David John Saunders v Central Manchester University Hospitals NHS Foundation Trust

Factual and Procedural Background

The Plaintiff seeks damages for personal injury and consequential losses arising from alleged clinical negligence during surgery to reverse an ileostomy at The Hospital in March 2012. Shortly after the surgery, the Plaintiff became seriously unwell, and it was discovered that his entire colon was ischaemic, necessitating removal and resulting in a permanent ileostomy. Additional complications included prolonged infection and further surgery, causing significant distress. The Plaintiff alleges negligent surgery caused damage to the bowel's blood supply. The Defendant denies liability, asserting the damage was caused by a naturally occurring blood clot.

The parties agree these are the only plausible explanations for the bowel damage, both being rare events. The court was tasked with determining which explanation was more likely based on the evidence. Initially, the trial was listed to consider both liability and quantum, but due to recent developments in the Plaintiff’s condition, quantum was deferred. A secondary allegation was abandoned, leaving liability for the primary surgical negligence allegation as the sole issue.

The Plaintiff, aged 60 at the time, had prior colorectal surgery for a rectal tumour, followed by a defunctioning loop ileostomy intended for later reversal. The Plaintiff’s medical history included myocardial infarction, ischaemic heart disease, smoking, high cholesterol, and hypertension. The Defendant’s consultant surgeon performed the reversal surgery on 20th March 2012, which was described as straightforward with no recorded intraoperative complications. The Plaintiff was discharged on 23rd March appearing well but became critically ill by 25th March, requiring emergency surgery which confirmed ischaemic necrosis of the colon and part of the small bowel.

Legal Issues Presented

1. Whether the damage to the Plaintiff’s bowel was caused by negligent surgical error during the ileostomy reversal.
2. Alternatively, whether the damage resulted from a naturally occurring thrombotic event unrelated to the surgery.
3. Whether the Plaintiff has discharged the burden of proof to establish negligence on the balance of probabilities.

Arguments of the Parties

Plaintiff's Arguments

• The only plausible cause of the bowel damage is iatrogenic injury during surgery.
• The injury was caused by damage to a branch of the superior mesenteric artery through excessive traction or torsion during the reversal procedure.
• Such injury would not occur absent a breach of the surgeon’s duty of care.
• The close temporal association between surgery and onset of symptoms supports causation by surgical negligence.
• The pattern and extent of damage to the colon and terminal ileum is consistent with occlusion of the marginal artery of Drummond, which is vulnerable to damage during surgery.
• The Plaintiff’s anatomy, including a short mesentery and adhesions, made inadvertent injury more likely without surgeon’s awareness.

Defendant's Arguments

• The bowel necrosis was caused by a naturally occurring acute arterial thrombosis, unrelated to the surgical procedure.
• The event was a rare but recognized mesenteric infarction analogous to myocardial infarction.
• The timing of symptom onset and normal postoperative recovery until discharge do not support immediate surgical injury.
• The site of vascular occlusion was anatomically remote from the surgical field, making iatrogenic injury unlikely.
• The Plaintiff’s pre-existing atherosclerotic risk factors explain the thrombotic event.
• The Defendant’s expert did not identify any mechanism by which the surgery could have caused the extensive vascular damage observed.
• The Defendant sought to introduce late evidence to challenge the pathology report but was refused due to procedural delay and prejudice to the Plaintiff.

Table of Precedents Cited

Court's Reasoning and Analysis

The court undertook a detailed factual and expert evidence analysis to determine whether the Plaintiff had proved that the bowel damage was caused by negligent surgical error rather than a natural thrombotic event. Both parties agreed the two explanations were the only plausible causes, though both were rare and unreported complications of ileostomy reversal.

The court carefully evaluated the temporal relationship between surgery and symptom onset, concluding that the four-day delay before significant symptoms emerged was longer than expected for an acute intraoperative arterial occlusion. While the Plaintiff’s expert proposed a gradual evolving injury mechanism, the timing was at the margin of plausibility and lent some support to the Defendant’s case.

Consideration of the Plaintiff’s anatomy, including a short mesentery and prior vascular changes, was relevant but not determinative. The anatomical site of vascular occlusion was remote from the surgical field, and neither expert could definitively explain how surgical manipulation could cause such extensive damage without recognition.

The court found the Defendant’s surgeon witness credible and accepted his evidence that the surgery was straightforward with no unusual events or indications of injury. The Plaintiff’s expert was found to be somewhat vague and inconsistent regarding the mechanism of injury and appeared to start from the assumption that something must have gone wrong during surgery.

The court rejected the Defendant’s late attempt to introduce new evidence challenging the pathology report due to procedural unfairness and prejudice. The pathology report and the surgeon’s acceptance of it were treated as accurate.

In balancing all evidence, the court found that the Plaintiff had not proved, on the balance of probabilities, that surgical negligence caused the injury. The absence of a clear mechanism, the delayed symptom onset, the anatomical considerations, and the credible denial of negligence by the surgeon weighed against the Plaintiff’s case.

Holding and Implications

The court’s final decision is that the Plaintiff has NOT established liability for surgical negligence.

The claim is therefore DISMISSED.

The direct effect is that the Plaintiff’s claim fails and no damages are awarded. The court did not set any new precedent, as the decision rests on the specific facts and evidence of this rare and unusual case.