Neutral Citation Number: [2007] EWHC 2881 (QB)
Case No: HQ05X0777
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION

Royal Courts of Justice
Strand, London, WC2A 2LL

Date: 06/12/2007

Before :

MRS JUSTICE DOBBS
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Between :

	Rosalind Colwill	Claimant	
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	Oxford Radcliffe Hospitals Nhs                             Trust	Defendant	

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James Badenoch QC (instructed by Field Fisher Waterhouse) for the Claimant
John Grace QC (instructed by Beachcrofts of Winchester) for the Defendant

Hearing dates: 23rd – 25th July 2007 
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Judgment

Mrs Justice Dobbs : 
Introduction
1.	This claim arises out of an infection contracted by the Claimant after her admission to the Infectious Diseases Unit of the Defendant’s Churchill Hospital in Oxford on 21st September 2002.   The septic thrombophlebitis which developed on her arm, caused by staphylococcus aureus, arose at the site where an intravenous cannula had been inserted, namely, in the right ante-cubital fossa (ACF)(the crook of her forearm).  Despite the administration of antibiotics, the infection did not come under control. Miss Colwill developed staphylococcal septicaemia and pneumonia complicated by Acute Respiratory Distress Syndrome (ARDS).  This has left her hemiplegic, almost blind and with severe cognitive impairment.  The issue for the court is one of liability.
Background
2.	Miss Colwill, the Claimant in this case, is employed by the Methodist Church as a Spiritual Director in Nigeria.  She flew to the UK in September 2002 to attend her niece’s wedding in Oxford.  On Saturday 21st September, she awoke with a fever.  She nevertheless decided to go to the wedding.  She had previously suffered from malaria, although blood tests in Nigeria had failed to identify which strain.  She asked her nephew, who is a doctor, if he could arrange a blood test at the local hospital.
3.	The nephew, Dr Patrick Feeny, formed the view that, as his aunt had been having intermittent problems with malaria for about two months, the safe course of action was to have her admitted to hospital to establish the cause of her illness.  He did not feel that his aunt was in imminent danger, but he wanted to get a diagnosis.  He rang the Registrar for Infectious Diseases and arranged for his aunt to be admitted to the Churchill hospital. 
4.	Miss Colwill was admitted at about 6pm that evening.  She was examined at 9.30pm by the SHO, Dr Ready.  Miss Colwill was complaining of fever, rigors, malaise and headache [B1/2].   She indicated that her condition felt like bad malaria.  She explained that she had a history of recurrent malaria for which she had self-medicated with Malarone and other anti-malarial medication. 
5.	On examination, Miss Colwill’s temperature was 38ºC.   No other abnormal signs were detected.  The differential diagnoses were: malaria (unlikely); typhoid/yellow fever; hepatitis or viral illness [B1/5].   An intravenous cannula was inserted into Miss Colwill’s right ante-cubical fossa.  
6.	On the following day, the 22nd of September, Miss Colwill was seen by Dr Ready who noted: “feels awful – constant fever” [B1/6].   The temperature was 38.2C. Further blood tests were sent for analysis.  Later that morning Miss Colwill was reviewed by the Registrar, Dr Williams.  He noted that the patient appeared “reasonably well, although sweating”.  Her temperature was 38.5ºC [B1/8].   Tests for malaria were negative and chest x-ray was normal.  At midday, Professor Warrell reviewed the patient. Malaria remained a possible diagnosis, but the anti-malarial drugs were stopped in order to assist diagnosis [B1/10-2].  The nursing notes recorded that the patient was drinking well [B2/109].
7.	On Monday 23rd September, Miss Colwill was seen by Dr Northfield, a registrar, who found her to be “well in self”.   After a trouble-free night, Miss Colwill was seen on the morning of 24th September by Professor Warrell.   There was no fever.  The patient was better [B1/12].   Sometime that morning, the cannula was removed by Nurse Matthie [A2/110.2; 110.4].   By 6.30pm, the nursing notes show that the patient was complaining of pain in her right arm at the IV site.  On the morning of 25th September, she was still complaining of pain at the site and appeared unwell.  At 7am on the 26th September, Miss Colwill was complaining of excruciating pain in the arm. She was pyrexial.   Antibiotics were prescribed. 
8.	It is not necessary to document the history of the patient after this date, save by way of very brief summary.  Despite the administration of antibiotics, Miss Colwill’s condition worsened.  Her sister, Mrs Feeny, had complained on 28th September to the nurse and then to the SHO on call about the standard of nursing care.  She wanted a review of her sister’s condition and wanted to speak to Dr Northfield, but she was told that he was at home [B1/18-9].   Mrs Feeny visited on 1st October and found her sister to be suffering from severe respiratory distress.   On 2nd October 2002, the Claimant was transferred to the Intensive Care Unit.  As identified in paragraph 1 above, serious consequences flowed from the complications arising from the infection.
The agreed issues
9.	There is agreement between the experts and parties on a number of important matters namely, that:
i)	the infection was caused by the presence of the in-dwelling intravenous cannula inserted on the Claimant’s first day in hospital, without placement of which all of the Claimant’s above injuries would have been avoided;
ii) 	the longer a cannula is left in situ, the greater the risk of infection;
iii) 	on the balance of probabilities, the failure to remove the cannula on the 22nd or 23rd September, did lead to cellulitis, progressing to staphylococcal bacteraemia and pneumonia;  
iv)	if antibiotic therapy had been started on the 25th September, the infection would have been checked, its progression prevented, and the Claimant’s injuries would have been avoided. 
10.	Subject to any gloss which may become apparent during the discussion of the experts’ evidence, in general terms it is agreed that:
i)	phlebitis is a common consequence of cannulation, wherever the cannula is sited;
ii)	it is unusual for phlebitis to progress to localised infection, and even more unusual for it to progress to systemic infection or septicaemia;
iii)	phlebitis can persist for 24 to 48 hours, and can cause fever, without evidence of infection;
iv)	similarly, it is unusual for thrombo-phlebitis to progress to infection;
v)	infection can occur in the absence of phlebitis or thrombo-phlebitis;
vi)	any infection is normally controlled and eliminated by antibiotics;
vii)	phlebitis must be distinguished from infection;
viii)	if infection is excluded, antibiotics should not be given;
ix)	in the absence of positive blood cultures, the only means of diagnosing or excluding infection is by clinical examination;
x)	antibiotics should not be given merely because the patient has a fever.
The issues for the court
11.	There are a number of issues on which the court has to come to a decision. They are as follows:
  (1)	Insertion of the cannula
Was insertion of a cannula on the 21st September, on the evidence, a necessary part of the Claimant’s care?   Was it negligent?
  (2)	Location of the cannula
What was the balance of risk to, versus the benefit to the Claimant of the placement of a cannula in her ACF, as compared to any alternative placement? Was insertion in the ACF negligent?
  (3)	Removal of the cannula
Was it negligent not to remove the cannula before 24th September 2002?
  (4)	The system
(i)	Was the system of documentation adequate?
(ii)	Did the operation of the system fall below a proper standard?
  (5)	Starting antibiotics
Was it negligent of Dr Northfield not to recognise the infection on 25th September and thereby to fail to start a course of antibiotics? 
Preliminary observations.
