CDE v Surrey and Sussex Healthcare NHS Trust

The claim in this appeal arises from the brain injury suffered by the appellant/claimant around the time of her delivery on 4 June 2018 at East Surrey Hospital (“the Hospital”). The claimant, a severely brain-damaged child, is represented by her mother (“M”) and litigation friend. She was born by caesarean section having suffered acute profound hypoxic ischemia (“PHI”) before, during and following her birth. She suffers from quadriplegic cerebral palsy with severe global developmental delay.

It is the claimant’s case that following M’s admission to the Hospital at 36 weeks and 1 day gestation, as a result of negligent care provided to her, the claimant’s delivery was not competently managed. It is agreed that the injury resulted from a short period of near total hypoxic ischaemic injury. The claimant contends that the delay in delivery, which resulted from a delay in transfer of M to the labour ward and thereafter a delay in commencing the monitoring of her heart rate during delivery, caused or materially contributed to her injury.

In this appeal, the claimant seeks to overturn a finding of fact made by Ritchie J (“the judge”) as to the time at which Miss Nicks, the consultant obstetrician on duty, would have entered M’s room in the labour ward having heard sounds representing bradycardia (reduction of the foetal heart rate (“FHR”)) emanating from the transducer linked to the cardiotocograph (“CTG”) which was set up to monitor FHR had the CTG been set up earlier and had the sounds representing bradycardia been heard by Miss Nicks when she was first outside M’s room.

The judge made findings of fact in the liability-only trial, which included the following:

For reasons which the judge described as not having being adequately explained, M was not transferred to the labour ward but instead was transferred to the antenatal ward. During the transfer M suffered severe pain and made that verbally plain. The transfer to the antenatal ward occurred between 16:50 and 17:20. At 17:20 Midwife Reeves noted: “Transfer to ward pain has increased 3-4:10 D/W SPR Emmanuel for Transfer to D/S. LWC informed awaiting a room on D/S”. Between 17:20 and 17:50 no further entries are made in the clinical notes. During this period M was in severe pain but was not reviewed by an obstetrician.

M arrived on the labour ward just before 17:50. She was in pain and visibly so. Introductions took one minute after which M was hooked up to the CTG by Midwife Reeves, which took one minute. By 17:51 the transducer was sounding out the claimant’s heartbeat, which was bradycardic.

At [98] the judge recorded that Miss Nicks was carrying out her ward round at 17:50 and was standing outside the room into which M had been transferred. She heard what appeared to her, from the sounds being made by the CTG transducer, to be bradycardia. She entered the room at 17:52, the CTG trace started at 17:53 (the sound was being emitted before the trace started) and bradycardia was becoming apparent. Miss Nicks carried out an ultrasound and confirmed bradycardia. She did a quick examination of M. At 17:55 she had decided a crash super-fast caesarean section under general anaesthetic was needed. Her working diagnosis was a partial abruption of the placenta. Doctor Heath was sent to prepare the theatre. The procedure commenced at 18:05 and significant blood was found in M’s abdomen before the uterus was opened. The claimant was born at 18:08 with meconium-stained liquor. A period of 17 minutes occurred between the start of the CTG transducer sounding out the bradycardia and the claimant’s birth. Delivery was achieved in 13 minutes from the decision to operate.

Miss Nicks stated that had a CTG been instigated earlier on the labour ward she could not say whether the emergency caesarean section would have occurred earlier save that a useful trace to diagnose bradycardia would take three minutes and the decision would have been made after that [99]. Miss Nicks would have taken action earlier in the labour ward if M had been brought in earlier and the bradycardia had started earlier [101]. The judge found Miss Nicks to be a credible and impressive professional witness.

