Phoebe Charmaine Pickering v Cambridge University Hospitals NHS Foundation Trust
| Jurisdiction | England & Wales |
| Judge | Mr Justice Ritchie |
| Judgment Date | 17 May 2022 |
| Neutral Citation | [2022] EWHC 1171 (QB) |
| Docket Number | QB-2020-000119 |
| Court | Queen's Bench Division |
[2022] EWHC 1171 (QB)
Mr Justice Ritchie
QB-2020-000119
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
Royal Courts of Justice
Strand, London, WC2A 2LL
Catherine Ewins instructed by Ashtons Legal Solicitors for the Claimant
Claire Toogood QC instructed by Kennedys for the Defendant
Hearing dates: 4, 5, 6 and 9 May 2022
This judgment was handed down by the Judge remotely by circulation to the parties' representatives by email and release to The National Archives.
The date and time for hand-down is deemed to be Tuesday, 17 May 2022 at 10:00 am.
The Parties
The Claimant is a patient who attended Addenbrookes Hospital in Cambridge for treatment.
The Defendant runs Addenbrookes Hospital and is responsible for the standards of clinical care provided there.
Bundles
For the trial there were 10 paper bundles of documents together with written skeleton arguments.
The Issue
By the end of the trial there was one issue for the Court to determine. That was and is whether, but for the negligence of the Defendant, the Claimant would have avoided suffering a stroke due to the beneficial effects of Heparin treatment, which the Defendant should have given her starting just before 02:00hrs on 25 September 2015 and continuing until she was provided with therapeutic anti-coagulation using Warfarin or alternative modern pills.
Terminology
AF: atrial fibrillation.
INR: international normalised ratio.
LA: left atrium.
LAA: left atrial appendage.
TE: thrombo embolism.
TEE: transeosophageal echocardiography.
PE: pulmonary embolism.
SEE: systemic embolic event.
MHV: mechanical heart value.
TIA: transient ischaemic attack.
P value: P over 0.05 is the probability that the null hypothesis is true. The null hypothesis states that there is no relationship between the two variables being studied (one variable does not affect the other). It states the results are due to chance and are not significant. A statistically significant test result is P equal to or less than 0.05.
Confidence Interval: this figure shows the range of results within the sample and hence the level of confidence that we can have that the stated result will be repeated in the whole population. The wider the CI, the wider the likely range of results in the population, the narrower the CI, the narrower the range of results.
The Evidence
I heard evidence from the following witnesses: Dr. Jaffey, Mr. Saab, Dr. Michael, Professor Mehta and Dr. Patel.
An expert report from Dr. Giallombardo was served by the Defendant but he was not called. The Claimant relies on some parts of it.
No lay witnesses were called, however witness statements were provided by the Claimant, her husband and son. In addition witness statements were served by the Defendant from the treating clinicians: Dr. Roderick MacKenzie and Dr. Omar Elsaka. Neither of them was called.
The Medical history
In September 2015 the Claimant was 52 and a half years old. Her relevant medical history (with deletions for privacy) is set out below.
12 09 85 Diagnosis of muscular dystrophy.
12 05 97 Ambulatory electrocardiogram showed atrial fibrillation.
19 01 04 Cardiology clinic letter: “In view of the significantly increased left atrial size, along with Mrs Pickering's history of atrial fibrillation, I do feel that she now needs to be considered for anti-coagulation, if pregnancies in the future are not an issue:”
01 12 04 Cardiology clinic letter: “She and her husband have been concerned about long term anti-coagulation and also about the need for beta blockade. I spent some time explaining to them that both were advisable long term, the Warfarin to reduce the risk of stroke, and the beta blocker to protect her ventricles from rapid rates. But she is unhappy about taking anything more than just aspirin and since the decision is not urgent I thought the sensible plan was continuing follow up … If there is any evidence of deterioration such as increasing left atrial size then the case for anti-coagulation would be strengthened.”
19 01 05 Cardiology clinic letter: “The other more pressing issue is regarding anti-coagulation with Warfarin. Again Mrs Pickering has been averse to this although her echocardiogram did show that the longitudinal dimension of her left atrium was significantly increased. I do agree with her that … are more pressing at present but she is aware that in the long term anti-coagulation would be strongly suggested in view of her increased left atrial size and the increased risk of a cerebral vascular event. I have also spoken to her that if we did start anti-coagulation, then we would need to be aware should she wish a further pregnancy. She is not taking any form of contraception at present”.
