LMN v Swansea Bay University Health Board

In a clinical-negligence claim, the claimant must prove both breach of the contemporaneous professional standard and causation. The Bolam test, as qualified by Bolitho, requires the court to assess whether the professional opinion relied on has a logical and defensible basis.

Where material contribution is relied upon, the alleged breach must have contributed more than negligibly to the injury itself. Contribution to a risk, or coincidence with an independently causative event, is insufficient. The material-contribution principle does not remove the need to identify a negligent factor which added to the claimant’s injury.

The claimant suffered profound neurological injury following an exceptionally difficult caesarean delivery. The fetal head was impacted and 17 minutes elapsed between uterine incision and delivery. The claimant alleged negligent delays in obstetric review, fetal blood sampling, preparation for delivery, instrumental delivery and caesarean section.

The defendant denied breach and causation. It relied on the contemporaneous clinical standards, the normal fetal blood-sample result, and the unexpected impaction as the cause of the delay and hypoxic injury. The central issues were whether the defendant’s care fell below the required standard in 2003 and whether any breach caused or materially contributed to the injury.

1. Claim dismissed. The claimant failed to establish either breach of duty or causation.
2. The applicable standard was that of the reasonably competent medical practitioner in the relevant field in 2003. Applying Bolam, as approved and explained in Bolitho, the court considered whether the defendant’s management was supported by a responsible body of professional opinion with a logical and defensible basis.
3. The pathological CTG justified fetal blood sampling. The result, showing a pH of 7.29, was within the normal range and indicated that there was no acute fetal compromise. The obstetrician’s plan to obtain the result, consult the consultant and proceed to delivery was consistent with good practice and the applicable 2003 guidance. The subsequent steps did not involve negligent delay.
4. The injury was sustained during the 17 minutes between uterine incision and delivery, when the fetal head proved exceptionally difficult to disimpact. The court preferred the evidence that the degree of impaction would not have been materially less at an earlier time. It was speculative to infer that earlier delivery would have made the head sufficiently less impacted to avoid injury.
5. The ordinary “but for” test was not satisfied. The alternative material-contribution case also failed. Following Bailey, the claimant had to show that a negligent factor contributed more than negligibly to the injury. The claimant could not identify any negligent cause contributing to the impaction or the critical delay. Medical uncertainty about when impaction occurred could not itself establish material contribution.
6. The court distinguished the material-contribution discussion in CNZ, which had been expressly treated there as obiter. Since no breach was established, and the only identified causative event was the unexpected impaction and resulting delay during surgery, the claim was dismissed.