Lane v Worcestershire Acute Hospitals NHS Trust & Anor

Under the Bolam test, a doctor is not negligent where treatment accords with a responsible body of medical opinion. Under Bolitho, the court must nevertheless assess whether that opinion has a logical and defensible basis, including whether it properly weighs comparative risks and benefits. The court must not merely prefer one logically supportable medical opinion over another.

The standard concerns the medical activity undertaken, not the individual’s usual specialty or status. Causation ordinarily depends on the balance of probabilities and the conventional but-for test. Where several factors contribute to injury, liability is established only if the negligence probably made the difference to the outcome.

The claimant suffered a myocardial infarction, developed right-arm ischaemia after coronary intervention, underwent delayed vascular surgery and later required amputation. She alleged negligence by two NHS trusts concerning delayed transfer, delayed surgery and the technique used during thrombectomy.

By closing submissions, the claim against the first defendant and several allegations had been abandoned. The remaining issues concerned the cardiological advice to delay transfer, the vascular decision to defer surgery while attempting to stabilise the claimant, the failure to clear the ulnar artery and perform completion angiography, and causation.

1. Standard of care. The court applied the principles in Bolam v Friern Hospital Management Committee [1957] 1 W.L.R. 583, Maynard v West Midlands Regional Health Authority [1984] 1 W.L.R. 634 and Bolitho v City & Hackney Health Authority [1998] A.C. 232. A responsible body of professional opinion must withstand logical analysis. The court must assess the opinion, but must not substitute its preference for another opinion that is also logically supportable. The comparative risks and benefits of transfer and surgery had been properly considered.
2. The standard was that of the activity undertaken. A doctor performing vascular surgery was held to the standard of the reasonably competent vascular surgeon. No higher standard was established merely because the procedure occurred at a teaching hospital. The court followed the approach in Wilsher v Essex Area Health Authority [1987] 1 Q.B. 730.
3. The cardiological advice to increase intravascular volume and monitor the claimant before transfer was reasonable, responsible and logically supportable. Immediate transfer was a reasonable alternative, but it was not the only permissible management plan. The additional surgical and consultant reviews did not amount to negligence or cause significant delay.
4. The decision to defer surgery until the cardiac condition had been stabilised, or until further improvement was no longer possible, was also supported by a responsible body of vascular opinion and survived logical analysis.
5. Once the brachial and radial arteries had been cleared and reperfusion achieved, a reasonable body of vascular surgeons was not required to perform ulnar thrombectomy or completion angiography. Fasciotomy was not clinically indicated and the allegation was abandoned.
6. Applying the balance-of-probabilities and but-for approach described in Bailey v Ministry of Defence [2008] EWCA Civ 883, the court found that the arm would have re-thrombosed even after earlier surgery. Continuing cardiogenic shock, hypotension, vasoconstricting inotropes, surgery-related arterial injury and heparin-induced thrombocytopenia were sufficient causes. The claim was dismissed against both defendants.

Not stated in the judgment.