Proving a Breach of Required Standard in Medical Negligence

Proving a Breach of Required Standard in Medical Negligence

Essay Question:

A claimant seeking damages in negligence for a loss sustained in the course of medical treatment has several high hurdles to surmount. In particular, proving a breach of the required standard and establishing causation may be highly problematic, often for reasons of public policy as judges attempt to balance justice for the claimant against the wider impact their decision may have on society as a whole.

With reference to relevant case law and academic commentary, critically analyse the accuracy of this statement.

Introduction

My attempt in this essay is to articulate the experience of a claimant seeking damages in the course of medical treatment, identify the hurdles that they have to go through and the establishment of a clear case they have to present in establishing causation. I will also be examining the role of the judges in this regard and rational as to why public policy play a crucial role and impact on the decisions.

The law of tort has a number of components to it for the a claim to be established[1] they are;

1. The protection of legal and legitimate interests of individuals
2. Recognition and establishment of normative standards of behaviour
3. Provision of those who have been wronged with compensation
4. Acknowledging the wrong or harm, and providing retribution

In tort,’ the standard remedy is damages’[2] the law of tort is mediated by civil proceedings with a wide range of rights, obligations and remedies. The law of tort can be distinguished from criminal and contract law. In criminal law, this is wrong against the states statutes, policies and law, while the contract law focuses on the rights and obligations of parties in a contractual arrangement. However there may be times when this line is blurred an example can be an assault or grievous bodily harm which may be deemed to be criminal, but also give rise to civil actions for compensation.

In the law of negligence there are four elements that need to be proven for a successful claim[3];

1. The negligent party owed a duty of care to the victim. The establishment of a duty owed by one person to the other
2. There was a breach of the duty of care. This in effect means that the person who owes the duty of care has breached that duty.
3. Causation (the negligent caused the injury/loss). As a result of the breach, this causes a damage or injury to the affected party or parties.
4. Damage or injury occurred. The damage or the injury occurs and has made the affected person to suffer a loss.

Lord Hoffman in his lecture at Bar Council Law Reform Lecture said that the concept of the duty of care, whose moral basis had been the Aristotelian concept of corrective justice, did not fit well upon questions involving the administration of public bodies. Unlike individuals, such bodies often have no choice as to whether to provide a service or not; their funds are limited and, in a democratic country, they have choices about their spending priorities. So the question of whether they have acted reasonably in matters of administration cannot be equated with whether a plumber or doctor has exercised reasonable care. He criticised as hopelessly question-begging the well-known quotation from Lord Bingham: “the rule of public policy which has first claim on the loyalty of the law [is] that wrongs should be remedied.” And then there was the question of democracy. Was it right for judges to create a duty of care in private law when Parliament had omitted to do so? Creating such a liability means adding to the financial burdens on the public body: to defend actions or to pay compensation. Was it not better for Parliament to decide whether resources should be used in this way? The courts are ill-equipped to assess the effect of the introduction of new causes of action on the behaviour of public bodies.[4]

In Hill v Chief Constable of West Yorkshire [1989] AC 53, the House of Lords held that, as a matter of public policy, the police were immune from actions for negligence in the investigation and suppression of crime. Lord Keith wrote the main opinion. He said rather cautiously that “in some instances the imposition of liability may lead to the exercise of a function being carried on in a detrimentally defensive frame of mind. The possibility of this happening in relation to the investigative operations of the police cannot be excluded”. He also gave other reasons for holding that no duty of care was owed. These included that, if actions were instituted arising from a police investigation, it would be necessary to examine the manner of the conduct of the investigation. This would entail scrutinising a variety of decisions on matters of policy and discretion, for example as to which particular line of inquiry is most advantageously to be pursued, and what is the most advantageous way to deploy the available resources. A great deal of police time, trouble and expense might be expected to have to be put into the preparation of the defence to the action and the attendance of witnesses at the trial. The result would be a significant diversion of police manpower and attention from their most important function, that of the suppression of crime. A similar approach to public policy was applied in Calveley v Chief Constable of the Merseyside Police [1989] AC 1228 where it was held that no duty of care was owed by the police in the conduct of disciplinary proceedings against a police officer.[5]

What are the hurdles?