12.	Before considering the individual headings, there are two issues to be dealt with.  The first concerns the question of disclosure.  A few days before the start of the trial, lawyers for the Defence, following enquiry by solicitors for the Claimant, disclosed the statement of Dr Ready.  This statement had been made for a hospital inquiry some weeks after the Claimant’s admission into hospital.  On the day of, or on the day before trial, the statements of Nurse De la Cruz, Nurse Matthie and Staff Nurse So were disclosed.  During the trial itself, on questioning by the court, it transpired that Dr Northfield had also made a short statement to the hospital.  The statement, having been located in the files of the solicitors for the Defence, was disclosed at that stage.
13.	Mr Badenoch QC, Counsel for the Claimant, accepts that he failed to note the reference in Dr Miller’s report to the statement of Dr Ready until a late stage. However, he has rightly pointed out, that this, and the other statements (to which there was no reference), ought to have been made available during the usual process of disclosure, as they are highly material.   No satisfactory explanation for the failure to disclose has been offered by the Defence, save to say that the Claimant’s lawyers did not ask for them.
14.	Recent enquiries made by the Defendant to locate the authors of the statements have failed.  Earlier disclosure might well have yielded a different outcome.  As a result, counsel for the Claimant has been unable to cross-examine a number of potentially important witnesses about the content of their entries in the medical records, the detail of their statements and other relevant matters, including the procedures adopted in their working practices.
15.	As noted above, Dr Miller refers to the statement of Dr Ready in his report, although he did not list it at the beginning of the report as being material he had read.  In evidence, he accepted that he probably had read the statements of the other members of staff, but had failed to record this fact in his report.  Whilst this is of some concern, more troubling still, is Dr Miller’s failure to disclose his prior relationship with the Defendant’s key witness, Dr Northfield, the latter having worked in the recent past as a Registrar under Dr Miller.  When cross-examined about this, Dr Miller said that he did not consider this fact to be relevant.  He accepted that he was on very friendly terms with Dr Northfield, but did not think that it would compromise his independence.  This approach shows both a lack of judgement and failure to consider adequately the issue of conflict/bias, whether actual or perceived.
16.	This leads me on to the second issue which relates to the experts.  Each side has criticised the other side’s expert.  The criticisms have been noted.  Despite his connections with Dr Northfield, I accept that Dr Miller has not been consciously biased in this case.   On occasions, however, his evidence has given the impression that he was trying to “fight” the defence corner.   He has been prone to speculate about the reasons or justifications for certain actions in the absence of evidence supporting such an approach.   I give some examples:  i) at paragraph 19.3 of his report [A6/172] Dr Miller says that it was not unreasonable to maintain venous access for 72 hours even though it was not being used.  Had Miss Colwill suffered a catastrophic cardiovascular collapse requiring resuscitation, it might have been considered negligent not to have established venous access.  He was forced to accept in cross-examination, however, that on 23rd September there was no evidence pointing the possibility of imminent cardio-vascular collapse.  Moreover, he seemed to give little weight to the policy of the hospital at the time; ii) in paragraph 23.2 of the same report, he justifies leaving the venous access in place, on the basis of standard practice, and on the basis that there was a significant chance that Miss Colwill may have required intravenous fluids or drugs or that further blood samples may be required.  He had to concede in evidence that there was no evidential basis or justification for the use of intravenous fluids or drugs; iii) in questions 1.3 and 1.4(i) of the joint experts’ report [A6/191-2], Dr Miller justifies placement of the cannula in the ACF on the basis that it may well have been that the ACF was the only site where reliable venous access could be obtained.  This is speculation and it ignores the evidence of Dr Ready and Dr Conlon, to the effect that there were no problems with cannulation; iv) in his report and joint expert’s report, he justified Dr Northfield’s decision not to prescribe antibiotics on 25th September, on the basis, that, inter alia, it could have complicated the diagnosis of the illness that precipitated admission.  Both Dr Northfield and Dr Miller were forced to concede in cross-examination that in fact the prescription of antibiotics would not have masked the various differential diagnoses made in relation to the admitting illness; v) despite the odd circumstances of the wrongly-dated note in the margin made by Dr Northfield, and the discrepancies between Dr Northfield’s clinical note, his statement to the hospital and his witness statement, Dr Miller is at great pains to point out how carefully Dr Northfield had considered the issue of infection; vi) in paragraph 20.1 of his report, Dr  Miller indicates that antibiotics would not be used until Grade 4 or 5 of the Tagalakis grading scale of clinical criteria regarding intravenous sites has been reached [A6/172].   The context of this statement gives the impression that this fact emanates from the Tagalakis publication.  At question 4 of the Defence Joint Experts’ report, the experts were asked if they agreed that antibiotics would not be administered until the signs and symptoms reached grade 4 or 5.  One would have expected the answer to be “yes” from Dr Miller given what was written in his report.  However the joint answer indicates that the decision to start antibiotics is a clinical one and that the grading system only forms part of the clinical decision making.  The answer goes on to indicate that the Tagalakis paper does not give specific advice on when to start antibiotics.  Dr Miller’s statement in his report is at best confusing and at worst misleading.   
17.	There has been criticism by the defence that Professor Geddes is no longer in current daily practice and that he has not been so since 1999.   It is submitted that his views on practice in 2002 should be regarded with caution.   He is also criticised for being partisan, for misreading the nursing notes, and for using the benefit of hindsight in relation to some of his opinions.  It is true that Professor Geddes was not in full time practice in 2002, but, as he pointed out in evidence, since 2002 he has been a non-executive member of a NHS Trust, he has been on several sub-committees related to patient safety and he has chaired the clinical governance sub-committee, besides being the editor of the monograph on hospital infection published in 2000.   He was one of the foremost experts in his field.   Both Dr Miller and Dr Conlon worked under him. Professor Geddes accepted that he had misread an entry in the nursing notes and he accepted on one occasion that his opinion was with the benefit of hindsight.   He made one or two errors in his reports, as did Dr Miller.  He also accepted that a couple of points about the medical records had only struck him during the trial. Dr Miller also failed to address these new issues in his report.   Overall, I found Professor Geddes to be a clear and persuasive witness.  Where the two experts disagreed, save, for where I have indicated in the body of the judgement, I preferred the evidence of Professor Geddes to that of Dr Miller 
(1) Insertion of the cannula.
  a) 	Summary of the evidence
18.	In his evidence, Dr Feeny said that when he took his aunt to the hospital, she was complaining of aches and pains, but alert and orientated and well in herself.   The only cause of concern was that she had a fever with no obvious cause.   She needed to go to hospital because of the type of investigation needed to exclude malaria.   He was not concerned about any imminent danger of collapse.
19.	As indicated in paragraphs 4-6 above, the clinical notes show that on examination Miss Colwill’s temperature was 38ºC, but that no other abnormal signs were detected. It was noted that the patient was “well and comfortable” and was managing good volumes of fluid [B1/3-4].  The differential diagnoses were: malaria (unlikely); typhoid/yellow fever; hepatitis or viral illness [B1/5].  The patient was to be encouraged to drink fluids [B1/5].   Although not documented in the clinical notes, there is reference to an IV cannula being in place in the nursing notes [B2/109].  Additionally there is an entry in the cannula chart, although, as will be seen later, this entry was backdated [B4/102].   A saline prescription was written, with instructions to hold the prescription until the laboratory results were available [B1/5].  Despite this instruction, it appears that a saline drip was administered to the patient between midnight on 21st and 7am on 22nd September [B4/124; B5/134.1].
