Philipa Hodgson v Dr Daniel Hammond & Anor

In a clinical negligence claim involving suspected pelvic inflammatory disease, a general practitioner who has a working diagnosis or substantial suspicion of PID must adopt a low threshold for investigation and take all reasonable steps to confirm or exclude it. Where the patient is available for examination, a pelvic examination is ordinarily mandatory. Improving symptoms, partially effective antibiotics, reassuring observations, safety-netting, or repeat blood tests do not replace that examination where the underlying infection may persist or recur. An expert opinion that treats a resolving presentation as removing the need for examination may fail the Bolitho requirement of logical analysis, particularly where it does not weigh the risks of delayed treatment against the modest burden of examination. A doctor considering recent colleagues’ notes must take their relevant suspected diagnosis into account.

The claimant brought a clinical negligence claim against two general practitioners concerning consultations on 30 August and 5 September 2016. She alleged that Dr Hammond failed to arrange a pelvic examination when he recorded a possible resolving pelvic infection, and that Dr Dieleman failed to arrange one after reviewing her results and recent records.

It was accepted that she had PID at the relevant time. Causation was no longer disputed after a concession by Dr Hammond. The principal issues were whether each defendant’s conduct was supported by a responsible body of medical opinion and whether the defendants’ experts’ opinions could withstand logical analysis.

1. Liability. The claimant succeeded in negligence against both defendants. A separate judgment was to address condition, prognosis and quantum.
2. The court applied the Bolam test, as adopted in Maynard, subject to the logical-analysis qualification in Bolitho. A responsible body of professional opinion must have a logical and defensible basis, including proper consideration of comparative risks and benefits.
3. The medical evidence established that PID requires a low threshold for consideration and a high index of suspicion because symptoms and signs vary and the consequences of delayed or inadequate treatment may be serious. If PID is being considered, all reasonable steps must be taken promptly to confirm or exclude it. A pelvic examination was mandatory in the circumstances identified by the experts, and empirical treatment could be appropriate even without definitive diagnosis.
4. Dr Hammond had considered PID as a working diagnosis, although he described it as resolving. His failure even to consider arranging a pelvic examination breached duty. Alternatively, the supporting opinion of Dr Hampton was incapable of logical analysis. It relied on improving symptoms, a quiet abdomen, prior co-amoxiclav and safety-netting, but did not properly account for the waxing and waning nature of PID, the possibility that non-standard antibiotics had only masked the condition, the high risk of delayed treatment, or the availability of straightforward examination. Repeat blood tests and instructions to return if worse were not adequate substitutes.
5. Dr Dieleman was more likely than not to have read the recent notes of Dr Dickwella and Dr Hammond. He therefore knew that PID was a potential diagnosis and that no pelvic examination had yet been performed. His failure to call the claimant in for examination was unsupported by any responsible body of general practitioners and breached duty.
6. The court determined breach without hindsight, assessing the decisions prospectively in light of the information available at each consultation. C v North Cumbria University Hospitals NHS Trust was applied in assessing expert evidence.