For a claim to be successful, a number of hurdles will have to be crossed. These include causation, relationship, and direct link between the harm and the action of the defendant

• Causation

Causation is at the heart of what needs to be proofed by the claimant that the defendant’s action is responsible for their misfortune or ham. Factual causation is determined by reference to the “but for” test, the “scope of liability”. Causation is central to the interpersonal responsibility. The starting point to developing any test for causation must be an accurate understanding of what purpose the doctrine of causation has in negligence. It will be argued here that the concept of causation in law is narrower and more precise than the use made of the term ‘cause’ in everyday language because, as Stapleton has explained, causation can be understood in a wide range of senses, from involvement, to explanation, to blame[6]. Negligence law does, however, put its understanding of causation to a specific purpose, namely establishing a causal link between a particular instance of negligence and a particular harmful outcome.[7] The understanding of the day to day meaning of the word causation is different from the legal interpretation of causation. The law requires a standardised approach with accuracy, consistency and precision.

Wright has shown, however, that in everyday language ‘cause’ is often shorthand for ‘the cause’ rather than ‘a cause’: The phrase “a cause” usually refers to causation per se – the fact of being one of many contributing conditions. The phrase “the cause” generally is used to denote which of the many contributing conditions is legally or morally responsible…“The cause” is merely an elliptical way of saying “the (most significant for our purposes) cause”[8].

It will be erroneous to rely on the ordinary definition as it relies on making evaluative judgement rather than the articulation on which the judgement is based. Hart and Honoré, however, identified three issues and it is important to understand which of these are causal and which are evaluative. These three issues are: causally relevant condition, causal connection, and remoteness of damage[9]. The first relates to the historical involvement of negligence in the occurrence of harm. This is refers to as the factual occurrence whilst the second establishes which of the relevant conditions actually causes harm and the third distinction relates to whether harm was too remote to cause harm.[10]

In the case of Barnett v Chelsea & Kensington Hospital [1969] QB 428, the need for a factual determination of whether the defendant caused the alleged action is emphasised. The action in this case was brought by the victim family. The victim presented at the hospital Casualty department which was provided and run by the defendant. The victim is one of the 3 watch men that presented themselves. They were seen by a nurse on duty and presented their symptoms described as vomiting 3 hours after drinking tea. The nurse contacted the doctor on call and was advised to send the men to go home. About 5 hours after the men left, one of them died from arsenic poisoning. The family alleged that the hospital was negligent. The issue to consider is whether the defendant’s negligence causes the death. However, the court decision did not hold the defendant liable for the death. This decision established the ‘but for’ test. But for the defendant’s breach of duty result in harm to the plaintiff. The medical evidence shows that the victim would have died even if the treatment was administered. The actual cause of death was the arsenic poisoning. In this case it was establish that the plaintiff failed to establish the balance of probabilities that the death was as a result of the defendant’s negligence.[11] A claimant must prove their case on the balance of probabilities that harm was caused by the defendant’s breach of duty. This is a major hurdle to go through in court and makes it difficult for plaintiff to win a case.

• The Reasonable Person

A person is deemed to have become negligent if the person departs from the conduct of a reasonable person who acts under similar situations or circumstances.

This test provides an objective measurement by which people are judged in law of negligence.

It is very important that the person who brings an action to court cannot argue on the basis of what an average or a typical person in the community will interpret to be the test of a reasonable person but this is measure by a composite view of how the community members will view a course of action. 

In order to determine reasonableness, a number of other factors will have to be taking into consideration including experience, level of knowledge, what the individual is engaged in, physical attributes of the person and the circumstance within which that individual finds him/her self-including environmental factors during the event that is in question.

