The concept of medical negligence is one of the most important issues in Torts outlining the boundaries of negligence and human error committed by medical professionals. The analysis of Robinson V. Post office and Another [1974] 1 W.L.R. 1176, a case of the English law, offers insight into the implications of medical negligence in torts. The case analysis is structured in the following sequence: Facts, Arguments and Analysis.

Facts:
On February 15, 1968, in the morning. Mr. Robinson, a 34-year-old post office employee fell from a ladder (which is the property of and maintained by the post office) while coming down from one of the post office tower trucks. The ladder became slick as a result of oil leaking from a pump, resulting in him suffering a three-inch wound on his left shin.

Despite the injuries, he persisted in his work till his shift concluded at 5.30 p.m., subsequently seeking medical attention from his general practitioner, Dr. McEwan. Following a short investigation into the timing of the injury and the patient's medical background, Dr. McEwan administered an Anti-Tetanus Serum (referred to as ATS hereafter). After a period of nine days in good health, the plaintiff was then hospitalized and diagnosed with encephalitis, a medical condition resulting from ATS exposure. This sickness ultimately caused brain damage and permanent partial disability.

On March 12, 1968, he initiated legal proceedings against the Post Office, seeking financial reparation for the harm he endured due to brain injury. During the trial, the post office acknowledged responsibility for the plaintiff's shin damage but denied responsibility for his brain damage, asserting that it was caused by the doctor's medical negligence. Consequently, the plaintiff modified his prayer and demanded reparation for his harm from either one or both parties. The court determined that the Post Office bears full responsibility for the plaintiff's claim. The Post office filed an appeal, while the plaintiff filed a cross-appeal against the doctor.

Judgement
The court determined that encephalitis was a rare yet foreseeable outcome of giving ATS. Although the doctor failed to deliver a test dose to the plaintiff which amounted to negligence, he was not negligent in providing the ATS. Therefore, the doctor bears no responsibility for the plaintiff's encephalitis, and the entire liability rests with the Post Office.

Analysis
The key concepts applicable in the case are stated below. Each concept is analyzed using the IRAC methodology (Issue-Rule-Application-Conclusion).

Medical Negligence:
Issue:

• Whether Dr. McEwan was negligent in administering ATS
• Whether Dr. McEwan was negligent in not administering a test dose.

Rule: There are two tests applicable to test Medical Negligence. They are:

1. Bolam's Test: This test was established in Bolam v. Friern Hospital Management Committee, 1957. (BOLAM AND BOLITHO TEST, n.d.). The test to determine the negligence can be inferred from the judgment of the case, i.e., "A doctor is not guilty of negligence if he has acted in compliance with the practice accepted as appropriate by a responsible body of medical men skilled in that particular art." Putting it the other way round, a doctor is not negligent if he complies with such a practice merely because a body of opinion holds a contrary view.
2. Bolitho's Test: This test was established from the case of Bolitho v. City and Hackney Health Authority (1997). The test modifies Bolam's test and clarifies that a "responsible" body of medical men means that the opinion of the body must not be unreasonable and should have a logical basis. (BOLAM AND BOLITHO TEST, n.d.)

Application: Since Robinson V. Post Office is a 1974 case, only Bolam's test was applied (as mentioned in the case report):

1. The first question of negligence is whether Dr. McEwan was negligent in administering ATS. Considering opinions from various medical witnesses: Two witnesses with specialist knowledge in this field, Dr. Smith and Dr. Thompson approved administering ATS, and Dr. Taylor, even though he said that he would not himself have given ATS, clarified that he was stating a personal opinion. Dr. Taylor and Mr. Sharrard admitted that the case was such that it would not have been right to ignore any anti-tetanus precautions altogether. Inferring from the above-stated opinions, it can be concluded that Dr. McEwan was not negligent. This conclusion can be reached using Bolam's test that while carrying out medical treatment, Dr. McEwan was not bound to prefer Mr. Sharrard's school of thought over that of Dr. Smith. He was not negligent merely because an opinion (in this case, that of Mr. Sharrard) contradicts his view.
2. In The second issue of administering test doses, the opinions of medical witnesses include information on their methods of administering test doses. They all deem it necessary to administer a test dose, especially when ATS is given a second time to the patient. McEwan's method, different from the registered procedure, was rejected by Dr. Thompson and Dr. Smith as a valueless procedure. McEwan's unconvincing claim of lack of time in a busy surgery can also be dismissed.

Conclusion:

1. Dr. McEwan was not negligent in the administration of ATS.
2. Dr. McEwan was negligent in not administering a test dose.
3. Remoteness of Damages: Causation:

Issue:

• Whether the Doctor's negligence by omission of administering a test dose materially contributed to encephalitis.

Rule:

1. The Bonnington Test: Bonnington Castings Ltd. V. Wardlaw (1956) AC 613 established the material contribution test for causation. This test analyzes whether an action or omission of an action has materially contributed to the damages incurred by the plaintiff. Here, Material means more than de minimis (non-negligible). (Suen, 2019)
    
2. But-for test: This test was established by Barnett v Chelsea and Kensington Hospital Committee [1969] 1 QB 428, [1968] 2 WLR 422. It establishes the relation between the defendant's breach and the claimant's loss to place liability for that loss on the defendant. The test requires a burden of proof on a balance of probabilities. It considers the phenomenon of multiple causes and divisible injuries and holds tortfeasors accountable for the damage the claimant has incurred due to their negligence. (Suen, 2019)

Application:

1. The proper test dose, even if administered, would likely not have shown any reaction in light of the patient's medical history. If the patient did not produce a reaction until three days after full dose administration (1500 units), it is unlikely that the patient would have produced a reaction to the test dose (200-300 units) within half an hour. Thus, whether or not a test was administered does not make a difference to the patient contracting encephalitis.
    
