“Indivisible Injury” has more than one meaning so make sure you’re not at cross purposes with the judge

1. The essential facts are that the Claimant had chest pain and needed angiography (an investigation of the blood vessels to the heart). He stopped warfarin (a long term anticoagulant) on 23 April, had the angiogram on 27 April and restarted warfarin on 29 April. The next day he suffered an ischaemic stroke which has resulted in permanent and severe physical and cognitive disability.
2. There was a dispute on breach of duty as to whether the total period for which warfarin was stopped should have been 3 days rather than 6 and whether it should have been restarted earlier and at a higher dose.
3. The judge preferred the Defendant’s expert evidence on breach of duty and was entitled to. That’s not the problem.
4. On causation the Claimant’s case was that if the warfarin had been properly managed he either would not have had the stroke or alternatively, the reduced dose materially contributed to the stroke.
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Am I the only one who thinks that the legal tests in clinical negligence are sometimes harder to understand than they should be?

The case law on my favourite topic – Bolam and other tests for breach of duty – is littered with confusion. And it strikes me that Material Contribution is too.

The But For test is, thankfully, beautifully simple and easy to understand. But what if your experts can’t tell whether the outcome would probably have been avoided or the same and you have to use the causation test of Material Contribution ?

The case of Davies v Frimley Health NHSFT 2021 EWHC 169 QB earlier this year is a recent example of the Court addressing both tests on causation in clinical negligence.

This is a strange read.

The issue on appeal to the Supreme Court was:

“If a child born with more than one disability would not have been born but for a doctor’s failure to advise of the risk of their being born with one of those disabilities, can the mother sue the doctor for the costs associated with all of the child’s disabilities, or only for the costs associated with the disability the doctor was consulted on?”

The High Court’s answer was that a claim lies for all of the costs. That was reversed on appeal. The Supreme Court upheld the Court of Appeal. For the underlying facts, see the brief account at the end of this blog.

A very common scenario in clinical negligence and personal injury claims is that the claimant’s negligent injury occurs on a background of pre-existing disability – how does the court assess the damages for care in the claim?

Examples of pre-existing disability in my own cases have included-

• Hydrocephalus;
• Spina bifida;
• Significant learning disability;
• Partial spinal cord injury at C5 resulting in tetraparesis.

The cases of Sklair and Reaney give some guidance as to the correct approach.

There has been a revolution in genetic testing over the past decade. Technological advances have greatly increased the scope and use of testing. Testing is now faster and cheaper.

This has meant that it has become easier to analyse a whole, or large sections of a genome in detail[1]. This innovation brings with it ethical challenges, most notably in terms of consent and disclosure to other family members who may be affected by information identified[2].

These developments are beginning to ripple out to clinical negligence litigation. As they do, the courts will be asked to conduct a sensitive balancing exercise between the Claimant’s Article 8 rights and the Article 6 rights of the Defendant to defend himself.