Alongside knowledge is the consideration for special skills. If a person engages in an occupation or activity like being a doctor or a dentist, the standard of measure will be that of a conduct of a reasonable skilled person with a level of experience and adjudged competence. However the law does not make adjustment for juniors or inexperience or a learner.

Physical Characteristics is another attribute that is used as a measure of reasonableness. A measure of reasonableness must take into account the same physical characteristics. In order to be negligent a person must have physical characteristics that will enable them to perform the task.

A physically disabled person cannot be expected to save or rescue people from a burning house.

Although physical characteristics are taking into consideration, mental capacity is not taken into account in the determination of a person’s negligence. Mental capacity is largely ignored. A person who is temporarily intoxicated cannot claim not to be negligent if driving, under the influence of alcohol.

But in the case of children, whilst they may be found negligent they are not held to the same standard of test. The reasonable test for a child is evaluated by their age, understanding and level of experience. It is important however to stress that if a child is engaging in what is regarded as an adult activity, they will be measured with the same standard as an adult.

Within the reasonable test is the view that acting in an emergency can subject individuals to mistakes and errors. This will interpreted as level of reasonability under the circumstance but the court will have to take the view of the level of predictability. Can it be foreseen and acted upon?

The conduct of others is another variable taking into account as to how individuals regulate themselves in comparison to the conduct of others.

• The Burden of Proof

In negligence cases, the plaintiff must be able to proof that the accused or the defendant deviates from the reasonable test. Whilst the action brought before the court relies on the plaintiff’s ability to proof the reasonable person test is put to a considerable examination. Though it is recognised that the plaintiff have more avenues to proof reasonableness by using the violation of the statutes that has been put in place to protect members of the society. The plaintiff may also use the experts to present their argument or bring about information around circumstantial evidence to argue the case. These are not particularly easy argument to convince the judges or the jury.

In the case of Hotson v East Berkshire Area Health Authority the plaintiff fell from a tree and the treatment that was administered was adjudged to be wrong which left the plaintiff with permanent hip joint damage. The plaintiff had been working at a height of 70ft, but the defendant had not provided the safety harness to secure safety despite the fact that under the law, there is an obligation to provide the plaintiff with the harness that will ensure safety.[12] Though there was evidence in this case that had this being provided, the plaintiff may not have worn it. The issue for the court was the question of liability. Could the hospital be liable for reducing the chance of recovery due to poor treatment? It was upheld that the burden of proof is not strong enough as causation could not be established. It was found that the argument did not stand the test of the balance of probabilities and only 25% chance that the poor treatment, affected the plaintiff chance of recovery. In order to satisfy the law, the balance of probabilities required would be about 50% chance. The action failed and the under the “all or nothing “approach, the chance of partial admission of liability is not enough to win a case despite admission by the defendant in admitting negligence but not liability.

Whilst there has been a debate about the recent move in the case of Fairchild v Glenhaven Funeral services Ltd [2003] 1 AC 32 to weakening the test for factual causation in this case. The plaintiff developed a type of cancer called mesothelioma which is caused by exposure to asbestos. The plaintiff had previously worked for various employers. The defendants joined the action did not include all of the employers, but the medical opinion did conclude in their evidence, which of the employers has been responsible for the exposure. The ‘but for test’ was not satisfied. The question for the court was whether the defendants could be held responsible? Whilst the court of appeal ruled that the medical evidence in this case could not be relied on to determine causation, but the House of the Lords considered using the approach in the McGhee v National Coal Board [1973]. This was seen as defendants having employed the plaintiff, contributed to the exposure from which the cancer was contracted. As the cancer is regarded as an indivisible condition, it was ruled that the defendants have jointly and severally liable.[13] This judgement was seen as being in the favour of the plaintiffs who brought action to court.

In the case of Hucks v Cole 1968, the plaintiff who was admitted to a maternity ward was suffering from septic spots on her skin which had the potential of the organisms which may cause puerperal fever. The doctor refused to treat the patient with penicillin. In this case, a number of expert doctors were called as witnesses and came to the conclusion, that their decision would have being the same as the doctor who refused to treat the patient.

