Clements v Imperial College Healthcare NHS Trust

In a claim concerning sudden unexpected postnatal collapse, the claimant had to prove on the balance of probabilities that the proposed mechanism caused the injury. The modified approach applicable where several cumulative causes contribute to an injury did not assist where the claim depended on one unproved cause. Association between collapse and skin-to-skin contact did not establish causation. A responsible body of midwifery opinion could reassure a new mother that a correctly positioned baby would move its head to breathe. The very low risk of sudden collapse did not make that reassurance illogical or unreasonable. Applicable guidance did not require a midwife to interrupt early bonding and breastfeeding to take routine measurements strictly within one hour of birth.

The claimant suffered severe neurological injury after suddenly stopping breathing shortly after birth while in skin-to-skin contact with her mother. Her claim against the defendant NHS Trust alleged that the attending midwife had given negligent reassurance about the baby’s ability to breathe and had failed to return earlier to check mother and child.

The trial concerned liability only. The central issues were whether the baby’s collapse was probably caused by obstruction from the mother’s breast, whether the advice was negligent, and whether the midwife was required by applicable guidance or clinical practice to return by approximately one hour after birth.

1. Causation. The claim depended on establishing that obstruction by the mother’s breast caused the baby to stop breathing. The medical evidence established profound asphyxia but did not establish its cause. The literature identified possible mechanisms for sudden unexpected postnatal collapse, but the proposed causes remained hypotheses and association with maternal contact did not prove causation.
2. The modified approach described in Bailey v MOD [2008] EWCA Civ 883 applied to cumulative causes of injury. This was not such a case. The claimant therefore had to prove that suffocation by the mother’s breast was more likely than not to have caused the collapse. Applying the reasoning discussed in Wilsher v Essex Area Health Authority [1988] AC 1074, that burden was not satisfied.
3. Advice about breathing. The court applied the approach in Bolitho v City and Hackney Health Authority [1998] AC 232. A body of professional opinion may be rejected where it cannot withstand logical analysis, but it is not enough that another view is also logically supportable. The accepted midwifery practice of reassuring mothers that a correctly positioned baby would move its head to breathe had a logical and proper factual basis.
4. The risk of sudden collapse within two hours of birth was exceptionally low. Even assuming that every such event was attributable to breastfeeding, the risk was not sufficiently material to render the reassurance unreasonable. The proposed advice to keep the baby’s nose clear could itself cause unnecessary anxiety and interfere with relaxed early breastfeeding and bonding. The first allegation of breach therefore failed.
5. Return and checks. The relevant local and national guidance did not require the midwife to return precisely one hour after birth, or within five minutes thereafter, to take routine measurements. The guidance encouraged skin-to-skin contact and early breastfeeding, with routine measurements after the first hour. The midwife had correctly positioned the baby, observed feeding, left both parents present, and remained nearby and immediately contactable. The second allegation of breach also failed.
6. The claim was dismissed on liability. The court concluded that the collapse remained unexplained and that neither breach nor causation had been established.