The findings of fact and breach of duty made by the judge included the following:

Having considered the evidence of obstetric experts, Miss Leonce on behalf of the claimant and Mr Tuffnell on behalf of the defendant, the judge made additional findings on the balance of probabilities which included the following:

The judge found that M should have been transferred to the labour ward within 10 to 20 minutes of the decision made by the consultant at 16:50 hours. She should have arrived at the labour ward by 17:10 hours [233]. Applying the “but for” scenario, the judge found that soon after arrival on the labour ward M would have been assessed by an obstetrician and a vaginal examination would have shown the cervix was only 1 cm dilated. A CTG would have been attached. M’s blood pressure would have remained normal. The obstetric registrar would have had placental abruption as the more likely diagnosis than threatened pre-term labour [234].

The judge considered expert evidence given by neonatologists, a paediatric neurologist and neuroradiologist and made findings of fact in relation to factual causation which included the following:

At [296] and [297] the judge stated:

The judge found that it would have taken 17 minutes from the time that Miss Nicks walked into M’s room to the time of delivery of the claimant on the “but for” scenario as it did in real life on the 4^th of June 2018 [298]. Upon this basis he concluded that despite the findings of breach of duty the claim failed on factual causation [299]. On the balance of probability the baby would have been born brain-damaged in any event. The brain damage was caused by PHI. This would have occurred even if the defendant’s staff had not been negligent in their care for her mother on the antenatal ward before the bradycardia started [300]. The injury was caused by an extremely rare vascular malformation of the mother’s uterus which led to a bleed but which did not lead to a drop in the maternal blood pressure or a substantial increase in the maternal heart rate. It led to an unforeseeable reduction and then cessation of placental perfusion to the baby which created an emergency when bradycardia occurred alongside the PHI [301]. In real life the emergency occurred just as M was arriving on the labour ward at around 17:49 hours and it was picked up very fast by Miss Nicks. The judge stated that Miss Nicks and her team acted with hugely impressive professionalism and speed to deliver the baby within 17 minutes of the emergency [302].

Expert evidence from neonatologists was given by Professor Mitchell on behalf of the claimant and Doctor Jane Hawdon on behalf of the defendant. Doctor Mike Pike, a paediatric neurologist, provided a letter of advice on behalf of the claimant. There was agreement between the experts that the first 10 minutes of PHI would have been compensated by the foetus, as a result it was likely that the claimant would have survived without brain injury. Doctor Pike’s evidence was that insults lasting 15 to 20 minutes result in increasingly severe brain injury but survival, while insults of 25 minutes or more are likely to result in death.

Professor Mitchell explained the “older view” of categorising damage caused by PHI, namely that following the initial of 10 minutes of non-damaging PHI, there were three periods each lasting 5 minutes where damage occurred with reasonably predicable results. The first 5 minutes produced mild damage, the second 5 minutes produced moderate damage and the third 5 minutes produced severe damage [252]. Professor Mitchell was “firm in his view”, that any saving of time or duration of PHI would avoid some injury. The shorter the duration of PHI, the lower the level of primary injury which would have been suffered by the baby [254]. He stated that if PHI was of shorter duration then the period of resuscitation needed after birth likewise would be shorter. The judge noted the double benefit of a reduced period of PHI [257].

Doctor Connolly, a neuroradiologist, gave evidence on behalf of the claimant. He concluded that had delivery been achieved before 17:53 all of the brain damage would have been avoided, had delivery occurred before 18:08 some brain injury would have been avoided [262]. Doctor Hawdon calculated that damage began at around 18:00 hours, following 10 minutes of compensation by the foetus [272].

The judge preferred Professor Mitchell’s explanation of the likely duration of the PHI and found at [280] that any reduction in the period of PHI would have reduced primary injury to the claimant’s brain neurones. There is no respondent’s notice in relation to the judge’s findings as to the likely duration of the PHI and his finding that the shorter the duration of PHI the lower the level of primary injury to the claimant.

The judge set out the relevant principles contained in the authorities, in particular Bolam v Frien Hospital [1957] 1 WLR 582 (“Bolam”) and Bolitho v City and Hackney HA [1998] AC 232 (“Bolitho”). In Bolam McNair J stated that in the case of a medical man, negligence means a failure to act in accordance with a practice accepted as proper by a responsible body of medical men.