This case has always been criticised as collusion by the medical profession. The court held the defendant negligent, as the doctor had knowingly avoided risk on which there was no proper basis.

Judge Sachs LJ said: ‘When the evidence shows that a lacuna in professional practice exists by which risks of grave danger are knowingly taken, then, however small the risk, the court must anxiously examine that lacuna-particularly if the risk can be easily and inexpensively avoided. If the court finds, on an analysis of the reasons given for not taking those precautions that, in the light of current professional knowledge, there is no proper basis for the lacuna, and that it is definitely not reasonable that those risks should have been taken, its function is to state that fact and where necessary to state that it constitutes negligence. In such a case the practice will no doubt thereafter be altered to the benefit of patients. On such occasions the fact that other practitioners would have done the same thing as the defendant practitioner is a very weighty matter to be put on the scales on his behalf; but it is not, as Mr. Webster readily conceded, conclusive. The court must be vigilant to see whether the reasons given for putting a patient at risk are valid in the light of any well-known advance in medical knowledge, or whether they stem from a residual adherence to out-of-date ideas.’[14][15]

This case brings into focus the fact that a number of doctors said they would have taken the same decisions; it has not stopped the court coming to a different conclusion.

Imposing a duty of care may cause public officials to respond in an unduly risk averse or “defensive” manner. This is a recurring theme in some of the cases. For example, in the Bedfordshire case, it was said that if social workers were made liable for wrong decisions in respect of removing children at risk, they might hesitate when it came to making such decisions in the future. The delay would prejudice the child who was actually being abused, as well as other children who would suffer as a result of slower decision-making by individuals: p 750.[16]

It can be argued that usually, the courts are always cautious about ruling against the medical professionals for policy reasons.[17]

In The case of Bolitho V City and Hackney Health Authority [1998] AC 232, was another landmark ruling in medical negligence. The mother of the victim, a two year old child was rushed to the hospital following a respiratory failure and suffered a brain damage and eventually died. It was alleged that the doctor did not attend due to a technological failure. It was argued that the child could have been saved had the doctor attend and provide a specific procedure which would have saved the child’s life. The defendant argued that the doctor would not have carried out the procedure as the outcome may have been the same. This argument was supported by a number of medical doctors. [18]

However, the court concluded that the defendant’s action was based on an omission to act and had to consider that the ‘but for’ test in a hypothetical situation. Lord Browne-Wilkinson said: ‘it will very seldom be right for a judge to reach the conclusion that views genuinely held by a competent medical expert are unreasonable. The assessment of medical risks and benefits is a matter of clinical judgment which a judge would not normally be able to make without expert evidence. As the quotation from Lord Scarman makes clear, it would be wrong to allow such an assessment to deteriorate into seeking to persuade the judge to prefer one of two views both of which are capable of being logically supported. It is only where a judge can be satisfied that the body of expert opinion cannot be logically supported at all that such opinion will not provide the bench mark by reference to which the defendant’s conduct falls to be assessed.’[19]

However the implication of ruling against the body of evidence by the medical profession is that this may create a risk avoidance on the part of the medical profession because of the fear of been sued and may be more dangerous for patients.

This further creates a major hurdle for the plaintiffs in arguing before the courts as the judges may have a view on the implication of the ruling on the profession and the discharge of their duty to the society.

