The Case
The case involved a claim of clinical negligence brought by the administrators of the estate of a woman who died from a stroke in January 2018 ("the patient"). The central issue relating to breach of duty was whether the doctors treating the patient, Dr Chu and Dr Mehta, ought to have prescribed antihypertensive drugs to control her high blood pressure. The central issue on causation was whether the fatal stoke would have been avoided had these drugs been prescribed.
Dr Chua
Due to high blood pressure readings during pregnancy, the patient had been prescribed labetalol, an antihypertensive drug. After the child’s birth, she revisited the doctor’s surgery where see was seen by Dr Chua on 6 September 2017, and Dr Mehta on 18 October 2017. Both doctors chose to await the results of an ambulatory blood pressure monitoring (‘ABPM’) before prescribing further medication.
In giving evidence at the trial, Dr Chua accepted that he had made two mistakes in treating the patient: he did not check her blood pressure history, which would have revealed six previous occasions of high blood pressure over the previous 5 years, and he did not realise that the normal blood pressure reading taken at the surgery on 28 April 2017 was on the day after she had been prescribed labetalol, which could have caused the normal reading.
Dr Lieberman, the expert witness for the claimant, expressed the view that, without these errors, Dr Chua would have prescribed the patient antihypertensives to be taken at the conclusion of her course of labetalol, without waiting for the results of the ABPM.
The NICE guidance
The NICE guideline CG127 “Hypertension in adults: diagnosis and management”, which applied at the time, divides hypertension into three categories:
“Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.”
The guidance provides:
“1.2.3 If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
1.2.4 If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension.
1.2.5 If the person has severe hypertension, consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.”
While NICE guidance is not intended to be entirely prescriptive, it should be taken “fully into account”, and cases where practitioners are liable to be found negligent despite following guidance are likely to depend on the specific circumstances.
As none of the patient’s historical blood pressure readings fell within the category of severe hypertension, the judge found that offering ABPM would have, at first blush, been appropriate even if Dr Chua had taken into account the additional information.
The evidence of Dr Lieberman
In his report of October 2022, Dr Lieberman did not reference the NICE guideline in his analysis of Dr Chua’s decision to proceed with ABPM, simply concluding that there was “no logic” in doing so. He also criticised Dr Mehta’s decision not to prescribe antihypertensive medication when the blood pressure reading was 150/105 noting that “[a]t this point, treatment was necessary in line with the NICE guidance on hypertension”. He did not explain how the wording of the NICE guidance mandated the abandonment of the ABPM route, when the reading fell short of the threshold for immediate intervention.
Dr Lieberman contended that the elevated blood pressure readings available to Dr Chua were sufficient to mandate him to depart from the guideline. However, under cross-examination, he conceded that he had made a mistake in his report in exonerating Dr Wadeson. Dr Lieberman accepted that Dr Wadeson, who had examined the patient earlier and had had access to the same number of historical readings as Dr Chua, had also been in breach of duty in not immediately prescribing hypertensive medication.
Dr Lieberman further conceded during cross-examination that, if Dr Chua had acted correctly, Dr Metha could not be criticised for continuing with this treatment plan.
The judge’s view
The judge noted that “[t]he combination of Dr Lieberman’s failure in his report to analyse the position of Dr Chua with any reference to the NICE guideline and his belated attempt in the witness box to salvage his conclusions by casting blame upon Dr Wadeson, whom he had earlier expressly exonerated, fatally undermined the plausibility of his conclusions. In my view, he had failed from the outset to take into adequate account the NICE recommendations as a result of which his subsequent analysis became incoherent.”
Learning points
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Experts should ensure that they fully understand any NICE guidance that applies to the case and have all the relevant facts required to apply the guidance correctly.
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Experts should correctly apply the NICE guidance to the facts of the case, ensuring that they are consistent in the application of the guidance.
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While NICE Guidance is not intended to be entirely prescriptive, where the practitioner has followed NICE guidance, demonstrating negligence will depend on explaining how the specific circumstances of the case required a departure from guidance.