Rebecca Hepworth v Dr Amanda Coates

In a clinical-negligence claim concerning cauda equina syndrome, the Bolam test remained the applicable standard. A GP was not negligent where, on the evidence, she asked the necessary red-flag questions in a form the patient understood and acted on the answers given. Medical records are important evidence, but they carry no conclusive presumption of accuracy and must be assessed with all other evidence. If breach had been established, damages would have been assessed by comparing the claimant’s actual condition with the condition that would probably have resulted from an urgent hospital referral.

Rebecca Hepworth claimed damages from Dr Amanda Coates for allegedly failing, at a consultation on 5 November 2018, to diagnose red-flag symptoms of cauda equina syndrome and arrange urgent hospital referral. She contended that earlier surgery would have materially improved her neurological, urological and functional outcome. Liability, causation and quantum were disputed.

The court determined whether the necessary questions had been asked and understood, whether the consultation fell below the applicable professional standard, and, if so, what loss would have resulted.

1. Liability. The applicable test was the standard stated in Bolam v Frien Hospital [1957] 1 WLR 582 at 587. A clinician is not negligent when acting in accordance with a practice accepted as proper by a responsible body of skilled medical practitioners.
2. The agreed expert evidence established that the red flags for cauda equina syndrome included bilateral sciatica, significant bilateral neurological deficit, altered urinary flow or control, loss of rectal fullness, perianal or genital sensory loss, and anal-sphincter laxity. A single red-flag symptom would ordinarily require further investigation and urgent hospital referral rather than an outpatient MRI.
3. The factual evidence was affected by the passage of time. The court therefore attached particular importance to contemporaneous documents and inherent likelihood. Medical records were important but were not presumed to be more accurate than other contemporaneous evidence. The proper approach was to assess all the evidence and decide which account was preferable.
4. The court found that Ms Hepworth had experienced some perianal and genital numbness before the consultation, but had not lost control of her bowels. Dr Coates had asked about saddle anaesthesia and bladder and bowel function in wording that Ms Hepworth understood. Ms Hepworth answered that she had not experienced the relevant symptoms. The alleged breach was therefore not proved and the claim was dismissed.
5. If breach had been established, the court found that an urgent referral would probably have led to surgery on or about 6 November 2018. Earlier surgery would have avoided bladder dysfunction, right lower-limb numbness, right lower-limb neuropathic pain and continuing bowel dysfunction. It would not have avoided back pain or saddle sensory loss, and would have reduced, but not eliminated, psychologically and pain-mediated right-leg weakness and foot drop.
6. Had damages required assessment, they would have been calculated by comparing the actual condition with the counterfactual condition following timely surgery, applying the ordinary civil burden and standard of proof and allowing only losses proved on the balance of probabilities.

First-instance decision. The judgment states that the claim was dismissed because breach of duty was not established.