• Duty of Care

An area of hurdle for the plaintiff is in the duty of care. There has to be an established relationship that the defendant owed the plaintiff the duty of care as a defendant is not liable if they do not have a duty of care. The duty of care is mediated by the neighbourhood test as in the case of Donoghue v Stevenson [1932] AC 562 

 Lord Atkin in his ruling said that

“The rule that you are to love your neighbour becomes in law you must not injure your neighbour; and the lawyer’s question” Who is my ‘ neighbour?” receives a restricted reply. You must take reasonable care to avoid acts or omissions which you can reasonably foresee would be likely to injure your neighbour. Who then in law is my neighbour? The answer seems to be persons who are so closely and directly affected by my act that I ought reasonably to have them in contemplation as being so affected when I am directing my mind to the acts or omissions which are called in question.”[20]

In this case Mrs Donoghue attended a café with a friend where they were served with ginger beer and ice cream. She poured half of the beer onto the ice cream and consumed the part of the rest directly from the bottle and then poured more onto the ice cream. A decomposed snail flowed from the bottle leaving Mrs Donoghue to suffer injury. She made a successful application to court. This case became the landmark ruling and providing the approach which is referred to as a neighbourhood test.[21] The neighbourhood test that anyone bringing action to court has to argue successfully rest on two requirements. The reasonable foresight of harm and a relationship of proximity.

Prior to the case, it was sufficient to argue on the basis that the plaintiffs have to establish an existing duty relationship, but this test broadened the approach and enabled claimants in a wide range of situations. A number of subsequent cases have sought to narrow its application. In the case of Anns v Merton London Borough Council [1978] AC 728, Lord Wilberforce came up with a two stage test. The first stage was to examine whether the loss was reasonably foreseeable and whether a relationship of proximity exists, if this is proved a duty of care is established and the second test may then be that the defendant can put forward policy considerations to negate the liability.

The first stage was similar to the case test in Bolitho’s case. But in order to address the implication that this may result in the courts been inundated by claims, the second stage provided a support for the defendant to use policy as a defence from the imposition of the duty of care.

Despite the view that the Anns test attempted to use the second test to limit the claimant’s ability to pursue claims and put more hurdles for the claimant to surmount. The House of Lords in the Caparo case sought to further narrow the approach and ruled against the Anns. In Caparo Industries Plc v Dickman [1990] 2 AC 605, Lord Bridge came up with a three stage test. The claimant must be able to establish that harm was reasonably foreseeable, that there was relationship of proximity and that it is fair, just and reasonable to impose a duty of care[22] [23].

Whilst in Anns test the liability is established once the claimant is able to argue successfully reasonable foresight, proximity and demonstrate policy factors for negating liability, under the Caparo test it is the responsibility of the claimant to put forward policy reasons for imposing liability.[24]

This series of Judges introducing tests can only be seen as increasing the hurdles of the claimants in seeking redress. Even those who expressed a grudging admiration for what the majority had decided in Donoghue v Stevenson were keen to make it clear that there had to be limits: ‘The decision in the Donoghue case was one of good sense and social necessity, but social necessity and good sense require some limits”.[25]

More recently, discussions about the proper reach of the law of negligence have resulted in Parliamentary debate and the 21 passing of legislation seeking to influence the standard of care applied by the courts in certain areas of social activity.[26]

The demonstration of the hurdles that the claimants have to go through can also is seen through the prism of the access to services as in case of health care where the courts are cautious.

The courts have largely distanced themselves in being critical of these arguments. In R v Secretary of State for Social Services, ex p Hincks (1980)[27], Samantha and Samantha 2015 (page 49) summarised that the Judge in this case ruled that the ‘Secretary of State is not under any obligation to meet every demands for healthcare and can only do what is achievable with limited resources’.

However in a number of cases the process of decision-making process has been subject of Judges focus, rather than the decision to question the government to decide on access to medical treatment. In the R v North East Devon Health Authority, ex parte Coughlan[28] the application for judicial review was upheld in the favour of the applicants. However there is a clear distinction made by Lord Woolf MR that the decision to move the occupants of Mardon House was more to do with the breech of promise as opposed to the decision to fund care. In R v North Derbyshire Health Authority, ex parte Fisher,[29] the court found that the Health Authority had acted unlawfully in following the Department of Health guidelines following the refusal to fund Beta-Interferon except in relation to clinical trials. This decision was asked to be considered in relation to national policy set by the Department of Health rather than a court decision to compel NHS to provide treatment. In a 2006 case, R (Ann Marie Rogers) v Swindon Primary Care Trust and Secretary of State[30], the decision not to fund the use of Herceptin for the condition was overturned due to fairness of refusing treatment to one individual within an eligible group. Some may have seen this as a land mark ruling of using the law to successfully gained access to medical treatment; Keith Syrett[31] argued that the ruling is more about that transparency and honesty about scarce resources by the PCT. This was more highlighted in the case of R (on the application of Otley) v Barking and Dagenham NHS Primary Care Trust.