20.	In an undated statement for the hospital’s internal inquiry, Dr Ready (the SHO who carried out the cannulation) indicated that the patient appeared clinically dehydrated. She therefore placed IV access, but decided to wait for the results of the blood tests before commencing intravenous infusion.  She used the venflon for the removal of blood for tests.  The renal function tests which came back did not indicate dehydration, and the doctor therefore decided to hold off administering IV fluids overnight and to review whether Miss Colwill’s oral intake continued to be adequate [A2/110.1].   However, as has been indicated, the doctor had prescribed a saline drip, and this was given to the Claimant overnight by a nurse.   There was no further use of the cannula from the morning of 22nd September. 
21.	Professor Geddes did not express any adverse conclusions in relation to the insertion of the cannula in his two reports.  In the “Questions for Experts”, posed by the Claimant, he indicated that use of a cannula for the treatment of the Claimant at the time of her admission was “probably not” necessary [para 3.4 @ A9/195].  This answer was given at a time when the statement of Dr Ready had not been disclosed to the Claimant.  In evidence- in- chief, Professor Geddes maintained that from all the information now available, he could see no clinical reason for cannulation.  In his opinion, blood samples could be taken in the normal way; the tests showed no evidence of dehydration or of clinical septicaemia; low blood pressure on its own would not justify cannulation and there was nothing in the Claimant’s history to point to a risk of imminent collapse.   He did concede, however, that it was common practice in Accident and Emergency for the first doctor who sees the patient to insert a venflon for two reasons: because they do not yet know the condition from which the patient is suffering, and because the patient may have to lie on a trolley for several hours until a ward is found.  It is not a practice with which he agrees.  He also conceded in cross- examination that some reasonably competent doctors would have cannulated in the circumstances of this case.  
22.	Dr Miller in his report said as follows: “It is arguable in retrospect that there was no absolute indication for the intravenous cannula to have been inserted and maintained.  However, it is almost universal practice for patients admitted as emergencies through an accident and emergency department to have an intravenous cannula inserted.” [A6/171].  He went on to say: "therefore, although the practice of inserting an intravenous cannula where there is no specific requirement for intravenous fluid may not be regarded as best practice, it is extremely widespread and could not be regarded as negligent.”
23.	In reply to the question posed by the Claimant’s lawyers on this issue (3.4), Dr Miller explained that it was routine practice for IV access to be obtained in any emergency admission for the purpose of obtaining blood samples, for IV administration of drugs or for resuscitating a patient in the event of sudden collapse.  It is common practice to maintain the cannula until the diagnosis is made and the patient is clinically stable, and no longer requiring, nor likely to require, IV therapy or fluids [A9/195-6].  In cross-examination, (in the absence of tests suggesting dehydration), Dr Miller justified the insertion of the cannula on the basis of possible collapse in the light of the fact that the Claimant had just returned from Africa with a high fever, low blood pressure and with a history of heart problems. There was also the possibility of dehydration.
  b)	Submissions
24.	The Claimant submits that there was no clinical need for the insertion of the cannula on 21st September.  The insertion of the cannula flew in the face of the hospital’s own policy (“Policy for the prevention of infection associated with Intravascular Therapy”) which warns that the use of the IV route for the administration of fluids and drugs must be regarded as an invasive procedure and, as such, carries inherent risks [A8/184].  The Defendant submits that there was justification for the insertion of the cannula.  Professor Geddes did not address this issue in his report and this, it is submitted, undermines his evidence that such insertion was unnecessary.   Insertion of the cannula is defended by Dr Miller. 
  (c)	Discussion and decision
25.	Looking at the evidence with the benefit of hindsight, it would appear that the Claimant was not dehydrated.  Although there is no indication in the detailed clinical notes written by Dr Ready that the Claimant, on examination, appeared clinically dehydrated, Dr Ready wrote two prescriptions for a saline drip which would tend to support her assertion that she had formed an impression of dehydration at the time.    Dr Ready was either unaware, or has forgotten, that one prescription was acted upon by the nurses.  It is apparent that the second prescription was not acted upon.  This would be consistent with the doctor reviewing the test results later on and communicating that IVI was not necessary.  There is an entry in the nursing notes dated and timed 22nd September 7.30am “IV cannula in situ for further care” [B2/109].  This entry would have been written by the nurse who administered the saline drip.  The nurse clearly thought that the cannula was in situ for a purpose.  However, it would seem that there was a failure in communication, either by the doctor failing to tell the nursing staff that IVI was not required at all, or a failure by the nursing staff to heed or understand the SHO’s instructions. 
26.	Although the tests show that the Claimant was not dehydrated, it would not be right in my judgement, to characterise the decision to insert the cannula as negligent.  The doctor made a judgement at the time that the patient was clinically dehydrated.  As Dr Conlon said in evidence, it is possible to be clinically dehydrated but not bio-chemically dehydrated.  Evidence of Dr Ready’s state of mind at the time is supported by the independent evidence of the saline prescription.  It is true that Dr Ready did decide to defer administration of the prescription until after the results of the blood tests had come through, but she did then use the cannula to take blood for the many blood tests which were to be performed, (cannulation being simpler when many blood samples are needed).   It would have been preferable for the doctor to have waited to see if IVI was actually necessary, but it would be inappropriate, with the benefit of hindsight, to suggest that the doctor’s reasons for cannulating at the time were unsustainable.  In reaching this decision, I bear in mind that,  although Professor Geddes now says that there was probably no need for cannulation at all, no criticism was made by him of the cannulation in his two reports, despite the fact that he was aware of the Claimant’s allegation that cannulation should not have been carried out.   I also take into account his concession in cross-examination that some reasonably competent doctors would have cannulated.   It follows, therefore, that I do not find that the decision to cannulate was negligent.
  (2) 	Location of cannula
 	  a)   Summary of the evidence
27.	The hospital’s policy in force in 2002 reflected the current learning and practice, and included the following [A8/184]:
“1.3 The presence of an invasive cannula breaches one of the body’s natural defence mechanisms, the skin, creating an access point for micro-organisms and the potential for infection”
2.1 The use of intravascular devices can be complicated by a variety of local or systemic infectious complications, including phlebitis, septicaemia and metastatic infection…”
28.	As for siting of the cannula, the hospital policy says: 
“Insertion: Careful selection of the best insertion site can minimise the risk of infection. For peripheral cannulae the ideal vein to access is on the distal part of the arm…” [A8/185]”; and 
“5. Insertion site and precautions at insertion:
5.1 Selecting the best insertion site for the patient can minimise the risk of infection. Several factors should be assessed when determining the site of cannula placement, including…the relative risks of mechanical complications e.g. … the risk of infection. 
5.2 Peripheral cannulae insertion:
The ideal vein to access should be situated on the distal part of the patient’s arm but away from previous attempts. Sites near joints should be avoided to reduce the likelihood of mechanical phlebitis.”
29.	The experts agree that “cannulae sited over joints irritate veins and cause thrombophlebitis as a result of movement at the joint"; and that, save where there is good reason for it, such siting should be avoided.   This is because avoidance is “in the best interests of the patient’s safety” as “it reduces the risk of thrombophlebitis” [Joint report, answers 1.1, and 1.2, (i), (ii), (iii) & (iii) - A9/191]. 
30.	Infection from cannulation is made more likely where there is vein irritation leading to inflammation (mechanical phlebitis) leading to clot formation (thrombophlebitis). Dr Miller in his answer 1 at Joint Report II [A2/208] explains that for these specific reasons:
(a) 	cannulation in the ACF “has never been regarded as best practice”; and 
(b) 	the veins in the forearm or back of the hand are “the preferred site” unless they are difficult to access, or the patient may later need dialysis.
