Clinical negligence and the insistent patient, and forgiving the expert’s inexcusable behaviour.

A useful reminder of the expert’s duty of care when a patient demands treatment, and an interesting example of a judge criticising an expert’s behaviour while not regarding it as fatally damaging the expert’s evidence, arose in the case of Holdsworth v Luton and Dunstable Hospital [2016] EWHC 3347.

The insistent patient

The claimant underwent repeated knee replacement surgery (unicompartment followed by total knee) for persisting joint pain and was left with severe and disabling chronic pain.  Her case was that no reasonably competent surgeon would have carried out the first replacement surgery on her given her presenting circumstances.  The judge accepted the defendant’s evidence that the claimant had made it abundantly clear to the surgeon that she was intent upon having knee replacement surgery which she saw as the solution to her pain.  That fact however was irrelevant to the issue of whether the surgeon’s decision to carry out the surgery was negligent.

But I stress (and it needs to be stressed) that the mere fact that a patient is insistent about receiving a certain type of treatment does not and cannot, of itself, justify such treatment being provided.  The mode of treatment must always be a clinical decision based upon a clinical assessment as well, of course, of taking into account the patient’s wishes.”

Excused inexcusable behaviour

Seeking to revise a joint statement (following a joint discussion) setting out the expert’s view after signing off on it is extremely unwise and unprofessional behaviour, whatever the excuse or explanation.  It throws serious doubt at the reliability of the expert’s opinion and demonstrates the expert’s lack of understanding of the role and importance of the whole process of the joint discussion and production of the joint statement.  One of the experts in Holdsworth did precisely this, then appeared to get away with it, but in the end had his expert opinion rejected by the judge.

I bear in mind the justifiable criticisms which are made of Professor X in the way in which he dealt with revision of the experts’ joint statement after he had signed it off. I find his explanation of dyslexia as a reason for attaching his signature to the original joint statement, the contents of which he did not agree, somewhat baffling. I should record that Professor X was clearly embarrassed about the way in which he had dealt with the joint statement. However, I should equally make it clear that in evaluating the respective merits of the experts’ opinion, I do not attach any weight to his somewhat unprofessional approach to the preparation and revision of the joint statement. The reality is that, in the main, the views he expressed in evidence were properly reflected in the original draft of the joint statement.”

Failing to demonstrate independence of thought or failing to comply with the duty to assist the court is usually fatal to the expert’s credibility and the expert’s standing as an expert.  In Holdsworth the judge concluded that the opposing expert had become ‘an advocate in the cause’ in expressing his very positive view of the chances of success of the joint replacement surgery.  In some cases that would be enough to see that expert’s evidence rejected for all purposes.  However on important issues in dispute the judge still accepted the expert’s opinion because “I am satisfied that, in the main, he was giving his genuinely held opinion to the Court and doing his best to assist the Court.  In particular, the Court is bound to be impressed by his candour that he himself would not have carried out [the initial joint replacement surgery] in these circumstances.”


Two surprising escapes from disaster for the experts involved, but not escapes from serious criticism.  In 9 cases out of 10 the judge would have responded very differently and much less favourably to the credibility of the experts in the light of such criticism.

[Who or what is medico-legal minder?  Terms and conditions apply]

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