In R (Murphy) v Salford Primary Care Trust the Judge sets out legal principles in determine cases of this nature. It clearly states;

• The NHS is entitled to take into account the financial constraints in making decisions about funding
• The limitation of the Courts in getting involved in the Clinical Commissioning Groups decisions save for when the adherence to the policy or irrationality in decision making can be proven.
• It is not the Courts role in expressing opinions or to express medical judgement.
• It is lawful for the for an NHS organisation to refuse to pay for treatment unless it is an exceptional circumstances if that can be predicted.

This case is a clear demonstration that using the law to gain access is limited with the limitations of what the court can do or not do. 

Conclusion

One of the tenets of Magna Carta is that justice shall be done by the law of the land and must be determined by the due process of law. The law of tort has developed over hundreds of years in response to the changing social, economic and political landscape. The perceived notion of the development of compensation culture has raised concerns and has influenced the changes to the law[32].

The Parliamentary enquiry which reported in the same year concluded that the ‘evidence does not support the view that increased litigation has created a “compensation culture”.[33]

However this has not stopped the Parliament in passing two legislations that is aimed at curtailing and reducing claims. The Compensation Act 2006, and Social Action, Responsibility and Heroism Act 2015.

 It is evident from this essay that In order to succeed, claimants have to establish that the injury was as a matter of law attributable to the fault of someone else. That is what had to be established in the Bogle case. The law requires fault. It requires a duty of care, breach and causation of loss. These are not always straightforward matters to establish. The courts have certainly not taken an approach which has lowered the standard of care, made it easier to establish negligence or introduced a test which allows claims to succeed in the absence of fault (except, of course, where the law imposes strict liability).[34]

The burden of a judgement on the government and tax payers will continue to be an ongoing interactive dynamics in the law of negligence for the foreseeable future where judges will continue to balance the burden on the society and the need for individual fairness and justice.

 List of cases

Anns v Merton London Borough Council [1978] AC 728 

Blyth v Birmingham Waterworks Co (1856)

Bolitho V City and Hackney Health Authority [1998] AC 232

Caparo Industries Plc v Dickman [1990] 2 AC 605

Donoghue v Stevenson [1932] AC 562

Fairchild v Glenhaven Funeral Services Ltd [2002].

Hotson v East Berkshire Area Health Authority [1988] UKHL 1

Hucks v Cole: CA 1968

Hill v Chief Constable of West Yorkshire [1989] AC 53

McGhee v National Coal Board [1973]

Nettleship v Weston [1971]

R v Secretary of State for Social Services, ex p Hincks (1980)

R v North East Devon Health Authority, ex parte Coughlan

R v North Derbyshire Health Authority, ex parte Fisher

R (Ann Marie Rogers) v Swindon Primary Care Trust and Secretary of State

R (on the application of Otley) v Barking and Dagenham NHS Primary Care Trust

R (Murphy) v Salford Primary Care Trust

Wilsher v Essex AHA [1987

Bibliography

Birmingham V. and Brennan C., Tort Law, (2008) Oxford University Press

DeRoche, WEP ‘Torts – Negligence – Duty of Care – Liability of Contractor to Third Person’ (1935) 13 Can B Rev 112, 114 

Cooke J., Law of Tort, (2009) Longman

Herring, J, Medical Law and Ethics, 6th ed 2016 OUP

Jackson E, Medical Law, 4th ed, 2016, OUP

Katter N., “Who then in law is my neighbour?” – The Tort Law Review 12(2):pp. 85-97. (2004)

Kidner R., Casebook on Torts, (2008) Oxford University Press

Oughton D., Marston J. and Harvey B., Law of Torts, (2007) Oxford University Press

Parker, A ‘Changing the Claims Culture’ (2006) 156 NLJ 702.

