Elayoubi BHNF Kolled v Zipser & 2 Ors

In the present case the relevant skill was that of a specialist obstetrician and gynaecologist. 9 In Kondis v State Transport Authority (1984) 154 CLR 672 at 686, Mason J held: The liability of a hospital arises out of its undertaking an obligation to treat its patient, an obligation which carries with it a duty to use reasonable care in treatment, so that the hospital is liable, if a person engaged to perform the obligation on its behalf acts without due care.

10 The first and second defendants have cross claimed against the third defendant which, in turn, has cross claimed against the first and second defendants. Each of the cross claims seeks indemnity or contribution pursuant to s 5(1)(c) of the Law Reform (Miscellaneous Provisions) Act 1946. 11 The issues for determination by the Court are thus the liability of each of the defendants to the plaintiff, and, in the event the plaintiff is successful, the assessment of damages and the apportionment of liability between the defendants, if appropriate.

The primary witnesses 12 TK gave evidence in the plaintiff's case. It was accepted by the parties that TK's husband was unfit to gave evidence for medical reasons. Wassif gave evidence but, by reason of his youth in 1984, the value of his evidence was limited. Expert evidence as to liability was given for the plaintiff by Mr Clements, a British obstetrician and gynaecologist; Dr Molloy, a Sydney based obstetrician and gynaecologist; and Sister Orrock a lecturer in the Faculty of Nursing and Midwifery at the University of Sydney. A report of Ms Carroll, a registered nurse and midwife with experience in management, lecturing and teaching, was tendered.

13 Expert evidence as to liability was given for the first and second defendants by Dr Lyneham, an obstetrician and gynaecologist. Evidence was also given by the first defendant, Dr Booth, an obstetrician and gynaecologist who, at the time of the birth of the plaintiff, was a third year obstetric Registrar; and Sister Shipley, who attended TK on admission to the hospital on 12 October 1984. The reports of the late Dr Hinde, an obstetrician and gynaecologist qualified by the first and second defendants, were tendered. 14 The third defendant called Dr Bhardwaj, an obstetrician and gynaecologist, who assisted at the birth of Wassif. She was, at the time of Wassif's birth, a second year Registrar at PANCH. 15 Each of the expert witnesses qualified to give evidence by the parties had considerable experience and standing in his or her area of specialisation.

TK's evidence 16 TK's evidence, which was disputed in a number of respects, was, essentially as follows. 17 She was born in Lebanon in 1954. In 1968 she married. She migrated to Australia in 1971. She had three children by her first husband all of whom were delivered vaginally. She encountered no difficulties or complications with any of those pregnancies or births. 18 In 1975 she separated from her first husband who left Australia taking the children with him. She subsequently met and married Mr Elayoubi. They lived in Melbourne for a time during which she became pregnant with Wassif. She attended the PANCH Antenatal Clinic in respect of that pregnancy. In mid October 1978 she experienced bleeding during the pregnancy and required blood transfusion. She was told, prior to Wassif's birth, that the baby was "going sideways" and she would have to have an operation for his delivery. The operation was performed. As a result she was left with an obvious permanent vertical scar of her abdomen extending from just below her umbilicus to the pubic area. There were some problems with Wassif and she and Wassif remained in hospital for about two weeks after the birth. 19 She did not see a doctor after the delivery. She saw nurses, but no doctor came and explained anything to her. She was not told about the type of operation which had been performed nor was she given any papers or a letter to her doctor to take with her. No one said anything to her about what she should do if she fell pregnant in the future, no one gave her any warnings about future pregnancies or told her whether she would be able to have further children. She returned on a number of occasions to the paediatric clinic at PANCH with Wassif but on none of those occasions was anything said to her about the operation she had had or what she should do if she became pregnant. She expressly denied that she understood the operation was because of placenta praevia [placenta implanted in the lower uterine segment].

20 In 1981 she and her husband returned to Sydney. 21 In 1984 she became pregnant with the plaintiff. The pregnancy progressed normally. She was referred to the antenatal clinic at the hospital by a general practitioner, Dr Quidwai. She told Dr Quidwai that her menstrual periods were always regular and when her last menstrual period had been. On her first visit to the hospital she attended the antenatal clinic where she saw the first defendant. The first defendant carried out an examination of her and examined all her stomach. He asked about the operation scar on the stomach and she said it was "… because I had baby". She told the first defendant the reason for the operation was the baby was lying sideways. She told him the location of the hospital where she had had the operation. She confirmed that she was able to remember the name of the hospital. She was not told by the first defendant or any other person at the hospital that she was to come in immediately to the hospital at the sign of the first contraction. 22 Her understanding after the consultation with the first defendant was that the pregnancy would be managed as a normal pregnancy and that there would be a normal vaginal birth. 23 At 9pm on Thursday 12 October 1984 she began to feel contractions. These felt no different from the contractions she had experienced in respect of her other children. She was not concerned to get to the hospital quickly at that stage and continued to serve in the shop which she ran with her husband until 10pm. The shop closed at 10pm and her husband moved the sales items from outside and the shop was shut at about 10.20pm. The family then went to their home which was in the next street. There she washed Wassif, dressed him in his pyjamas, checked her bag and said to her husband "We'd better go". Her husband drove her to the hospital, the trip took about 10 - 15 minutes. Between 9pm and the shutting of the shop the contractions started coming, but not very quickly. "During the journey the contractions were just starting heavier." She agreed the contractions were "a progressive sort of thing" and they started to become very heavy. This occurred after 10pm when she was at the hospital. 24 At the hospital she went to the front desk. A nurse was called and she was taken to a room where she was asked to sit on a bed. The nurse examined her. She complained she had a knife-like pain in the stomach. She said she had never experienced pain of that sort before. She told the nurse of the pain. The nurse gave her cotton wool and told her to clean her nails. The nurse then drew the curtains and walked away. TK was screaming and did not remember anything after that. She thought she passed out. Her next memory was of waking up and being told by a doctor that she had a boy but he was not normal.

Additional history 25 The hospital records note that TK was admitted to the hospital at 11pm "with history of contractions since 10.45pm". 26 TK was examined by Sister Shipley on admission and subsequently by Dr Booth. A decision was taken to perform an elective caesarean section for breech presentation. The on call obstetrician (Dr Simpson) and anaesthetist (Dr Hines) were requested to attend at the hospital to perform the operation. They duly attended and appropriate surgery was performed. The plaintiff was born at 12.28am.

27 The pregnant uterus has an upper and a lower segment. The upper segment is thick and muscular. A vertical incision into the upper segment (classical caesarean section) heals only by scar tissue. This creates a risk of rupture in the event of later pregnancy. The risk arises both before and after the commencement of labour with approximately 50% of such ruptures occurring before the commencement of labour. 28 The lower segment comprises the less active part of the uterus. It varies in dimension dependant upon whether labour has commenced and, if so, the stage to which labour has progressed. A vertical incision into the lower segment heals creating a risk of rupture in the event of any later pregnancy but of a lesser degree than that arising from a vertical incision into the upper segment. If there is no encroachment upon the upper segment the risk is little different than that of a transverse incision for a lower segment caesarean section. 29 The degree of risk of rupture of the uterus after pregnancy following a lower segment caesarean section was 1 - 2% in 1984. The risk of rupture of the uterus following a classical caesarean section was 2 - 5% in 1984. 30 If an incision into the lower segment extended vertically into the upper segment the risk of a subsequent rupture of the uterus was, for all practical purposes, the same as for a classical caesarean section.

31 In 1978 the majority of caesarean sections were performed using a transverse incision to the lower segment of the uterus. Classical caesarean sections were performed, albeit very rarely. Mr Clements gave evidence the absolute indicator for a classical caesarean section was where the baby was lying across the womb with an arm in the vagina with the membranes ruptured and the labour obstructed. Relative indicators for a classical caesarean section were if the lower segment was very vascular or there was a tumour in the lower segment or the baby was lying across the uterus. 32 The classical caesarean section was usually confined to the upper segment of the uterus although, on occasions, it might extend to the lower segment. 33 A vertical incision of the lower segment was described as a very unusual type of operation by Dr Bhardwaj and as "very very uncommon" in 1978 by Mr Clements. 34 Such an incision would necessarily extend into the upper segment (Dr Molloy), almost inevitably extend into the upper segment (Dr Clements) or would be very likely to do so save perhaps if performed late in labour with strong contractions being present (Dr Lyneham).

35 The consequence of performing a classical caesarean section, or making an incision into the lower segment which extended into the upper segment, was that, in respect of any future pregnancy, appropriate medical care required that an elective caesarean section be performed at approximately 38 weeks gestation, vaginal delivery should not be attempted and the patient should be instructed to inform subsequent treating doctors of these matters and to come to hospital as soon as possible should she come into labour, feel contractions, rupture her membranes or if she had pain, bleeding or signs of anything unusual.

Liability - the third defendant 36 The question of the liability of the third defendant ultimately raised three issues for determination: (a) What was the nature of the caesarean section performed on 31 October 1978? (b) Was TK given appropriate advice and warnings in respect of that procedure and its consequences? (c) Was the failure to appropriately advise and warn TK (if such failure occurred) causative of the harm which befell the plaintiff? These issues are considered hereunder.

