“Meningitis causes death in a number of ways but most commonly by meningeal inflammation leading to tissue oedema, brain swelling and decreased blood supply to the brain tissue leading to its ultimate death.”
“The experts agree that early raised pressure is not a barrier to survival but that as it advances it becomes a positive feedback cycle best studied in traumatic brain injury in which underperfusion results in ischaemia, swelling, cell death and further raised pressure.”
“Meningitis caused by bacteria is not self-limiting. It is a medical emergency and since one cannot distinguish from the clinical picture alone whether a person presenting with symptoms and signs consistent with meningitis has a bacterial or non-bacterial cause the universally agreed approach is to treat as soon as possible on the basis that the cause is bacterial while trying to make a firm diagnosis through various laboratory tests. Hence all guidelines emphasise that treatment should be started on ‘suspicion’ of meningitis and that it is not necessary to have concrete diagnostic proof of a bacterial cause before starting antibiotics.”
“In the context of meningitis the delay of three hours and 10 minutes to 13.20 is extremely significant. There are a number of publications documenting the issue of delay in antibiotic administration if meningitis is suspected. One of the most relevant is from Køster-Rasmussen (2008, Journal of Infection). This confirms, but more accurately quantitates, data from other publications showing that delay in antibiotic therapy correlates independently to unfavourable outcome. The odds for an unfavourable outcome may increase by up to 30% per hour of treatment delay. In this publication where outcome was determined in 184 cases and adult mortality was 33%, mortality was 10% for a delay in administration of antibiotics by up to 2 hours, but rose to 30% with a delay of 2 – 4 hours. Thus a more than doubling of mortality rate occurred. Although this cannot be extrapolated exactly for individual cases it suggests that the delay experienced by GD may have more than doubled her risk of death”
“It was still potentially treatable even with pneumocephalus.”
“These are global figures but since the ear is a common site for infection that leads to meningitis they would likely apply to this situation.”
“The rate of clinical deterioration of GD was rapid, however, we have no definitive way of knowing the exact time, and whether it was before or during her admission, at which bacteria first invaded her meninges, or the size of the invasive inoculum, or the virulence of the organism however I do not consider that the rate of progression of the illness was truly exceptional for an organism such as Streptococcus pneumonia in which fatality rates of 22% among adults in the Western world are quoted. Appropriate antibiotics given within an hour of admission to hospital would, I believe, on the balance of probabilities, have given GD a reasonable chance of survival.”
“44. The rapidity of her decline relates directly to the delay in giving her antibiotics. Delay in antibiotics is a greater risk in cases of meningitis than is the presence of a higher disease severity. In other words, antibiotic delay has a more profound negative effect on outcome than does the degree of severity of the presentation. I would emphasise again that we have no evidence to suggest that this particular organism was in itself particularly virulent; it may or may not have been, but whether it was is not germane to the argument. Whatever the level of virulence of an organism, it does not influence how susceptible it is to antibiotics. Antibiotics given at an appropriate time … as soon as possible in the case of meningitis … are more important than the completely speculative level of virulence of the organism involved. 45. GD on arrival at hospital had a GCS which put her in a group of predicted favourable neurological outcome, had she been treated. She was not obtunded or in an elderly age group to put her at increased risk of poor outcome. There is no reason to suppose that her case was atypical and she does not have any prior medical history suggestive that she would be expected to have a worse outcome than average. 46. My belief is that had IV antibiotics been given at 10.25 instead of 13.20 GD would have survived. I also believe that had they been administered at any time up to 12.00 then on the balance of probabilities GD would have survived.”
“In my opinion, this case was very unusual with Mrs Davies showing a very rapid progression for which there is no obvious explanation. In these circumstances it is my opinion, on a balance of probabilities basis, that an earlier administration of antibiotics, against either of the above timelines, would not have altered the outcome in this case. I reach this conclusion because the delay in providing effective antibiotics rested, as demonstrated above, between 3 to 1.5 hours and it is unlikely that such a relatively short earlier administration would have been able to have altered the course of the infection such that the outcome would have been Mrs Davies’ survival.”