Sir Frederick Pollock, The Law of Torts: A Treatise on the Principles of Obligations arising from Civil Wrongs in the Common Law (4th ed 1895)   

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[1] https://www.cilex.org.uk/pdf/FINAL accessed 30th May 2017

[2] https://www.cilex.org.uk/pdf/FINAL accessed 30th May 2017

[3] Donoghue v Stevenson [1932] AC 562

[4] Lord Hoffmann lecture on 17 November 2009 entitled “Reforming the Law of Public Authority Negligence”.

[5] Lord Dyson, Master of the Rolls on the Duty Of Care Of Public Authorities: Too Much, Too Little Or About Right? Given at the Richard Davies Lecture 27 November 2012

[6] Jane Stapleton, ‘Choosing what we mean by “Causation” in the Law’ (2008) 73 Mo L Rev 433, 438

[7] Richard Wright, ‘The NESS Account of Natural Causation: A Response to Criticisms’ in Richard Goldberg (ed.) Perspectives on Causation (Hart Publishing 2011) 290-1.

[8] Wright, ‘Pruning’ (n4) 1012.

[9] Hart and Honoré (n7) xlvii.

[10] ibid 305-307

[11] Barnett V Chelsea And Kensington Hospital Management Committee [1969] 1 Qb 428

[12] Hotson v East Berkshire Area Health Authority [1988] UKHL 1

[13] Fairchild v Glenhaven Funeral services Ltd [2003] 1 AC 32.

[14] http://swarb.co.uk/hucks-v-cole-ca-1968/

[15] Hucks v Cole 1968

[16] Lord Dyson, Master of the Rolls on the Duty Of Care Of Public Authorities: Too Much, Too Little Or About Right? Given at the Richard Davies Lecture 27 November 2012

[17] http://www.bitsoflaw.org/tort/negligence/study-note/degree/damage-causation-factual-legal

[18] Bolitho V City and Hackney Health Authority [1998] AC 232

[19] http://swarb.co.uk/bolitho-v-city-and-hackney-health-authority-hl-24-jul-1997-3/

[20]Donoghue v Stevenson [1932] AC 562 

[21] Donoghue v Stevenson [1932] AC 562 

[22] http://www.e-lawresources.co.uk/Duty-of-care.php

[23] Caparo Industries Plc v Dickman [1990] 2 AC 605

[24] http://www.e-lawresources.co.uk/Duty-of-care.php

[25] DeRoche, WEP ‘Torts – Negligence – Duty of Care – Liability of Contractor to Third Person’ (1935) 13 Can B Rev 112, 114 

[26] Compensation Act 2006 which received the Royal Assent on 25 July 2006. For an article by one of those who advised on the draft legislation, see: Parker, A ‘Changing the Claims Culture’ (2006) 156 NLJ 702.

[27] http://static.aston.ac.uk/applet/protected/prof_ethics/briefing_rationing.pdf

[28] https://www.sochealth.co.uk/national-health-service/health-law/r-v-north-and-east-devon-ha-ex-parte-coughlan-1999-payment-for-nursing-care/

[29] http://static.aston.ac.uk/applet/protected/prof_ethics/briefing_rationing.pdf

[30] http://www.pfc.org.uk/caselaw.pdf

[31] ‘Opening eyes to the Reality of Scarce Health Care Resources? R (on the application of Rogers) v Swindon NHS Primary Care Trust and Secretary of State for Health’ (2006) Public Law 664-73

[32] Lord Falconer, Compensation Culture, (22 March 2005) at 1 – 2

[33] (HC 754–I) at13.

[34] Lord Dyson Lecture on Compensation Culture at the Holdsworth Club Lecture on the 15th March 2013