Joseph Michael Beech (by his Litigation Friend Joanne Mounsey) v Dr A P Timney (1st Defendant) Mr A W Paterson (2nd Defendant)
| Jurisdiction | England & Wales |
| Judge | Mr Justice Turner |
| Judgment Date | 29 July 2013 |
| Neutral Citation | [2013] EWHC 2345 (QB) |
| Docket Number | Case No: 6WH01017 |
| Date | 29 July 2013 |
| Court | Queen's Bench Division |
[2013] EWHC 2345 (QB)
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
MANCHESTER DISTRICT REGISTRY
Sitting at:
35 Vernon Street
Liverpool
L2 2BX
Mr Justice Turner
Case No: 6WH01017
Mr Bill Braithwaite QC & Dr Simon Fox (instructed by K J Commons & Co) for the Claimant
Mr James Rowley QC & (instructed by MPS) for the Defendants
Hearing dates: 17 th to 25 th June 2013
Approved Judgment
Introduction
On 6 th November 2003, the claimant, then aged 35, had a stroke as a result of which he now suffers from physical and cognitive deficits which will be permanent.
He contends that his stroke was caused by the negligence of the defendants. The first defendant, Dr Timney, was the claimant's general practitioner. The second, Mr Paterson, was a consultant oral and maxillo-facial surgeon. Those representing the claimant have conceded that this is a case in which either both defendants are to blame or neither. In the event, therefore, the evidence and submissions in the case have been confined to matters material to Dr Timney's involvement and I am not required to make any specific findings as to the role of Mr Paterson.
In essence, the claimant's case is that his stroke was caused or materially contributed to by high blood pressure. It is contended that Dr Timney should have measured and recorded his high blood pressure at an early stage and that, had he done so, the claimant would then have embarked on a treatment regime which would probably have prevented the stroke.
Preliminary issues relating to breach of duty and causation now fall for this court to determine.
Background
Prior to the events leading up to his stroke, the claimant's medical history was, for the most part, unremarkable. He was an infrequent visitor to Dr Timney's surgery. However, on 21 March 2003, he attended complaining that he was waking up with headaches which often recurred at teatime. Dr Timney made two records of this visit. One was in a handwritten note in the Lloyd George card format. The other was by way of an entry on a computer. At the time, the practice was graduating from the traditional method of record keeping to the more modern. Dr Timney was in the habit of using both.
The handwritten note relating to this visit records that Dr Timney had taken the claimant's blood pressure which he recorded to be 110/80. This is a reading which falls within the low side of normal.
Dr Timney attributed the claimant's headaches to ergonomic factors. He recommended postural exercises and proscribed Meloxicam, a drug with analgesic properties.
This treatment did not, however, provide a cure. In May 2003, the claimant was complaining of facial pain and "bad heads" to his dentist who referred him to Mr Paterson for a second opinion. Mr Paterson went on to remove the claimant's left lower wisdom tooth under local anaesthetic. He did not take the claimant's blood pressure.
This procedure did not alleviate the problem. Indeed, on 28 October 2003, the claimant went back to Dr Timney and presented him with an array of problems comprising:
i) recurrent anxiety;
ii) headache;
iii) a toe infection;
iv) swelling to the thigh;
v) backache;
vi) blood in the urine (haematuria); and
vii) blood in his ejaculate (haemospermia).
Of these signs and symptoms, Dr Timney was most concerned about the haematuria and haemospermia and referred the claimant to a consultant urologist. He did not, on this occasion, take the claimant's blood pressure.
On 6 November 2003, disaster struck. The claimant was admitted to Workington Infirmary suffering from slurred speech and weakness in his right arm and leg. He was found to have suffered a stroke in the form of a large left frontal intracerebral haemorrhage.
In the aftermath of this catastrophic event, tests revealed a number of potentially relevant features:
i) very high blood pressure;
ii) left ventricular hypertrophy;
iii) a mildly dilated aortic root;
iv) grade II changes to the optic fundi.
The central issues
This litigation has generated a very considerable number of collateral issues upon most of which there has been a substantial amount of dispute between the experts. Whilst it would be wrong to discount these areas of controversy as being wholly immaterial to the task of determining the outcome of this litigation, it remains important not to lose sight of the central issues. They are:
i) was Dr Timney's blood pressure reading of 21 March 2003 taken and recorded with reasonable care?
ii) if not, would a reading taken and recorded with such care have resulted in the initiation of treatment which would have prevented the stroke? 1
These issues are crucial because, whatever other mistakes Dr Timney may or may not have made, the claimant concedes that only the controversial blood pressure reading/recording of 21 March 2003 could have been causatively relevant to the stroke.
