Practice

Case examples

Page last reviewed 27 October 2026

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The three examples below are illustrative — composites built to show the type of question I am instructed to answer and how I reason through it, not an account of a specific claimant or firm.

Choose an example

Three types of instruction

Select one of the three cards below to see the full reasoning behind it, from the instruction received through to the conclusions reached.

Illustrative example

Delayed diagnosis affecting the extent of surgery

Instructed by the claimant’s solicitors to address two aspects of the case: firstly, whether a lesser lung resection would have been possible rather than the complete resection the claimant underwent; and secondly, whether earlier surgery could have avoided the need for adjuvant radiotherapy. I was also asked to comment on the surgical options available at each stage up to the date of diagnosis.

Instructed to address

Breach of duty and causation

Whether the operating surgeon acted appropriately given the size and position of the tumour at diagnosis
Whether a lesser, lung-sparing resection would have been possible had the tumour been identified sooner
Whether adjuvant radiotherapy could have been avoided

Records reviewed

Full disclosure

GP records
Hospital records, each relevant admission
Imaging, including CT and PET
Operation note
Paginated chronology

Outside this instruction

Where the boundary sits

I noted that the initial biopsy result was later found to be incorrect, and recommended a histopathologist be instructed separately to determine whether that misreading involved any breach of duty — a question outside thoracic surgery.

Background

How the chronology was read

2012 to 2017. First presents to GP with a wheeze, seen with increasing frequency for chest symptoms, without referral to a respiratory physician.

November 2017 and October 2018. On the balance of probabilities, a sleeve resection — detaching the airway above the tumour and reattaching it to restore continuity — would most likely have been possible at either point.

Diagnosis, two years later. Bronchoscopy and EBUS biopsy identify a 22mm mass compressing the right main bronchus. At this size, a sleeve resection is no longer a safe option.

Within weeks of diagnosis. Complete removal of the lung is carried out, the only appropriate option given the proximal extension of the tumour by that stage.

Tumour, right main bronchus

Illustrative schematic only, not drawn from any patient’s imaging.

Reasoning

Conclusion

No breach of duty by the operating surgeon. The missed opportunity lay earlier, in primary care and in the original biopsy reading, not in the surgery itself.

No breach of duty by the operating surgeon, who removed the whole lung appropriately given the tumour’s size and proximal extension at the point of surgery A sleeve resection would most likely have been achievable in 2017 and 2018, though 2019 is too close to the eventual diagnosis to call with confidence Adjuvant radiotherapy carries a materially higher risk of bronchopleural fistula after complete lung removal — a view I consider supported by Professor Corinne Faivre-Finn’s published work on thoracic radiation oncology The missed opportunity sat in primary care and in the original biopsy interpretation, not in the surgery itself — both flagged as questions for a GP and a histopathologist rather than stretched to cover in my own opinion

What this shows

Scope held to thoracic surgery, even where it would be easier not to

A view at each point in time Not just whether something was negligent at the point of discovery, but what was achievable, or expected, at each earlier point — worked out stage by stage.

Named where I rely on others Where my opinion rests on published research or a trust’s own guideline, I say so and name the source, rather than presenting it as my own finding.

Checked before release This kind of reasoning is checked against the published report standard before it reaches you.

Illustrative example

Rib fractures following a road traffic collision

Instructed to provide a condition and prognosis report following a side-impact collision in which the claimant, restrained by a seatbelt, sustained multiple rib fractures with a flail segment on the left side. Asked to address current functional limitation, prognosis, and whether reported ongoing chest wall pain is attributable to the index accident.

Instructed to address

Condition and prognosis

The nature and severity of the chest wall injury sustained
Current functional limitation and its likely duration
Whether ongoing chest wall pain is attributable to the index accident or to an unrelated pre-existing condition

Records reviewed

Full disclosure

Ambulance and emergency department records
CT imaging of the chest
GP records, including pre-accident consultations
Physiotherapy notes
Claimant’s witness statement

Outside this instruction

Where the boundary sits

The claimant’s pre-existing degenerative spinal condition was noted in the GP records but falls to an orthopaedic or spinal expert; I have confined my opinion to the chest wall injury and its sequelae.

Background

How the chronology was read

Day of the accident. Presents to the emergency department with a flail segment affecting four consecutive ribs on the left side, confirmed on CT. Managed conservatively with analgesia and physiotherapy.

