretation of blood-pressure and biochemical readings, and the competing risks of fluid overload, re-intubation, dehydration and hypotension. The central issues were whether the defendant’s clinicians had acted below the standard of a reasonably careful clinician and, if so, whether the alleged breaches caused the brain injury.

1. The claim was dismissed. The court applied the principles in Bolam v Friern Hospital Management Committee, [1957] 1 WLR 582, and Bolitho v City and Hackney Health Authority, [1998] A.C. 232. A departure from the practice of many units was insufficient if a responsible body of clinicians could support the approach and that approach was capable of withstanding logical analysis.

2. Clinical treatment had to be directed to the individual child. General protocols and comparisons with other units could not determine whether treatment was too aggressive or too quick. The clinician had to evaluate the child’s condition, the effects of each intervention and the competing risks at the relevant time.

3. The rapid increase of Captopril to the full dose did not itself establish negligence. The relevant question was whether the blood-pressure response to each dose contraindicated the next dose. Before the night of 27 September, the available readings did not demonstrate a contraindicating downward trend. The omission of a later dose showed that treatment was not administered mechanically.

4. Fluid restriction was a legitimate treatment aimed at reducing the risk of fluid overload and re-intubation. Dehydration had to be assessed holistically by reference to weight loss, biochemical markers, clinical presentation and, where relevant, urine output and the risk of pulmonary decompensation. Alexander was at most moderately dehydrated, and the evidence did not show that a competent clinician should have ended the restriction or administered a fluid bolus.

5. The court also considered causation, although it was unnecessary to the result. It would have found that moderate dehydration and inadequate cerebral perfusion caused or contributed to the clot and infarct, but that the injury was rare and not reasonably foreseeable to clinicians during the critical period.

First-instance judgment of the High Court (Queen’s Bench Division). No earlier appellate decision is stated in the judgment.