OAJ v Dorset County Hospitals NHS Foundation Trust

In clinical negligence claims, the standard is the ordinary skill of an ordinarily competent practitioner exercising the relevant special skill. A professional practice must have a logical basis, particularly where it involves weighing risks against benefits. A claimant must nevertheless prove that the breach caused the injury.

Where a pregnant patient presents after spontaneous rupture of membranes with blood-stained liquor, reassuring maternal and fetal assessments may justify conservative management and no immediate obstetric referral. Fresh bleeding combined with an abnormal fetal trace may instead require prompt caesarean delivery and continuing fetal monitoring. A breach occurring after an injury has already become irreversible does not satisfy causation.

The claimant suffered severe brain damage before or around his birth at the defendant’s hospital. His case alleged that midwives should have referred his mother for obstetric review, provided continuous cardiotocography and arranged earlier delivery after bleeding following spontaneous rupture of membranes. He also alleged that the consultant obstetrician should have diagnosed suspected placental abruption earlier, selected a more urgent caesarean category and maintained fetal monitoring after transfer to theatre.

The trial concerned preliminary issues of breach and causation. The central questions were whether the midwives or obstetrician breached their duties and, if so, whether any breach caused or materially contributed to the brain injury.

1. Standard of care. The court applied Bolam v Frien Hospital [1957] 1 WLR 582 and Bolitho v City and Hackney HA [1998] AC 232. The relevant practice had to represent the ordinary skill of an ordinarily competent practitioner and have a logical, defensible basis, including proper consideration of comparative risks and benefits.
2. Midwifery care. On admission, the mother was clinically well. The fetal trace, maternal observations and examinations were reassuring, and only blood-stained liquor was seen. In those circumstances, a reasonable body of midwives could conclude that immediate obstetric referral, continuous monitoring or immediate induction was not required. The midwives were therefore not in breach. The later fresh bleeding was referred to the consultant within 13 minutes, so no breach arose from that episode.
3. Obstetric care. At 08.48 am the consultant negligently overlooked the recent record of fresh bleeding, diagnosed a local cause without examination and failed to treat the combination of fresh bleeding and the unusual fetal trace as suspected placental abruption. A caesarean section should have been arranged as soon as possible. Category II was sufficient because the trace did not establish an immediate threat to life. After the decision for caesarean delivery, fetal heart monitoring should have been continued in theatre by cardiotocography or regular manual measurements.
4. Causation and outcome. The severe brain injury was caused by an acute profound hypoxic-ischaemic event lasting approximately 20–25 minutes, probably between 05.15 and 07.50 am, before the daytime trace began. The likely mechanism was reversible cord compression. The injury was therefore not caused by anyone’s negligence. The later breaches made no difference to the outcome and made no contribution to the injury. The claim was dismissed.