In Bolitho Lord Browne-Wilkinson restated the test and added:

As to causation in the context of a medical negligence claim, the judge cited the authority of Bolitho as follows:

The grounds of appeal now relied upon are:

Permission to appeal was given by Stuart-Smith LJ on 28 March 2023, his reasoning includes the following:

The skeleton arguments of the claimant and the defendant each addressed this specific aspect of the appeal. At the hearing, Ms Gumbel KC did not pursue this point and instead relied on the two original grounds of appeal above.

The grounds of appeal can be summarised thus: the judge’s findings at [296] and [297] take no account of the fact that Miss Nicks was outside the labour ward by 17:50. Miss Nicks’ evidence was that, as soon as she heard the bradycardia she went into M’s room. Had the CTG been operating as it should have been, Miss Nicks would have heard the bradycardia at 17:50 and entered M’s room by 17:51. This represents a timing of one minute earlier than the judge’s findings which were postulated on what the midwife would have done. There was no need to invoke what a midwife observing the trace would have done because Miss Nicks accepted that had she heard the bradycardia earlier she would have immediately entered M’s room. On the “but for” scenario, Miss Nicks would have heard the bradycardia as soon as she arrived at 17:50 and would have entered. The flaw in the judge’s findings were that they omitted to take account of the fact that Miss Nicks was in fact outside at 17:50.

The claimant contends that the judge applied the incorrect legal test namely that set out in Bolam as to what a responsible midwife would have done rather than the test set out in Bolitho which is what Miss Nicks would have in fact have done. On the judge’s findings, the CTG should have been running prior to Ms Nicks’ arrival. It follows that as she was outside at 17:50 she would have heard the bradycardia, which started at 17:48-17:49 and gone straight into M’s room. Accordingly, Ms Nicks’ entry would have been at 17:51 not 17:52 as the judge found. Ms Nicks would have proceeded exactly as she did upon entering with the result that delivery would have occurred one minute earlier at 18:07.

The flaw in the judge’s reasoning was to find that the midwife would probably have called for obstetric assistance within one to two minutes or a maximum of three minutes of detecting the bradycardia. There was no need to build this into the timings as it did not reflect the real life situation. The judge wrongly elided the situation of a midwife taking three minutes before she called the obstetrician, with the situation of the consultant who is outside the room at 17:50 and who would have heard the bradycardia as the CTG was running on the “but for” scenario.

On behalf of the claimant Ms Gumbel KC, accepts that the point raised in this appeal is a narrow one which results in a finding that delivery should have taken place one minute earlier. She contends that, relying upon the evidence of Professor Mitchell, every minute of PHI counted in terms of causation and to the assessment of whether the total period of PHI caused or materially contributed to the claimant’s injury.

Mr Sheldon KC, on behalf of the defendant, contends that the appeal is concerned with a straightforward factual conclusion made by the judge namely that, even if the CTG trace had become bradycardic at 17:48/17:49, Miss Nicks would probably have intervened at the same time as she did, namely 17:52. There is no Bolam/Bolitho error of law.

At trial, the claimant’s case was not that Ms Nicks would have entered the room one minute earlier. There was no evidence before the court, nor was the judge invited to find, that there was a 60 second period when Miss Nicks was standing in a static position outside M’s room in circumstances where she might have heard a bradycardia had a CTG commenced earlier. The judge was not asked to analyse where Ms Nicks was, and what she would have been able to hear between 17:50 and 17:51. Ms Nicks was not questioned about it, Midwife Bond was not called as a witness and the evidence of Doctor Heath did not address the issue.

A Respondent’s Notice was filed which addressed the argument which the appellant was then seeking to advance, namely that Miss Nicks was present outside the delivery room at 17:48/17:49 and would have delivered the claimant 2-3 minutes earlier had a CTG been running at that time. It was submitted that such a claim formed no part of the claimant’s pleaded case at trial. As previously noted, Miss Gumbel KC no longer pursued this aspect of the appeal.

