Failes v Oxford University Hospitals NHS Trust

In a clinical negligence claim, a breach of duty does not establish liability unless it caused the injury complained of. Nursing staff should escalate a recorded neurological deterioration to clinicians, particularly where the observation chart would otherwise lack practical utility. However, the court must assess the whole evidential picture, including the patient’s own account, contemporaneous clinical assessments, expert evidence and limitations in the records. A temporary variation in recorded function may reflect pain or fatigue rather than a material deterioration. Where later detailed assessments establish an improving trajectory, the claimant must prove that earlier intervention would probably have avoided the injury.

The claimant suffered permanent paralysis after surgery to remove a spinal-cord tumour. He alleged that nursing staff negligently failed to report entries in a laminectomy observation chart recording deterioration in lower-limb function on 11 June 2015. He contended that a neurological review, MRI and emergency surgery would then have prevented the subsequent paralysis.

The defendant accepted that the chart entries should have been escalated, but disputed their accuracy and causative significance. It relied on the claimant’s improving mobility, the clinical and physiotherapy assessments on 12 June, and the acute deterioration on 15 June. The central issues were whether there had been a material deterioration on 11 June and what would have occurred had the chart been brought to the surgeon’s attention.

1. Claim dismissed. The failure to bring the laminectomy-chart entries to a clinician’s attention fell below an acceptable standard of nursing care, but the claimant did not establish causation.
2. Fact-finding required a careful and systematic assessment of the totality of the evidence, including evidential gaps. The court should not assume that every evidential piece must fit perfectly before a finding can be made.
3. Contemporaneous medical records ordinarily provide a useful starting point because they are made pursuant to professional duties and serve an ongoing clinical purpose. That starting point is rebuttable and does not displace the need to assess the records against other evidence.
4. The laminectomy chart was a screening tool with significant limitations. It used broad categories, treated each limb as a whole, and did not equate directly to neurological power. Greater weight was given to targeted clinical and physiotherapy assessments, the claimant’s own account, and his demonstrated ability to mobilise.
5. The recorded deterioration on 11 June was treated as a temporary dip associated with pain and fatigability, not a material neurological decline. The claimant’s recollection of improving right-leg power on 12 June, the surgeon’s assessment, the physiotherapy assessment, his subsequent independent mobility and the absence of contemporaneous complaints supported an improving trajectory until the acute deterioration on 15 June.
6. Had the chart entries been escalated, further neurological assessment would not have identified material deterioration and emergency surgery would not have been undertaken. The alleged breach therefore did not cause the paralysis.
7. The court criticised the inadequate nursing response to the claimant’s headaches and medication needs, the delay in obtaining the MRI on 16 June, and errors in the defendant’s root-cause analysis report. These criticisms did not alter the outcome.