Dowson v Lane

In a clinical-negligence claim, a GP is judged by the standard appropriate to the task performed. A trainee receives no lower standard where the task is the same as that performed by a qualified GP.

Under the Bolam test, a practice supported by a responsible body of professional opinion ordinarily avoids liability, even where another body would adopt a different approach. Under Bolitho, the supporting opinion must have a logical and defensible basis, including proper consideration of relevant risks and benefits.

A diabetic patient’s unilateral foot swelling, without redness, warmth or deformity, did not necessarily require referral for suspected Charcot arthropathy. A negative ultrasound, without new or changed symptoms, did not by itself create such a duty.

The claimant, who had type 1 diabetes, alleged that the defendant GP negligently failed to diagnose suspected Charcot arthropathy in her left foot and to refer her to a specialist diabetic foot clinic in March or April 2014.

The claim was tried on breach of duty and a limited causation issue concerning deformity identified when Charcot arthropathy was diagnosed in December 2014. One pleaded allegation was abandoned, and the alleged significance of a DVT investigation was not pursued.

The central issues were whether the defendant’s approach was supported by a responsible body of professional opinion and whether the later ultrasound result should have altered that position.

1. The claim was dismissed. The court held that the defendant was not in breach of duty on either occasion ultimately relied upon.
2. The applicable standard was the standard appropriate to the task. The defendant’s status as a GP Registrar was irrelevant because she was performing the same task as a GP. The court applied the principles in Bolam v Friern Hospital Management Committee [1957] 1 WLR 583 and considered the qualification in Bolitho v City & Hackney Health Authority [1998] AC 232.
3. The evidence established that, in 2014, a body of GP practice regarded swelling alone in a diabetic patient as insufficient to trigger referral for suspected Charcot arthropathy. Swelling or oedema had several more common explanations, and Charcot ordinarily presented with a relational group of swelling, redness and warmth. The practice was therefore supported by a responsible body of professional opinion.
4. The court rejected the contention that this practice failed the Bolitho requirement of logical analysis. The approach reflected a defensible assessment of the rarity of Charcot, the symptoms presented, and the competing clinical possibilities, notwithstanding the serious consequences of delayed diagnosis.
5. The 2015 NICE guidance could not itself impose a standard retrospectively. It did not undermine the finding that a responsible body of practitioners in 2014 would not necessarily refer a diabetic patient presenting with swelling but without redness, warmth or deformity.
6. The negative ultrasound result did not, without any new or changed symptoms, sufficiently increase the likelihood of Charcot to require referral. Other explanations, including lymphoedema, remained more likely.
7. As an alternative and non-operative conclusion, the court explained the staged approach in Bailey v Ministry of Defence [2009] 1 WLR 1052 to cumulative causation. The court considered that the present progressive process did not require resort to the modified material-contribution test. Had breach been established, earlier referral in March or April would probably have avoided the need for customised shoes, although further losses after December 2014 were not determined.