The defendant relies upon the fact that Miss Nicks’ evidence, written and oral was prefaced by the word “around” in respect of her memory of timings. In her witness statement, Miss Nicks stated that she was “…doing my routine ward round on the labour ward and at around 17:50 hours I arrived outside the room where (M) had been transferred to. From recollection I heard what appeared to be bradycardia so entered the room. I entered the room at around 17:52 hours to assess (M). A CTG was started and I heard what I suspected was a fetal bradycardia”. The defendant contends that within the contemporaneous record and the factual evidence were critical gaps in the timings because Miss Nicks was not asked the relevant questions and Ms Bond was not called as a witness.

The findings contained at [297], in particular the first sentence, fall within the judge’s analysis of factual causation. The findings of fact relating to Miss Nicks’ timings were made earlier in the judgment for a different purpose namely recording findings from the “general run of evidence”, they were not being applied to the issue of factual causation. The findings are set out at [140] and [141] as follows:

The defendant submits that as the court is being asked to overturn a finding of fact, a very high threshold has to be met. The first sentence of [297] represents a reasonable conclusion for the judge to have reached. There was nothing in the evidence which compelled a conclusion that there was a one minute period of potential action on the part of Miss Nicks which was lost as a result of the defendant’s negligence. The contemporaneous medical records paint an unclear picture of precisely who was where and when, there was some evidence on approximate timings in the witness statement of Ms Nicks that she was outside at 17:50 talking to Midwife Bond. Midwife Bond wrote a contemporaneous note timed at 17:51 stating that she was introducing herself to the patient.

Finally, the case now relied upon by the claimant, namely one ‘lost minute’ was not pleaded nor argued before the judge.

This tragic case involves the birth of a severely brain-damaged child. At the trial, the court received evidence from those responsible for the clinical care of the claimant and her mother together with a number of experts called on behalf of the claimant and the defendant. The judge approached the analysis of the factual and expert evidence with care. He made clear and detailed findings of fact, findings of breach of duty in respect of the midwifery and obstetric care provided to the claimant’s mother in the period prior to the claimant’s birth and following from that, findings of factual and medical causation. The sequence of events on 4 June 2018 from 16:50 to the delivery of the claimant at 18:08 is critical to the assessment of what in fact happened and what should have been done by those at the defendant’s hospital responsible for the care of M and her child.

The claimant’s case has undergone a number of iterations in respect of when it is alleged delivery of the claimant should have taken place. In summary they are:

At trial the claimant’s case did not proceed upon the specific basis that delivery should have taken place at 18:07. The closest the claimant came to such an allegation is set out in para 5.6 of the Amended Particulars of Claim as follows:

The claimant’s written closing submissions concluded with these words:

At this appeal, there was a further shift in the claimant’s case namely the abandonment of the first point in this appeal for which permission had been granted (paras 23 and 24 above). Mr Sheldon KC, who has represented the defendant throughout these proceedings, is to be commended upon the calm yet cogent professionalism with which he has dealt with the changes in the claimant’s case which the defendant has been required to meet.

This appeal now turns on a narrow issue: did the judge fall into error in finding that Miss Nicks would probably have walked into M’s room at the same time as she did, namely 17:52? (First sentence [297]). The time Miss Nicks walked into M’s room is identified at [141] of the judgment (para 33 above).

Unchallenged is the evidence, now found as fact, that Miss Nicks was outside M’s room at 17:50, timed the start of her note at 17:50 and heard the bradycardia at 17:51. Miss Nicks’ note is set out as follows:

Based upon this evidence, logic would indicate that Miss Nicks began her note at 17:50 but upon hearing the sound of bradycardia she immediately entered M’s room. It follows that there was a short period after 17:50 when Miss Nicks was in fact outside M’s room writing her note. Upon the judge’s findings, the CTG should have been operating at 17:50. It follows that upon her arrival outside M’s room, Miss Nicks would have heard the bradycardia and would have immediately entered the room.