31.	“Thrombophlebitis predisposes to bacterial invasion” (Professor Geddes’ report para 6.2 [A3/124]).  With regards to the increased likelihood of infection in the ACF, there is disagreement between the experts (see question 6 in Joint Report II [A9/209]).  Professor Geddes says that placement in the ACF "made infection more probable".  Dr Miller is of the view that “the infection could have occurred wherever the cannula was sited.”   In evidence, Dr Miller said that there is no empirical evidence available to suggest an increased risk of infection.  This was conceded by Professor Geddes in cross-examination.
32.	Professor Geddes, in evidence, said that there was no justification for cannulation in the ACF at all.  There was no impairment of the patient’s cardio-vascular system such as might cause the pressure in the veins to be low, thus making them not readily accessible in the back of the hand or forearm.
33.	Dr Miller, on the other hand, suggested that there may have been problems which justified use of the larger vein.  If, for instance, there were cardio-vascular failure, then it could be difficult to locate the veins and get access.  It is to be noted that the Claimant was subsequently cannulated twice in the back of her hand, which Professor Geddes also relies on for his opinion that cannulation in the ACF was inappropriate [B2/112].   Dr Miller disagrees that this conclusion necessarily follows. 
            b)	Submissions
34.	The Claimant submits that placement of the cannula in the antecubital fossa (ACF) was negligent because there was no medical need for such placement.  Dr Ready had recently transferred from the renal unit where such placements were commonplace (see Dr Conlon @ para 4 [A2/95]).  She no doubt carried on this practice, giving no thought to the need for it in this particular case.   The Defendant draws attention to the fact that this allegation made its first appearance in the Re-Amended Particulars of Claim.  Whilst it is accepted that placement in the ACF may have contravened hospital policy, it is argued that this was not negligent in the “Bolam” sense. Professor Geddes nowhere in his reports condemns this action as a matter of general medical practice, but merely points to the fact that it was contrary to hospital policy. Placement in the ACF did not of itself lead to the infection, which could have happened wherever the cannula was placed.   The ACF is used frequently, due to ease of access to larger veins.  There is insufficient evidence that no reasonably competent doctor would have used it in the circumstances, especially given the evidence in this case, of reduced blood pressure. 
  c) 	Discussion and decision.
35.	It is not apparent whether Dr Ready was aware of the hospital policy.  It can be inferred that she was not.  Her statement reveals that there was no problem cannulating.  Dr Conlon’s conversation with Dr Ready reveals that the SHO was clear that cannulation was easy and did not involve multiple attempts [Eii@A2/106].
36.	It is clear from the evidence of Dr Northfield that he was not aware of the hospital policy document.  In his statement he said: [para 6, A2/62] that: “the cannula had been placed in the crook of the patient's right arm, which is a standard entry point for cannulae”.   In cross-examination he modified his approach and indicated that it was a standard entry point for certain groups of patients.  He acknowledged that he had not been aware of the existence of the hospital policy document. 
37.	Cannulation in the ACF, as the experts agree, is uncomfortable for the patient.  It is likely to result in repeated movement of the cannula within the vein, which in turn makes irritation and phlebitis/thrombophlebitis more likely.  However, the experts disagree as to the increased likelihood of infection.
38.	The cannula was obviously uncomfortable in this case.  The cannula was bent and it broke off on removal, leaving a small piece in the arm.  There is no medical indication from the records to justify the use of the ACF.  There is no basis for Dr Miller speculating that cannulation in the normal sites may have been difficult – the statement of Dr Ready undermines that suggestion.  The fact of low blood pressure also does not assist, as Dr Ready makes no notes or observations to this effect to justify the use of the ACF. 
39.	Whilst instinctively one would expect cannulation in the ACF to carry a higher risk of infection because of the potential for irritating the vein, there is in fact no empirical evidence that this is the case.   Dr Miller has indicated as much, and Professor Geddes accepted this fact, although maintaining his opinion, that siting of the cannula in the ACF does carry an increased risk of infection.   There is nothing in the hospital policy to suggest that this is the case.  Were there to be medical learning on the issue, then one would have expected it to be in the policy, in order to emphasise the risk.  I am not satisfied, therefore, on the balance of probabilities that the site itself was the, or a material cause of the infection arising. 
40.	This was, in my judgement, a case of a junior doctor who was unschooled in the hospital policy, carrying out a practice to which she had become accustomed on another ward, without any consideration of the discomfort to the patient.  It is interesting to note that Dr Miller, having acknowledged that this has occurred in his hospital on many occasions, was forced to admit that he was “not proud” of this practice.  Professor Geddes also acknowledged that it was a common, but unacceptable practice of junior doctors. The fact that many junior doctors automatically choose the site does not make this practice acceptable.  The fact that the site offers easy access for doctors is not of itself a justification for such use.   There is no evidence of any medical reason for the insertion of the cannula in the ACF.   The policy is clear and the evidence of the experts is clear, namely, absent any justification, it is not appropriate to place the cannula in the ACF.  However, whilst placement in the ACF clearly caused discomfort to the patient and was undesirable, on the balance of probabilities, for the reasons set out above, whilst I find that it was poor practice, I do not find that it was negligent to place the cannula in the ACF.

(3) 	Removal of the cannula
a)	Summary of the evidence
41.	No contemporaneous record was made of the removal of the cannula.  There is evidence from Fiona Mathie, one of the nurses, that she removed it either on the night of 23rd or morning of 24th as it had been in for 72 hours and the patient was complaining of “awkwardness” [A2/110.2-3].   Dr Northfield, recalling that the cannula was removed on 24th September, but not having been aware of  it previously, said “On this day Miss Colwill reported discomfort from the IV cannula, and I asked one of the nursing staff to remove this, given that it was no longer being used” [para 7 A2/63]. In his statement for the hospital review, his recollection was different “On Tuesday (24th) I questioned her about cannulas (given her ongoing fevers) and she said it was painful. I asked a staff nurse to remove it” [A2/66A].   In evidence-in-chief, he said that on 24th, after the ward round, someone told him that Miss Colwill had a cannula in place which was uncomfortable and he directed that it be removed.   In cross-examination he said that he was not aware of the cannula insertion form, nor would he have looked for one.   It did not surprise him that Dr Ready had made no entry about cannulation in the medical notes.  
42.	The Claimant, who retains some pre-coma memory, says in her statement @ paras 12, 13 and 15 [A2/44-5] that there was “real and significant pain” in her arm, of which she complained on many occasions to the nursing staff, whom she felt “were not paying me much attention”, and that she was “always told that there was nothing wrong”.  
43.	By 7.00 am on the 22nd September, when the saline infusion was completed, it was not needed and never used again thereafter for any purpose [Joint experts’ report answers 3.2 (a) to (c) and 3.3 (a) to (f) @ [A9/195].   The hospital policy states that: “any intravascular device must be removed as soon as it is no longer required, and earlier if considered to be a source of infection” [A8/185].   The experts agree with the policy [Joint answer 4.1 @ A9/196].  The policy continues @ 8.1 that: “the catheter must be observed regularly (at least daily) and every time it is used for signs of infection, inflammation or phlebitis.   Any intravascular device MUST be removed as soon as it is no longer required because the infection rate is related to the duration of the placement”.  There is no record of any daily monitoring of the cannula, the device only first coming to the attention of Nurse Matthie on the 23rd September, when Miss Colwill drew the nurse’s attention to it [A2/110.2].