The nature of the caesarean section performed on 31 October 1978 37 Central to the plaintiff's case was the assertion that the caesarean section for Wassif involved a vertical incision directly into the upper segment (a classical caesarean) or an incision into the lower segment which extended vertically into the upper segment. 38 There was no direct evidence establishing, with certainty, the nature of the caesarean section performed on 31 October 1978. The obstetric file relating to TK at PANCH, which would have contained the operation report and notes, was destroyed on or about 26 August 1994 in accordance with appropriate protocols. The operating theatre register, which should have contained a description of the operation, could not be located. The operating surgeon, Dr Dawson, did not give evidence. His assistant at the operation, Dr Bhardwaj, gave evidence but had no recollection of Wassif's birth. 39 Although TK had a central vertical scar extending from just below the umbilicus to the pubic area it was generally accepted by the expert witnesses that this merely evidenced a skin incision and was equivocal as to the nature of the incision into the uterus. As the first defendant and Dr Lyneham confirmed, such an incision was not unusual in 1978.

40 The only relevant records of PANCH which were available at the trial were a birth register and the paediatric records relating to Wassif. The birth register entry was in the following terms.

Admission Position Date and NAME on Accoucheur REMARKS Time Delivery 31/10/78 HADAYA TAMAM LUSCS DR DAWSON / DR BHARDWAJ APH - PLACENTA PRAEVIA … Breech

41 "LUSCS" is an acronym for "lower uterine segment caesarean section". The paediatric records contain a number of references to Wassif's birth by "LSCS" (lower segment caesarean section) or "LUSCS". Thus the available contemporaneous records indicated the incision was to the lower segment. 42 Dr Bhardwaj gave evidence that if a classical caesarean section had been performed it would have been so described in the operation report. If a transverse lower segment incision with vertical extension into the upper segment had occurred it would be described in the operation report as an inverted T incision. The description LSCS should be confined to an incision of the uterus wholly confined to the lower segment. 43 Mr Clements gave evidence that if a doctor had undertaken a lower segment caesarean section with a vertical uterine incision it would be probable the operation would be recorded as "LSCS" but the vertical part of it was sufficiently unusual to demand a special note.

44 The information in the birth register was, as a matter of general practice, completed by the midwife present at the birth. There was no direct evidence as to the source of the information contained in the birth register entry for Wassif. Sister Orrock gave evidence that such entries were normally taken from the obstetric notes. Mr Clements said the information would be obtained from the obstetric notes rather than the paediatric notes but that, in his experience, midwives made the entry from their own observations of the operation and that a precise description of the caesarean section was not necessary for the birth register or the paediatricians. The source of the entries in the paediatric records was unclear though unlikely to have been the operation notes. 45 There was also evidence, which was not disputed, that many nurses use the expressions LSCS or LUSCS to describe any caesarean section irrespective of its nature. In these circumstances the available documentary evidence from PANCH cannot be regarded as conclusive as to the nature of the caesarean section performed on 31 October 1978. 46 It is thus necessary to have regard to other evidence in order to determine the nature of the caesarean section performed on 31 October 1978. That evidence, primarily, was as follows: (a) Dr Simpson, who delivered the plaintiff, was an experienced obstetrician and gynaecologist. He recorded in his operation note "Ruptured uterus - previous classical caesarean section"; (b) Dr Booth, who assisted at the plaintiff's delivery, was also of the opinion there had been a rupture of a previous classical caesarean section. She gave evidence that on operation she observed adhesions from the bladder to the uterus; (c) The histopathology report dated 23 October 1984 stated: MACROSCOPIC … There is a ragged longitudinal tear running the full length of the anterior wall of the uterus. On each side of the tear there are dense adhesions on the surface of the uterus. Along one edge of the tear there is a smooth depressed area suggestive of old scar tissue. The lining of the uterus is roughened. MICROSCOPIC Sections from the lining of the uterus show some residual decidua. The myometrium generally shows mild oedema. Sections from the torn areas confirm the presence of adhesions on the surface and also show some fibrosis and degenerate muscle. The endocervical tissue is oedematous and congested, and also shows a moderate acute inflammatory infiltrate. The distribution of adhesions and fibrosis is consistent with the history of previous classical caesarean section. (d) Mr Clements gave evidence that the pathology report established the uterine incision extended considerably into the upper segment and the adhesions from the bladder to the uterus were consistent with a vertical incision to the lower segment. He concluded on the balance of probabilities that the caesarean section performed at the delivery of Wassif was a classical caesarean section. He saw nothing in the pathology report which led him to conclude the incision was other than vertical. (e) Dr Lyneham, largely relying upon the report of adhesions from bladder to uterus, considered it extremely likely that the predominant part of the incision had been to the lower segment though he accepted that an incision to the lower segment may well have extended to the upper segment of the uterus. (f) Dr Molloy considered there had been a transverse incision of the lower segment which extended vertically into the upper segment. 47 In my opinion, the probabilities favour the conclusion that the caesarean section involved a vertical incision into the lower segment of the uterus which extended vertically into the upper segment, and I so find. Was TK given appropriate advice and warnings in respect of the operation and its consequences? 48 The alleged breaches by the third defendant are particularised in the Further Amended Statement of Claim, dated 19 December 2006, in the following terms: (a) Failing to advise the Plaintiff's mother of the high risk following classical caesarean section. (b) Failing to advise the Plaintiff's mother of the need to inform her present and future treating practitioners of the fact that she had undergone a delivery by classical caesarean section. (c) Failing to advise the Plaintiff's mother's treating practitioners of the fact that she had undergone a delivery by classical caesarean section. (d) Failing to warn the Plaintiff's mother that she had or may have a significantly higher than normal risk of uterine rupture in late pregnancy or during birth. (e) Failing to warn the Plaintiff's mother that future vaginal delivery was contra-indicated due to the significantly higher than normal risk of uterine rupture in late pregnancy or during birth consequent upon her having undergone a delivery by classical caesarean section. 49 It was common ground among the medical experts, and the third defendant accepted, that reasonable care required that a patient upon whom a classical caesarean section was performed should be informed at the hospital where the operation took place of the nature of the procedure performed, and the risks arising from that procedure in the event of future pregnancy. She should be advised that she should inform those treating her for subsequent pregnancies of the nature of the procedure performed. Such advice and warnings should be clear and appropriate efforts should be made to ensure they were understood. Similar advice and warnings were required where an incision into the lower segment of the uterus extended vertically into the upper segment. 50 It was submitted that PANCH should have given such information to TK both orally and in writing. No written document containing such information was given to TK. Dr Bhardwaj gave evidence it was not the practice in 1978, or today, to give patients a written document setting out details of the procedure performed and advice and warnings as to any consequences resulting therefrom. Mr Clements gave evidence that it was a common, but not uniform, practice to provide a written record for the patient. In my opinion it has not been established that there was a duty in 1978 to provide a written record to the patient. Further, there was no direct evidence any such document would have been retained by TK particularly with her move interstate nor was it established that if such document had been retained by TK and given to the hospital it would have resulted in the harm to the plaintiff being avoided.

51 The third defendant did not adduce any direct evidence as to the advice or warnings, if any, given to TK. Dr Bhardwaj gave evidence that in 1978 it was her usual practice to discuss matters of importance with the patient following an operation. She would discuss the operation and its consequences. She had been taught that where there was a classical caesarean scar she was to make the patient aware that she had such a scar, that a vaginal delivery was fraught with danger and that she must make her future obstetrician aware of such a scar. She was aware of the possibility of a misunderstanding and the need to endeavour to be understood by the patient. If there was a language problem an interpreter would be used. She used non technical language when discussing matters with patients. I accept the evidence of Dr Bhardwaj as to her usual practice in 1978. I also accept TK's evidence that she did not have problems understanding what was said to her in English. 52 Dr Bhardwaj said it was not possible she would not have seen TK in the 10 days TK remained in the ward post operatively, though she agreed that on occasions she had been mistaken for a member of the nursing staff by patients. 53 Dr Bhardwaj gave evidence that in 1978, in addition to her discussing the operation and its consequences with the patient, it was the usual practice for the surgeon who had operated to discuss with the mother the dangers of future vaginal delivery in the event of a classical caesarean or a lower segment caesarean with a vertical incision into the upper segment. There was no evidence Dr Dawson gave any advice or warning to TK. Dr Dawson was not called by the third defendant to give evidence. It was conceded he was available. 54 In her evidence TK denied that any advice or warnings were given to her at PANCH, she denied she had had a placenta previa. However the hospital's antenatal card relating to TK recorded "placenta previa". The only source for such information, on the evidence, was TK. She had told Mr Clements the midwives at PANCH had told her she had had a placenta previa. It is arguable that it would be expected that if TK was given this information then appropriate warnings and advice would have been given to her at the same time particularly if she had mistaken Dr Bhardwaj for a member of the nursing staff. 55 There was, however, support for TK's assertion that no advice or warnings were given to her at PANCH in the fact she did not inform the first defendant or the hospital of the nature of the caesarean section performed at PANCH or that she had been warned not to undergo a vaginal birth. After the plaintiff's birth Dr Booth asked TK "was she aware that she had had a previous classical caesarean up and down and that she required delivery by caesarean in the future". TK replied in the negative, an answer which impressed Dr Booth as genuine. 56 Possible explanations for TK not informing the first defendant or the hospital of the nature of the previous caesarean section require consideration. They are: (a) Drs Dawson and Bhardwaj did not appreciate the incision had encroached upon the upper segment. If this was so a warning would not have been considered necessary or given. Dr Booth gave evidence that sometimes a surgeon may encroach upon the upper segment without being aware he had done so. However Dr Bhardwaj said an operating surgeon would be well aware if a lower segment incision encroached into the upper segment. Dr Lyneham accepted a surgeon would have "a pretty good idea" whether he had encroached into the upper segment or not; (b) Dr Bhardwaj may have departed from her usual practice on this occasion for some reason, now forgotten, and failed to give the appropriate advice and warnings. Dr Dawson may have relied upon Dr Bhardwaj to give the advice and warnings; (c) TK may have been given an appropriate warning, understood and remembered it, but have been afraid to speak up when she saw the first defendant or on other visits to the hospital's antenatal clinic. I consider this unlikely. TK did not appear to me to be the type of woman who would be shy where the welfare of her children was concerned and particularly where what was being contemplated was a vaginal delivery, the very matter against which she would have been most strongly warned had a warning been given; (d) TK may have been given an appropriate warning, understood it, but later forgot it. Whilst this is possible there was evidence that mothers tended to remember and heed advice when it concerned the welfare of their children. I accept that evidence and would apply it particularly to TK whose concern for the welfare and care of the plaintiff was obvious; (e) TK may have been given an appropriate warning but failed to fully comprehend it and for that reason not remembered it. This may have been a consequence of Dr Bhardwaj perhaps been mistaken for a member of the nursing staff so that TK did not listen as carefully as she would have if the warning and advice had been given to her by someone who was obviously a doctor. However this would be unlikely having regard to the care which Dr Bhardwaj took to ensure her warnings were understood.

