Rebecca Hepworth v Dr Amanda Coates

This is a clinical negligence claim alleging failure to diagnose cauda equina syndrome (CES) at a face to face general practice consultation on 5 November 2018. The court applied the Bolam test to assess breach and considered the weight to be given to contemporaneous medical records, contemporaneous WhatsApp messages and witness recollection. The GP experts agreed the red flag symptoms for CES and that a competent GP confronted with such symptoms would refer urgently to hospital rather than arrange an outpatient MRI.

On the facts the judge found that, on the balance of probabilities, Dr Coates asked the relevant questions about bladder, bowel and perineal sensation in a form a female patient would understand (asking whether sensation was affected when wiping after using the toilet) and that Ms Hepworth answered that she had not experienced such loss of sensation at the consultation. The court therefore concluded there was no breach of duty by Dr Coates. The judge made extensive findings as to witness reliability, the relative weight of contemporaneous notes (including physiotherapy notes) and WhatsApp messages, and resolved conflicts on inherent likelihood.

Because breach was not made out, the claim was dismissed. The court nevertheless addressed causation and quantum on a hypothetical basis and set out what awards it would have made had liability been established.

Background and parties: The claimant, Rebecca Hepworth, sued her GP, Dr Amanda Coates, for damages for clinical negligence arising from an alleged failure to diagnose red flag symptoms of cauda equina syndrome at a consultation on 5 November 2018. Ms Hepworth was admitted to hospital on 9 November 2018 and had emergency spinal surgery on 10 November 2018. She claims that earlier referral would have led to surgery some four days earlier and materially better outcomes.

Nature of the claim / relief sought: Damages for clinical negligence for failure to diagnose CES and consequent additional injury, including large claims for past and future losses (special damages in excess of £5 million were pleaded).

Issues for decision:

• Whether Dr Coates breached the duty of care by failing to diagnose possible CES or to refer Ms Hepworth urgently to hospital at the 5 November consultation.
• If breach were established, whether that breach caused a worse outcome (factual and medical causation) and, if so, the quantum of general and special damages and future care needs.

Evidence and approach: The judge emphasised the fallibility of memory and the importance of contemporaneous documents. Evidence included GP notes, physiotherapy contemporaneous notes, WhatsApp messages, NHS 111 and hospital records, and oral evidence from lay witnesses, the parties and numerous experts (GP liability, neurosurgery, urology, psychiatry, neurorehabilitation, physiotherapy, occupational therapy and care). The GP experts produced a Joint Statement agreeing the red flag signs of CES and that a competent GP would refer urgently if those were reported.

Court reasoning and findings: The judge made extensive credibility findings: all lay witnesses’ recollections were unreliable in parts; contemporaneous notes (particularly the physiotherapist’s) were given significant weight; and inherent likelihood was applied to reconcile conflicts. The judge found on the balance of probabilities that Ms Hepworth had experienced perianal/genital numbness on 3 November but that by 5 November, when asked in a form understood by a woman (whether she could feel when wiping after going to the toilet), she answered that she had not experienced loss of perineal sensation. The court found that Dr Coates did ask the relevant questions and that the clinical record was not evidence of breach. The complaint that the GP had referred for an outpatient MRI rather than urgent hospital assessment was not decisive because the judge found no report by the patient of red flag symptoms at the consultation in the sense required.

Causation and quantum (hypothetical): The judge addressed causation and prognosis if breach had been established. Experts agreed that an earlier urgent referral would have led to hospital assessment and earlier surgery (around 6 November) and that earlier surgery would have avoided some bladder dysfunction, right lower limb numbness and right neuropathic pain, but not necessarily ongoing back pain or saddle sensory loss. The judge set out detailed provisional awards and findings on future care, rehabilitation, equipment and accommodation needs, but declined to make awards because liability was not established.

The claim is dismissed. The court found on the balance of probabilities that Dr Coates asked the relevant questions about bladder, bowel and perineal sensation in a form a female patient would understand and that Ms Hepworth gave answers which did not disclose the red flag symptoms that would have required an urgent hospital referral. The judge preferred contemporaneous records and inherent likelihood in resolving conflicts of recollection and therefore concluded there was no breach of duty by Dr Coates. Causation and quantum were considered hypothetically and the judge set out what would have been awarded had liability been established.