44.	Dr Northfield indicated in his statement to the hospital, in his statement prepared for this case, and, in evidence, that he was unaware of the existence of the cannula prior to 24th September.  Had he been so aware he would have taken it out on 23rd September when he first treated the patient.   In his statement for the hospital review, he stated that he would have been surprised if the patient had a cannula, as she was looking “very well” [A2/66a]. 
45.	In their joint report [A9/205], the experts agreed that “the cannula should have been removed when it was no longer required”.   However it is agreed that it was common (but not best) practice in 2002 to leave a cannula in situ for longer than it was required.  It is agreed that in the UK literature, it is recommended that cannulae should be removed within 48 to 72 hours of insertion.
46.	As to the effect of the cannula remaining in until 24th September, Dr Miller, in his report @ para 24.4 [A6/177] states that: “not removing the cannula on the 22 or 23 September on the balance of probabilities did lead to the subsequent consequences of cellulitis progressing to staphylococcal bacteraemia and pneumonia”.   He sought to amend this response, but eventually in cross-examination agreed that removal on 23rd would, on the balance of probabilities, have prevented the infection from taking hold and would have prevented the consequent complications suffered by the Claimant.
47.	Professor Geddes also sought to clarify his written opinion in court, but in the end expressed a similar view to that of Dr Miller: that removal of the cannula on 23rd September, would, on the balance of probabilities, have prevented the infection from taking hold. 
b)	Submissions
48.	The Claimant submits that it was negligent not to remove the cannula before 24th September 2002, this date now being the agreed date when the cannula was removed.  It was last used in the early morning of 22nd September.  There was no clinical indication for its continued use or presence.  The Defendant submits that the cannula was removed within the 72 hours accepted in the hospital policy.  Professor Geddes appeared to accept that the cannula could remain for 48 hours from 21st September.  This would not necessarily result in removal before the morning of 24th September since the 48 hours would expire in the night of 23rd September.  There is no evidence of any adverse signs in relation to the cannula on 22nd or 23rd. 
c) 	Discussion and decision
49.	Despite Dr Miller [A6/172] indicating that it was not unreasonable to leave the cannula in place after 22nd September, in case of sudden collapse and to afford access to blood for tests, he conceded in cross-examination that there was no suggestion that the patient was in imminent danger of cardio-vascular collapse on 23rd September.  There was therefore no continuing need for the cannula to be in place after that date and according to hospital policy, it should have been removed.   Who was negligent? In the circumstances of this case, it is difficult to point to a positive decision to leave the cannula in situ, or to a failure by a particular individual to consider whether the continuing presence of the cannula was necessary.  That is because no doctor other than Dr Ready was aware of the existence of the cannula.  Dr Ready, no longer had care of the patient after the initial examination, although she did see the patient to enquire how she was [A2/110.1].   Dr Northfield was not aware of the cannula until 24th September.  Nurse Matthie, who removed the cannula, was not aware of it until 23rd September, although there was a note of it in the nursing records on the 22nd.   There was no note of the date of the insertion of the cannula until Nurse Matthie backdated the records on 23rd September [A2/110.2].   It is difficult therefore to attribute responsibility to any one particular person or group of persons.  The failure, it would appear, lies in the record-keeping and in the apparent lack of communication.  This will be considered under the following heading. 
  (4) 	The system
a) 	Summary of the evidence
50.	The hospital’s own policy reads: “Documentation. The date of insertion of an intravascular device must be recorded in the patient’s notes” [A8/185].  Dr Ready made no record in the clinical notes of the cannulation.  The hospital had a form (cannula chart) which was to be filled in by the relevant doctor to record the fact and timing of cannulation [B2/102].  This form was not filled in by Dr Ready on the 21st September.  It was filled in on 23rd September by Nurse Matthie and backdated to 21st, based on the information given to her by the patient.  The form was kept in the nursing notes which the doctors did not read, and would not be expected to read.
51.	The fact that a cannula was in situ was recorded in the nursing notes of 22nd September at 7.30am by a nurse from whom there is no statement [B2/109].   In Dr Northfield’s statement he says: "During this examination it is likely that I had no knowledge that she had a cannula in place, so I had no need to inspect it.  The cannula had been placed in the crook of the patient's right arm, which is a standard entry point for cannulae.   It is likely that the cannula was covered with the patient’s nightgown during my examination.   The patient made no reference to the cannula site herself, such as a complaint of pain, otherwise I would have recorded this in the notes” [A2/62].   Dr Northfield admitted in evidence-in-chief that he was not aware of the special form which records cannulation and thus would not have looked for it in the nursing notes.  Although it was important that he knew about the cannula, he did not expect there to be a record of removal.  He himself did not make a note of removal on 24th September nor did Nurse Matthie.  In cross-examination, Dr Northfield said that it did not surprise him particularly that Dr Ready had made no note of the IV insertion, as some doctors did whilst others did not. 
52.	In his report for the hospital trust, Dr Conlon acknowledged the failures of record- keeping.  He said: (a) “it is clear that the documentation relating to the time of cannulation and the subsequent care of the indwelling catheter was below the standard expected with best practice.  A better system for documenting the insertion and removal of cannulae has been adopted by the ward…” [Para Bi, A2/109];   (b)"Following this unfortunate and serious incident it is recognised that better systems for documenting and assessing intravenous cannula placement needed to be introduced and now have been." [Summary A2/109].   In evidence, he explained that he would not have expected the fact of insertion of the cannula to be shown in the clinical notes, but to be shown on the form kept in the nursing notes.  Additionally, he would expect the nurse to discuss the fact with the doctors.  He explained that the system has changed and stickers are now put in the drugs chart, with the date and time of cannulation, so that the doctor can see it when looking at the drugs chart. 
53.	Professor Geddes said that he would have expected Dr Ready to note the insertion of the cannula in the medical notes as an absolute requirement.  He would have expected it to be in the plan.  Given the high number of doctors who attended on the patient, it was important that the system allowed for an alert to the doctors of the presence of a cannula.  He would also expect to be informed by the ward sister or nurses about its presence.
54.	Dr Miller in the Joint Report answer 16 [A9/211], took a different view. In his opinion it was "reasonable practice in 2002 not to record when a cannula is removed in the patient's medical records".   In the Joint Report answer 6c, he said that it was not common to record the event in the medical notes [A9/198].
   b) 	Submissions
55.	The Claimant submits that “reasonable standards of care require there to be in place, enforced and complied with, a reliable system for communicating to successive medical attendants the fact and timing of cannulation”.  There was a failure in this regard, which it is submitted is “outwith reasonable standards of care”.  It was causative of the problem which developed, because, but for the failure, the cannula would have been removed on 23rd, which would have averted harm.  The Defendant submits that this new allegation takes the case no further.  It is accepted that a hospital may be held to be negligent for a “system failure”, but such cases are a long way from this one.  There is no evidence, the Defendant submits, that the system in place in 2002 fell below the standard reasonably to be expected of the hospital at the time. 
   c) 	Discussion and decision.