57 I accept that, on the balance of probabilities, Dr Dawson would have been aware his incision had encroached upon the upper segment and that an appropriate warning to TK was required. I infer that the evidence Dr Dawson would have given, if called to give evidence, would not have assisted the third defendant's case. As a consequence I have concluded that I can more readily accept TK's evidence that she was not given adequate advice or warnings notwithstanding that she was obviously given some information as to the nature of the procedure performed and the reasons for it. I find that TK was not given adequate advice or warnings by PANCH as to the risks consequent upon the caesarean section there carried out. 58 The third defendant conceded it did not advise TK's treating practitioners in 1978 that she had undergone a classical caesarean section. However it did not accept it was subject to a duty to do so.

59 The evidence was equivocal as to whether the accepted practice in 1978 was that a hospital inform the referring doctor, by letter or otherwise, of the nature of the procedure which had been performed at the hospital on the referred patient. Dr Bhardwaj's practice was to write to the referring doctor. She considered it good practice to do so. 60 However it is unnecessary to pursue that question as, even assuming the alleged duty, there is no satisfactory evidence to establish any causal link between a failure by the third defendant to notify the referring doctor and the harm which befell the plaintiff. There was no evidence identifying the referring doctor and no evidence TK could have identified him in 1984. It is clear the first and second defendants would not have known who to contact unless the information was supplied by TK or perhaps, by PANCH. The extent of the referring doctor's involvement with TK was not the subject of evidence and there is no evidence that he would have used the information to warn TK of the risk or, if he had given such a warning, it would have resulted in the avoidance of harm to the plaintiff. Was the failure to appropriately advise and warn TK causative of the harm which befell the plaintiff?

61 Appropriate advice and warnings would have informed TK of the nature of the operation, the reasons for it, that in the event of a further pregnancy there was an increased risk of rupture of the uterus, that the baby would have to be delivered by caesarean section at 38 weeks gestation and that the baby should not be delivered vaginally. She would have been warned that she should attend hospital as soon as possible should she come into labour, feel contractions, rupture her membranes or bleed and that she should inform subsequent treating doctors of her history in regard to the previous operation. 62 Assuming TK had remembered such advice and warnings and passed them on to the hospital the plaintiff's position would have been no different as: (a) the pregnancy did not proceed to the date when an elective caesarean section would have been performed; (b) although it was planned that TK have a trial of labour that did not occur. A caesarean section was substituted. No attempt was made to deliver the plaintiff vaginally; (c) TK was told by the first defendant to attend as soon as possible at the hospital should she come into labour, feel contractions, rupture her membranes or bleed; (d) the knowledge of the nature of the previous caesarean section would not have resulted in the treatment at the hospital being expedited to such an extent as would have reduced the harm suffered by the plaintiff.

These conclusions are more fully dealt with later in this judgment. 63 In my opinion the plaintiff has failed to establish the necessary causative link between the acts and omissions of the third defendant and the harm which befell him. Accordingly there will be a verdict and judgment for the third defendant. Liability - the first and second defendants - antenatal care 64 A large number of allegations of breach of duty by the first and second defendants in respect of antenatal care are particularised in the Further Amended Statement of Claim dated 19 December 2006. 65 The hospital records indicate that in respect of her pregnancy TK attended the hospital on 7 June 1984 when blood grouping was performed, and on 18 June 1984 when a nursing history was recorded. She attended the antenatal clinic on 31 July 1984, 18 September 1984 and 2 October 1984. An ultrasound was reported on 20 September 1984. She was asked to return in 2 weeks time on 31 July 1984 and 18 September 1984 and in 1 week's time on 2 October 1984 but, for reasons not disclosed, she did not attend as requested on those occasions. Her next attendance at the hospital after 2 October 1984 was her admission on 12 October 1984. The only oral evidence from the first and second defendants as to TK's attendance at the antenatal clinic was given by the first defendant in respect of the attendance on 31 July 1984. Prior to the consultation with the first defendant entries had been made on TK's records which stated "placenta previa" and "for trial of labour" [i.e. a vaginal birth would be attempted]. 66 The allegations of breach are grouped and considered separately hereunder.

Group A (22) During the course of the Plaintiff's ante-natal attendances at the hospital, neither the First Defendant nor the Second Defendant, its servants and agents: (a) Identified that the Plaintiff's mother had previously undergone classical caesarean delivery. (b) Identified that the Plaintiff's mother may have previously undergone classical caesarean delivery. (33) (a) Failing to take a proper history. … (c) Failing to take any or any sufficient notice of: (i) The recorded history of placenta praevia in relation to the Plaintiff's mother's pregnancy with her son Wassif. (ii) The vertical scar on the Plaintiff's mother's abdomen resulting from the birth of her son, Wassif. (iii) Certifying that the Plaintiff's mother was fit for a trial of labour without sufficient information about her prior obstetric history. (f) Writing "LSCS": (i) As shorthand for caesarean delivery. (ii) When the Plaintiff's mother had not referred to any particular form of caesarean section delivery in relation to the birth of her son Wassif. (g) Failed to assume with the history given and in the absence of the Plaintiff's mother's medical notes in relation to the 1978 pregnancy that it was a "classical caesarean section". 67 The first defendant has no recollection of his consultation with TK. His evidence was based on his usual practice and the antenatal records. 68 The first defendant said he would have been given and read the antenatal records prior to examining TK. He thus would have been aware that TK had had a placenta previa with Wassif, that she had undergone a caesarean section which was described as LSCS, that the caesarean section followed previous vaginal births, and that it was proposed that there be a trial of labour. 69 No written documentation from PANCH or the referring general practitioner in relation to the pregnancy with Wassif was produced to the hospital or the first defendant. The referring letter from Dr Quidwai contained no information relating to the previous caesarean section. 70 A classical caesarean section was rare. A lower segment caesarean using a vertical incision of the lower segment was rarer still. A transverse lower segment incision extending vertically into the upper segment was also rare. The description on the antenatal card of a previous LSCS was suggestive that the usual transverse incision confined to the lower segment had been made.

