Tuffin v University Hospitals Coventry and Warwickshire NHS Trust [2024] EWHC 3318 (KB) (20 December 2024)
This judgment follows trial of the issue of causation in a clinical negligence claim arising out of personal injuries sustained by C after she underwent elective surgery to her spine on 7 July 2015 for prosthetic replacement of lumbar intervertebral discs. C was not given appropriate chemical thromboprophylaxis (specifically an anticoagulant called Clexane) after the operation as a result of which it is agreed that she suffered a deep vein thrombosis (“DVT”) and subsequently post thrombotic syndrome. [1]
In September 2018 the claimant underwent an amputation of her left leg, above the knee. [2]
The issue before me is whether the decision to amputate was caused or materially contributed to by the negligent failure of D to administer Clexane after the operation in 2015. [3]
By its defence D admitted that:
i) “…the failure to administer Clexane starting 24 hours after surgery on 7 July 2015 represented a breach of duty.”
ii) “…as a consequence of the breach admitted above C developed a DVT on 17 July 2015 which she would otherwise have avoided.”, and
iii) “…as a result of the admitted breach of duty, C developed a mild to moderate post thrombotic syndrome as a result of the deep vein thrombosis.” [4]
Prior to the surgery C had been disabled by back and leg pain and had previously undergone surgery which had been unsuccessful. She also, in the course of previous treatment for this condition, had a spinal cord stimulator fitted which had limited effect on her symptoms. [5]
C’s primary case is that complications from the negligent treatment by the defendant immediately after the surgery led to her requiring the amputation in September 2018 leaving her much more seriously disabled than she had previously been. She says that as a result of the negligence she developed excruciating pain, vascular ulcers and infections which were together so disabling that ultimately she was left with no choice but to undergo the amputation. [6]
D’s case is that the need for amputation and the symptoms which led the claimant to decide to undergo that surgery were the result of her developing complex regional pain syndrome (“CRPS”) and not as a result of their admitted negligence or the DVT. [7]
C submits that the contemporaneous medical evidence is “somewhat difficult to disentangle” ie as to whether the cause of the amputation is the DVT or CRPS, and therefore her alternative case is that the DVT and post-thrombotic syndrome, which she says that she also suffered as a result of D’s negligence, at least made a material contribution to the need for an amputation in due course and that therefore she is entitled to a finding against D on the issue of causation on either of these two bases. C submitted in closing that if the court cannot disentangle the two pathologies then it should reach the conclusion that D’s negligence which led to the DVT made a material contribution, without the need to apportion the causes or make findings as to the percentage of their respective contributions. [8]
While D admits that it was in breach of the duty that it owed C in that she was not prescribed Clexane within 24 hours of her spinal surgery on 7 July 2015 and that C therefore developed an avoidable DVT which, it is agreed, in turn led to C developing a post thrombotic syndrome, it denies that there is any causative link between the admitted breach of duty and C’s above knee amputation. D’s submission in closing was that there was a fundamental flaw in C’s case which failed sufficiently to analyse the symptoms which led to amputation and to identify the cause of those symptoms. As that submission was developed it was suggested that C’s two experts did not refer to or consider all three of the symptoms which are said to have led to the amputation. As a result it is argued that I should treat the C’s case generally and the written expert evidence which supports it with a considerable degree of caution. D alleges that the CPRS, which it says was the cause of amputation, was most likely triggered by the spinal surgery or was pre-existing or arose spontaneously and that the claimant would have undergone an amputation of her left leg whether or not she had developed a DVT. [9]
C’s submission is that on the balance of probabilities if the claimant had not developed a DVT and post thrombotic syndrome she would not have developed CRPS, if it is found that she did. [10]
Bailey v Ministry of Defence [2008] EWCA Civ 883 applied [15]
For the reasons which I have set out above I find that D is liable to C for the DVT and post thrombotic syndrome but not for the CRPS and not for her left above knee amputation. [156]
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