56.	There can be no doubt that, had there been awareness on the part of the doctor, before 24th September, of the existence of a cannula which was not being used, it would have been removed.  Had it been removed on 23rd September, it is agreed that the ensuing complications would have been avoided.  There was a system in place.  It should have worked, either by the doctor making a note on the prescribed form, and/or the nurses informing the doctors of the existence of the cannula.  It is odd that the fact that the form had not been completed was not picked up until 23rd September, given that Miss Colwill herself states that she was regularly complaining about the cannula [A2/44] and, according to Dr Conlon’s discussions with the nursing staff, Miss Colwill was complaining initially of awkwardness [Aii, A2/109].   This does not seem to have been drawn to the attention of any doctor until Miss Colwill was complaining of pain. This is consistent with Miss Colwill’s assertion that she felt that the nurses were not paying her much attention  and saying there was nothing wrong when she complained and were “poo-pooing the symptoms and the pain in her arm” [A2/44].
57.	Dr Northfield was unaware of the existence of the cannula chart.  One has to assume that Dr Ready was also unaware of the chart, given that she did not fill it in.  It would appear that neither Dr Northfield nor Dr Ready was aware of the hospital policy document, a copy of which, according to Dr Conlon, was available on the ward.   If Dr Ready had been aware of the policy, then no doubt she would have given thought to the siting of the cannula in the ACF.   If it had been sited in the usual place for that type of cannula, it would have been noticed by the doctors.
58.	The unknown nurse who administered the saline drip made a note of the existence of the cannula in the nursing notes on 22nd September (7.30 am).   However, it was not until some time on the following day, that a different nurse became aware of the cannula, not from the nursing notes, but because the patient told her.   It is not clear whether the nurses would have relied on the chart or on the nursing notes for the information.  There is no evidence about what was meant to happen on hand-over between shifts.  It is also not clear whether the lack of knowledge on the part of the doctors about the cannula chart and the policy on cannulation was due to lack of diligence on their part in reading any documentation issued by the hospital, or a failure of the hospital to draw the documents and policy to the attention of the medical staff.   This lack of evidence, is largely due to the fact that this was an issue which was raised late in the day, and because of the late disclosure by the Defendant, none of the nurses was available to give evidence.
59.	What is not in doubt is that there was a failure in communication somewhere along the way.   There was a system in place which should have worked.  On this occasion, it did not.  It has now been improved.  As before, it is difficult, due to the lack of evidence, to pinpoint the problem - whether it was negligence on the part of the staff, in that they knew or ought to have known about the form, or whether it was negligence on the part of the hospital in not drawing the attention of the doctors to the policy and the form.  There is no evidence to suggest which is the more likely reason.
  (5)	Starting antibiotics.
  a)     Summary of evidence of events with observations of the experts interspersed.
60.	On Monday 23rd September, Dr Northfield found Miss Colwill to be “well in self”. Fever, myalgia and nausea was present [B1/11].  Malaria screening was negative. Fluid intake was encouraged and by the late afternoon/evening the patient was feeling “much brighter”.   Her temperature was going down and she  “had visitors most of the afternoon” [B2/109].  In Professor Geddes’ opinion, the impression is of a self-limiting viral infection now resolving, a probability reinforced by the entries at 06.00, 13.15 and 14.30 on 24th September, which show that the fever and nausea had gone and that Miss Colwill had slept well overnight, with no problems recorded [B2/109-110].   She was seen on the morning of 24th September by Professor Warrell.  There was no fever and the patient was better [B1/12].   The laboratory results to date were “uninformative”.   Ultrasound scan of the abdomen was normal.  Some time that morning, the cannula was removed by Nurse Matthie [A2/110.2; 110.4]. 
61.	By 6.30pm on 24th September, the nursing notes show that the patient was complaining of pain in her right arm at the IV site.   No redness or swelling was noted by Rowena De La Cruz, but she did note a small scab where the venflon had been inserted.   She advised the patient not to touch and remove the scab as it could cause infection [A2/110.4].   The site was cleaned with saline.   A hot compress was applied and painkillers were administered [B2/110].   The nurse then asked Staff Nurse Michael So to check the site.   Staff Nurse So recalls that the patient was complaining that there was a tiny bit of venflon remaining in the arm.  On examination, the site was a bit red with a small black scab.  He instructed that the matter be reported immediately to the SHO or a doctor [A2/110.6].    Professor Geddes points to the fact that pain was a new development, which occurred after removal of the “uncomfortable” cannula from the arm.   By early evening the Claimant had developed a recurrence of fever more than 24 hours after removal of the cannula [B3/120].   The experts agree that "the infection in the cannula site, and the staphylococcal septicaemia, had started by 24th September" [Joint Report, summary point (iii) A9/205]. 
62.	On the morning of 25th September, Miss Colwill was complaining of pain of the right arm at the IV site.  It appeared to be swelling.  The patient seemed unwell, and was weak, with a poor appetite [B2/110].   Her temperature was recorded at 37.9ºC.   At 16.00 hours the nursing records indicate that the nurse liaised with Dr Ready due to the concern about the pain in the arm.  It is recorded that Dr Ready was to see the patient at some time.   It appears, however, that Dr Ready did not examine the patient.   In evidence, Dr Northfield was uncertain about whether Dr Ready had spoken to him about the problem. 
63.	At some stage during that morning, it appears that Miss Colwill managed to work a small piece of venflon out of her arm [A2/44-5].  A wrongly-dated note (26th September) deals with Dr Northfield’s examination of the afternoon 25th September [B1/13-4].   The notes show that Miss Colwill was suffering from fever and nausea and complaining of pain from right venflon.  She had a temperature of 38ºC.  His recorded impression was “malaria less likely/?TB/Brucella/acute HIV”.  He set out a number of tests to be done in relation to various possible viruses, including an echocardiogram which was arranged for five days later [B2/111]. 
64.	In a margin to the notes, Dr Northfield recorded that the venflon site was painful but that there was no collection/cellulitis/pus and the elbow was not irritable.  The nursing notes record at 4pm that the patient was still complaining of pain in the right arm.   A warm compress was applied [B2/110]. 
65.	It would appear that either at the time of the examination or shortly after it, the Claimant told Dr Northfield “…that a piece of the cannula appeared to have been broken off and had recently extruded itself from the arm.   I thought this would explain the continuing phlebitis as a retained piece of plastic from the cannula would have continued to irritate the vein, and also indicated that the cannula may have led to a degree of local trauma” [statement A2/63].   The experts agree “that a bent cannula is likely to add additional risk of causing irritation of the vein and so of producing mechanical phlebitis” [Joint Meeting Report answer 2(ii)(c), A9/193].   The experts also agree [Joint Report question 7.2 [A9/200]] that in the light of this elicited history of a retained foreign body and Dr Northfield’s  thinking on the 25th September about its effects, that (a) “There should have been present to his mind an extremely high index of concern about the risk and/or the fact of SA infection”; (b) “That the risk of incipient infection by Staphylococcus aureus was in the light of his said concerns a real and present one”; and (c) "That the danger to the claimant if such an infection was present and was allowed to progress and check might be very great indeed…”
66.	In his statement, Dr Northfield comments as follows: “complaint of pain on the 24th September (and subsequently on the 25th) was probably the first sign of inflammation at the cannula site”.   However, phlebitis or inflammation of the vein cannulated is common and is caused by mechanical irritation of the vein by the cannula.   It is often not connected with definite infection.” [para 16 [A2/64]].  In his evidence, he said that the results became more consistent with infection, but that there was no early warning that he could have acted upon.   In his opinion there was no sign of infection.   In cross-examination, he said that the increase in temperature was consistent with the fluctuating fever Miss Colwill presented with.   The pain might have been from the removal of the cannula triggering phlebitis. 
