Medical causation – decision of the Administrative Court

A recent decision from the Administrative Court considers the use of medical statistics in inquests and the position with medical causation being left to a jury. Medical causation is often extremely convoluted and the law regarding legal causation of medical injuries can be complex. Karla Drabble looks at the case of R (Chidlow) -v- Senior Coroner for Blackpool and Flyde [2019] EWHC 581 (Admin) to see what impact this will have on future inquests. 

The facts

On the evening of 27 July 2009, Mr Bibby was seen on the floor of his flat by police. A call was made to NWAS at 23:54 requesting an ambulance, which was graded as amber. At 00:03 on 28 July 2009, the police forcibly entered Mr Bibby’s flat and found him lay on his back with a grey complexion and laboured breathing. At 00:10, the police made a second call to the ambulance service noting that Mr Bibby was now fitting. By 00:30, Mr Bibby’s breathing remained laboured, he was pushing back and limb restraints were used. Mr Bibby made a last gasp and stopped breathing. At 00:36, police made another call to NWAS and the response was upgraded and a rapid response vehicle was dispatched. The police explained that the patient wasn’t breathing and the case was escalated to a purple code, which signifies a patient in cardiac arrest. This required an eight minute vehicle response. The first ambulance arrived on scene at 00:46. On arrival, Mr Bibby was found to be asystolic (no electrical activity in the heart), his pupils were fixed and he was not breathing. Further resuscitation attempts were unsuccessful and Mr Bibby was pronounced dead at the scene at 00:47. NWAS admitted that there was a delay in an ambulance attending the scene.

What did the court determine?

There is a distinction between being able to identify what someone died from and being able to say whether, regardless of what precisely caused their death, their life could have been saved with earlier medical attention. Failure to discern this difference led the Senior Coroner in this case to err in law when he withdrew from the jury the question of whether an admitted delay in an ambulance attending contributed to the deceased’s death. The coroner had wrongly concluded that, as there was no clear cause of death, it was unsafe to allow a jury to consider the causal effect of the delay in him receiving treatment.

When considering whether it is safe to leave such an issue to the jury, a coroner must have regard to all relevant evidence. In addition, such evidence in relation to a particular deceased and the circumstances of their death may include general statistical evidence drawn from population data such as the rate of survival of a particular group. However, such general statistical data alone is unlikely to be sufficient.

In most cases, there will be other evidence as to whether the deceased probably would or would not have fallen in to the group of likely survivors. As per Paragraph 52 concludes:

‘In deciding whether to leave an issue of causation to a jury, a coroner should consider both limbs of the Galbraith Plus test. Causation should be left where there is evidence upon which the jury could properly and safely find that, on the balance of probabilities, the event or omission had more than minimally, negligibly or trivially contributed to death. That is the crucial test.’

There will therefore need to be something more than merely medical statistics that suggest the deceased would probably have been in the category of survivors; even where survivors are a majority category.

At the inquest, evidence was heard from a medical expert (consultant in critical care and emergency medicine and medical director of advanced life support training) who explained that both doctors and paramedics deal with patients all of the time where they don’t actually know the diagnosis. The Administrative Court considered the jury were not bound to accept this expert’s opinion, but his view was not so obviously unreliable that it was not safe to leave the issue of causation to the jury. Establishing the medical cause of death would plainly have assisted but was not, as the expert explained, essential to being able to form an opinion as to the effect of delayed treatment.

Impact

The impact of this case is to reiterate the ‘Galbraith Plus’ test. Causation, and other matters, must be left to the jury where there is sufficient evidence to do so and where a conclusion on such a matter would be safe. By itself, mere general statistical evidence is unlikely to be sufficient, however if accompanied by other evidence may safely be left to the jury to consider.

Read the full judgment of R (Chidlow) -v- Senior Coroner for Blackpool and Flyde [2019] EWHC 581 (Admin) 12 March 2019.