Perez v Coombe: High Court Clarifies the Status of Clinical Guidelines and the “Two-Schools-of-Thought” Defence in Irish Medical-Negligence Law

1. Introduction

Citation: Perez v Coombe Women & Infants University Hospital & HSE [2025] IEHC 396 (Egan J, 8 July 2025)

This High Court decision arose from a multi-defendant obstetric action in which the plaintiff, Ms Virginia Gimenez Perez, claimed that:

(i) the Coombe Women & Infants University Hospital (“the Coombe”) negligently mis-managed her labour and a primary post-partum haemorrhage (PPH); and
(ii) the Midland Regional Hospital, Portlaoise (“MRH”) negligently failed to diagnose and treat a secondary PPH allegedly caused by retained products of conception (RPOC).

At its core the case concerned whether clinical guidelines (IMEWS, RCOG 2016, NICE 2017) and text-book “triggers” for escalation translate into binding legal duties, and how the long-standing Dunne test, as distilled in Morrissey, operates when two legitimate approaches to treatment exist (“two schools of thought”).

2. Summary of the Judgment

Ms Justice Emily Egan dismissed all allegations of negligence. Key holdings include:

The plaintiff failed to prove that either hospital’s acts or omissions fell outside the range of conduct a reasonably competent midwife/obstetrician could adopt.
Guidelines (IMEWS, RCOG, NICE) are aids to clinical judgment, not a mandatory “tick-box”. A clinician may depart from them provided the departure is defensible and consistent with prevailing professional standards.
Where two acceptable clinical approaches exist (conservative versus surgical management; early versus delayed escalation) either may be chosen (Dunne points 4 & 5) without incurring liability.
Under-estimation of blood loss, and documentation anomalies, did not amount to a negligent failure because (a) visual estimation was common practice at the material time and (b) the plaintiff’s condition stabilised rapidly.
Even had any breach been established, causation was not: the plaintiff’s subsequent mental health sequelae flowed from the ultimately necessary ERPC, not from earlier alleged lapses.

3. Analysis

3.1 Precedents Cited

Dunne v National Maternity Hospital [1989] IR 91 – classic six-point test for professional negligence, emphasising that liability arises only if the defendant’s course is one no peer would take.
Morrissey v HSE [2020] IESC 6 – Supreme Court clarification that Dunne contains an “overarching principle” (reasonable peer standard) plus “subsidiary considerations”; rejected Bolam/Bolitho divergence and confirmed Irish approach.

Egan J applied those cases to distil a two-stage inquiry: (1) ascertain the professional standard of approach; (2) decide whether defendants complied.

3.2 Legal Reasoning

a) Determining the “Standard of Approach”

The Court relied heavily on extensive expert testimony (two obstetricians, two midwifery experts) to define prevailing Irish practice. Crucially the Judge held:

“It is not for the court to impose its own clinical views … the standards of the profession itself, demonstrated by evidence, set the benchmark.”

b) Guidelines v. Judgment

IMEWS flagged a blood-pressure “trigger” obliging midwives to call an obstetrician. However, simultaneous normal readings suggested the aberrant figure could be equipment error or vasovagal episode.
The Court recognised that each of IMEWS, RCOG, NICE prescribe slightly different steps; therefore strict adherence to any single algorithm cannot be the legal yardstick.
Egan J expressly stated: “One does not manage a patient by rote, but by applying clinical judgment and experience.”

c) Two Schools of Thought

On multiple pivotal issues (early surgical evacuation versus conservative management; immediate second-line drugs versus watchful waiting) credible expert evidence supported opposite views. The Court therefore invoked Dunne (4)–(5): a practitioner choosing either school is not negligent so long as that choice is reasonable.

d) Consent and Causation

Consent to ARM (artificial rupture of membranes): Though not documented, the Judge accepted midwife evidence of routine practice and found the plaintiff’s recollection unreliable given labour-room stress.
Consent to Conservative Management: Even if detailed notes were sparse, the plaintiff failed to prove she would have opted for early ERPC if the option had been explicitly offered; ergo no causative breach.

3.3 Likely Impact of the Decision

Guideline Status Clarified. Irish courts will treat clinical protocols as persuasive but not dispositive; deviation ≠ negligence per se, reinforcing professional discretion.
Bolsters “Two-Schools” Defence. Where responsible bodies prefer different yet legitimate options, plaintiffs face a high hurdle in proving negligence unless they can show the chosen option is outside the reasonable range.
Documentation & Estimation. The Court signalled leniency toward historical (now outdated) practices—e.g., estimating rather than measuring blood loss—when those practices were standard at the time.
Causation Discipline. Plaintiffs must grapple with both factual causation (would an alternative course have prevented harm?) and choice-based causation (would patient have accepted the alternative?).
Resource-Conscious Reasoning. Egan J referenced realities of a “busy labour ward” and finite anaesthetic availability, embedding systemic context into the negligence analysis.

4. Complex Concepts Simplified

PPH (Post-Partum Haemorrhage): Excessive bleeding after birth. “Primary” = within 24 hrs; “Secondary” = 24 hrs–12 weeks.
RPOC: Small fragments of placenta or membranes left inside the uterus, impairing contraction and prolonging bleeding.
IMEWS: A chart similar to general “early warning scores” that flags worrying vital-signs combinations in obstetrics.
ERPC/EUA: Surgical evacuation (“D&C”) under anaesthetic to remove RPOC.
Dunne Principles: Six propositions guiding Irish medical-negligence law; key idea: liability only if no peer would act likewise.
Two Schools of Thought: If competent professionals reasonably differ on best treatment, a doctor may adopt either without negligence.
Uterine Atony: Failure of the womb muscle to contract after birth, a leading cause of PPH.
Uterotonics: Drugs (e.g. syntocinon, prostaglandins) that stimulate contractions to limit bleeding.
Blood-Loss “Estimate” v “Weigh”: Traditional eye-balling (prone to under-report) versus current best practice of weighing soaked materials.

5. Conclusion

Ms Justice Egan’s decision in Perez cements two complementary principles in Irish clinical-negligence jurisprudence:

Clinical guidelines, however sophisticated, are reference tools—not iron rules. Courts will scrutinise the reasoning behind compliance or departure, not the departure per se.
Where credible expert evidence identifies more than one prudent approach, courts will not second-guess the clinician’s election among them, absent evidence that the chosen path was plainly indefensible.

By applying these principles across obstetric and post-natal contexts, the judgment delivers a careful, pragmatic precedent that balances patient safety with professional autonomy, emphasising contextual judgment, contemporaneous standards, and causation discipline as the cornerstones of liability analysis in Irish medical litigation.