71 It was common ground the first defendant examined TK's abdomen and observed the scar and was told by TK that the scar was the result of the birth of Wassif. 72 It was common ground that a vertical incision into the abdomen was not unusual in 1978, and that a vertical abdominal scar would not raise a major suspicion on its own that a classical caesarean had been performed. 73 The first defendant said his usual practice in 1984 was to look at the original reason for the caesarean section. In this case the recorded reason for the caesarean section was "placenta previa". He would have confirmed with TK that that was the reason for the caesarean section and would have told her that as the placenta previa was a non-repetitive course she had the choice of trying for a vaginal delivery or having a repeat elective caesarean section. He would confirm with the patient that everything had gone normally post operatively. 74 The first defendant did not regard a placenta previa as an indication for a classical caesarean section. He had never seen or done a classical caesarean section for a placenta previa. In his opinion the standard operation for a placenta previa was a lower segment caesarean section. Dr Lyneham considered that a placenta previa was a possible reason for a classical caesarean section. Mr Clements considered a placenta previa, if anterior, could create an indicator for a classical caesarean but accepted that most obstetricians would still incise the lower segment transversely and that was what was advocated in the text books. In his opinion the presence of a placenta previa raised a possibility, but no more, that a classical caesarean section had been performed. In my opinion it was not unreasonable for the first defendant to discount the presence of a placenta previa as an indication of a classical caesarean section. 75 TK gave evidence she told the first defendant the reason for the caesarean section was that Wassif was lying sideways immediately before his birth. A nurse's note in relation to Wassif's birth refers to "emergency LUSCS for transverse lie …". However, I do not accept TK gave this information to the first defendant for the following reasons: (a) The first defendant gave evidence that in his opinion the only indication for a classical caesarean section is an impacted transverse lie. The importance of a transverse lie in this context was confirmed by Mr Clements who stated that a transverse lie was by far the most potent of the factors for a classical caesarean section, and Dr Lyneham who said that a transverse lie increased the likelihood of a vertical incision. (b) The first defendant gave evidence TK would not have told him that Wassif had been lying sideways as, if he had been so informed, he would have noted this important matter on the antenatal record. The antenatal record contained no such note. (c) No reference to a transverse lie had been noted on the antenatal card by those who had made notes on the card previously. (d) TK did not tell Mr Clements that Wassif was lying sideways. She did however tell him that there was a placenta previa although she denied in her evidence that she had ever known this or told any doctor of it. 76 Thus the indicator to the first defendant of a classical caesarean section, an impacted transverse lie, was absent. 77 Mr Clements gave evidence that if TK had been properly warned at PANCH he would have expected her to have informed the hospital of the warnings given to her. Dr Molloy said that in his experience women had no problem in remembering to inform subsequent treating doctors of these matters. Dr Lyneham said that a subsequent treating doctor would rely upon the previous warnings being recounted by the patient. The first defendant and the second defendant were not told by TK of any warnings. 78 The first defendant said he would not ask TK had she had a classical caesarean section because that would not have occurred to him. If he had asked, TK, presumably, would have answered in the negative or that she did not know. 79 In my opinion, the evidence before the first defendant at the consultation with TK was not such as should have caused the first defendant to conclude or assume that TK had previously undergone a classical caesarean section or a lower segment incision extending into the upper segment. The probability on the information before him was that TK had undergone a transverse lower segment incision with no involvement of the upper segment. I do not consider that, having regard to the state of the information available to him the first defendant was acting unreasonably in contemplating a trial of labour or in leaving the papers marked "LSCS" or that his action evidenced an absence of reasonable care.

80 No additional information was gained subsequent to the examination on 31 July 1984 to alter this assessment prior to the birth. Group B (22) During the course of the Plaintiff's ante-natal attendances at the hospital, neither the First Defendant nor the Second Defendant, its servants and agents: (d) Wrote to or contacted the Third Defendant to obtain a copy of the obstetric records in relation to the Plaintiff's mother's prior delivery of 31 October 1978. (33) (e) Failing to contact the Northern Hospital in Epping, Victoria where the Plaintiff's brother Wassif was born in order to ascertain the type of caesarean section by which Wassif was delivered. 81 The first defendant gave evidence that it was his usual practice with any form of previous caesarean section to write to the previous hospital where the procedure had been performed seeking details. As there was no copy of such a letter in TK's hospital file he conceded the likelihood was he had not written to the previous hospital on this occasion. The only reason he could suggest for that was that TK had not been able to tell him the name and address of the previous hospital where Wassif had been born. However it is unlikely TK would have forgotten where Wassif was born particularly as she had attended the antenatal clinic there on a number of occasions, had been admitted for a blood transfusion and had attended there following Wassif's birth. She said, in evidence, she had told the first defendant its location and that she was able to remember its name. Her evidence in this regard was not challenged. I accept it. 82 The failure to send such a letter gives rise to three issues (a) were the first and second defendants under a duty to seek additional information from the previous treating hospital?; (b) if such information had been sought would it have been supplied and (c) what would the content of the information supplied have been? 83 Dr Molloy considered that there was an obligation to write to the previous hospital in the event of any type of prior surgery notwithstanding the quality of history given by the patient. Mr Clements considered it was good practice with a person presenting with a history such as TK's and a vertical scar to enquire of the previous hospital but he would often accept a patient's history, when it was clear, without writing to the previous hospital. Dr Lyneham would not write to the previous hospital if he obtained a history with which he could feel satisfied. However he would have made an enquiry if he had received a history of a vertical incision, placenta previa and a transverse lie. Mr Clements observed that many doctors did not write in any circumstances. Dr Hinde was of the opinion that proper practice would have been to write if a trial of labour was proposed. 84 In Rogers v Whitaker (1992) 175 CLR 479 at 487 and 489 the High Court held: In Australia, it has been accepted that the standard of care to be observed by a person with some special skill or competence is that of the ordinary skilled person exercising and professing to have that special skill. But, that standard is not determined solely or even primarily by reference to the practice followed or supported by a responsible body of opinion in the relevant profession or trade … Whether a medical practitioner carries out a particular form of treatment in accordance with the appropriate standard of care is a question in the resolution of which responsible professional opinion will have an influential, often a decisive, role to play. 85 The possibility that TK had undergone a caesarean section which involved an incision into or extending into the upper segment was slight, on the material before the first and second defendants, but could not be excluded. A trial of labour was proposed. That would be inappropriate and potentially dangerous to the plaintiff if TK had undergone a classical caesarean section or one where the incision extended into the upper segment. The inconvenience and expense of writing to the other hospital would have been minimal, indeed it was the first defendant's usual practice to do so. I accept Dr Hinde's opinion that in the circumstances, as a trial of labour was proposed, the first or second defendant should have written to PANCH seeking details of the previous surgery. I find the failure to do so evidenced a lack of reasonable care.

86 There was affidavit evidence from Dr Leslie, the former Medical Director of PANCH between 1977 and 1991 as follows: Upon receipt of a request for a patient's obstetric history, either the Deputy Medical Director or myself would review the patient's complete medical file which comprised the admission and discharge summaries, operation notes and anaesthetic records, progress notes and the clinical notes of treatment, including the mode of delivery, and any significant medical information. I am aware, and was so aware in 1978, of the difference between a lower segment caesarean section and a classical caesarean. If a patient had undergone a classical caesarean, the operation notes completed by the obstetrician and contained in the patient's file should clearly state this. I am aware, and was so aware in 1978, that if a patient had had a classical caesarean that it was imperative that that fact be included in any obstetric history report provided by the hospital. Then either the Deputy Medical Director or myself would dictate a response to the inquiry that we would then provide to our secretary to type up. To the best of my recollection these responses were completed within 2 or 3 days of receipt and were posted back to the requesting hospital or Medical Practitioner within less than a week. 87 That evidence of Dr Leslie was not challenged and I accept it. As TK's obstetric file was not destroyed until 1994 I accept that a request from the first or second defendant to PANCH would have been responded to by Dr Leslie or the third defendant's Deputy Medical Director. 88 The remaining issue is what would have been the content of the information supplied. 89 The first and second defendants submitted that the obstetric file and operation note would refer only to "LSCS" as that is what Dr Dawson understood he had done. 90 That submission was based, in part, upon a letter of instruction from the third defendant's solicitor to a qualified doctor which said: We are instructed that according to the birth register extract the Plaintiff's mother was attending Dr Ashton's public antenatal clinic. Dr Barry Dawson was the consultant 'on call' who performed a lower segment caesarean section for antepartum haemorrhage due to placenta previa combined with a breech presentation at 35½ weeks gestation with ruptured membranes at 07.20 hours on 31 October 1978. Further the paediatric notes for Wassif Elayoubi record in a number of places the delivery was by LUSCS, ie lower uterine segment caesarean section which would appear consistent with the birth register extract which records the mode of delivery as LUSCS. We are further instructed it is likely this caesarean section was performed through a midline vertical abdominal incision on the plaintiff's mother's abdomen. The reason to use the vertical abdominal incision in the operation on 31 October 1978 would have been that there was placenta previa and an abnormal presentation of the foetus with ruptured membranes. The vertical incision through the abdomen allowed for extension of the incision if necessary due to difficulty in extracting a baby 'trapped in the uterus' by abnormal lie with all the liquor drained out. 91 I was asked to infer from that letter that Dr Dawson instructed the solicitors for the third defendant that the procedure was a lower segment caesarean section performed through a vertical incision. In my opinion a fair reading of the letter does not enable me to infer that the source of the "further instructions" was Dr Dawson or that the incision to the uterus (as opposed to the abdomen) was of a particular type.

92 Nevertheless, I am not satisfied on the balance of probabilities that the response from PANCH would have indicated other than a lower segment caesarean section for the following reasons: (a) No Jones v Dunkel inference is available against the first or second defendant in respect of this issue; (b) Mr Clements gave evidence that if a doctor had undertaken an LSCS with a vertical uterine incision it would be probable the operation would be recorded as "LSCS" but the vertical part of it was sufficiently unusual to demand a special note. There was however no evidence that there was any established practice of including a special note and there was no evidence Dr Dawson would have done so; (c) Dr Dawson may have been aware of an encroachment into the upper segment but may not have noted it either by oversight or because his practice was to only record the primary surgery; (d) The relevant entry in the birth record provides some support for the conclusion that Dr Dawson may have recorded, on the operation notes, no more than that the procedure was a lower segment caesarean section; (e) Dr Leslie was the Medical Director of PANCH. He was a qualified medical practitioner but seemingly not an obstetrician. His affidavit evidence (see [86]) above relevantly goes no further than indicating that he distinguished between a lower segment caesarean section and a classical caesarean, that the operation notes completed by the obstetrician should clearly state if the patient had had a classical caesarean and that fact would be included in any obstetric history provided by the hospital. However the operation upon TK was to the lower segment and would have been noted as such. It was not a classical caesarean as normally understood and would not have been so described in the operation notes. In my opinion it is unlikely that Dr Leslie or his deputy would have done other than inform the hospital, if enquiry had been made, that TK had undergone a lower segment caesarean section. As Dr Lyneham observed, a doctor would infer from such a response that the incision was transverse. Such a response would have confirmed the conclusion which the first defendant had reached from the material which had previously been available to him namely that TK had had a normal (transverse incision) lower segment caesarean section. 93 It was also submitted for the plaintiff (although not expressly particularised) that an enquiry of the general practitioner, who had referred TK to PANCH, should have been made. I reject this submission. There is no satisfactory evidence that this was the common practice at the time and I do not find the first or second defendant was under a duty to do so. Additionally there was no evidence that the general practitioner would have known what procedure had been performed or that TK would be able to identify him in order that enquiry would be made. Similarly there was no evidence from which I could infer Dr Qidwai was aware of TK's earlier medical history concerning the birth of Wassif. Group C (22) During the course of the Plaintiff's ante-natal attendances at the Hospital, neither the First Defendant nor the Second Defendant, its servants and agents: (f) Warned the Plaintiff's mother to attend upon the hospital at the first sign of a contraction in the pregnancy which was then under management by the First and Second Defendants.

