JRM v KING’S COLLEGE HOSPITAL FOUNDATION TRUST

In a clinical negligence claim, an elevated CRP result is relevant evidence of inflammation, but it does not automatically require delivery. Its significance must be assessed with the patient’s clinical condition, the risks of continuing the pregnancy and the other available evidence. A responsible body of medical opinion must have a logical and defensible basis, but the court must not choose between competing views which are each capable of logical support.

Where forceps are used, the court may infer negligent application and excessive force from contemporaneous records, the pattern and severity of bruising, and the medical evidence. The claimant must prove on the balance of probabilities that the negligent delivery caused the injury.

The claimant, born prematurely at the defendant hospital, suffered severe spinal cord injury around the time of birth. His case was that the defendant negligently failed to induce labour earlier, despite an elevated CRP result, maternal pain and allegedly offensive liquor, and that the delivering obstetrician negligently applied forceps when the baby was in an occipito-lateral rather than occipito-anterior position.

The parties agreed that the injury resulted either from traumatic arterial injury during instrumental delivery or from an embolic event. They further agreed that, if excessive force had been used during delivery in the occipito-lateral position, the delivery was negligent and could have caused the injury. The issues were whether earlier delivery was required, whether leaving a pessary in place was negligent, and how the forceps delivery was conducted.

1. Earlier delivery. The elevated CRP result was relevant and provided a warning requiring clinical assessment. It was not, however, conclusive that labour had to be induced. Applying the principles in Bolam v Friern Hospital Management Committee (1957) 1 WLR 582, as explained in Sidaway v Governors of Bethlem Royal Hospital [1985] AC 871 and Bolitho v City and Hackney Health Authority [1998] AC 232, the court accepted that the decision required clinical judgment balancing the elevated CRP against the absence of sufficiently persuasive clinical signs and the benefits of prolonging a very premature pregnancy. The claimant failed to establish that earlier induction was required.
2. Pessary. The decision to leave the pessary in situ was not negligent. There was also no reliable evidence that it caused or materially affected the mode of delivery.
3. Conduct of delivery. The contemporaneous neonatal records showed extensive bruising before respiratory treatment or intubation. The location of bruising to the nose, central face and scalp was consistent with forceps applied to an occipito-lateral presentation and inconsistent with proper application to an occipito-anterior presentation. The records and photographs were preferred to the evidence of the delivering obstetrician and the assisting registrar. The failure to call relevant midwives and neonatal staff further weakened the defendant’s account.
4. Causation and outcome. The court found that the baby was occipito-lateral, that the forceps were wrongly positioned and pulled with excessive force, and that this caused the spinal cord injury. Judgment was therefore entered for the claimant.

First-instance judgment. No appellate history was stated in the judgment.