Rai v University Hospitals Coventry And Warwickshire NHS Trust

In a clinical negligence claim following sleeve gastrectomy, discharge was reasonable where the patient’s overall condition had improved sufficiently to permit adequate oral intake and effective pain control. Normal observations and laboratory results did not determine the issue by themselves; the court assessed the complete clinical picture, including symptoms, analgesic requirements and evidence of oral intake.

For causation, the court had to choose between competing expert opinions. A clinically stable patient with suspected staple-line failure would ordinarily be monitored and investigated, with CT imaging generally preferred before re-exploration. Early laparoscopic exploration was not required merely because clinical suspicion remained where the evidence did not establish, on the balance of probabilities, that intervention would have prevented the subsequent failure.

The claimant brought a liability-only clinical negligence claim against the defendant NHS Trust after a laparoscopic sleeve gastrectomy on 16 February 2013. Quantum had been agreed.

She alleged that the defendant negligently discharged her while she had persistent pain, nausea, vomiting and an inability to tolerate fluids, failed to investigate a developing staple-line leak, and thereby caused avoidable sepsis, fistula formation and consequential injury. The defendant denied breach and causation.

The central issues were whether the claimant was sufficiently well for discharge on 18 February 2013, whether further investigation or admission was required, and whether earlier intervention would probably have avoided the subsequent complications.

1. Evidence. The court admitted the late witness statement and oral evidence of Sister Ursell. The circumstances differed materially from Wisniewski v Central Manchester Health Authority [1998] PIQR P324, where significant weight had been placed on the absence of a witness whose evidence was necessary to address what would have occurred. Here, the witness’s evidence addressed a key factual issue, the claimant was not taken by surprise, and admission best served the overriding objective.
2. Breach of duty. The relevant question was whether the claimant was “well” when discharge was decided. Although she had earlier been unable to tolerate water and had required unusual analgesia, the court accepted the nursing evidence that she had eaten some lunch without vomiting and had obtained effective relief from oral analgesia. That combination amounted to sufficient wellness for discharge. The clinical observations and laboratory results were within the expected range, and the claimant’s contrary recollection was affected by the passage of time and later hospital admissions. There was therefore no breach of duty.
3. Causation. The court accepted that staple-line failure was progressive and had probably begun by 20 February, while a frank leak probably developed on 1 March. The claimant was clinically stable, and the evidence indicated that imaging on 18 or 19 February would probably have been negative or regarded as within normal postoperative limits. The court preferred Professor McMahon’s view that continued monitoring and investigation, rather than immediate laparoscopic repair, represented the appropriate course. Mr Fiennes’s estimate gave intervention on 19 February only a 50 per cent prospect of preventing full staple-line failure, which did not satisfy the balance of probabilities.
4. The claim therefore failed on both breach of duty and causation.

First instance decision. No prior or subsequent appellate decision is stated in the judgment.