QB-2022-000824 - [2025] EWHC 1610 (KB)

The experts are agreed in all material respects in relation to causation. They agree that if the Claimant had a pelvic examination by the First Defendant on 30 August 2016 or by the Second Defendant if he had called the Claimant into the practice on or shortly after 5 September 2016, on the balance of probabilities she would have been found to have mild pelvic tenderness (Mr Magos believes also possibly fullness in the left adnexa, Mr Raine-Fenning believes cervical excitation but on balance no fullness or mass). They are agreed that this would have led to a possible diagnosis of PID and had triple swabs taken and started immediately on broad-spectrum antibiotics aimed at treatment of PID in accordance with national guidelines of the Royal College of Obstetricians/British Association of Sexual Health and HIV, pending microbiology results.

They agree that the Claimant’s tubo-ovarian abscess developed as a result of the PID, namely the ascending infection from the cervix spreading to the left fallopian tube, blocking it, which caused it to be filled with fluid which then formed the abscess. They were not agreed on what organism caused or may have caused the infection but that is not a dispute that I need to determine, in my judgment. They all agree that the results of the triple swabs taken at the time of the pelvic examination would have identified the organism and discussion with a microbiologist would have ensured that appropriate antibiotic treatment was given or continued.

The experts agree that the Claimant’s tubo-ovarian abscess most likely developed in or after late September 2016. As I summarised in my judgment on breach of duty, it was noted during her laparoscopies that the Claimant’s Pouch of Douglas and both adnexa were “obliterated” such that the left ovary was buried and could not be seen, the uterus was covered by adhesions and the rectum was densely adherent to the uterus. It was also noted that the adhesions involve her right fallopian tube which appeared abnormal at the fimbral end, which was slightly clubbed. The experts agree that with treatment for PID following the consultations on either 30 August 2016 or 5 September 2016 she would have avoided the following:

Mr Raine-Fenning’s opinion in relation to para 15(vi) above goes a little further than that of Mr Magos and Mr Slack in the joint report. He opines that on the balance of probabilities her uterus would not be densely adherent to her rectum and so she would not have suffered from dyschezia. In cross-examination by Mr Gibson he said that on balance, with earlier treatment, she would still have developed adhesions but these would have been limited to the left side and left fallopian tube, and would be very unlikely to have developed adhesions which (i) involved the uterus and obliterated the Pouch of Douglas; and (ii) caused the rectum to be adherent to the uterus, both of which he described as unusual. He said, “we don’t see that often outside of endometriosis”. Mr Slack agreed with this in cross-examination by Mr Dufficy. He said that dyschezia and dyspareunia are different and should not be taken together, and he agreed with Mr Raine-Fenning’s opinion that the dyschezia is likely caused by the fact that Claimant’s rectum is adherent to the uterus and so would have been avoided with earlier treatment. Mr Magos did not appear to disagree in cross-examination, also distinguishing between dyschezia and dyspareunia, and noting that the dyspareunia pain could be caused both by inflamed tissue of chronic PID and adhesions, and it is difficult to assess what importance each of these problems plays in her current pain. On balance I find that timely treatment: (i) would have avoided the dyschezia entirely, and (ii) would have significantly reduced the dyspareunia as it would likely have avoided the PID becoming chronic at all, and reduced the severity and extent/density of adhesions.

The experts all consider that the Claimant’s risk of infertility or sub-fertility and ectopic pregnancy would, however, still have been increased by the PID, even with appropriate and timely antibiotic treatment, whether this was provided on or shortly after 30 August 2016 or 5 September 2016. In relation to ectopic pregnancy, they agree that her risk of ectopic pregnancy would actually be higher with appropriate and timely antibiotic treatment, although the increased risk to her fertility would be lower. Mr Slack explains in the joint report that the effect on her fertility is related to the PID and its effect on the fallopian tube rather than the tubo-ovarian abscess, as is the risk of ectopic pregnancy. However, the delayed treatment resulted in the Claimant having her very damaged left fallopian tube removed entirely, leaving her at an overall lower risk of ectopic pregnancy albeit with a higher risk profile for infertility. Mr Magos relies on literature (Hillis et al, 1993) to support his opinion that the risk of infertility and ectopic pregnancy is increased with any woman diagnosed with PID where treatment is delayed even by a few days. I accept their evidence.