Kirsty Canavan v Dr Edward Gaynor

In a clinical negligence claim concerning diagnosis and referral, a doctor is not negligent merely because another respectable body of medical opinion would have taken a different course. The court must assess whether the opinion supporting the treatment is responsible, reasonable and capable of withstanding logical analysis. It must also consider whether the experts have balanced the relevant risks and benefits.

Where examination findings reasonably support one diagnosis and make a serious alternative sufficiently unlikely, a doctor may reasonably exclude that alternative and provide safety-netting rather than refer immediately. The court should not impose a higher standard because the eventual consequences were grave or because hindsight shows that the alternative diagnosis was correct.

The claimant attended a homeless drop-in general practice clinic after a missed intravenous injection into her groin. She complained of pain, difficulty walking and feeling hot and shivery. Examination recorded a large, deep, tender lump which was not hot or red. Her temperature was normal and there was no tachycardia.

The defendant diagnosed a haematoma, prescribed analgesia and gave safety-netting advice. The claimant later developed necrotising fasciitis and required amputation of her leg. Causation was admitted, but breach was denied. The central issue was whether a reasonably competent GP should have retained abscess or infection as a diagnosis requiring hospital referral, or whether the clinical findings reasonably supported exclusion of that diagnosis.

1. The claim failed. The defendant’s decision not to refer the claimant to hospital or arrange further investigation was a course supported by a reasonable body of general practitioners. Judgment was therefore given for the defendant.
2. The applicable standard was the Bolam test, as refined by Bolitho. The court had to determine whether the professional opinion supporting the defendant’s conduct was responsible and reasonable, whether the relevant risks and benefits had been weighed, and whether that opinion was capable of logical analysis. The exercise was not a choice between whichever expert opinion the judge preferred.
3. The court rejected the proposed lacuna analysis. This was not a case in which medical practice had left an unjustifiable gap requiring universal referral in circumstances of this kind. The court was not assisted by treating the case as one where current knowledge showed that the risks should necessarily have been avoided.
4. The contemporaneous records and examination findings were important. The claimant had a normal temperature, no tachycardia, no redness or heat around the lump, and a solid deep lesion following a missed injection. Those findings, considered with the history, logically supported a haematoma and made abscess or infection sufficiently unlikely to be reasonably excluded in primary care.
5. The defendant had considered differential diagnoses and carried out an appropriate examination. The court accepted that the safety-netting advice probably included instructions to seek medical help or attend hospital if the condition worsened, together with an explanation of warning signs and the expected recovery period. That advice mitigated the risk associated with non-referral.
6. The claimant’s expert placed excessive weight on the reported symptoms of feeling hot and shivery and treated them as establishing rigors or a febrile illness. That reasoning did not sufficiently account for the normal examination findings and was affected by hindsight. The defendant’s expert’s opinion was rational, balanced and logically defensible.