In Bell v Bedford Hospital NHS Trust [2019] EWHC 2704 (QB) the claimant established clinical negligence but failed to prove causation.



The claimant suffered a major stroke that left her with significant permanent disabilities.  She claimed that there had been negligence on the part of clinical practitioners in failing to note and treatransient ischaemic attacks (TIAs) in the period up the the major stroke.


HHJ Deborah Taylor found that the failure to make a diagnosis of TIA on several occasions was negligent.


The judge then considered the issue of causation.  In particular the claimant had a history of not responding to or complying with the recommendations of health professionals.

Had Ms Bell been diagnosed with a TIA, or kept under review as having a possible TIA what treatment and advice would she have received?
    1. It is Ms Bell’s case that had she been diagnosed with a TIA or even a possible TIA a more intensive approach would have been taken, by her family and by medical practitioners. She would have been coded for TIA at her GP practice, and dosage and compliance would have been regularly checked and increased as appropriate to ensure that hypotension, cholesterol levels and blood pressure were kept at acceptable limits.
    2. Dr Bowler’s opinion was that the treatment and advice would have been the same. Ms Bell would have, as she had been, advised to make changes in her lifestyle, to stop smoking and to take her medication. She would have been, as she had been, prescribed statins for her cholesterol, aspirin and blood pressure medication.
    3. An important aspect, in my judgment, is that it is agreed Ms Bell had already been prescribed the same type of medication, and given the same advice on stopping smoking and losing weight as she would have been given had a possible TIA been diagnosed in either October 2009 or January 2010. Even if a definite diagnosis of TIA had been made (and Professor Brown did not go this far in evidence), again, the range of medication and advice would have been the same.
    4. The evidence of Dr Hawarth, supported by Professor Brown was that if a positive diagnosis of TIA had been made, Ms Bell’s notes would have been marked accordingly, and engagement with her GPs would have been more targeted and better monitored. It was as a result more likely that compliance with medication, and cessation of smoking would have been achieved. Dr Haworth said in evidence that he believed that Ms Bell would have been asked to come back for review more frequently if she had been coded as having suffered a TIA on the GP’s computer. If she had attended for review, she may have been given higher doses of statins or anti-hypertensive medication to control her cholesterol level and blood pressure.
    5. Insofar as different dosage would have been given, there is no evidence that this would have involved more than subtle increases or decreases. At one stage Ms Bell was taken off aspirin, which was reinstated by Dr Cox. Dr Hawarth agreed that there was a balance between the gastric effects of continued use of aspirin, and its accepted efficacy in preventing stroke.
    6. In any event, any monitoring or changes in drug regime were dependent on Ms Bell attending and complying.
Would Ms Bell have been compliant in taking medication and/or in following the advice given?
  1. There was general agreement between Dr Hawarth and Dr Budd that research evidence and their own experience showed better adherence to medication as secondary prevention as opposed to primary prevention. Dr Budd’s opinion was that there was no clear reason to suppose that Ms Bell would have followed medication advice any more assiduously.
  2. Dr Hawarth said in cross examination that even if Ms Bell had no firm diagnosis, but believed she had a TIA, whether she was as influenced by that would depend on her level of understanding and the full facts being available to her. The degree of compliance was dependent on the GP – those with more skills of persuasion and able to form a rapport were more likely to achieve better results. Whilst he believed that Ms Bell’s compliance would have been improved by a diagnosis of TIA, he could not say that it was more likely than not that she would have taken her medication every day as prescribed, but that she was likely to have taken more medication than before.
  3. Dr Hawarth was referred to the paper Medical Adherence-where are we today? and the range of factors affecting compliance. There are a number of factors in the section headed Patient- Related Dimension which may apply to Ms Bell in this case, in particular, confidence in ability to follow treatment, motivation and psychosocial stress.
  4. Statistical research data needs to be considered against the factual evidence in individual cases. It is clear from the letters and notes from Ms Bell’s GP practice, that irrespective of diagnosis, considerable effort was put in to supporting her and providing advice, encouragement and support in stopping smoking. Requests and reminders to attend for monitoring of blood pressure were sent and ignored. Dr Rashid insisted that Ms. Bell have an appointment with Dr Elmarimi despite his reluctance. Dr Mehta gave strong advice about compliance. The notes show that Ms Bell believed she had a TIA, and that there was a continuing belief at the practice that she may have had a TIA. Nonetheless, Ms Bell’s attendance at appointments and compliance with medication was poor. According to Mrs Ursell there had been some improvement after Dr Mehta’s advice. The incident on 9 March and the subsequent stroke were during this period of reported compliance.
  5. I conclude that even if Ms Bell had been given a diagnosis of possible, probable or definite TIA, and advised of any necessary changes in her lifestyle in October 2009, on a balance of probabilities she would have been no more compliant with medication, stopping smoking, or losing weight for any more time than previously, nor in a way which would have made a difference. Similarly, had she been diagnosed with a possible, probable or definite TIA in January 2010, it is unlikely that her ability to make changes in her lifestyle and compliance with taking medication would have improved. The history apparent from her notes shows numerous attempts to give up smoking, failures in compliance with advice given and failure to take medication prescribed. The stress of aspects of her life is understandably given as a reason for her inability to effect change. This is one of the factors identified in the research paper referred to above as affecting adherence. Those stress factors remained.
  6. In addition, the evidence from the notes and from Mrs Ursell is that, even though this was not Dr Elmarimi’s view, Ms Bell believed that she had had a TIA, knew of the family history of stroke, and was aware of her own medical risk factors. Against that background she had been advised very strongly by doctors at her own surgery as well as on visits to hospital of the need for compliance, but had not managed to achieve it on a concerted continuing basis.


