Jaclyn McCaul v Lancashire Teaching Hospitals

In a clinical negligence claim, the claimant must prove both breach of duty and causation of the alleged loss. A management plan does not necessarily dictate the treatment ultimately undertaken where intra-operative findings justify a different course. The court may assess the surgeon’s usual clinical practice and contemporaneous medical evidence when deciding what occurred. Subsequent deterioration, including the need for a higher amputation, does not by itself establish that the earlier treatment was negligent or that it caused the loss. The claim fails where the evidence establishes a reasonable intra-operative decision and does not prove that the alleged omission caused the later outcome.

The claimant underwent vascular surgery intended to improve blood flow to her right leg. A below-knee amputation was subsequently followed by an above-knee amputation. Her remaining claim alleged that the surgeon negligently failed to perform an iliac angioplasty during the operation, and that this omission caused the need for the above-knee amputation.

The defendant accepted vicarious responsibility for any negligence but disputed breach and causation. The court had to determine whether there was adequate arterial inflow during the operation, whether the surgeon acted reasonably in proceeding with femoral endarterectomy alone, and whether the later outcome established causation.

1. Claim dismissed. The claimant did not establish negligence. Compensation required proof of negligent treatment leading to loss.
2. The operative management plan was a recommendation rather than an order. It did not require angioplasty if the surgeon’s intra-operative assessment showed that it was unnecessary or contraindicated. It would be wrong to allow a pre-operative plan or history to dictate a surgical course plainly inconsistent with what was found during surgery.
3. The court accepted the surgeon’s evidence that he assessed arterial inflow during the operation and found it to be good. His account was consistent with standard vascular surgical practice, including the assessment of blood flow before undertaking the endarterectomy.
4. The absence of express reference to good inflow in the operation note did not undermine that conclusion. The record of good downstream pulses and the surgeon’s usual practice supported the finding that the procedure was not performed without regard to inflow.
5. The subsequent failure of the below-knee amputation and need for an above-knee amputation did not, of itself, prove poor inflow at the time of surgery. The evidence identified other factors capable of contributing to a poor outcome, including smoking, peripheral vascular disease, prothrombotic risk and impaired healing.
6. Had poor inflow during the operation been established, causation would have been made out. On the evidence, however, the claimant failed to prove breach and the claim therefore failed.