Flanaghan v University Hospitals Plymouth NHS Trust

In a clinical negligence claim, a defendant is not negligent where the treatment adopted was supported by a responsible and logically defensible body of medical opinion. The court must assess the evidence itself and must not decide the case by simply choosing between competing expert opinions. Conservative management may fall within the reasonable range even where imaging shows serious abnormality, if the patient’s clinical condition and the comparative risks support that approach. Similarly, the timing and method of surgery may be reasonable where competent medical opinion recognises legitimate advantages and disadvantages in competing procedures. Judicial assessment is prospective and must avoid hindsight.

The claimant developed cervical cord compression and related neurological signs. In 2008, a neurosurgeon recommended conservative management, with advice to seek urgent review if symptoms deteriorated. After a fall in October 2012, she underwent multi-level anterior cervical discectomy and fusion followed by posterior decompression, but became tetraplegic.

The claimant alleged that the 2008 management was negligent and that the 2012 surgery should have been delayed, preceded by CT imaging, and performed by vertebrectomy rather than anterior cervical discectomy and fusion. The court determined preliminary issues of liability and causation.

1. Applicable standard. The court applied the principles in Bolam v Friern Hospital Management Committee [1957] 1 WLR 583 and Bolitho v City and Hackney Health Authority [1998] AC 232. A practice supported by a responsible, reasonable and respectable body of medical opinion will ordinarily satisfy the standard, but the opinion must have a logical basis. The court must assess the issue itself and must avoid judging the clinician with the benefit of hindsight.
2. The court adopted the structured analysis summarised in C v North Cumbria University Hospitals NHS Trust [2014] EWHC 61. Relevant considerations included the experts’ good faith, competence, responsibility, respectability, reasonableness and, above all, the logic of their opinions in light of the evidence as a whole.
3. The decision in 2008 to offer conservative treatment, coupled with advice about symptoms requiring re-referral, was within a reasonable range of medical opinion. Annual review and repeat MRI scanning were not mandatory. The claimant’s limited clinical symptoms and the balance between operative and non-operative risks supported the management adopted.
4. The 2012 allegations failed. There was a recognised range of opinion about immediate surgery compared with delay, and no requirement for a pre-operative CT scan. Given that the compressive pathology was principally at the disc level, anterior cervical discectomy and fusion was a reasonable and, in the circumstances, preferred procedure over vertebrectomy. The failure to remove all osteophyte, the management of the cerebrospinal-fluid leak, and the decision not to convert to vertebrectomy did not establish breach of duty.
5. The court did not need to determine causation. The claim was dismissed.