67.	Professor Geddes points to the fact that, throughout that day, the pain in the arm was constant and persisting, despite the administration of pain-killers.   It had been painful for 24 hours [A3/135 para 9.6].   It was associated with swelling, fever and illness.   Increasing and accumulating features of infection were now present and recorded, as were obvious concerns of nurses.   Nothing was administered except pain-killers [B3/133/137] and “cool water”.   On that day, the 25th September, yet further evidence pointing to possible or actual infection emerged.  The Claimant’s white blood cell count, (the cells which are called up to fight infection), rose –a marker of bodily response to infection. (Geddes para 8.4 [A3/128]).  Having been continuously raised at 10 am and 2pm, [B3/120], Miss Colwill’s temperature had gone up further to 39 degrees by 6.30pm, despite the aspirin etc. tending to reduce it.   This was, in his opinion, a pointer to acute infection [A3/135 para 9.6]. 
68.	Dr Miller takes the view that Dr Northfield carried out a comprehensive examination. He was clearly alive to the risk of infection, but found no evidence to justify the use of antibiotics at that stage.   In his response to question 7d of the Joint Report, he stated: “ It is common for cannula sites to be a bit inflamed due to mechanical irritation, and such inflammation often  settles after the removal of the cannula"  [A9/200]. 
69.	At 7am on the 26th September, Miss Colwill was complaining of excruciating pain. She was pyrexial.  There was some limited movement on flexion.  The nurse was advised to try Voltarol [B2/110].    Dr Feeny and Mrs Feeny noticed that Miss Colwill had developed a very significant drip site infection with gross swelling and erythema from her right shoulder to wrist, with pus oozing from the ACF drip site. 
70.	Dr Northfield note for 26th September records: “Fever remains. Obvious spreading cellulitis r. forearm. V. painful. Feels tense. St restriction of hand flexion.  Review by hand surgeon”.  He ordered the anti-biotic Vancomycin to be administered.  An ultrasound of the right forearm noted “marked soft tissue oedema surrounding the right ACF puncture site” [B1/15].   Blood cultures taken on 25th September, showed a staphylococcal species of bacteria.  A swab from the IV line site taken on 26th September showed a growth of staphylococcus aureus, as did the blood cultures taken on that day [B1/18].
71.	Professor Geddes takes the view that the severity of the true condition on the 25th is supported and confirmed by the findings on the 26th.   Dr Miller says that nothing can be read into the findings the following day. 
b) 	Submissions. 
72.	The Claimant submits that, given the history and the presenting signs, on 25th September there was evidence of infection, such that antibiotics should have been started on that day.  The failure by Dr Northfield to prescribe antibiotics was negligent.  The real question is: “Did Dr Northfield on the 25th September give properly and adequately careful consideration to the possibility of infection?  The case for the Claimant is that, on a proper view of the evidence, he did not for the following reasons: 
i)	Signs of infection are pain, swelling and redness (which may extend to become cellulitis and erythema), malaise, persisting high fever, and low blood pressure.  On 25th September there were features of infection present which are features of phlebitis alone. 
ii)    The evidence shows that the blood pressure fell to a low level on that day; that       the temperature had gone up to 38°C, staying there for an appreciable period, and then spiking to 39°C, neither being features of  phlebitis.  The statement of Staff Nurse So shows that there was “redness” on the 24th.   The nurses’ notes record the appearance of swelling for the first time on the 25th.  The swelling was accompanied by the persistence of pain, sufficient to cause the nurses to liaise with the doctor about it, even though they themselves had access to a variety of strong painkilling drugs.   Add to this, the Claimant’s obvious malaise.   All of these factors were new developments.  The patient was clearly getting worse, not better, since the removal of the device.
iii) 	It is quite clear that Dr Northfield was focussing on the admitting illness and not on the cannula site, as his note was directed to a variety of differential diagnoses.  Infection from the cannula is not mentioned in the notes.  The assertion that there was a possibility of endocarditis is unsustainable. 
iv) 	The appearance of the wrongly-dated notes shows that they were clearly not      contemporaneous. 
v) 	The evidence of the relatives. 
73.	The Defendant submits that, following a careful clinical examination, Dr Northfield, a truthful and conscientious doctor, made a clinical judgement which was appropriate at the time.  There was insufficient evidence of infection; to prescribe antibiotics “blind” might mask and complicate the patient’s illness which was, as yet, undiagnosed.  It is common for cannula sites to be inflamed due to phlebitis (mechanical irritation) and such inflammation is likely to subside after removal of the cannula.  As soon as there was visible evidence of infection, Dr Northfield immediately prescribed antibiotics.  There was no negligence.
74.	The Defence makes the following specific points:
i) 	the return of a raised temperature and nausea, and “feeling unwell” were consistent with the previous course of the then-unknown illness for which Miss Colwill had been admitted.   Hindsight may show otherwise, but that is not the point.   Fevers are frequently diphasic or multiphasic;

ii)	the significance of a reduced blood pressure only occurred to Professor Geddes halfway through the trial.  There is no reason why it should have occurred to Dr Northfield at the time;

iii)	reliance on the duration of complaints of pain does not assist.  Although the Claimant had first complained of pain at 18.30 on 24/9, Professor Geddes accepted that with a history of the additional trauma of self-removal of a piece of cannula, pain the next day would not be surprising.  In any event, the evidence of pain is neutral: it is common ground that pain from phlebitis can last for 24 to 48 hours;

iv)	there is no evidence that the pain increased between 24th and 25th September. Miss Colwill slept well over that night [see B2/110, 0630], and the drug charts show that she required and was given no extra analgesia on 25th.   The suggestion that the nurses were very concerned about the pain on 25th is without any foundation.

v)	As to the appearance of the arm on 25th, the signs were consistent with phlebitis.    Dr Northfield excluded cellulitis.  Deterioration was not until the morning of 26/9, and therefore a review later on 25/9 would not have provided any new information. An inference cannot be drawn from the appearance of the Claimant’s arm on 26th.    The court should prefer the objective evidence of Dr Northfield to that of the relatives, as their view is bound to be coloured by their relationship.  If the relatives were correct, it is inconceivable that the radiologist Dr Pretorius would have written the note that he did [B1/15].
c) 	Discussion and decision. 
75.	As Counsel for the Defendant rightly points out, this heading is the core allegation in the case.  The parties are agreed that this issue is not a Bolam/Bolitho situation.  The decision depends essentially on questions of fact and on the assessment of the evidence of Dr Northfield.  I therefore turn to deal with his evidence.
