Abstract
Facts
SSC had a complicated and poor obstetric history. Her first pregnancy in 2001 culminated at 25 weeks with severe early onset fulminating pre-eclampsia. The baby was delivered by emergency Caesarean section but sadly did not survive. The incision into the uterus put SSC in the high-risk category of suffering a ruptured uterus in any further pregnancy.
Her second pregnancy, in May 2002, was complicated by a uterine rupture at 33 weeks despite very careful monitoring; this baby survived and is healthy. At the operation, there was a 5 cm tear along the line of the previous uterine incision. SSC was advised that any further pregnancies would be at great risk of a uterine rupture, which could result in a hysterectomy if any haemorrhage was uncontrollable.
With her third pregnancy in early 2003, SSC was appropriately referred for consultant care at the Nottingham City Hospital due to the very high risk of uterine rupture, which could happen at any point in the pregnancy. The care plan devised included admission from 32 weeks gestation for rest and observation and to expedite delivery at the slightest hint of labour. The pregnancy progressed reasonably well up to 29+5 weeks, when SSC experienced abdominal pain and was admitted to the City Hospital on 4 December 2003 at 21:20. Her consultant was on holiday at the time of her admission and despite the very clear plan recorded in her notes it was not followed. At this point she was examined by a registrar and the suspicion was that she had a uterine rupture. The fetal heart was recorded as normal. Appropriate blood samples were taken in preparation for a Caesarean section. Review by a senior registrar was undertaken at 22:00 and again a high suspicion of uterine rupture was noted. The decision was made to keep matters under review. At 22:35 the on-call consultant was requested to attend and he performed an ultrasound scan which showed some ‘ballooning’ of the uterus at the utero-cervical junction and upon seeing this, he made the decision to perform a Caesarean section. However, before any arrangements were made, at 22:55 SSC was vomiting and the pain increased significantly. She distinctly heard a noise, a ‘pop’ and then remembers that the midwife had difficulty in locating the baby's heartbeat. The Consultant performed an ultrasound which confirmed that the fetal heart rate was brachycardic and a crash Caesarean was undertaken.
Delivery occurred at 23:33 with the baby found in the amniotic sac with the abdominal cavity with the placenta already separated from the uterus due to its anterior position. Baby LSC was in an exceptionally poor condition at birth and did not survive the resuscitation attempts and died very shortly after being born, being certified dead at 01:00 on 5 December 2003.
Allegations
The Claimant's allegations were that the medical staff were negligent in that they failed to recognize the urgency of the situation upon her admission and to proceed to an emergency Caesarean section long before they actually did so. The registrar had made the correct diagnosis by about 21:40 and had recognized that it would be necessary to perform a Caesarean section but it did not happen. The actual decision to perform a Caesarean section was not made until approximately 23:35 and even so, the first Claimant was not rushed to theatre until the fetus was found to be brachycardic at 23:00, by which stage she was transferred to theatre within 2–3 minutes. The Claimant's case was that delivery should have been at least one hour sooner than the actual time of delivery. The Claimant's case is that the rupture of the uterus probably occurred between 22:55–23:00 when the first Claimant was noted to be vomiting. It was the Claimant's case that had a reasonable standard of care been offered, delivery would have occurred before the uterine rupture. If delivery had been at any time before the rupture then LSC would almost certainly have survived in an undamaged condition despite his prematurity.
The first Claimant was fully aware of her risk of uterine rupture and it was no surprise to her when the registrar told her a Caesarean section would be necessary. The first Claimant was anxious to proceed to delivery by Caesarean section. The first Claimant was owed a duty of care due to the doctor–patient relationship which existed between her and the Defendant. The second Claimant was the husband of the first Claimant and the father of the unborn child. He was present throughout. He was a secondary victim in the event of any negligence covering the treatment of his wife and the delivery of his unborn child, and the Defendants owed him a duty of care accordingly.
It was alleged by the Claimants that the Defendants failure to proceed to a Caesarean section earlier caused the death of LSC. Furthermore the first and second Claimants both developed a pathological grief reaction which had become a depressive disorder.
Evidence
Supportive evidence was obtained from a consultant in fetal maternal medicine. This highlighted that there was clear evidence that SSC was showing signs of a uterine rupture when she initially presented to Nottingham City Hospital and as such an emergency Caesarean section should have been performed soon after admission and at least an hour before it subsequently occurred.
Psychiatric evidence was obtained by both Parties. The Claimants' expert diagnosed the first and second Claimants as suffering from mixed anxiety and depressive reactions with both still being adversely affected some four years after the index event and highlighted that they would need cognitive behavioural therapy and psychodynamic psychotherapy in order to overcome their injuries.
The Defendants expert agreed with the Claimants' expert's diagnosis however he stated that the Claimants would have difficulty in engaging in therapy.
Proceedings
A Letter of Claim was served on the Defendants on 28 February 2006. A Reasoned Response was received dated 13 June 2006, where the NHSLA on behalf of the Defendants denied liability on the basis that the first Claimant was the author of her own misfortune by insisting on having a scan before consenting to a Caesarean section. This was categorically denied. The Particulars of Claim were served on 10 October 2006 which was followed by a Defence on 6 March 2007, which admitted liability. The case therefore proceeded on a quantum only basis.
The Defendant's initially tried to resolve the claim on the basis of the Claimant's disclosed Condition and Prognosis reports but despite a number of offers and counter offers this was not possible. The Defendants decided to obtain their own expert opinion which was extremely sympathetic to both Claimants and so resulted in a further round of offers and counter offers, eventually compromising in a global settlement at £82,500.
This was a global settlement and therefore there is no breakdown of general and special damages. The Claimants were awarded bereavement damages in the sum of £10,000, general damages in the region of £30,000 each with a sum of £1000 to reflect the infant's pre-death pain and suffering and special damages in the region of £11,250. The special damages claim takes into consideration the equipment/clothing purchased by the Claimants for their child; treatment for their psychiatric disorders together with a loss of earnings claim for the first Claimant.