I accept the defendant’s contention that in her written evidence Miss Nicks prefaced her timings by the word “around”. In my view this does not overcome the fact that the judge, having considered the evidence, made findings of specific timings. I do not consider there is any force in the argument that the judge’s initial findings as to timings relating to Miss Nicks were set out in an earlier part of the judgment which was not addressing the issue of factual causation.

In my judgment, given the unchallenged evidence of Miss Nicks that she was outside at 17:50 and would have entered M’s room earlier had she heard the bradycardia, there was no need for the judge at [296] to postulate what a midwife would or should have done when the trace became bradycardic at 17:48/17:49. Specifically, there was no need for the judge to build into the scenario the 1, 2 or 3 minutes allowance for a midwife calling for obstetric assistance when it was noted that the trace became bradycardic at 17:48-17:49 because, on the evidence before the court, within one minute (17:50) Miss Nicks was outside M’s room and would immediately have entered upon hearing the bradycardia. That being so, Miss Nicks would have entered M’s room at 17:51, not 17:52 as found by the judge, which would have led to a saving of one minute and delivery at 18:07.

In considering why the judge felt the need to postulate what a midwife would or should have done as set out in [296] and, as a result, timed Miss Nicks’ entry into M’s room at 17:52, I think it likely that he based these findings upon the scenario set out in paragraph 15 of the defendant’s written closing submissions which stated:

I understand the claimant’s contention that the judge appears to have incorrectly applied the Bolam test as to what a responsible midwife would have done. The judge’s assessment of a midwife’s action appears to have been based on a proposition put by defence counsel as recorded at [208] that “reasonable” timing would have included a period of three minutes for the midwife to recognise the bradycardia and call the obstetrician commencing at 17:49. The concept of what is reasonable invokes the wording of the Bolam test as to what a responsible midwife would have done. In my judgment, there was no need to approach the facts in this way as this was more akin to a Bolitho scenario. On the evidence before the court, it was known what Miss Nicks would have done had she heard the bradycardia at 17:50 which would have occurred on the “but for” scenario. On hearing the bradycardia at 17:50 when she arrived outside M’s room, Miss Nicks would not have begun writing her note but would instead have gone into M’s room, which would take her in at 17:51.

I therefore accept the claimant’s contention that there was a flaw in the judge’s reasoning and that his finding that Miss Nicks would probably have walked into the room at the same time as she did, namely 17:52, does not in fact represent what would have happened on a “but for” scenario. The flaw could be categorised as an error of law or straightforwardly as an incorrect finding of fact. Whichever approach is adopted, the fact is that on the judge’s timings an error occurred and a minute was lost.

An appellate court is conscious of the approach to be adopted when considering interfering with findings of fact made by the trial judge. They are set out by Lewison LJ in Staechelin v ACLBDD Holdings Limited [2019] EWCA Civ 817 at [29]:

As to the meaning of “plainly wrong” in Henderson v Foxworth Investments Ltd [2014] UKSC 41, [2014] 1 WLR 2600:

Notwithstanding the care which the judge brought to this trial, and the detailed and clear analysis of complex evidence which is contained within the judgment, I am satisfied that he was wrong to find on the facts that Miss Nicks would not have entered M’s room until 17:52 for the reasons which I have identified.

I understand the concern of the defendant that the case, as now formulated, was not specifically before the judge at trial. That said, the claimant’s pleadings and written submissions did eventually postulate a delivery of 1 – 3 minutes earlier and following from that, a submission that the same would have made a material difference in respect of the issue of causation and injury. It was not until the judge made specific findings that either party knew with certainty the factual basis for breach of duty and for factual and medical causation. The judge accepted the claimant’s expert evidence that in terms of injury, every minute of PHI would count. The injuries sustained by the claimant are of the utmost severity, a fact which would be reflected in any award of damages.

