UK: Misguided Treatment

Last Updated: 30 November 2001
Article by Ross Brain

Co-written by Patricia Hitchcock

At inquest, neglect is now more broadly defined in medical cases, say Patricia Hitchcock and Ross Brain

MH WAS 38 years old when he died at Medway Maritime Hospital, Gillingham, Kent on 16 November 1999, of multi-organ failure due to sequestration of sickle cells during a severe sickling crisis. MH suffered from haemoglobin SC disease, a sickle cell disorder, and had a long history of admissions. He had suffered two lung crises in the mid-1980s but was in reasonably good health between crises.

He was admitted on 11 November with all the typical features of a painful sickling crisis and was treated with diamorphine and fluids. The following day, a Friday, he was still in some pain and had developed basal crepitations and a slight cough; the plan was to send sputum for culture and to treat any pyrexia with antibiotics. MH was not seen by a doctor over the weekend despite continuing pain and pyrexia and was not given antibiotics. On Sunday night, he collapsed with severe diarrhoea, fecal incontinence and vomiting. No doctor attended. By Monday morning, he had deteriorated considerably. Blood chemistry results showed raised urea, creatinine and potassium levels. Dextrose, insulin and calcium were given. Later that day, the pain was generalised in back, buttocks and abdomen and was reported to be far more severe than that experienced in previous sickling crises. His haemoglobin had dropped from 11 to 9.5 g/dl.

On Tuesday morning MH was confused and distressed and in severe pain; he was bleeding per rectum and had significant abdominal tenderness around the liver. Sickling, involving the brain and viscera, was diagnosed; haematology results returned in the late morning showed 5.2 g/dl. Six units were cross-matched. Before any blood had been transfused, at about midday, he collapsed with unrecordable blood pressure and fixed and dilated pupils. He was transferred to ITU, where he became tachycardic and a haemoglobin of 2.0 g/dl was recorded. There was ample clinical evidence of disseminated intravascular coagulopathy. Resuscitation was discontinued shortly before 14.30 and MH was certified dead at 17.50.

Coroner admits expert evidence

The coroner, who had initially intended to rely on the evidence of the treating doctor, was persuaded to admit expert evidence from Professor Sir David Weatherall, acknowledged by all parties to be the leading world authority on sickle cell disorders.

He emphasised the importance of careful monitoring and particularly criticised the 48hour gap in medical treatment over the weekend, the failure to consider exchange transfusion at any time or to give antibiotics. By the time that direct transfusion was considered, the window of opportunity had closed. In Professor Weatherall's view vigorous transfusion therapy was clearly indicated on the Sunday evening and such treatment, even given on the Monday, would probably have saved MH's life.

The coroner declined to leave a verdict of unlawful killing to the jury but directed them on natural causes, 'natural causes to which neglect contributed' and an open verdict. He defined neglect in accordance with the leading case of R v HM Coroner for North Humberside & Scunthorpe, ex p Jamieson [1994] 3 WLR 82 as 'a gross failure to provide medical attention' and directed the jury that to return such a verdict they must believe that 'there was a clear causal connection between the gross failure and the death'. The jury returned a verdict of natural causes to which neglect contributed.

Test for neglect

The case is interesting because the Jamieson test had formerly been considered to require a total absence of care, or a failure to take an obviously necessary step (such as call a doctor). The tests for neglect set out in Jamieson require in this context that the need for basic medical attention must be obvious, the patient must be dependent on others to provide that attention and there must be a gross failure to provide or procure it.

Poor medical care was held not to meet this test in at least two cases following Jamieson. In R v HM Coroner for Birmingham, ex p Cotton [1995] 160 JP 123, the court took the view that, where death resulted from a clinical judgment (which might or might not be negligent), the issue must not be left to the jury. The issue was also raised in R v HM Coroner for Surrey, ex p Wright [1997)] QB 786, a case where death resulted from failure to maintain a patients airway during minor dental surgery and the coroner had declined to empanel a jury and returned a verdict of accidental death. Tucker J, determining the application for review, agreed that, despite the coroner's finding of fact that death resulted from lack of care the verdict was appropriate; he held that neglect must be 'continuous or at least non-transient', that it was not an appropriate description of the negligent lack of care here and reiterated that matters of negligence are better decided in a civil action by a judge. It seemed that any medical treatment, however inept, would lift the case out of the 'neglect' bracket.

The first attempt to broaden the rule came in Re Clegg (reported as R v HM Coroner for Wiltshire, ex parte Clegg [1996] 161 JP 521). This was a case of aspirin overdose, where the deceased reached hospital some 12 hours before she died; the coroner considered the Jamieson test and allowed the verdict to go to the jury although some care had been provided, since there had been a failure to treat the aspirin poisoning from which the patient was dying. The Divisional Court, although alerted to the ratio of Cotton, supported the coroner's approach (the editors of Jervis on Coroners comment that this directly contradicts Cotton and that the court had neither a transcript nor a report of that judgment).

MH: treatment misguided

In this case, MH had received medical and nursing treatment over a period of five days in hospital and his true condition was correctly diagnosed. Nonetheless, it was argued that the treatment given was so misguided that it was of little more use than no treatment at all. The coroner accepted that in the circumstances the verdict could properly be left to the jury. Essentially, the test was here broadly applied to allow a jury to consider whether or not medical treatment actually given was so poor (or irrelevant to the patient's true condition) as to amount in fact to a gross failure to provide basic medical attention.

The correctness of this approach has now been confirmed by the Court of Appeal in R v HM Coroner for Inner London North, ex p Touche (21 March 2001, unrep). Mrs Touche died at the Portland Hospital of a cerebral haemorrhage 11 days after giving birth to twins, and the inquest heard expert evidence to the effect that the failure to monitor her blood pressure and identify severe hypertension was 'astonishing'.


It is encouraging that the courts are no longer prepared to ignore issues relating to the quality of treatment at the inquest stage; it is to be hoped that some of the delays, cost and risk of clinical negligence litigation may be alleviated by this early scrutiny.

It also underlines the need for families to be properly represented at the inquest stage: in the recent case of R v HM Coroner for Inner West London, ex p Scott (13 Feb 2001, unrep), for example the family's solicitor conceded at the inquest that neglect was not open to the jury where a suicidal schizophrenic man hanged himself in custody. The Administrative Court (Keene LJ and Penry-Davey J) were persuaded otherwise and, quashing the jury's verdict, ordered a fresh inquest.

Patricia Hitchcock is a barrister practising from Cloisters chambers. Ross Brain is a solicitor in the clinical negligence department at Kingsley Napley.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on

Click to Login as an existing user or Register so you can print this article.

In association with
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at and we will use commercially reasonable efforts to determine and correct the problem promptly.