Rebecca Thorp & Ors v Dr Harinder Mehta

Following a clinical guideline will ordinarily be strong evidence against negligence, but it does not remove the duty to exercise judgment in the individual case. A departure from guidance will generally require particular circumstances and a properly reasoned clinical basis.

Under the patient-centred approach in Montgomery, a doctor must take reasonable care to discuss a reasonable alternative treatment where a reasonable person in the patient’s position would likely attach significance to it, or where the doctor knows or ought to know that the particular patient would do so. Breach does not establish causation. The claimant must prove that, if informed, the patient would probably have chosen the alternative and that the choice would probably have avoided the injury.

The claim was brought by the administrators of Amanda Thorp’s estate against Dr Chua, Dr Mehta and the relevant NHS foundation trust. It alleged that negligent failure to prescribe antihypertensive medication caused Amanda’s fatal stroke.

The principal breach issue was whether Dr Chua and Dr Mehta should have prescribed medication immediately or could reasonably await ambulatory blood pressure monitoring under NICE guideline CG127. A further issue was whether Dr Mehta should have discussed immediate medication as an alternative. The court also considered whether any breach caused the stroke.

1. Claim dismissed. The claimants failed to establish both causative breach and causation.
2. Applying the Bolam/Bolitho approach, Dr Chua was entitled to follow the NICE recommendation of arranging ambulatory blood pressure monitoring. The recorded readings did not meet the guideline’s threshold for severe hypertension, which permitted immediate treatment without awaiting monitoring. The guideline was not wholly prescriptive, but liability despite compliance would depend on particular circumstances and proper clinical reasoning.
3. Dr Chua’s separate failures to identify the earlier blood-pressure history and to appreciate the significance of the normal reading taken while Amanda was taking labetalol did not alter the conclusion that awaiting monitoring was reasonable. The claimants’ expert evidence was materially undermined by its failure to engage coherently with the guideline.
4. Dr Mehta was not negligent merely because he continued Dr Chua’s plan, and neither doctor was required to give more emphatic advice about attending monitoring. However, Dr Mehta should have raised the alternative of immediate antihypertensive treatment. A reasonable body of practitioners could regard that as a reasonable option, but the Bolam analysis did not itself answer the patient-information question.
5. Under Montgomery, the duty required discussion of the reasonable alternative because a reasonable person in Amanda’s position would likely attach significance to the risk of delay, particularly given her medical history and patchy attendance. The doctor could still recommend monitoring as the medically preferred option.
6. The breach was not causative. On the balance of probabilities, Amanda would probably have continued with ambulatory monitoring because it could exclude the white-coat effect and avoid a likely lifetime of medication. The claimants also failed to establish that her hypertension was chronically at the very high levels shown in three later home readings. The court declined to determine the doubly hypothetical issue of whether earlier medication would have prevented the stroke.