Source: http://ukhealthcarelawblog.co.uk/other-blogs/2-uncategorised/73-the-ten-rules-of-nervous-shock
Timestamp: 2019-04-21 22:50:37+00:00

Document:
Rule 1: The court will (almost) always be sceptical and unsympathetic.
Rule 2: Alcock remains the law. It is arbitrary and unfair.
Rule 3: It is almost impossible to win a secondary victim claim.
Rule 4: Your best hope is to make your client a primary victim.
Rule 5: ‘Shocking’ requires something truly extraordinary.
Rule 6: Walters was correctly decided but will rarely be followed.
Rule 7: Shock is required, neither ‘mere death’ nor a gradual decline will ever be enough.
Rule 8: A gap in time between breach and injury is a huge hurdle.
Rule 9: We should keep fighting these cases, but only the very strongest ones.
Rule 10: Great care is required with factual & expert evidence (including C&P reports).
1. The first rule of nervous shock is, I am afraid, that you are going to struggle to succeed with your claim. The court will almost always be sceptical and unsympathetic (even if the judgment asserts otherwise).
2. Historians looking back on nervous shock claims will see a golden decade from December 2002, when we had that excellent and humane decision of the Court of Appeal in Walters v. Glamorgan. In that period, which coincided generally with a benign attitude towards the settling of cases by the NHSLA, you could happily ‘piggyback’ a claim by a secondary victim on that for the primary victim. For example the parent or spouse of a sick patient could reasonably expect to settle a claim for £10,000 plus reasonable costs. It came as a shock therefore when the Court of Appeal found in the Defendant’s favour in Taylor v Novo in March 2013. At that point, just as the NHSLA was adopting a more robust approach to fighting clinical negligence claims, it seems that a decision was made to fight all secondary victim claims.
3. If you look back over the years it is striking just how few big nervous shock decisions have been in favour of claimants. The phrase ‘nervous shock’ was first used in Victorian Railway Commissioners v. James & Mary Coultas (1888) 13 App. Cas. 222.
4. The facts sound like something out of a Victorian melodrama. At about 9pm in the evening on 8th May 1886 Mary Coultas, her husband and her brother were driving home from Melbourne, Australia. They were in a buggy which was pulled by a horse. They had to cross a railway line. When they got to the level crossing the crossing keeper opened the first gate and were part way across when they saw a train coming fast towards them. The keeper shouted to get back but James Coultas yelled at the keeper to open the opposite gate. He urged on the horse. As the train approached Mary Coultas fainted and fell forward in her brother’s arms. The buggy lurched forward, the train whistled past, missing them by a fraction.
5. The jury found that the level crossing keeper had been negligent in opening the first gate and inviting the plaintiffs on to the crossing when it was not safe.
8. Their Lordships were not going to give damages for mental illness caused by ‘mere sudden terror’.
10. In other words it would lead to too many claims and to made up claims. That could not be permitted.
11. It took over a hundred years for this obvious injustice to be corrected. In Page v Smith  AC 155 the House of Lords finally accepted that someone who might have suffered physical injury from the Defendant’s negligence but had not, could recover damages for psychiatric injury. In that case the claimant though not physically injured in a low speed road collision had developed chronic fatigue syndrome as a result of the shock of the accident. Lord Lloyd famously distinguished between primary and secondary victims, holding that in the case of a primary victim foreseeability of physical injury alone was sufficient to enable the claimant to recover in respect of psychiatric injury.
12. The real breakthrough in what we call ‘nervous shock’ claims came with McLoughlin v O'Brian et al  1 AC 40, Lord Wilberforce accepted that physical injury was not necessary for a successful claim for psychiatric injury. A mother who came to hospital and found her family in the immediate aftermath of a serious road accident was entitled to damages for her psychiatric injury.
d. fourthly, that the injury suffered arose from witnessing the death of, extreme danger to, or injury and discomfort suffered by the primary victim.
e. Lastly, in each case there was not only an element of physical proximity to the event but a close temporal connection between the event and the plaintiff's perception of it combined with a close relationship of affection between the plaintiff and the primary victim.
