Stuart Runciman v University Hospital Southampton

In a clinical-negligence claim, breach is assessed by reference to whether the clinician acted in accordance with a responsible, reasonable and respectable body of professional opinion having a logical basis. The court must evaluate that opinion against the evidence as a whole and must guard against hindsight.

Where treatment is time-critical, a clinician may reasonably treat the diagnosis considered most likely without first obtaining additional imaging, provided the competing diagnosis has been considered and the decision reflects a proper balancing of risks and delay. On causation, the claimant must prove on the balance of probabilities that the injury would have been avoided. Material contribution is relevant only where medical science cannot establish conventional causation.

The claimant brought a clinical-negligence claim arising from the death of his wife after she presented with headache, vomiting, sudden neurological symptoms and was treated for presumed arterial ischaemic stroke with alteplase. Her condition was later diagnosed as cerebral venous sinus thrombosis and she died from extensive cerebral injury.

The claimant alleged that the clinicians should have recognised the possibility of cerebral venous sinus thrombosis, obtained a CT venogram and administered heparin instead of alteplase. The defendant denied breach and causation. The central issues were whether the decision to administer time-critical thrombolysis without prior CT venography fell below the required standard and, if so, whether earlier heparin treatment would probably have avoided the death.

1. Claim dismissed. The court found no breach of duty and held, alternatively, that any breach would not have caused or contributed to the death.
2. The governing test was the Bolam test, subject to the requirement in Bolitho that the professional opinion relied upon must have a logical basis. The question was whether no reasonably competent neurologist would have acted as the treating clinicians did. The court was required to evaluate the experts’ reasoning itself.
3. The clinicians reasonably regarded acute arterial ischaemic stroke as more likely than cerebral venous sinus thrombosis. The latter was considered, including through discussion with the radiologists. Headache, normal fundoscopy and a normal plain CT did not make cerebral venous sinus thrombosis the more likely diagnosis. A CT venogram would have caused a material delay in treatment, and the decision to administer alteplase was a reasonable professional judgment in a time-critical situation. The court rejected the allegations that cerebral venous sinus thrombosis had been ruled out on the plain CT and that timely CT venography was required.
4. On causation, the appropriate counterfactual treatment would have been prompt heparin and no alteplase. The thrombus was extensive from the outset. The evidence showed no meaningful improvement or recanalisation after five days of heparin. Infarction secondary to cerebral venous sinus thrombosis, rather than haemorrhage, caused the death. Alteplase materially worsened the haemorrhage, but the haemorrhage did not cause or contribute to death.
5. The claim therefore failed on conventional “but for” causation. The material-contribution approach did not apply because the evidence permitted the court to determine causation on the balance of probabilities. The parties were invited to agree the consequential order, including costs, within seven days.