Macaulay v Karim & Anor

A hospital may be liable where its systems fail to obtain an important diagnostic test, recognise that the patient has left before it is performed, and warn or contact the patient in circumstances requiring further investigation. In a patient with potentially serious infection, an abnormal presentation does not justify delay where the clinical evidence supports an urgent diagnostic scan. The court assesses causation on the balance of probabilities, including the probable effect of timely surgery. A general practitioner is not negligent where the symptoms proved at trial were not shown to have been communicated in a way that should have prompted examination or urgent referral.

The claimant developed severe sepsis, necrotising fasciitis and ultimately extensive amputations after attending his general practitioner on 12 and 14 October 2011 and the defendants’ hospital on 13 October 2011. He alleged that Dr Karim and Croydon Health Services NHS Trust had failed to diagnose and treat the developing infection promptly.

The central factual dispute concerned whether the infection began as an ischiorectal or perianal infection and tracked upwards, or began as occult pelvic sepsis. The court also considered whether the hospital’s failure to complete blood testing, investigate urgently, and respond to the claimant’s departure caused the subsequent injuries.

1. Aetiology. On the balance of probabilities, the infection began in the ischiorectal fossa, developed into necrotising fasciitis, and tracked upwards into the pelvis. The contemporaneous records of persistent anal and rectal pain, together with the radiological evidence, were more persuasive than the hypothesis of primary pelvic sepsis caused by a perforated diverticulum.
2. Hospital treatment. The triage request for blood tests should have been fulfilled within two hours. The failure to obtain them, and the failure of the surgical team to chase the relevant results, fell below an acceptable standard. The surgical team should also have repeated the observations and, once infection was indicated or reasonably suspected, arranged an urgent CT scan.
3. An urgent CT scan would probably have identified the ischiorectal infection. The claimant should then have been admitted, given intravenous fluids and antibiotics, monitored closely, and operated on by the morning of 14 October. The evidence established that timely surgery would, more probably than not, have avoided the leg and digital amputations.
4. Where a patient who has remained in the emergency department for several hours leaves before an important commissioned test is performed, the hospital should identify the absence, consider the clinical risk, and attempt to contact the patient using the available telephone information. The claimant’s departure was not a fully informed decision. The approach in Darnley v Croydon Health Services NHS Trust [2017] EWCH Civ 151 did not remove that distinct system-based duty.
5. The claim against Croydon Health Services NHS Trust therefore succeeded. The claim against Dr Karim failed. The claimant had not proved that he communicated constipation or urinary difficulty on 12 October in a way that required a face-to-face consultation, nor that his presentation on 14 October required urgent hospital referral.