> I would refer list members to the Bolitho judgement but
> basically the defendant
> (Healthcare Trust) succeeded as the failure to intubate was
> according to accepted
> opinion (despite plaitiffs expert evidence to the contrary)
> AND was SENSIBLE
> given the risks of RSI in a young child.

Not quite. Bolitho failed on causation- it was negligent for the registrar
not to attend the child. However this act of negligence did not cause the
damage as expert opinion held that it was likely that had she attended she
would not have intubated. The issue was not whether intubation was sensible
but whether it would have been done. The registrar was negligent in her
actions but the injuries would still have occurred had she not been.
However on the standard of care issue, Bolitho (particularly the judgement
of Dillon LJ) allowed the courts to reject a body of medical opinion if
satisfied that 'the reasons of one group of doctors do not really stand up
to analysis'.
Another case of note is Smith v Tunbridge Wells HA from 1994- on consent for
TURP, failure to warn of impotence was held negligent although at the time
of the incident that was the practice of some surgeons because the judge
felt it neither reasonable nor responsible.

> It seems however that a plaintiff could now successfully
> argue that "full immobilisation
> would be safest until the spine can be cleared" as this would
> be the sensible
> thing in lay opinion, despite a "reasonable body of medical
> evidence" that may
> say full immobilisation would not necessarily always be
> appropriate.

There is scope (under Bolitho) for a court to accept the plaintiff's
argument that there is no evidence for the safety or efficacy of full
immobilisation. Unlikely but possible

> Full immobilisation
> may considered a cheap, non-hazardous intervention, so little
> harm result; the
> argument against is of course pain, pressure sores, and
> potential harm occuring
> during the immobilisation procedure. (yet to be tested in law).

If a patient suffers a pressure sore (as many do) it is no defence to say
that this is a rare complication. In that case it occurred. Conversely,
there is the theoretical risk of spinal injury from not using a board. I am
not aware that this is an actual risk.
Overall, use clinical judgement. The decision to use or not to use a board
should be based on this rather than defensive practice.

Useful questions for study:

1. Are spinal cords ever injured from 'normal' movement in A and E
departments/ wards (as opposed to during extrications)?
2. Does spinal 'immobilisation' prevent this (and I am aware of studies
suggesting that longboards or collars have little effect on movement of the
unstable neck) and if so, what are the effective interventions?
3. What is the incidence of serious side effects (raised ICP, pressure sores
etc.) from each of these interventions.

Has anyone done a formal literature review?


Matt Dunn
Warwick


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