“The earliest stages of this are reversible with appropriate treatment but become progressively less reversible as treatment is delayed.”
“I do not think there was anything exceptional about this patient or this organism.”
“Based on personal experience, as well as the literature and considering the opinions of the other experts, I believe on a balance of probability that this failure of duty of care led to the death of Mrs Gabrielle Davies.”
“This lady had a rapidly progressive fulminating infection which rapidly spread from the right middle ear to the meninges.”
“The onset of coma in the presence of a poorly/partially treated meningitis dramatically increases the morbidity and mortality of the cranial sepsis.”
“Patients who ‘walk and talk’ on arrival at hospital have a good chance of survival if ‘triaged and treated’ urgently with IV antibiotics. Had IV antibiotics been given three hours sooner at 10.25 instead of 13.20 then on a strong balance of probabilities the Deceased would have survived. A delay in iv antibiotics any time up to 12:00 on a balance of probability she would have survived.”
“Antibiotics alone will not treat the raised intracranial pressure of infection and only if given before the start of the vicious cycle will they prevent progression to infarction. It is my opinion that by the time the Deceased started to develop a severe headache and vomiting the meningitic process was becoming well established and her death was, on the balance of probability, inevitable.”
“… and I would therefore suggest that the application of ‘antibiotics within the hour’ principles to severe brain infections is sadly less time critical than would be hoped: if there is (as in this case) a fulminant brain infection and a deteriorating patient I do not think the immediacy of antibiotic management will likely resolve the problem whereas this is more likely to be the case with systemic sepsis.”
“They agree that overall patients with pneumococcal meningitis that present alert to hospital are not likely to die on balance of probability. The prognosis will be influenced by comorbidities of the patient (the deceased was normally well), rate of progression of the neurological sequelae with rapidly progressive disease having a worse outlook, and any undue delay in instituting treatment.”
“Survival would have been more likely as the deceased was orientated, rather than comatose, and premorbidly healthy. Death would have been more likely due to the rapid deterioration during the course of the day 25.02.2015 which is indicative of a fulminate version of meningitis.”
“I consider that had intravenous antibiotics been given within one hour (about 10:10) then, on the balance of probabilities, Mrs Davies would have survived. Had they not been given for three hours (about 12:00) then I believe that, on the balance of probabilities, she would have died. Between those times, I consider that the outcome is uncertain and I am not therefore able to express a view on the balance of probabilities. However, I can say with confidence that during the time Mrs Davies deteriorated I consider that any delay between about 10:10 and 12:00 made a material contribution to her decline and death.”
“strong” balance of probabilities at 10.25 – to his letter of9 June 2020 : balance of probabilities views at 10.10 and 12.00, but not in between. He said that the records had not changed, but as the process proceeded he became more cautious and “felt I had to moderate. I’ve modified my opinion.”
“I was not so sure.”
“On the other hand, care should be taken not to take the logic of this reasoning too far in the opposite direction. If the evidence is that, say, 80 per cent of patients survive with prompt treatment, but 20 per cent die even with prompt treatment, the fact that the patient died following delayed treatment does not establish that he probably fell into the 20 per cent category at the outset and therefore the delay did not contribute to the death. The assessment of causation would turn upon the detailed medical evidence, both as to the overall statistical chances of survival and the particular condition and circumstances of the patient.”
“In conclusion, this retrospective study adds to the known data of bacterial meningitis by specifying the incremental effect of treatment delay on clinical outcome in general, and not only after the severity of the disease has progressed.”
“The medical evidence was that pneumoconiosis is caused by a gradual accumulation in the lungs of minute particles of silica inhaled over a period of years. That means, I think, that the disease is caused by the whole of the noxious material inhaled and, if that material comes from two sources, it cannot be wholly attributed to material from one source or the other.”