(33) (h) (v) alternatively failure to instruct the Plaintiff's mother to attend urgently at the hospital upon experiencing her first contractions. (34) (b) The plaintiff's mother would or should have been told to proceed immediately to the hospital at the first sign of pain and labour because of the increased risk of rupture. 94 The first defendant gave evidence that it was his usual practice to advise any pregnant woman who had had a previous caesarean section of any type and who was listed for trial of labour to come into hospital as soon as possible should she come into labour, feel contractions, or rupture her membranes and that if anything unusual occurs in her late pregnancy she should report to the labour ward to check it out with nursing staff. I accept that evidence. 95 TK denied in evidence that she was given such advice by the first defendant.

96 I prefer the evidence of the first defendant. I infer he did give such advice to TK as his "usual practice" conformed to that generally accepted as appropriate practice at the time, no reason was apparent as to why he would have departed from that practice and I have concluded, for reasons which appear later in this judgment, that TK arrived at the hospital as soon as possible after the commencement of contractions. 97 Alternatively, if there was such a failure, it was not causative of the harm to the plaintiff as TK, in any event, came into the hospital as soon as possible upon feeling contractions. 98 The first and second defendants did not warn TK that she had or may have had a significantly higher than normal risk of uterine rupture in late pregnancy or during birth as they were not aware that she had previously undergone a lower segment incision which had extended into the upper segment of the uterus. In any event, such a warning would only have served to heighten TK's concern to make certain that she proceeded to hospital as soon as possible upon the onset of contractions which I find she did.

Group D (34) (a) The plaintiff's mother would or should have been told to ring the hospital prior to going in at the first sign of pain or labour. 99 There was no satisfactory evidence that it was the usual practice in Sydney hospitals in 1984 to instruct pregnant women who had undergone a previous classical caesarean section to ring the hospital prior to going in at the first sign of pain or labour. 100 The only medical evidence in support of such a practice was given by Dr Molloy. He gave evidence that upon receipt of the phone call the hospital could have rung the surgeon and anaesthetist and informed them to be on alert as they may have to get in to the hospital very quickly. He would have caused the theatre to be opened in advance of TK's arrival at the hospital. 101 Mr Clements supported this approach but only for the purpose of stopping operating theatre staff leaving the hospital at the end of their shift if there was a prospect surgery would be required. In the present case the operating theatre staff were at the hospital when TK arrived and a phone call would have had no effect on their actions. Both Mr Clements and Dr Lyneham confirmed it was reasonable before calling in the surgeon and anaesthetist to examine the mother to ensure she was in labour. In those circumstances little, if anything, was to be gained in TK's case by telephoning the hospital in advance of her arrival. There is a significant cost of opening the theatre and this should be avoided until it is apparent surgery will be required. In any event the hospital was unaware TK had undergone a caesarean section involving a vertical incision extending into the upper segment.

Group E (22) (h) Failed to refer the Plaintiff's mother to a major teaching hospital which had the facilities appropriate to manage her pregnancy. 102 The plaintiff submitted that if the first and second defendants had known, or suspected, that TK had had a prior caesarean section involving a vertical incision extending into the upper segment of the uterus, or had intended to undergo a trial of labour, having undergone a prior caesarean section of any description, reasonable care required that the pregnancy and birth be managed at a teaching hospital. This was because specialist obstetricians and anaesthetists were only present at the hospital from 6am to 6pm, and were otherwise on call, and the theatre staff normally departed at 11pm and resumed at 6am. 103 This submission was supported by Mr Clements whose reasoning, in short, was as follows: (a) All of TK's care in respect of the pregnancy should have been provided at the one hospital; (b) TK may have required a surgical procedure in respect of her pregnancy at any time, day or night; (c) At the hospital the surgeon and anaesthetist were on call between 6pm and 6am and the theatre staff were on call between 11pm and 6am; (d) A teaching hospital would have an operating theatre and surgical, anaesthetic and operating theatre staff available on site 24 hours per day, 7 days per week; (e) A teaching hospital was located equidistant from TK's home as the hospital. 104 The first defendant, Dr Lyneham and Dr Hinde would not have referred TK to a teaching hospital. Dr Molloy considered it questionable as to whether TK should have been referred to a teaching hospital.

105 The nearest teaching hospitals to TK's home were St George, Westmead and Royal Prince Alfred ("RPA") Hospitals. RPA was the closest. However it was not a similar distance from TK's home as the hospital. There was evidence that a computer program indicated that it took 23 minutes to travel from TK's home to RPA and 10 minutes to travel from TK's home to the hospital. However the first defendant gave evidence (in a statement tendered in evidence) that he worked regularly at Greenoaks Private Hospital in Greenacre (near TK's home) and needed to travel past RPA on his way home from Greenoaks and vice versa. He said: It used to take me approximately 35 minutes travel from Greenoaks to RPA and vice versa, and I was always travelling in the opposite direction to the predominant flow of traffic. Furthermore I knew all the back road shortcuts. I would estimate that the time taken in peak traffic going with the flow of traffic, would probably average 45 minutes.

I prefer the evidence of actual travelling times experienced by the first defendant to the computer generated figures. Adopting the figure of 35 minutes as being indicative having regard to the likely traffic at about 11pm, TK, if she had left home at 10.45pm, would have arrived at RPA at approximately 11.20pm. 106 There was no evidence that, at any of the three teaching hospitals nominated, an obstetrician and an anaesthetist were available on site 24 hours per day 7 days per week. Such evidence as there was was to the contrary. Dr Booth gave evidence she had worked at St George Hospital and doctors did not remain at the hospital overnight. Dr Lyneham worked at RPA. He gave evidence that a theatre team was at the hospital 24 hours per day 7 days per week but the anaesthetist and visiting medical officer had to be called in. Dr Molloy, when asked, said he was unaware of staffing levels at either St George or Westmead Hospital. There was no evidence as to how long it would take a surgeon or anaesthetist to arrive after being called in at the teaching hospital. 107 I find no breach by the first or second defendant in not referring the management of TK's pregnancy and the birth to a teaching hospital. Any referral would have required the agreement of TK. There was no evidence from TK that she would have agreed to that course. I would not infer her agreement would be forthcoming particularly having regard to the greater travelling time required in relation to antenatal visits. Neither does the evidence establish that had the plaintiff been born at RPA the harm which befell him would have been avoided.

(22) (g) Being an irregular attender the Second Defendant ought to have followed up the Plaintiff's mother by telephone after she did not attend 9th October 1984 in the event they knew or ought to have known the Plaintiff's mother had a previous Caesarean Section.

108 At the antenatal consultation on 2 October 1984 TK had been asked to attend at the antenatal clinic in one week's time. She did not attend. No reason was given for her non-attendance. There is no evidence the hospital attempted to contact her to make an alternative appointment.

109 There was no satisfactory evidence that reasonable care required a hospital in 1984 as a matter of course to follow up any patient who did not attend an antenatal appointment. I do not consider it reasonable to impose such a duty. Dr Molloy was the only expert who so suggested. 110 In any event the evidence does not establish: (a) that any attempt to contact TK necessarily would have been successful, this being a time prior to mobile phones and there being no evidence TK had a telephone answering machine or someone available to take calls; (b) that, if TK had been contacted by the hospital, a new appointment could have been arranged before 13 October 1984; (c) that the reason that TK did not attend on 9 October 1984 would not have prevented her attending on the following days; (d) that if a new appointment had been arranged TK would have attended; (e) If TK had attended the antenatal clinic between 9 - 12 October 1984 the course of the pregnancy would have been relevantly different. Group G (33) (d) Failure to discuss and advise delivery options with the Plaintiff's mother in the light of the fact that she had undoubtedly had a caesarean section and needed to be advised of possible consequences attending upon that fact. (22) During the course of the Plaintiff's ante-natal attendances at the hospital, neither the First Defendant nor the Second Defendant, its servants and agents: (c) Warned the Plaintiff's mother that she had or may have a significantly higher than normal risk of uterine rupture in late pregnancy or during birth.

