STUART NEIL DALCHOW v ST GEORGE’S UNIVERSITY NHS FOUNDATION TRUST

In a clinical negligence claim, a reasonable working diagnosis must still be assessed against the whole presentation. Severe and unusual symptoms may require urgent investigation. The court must decide breach for itself, giving substantial weight to responsible expert opinion while testing its logic and consistency. An inference from unexplained absent evidence requires an evidential basis and no credible explanation. Causation requires proof of what treatment would probably have occurred without breach and whether that treatment would itself have been negligent. Antibiotics alone may not establish a material difference where necrosis has commenced and effective treatment requires surgical debridement.

The claimant developed Fournier gangrene after routine scrotal surgery at the defendant hospital. He alleged that the treating doctors failed to investigate his severe postoperative pain urgently and failed to administer antibiotics promptly. The defendant admitted a breach in failing to administer prescribed antibiotics by 12.00, but disputed any further breach and denied that the breaches caused loss.

The central issues were whether there was negligence in delaying an urgent ultrasound scan or antibiotics, what would probably have happened had the scan been obtained earlier, and whether earlier treatment would have avoided or reduced the claimant’s injuries.

1. Disposition. The claim was dismissed. Breach of duty was established, including the admitted failure to administer antibiotics, but causation of recoverable loss was not proved.
2. Diagnosis and investigation. It was reasonable initially to treat a small haematoma as a working diagnosis. The claimant’s very severe and unusual pain nevertheless created sufficient diagnostic uncertainty to require an urgent ultrasound scan. Consultation with the consultant was not itself unreasonable. Once requested, the scan should have been obtained urgently, within about two hours. The unexplained delay justified an inference that there was no good reason for it, applying Wisniewski.
3. Expert evidence. Applying Bolam, Maynard and Bolitho, the court was not entitled merely to prefer one respectable body of medical opinion over another. It had to decide the issue itself, while giving substantial weight to appropriate expert opinion and testing whether it was reasonable and logical. The practical guidance in C (By his Father and Litigation Friend F) was accepted and followed.
4. Causation. On the balance of probabilities, an earlier ultrasound report would not have led to earlier surgery. A reasonable body of medical opinion could have treated the scan findings as indicating infection requiring antibiotics, observation and further assessment, rather than immediate surgery. Antibiotics alone would not probably have materially altered the outcome because necrosis had already commenced.
5. Material contribution. Alternatively, a condition is divisible where increased exposure or delay increases the degree of harm. Fournier gangrene involving progressively greater tissue and skin loss could in principle be divisible. That issue did not arise on the primary findings, and the pleaded alternative concerned an indivisible injury.