15. I have no difficulty with limiting the number of permissible claims. I agree that you could not permit a situation where all of Michael Jackson’s fans could sue his anaesthetist for their own mental suffering.
16. My complaint is that the categories of claimant are just too limited. I simply do not understand why a father who witnesses a stillbirth or whose child is seriously injured at birth should not be entitled to damages for that injury.
18. So Lord Steyn was accepting that the law made no sense and it was unfair. He was saying that if you want reform in this area it would have to come from Parliament and that in the meantime the courts would have to just do the best that they could. I have two problems with this. Firstly there is no prospect at all of Parliament tackling nervous shock. Secondly, by saying ‘thus far and no further’ we are now stuck with an increasingly anomalous view of psychiatric injury.
19. We look back now at the First World War generals who dismissed the suffering of shell shocked soldiers as a lack of moral fibre. Attitudes towards mental illness are at long last changing, and particularly in the last few years. The problem for us, and our clients, is that just at the time when society is beginning to understand mental illness better the courts have chosen to dig their heels in and revert 25 years to the November 1991 position taken in Alcock. Perhaps we shouldn’t be surprised, greater understanding of mental illness has taught us that it is more prevalent than previously understood which might make the courts more fearful not less of extending the categories for recovery of damages.
Lexi-Rae Speirs & Gemma Powell v. St Georges, QB, HHJ Simon Brown QC, December 2014. The ‘shocking’ component of a mother’s psychiatric injury was caused by seeing her daughter in an incubator 14 hours after birth rather than seeing the bruising from a negligent ventouse delivery immediately after birth. Therefore the mother was a secondary rather than a primary victim and did not satisfy the Alcock criteria because the negligent event – the delivery – had not caused the mother’s injury.
Wild v. Southend, Michael Kent QC, 3.12.14,  EWHC 4053 (QB) the facts of Alcock were analogous to those of the instant case in which W had experienced a growing and acute anxiety which started when the midwife failed to find a heartbeat and developed because of the staff's behaviour. W's experience did not equate to actually witnessing horrific events leading to a death or serious injury.
Brock v. Northamptonshire, QB, December 2014.  EWHC 4244 (QB), the primary victim was a teenage mum who had taken a paracetamol overdose. She was waiting for a kidney transplant when she was killed by the negligent insertion of an intracranial pressure bolt deep into her brain. Her parents went in the space of some 12 hours from believing that she would receive a lifesaving transplant to being told that she had suffered massive brain damage, would not receive a transplant, was almost dead and then switching off her life support machine. HHJ Yelton.
Ronayne v. Liverpool Women’s,  EWCA Civ 588. June 2015. The claimant saw his wife connected to various machines and the next day he observed her in her post-operative condition, unconscious, connected to a ventilator and being given four types of antibiotic intravenously. Her arms, legs and face were very swollen. Pressure pads were in place. Later he described his wife’s then appearance as resembling the “Michelin man” (a description treated by the CA with some scepticism).
Morgan v Somerset Partnership NHSFT, Bristol CC, February 2016. Where the Trust had admitted negligence in its treatment of the primary victim who had committed suicide his wife, who suffered an adjustment disorder after finding him with cut wrists in the family garage had her claim struck out. She could not show sufficient proximity to the negligent treatment.
Young v. Macvean  CSIH 70, February 2016, a mother was on her way to the gym when she saw a badly damaged vehicle behind a police cordon. Several hours later she was told that her 26 year old son had been in the vehicle and had died. She argued unsuccessfully that being informed of what had happened when she was no longer at the scene was part of the aftermath and that she was therefore entitled to damages for her psychiatric injury as a secondary victim.
c. cases where more than one person is advised of a diagnosis.
