Sanderson v Guy’s and St Thomas’ NHS Foundation Trust – the role of NICE Guidelines in clinical negligence cases

Sanderson v Guy’s and St Thomas’ NHS Foundation Trust [2020] EWHC 20 (QB)

This is a useful case with regards to the application of NICE Guidelines, determining that the Guidelines do not provide a substitute for clinical judgment but must be interpreted by the clinician and then applied in light of that judgment. The Guidelines considered in this case, relating to the use of electronic fetal monitoring, were contradictory and therefore did not provide a complete compendium of either definitions or clinical management options. The clinician’s actions were therefore found to be both reasonable and a logical application of the Guidelines.

Facts

A claim was brought by Beverly Sanderson as Litigation Friend on behalf of her niece Ashley Paige Sanderson. The Claimant suffered from moderately severe cerebral palsy caused by a short period of acute brain hypoxia in the minutes before her delivery in February 2002.

The issues before the Court related to the allegation that the Claimant’s CTG trace demonstrated a prolonged deceleration between 00.38 hours and 00.43 hours which continued over three contractions and in the circumstances, the only reasonable management was immediate and urgent instrumental delivery of the Claimant. It is alleged that the consultant obstetrician was negligent in deciding to perform a fetal blood sample rather than proceeding straight to urgent delivery.

Furthermore, it is alleged that there was a further delay in undertaking instrumental delivery following a period of bradycardia. It is alleged that but for the negligence, the Claimant would have been delivered earlier and the period of hypoxia would have been avoided or shortened.

Mrs Justice Lambert noted that:

The Claimant’s case that, at 00.43 hours urgent delivery was the only reasonable management option, rests on a highly selective interpretation of the NICE Guidelines. This theory relied upon the statement in the Guidelines that a prolonged deceleration of greater than three minutes is “clear evidence of acute fetal compromise” and the stated guidance that, where there is evidence of such acute fetal compromise, fetal blood sampling should not be performed and instead the baby should be delivered urgently.

There were arguments between the parties as to whether the trace complex between 00.38 hours and 00.43 hours did in fact indicate a single prolonged deceleration. However, even if this finding was accepted, Mrs Justice Lambert noted that the Claimant’s interpretation of the Guidelines in these circumstances, overlooked the somewhat contradictory guidance concerning the appropriate obstetric management in the presence of this trace feature. The preceding section of the Guidelines relates to management where the CTG trace is pathological, in which case, conservative measures are advised, with express reference to undertaking fetal blood sampling where appropriate or feasible. Only in circumstances where fetal blood sampling is not possible do the Guidelines recommend urgent delivery.

Mrs Justice Lambert concluded that:

• The Guidelines are a practical tool to be used in conjunction with clinical management.
• The only way in which the Guidelines are intelligible and workable is if the reasonable obstetrician also exercises his or her own judgement to assess the appropriate response to the trace as a whole.
• Whilst it is accepted that the trace mandated action, this did not render urgent delivery the only appropriate treatment option, the decision to perform a fetal blood sample to test for acidosis was a reasonable response.
• With regards to the alleged further delay in instrumental delivery following a period of bradycardia, Mrs Justice Lambert concluded that the consultant obstetrician acted as quickly as she could, acknowledging the “practical difficulties of the real world.” The index events occurred on a busy ward with limited staff.

The claim was therefore dismissed in full.

Summary

This case highlights that the NICE Guidelines are not intended to provide a practitioner with the complete description of the appropriate management and must be interpreted in conjunction with clinical judgment in light of the whole clinical picture. Ultimately, Bolam will be the relevant test applied. The treatment will not be negligent if supported by a reasonable body of practitioners, even if there is a body of opinion and as in this case, conflicting NICE Guidelines, offering a contrary view.