Medico-legal frameworks — structured SAQ (15 marks)

(a) Four-stage negligence test — applied (4 marks)

One mark per stage applied to the facts. ^[1][2][3]

• Duty of care. The obstetrician owed the patient a duty of care from the first antenatal contact; this is conceded in nearly every clinical negligence claim. Apply: a doctor-patient relationship existed, so duty is established (1).
• Breach of duty. Bolam sets the standard — a responsible body of obstetric opinion. Bolitho adds the logical-basis proviso: opinion must withstand logical analysis. Apply: a responsible body of opinion would have disclosed uterine rupture, accreta and hysterectomy, and offered TOLAC as a reasonable alternative; failure to do so was a significant departure and not logically defensible. The Rogers standard for disclosure applies independently (1).
• Causation. The plaintiff must show that, had the material risks been disclosed, she would have chosen differently (a Montgomery/Rogers 'but for' test) and that the chosen path would have avoided the harm on the balance of probabilities. Causation is contested — the trial of labour itself carries a small rupture risk (1).
• Compensable harm. Documented neonatal acidosis, Apgar scores and cord pH; quantified harm to be pleaded in the statement of claim (1).

(b) Standard for material-risk disclosure — applied (4 marks)

• Quote the Rogers v Whitaker test: a material risk is one that a reasonable person in the patient's position would attach significance to, or that the doctor knows or should know this particular patient would (1.5).^[1]
• Quote Montgomery: the standard is patient-centred; Bolam is rejected for disclosure; reasonable alternatives (TOLAC) are part of the disclosure duty (1).^[4]
• Apply: uterine rupture with prior caesarean is well-recognised, severe when it occurs, and central to this patient's choice between repeat caesarean and TOLAC. A reasonable person in her position, and certainly a person who has chosen to labour after a caesarean in another scenario, would attach significance to it. Placenta accreta and the risk of peripartum hysterectomy are material to a patient considering fertility and recovery. The omission is a Rogers/Montgomery failure (1).
• Note the no-fixed-percentage rule: materiality is fact-sensitive and includes rare risks with severe consequence (0.5).^[1][4]

(c) Elements of valid consent that should have been documented (4 marks)

One mark per element, with what should have appeared in the entry. ^[8]

• Capacity statement. "Patient demonstrated capacity to understand the procedure, alternatives and consequences. No reversible impairment identified." Missing in this entry (1).
• Voluntariness statement. "Patient spoke privately; no coercion or undue influence from partner or staff; opportunity for questions." Missing in this entry (1).
• Adequate information. Named risks (bleeding, infection, anaesthetic, uterine rupture, accreta, hysterectomy, thromboembolism, visceral injury, neonatal respiratory distress); named alternatives (TOLAC, planned repeat caesarean, expectant management); teach-back recorded in the patient's own words; interpreter if applicable (1).
• Process and outcomes. Time, date, attendees, material risks discussed, the patient's questions and goals in quotation, the agreed scope (and any exclusions), signature, name and designation of the clinician. Missing or partial in this entry (1).

(d) First-hour steps on receipt of the plaintiff letter (3 marks)

• Notify your medical defence organisation (MDO) immediately. Do not respond to the plaintiff letter, do not amend the notes, do not discuss the case with colleagues beyond the MDO brief (1).^[15]
• Preserve the records. Lock the original consent form, the antenatal record, the intrapartum CTG, the operation note, the neonatal resuscitation record, the staff roster and any phone records. Do not 'tidy' or rewrite (1).^[6][15]
• Open-disclosure posture. Continue to support the patient and family clinically; remember that an apology is not an admission of liability. Discuss any future contact with the patient through the MDO (1).^[10][15]