22. In Farrell v. Merton (2001) 57 B.M.L.R. 158: mum claimed for the psychological consequences of the trauma of the birth, which comprised the shock of having to undergo a caesarean operation, the shock upon learning of her child's condition, long term depression and anxiety. She contended that although she had not been permitted to see her son or told about his condition until he was one day old, there had been no break in the chain of causation between his birth and her first sight of him with the result that she was liable to be compensated as a primary victim in respect of psychological complaints which were still ongoing. The Defendant submitted that the cause of F's psychiatric illness was not the events surrounding the birth, but F's gradual realisation of K's condition. It maintained that such realisation was wholly unrelated to their breach of duty to her son with the result that F was only eligible for compensation as a secondary victim.
“I am satisfied that there is no break in the chain of causation and that the “trauma of the birth” encompasses not only the events in the operating theatre but also the position up to and including the first sight of her baby and the realisation (when told by the Paediatric SHO) of his disability. I therefore treat her as a primary victim.
“55 Since the pursuer in the present case actually suffered physical injuries as a result of the defenders' fault and negligence, the starting point is that he is a primary victim in terms of Lord Lloyd's classification. Mr Smith argued, however, that the pursuer's psoriasis and his depressive illness sprang not from the accident itself but from his anger at the happening of the accident. Hence he could not recover damages. I see no reason to give effect to such a distinction, even supposing that it can be realistically drawn in a given case. Regret, fear for the future, frustration at the slow pace of recovery and anger are all emotions that are likely to arise, unbidden, in the minds of those who suffer injuries in an accident such as befell the pursuer. If, alone or in combination with other factors, any of these emotions results in stress so intense that the victim develops a recognised mental illness, there is no reason in principle why he should not recover damages for that illness.
56 Not only is there no hint of the distinction advocated by Mr Smith in Lord Lloyd's speech in Page v Smith, but indeed the whole thrust of the speech is to quite the opposite effect. On Lord Lloyd's approach, all that matters is that the defenders were in breach of their duty of care not to expose the pursuer to the risk of personal injury and that, as a result of the breach, the pursuer suffered both physical and psychiatric injuries. The defenders are liable in damages for both types of injury and, in particular, for the exacerbation of the pursuer's psoriasis and for the depressive illness which followed—even if those developments were not reasonably foreseeable. Moreover, as the Second Division rightly held, 2003 S.L.T. 62 , 67E, it does not matter whether a psychologically more robust individual would have recovered from the accident without displaying either condition: the defenders must take their victim as they find him.
25. This case seems to me very important in childbirth cases where a mother has suffered psychiatric injury. Unless the circumstances of the birth would have been identical even without the Defendant’s negligence then we can argue with considerable force that where a psychiatric injury has been more than negligibly contributed to by the circumstances of the birth (as opposed only to a reaction to events subsequently) then mother is a primary victim and entitled to damages in respect of the whole of her injury.
26. For the importance of considering the whole circumstances of the birth see also Jones v Royal Devon and Exeter NHS Foundation Trust, QB, 20 March 2008, (2008) 101 B.M.L.R.154, King J. There was a claim for psychiatric injury by the mother of a child who died the day after delivery following ischaemia at birth (in utero). There was no suggestion by the Defendant that the mother was not a primary victim. In this case there was a helpful analysis from the obstetric expert, Mr Forbes, as to how the circumstances of the delivery and the anxiety faced by the Claimant during the delivery would have contributed to her overall injury.
27. See also Tredgett v Bexley Health Authority  5 Med. L.R. 178 where HHJ White found that both parents were primary victims and that the ‘event’ of birth lasted for some 48 hours from delivery. Although the classification of a father as a primary victim is in my view unlikely to be followed this case which was approved in Walters, lends support to the concept of the ‘extended event of birth’ which in turn helps to bring the mother and any injury she suffers firmly within the scope of the duty owed to a primary victim.
29. Of course even if mum is a primary victim you need to prove that the injury she suffered was contributed to by her participation as a primary victim – for example if the evidence is that the mother’s psychiatric injury had nothing to do with having given birth but was entirely explained by the dawning realisation some months later that her child was profoundly disabled then you will be vulnerable to the defence that the psychiatric injury has in fact nothing to do with the birth and that therefore for the purposes of the injury the mother is a secondary victim.
