Vanessa Middleton v Frimley Health NHS Foundation Trust

In a clinical-negligence claim, acute limb-ischaemia guidelines did not impose an inflexible requirement to operate within six hours. The appropriate time for surgery depended on the individual clinical circumstances, including the patient’s vascular history, collateral blood supply, symptoms, imaging and the competing use of scarce emergency-theatre resources.

Under the Bolam and Bolitho principles, the court must assess whether the defendant’s clinical approach was supported by a responsible and reasonable body of medical opinion with a logical basis. It must avoid merely preferring one logically supportable expert view over another. A claimant must also prove that any alleged breach caused the injury on the balance of probabilities. A speculative causal mechanism, unsupported by medical literature or clinical experience, is insufficient.

The claimant, acting as personal representative of her deceased husband, brought a clinical-negligence claim against the NHS Trust responsible for Frimley Park Hospital. She alleged that the Trust negligently delayed a femoro-femoral crossover graft for acute right-leg ischaemia on 18 November 2015.

The principal issues were whether urgent revascularisation was required by 15:00, whether the claimant’s husband should have been prioritised over another patient occupying the emergency theatre, and whether earlier surgery would have restored blood supply to the lumbosacral plexus and prevented the claimed symptoms.

The claim was determined at first instance following a four-day trial. Quantum had been agreed at £10,000 if liability were established.

1. Claim dismissed. The claimant failed to prove breach of duty and, in any event, would have failed to prove causation.

2. The court applied the Bolam test, as explained in Bolitho. The relevant question was whether the defendant’s approach was supported by a responsible and reasonable body of vascular-surgical opinion. The court was not required simply to prefer one professionally respectable opinion over another. It had to consider whether the supporting opinion had a logical basis, including proper attention to comparative risks and benefits. The approach was consistent with the guidance in Maynard and the summary in Dalton ([1957] 1 W.L.R. 582; [1984] 1 WLR 634; [1998] A.C. 232; [2019] EWHC 832 (QB)).

3. The Rutherford and NCEPOD materials were guidelines, not mandatory rules or fixed time limits. Although the claimant’s condition could be categorised as urgent, the appropriate timing depended on clinical judgment. His substantial history of vascular disease, evidence of continuing blood flow, absence of a cold or markedly pale limb, lack of excruciating pain, the need for CTA imaging and the practical demands of emergency-theatre allocation supported the defendant’s position.

4. The claimant also failed to establish that her husband was more urgent than patient two. Both were urgent cases requiring surgery within hours. The proposed reversal of patient two’s surgery after that patient had entered theatre would have been realistic only in exceptional circumstances, such as a life-threatening emergency.

5. The causation conclusion was alternative and therefore obiter. Even if breach had been established, the claimant’s theory that earlier reperfusion of the leg would have restored blood supply to the lumbosacral plexus was conjectural, unsupported by literature or the experts’ clinical experience, and insufficient to satisfy the balance-of-probabilities standard.