Corke v The Princess Alexandra Hospital NHS Trust

In medical negligence claims, compliance with a practice supported by a responsible body of medical opinion does not automatically establish that treatment was reasonable. The supporting opinion must withstand logical analysis, particularly where it involves weighing competing risks and benefits. A claimant must show that the chosen treatment fell outside the range of decisions reasonably open to a competent practitioner. A high risk of failure does not itself establish negligence where the practitioner reasonably balances that risk against the risks of delay, alternative treatment or taking no action. The court must assess the decision at the time it was made, with appropriate regard to the patient’s particular circumstances.

The claimant suffered a complex subtrochanteric femur fracture. The defendant’s consultant orthopaedic surgeon used a dynamic hip screw rather than an intramedullary nail, which was accepted to be the optimal device if practicable. The fixation later failed and the claimant’s leg was amputated.

The claimant alleged that the nail should have been used, that the fracture had been inadequately stabilised, and that delay in reviewing post-operative X-rays caused additional pain. The central issues were whether use of the dynamic hip screw was negligent under the principles in Bolam v Friern Hospital Management Committee and [1957] 1 WLR 583, as explained in Bolitho v City and Hackney Health Authority and [1998] AC 232, and whether the delay caused actionable damage.

1. The claim was dismissed. The claimant failed to establish negligence in the choice or insertion of the dynamic hip screw, or actionable injury caused by delay in reviewing the X-rays.

2. The court applied the principles in Bolam v Friern Hospital Management Committee [1957] 1 WLR 583, Bolitho v City and Hackney Health Authority [1998] AC 232 and Maynard v West Midlands Regional Health Authority [1984] 1 WLR 634. It was insufficient for the claimant to show that another competent medical opinion preferred the intramedullary nail. The defendant’s supporting opinion had to be capable of logical support.

3. The intramedullary nail was the optimal device, but the court accepted that the claimant’s extreme obesity, severe arthritic hip, restricted movement, fracture configuration and the difficulty of positioning and using the targeting device made nailing impracticable. It was reasonable to open the fracture site, and the failure to achieve a closed reduction was not negligent.

4. The decision to use the dynamic hip screw was reasonable despite its high risk of failure. The risks of attempting an unsuccessful nailing procedure, prolonging surgery, causing additional blood loss, delaying treatment or transferring the claimant had to be balanced against the risk associated with the screw. The fact that an implant carried a greater than 50 per cent estimated risk of failure did not make its use negligent.

5. The court rejected the argument that the timing of the decision to abandon the nail was determinative. Whether nailing was reasonably possible depended on all the evidence, including the claimant’s condition, the clinical assessment and expert evidence. The surgeon’s conduct in theatre was relevant but not conclusive.

6. The complaint about inadequate stabilisation also failed. It was unsupported by the pleaded causation case and, in any event, the evidence did not show that the use of cerclage wires or a different stabilisation method was the only reasonable option. The assessment of the fixing was not to be made with hindsight.

7. The admitted delay in viewing the X-rays did not cause pain beyond that reasonably expected after the operation, or more than minimal pain. The claimant therefore failed to establish actionable damage.