2. Using the but-for test, a question can be raised:
   But for the negligence in administering the test dose to the plaintiff, would the patient have suffered from encephalitis? The answer to this question again lies in the medical tendency of the plaintiff. Even if the doctor was not negligent and would have administered a test dose, the patient would have suffered from the disease.
   
   Conclusion:
   The doctor's negligence in not administering a test did not materially contribute to encephalitis; thus, the doctor is not liable for the disease.
    
3. Remoteness of Damages: Novus Actus Interveniens and foreseeability

Issue:

• Should the post office be absolved from liability pertaining to the plaintiff's encephalitis?
• Was the damage a remote consequence of their admitted negligence or not?

Rule:

1. Novus Actus Interveniens:
   It is a Latin term for the 'New Intervening Act.' (Novus Actus Interveniens (Isolated Torts), n.d.)"It can be defined as any intervening act that can separate or break off the legal connection between a defendant's conduct and the final injury incurred by the plaintiff, thus preventing the defendant from being held legally liable for the plaintiff's harm." The exceptions to the rule of Novus actus interveniens are listed as follows (Novus Actus Interveniens, 2021):
   • If the defendant has undertaken the intervening act intentionally.
   • If the intervenor cannot be held entirely responsible for the consequence.
   • If the intervening act was reasonably foreseeable.
   • If the intervening acts in question are involuntary actions or a mere reflex.
   Novus Actus and remoteness of the damage can be measured through the test of isolation, which states that if the event in question is isolated and snaps the causal chain, the initial wrongdoer is absolved from liability. (Novus Actus Interveniens, 2021)
    
2. The test of Reasonable Foresight:
   It states that "If the consequences of a wrongful act could be foreseen by a reasonable man, then they are not too remote. If, on the other hand, a reasonable man could not have foreseen the consequences, then they are too remote. And, an individual shall be liable only for the consequences which are not too remote, i.e., which could be foreseen." (Aslam, n.d.)
    
3. The Eggshell Skull Rule (or Thin Skull Rule):
   This rule was established by Smith v Leech Brain & Co. [1962] 2 QB 405. It states, "A tortfeasor must take his victim as he found him." The defendant is liable for the complete extent of the harm incurred by the plaintiff, even if the harm worsens due to a pre-existing medical condition. (Case Brief of Smith V. Leech Brain & Co., 2023)

Application:

1. In this case, the doctor's negligence cannot be considered as a novus actus for the following reasons:
   1. Exception 2 is applicable in this case. It has already been proven that the doctor's negligence did not materially contribute to the plaintiff's encephalitis. Therefore, the intervening actor (the doctor) is not responsible for the consequence.
   2. On Application of the test of isolation, the doctor's negligence on being isolated does not snap the chain of causation. The plaintiff would have contracted encephalitis even if the test dose had been administered, as proven earlier.
2. In this case, it is foreseeable that:
   1. If oil is negligently allowed to escape on a ladder, it is likely that a workman would slip and sustain the type of injury in question.
   2. Such an injury would require medical treatment
   3. The area where the postman worked (tetanus-prone area), and the nature of his work (going to different places) made it necessary for an anti-tetanus prophylactic to be used in case of an injury.
   The only aspect unforeseeable in this case was the extent to which the injury would cause harm to the plaintiff.
3. However, the unforeseeability of the extent of harm caused by the injury does not absolve the Post Office of complete liability towards the plaintiff in accordance with the Eggshell Skull rule, the Post Office had to take their employee as they found him, i.e., with an allergy to the second dose of ATS.

Conclusion:

1. The doctor's negligence cannot be considered as novus actus interveniens.
2. The Post Office cannot be absolved from liability for the plaintiff's encephalitis.

References:

1. Arakeri, J. (2019, May 28). All you need to know about Remoteness of Damages. iPleaders. Retrieved September 19, 2023, from https://blog.ipleaders.in/remoteness-of-damages/
2. Aslam, M. A. (n.d.). Remoteness Of Damage In The Light Of Tort. Legal Service India. Retrieved September 18, 2023, from https://www.legalserviceindia.com/legal/article-2310-remoteness-of-damage-in-the-light-of-tort.html
3. Bolam And Bolitho Test. (n.d.). Legal-lore. Retrieved September 18, 2023, from https://www.legallore.info/post/bolam-and-bolitho-test
4. Case brief of Smith v. Leech Brain & Co. (2023, February 20). BareLaw.in. Retrieved September 20, 2023, from https://www.barelaw.in/case-brief-of-smith-v-leech-brain-co/
5. Chawla, s. (2019, April 4). Negligence in law of Torts. iPleaders. Retrieved September 18, 2023, from https://blog.ipleaders.in/negligence-in-the-law-of-torts/#
6. Novus Actus Interveniens. (2021, July 9). Lexpeeps. Retrieved September 19, 2023, from https://lexpeeps.in/novus-actus-interveniens/
7. Novus Actus Interveniens (Isolated Torts). (n.d.). Legal Service India. Retrieved September 19, 2023, from https://www.legalserviceindia.com/legal/article-4131-novus-actus-interveniens-isolated-torts-.html
8. Rai, D. (2021, August 12). An analysis of medical negligence. iPleaders. Retrieved September 16, 2023, from https://blog.ipleaders.in/analysis-medical-negligence/
9. Singh, R. (2020, August 22). Negligence and its Defences. Indian Law Portal. Retrieved September 18, 2023, from https://indianlawportal.co.in/negligence-and-its-defences/
10. Suen, C. (2019, September 14). Material contribution: bridging the evidentiary gap. LSE Law Review Blog. Retrieved September 19, 2023, from https://blog.lselawreview.com/2019/09/material-contribution-bridging-evidentiary-gap/

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