76.	Whilst every allowance has been made for the obvious stress that Dr Northfield was suffering when giving his evidence, his clinical judgment and credibility being exposed to close scrutiny and criticism, I regret to say that, overall, I found him to be an unsatisfactory witness.   The following examples are illustrative of this assessment:  
i)	He often gave answers before the full question had been asked, so much so that Counsel for the Claimant had to remind him to wait till the end of the question. He frequently did not listen properly to the question being asked in cross-examination, and gave an answer to a different question.  A prominent example is the line of questioning relating to his statement made to the hospital regarding the insertion of the cannula and questions around the events of 23rd September.
ii)	He was ready to defend the actions of Dr Ready without proper thought.  In his evidence-in-chief he indicated that it was reasonable for Dr Ready to have used the cannula.  In cross-examination, when confronted with the statement he had made to the hospital, in which he indicated that he was surprised to see a cannula in place given how well the patient seemed, his first response was to say that he wanted that part of the statement struck from the record, as it was a “recoil emotional response” to the sequence of events as they unfolded.   He did not think the sentence was true.  Cross-examined further, he conceded that the sentence did in fact reflect the truth.   He also accepted that the cannula should have been taken out.  He also suggested, as did Dr Miller, that the cannula could have been inserted into the ACF because the patient was dehydrated and hypertensive, and that the veins might have been difficult to spot.  This suggestion was in the absence of any objective evidence.
iii)	He contradicted himself in evidence:  a) see (ii) above; b) in evidence-in-chief,  he referred to the patient complaining that the site was “uncomfortable”; in cross-examination he referred to being told that the patient had complained that it was “painful”.   He accepted that he had no explanation for the disparity.  A similar disparity is reflected in the witness statement and the statement to the hospital [A2/63; A2/66a].
 iv)	He made previous inconsistent statements: a) he gave different accounts in his witness statement and in his statement to the hospital about the circumstances of the removal of the cannula on 24th September [A2/63; A2/66a]; b) his description to the hospital of his findings on 25th September differed from his clinical notes of the findings [A1/13; A2/66a].
 v)	His evidence is contradicted by other evidence.   Each of his accounts as to how the cannula came to be removed on 24th September conflicts with the account given by Nurse Matthie to the hospital.
  vi)	He sought to justify his actions with little or no evidential foundation: a) in evidence-in-chief, Dr Northfield indicated that the prescribing of antibiotics might have masked the “important” diagnoses which could have led to complications.  In cross-examination, he conceded that antibiotics would not in fact have masked them; b) in evidence-in-chief, part of his justification for not prescribing antibiotics on 25th September was that the white cell count did not support any relevant diagnosis.  In cross-examination he conceded that he probably did not have the results of the white cell count at the time he conducted the examination of the patient as they would have come back later.
vii)	Given that he claims to write his notes chronologically, he had no credible explanation for a) why the notes on 25th September were written in the margin; b) why he found it necessary to underline the word “not” when he was not in the habit of emphasising negative findings; c) why he made no note of redness and swelling/puffiness which he now says he found on 25th; and d) why, if his diagnosis was that Miss Colwill was suffering from phlebitis and not an infection, this is not recorded in the notes.
viii)	He has been careless in his note-making and in his statement: a) at paragraph 6 of his witness statement, he refers to his findings on the 23rd September showing a systolic murmur.  He made no such finding until 25th September [A2/62]; b) he had no satisfactory explanation of why there was no note made about the circumstances of the removal of the cannula; and c) the wrong date of 26th of September entered instead of 25th and not noticed, even though on the following day he entered the correct date.  He seemed unconcerned about the error, indicating that “it is very common for people to write down the wrong date in medical notes”.
ix)	He was very defensive about criticism.
77.	All the above and other examples give the impression of a practitioner who is less than careful and attentive.   In addition to the fact that I have found Dr Northfield to be a generally unsatisfactory witness, I do not accept his evidence that he gave careful consideration to the issue of infection on 25th September, for the following reasons in particular:
i)	there is no reason for the notes to have been written in the margin following examination, given Dr Northfield’s usual method of making notes.  He has no satisfactory answer for having done so.
ii)	the detail of the negative findings, together with the underlining of the word “not,” is also at odds with the doctor’s usual way of indicating negative findings. 
iii)	Dr Northfield’s statement to the hospital, made some weeks after the event, referred to the site being “painful and oedematous but not red or fluctuant” [A2/66a].   In his evidence, he said that there was some swelling or puffiness and a small amount of redness at the site.  This is not reflected in the clinical notes, in the statement to the hospital, or in the witness statement made for these proceedings.  Indeed, if that is what he saw, it makes the entry in the margin of the clinical notes all the more strange.  One would expect an entry setting out the findings and indicating that there was no infection.   Instead the note in the margin is a list of all the signs one would expect to see if there was an infection, but expressed in the negative.  
iv)	The concentration of the entry of 25th September on the admitting illness.  When one looks at the various differential diagnoses, it is clear from the notes that Dr Northfield’s whole focus was on trying to identify the admitting illness, instead of considering the possibility of infection.  Had he really applied his mind to the question of infection, one would have expected to see a short note in the main body of the entry indicating that no infection was present, or that the findings were consistent with phlebitis, which he claims was his diagnosis.
v)	His reliance on the possibility of endocarditis, as justification for his decision not to use antibiotics is unsustainable on the evidence.
vi)	He has sought to play down the swelling in the arm on 26th September.  It was clearly swollen enough at the time of his and the nurse’s examination to cause restriction of flexion and to cause him to think that a hand surgeon was needed [B1/14; b2/110].   In evidence Dr Northfield said that it would only take a low level of concern to trigger a request for the hand surgeon to examine the patient. However, I prefer the evidence of the two members of the family on this aspect.   I do not accept that they have exaggerated, for three main reasons – first, because both of them were in the medical profession themselves and readily appreciating the stresses faced by a busy doctor, would not lightly criticise another professional; second, it is quite clear that Dr Feeny’s reason for complaining to the hospital about the treatment of the Claimant was not connected with a case for damages, but arose from his concern about the hospital practice, and his wish to draw matters to their attention, in order that their practices could be changed as a matter of urgency [A2/59], third, Mrs Feeny complained about the hospital’s treatment of the Claimant before the real complications arose [B1/18].
vii)	The Defence has suggested that Dr Praetorius’ note would not have read as it did, had the swelling been more extensive.  It would be speculation on the Court’s part to draw any inferences from the evidence of the scan.  The scan was not carried out for some hours after Dr Feeny had first seen his aunt, after antibiotics, painkillers and anti-inflammatories had been administered, and after Dr Feeny had elevated his aunt’s arm.  The Defendant has been aware of this assertion for some years, since the time Dr Feeny wrote his letter of complaint to the hospital, in which he described the condition of the Claimant’s arm on that day.  Despite this the Defence has not, however, called Dr Praetorius to deal with the issue.  
viii)	The evidence of the Claimant that the medical staff played down her complaints is corroborated to a certain extent by Dr Northfield himself, when he said in evidence words to the effect that “ I have never known a cannula to break, so we inferred that there might be a scab which she mistook for a piece of cannula… I did not think it important to have a note of the broken cannula”.    When dealing with the removal of the cannula and with the complaint of pain/discomfort on 24th September,  Dr Northfield said: “To be frank it was thought to be non-contributory to the evaluation as it is common for the site to be uncomfortable”.  Having dismissed the Claimant’s assertion about the piece of venflon and the complaint of pain, he was unlikely to be considering the issue of infection as seriously as he should have done, merely assuming, without analysis, that any pain complained of was probably phlebitis.  The effect of Dr Northfield’s evidence is that the incidence of infection from line insertion was not high, and that phlebitis was the usual manifestation of cannula insertion.  This is contrary to the evidence both of Dr Miller and Dr Conlon and to the information contained in the hospital policy to the effect, that the majority of infections of this kind at that hospital were associated with an IV site. 
78.	There is no dispute, that if Dr Northfield did not properly address his mind to the question of infection on the 25th September, then he was negligent in having failed to do so.   I do find that he was negligent.   I accept the evidence of Professor Geddes that there were signs pointing to the presence of an infection on that day.   Had Dr Northfield properly addressed his mind to the presence of infection, he should have prescribed antibiotics on that day.   As has already been noted, the experts agree, that had antibiotics been prescribed on that day, on the balance of probabilities, the complications would not have arisen.
79.	It follows from the foregoing that the court finds for the Claimant so far as liability is concerned.   Accordingly, judgment is for the Claimant.

1.