3128. This scenario is probably the most difficult. It is where a couple attend an appointment together and are given an incorrect diagnosis, for example of cancer. I don’t see why in principle, if the facts are right, you should not argue that a duty is owed to both of those attending and receiving the incorrect diagnosis.
3229. There is some support for this argument in the context of private consultations, where a duty exists in contract rather than just tort. In Less v. Hussain  EWHC 3513 (QB) a woman received negligent pre-conception advice from a private gynaecologist. She became pregnant and lost the baby at 26 weeks. She established breach of duty but failed on causation, the court finding that she would have chosen to become pregnant even with non-negligent pre-conception advice. HHJ Cotter QC went on to deal with the father’s claim for psychiatric injury. There was a dispute as to whether he had suffered psychiatric injury rather than ‘distress’ at the bereavement and the judge found that in any event there was no shocking event in the Alcock sense.
330. He went on to accept Katie Gollop QC’s submission for the Claimants that in principle damages for mental distress could have been awarded in contract to the father – because the consultation had been intended to seek peace of mind, by analogy with holiday and home improvement cases. On the facts he found that there was not in fact a contract between the father and the doctor, but did accept that circumstances might have been different. He relied heavily on the approach of the Court of Appeal in Yearworth v. North Bristol NHS Trust  EWCA 37 – where claimants were awarded damages for mental distress after frozen sperm that they had stored prior to chemotherapy was inadvertently destroyed.
34. The key point arising from each of these three very different scenarios is that when one door closes (conventional secondary victim claims) it is important to keep pushing and probing and looking for another way to achieve a just result. It may be that extending the categories of primary victim is a better solution than flogging a dead horse with claims by secondary victims.
362. Once you read this you might be forgiven for packing up and going home.
373. It begs the question how bad do things have to get to qualify as horrifying in hospital. Looking back at the list of recent cases we can see that out of brain haemorrhage, stroke, unsuccessful resuscitation of newborn babies, the death of babies, none is sufficient. You might think of this as a scale from 1 to 10. Scores of 1 to 3 are events so minor we would never have brought a secondary victim claim even before the recent tightening of approach. Scores 4 to 7 were probably enough in the old days but no longer. All the unsuccessful cases in recent years have been somewhere 4 and 7. What we are looking for now is a score of 8, 9 or 10. To get to this end of the scale you need some extra ingredient which takes the case out of the ordinary.
384. I think that if Walters were being decided today by a differently constituted appeal court, that which decided Ronayne for example, then the defendant’s appeal would probably have succeeded.
“The final events leading to Elliot’s death started at about 3am on Tuesday July 30, 1996, when his condition deteriorated significantly. The claimant was at that time sleeping in the same room as Elliot at the Prince Charles Hospital. She awoke at about 3am to hear Elliot making small choking noises in his cot; the claimant saw that there were large amounts of what was described as ‘‘a coffee ground blood substance’’; his body was stiff. She took Elliot to a nurse. The nurse told the claimant that Elliot was having a fit, though she did not appreciate that the fit had lasted an hour. The hospital notes record Elliot as being in a Grade 3 coma, responding only to deep pain. Elliot was transferred to the Intensive Care Unit of the Prince Charles Hospital at 4.15am. The claimant was told by a doctor at 4.45 am that it was very unlikely, and it would be very unlucky, if Elliot had any serious damage as a result of the fit. After speaking to the doctor she thought that Elliot might at worst be slightly brain damaged; she did not think it was life threatening. In fact Elliot had suffered a major epileptic seizure leading to a coma and irreparable brain damage.
At about 11am that day the claimant was told by a doctor at the Prince Charles Hospital after a CAT scan that there was no damage to Elliot’s brain, but that he wanted him transferred to King’s College Hospital, London, for a liver transplant. Eventually later that day an ambulance arrived and a medical team took Elliot to London where he was admitted at 6.30pm; a further CAT scan was carried out which showed universal attenuation in both cerebral hemispheres; it was interpreted as showing diffuse brain injury consistent with a profound hypoxic ischaemic insult.