10 08 05 Cardiology clinic letter: “Echocardiogram demonstrated overall reasonable left ventricular function and the left ventricle was undilated. In keeping with her atrial fibrillation her left atrium was dilated at 4.9cm. A mild eccentric jet of mitral regurgitation was noted but otherwise she had no significant valvular lesions.”
10 10 05 Cardiology clinic letter: “She is well and is asymptomatic from her atrial fibrillation. … She remains on aspirin 75mg od. … At present she is not keen for Warfarinisation and although she has a mildly dilated left atrium she has no other indicators to start formal anti-coagulation.”
24 01 07 Cardiology clinic letter: “Atrial fibrillation; moderate mitral regurgitation; muscular dystrophy. … she remains well with no real symptoms. In particular there is no shortness of breath, chest pain, dizzy spells or collapses. … It may be ultimately she will need a pacemaker. I have today recommended anti-coagulation for thromboembolic prophylaxis. She however was rather resistant to this idea and therefore we have agreed that we will re-review this at the next clinic …”
01 02 07 Cardiology clinic letter: “She takes just aspirin and is reluctant to take Warfarin.”
02 04 07 Cardiology clinic letter: “She feels unlimited as regards shortness of breath or chest pain and takes aspirin 75mg only. … I have discussed with Mrs Pickering her heart rate and the trends that this is in fact slowing and she may come to require permanent pacemaker insertion. As you are aware, her uncle who also suffered from myopathic problems, did suffer pacemaker problems, but in spite of this Mrs Pickering made it entirely clear that this is something she would consider if it was felt necessary. She is very keen to be closely monitored and she mentioned that she did not wish to take any risks whatsoever and would accept any advice regarding treatment.”
19 07 07 Cardiology clinic letter: “Although she does suffer from muscular dystrophy … she is fully mobile with a full and normal lifestyle. … is awaiting pacemaker implantation. Overall LV function is reasonable although she does have a degree of pulmonary hypertension. … she has been found this year to be significantly hypertensive …”
29 09 07 Cardiology clinic letter: pacemaker implanted.
01 09 09 Cardiology clinic letter: “ The question is the indication … for Warfarin. Her echocardiogram at Papworth on 8 October of last year showed that the left atrial size was 4.5 and with normal heart function otherwise. A further echocardiogram on 29 June would seem to indicate that not much has changed at this point. She does have two leads in the ventricle and has a single chamber two lead pacemaker. My view has generally been that she could remain off Warfarin for the moment. She remains under 60 years of age with normal heart function and I don't think the [muscular dystrophy] Lamin mutation would cause me to be more pro-active in terms of initiating Warfarin in place of aspirin”.
11 01 10 Cardiology clinic letter: “… we do have a very low threshold in these patients with Lamin A/C mutation for considering in particular ICD devices [implantable cardioverter defibrillator] in view of the risk of ventricular arrhythmias. Mrs Pickering … at present is being kept under close surveillance. … She is fully aware that should she develop symptoms in the interim period that she should seek urgent medical attention.”
06 08 12 Cardiology to neurology referral: “ … over the years she has in fact been difficult to persuade regarding investigation and treatment for example with a permanent pacemaker for atrial fibrillation with block which was put in in September 2007. She has not been keen in the past to be on anti-coagulation with Warfarin for her underlying atrial fibrillation and currently continues on aspirin. … it has only been recently that she has appeared keen for further involvement [re the muscular dystrophy].”
15 07 13 Cardiology clinic letter: “ … she is asymptomatic from the cardiac point of view and in particular denies any breathlessness, palpitations or syncope. … her other medication includes … aspirin although she comments that she takes her aspirin erratically. … 12 lead ECG showed paced rhythm with underlying atrial fibrillation. I have discussed with Mrs Pickering again the issue regarding Warfarinisation in view of her atrial fibrillation but this is still something that she does not feel she wishes to pursue at present. She did ask regarding the new oral anti-coagulant agent but again mentioned that she did not wish to commence at present but would consider this at a later date. I have mentioned to her regarding taking her aspirin on a regular basis.”
17 02 14 Cardiology clinic letter: “Recent episode of shortness of breath when boarding plane. … but she has no ongoing symptoms. I will arrange update of her echocardiogram which in August last year showed satisfactory left ventricular function with ejection fracture of 60–65%. Right...
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