Bell v Bedford Hospital NHS Trust (Rev 1)

Medical negligence requires proof of both breach of duty and causation. The clinical judgment standard asks whether the doctor acted in accordance with a practice accepted as proper by a responsible body of relevant professional opinion, and whether that practice was logically supportable. In diagnosing transient ischaemic attacks, symptoms must be assessed as a whole and in context. A specialist clinician may be required to keep a possible diagnosis in mind even where it is uncommon and an alternative diagnosis is plausible. A breach does not establish liability unless the claimant proves, on the balance of probabilities, that the breach caused the injury. Where competing causes remain equally plausible, causation is not proved.

The claimant suffered a major stroke in March 2012 after two earlier episodes in October 2009 and January 2010, which were agreed at trial to have been transient ischaemic attacks. She alleged that the defendant’s clinicians negligently failed to diagnose, or keep open the possibility of, a TIA and failed to review her after the second episode.

The issues were whether there had been a breach of duty in the diagnosis and follow-up, whether a TIA diagnosis would probably have improved medication adherence and lifestyle changes, and whether those changes would probably have prevented the later stroke.

1. The claim was dismissed. The claimant proved breach of duty but failed to prove causation.

2. The applicable standard was the Bolam v Friern Hospital Management Committee test as modified by Bolitho v City and Hackney HA: the doctor must have acted in accordance with a practice accepted as proper by a responsible body of relevant clinical opinion, and that practice must be capable of logical support. The court also applied the warning in Maynard v West Midlands Regional Health Authority that a judge’s preference between competing professionally supported opinions does not itself establish negligence. (para 35)

3. In the circumstances, Dr Elmarimi was in breach of duty in October 2009 by positively excluding TIA rather than keeping a possible TIA in mind. The symptoms had to be considered as a whole and in context. Relevant circumstances included the specialist TIA clinic, the unusual combination of symptoms, the claimant’s risk factors, and the fact that other clinicians had independently raised TIA as a possible diagnosis. The court rejected the diagnosis of a possible hypotensive episode as unreasonable. (paras 36–45)

4. The same reasoning applied in January 2010. The recurrence of symptoms after three months made TIA less likely, but did not justify failing even to review the claimant or investigate the possibility of TIA, particularly where another doctor had again raised that diagnosis. (paras 46–49)

5. On causation, the court found that a diagnosis of possible, probable or definite TIA would probably not have produced sustained improvement in medication compliance, smoking cessation or weight loss. In any event, the claimant had not proved that atherosclerosis was the cause of the stroke or that adherence to treatment would probably have prevented it. Atherosclerosis and dissection remained substantial competing possibilities, with cardio-embolism also possible. The burden of proof therefore remained unsatisfied. (paras 50–74)

6. The claim was dismissed notwithstanding the finding of breach of duty. (para 75)