“It is important to be clear precisely what Wardlaw decided. Did it decide that in a cumulative cause case where the inadequacies of medical science meant the relative potency could not be established all a claimant had to establish was a "material" contribution which in the words of Lord Reid meant something more than de minimis? Or did a claimant still have to establish that 'but for' the contribution of the negligent cause, the injury would not have occurred?”
“It seems to me thus respectfully that Lord Rodger in Fairchild accurately summarises the position when he says in paragraph 129 that in the cumulative cause case such as Wardlaw the ‘but for’ test is modified.” 178. Then, at [46], Waller LJ said this: “In my view one cannot draw a distinction between medical negligence cases and others. I would summarise the position in relation to cumulative cause cases as follows. If the evidence demonstrates on a balance of probabilities that the injury would have occurred as a result of the non-tortious cause or causes in any event, the claimant will have failed to establish that the tortious cause contributed. Hotson exemplifies such a situation. If the evidence demonstrates that 'but for' the contribution of the tortious cause the injury would probably not have occurred, the claimant will (obviously) have discharged the burden. In a case where medical science cannot establish the probability that 'but for' an act of negligence the injury would not have happened but can establish that the contribution of the negligent cause was more than negligible, the 'but for' test is modified, and the claimant will succeed.”
“152. Finally, these are not cases to which the Fairchild exception could foreseeably be made to apply. The House of Lords in that case and in Barker has made it plain that the scope of the exception will be very narrow. It is clear that the exception will only apply where the two or more potential causes act either through the same agent (eg asbestos dust in Fairchild or brick dust in McGhee v National Coal Board[1973] 1 WLR 10 ) or possibly through different agents which act on the body in the same way.”
“It was not necessary to rely on statistical evidence in that case to demonstrate that dust emanating from the swing grinders contributed to the disease. It contributed to the disease because its severity was proportionate to the amount of dust inhaled and the amount attributable to the swing grinders was material.” 183.He also said of the test in that case, at [46]: “That test is to be applied where the court is satisfied on scientific evidence that the exposure for which the defendant is responsible has in fact contributed to the injury. This is readily demonstrated in the case of divisible injuries (such as silicosis and pneumoconiosis) whose severity is proportionate to the amount of exposure to the causative agent.”
“Where the disease is indivisible, such as lung cancer, a defendant who has tortiously contributed to the cause of the disease will be liable in full. Where the disease is divisible, such as asbestosis, the tortfeasor will be liable in respect of the share of the disease for which he is responsible.”
“All other cases require that the claimant satisfies the "but for" test of causation. True, in the case of cumulative injuries, the law holds a negligent employer liable even if his negligence is responsible for part only of the victim's condition (provided only that it made a material, ie more than de minimis, contribution to the development of the condition). I have difficulty, however, in seeing this as a true exception to the "but for" test: although the claimant in Bonnington Castings Ltd v Wardlaw[1956] AC 613 , the case which first established the principle, recovered full damages for his condition (pneumoconiosis from the inhalation of silica), that appears to have been because the defendants took no point on apportionment; in a series of subsequent such cases damages have been apportioned, however broadly...”
“In Bonnington there was no suggestion that the pneumoconiosis was “divisible”, meaning that the severity of the disease depended on the quantity of dust inhaled. Lord Reid interpreted the medical evidence as meaning that the particles from the swing grinders were a cause of the entire disease. True, they were only part of the cause, but they were a partial cause of the entire injury, as distinct from being a cause of only part of the injury. Lord Reid’s approach was understandable in view of the way in which the case was argued.”
“The Board does not share the view of the Court of Appeal that the case involved a departure from the “but-for” test. The judge concluded that the totality of the claimant’s weakened condition caused the harm. If so, “but-for” causation was established. The fact that her vulnerability was heightened by her pancreatitis no more assisted the hospital’s case than if she had an egg-shell skull.”