Even if the claimant had been compliant the judge found that she had not established that appropriate treatment would have prevented the stroke given that the precise cause of the stroke had not been established.

    1. Professor Brown further asserted that the recurrent nature of the TIAs was an indicator that the cause was atherosclerosis rather than other potential causes. However, there was no support he could find in the literature for the proposition that atherosclerosis could cause recurrence of the pattern in this case: TIAs three months apart, followed by another TIA over two years later, followed by a stroke.
    2. In cross examination as to the cause of the stroke, Dr Bowler said that it was unknown. Whilst there were other alternatives, such as dissection and cardio embolic causes, as with atherosclerosis, there was no evidence as to either being the cause. Dissection was more likely than cardio embolic causes, and dissection could recur in different arteries with healing between events. The fact that the MRA after the stroke did not show dissection did not mean there was none, as it may have healed. Professor Brown considered that dissection was an unlikely cause as dissection in the carotid was often fatal, and dissection overall was unlikely to recur in the same place at the intervals in this case.
    3. Professor Brown’s view that the cause of Ms Bell’s stroke was atherosclerosis is based upon the overall picture of Ms Bell’s history, and a reliance on the Castaigne paper. In my judgment, the paper does not provide sufficient support, having regard to the ages of the research group, where age is an important factor. Further, this is a small study, carried out post mortem. Even in this study atherosclerosis of only the basilar artery, upon which Professor Brown’s views are based, is lacking on analysis. The literature as a whole is more supportive of the opinions of Dr Stoodley and Dr Bowler that basilar artery atherosclerosis comes late in development of atherosclerosis which more commonly involves the wider arterial system. That wider development is not supported by the 2012 MR angiograms. Similarly, the angiograms show no evidence to support dissection as a cause. Nor was any support for Dr Bowler’s views to be found in the medical literature.
    4. The burden is on the Claimant to prove causation. In this case, there are two potential causes, atherosclerosis and dissection which each have substantial factors on the evidence which render them equally unlikely. There is a third potential cause cardio embolism which is even more unlikely. I am therefore unable to conclude that the Claimant has succeeded in proving on a balance of probabilities that atherosclerosis was the cause of the stroke she suffered, and that as a result adherence to medication and advice given after a diagnosis of TIA would have prevented the stroke occurring.
  1. Whilst the Claimant has succeeded in proving breach of duty in this case, she has failed to prove causation. The claim must be dismissed.