The claimant had followed the ambulance in a car with Elliot’s father and arrived at King’s College Hospital at about 9pm that evening. She was seen by three doctors. They told her that Elliot had suffered severe brain damage as a result of the fit and he was on a life support machine. They told her that if a liver transplant was undertaken, the chances of survival were only 50–50 and he would be severely handicapped. The claimant described her feelings as being numb, panic stricken and terrified at the sudden turn of events; she had been told at the Prince Charles Hospital that he could have a liver transplant and she had been told then he could not. The consultant paediatric heptologist at King’s College Hospital described her as ‘‘stunned’’.
4036. The simple point is that the start of the ‘seamless tale’ was the mother waking to find her baby stiff. He was not convulsing or shaking, or frothing. There was a small amount of vomit (coffee grounds) on the cot sheet. Neither she nor the nurse thought there was much wrong at the time. The real shock comes after transfer to London when she is described as seeming ‘stunned’ when she is told that his chances are 50/50. He has a further CAT scan the following day and a decision is made to switch off the life support machine. I don’t underestimate any of the ‘shock’ involved but this was, to borrow the phrase of Tomlinson LJ in Ronayne, hardly unexpected in context.
4137. I think we have to accept the reality that there has been a stiffening of resolve in the High Court and the Court of Appeal. Walters has become a mythical fairy tale which allows it to be justified as something exceptional.
"I was shocked by what I saw. Katherine looked completely different to how she had been in the recovery room. The nurse explained to me what the machines were for. I held Katherine's hand and I spoke to her. I spoke to her for a long time and I spoke to her as if she was still with me. I can remember saying to her that there were all these George Clooney lookalikes on the ward, and she was missing them. I also talked about when we were going on holiday. I can recall that the nurse heard me speaking to Katherine. She told me to keep going and to keep talking to Katherine because she said that the hearing was the last thing to go. My reaction to this was 'what do you mean? Are you telling me she's going to die?' The nurse said it was a possibility and that the doctors were going to come and talk to me. The incident was an incredible shock to me. This was the first time that there had been any intimation that the condition that Katherine was in was possibly going to be fatal."
451. You will all know about Taylor v. Novo  EWCA Civ 194 which in March 2013 heralded the firestorm that has all but destroyed secondary victim claims. Crystal’s mum injured her foot when some shelving fell on her at work. 21 days later she collapsed in front of Crystal at home with a PE caused by a clot from her injured ankle. She suffered PTSD and won at first instance. The Court of Appeal accepted the Defendant’s argument that there was insufficient proximity between the breach of duty and the daughter’s injury. It would have been different if the collapse had taken place at the same time as the original injury.
“On Tuesday July 16, 1996 she noticed that the colour of Elliot’s eyes looked different. On July 17, 1996 she took him to see her general practitioner. He referred Elliot to the Prince Charles Hospital at Merthyr. Elliot was seen that day at the Prince Charles Hospital. Thereafter he was treated under the care of the Prince Charles Hospital, most of the time as an in-patient, but part of the time as an outpatient. The claimant was with him during his treatment.
Elliot was in fact suffering from acute hepatitis which led to fulminant hepatic failure. It is accepted by the defendants that he was not properly diagnosed or treated by the Prince Charles Hospital. The defendants also accept that if Elliot had been properly diagnosed and treated, he would have undergone a liver transplant and lived. It is not therefore necessary to set out the precise course of treatment and events until the period immediately preceding his death. It is, however, necessary to set out the events of the last two days as it is common ground on the psychiatric evidence that they caused her psychiatric illness.
473. This ‘Walters gap’ is just not addressed in Taylor v. Novo. There are no cases of which I am aware where this point has been tackled head on within a clinical negligence context but you can see how it might arise in cases where there has been a failure to diagnose a DVT and then injury occurs to both primary and secondary victim three weeks later (i.e. unlike Taylor v. Novo there is no initial injury); or with a failure to diagnose an acute coronary disease and the primary victim drops dead after several months.
