Jabang v Wadman & Ors

A doctor may be negligent by omitting an investigation where the presenting features require it, even though the precise diagnosis is not reasonably apparent. The standard is that of the reasonably competent doctor of the relevant type, assessed objectively by reference to the standards applicable at the time. A body of professional opinion supporting the conduct must withstand logical analysis. Thoracic back pain radiating around the chest may require spinal imaging because it can indicate serious pathology. Reassuring features may reduce suspicion but do not necessarily eliminate the need for investigation.

The claimant developed spinal tuberculosis after presenting repeatedly with back and chest pain. He alleged that four doctors were negligent in failing to investigate or diagnose the condition promptly, causing paraplegia.

The court considered separate allegations against two general practitioners, a consultant rheumatologist and an Accident and Emergency doctor. The issues included whether spinal imaging was required, whether an MRI should have been recommended, and whether the claimant’s condition required urgent investigation before a planned specialist follow-up.

1. Dr Wadman on 5 October 2011. Applying the principles derived from Bolam v Friern Hospital Management Committee [1957] 1 WLR 582 and Bolitho v City and Hackney Health Authority [1998] AC 232, the relevant standard was that of a reasonably competent GP, assessed objectively by reference to standards in late 2011. The court found that Dr Wadman had identified thoracic back pain radiating around the claimant’s chest. Although absence of spinal tenderness, normal observations and other features reduced suspicion, they did not eliminate concern about serious spinal pathology. A reasonable GP should therefore have arranged an x-ray of the thoracic spine. Failure to do so was a breach of duty. The agreed causation position meant that timely imaging would have led to treatment before paraplegia, subject to assessment of damages.
2. Dr Wadman on 28 October 2011. There was no separate breach. He had properly understood the physiotherapist’s request for imaging of the thoracolumbar junction, added imaging of the sacroiliac joints, and was entitled to take account of the physiotherapist’s recent and detailed assessment.
3. Dr Underhill. No breach was established on 18 October or 14 November 2011. On the first date, the evidence did not establish that a reasonably competent GP was required to arrange thoracic imaging. On the second, referral to a rheumatologist was an appropriate response to an unresolved diagnostic problem.
4. Dr Pool. The claimant had symptoms and signs involving the lumbar as well as the thoracic spine. However, the court held that the decision to await further blood tests, lung-function testing and the planned review, rather than immediately recommending MRI, was supported by a responsible body of rheumatological opinion and was not illogical. No breach was proved.
5. Dr Nkrumah. His task in Accident and Emergency was to determine whether there had been significant deterioration or a significant new symptom requiring urgent treatment or investigation before the imminent specialist appointment. He investigated leg power, paraesthesia and spinal tenderness and reasonably concluded that urgent treatment or imaging was not required. No breach was established.

The claim therefore succeeded against Dr Wadman in respect of the 5 October consultation. The claims against Dr Underhill, Dr Pool and East Sussex NHS Trust were dismissed.