It follows, and I so find, that the finding of fact that Miss Nicks would have entered M’s room at 17:52 and at the same time as in fact she did ([297]) must be quashed and the appeal allowed upon the basis that Miss Nicks would have entered the room at 17:51. The issue which now falls to be considered is what, if any difference, one minute would have made to the issue of medical causation. At trial this case did not proceed on the basis of a lost minute. None of the experts called to address the issue of medial causation were asked to specifically focus upon a delivery a minute earlier at 18:07 and what, if any difference, this would have made to the primary injury sustained by the claimant and the resultant period of resuscitation. Given the complexity of this issue I have concluded that this case should be remitted to the same judge for specific consideration, supported by further expert evidence, as to the effect upon the claimant’s injuries and functional disability of a delivery at 18:07.

To this extent, and for the reasons given, this appeal is allowed.

I agree with both judgments.

I also agree that the appeal should be allowed for the reasons given by Nicola Davies LJ and add my own concurring view in relation to four matters.

First, in a case where the judge assessed the evidence and made findings of fact with such meticulous care, I agree that we could not possibly depart from a finding of fact that was open to him on the evidence. However, the single error here was not one of fact-finding but of legal logic: on the judge’s own findings the claimant would have been born a minute earlier.

Second, there are many contexts in which short periods of time make no difference to the outcome of a trial, and it unnecessary for a court to be at all precise about timings. There are other contexts, of which this is one, where very short time periods may be critical. The judge rightly considered the evidence minute by minute and at paragraph 280 he made a broad finding that any reduction in the period of PHI would have reduced the primary injury to the claimant’s brain neurones. It was therefore not suggested to us that in a case of this kind, a minute of PHI is too short to be capable of mattering. Indeed Mr Sheldon rightly accepted that if there was a ‘lost minute’ the case would have to be remitted. As to his submission that the timings given by witnesses were approximate, I agree with Nicola Davies LJ. Once the judge had made findings on timings, they became fixed points. Now that the delay is measured at a minute, it will be a matter for the judge, having heard further expert evidence, to determine whether that period would as a matter of probability have spared the claimant any material part of her injury.

Next, Mr Sheldon very fairly made clear that the Respondent did not seek to defeat the appeal on the basis of any technical defect in the pleadings. However, he argued that it would be unfair to the judge to set aside his finding on the basis of a case that had not been specifically pleaded. It is true that, as seen at paragraph 37 above, the claimant’s case has been pleaded in a number of different ways. As to that, the judge rightly took account of the evidential difficulties caused by the defendant’s failure to start the CTG trace earlier (see paragraph 307). Further obstacles to clarity were introduced by the unreliable evidence of Midwife Reeves (paragraphs 75-96) and the misleading note and unreliable evidence of Dr Ekanem (paragraphs 113-125). But in any case it seems to me that everyone understood that the claimant’s irreducible case was that her injury had been caused by any delay in her delivery, and that on more than one occasion in the pleadings and submissions, this case was preserved. Moreover, the defendant expressly pleaded to three alternative periods of delay between 17:53 and 18.08 (judgment paragraph 24). I agree with Ms Gumbel that, given the forensic position in which this claimant had been placed, it would be harsh to penalise her for insufficient precision in the pleading of her case.

Lastly, a question arises as to the terms of the remitter, and whether the Trust should be allowed to call further witness evidence about exactly what occurred at the point of Ms Nicks’ arrival outside the labour ward. Mr Sheldon argued that, if there had been a focus on a minute’s delay, different evidence may have been called. For example, further questions would have been asked of Miss Nicks about what exactly happened outside the labour ward, and Midwife Bond might also have been called to give evidence. I do not accept that further evidence of that kind could make any difference. Miss Nicks’ undisputed account was that she arrived at 17:50 and was standing writing her note when she heard the CTG. Her oral evidence was that “if you are just outside the room you can hear the fetal heart. The fetal heart sounded slow so I went in.” (SB198). In closing submissions, the defendant noted that Miss Nicks’ ward round happened to bring her to a point just outside the door (SB9). There is therefore no room for the Trust to seek to recover the lost minute by calling evidence to challenge the conclusion that Miss Nicks would have heard the CTG at 17:50, and would have gone into the room directly.