111 The first defendant's evidence was that in accordance with his usual practice he would have discussed and advised TK as to delivery options. I accept that evidence. The first defendant and the hospital were unaware during the course of TK's antenatal attendances at the hospital that she had a significantly higher than normal risk of uterine rupture. No breach of duty as alleged is demonstrated. 112 In the events that occurred any failure as particularised was not causative of the harm which ultimately befell the plaintiff. Liability - The second defendant - early confinement 113 The breaches by the second defendant in this regard are particularised in the Further Amended Statement of Claim dated 19 December 2006 in the following terms: (22) During the course of the Plaintiff's ante-natal attendances at the Hospital, neither the First Defendant nor the Second Defendant, its servants and agents: (e) Warned the Plaintiff's mother of the risks of an unstable lie in the last month of her pregnancy. 33 (b) Failing to properly examine the plaintiff's mother, in particular, fail to order an ultrasound at the time of the first or second consultation to better determine the expected date of confinement. 33 (h) Failing to admit the Plaintiff's mother to hospital for early confinement at a time prior to 12 October 1984: (i) at all. (ii) in circumstances where previous classical caesarean delivery should have been known or suspected. (iii) in circumstances where the pregnancy was poorly dated. (iv) in circumstances where the Plaintiff's mother at her last two consultations had an unstable lie thereby exposing the Plaintiff's mother to the risk of such a condition, such as a prolapsed cord with resultant possible damage to the Plaintiff.

114 It was common ground that a pregnant woman who had undergone a previous caesarean section in which a vertical incision had been made into the upper segment of the uterus should be admitted at about 38 weeks gestation for an elective caesarean section.

115 The plaintiff gave evidence her menstrual periods were regular and she had given the date of her last menstrual period to Dr Quidwai, who had referred her to the hospital. Dr Quidwai, in his letter of referral, stated the last menstrual period was 31 January 1984. The uterine size at examination by the first defendant on 31 July 1984 corresponded to 26 weeks gestation which was consistent with a last menstrual period on 31 January 1984. A last menstrual period on 31 January 1984 was also consistent with the result of the ultrasound dated 20 September 1984. 116 The doubt as to the date of the last menstrual period arose because of an entry on the hospital antenatal attendance record which noted LMP 1/1/84 and EDC 10/10/84 with the latter date being struck out and replaced by 11/11/84. The entry 1/1/84 was written by the first defendant who explained that in so doing he must have erred in transposing the date from Dr Quidwai's letter of referral, that he had later corrected the estimated date of confinement to that appropriate for a last menstrual period of 31 January 1984 but had inadvertently omitted to correct the LMP entry on the antenatal card. I accept the first defendant's explanation. A second document, undated but headed "Previous obstetric history" had typed on it "31 February" with the word February overwritten with the word "January". The EDC was noted as early November. I find the date of the last menstrual period was 31 January 1984. 117 Based on a last menstrual period of 31 January 1984 TK was 36 weeks and 4 days pregnant as at 13 October 1984. Even assuming the second defendant had known TK had had a lower segment caesarean section which had extended into the upper segment, reasonable care did not require that she be admitted to hospital for that reason as her pregnancy had not reached 38 weeks. 118 There is evidence TK had an unstable lie in that the antenatal record reveals: 20 September 1984: U/Sound. Breech.

As previously observed, TK did not attend her next appointment at the antenatal clinic on 9 October 1984. The plaintiff's presentation on 12 October 1984 was breech. It may be that the plaintiff was in a breech position as at 9 October 1984 in which event no question of admitting TK to hospital would arise as a breech presentation would be relatively safe.

119 Dr Molloy gave evidence that, in the event of an unstable lie, very serious consideration should be given to admitting a pregnant woman into hospital at 34-week gestation and closely watching her. 120 Dr Lyneham, Mr Clements and the first defendant gave evidence that in the ordinary course a pregnant woman with an unstable lie would not be admitted into hospital until somewhere between 36 - 38 weeks gestation. This was because it was not uncommon for there to be activity in terms of the baby repositioning itself and ultimately coming to the correct position. The evidence of Dr Lyneham, Mr Clements and the first defendant accords with the relevant literature. Mr Clements accepted that it was within the ambit of reasonable practice to opt for 36, 37 or 38 weeks to admit a pregnant woman in the event of an unstable lie. Dr Molloy did not produce any literature to support the suggestion that a pregnant woman with an unstable lie should be admitted for observation at 34 weeks and this approach conflicted with that expressed in his original report. I prefer the evidence of Dr Lyneham, Mr Clements and the first defendant that in the event of an unstable lie it would not be unreasonable to delay admission to hospital until 38 weeks gestation. I reject the allegation of negligence in this regard. 121 It was submitted that an ultrasound should have been taken at the first antenatal consultation to confirm the expected date of confinement. An ultrasound was performed in September. It confirmed the expected date of confinement based upon a last menstrual period of 31 January 1984. It did not reveal any information which impacted upon the harm later suffered by the plaintiff. In my opinion there was no breach of duty in not arranging an ultrasound at the first antenatal consultation and in any event nothing flowed from the fact that it was not arranged. Liability - the second defendant's liability for treatment on 12 and 13 October 1984.

122 Oral evidence of what occurred at the hospital between 11pm on 12 October 1984 and the birth of the plaintiff was given by Sister Shipley and Dr Booth. This evidence was supplemented by hospital records which included the following: (a) labour ward report: 12/10/84 11pm Admitted with history of contractions since 10.45pm. O/A 3/60 mild On Palpation RSL [right sacral lie] Buttocks Engaged On VE [vaginal examination] Cx [cervix] 2cm dilated. PP - [presenting part minus] 3 No membranes felt. No liquor seen RMO paged for X-Match Pathology aware Dr Booth paged. IV Therapy sited 5% Dextrose 1L + 1/2 L 11.20pm Blood taken for X-Match Consent signed. 11.40pm Shave. FHS [foetal heart sounds] ↓ 80 11.45pm Mylanta given → OT [transferred to operating theatre] M Shipley RN

A separate page, also headed "labour ward report", recorded the foetal heart rate at 11pm on 12 October 1984 as 140 ®. A document headed "Labour record" stated labour began at 10.45pm on 12 October 1984. (b) 13 October 1984 - operation record stating inter alia: SURGEON: Dr Simpson ASSISTANT Dr Booth ANAESTHETIST: Dr Hines INSTRUMENT SISTER I/S: Sr Brook OP. COMMENCED: 13-10-84 OP FINISHED: 2.10am 12.25am

OPERATIVE FINDINGS: Ruptured uterus - previous classical caesarean section. Baby removed from peritoneal cavity - male infant - anoxic

OPERATION(S) PERFORMED: Laparotomy SubTotal Hysterectomy Uterus rupture in midline Vertically from lower segment up & over fundus. No tear in bladder visible but adhesions from bladder to uterus.

STEPS OF OPERATION: Amniotic sac ruptured & baby removed. Uterus examined & explored - complete extensive rupture with heavy bleeding [therefore] decision made to do hysterectomy.

(c) Registered Nurses' Operating Room Report, stating, inter alia: Operation commenced: 12.25am. Operation completed: 2.10am. Living male 12.28am. LSCS. Removal of baby from abdomen. Subtotal hysterectomy due to ruptured uterus. (d) Anaesthetic record indicating TK's temperature was taken by the anaesthetist at 12.15pm on 13 October 1984. 123 The chronology for 12 and 13 October 1984 constructed from the sources referred to in the preceding paragraph is as follows. At 11pm on 12 October 1984 TK presented at the hospital - she was taken to an examination room in the labour ward where she was examined by Sister Shipley. She gave a history of contractions since 10.45pm. An examination was performed by Sister Shipley during which she noted that the contractions were occurring at 3 minute intervals and were mild. The examination took approximately 15 minutes. Sister Shipley determined the plaintiff's presentation was breech and that as a consequence a caesarean section was required. She contacted Dr Booth. Dr Booth arrived about 5 minutes later. Dr Booth examined TK and confirmed the breech presentation and the need for elective surgery. She then telephoned the obstetrician who was on call (Dr Simpson) to confirm the correctness of her decision to proceed to a caesarean section for breech presentation. She then telephoned the anaesthetist (Dr Hines) who was on call and asked him to come to the hospital. He said he would only come if the operation was to be performed by Dr Simpson. Dr Booth then rang Dr Simpson again. He agreed to come in. A further call was made to the anaesthetist who said he too would come in. These calls were made between 11.25pm and 11.30pm. TK was then prepared for her operation. She was shaved, her jewellery was removed etc.

124 The foetal heart rate was recorded at 11pm. It was within the normal range at 140. A note made by Dr Booth and timed at 11.30pm refers to a foetal heart rate of 140. It was accepted in the conduct of the plaintiff's case that this was a foetal heart rate measured by Dr Booth between 11.20pm and 11.30pm and not a reference back to the foetal heart rate measured at 11pm. At 11.40pm the foetal heart rate was monitored by Sister Shipley. It was found to be 80. This was below the normal range. Dr Booth then listened to the heart rate and concluded it evidenced a prolonged bradycardia (slowness of the heart rate). 125 At 11.45pm TK was transferred to the operating theatre. The transfer took somewhere between 5 - 10 minutes (Sister Shipley) and 15 minutes (Dr Booth) to be completed. Dr Booth was unable to contact Dr Simpson or Dr Hines who were on the way as there were no mobile phones. It was unclear if they had pagers but Dr Booth was concerned that if she paged them they would have to interrupt their journey to find a phone to telephone the hospital and could even have returned to their homes. The foetal heart rate continued to be monitored but dropped to 40. Dr Simpson and Dr Hines arrived at the operating theatre at 12.10am on 13 October 1984. They scrubbed up, put on their surgical gowns. Dr Hines commenced to tend TK at 12.15am. The operation commenced at 12.25am and the plaintiff was born at 12.28am.