“209 Cases of clinical negligence present particularly difficult problems. The factual background of cases can be very different and often quite complex. The nature and timing of the “event” to which the breach of duty gives rise will vary from case to case.
495. Given the approach of the courts, the likelihood of the NHSLA fighting any nervous shock case to trial, the expense of issuing a claim and the reality that you will only be paid for winning I would not blame anyone who placed a blanket ban on their firm pursuing any secondary victim claim.
5046. At the same time, if we wanted only to do easy cases we would not have become clinical negligence lawyers. In my view despite all the problems identified there remains a glimmer of hope. These cases go in cycles and we may be in a death spiral for secondary victim claims but this will not continue for ever. Our hope must be that it doesn’t take as long for the recovery to start as it did after the Coultas case of the Victorian railway.
5147. So where is the hope? It lies in recognising that no one has banned secondary victim cases. The bar has not been placed impossibly high. If you pick the right case, a real stomach churner, where you have supportive expert evidence then your appeal to the court can be that yours is a Walters case.
5248. I think the way forward is best demonstrated in Galli Atkinson. There a mother had been told that her 16 year old daughter had been killed in a road accident, she went with her husband and other daughter to the mortuary and saw her daughter there. At first instance the claim failed because the recorder considered that her injury had been caused by being told of her daughter’s death, rather than seeing it herself and because seeing her daughter at the mortuary did not constitute the aftermath.
“5. … the appellant fell to her knees, sobbing uncontrollably. She would not be helped to her feet but crawled to where Livia lay on the trolley bed. She pulled herself up and saw Livia's injured face and the upper part of her body, although the lower part, which was grotesquely distorted, had been covered by a blanket. She cradled her, saying that she was cold. Seeing and holding Livia's body must have been devastating to the appellant. Although the worst injuries were hidden, her face and head were disfigured.
“23. Whether we like it or not, we are constrained to approach the question of psychiatric injury in cases such as the present on the basis of what Lord Lloyd described in Page v Smith  AC 155 at 189, as the “control mechanisms” identified by Lord Ackner. This is clear from the speeches of Lord Steyn and Lord Hoffmann in Frost v Chief Constable of South Yorkshire  2 AC4 55 , with both of whose speeches Lord Browne Wilkinson agreed. Both of their Lordships recognised that the law produced an unsatisfactory result. But both made it clear that the courts had to apply them, however unsatisfactory the result, unless and until Parliament intervened.
24. We have to consider therefore whether the appellant's present psychiatric condition which, as I have already said, has been accepted as being a condition which is capable of founding a claim for damages, was caused by shock resulting from her appreciation of an event or its immediate aftermath in the sense intended by Lord Wilberforce in McLoughlin.
551. I think one reason why so many nervous shock claims have failed in recent years is that they have been brought, understandably, as ‘bolts-ons’ to the main event. Their value and importance has not justified the same rigorous approach as we would normally apply to a clinical negligence claim.
562. My suggestion is that whilst 9 out of 10 potential secondary victim claims should now not be pursued for the 1 out of 10 that are you need to go full throttle.
• You need to identify the factual, legal and expert basis for your claim before you notify the defendant of the potential claim.
• You need to make sure that even your C&P evidence is consistent with your nervous shock argument – you don’t want to be vulnerable to the argument that you have tightened up the argument later in response to a defendant’s Alcock argument.
• You need to make sure that in every communication with the dDefendant, every witness statement and your expert evidence you are emphasising the horror of what happened.
• You should acknowledge that such claims will normally fail and make clear that you see your claim as different and explain why. The Defendant needs to be made to feel at risk.
• You need to emphasise ‘exceptionality’ – the court will only find for you if you can persuade the judge that he/ she is not in any way diluting the ‘party line’ or ‘we don’t do secondary victim claims’.
• You need to develop a ‘narrative’ or to use LJ Ward’s phrase a ‘seamless tale’. In both Walters and Galli-Atkinson it is clear that the court wanted to find for the claimant, you have to make the court want to find for you and then give the judge the necessary ingredients.
• You should make a properly costs-protective part 36 offer.

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