Tuffin v University Hospitals Coventry and Warwickshire NHS Trust [2024] EWHC 3318 (KB) (20 December 2024)

Clinical negligence cases are often complex – the application of uncertain legal principles to detailed medical facts. 

In this case, breach of duty was not in dispute; the issue before the court was causation.

It is trite to say negligence is breach of duty causing injury – the task before the court here was to determine: what was the injury? or more specifically, did the negligence cause the amputation? 

The negligent omission took place where C had existent medical conditions. Moreover, there were two post operative complications: post thrombotic syndrome (negligent) and CRPS (non-negligent). These are distinct aetiologies with different pathologies; they are generally clinically distinct.

There is recognition by the courts that the law on causation is not clear: it can be uncertain and unpredictable. Causation is an issue of fact but determined according to legal rules. There are various legal tests: “but for” and “material contribution”. The legal argument on causations often turns on which test to apply to the particular facts.  

C alleged “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”. D’s case was that the need for amputation was the result of her developing complex regional pain syndrome (“CRPS”).

C submitted: “the contemporaneous medical evidence is “somewhat difficult to disentangle” ie as to whether the cause of the amputation is the DVT or CRPS”. C relied on the doctrine of material contribution.

Here the court was able to “disentangle” the evidence: D was liable to C for the DVT and post thrombotic syndrome but not for the CRPS and not for her left above knee amputation.

For a critical review on the doctrine of material contribution, please see the Causation chapter by Anthony Barton in “Clinical Negligence” (Bloomsbury; sixth edition, 2023) edited by Michael Powers KC and Anthony Barton.