126 The alleged breaches by the second defendant in respect of the treatment on 12 and 13 October 1984 are particularised in the Further Amended Statement of Claim dated 19 December 2006. They are grouped and considered separately hereunder:

GROUP X 27 (a) During the Plaintiff's mother's confinement the Second Defendant failed to monitor the Plaintiff in the circumstances when it knew or ought to have known the increased risk of uterine rupture, whether or not it knew of the existence of a previous classical caesarean section. 127 There was evidence of three methods of monitoring the foetal heart rate available at the hospital in 1984. A CTG monitor could be attached to the pregnant woman. This would provide a continuous trace of the foetal heart rate. A Doptone could be strapped to the pregnant woman's abdomen. This provided a constant sound monitor though it produced no trace. The third method was by auscultation (listening to the heart sound by application of examiner's ear to the patient's skin or using a stethoscope). 128 There was evidence from Sister Orrock that it was appropriate to monitor the foetal heart rate by auscultation every 15 minutes in the circumstances that presented. Dr Lyneham gave evidence that it was not necessary to monitor the foetal heart rate electronically (provided trial of labour was not attempted) but it should be monitored regularly by auscultation. He gave evidence that it was normally recommended that the heart rate be checked every half hour in labour, though arguably, as there had been a previous caesarean, it would be reasonable to check it after 15 minutes but half an hour was a normal frequency.

129 If Dr Booth had monitored the foetal heart rate between approximately 11.20pm and 11.30pm this would be within the bounds of proper practice. If however there was a gap of 40 minutes from 11pm to 11.40pm in the monitoring of the foetal heart rate this, in Dr Lyneham's opinion, would demonstrate a departure from good practice. 130 The plaintiff submitted the second defendant should have electronically monitored the foetal heart rate continually from the time of the admission and that if this had been done signs of foetal distress would have been apparent earlier than 11.40pm with the result that the contacting of Drs Simpson and Hines would have been brought forward. Alternatively monitoring by auscultation should have occurred at 15 minute intervals. 131 I accept the evidence of Dr Lyneham and Sister Orrock that proper practice did not require electronic or continual monitoring in 1984 and that it was appropriate to perform monitoring by auscultation. I accept the evidence of Dr Lyneham that it was not contrary to good practice to monitor the foetal heart rate by auscultation half hourly. 132 Whether monitoring between 11pm and 11.40pm, additional to that which took place, would have revealed any indication of foetal distress is a matter of speculation. The fact that the plaintiff survived to be born at 12.28am suggests it may have been unlikely. There was no allegation of a failure to monitor from 11.40pm on. In my opinion, no breach by the second defendant in this regard has been established.

GROUP Y 34 (i) As a result of the breach by the first, second and/or third defendant of its duty to the plaintiff, the caesarean section operation by which the plaintiff was delivered was materially delayed in that the plaintiff's mother did not immediately go to hospital upon first experiencing contractions nor did the plaintiff's mother book to undergo an emergency Caesarean Section immediately after her initial contractions thereby delaying the assembly of the critical hospital staff and preventing the plaintiff's mother from entering hospital earlier than she did, thereby the injury and damage to the plaintiff might have been avoided. (ii) Further, the second defendant's system was defective in that it was not possible to deliver the baby in a timely manner. Particulars of this are as follows: A. If the first or second defendants had diagnosed the previous classical Caesarean Section, the antenatal treatment and advice together with the treatment of the plaintiff's mother when she presented on 12 October 1984 should and would have been different in the following respects: (a) The plaintiff's mother would or should have been told to ring the hospital prior to going in at the first sign of pain or labour. (b) The plaintiff's mother would or should have been told to proceed immediately to the hospital at the first sign of pain or labour because of the increased risk of rupture. (c) The plaintiff's mother could have been at hospital within 15 minutes of the first sign of labour. (d) The labour ward nurse and/or midwife upon receiving the phone call would and should have arranged for a theatre to be opened and the anaesthetist and a suitably qualified obstetrician to be available to perform and emergency caesarean section. (e) Upon presentation at the hospital the plaintiff's mother would have immediately been prepared for surgery without delay to confirm that she was in labour as it would have been known that 50% of uterine ruptures occur in mothers with a history of previous classical Caesarean Section before labour.

Had the above steps been taken the plaintiff would have been born some time between 9.45pm and 11.43pm depending upon the finding as to the timing of the mother's initial contraction.

133 The issues raised by these particulars in the main have already been dealt with. I have held that the second defendant was not negligent in not concluding or assuming there had been previous caesarean section which involved a vertical incision into or encroaching into the upper segment, that no purpose would have been served by TK telephoning the hospital in advance of presenting, that TK had been told to proceed immediately to the hospital at the first sign of contractions, labour or pain, TK could be at the hospital within 15 minutes of the first sign of labour or contractions and was. 134 Mr Clements and Dr Lyneham were of the opinion that even if the hospital had been aware of the nature of the previous caesarean section it would still be necessary to make a diagnosis that TK was in labour before deciding to perform the caesarean section and marshalling the necessary medical and operative staff. This would take about half an hour from the time of admission. Dr Molloy initially appeared to agree with this but later said he would call personnel in without examination. I prefer the evidence of Mr Clements and Dr Lyneham. There may have been a saving of up to 5 minutes if TK was known to have had a caesarean of the type she had as Dr Booth would have only had to ring each of the doctors once and it would have been unnecessary for her to perform a vaginal examination to confirm the breech presentation. Dr Lyneham gave evidence that opening the theatre would mean the opening of costly equipment which one does not do unless sure an operation will be proceeding. In any event the theatre was open before the arrival of Drs Simpson and Hines. 135 The conclusion drawn in these particulars encompasses the acceptance of TK's evidence that she felt the initial contraction at 9pm. I am unable to accept that evidence for the following reasons: (a) TK's evidence at the hearing was that the contractions had started at precisely 9pm on 12 October 1984. She was aware of that time as there were some regular customers who came at about that time to the shop and this caused her to check the clock. She had always told people her contractions started at 9pm; (b) TK's evidence was contrary to the history recorded by Dr Harbord that TK was admitted 30 minutes after the onset of contractions. It was contrary to Mr Clements's history of contractions commencing at 9.10pm and contrary to the original Statement of Claim which asserted TK presented to the hospital at about 10.30pm with a history of contractions over the preceding period of less than 30 minutes; (c) TK's evidence was contrary to the history recorded at the hospital at 11pm of "contractions since 10.45pm". The hospital entry was made by Sister Shipley who said the entry was made contemporaneously and recorded TK's response to the question "When did contractions start?". Sister Shipley said there was no language problem, if there had been she would have obtained an interpreter and noted the fact on the record. Sister Shipley was an experienced midwife. She had no reason not to accurately record TK's answers. It was suggested to her that she was concerned to know when the contractions became regular but she denied that the question was in that form. I accept Sister Shipley's evidence. 136 I find that the contractions commenced approximately 15 minutes before TK's arrival at the hospital at 11pm. The exercise of reasonable care would not have resulted in the plaintiff being born sometime between 9.45pm and 11.43pm. GROUP Z B. Even with a breech presentation, absent the knowledge of a previous classical Caesarean Section, the delay from the decision to operate to delivery was excessive and not in accordance with appropriate standards.

137 Dr Lyneham and Mr Clements were of the opinion that it was necessary to confirm TK was in labour before arranging to open the operating theatre and summoning the surgeon and anaesthetist. They each accepted that approximately half an hour was required to attend to these matters and it would be necessary to attend to them irrespective of whether or not it was known that the patient had undergone a previous caesarean section involving an incision into, or encroaching upon, the upper segment. I have accepted that evidence. 138 In his report, dated 20 October 2005, Dr Molloy stated that in 1984: Taking one hour to open the theatres, to have the patient anaesthetised, and the baby delivered would have been considered reasonable practice.

In a report dated 4 August 2005 he had referred to the organisation of the caesarean section at the hospital as being done "in an exemplary manner and as fast as possible at the time, being in the middle of the night". 139 However in his oral evidence, Dr Molloy, expressed a different opinion. He stated that the "gold standard" for delivery of a child by caesarean section from the time of the decision to proceed in that way to birth was 30 minutes. Although he conceded it was fairly standard in the majority of hospitals that there would not be a full surgical complement present to perform emergency procedures at all times he nevertheless asserted that the gold standard applied irrespective of whether the surgeon and anaesthetist were in the hospital or not at the time the decision to proceed by caesarean section was taken. 140 The evidence does not establish that in 1984 it was reasonable or practicable to have suburban hospital obstetric units staffed by specialist obstetricians and anaesthetists present on site at all times of the day and night. There was no evidence as to the general availability of specialists to work in the hospital and the proximity of their homes to the hospital. There was evidence the first defendant took 35 minutes to get from his home to the hospital in an emergency and that Dr Booth did not regard the 40 minutes taken by Drs Simpson and Hines to attend the hospital as untoward. The evidence of Dr Hinde was that the staffing arrangements at the hospital were common place in hospitals in 1984. Specialists had to be summonsed to the hospitals in the case of emergencies outside hours. There was no practical alternative. I accept this evidence. 141 Dr Lyneham gave evidence that even if it had been known that a previous classical caesarean section had been performed, a period of about one hour between the decision to deliver by caesarean section and the birth fell within the period of time that in 1984 would normally be expected and was reasonable. 142 Dr Hinde concluded there had been no departure from proper practice in respect of the delivery time for the plaintiff. 143 Mr Clements was of the opinion that, given the surgical team was not on site, that the sort of interval between the decision to perform the caesarean section and delivery would inevitably be in the order of an hour and given the circumstances this fell within the ambit of reasonable practice at the time. 144 I am unable to accept Dr Molloy's opinion which not only is in conflict with the opinion expressed by him in written form but is also in conflict with the opinions of Mr Clements and Drs Lyneham and Hinde.