First six weeks. Acute pain and restricted chest wall movement, consistent with the expected course of a flail segment injury of this severity.

Six to twelve months. Radiological union of the fractures is confirmed. Reported pain persists, localised to two rib sites with ongoing tenderness on examination.

Examination, eighteen months post-accident. Findings consistent with post-traumatic costochondral irritation at the sites of the most severely displaced fractures.

Flail segment, four ribs, left side

Illustrative schematic only, not drawn from any patient’s imaging.

Reasoning

Conclusion

The index accident accounts for the ongoing symptoms. Initial management was appropriate, and residual discomfort at eighteen months is explained by post-traumatic costochondral irritation, not by the pre-existing spinal condition.

The flail segment injury and its initial management were consistent with accepted practice for an injury of this severity Ongoing pain at eighteen months is explained by post-traumatic costochondral irritation at the two most severely displaced fracture sites, not by the pre-existing spinal condition noted in the GP records On the balance of probabilities, residual symptoms are likely to improve further but some permanent, low-level discomfort on exertion is probable A referral for image-guided costochondral injection was recommended as a reasonable next step, to be addressed in treatment recommendations rather than prognosis alone

What this shows

Scope held to thoracic surgery, even where it would be easier not to

A view at each point in time Not just whether something was negligent at the point of discovery, but what was achievable, or expected, at each earlier point — worked out stage by stage.

Named where I rely on others Where my opinion rests on published research or a trust’s own guideline, I say so and name the source, rather than presenting it as my own finding.

Checked before release This kind of reasoning is checked against the published report standard before it reaches you.

Illustrative example

Chest drain inserted into the liver

Instructed on behalf of the defendant trust to address breach of duty following the insertion of a chest drain for a traumatic pneumothorax, during which the drain was advanced into the liver. Asked whether the site chosen and the technique used fell below the standard expected of the grade of clinician who performed the procedure.

Instructed to address

Breach of duty

Whether the site chosen for insertion was appropriate given the claimant’s presentation
Whether imaging guidance was indicated and, if so, whether its absence fell below the expected standard
Whether the operator’s grade and level of supervision were appropriate to the procedure

Records reviewed

Full disclosure

Emergency department records and trauma call documentation
Pre- and post-procedure imaging
Procedure note and consent documentation
Staff rota confirming the operator’s grade
Trust guideline on chest drain insertion in force at the relevant date

Outside this instruction

Where the boundary sits

The claimant’s subsequent liver function and recovery from the hepatic injury itself were addressed separately by a hepatobiliary surgeon; my opinion is confined to the standard of the chest drain insertion.

Background

How the chronology was read

On presentation. Claimant arrives with a traumatic pneumothorax following blunt chest trauma, confirmed on chest X-ray. Drain insertion is clinically indicated.

At insertion. The drain is sited outside the recognised safe triangle, without ultrasound guidance, by a clinician in their first year of training, without documented senior supervision.

Post-procedure imaging. Confirms the drain tip within the liver parenchyma. The error is identified within the hour and the drain is withdrawn under surgical guidance.

Trust guideline, in force at the relevant date. Required ultrasound guidance for insertion outside the safe triangle, and senior review for any trainee’s first unsupervised insertion.

Outside safe triangle Tip in liver

Illustrative schematic only, not drawn from any patient’s imaging.

Reasoning

Conclusion

The insertion technique fell below the standard required by the trust’s own guideline. This was a breach of duty, not a recognised complication of a properly performed procedure.

Insertion outside the safe triangle, without imaging guidance, by an unsupervised first-year trainee fell below the standard required by the trust’s own guideline in force at the time This was a breach of duty, not a recognised complication of a properly performed procedure The error was identified and corrected promptly, which is relevant to causation of any lasting injury but does not affect the position on breach The question of whether the hepatic injury itself was managed appropriately once identified is outside thoracic surgery and was addressed by a hepatobiliary surgeon

What this shows

Scope held to thoracic surgery, even where it would be easier not to

A view at each point in time Not just whether something was negligent at the point of discovery, but what was achievable, or expected, at each earlier point — worked out stage by stage.

Named where I rely on others Where my opinion rests on published research or a trust’s own guideline, I say so and name the source, rather than presenting it as my own finding.

Checked before release This kind of reasoning is checked against the published report standard before it reaches you.

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