Chronic Pain Syndrome following DVT – Coincidence or Causation?

Bevan Brittan successfully defended University Hospitals Coventry and Warwickshire NHS Trust in the case of Jessica Tuffin v University Hospitals Coventry & Warwickshire NHS Trust [2024] EWHC 3318. This liability trial in the Royal Courts of Justice dealt with complex issues of causation.

The Claimant was seeking damages estimated at over £2 million alleging that the Defendant’s negligence had led to her undergoing an above knee amputation of her left leg in September 2018.

Background

The Claimant had a history of chronic back pain and failed back surgery. In July 2015 she underwent a second attempt at spinal surgery which seemed to have gone well. Unfortunately there was a failure to give her anticoagulants to prevent DVT following the surgery and she developed a DVT in her left leg shortly after discharge from hospital.

The DVT was treated appropriately but over the next weeks and months the Claimant developed increasing pain, immobility and other symptoms in her leg which she maintained were a result of the DVT and post-thrombotic syndrome (PTS) affecting the circulation in her leg. Most of her treating doctors felt that she was developing complex regional pain syndrome (CRPS) but there was a mixed picture with some occlusion of her veins due to the PTS. She underwent stenting in an effort to improve blood flow but this proved to be ineffective.

Finally, unable to bear the pain and deformity that had developed, the Claimant underwent an above knee amputation of her leg in September 2018.

Issues in the Claim

The Claimant argued that she had not had CRPS but instead her pain and symptoms had been due to PTS and this was what led to her undergoing amputation.

Her alternative case, it if was found that she had developed CRPS, and if it was found that this was the reason why she had undergone amputation, was that the CRPS had been caused by the DVT/PTS. Failing that her fall-back position was that it was impossible to say exactly what had caused the CRPS/amputation but the DVT/PTS must have made a material contribution. 

The Defendant had admitted causing the DVT and the PTS but denied that had led to her developing CRPS in the leg or to the amputation. The Defendant made an early offer of £100,000 to compensate for just the DVT and mild to moderate PTS.

At the Costs and Case Management Conference, the Court agreed with the Defendant that there should be a trial of a preliminary issue to determine whether the Defendant was liable to the Claimant for the development of CRPS and/or the Claimant’s left leg above knee amputation.

Judgment

Following a four-day trial in May 2024 in which he heard from the Claimant and vascular and pain management experts for both parties, His Honour Judge Dight CBE gave judgment in December 2024.

He found in favour of the Defendant on the preliminary issue, holding that although the Defendant was liable for the DVT and PTS, it was not liable for the Claimant developing CRPS or her left above knee amputation.

Comment

This case illustrates that even if there is a very close temporal relationship between the negligence and the problems that subsequently develop, the Court must avoid falling into the trap of automatically assuming that one has led to the other. In the end it was possible to prove, based on good expert evidence and meticulous consideration and interpretation of the medical records and literature, that there was no connection, tempting though that conclusion was.

Vascular surgeons explored the role played by the DVT and PTS in the Claimant’s symptoms. Pain management experts considered whether she had developed CRPS and, if so, whether that had been linked to the DVT. Both gave views on the reason for the amputation.

For the Claimant, Dr Towlerton (pain management) asserted that not all of the criteria for CRPS had been met and that the PTS offered an alternative explanation for the Claimant’s problems. He and Mr Jenkins (vascular) relied heavily on the fact that the CRPS had developed very shortly after the DVT in the same leg and felt that it was too coincidental and must somehow have been causative. However, Dr Towlerton was only able to point to one report in the literature of CRPS occurring after a DVT although both experts gave anecdotal evidence of it happening.

The Defence case succeeded primarily due to the clear, logical and convincing evidence given by Professor Stansby (vascular) and Dr Simpson (pain management). The Court was clearly impressed by the extensive knowledge and experience of Dr Simpson both in treating CRPS and in working with vascular patients. Her evidence was that in over 30 years of practice she had never seen a single case of DVT causing CRPS, however, she had seen many cases of CRPS developing following spinal surgery (rare though that was). She argued that DVTs are extremely common and if they led to CRPS then we would know about it.

Counsel, Matthew Barnes of 1 Crown Office Row, had a meticulous grasp of the medical issues and was able to break down and explain the technical points, taking the Court through the clinical notes and in the expert reports and the literature. In cross examination he was able to elicit several concessions from the Claimant’s experts providing a foundation for his detailed closing arguments.