145 I prefer the evidence of Mr Clements and Dr Lyneham that delivery up to about an hour after the decision to proceed to surgery was within the bounds of reasonable practice and that, as Dr Hinde concluded, there had been no departure from proper practice. 146 The plaintiff, when born, had no heart rate and was not breathing, though he was able to be resuscitated. 147 Mr Clements gave evidence that, where there was a total or near total lack of oxygen, a foetus at 36 weeks gestation could survive 10 minutes without suffering permanent harm, would suffer irretrievable brain damage at 10 - 20 minutes and would be dead at 30 minutes. He accepted that foetal bradycardia of less than 20 minutes could be associated with significant brain damage. 148 Dr Booth gave evidence that with a bradycardia of 80, brain damage would be beginning after 10 minutes and after 20 minutes there would probably be very severe damage. 149 The precise time at which the rupture occurred is not known. Dr Lyneham was of the opinion the foetal heart rate of 80 was a consequence of the uterine rupture. The rupture of the uterus can be spontaneous or gradual. It is likely, but not necessary, that it be accompanied by sudden severe pain. 150 The original Statement of Claim alleged that shortly after admission, TK commenced to suffer knife-like pains in the abdomen of which she complained to the nursing staff. In further and better particulars it was asserted the complaint of knife-like pain was made between 20 - 30 minutes after TK's arrival at the hospital. TK in her evidence initially said the knife like pain began when she was going to the hospital. She later said she did not remember when it started but she told the nurse of it after being told to sit on the bed. She then said the knife-like pain started when she was told to sit on the bed. 151 There is no record in the hospital notes of a complaint by TK of a sharp knife like pain at any time. Both Sister Shipley and Dr Booth said normally they would have noted such a complaint. Dr Booth suggested that the complaint may have been made when the bradycardia was observed and that, as the matter then became urgent, noting it was overlooked. In my opinion the probability is that TK first experienced the sharp knife like pain at about 11.40pm. 152 It would appear from the evidence that the probability is that the rupture began at or shortly before 11.40pm. Mr Clements, in order to explain how the plaintiff managed to survive until he was born at 12.28am, hypothesised that initially there was only a partial rupture. Nevertheless it would appear that with a bradycardia of 80 at 11.40pm subsequently falling to 40 that by midnight or shortly thereafter the plaintiff was in all probability grossly and irretrievably brain damaged. 153 In my opinion it has not been established the time taken from the decision to operate to delivery was excessive and not in accordance with 1984 standards. 154 Further, it has not been established that if the plaintiff had been born any time after midnight he would not have suffered severe brain damage and long term dependency on carers and others. Mr Clements, who gave the primary evidence on this aspect, said he was unable to express a view on this matter. 155 In my opinion, the plaintiff has failed to establish liability on the part of the first or second defendants. Accordingly there will be a verdict and judgment for the first and second defendants. Damages 156 The parties reached agreement as to the quantum of most heads of damage recoverable in the event the plaintiff was successful in his claim. A schedule of the agreed damages has been initialled by me and placed with the papers. 157 Three heads of damage were not agreed. Although my findings as to liability render it unnecessary to assess damages, I make the following comments against the possibility the matter may go further.

Fund Management 158 The defendants did not dispute the plaintiff's entitlement to damages for fund management, but disputed its quantum. 159 The plaintiff submitted fund management should be assessed by reference to fees charged by the Office of the Protective Commissioner ("OPC"). 160 Evidence was adduced by the plaintiff that OPC would charge fees of $866,765 for managing $7.2 million for 18 years. The fees comprised an annual management fee of 1.1 percent on the fund (plus an additional 1% in the first year capped at $2,200) and an annual investment management fee on 0.5 percent on the whole of the fund. 161 The defendants' adduced evidence that Australian New Zealand Executors and Trustee Company Limited ("ANZ") would charge fees of $327,636 to manage a fund of $7 million for 18 years. The ANZ fees comprised an establishment fee of $5,500 and an annual investment fee of 1.1 percent on the fund up to $5 million and 0.66 percent on that part of the fund which exceeded $5 million. The fee would be $387,604 if ANZ was appointed private manager under the OPC in which event an additional supervisory fee of 4 percent would be chargeable payable to the OPC. The ANZ fees were treated as totally tax deductible, the OPC management fee was treated as tax deductible as to 20 percent and the investment management fee as totally tax deductible. There was no evidence from a taxation expert to confirm that the taxation treatment was correct. 162 There was evidence that the ANZ fees were comparable with other reputable management organisations, that ANZ provided broadly the same services as OPC, and that the ANZ Banking Group Limited (of which ANZ was a wholly owned subsidiary) was a reputable organisation. I accept that evidence. 163 The defendants submitted there was no reasonable basis upon which to prefer OPC's management over management by ANZ and that damages for fund management should be assessed at the ANZ rates, the plaintiff being required to mitigate his loss. 164 The plaintiff submitted there was a risk that ANZ may encounter financial difficulty. Reference was made to the liquidation of a Victorian trustee company in relatively recent times. It was submitted the difference in the fee structure suggested that the standard of service provided by ANZ may be inferior to that provided by OPC and a weighting toward Australian equities in the investment spread of ANZ was somewhat concerning. Overall it was submitted OPC was the preferable manager as it was more conservative and was in fact a statutory authority governed by statutory regulations. 165 In my opinion there is, on the evidence before me, little to choose between OPC and ANZ as fund managers. There is no evidence ANZ is financially unsound or likely to become such. The plaintiff owes a duty to mitigate his loss. In these circumstances I would have calculated the damages under this head at the ANZ rates once the capital sum to be managed was calculated.

Housing 166 The plaintiff adduced expert evidence from Mr Hardiman as to the cost of providing accommodation suitable for the plaintiff's needs. The defendants adduced evidence from Mr Hesse to like effect. There was a discrepancy between the figures of considerable proportions. This was largely due to issues as to inclusions and the overall approach taken rather than with the cost of materials as such. 167 The plaintiff submitted he was entitled to the capital cost of purchasing a home and land suitable for his needs (less offsets). He relied upon Weideck v Williams [1999] NSWCA 346. 168 The defendants submitted the damages recoverable under this head was the marginal cost of securing suitable accommodation or, to put it another way, the cost of adapting the sort of house the plaintiff would live in if he was not disabled, to meet his special needs. 169 The defendants' submission accorded with the normal approach to be adopted unless the facts of the case justified something different - Weideck at [7]. In Weideck the Court held the facts justified something different because the plaintiff, pre-injury, was living in a caravan and would have continued to do so but for injury. It was submitted here that the fact the plaintiff was injured at birth justified a similar approach. 170 In my opinion, the age of the plaintiff when injured does not make this a special case nor is there any other matter which makes this a special case. The usual approach to the assessment of damages under this head is to be preferred. 171 The approach of the plaintiff's expert appears to involve assessing the plaintiff's needs at an optimal rather than at a reasonable level e.g. the provision of a duplex for the carer. The defendants' expert appears to adopt what is, to my mind, an overly restrictive approach e.g. the non provision of wheelchair access to the kitchen area. 172 As the Court observed in Weideck at [18] "In this area of assessment, the Court must take a pragmatic approach". Adopting such an approach I would have allowed damages under this head at $150,000. 173 A claim was also made for a spa pool. I would have allowed the cost of a spa pool and the cost of maintaining and running it. 174 A claim was made for air conditioning. It was conceded there was no evidence that this was a requirement resulting from the plaintiff's condition. I would not have allowed this claim. 175 A claim for a hoist was made but would have been rejected as it had already been included in the agreed damages.

Holidays 176 The plaintiff has some capacity to recognise his surroundings, although just how much is uncertain. It is apparent he gets pleasure from interacting with his relatives. 177 The plaintiff has claimed holiday costs. The usual evidence was before the Court costing holidays from Tamworth through to overseas destinations. 178 The defendant would allow the plaintiff $2,000 per annum for holiday expenses. This was based upon evidence that a holiday at Manly would provide the plaintiff with an appropriate change of scene. Such a venue would not involve the incurring of any significant travelling costs. However accommodation at a hotel/motel would involve the additional cost of the plaintiff obtaining a room suitable for a disabled person and accommodation for a carer. 179 The plaintiff does not press for overseas holidays but submits that the allowance of $2,000 per annum is inadequate. 180 I agree that the sum of $2,000 per annum is inadequate. I would have allowed $5,000 per annum under this head.

Orders 181 The orders of the Court are: (1) Verdict and judgment for the first, second and third defendants; (2) The plaintiff is to pay the costs of the first, second and third defendants. *******

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