The parties' respective cases on the central issue of fault
The claimant's case is that the claimant's blood pressure was probably significantly elevated at the time of his first visit to Dr Timney. The recorded measurement of 110/80 was not correct and if Dr Timney had acted with reasonable care he would have appreciated that the claimant's blood pressure was actually in the region of 180/100 or higher.
The defendants' case is that Dr Timney took and recorded the claimant's blood pressure accurately and with reasonable care.
What could have gone wrong?
Initially, the claimant advanced three distinct theories to explain how Dr Timney may have come to record a falsely low blood pressure. These included (i) a fault in the instrument used to take the reading and (ii) the improper interpretation of the "auscultatory gap". In opening, Mr Braithwaite QC for the claimant all but abandoned these explanations. He was realistic so to do. There was no evidence that there was any likelihood that a fault had arisen in the sphygmomanometer sufficiently serious to give rise to a wildly inaccurate reading and which could otherwise have gone unnoticed. Further, it was conceded by Mr Saltissi, the claimant's expert cardiologist, that, whereas a mistaken interpretation of the auscultatory gap might plausibly give rise to an underestimation of systolic blood pressure and/or an overestimation of diastolic blood pressure, it could not explain an error of underestimation of both at the same time.
This left only one residual explanation consistent with negligence. Dr Timney had measured the claimant's blood pressure correctly at a very high level but had subsequently recorded it inaccurately at a relatively low level.
There can be no doubt that if this is what occurred then it represented a very serious mistake indeed. In particular, if the blood pressure as measured was 180/100 or higher then it would have been a very clear indication of a seriously elevated level upon which a generally competent general practitioner would be expected to act regardless as to whether he had subsequently noted it down accurately. It is inherently unlikely that such a bad mistake would be made. Dr Boyd, the claimant's expert in general practice had only ever once before come across a similar (but not identical) case in which a doctor had actually omitted to take a blood pressure reading but had subsequently recorded a normal reading in the notes. In the present case it is the accuracy and not the genuineness of the entry which is in issue.
One basis upon which the claimant seeks to undermine the reliability of the recorded measurement is with reference to other respects in which it is suggested that Dr Timney's acts and omissions fell short of what could have been expected of a competent practitioner. The greater the extent of his other shortcomings, the easier it is to conceive of him inaccurately recording the blood pressure reading and failing to act on a disturbingly high measurement.
Dr Timney
Dr Timney was criticised on a number of counts. The defendant's expert in general practice conceded that some of these criticisms were valid.
In particular, it was common ground that early morning headaches are a "red flag" symptom with respect to the possibility of raised intracranial pressure and that a general practitioner should always inspect the optical fundi for evidence of damage. Dr Timney did not do this. His explanation was that his surgery was too light in the daytime and that he would ask patients to come back in the evening if such an examination were needed. He said that he did not use drops to dilate the pupils because this could be uncomfortable.
These explanations were inadequate and I am in no doubt that, even making all due allowance for the lighting conditions, Dr Timney should have made sure that he was able to perform the examinations which the complaint of early morning headaches mandated. As it happens, we know from the results of later fundoscopies that even if Dr Timney had carried out an examination it would not have sounded alarm bells so as to have given rise to a causative difference on the facts of this case.
Another area in which Dr Timney was subject to legitimate criticism was in respect of poor record keeping. His notes of the visit of 23 March and other visits were inadequately detailed. In particular, his record of the history of headaches presented to him in March was too concise. Another example of poor record keeping was afforded by a computer entry which purported, on its face, to relate to the claimant but actually referred to an attendance by his father.
In his first witness statement, Dr Timney was dealing, hypothetically, with the course of treatment he would have...
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Health Alert (Australia) - 5 August 2013
...experts personally. United Kingdom Joseph Michael Beech (by his litigation Friend Joanne Mounsey) v Dr A P Timney and Mr A W Paterson [2013] EWHC 2345 (QB) No causative act of negligence by treating doctors regarding patient's brain haemorrhage. LEGISLATION Commonwealth National Health (hig......