High Court of Ireland Decisions

1. The plaintiff's action has been brought against St. James's hospital, Dublin, Doctor Michael Buckley (Doctor Buckley) and Professor Donald Weir, both of whom are senior consultant physicians on the staff of the hospital which is one of the largest in Ireland and a major teaching institution for medical students. At the commencement of the action the plaintiff withdrew her claim against Professor Weir. She is the widow and personal representative of Joseph Wolfe, deceased, and the action has been brought on her own behalf and on behalf of the other statutory dependants of the deceased pursuant to the provisions of the Civil Liability Act, 1961 arising out of his death which it is pleaded was occasioned by the negligence and breach of duty and/or breach of contract of the defendants or either of them. The issues of liability and damages are contested by the defendants.

2. The following facts were established in evidence:-

3. Joseph Wolfe died while an in-patient at St. James's hospital on 11th November, 1991. He was 33 years of age. A post-mortem examination revealed that the primary cause of death was a phaeochromocytoma (phaeo), being a species of abdominal tumour which had not been diagnosed by or on behalf of the defendants or by any other person. It is not in dispute that the deceased probably was suffering from the phaeo at all times material to the action. The net issues as to liability are whether in the light of the evidence the phaeo ought to have been diagnosed or discovered by or on behalf of the defendants or either of them while the plaintiff was under treatment at the hospital in March, 1989 and/or subsequently in April, 1991 or at some other time which would have lead to appropriate surgical intervention to cure his condition. Alternatively that abdominal and related symptoms suffered by Mr. Wolfe should have been investigated thus leading to the probable discovery of the phaeo tumour. It is common case that if such a tumour is found, the probability is that surgical treatment would be successful in effecting a complete cure. It is also common case that when the deceased was brought to the hospital in the early hours of 10th November, 1991 he was terminally ill and, if the phaeo had been diagnosed at that time, removal of it then probably would not have saved his life. The tumour which was revealed at the post-mortem was of significant size and was situated behind the liver. It is not in dispute that phaeos are very rare and are often difficult to detect and diagnose. If undiscovered they are fatal. They produce catecholamines which ultimately have an effect on the heart and lead to cardiac arrest. The progression from the time when the tumour forms until death if undetected may extend over a period of years during which the sufferer may experience intermittent attacks of abdominal pain. Other symptoms may include vomiting, sweating, headaches, shaking and hypertension (high blood pressure). In the vast majority of cases the latter symptom manifests itself either as continuous hypertension or as hypertension which occurs during attacks only and then reverts to normal when they subside. Hypertension is generally regarded as the prime symptom associated with phaeo tumours. However, a small fraction of sufferers, about 10% or less, are normotensive and do not have hypertension, even during attacks following the release of adrenaline or noradreneline from the tumour. Sufferers from phaeo tumours which are normotensive at all times comprise a rarity within a rarity. Learned medical literature and research at the Mayo Clinic in the US and elsewhere indicates that most phaeo tumours, even when hypertension is a symptom, are not discovered until post-mortem and many others discovered in the lifetime of the sufferer are found serendipitously in tests for other possible sources. Professor Wass (of Oxford University and the Radcliffe Infirmary, Oxford whose special expertise as an endocrinologist includes such tumours) was treating three phaeos at the time when he gave evidence, two of which were found in that way. The reason is that they are described as being "great mimics" i.e. the symptoms, including hypertension, are referable to a wide range of aliments which are much more common and, therefore, far more likely to be the cause of the patient's symptoms than a phaeo tumour.

4. The late Mr. Wolfe joined the national army in 1977 and served until 1982.

5. He married on 21st July, 1979. At the end of his military service he joined the Dublin Port and Docks Board as a labourer and continued in that employment until 1985 when he became redundant. He did not obtain any other regular employment thereafter but did supplement social welfare payments by earnings as a musician in a band which played in pubs normally on a weekly basis and often more frequently. He was trained in the army school of music and had been a saxophone player in one of the army bands.

6. As to Mr. Wolfe's health; while in the army he suffered from a lung problem which was duly treated in hospital and from which he appears to have made a complete recovery. It has no relevance to this case. The plaintiff described her husband as having been "in perfect health" until a few months before presenting at St. Vincent's hospital, Dublin on 11th February, 1989. However, the deceased in course of hospitalisation stated that he had suffered from "panic attacks" from time to time over the years which he ascribed to distress resulting from the loss of his full-time employment with the Dublin Port and Docks Board in 1985. In the light of his wife's evidence it seems that such attacks were not of great significance till in or about the latter part of 1988. Mrs. Wolfe deposed that for several months prior to his attendance at St. Vincent's hospital her husband was "getting headaches and starting to get shakes". They were not continuous but were coming and going. They would last for a day or a few days. On those occasions Mr. Wolfe sat in a room holding spectacles on to see whether that would stop the headaches. He was described as also getting shakes and sweats. As soon as the attacks ended he would go to sleep and would be symptom free thereafter until the next attack. The plaintiff described her husband’s shaking and sweating as being severe. The latter symptoms would usually last for less than an hour and then they would go away. He used to get two or three attacks a week and then be free of them for about two weeks till they came back again. She described that on 11th February, 1989 he had a particularly severe attack of headache which lasted for a whole day and he was unable to bear it in consequence of which she phoned for an ambulance. St. Vincent's hospital was on that date the emergency hospital for the area where Mr. Wolfe resided and so he was brought there. The shaking and sweating from which he had suffered were gone before the ambulance arrived but the headaches remained. Mrs. Wolfe stated that headaches had continued all day but the sweats and shakes on that occasion had followed the usual pattern and lasted about half an hour before they resolved. The St. Vincent's hospital records indicate, inter alia, that Mr. Wolfe was treated as an out-patient and was detained for about 3 hours. His blood pressure was checked and was normal. He described his symptoms as a sudden onset of occipital then frontal headache which had commenced that evening. He said that he had had a similar episode six years previously which resolved spontaneously. He had suffered from nausea and vomiting which "almost improved" after the onset of the headache. The latter had come in "spasms/waves" with vomiting associated with the spasms. He had no history of migraine but had a history extending over 3 years of episodes of generalised shaking which previously had been relieved by valium from a neighbour. He is recorded as stating that in course of attacks he goes pallid, with palpitations and generalised fine tremor (on his right side more than left) at any time of day with variable duration from seconds to hours. No positive diagnoses was made at St. Vincent's hospital but by way of "impression" it was recorded that Mr. Wolfe had suffered from "a probable migrainous event". He was advised about that and referred to a neurologist for expert opinion if any further episode occurred. It was indicated in the notes that the plan proposed was simple analgesics (ponstan) and a review on the following Monday by his GP. On that basis Mr. Wolfe was discharged home. One of the final entries made about him was "A pleasant man, no distress. Says pain is much better now, almost gone". He returned home by ambulance at about 10.00 p.m. The plaintiff stated that her husband’s headaches continued on the following days. It appears that he visited a GP and subsequently attended the Accident and Emergency department at St. James's hospital at 10.00 p.m. on 15th February, 1989 i.e. four days after his discharge from St. Vincent's. His complaints were recorded in the hospital notes as being "a severe headache, one last Saturday. Vomiting. Previous medical history: Vincent's last Saturday, same complaint". His temperature, pulse, respiration and blood pressure were all normal. Mr. Wolfe complained of headache which had been severe for 4-7 days with intermittent bouts. He had vomited on that particular day and on examination he was fully orientated but distressed with pain. A provisional diagnosis of viral illness was made. He was admitted as an in-patient at 1.00 a.m. on 16th February. The following information, inter alia, is set out under a heading "Record of nursing care and patient's progress". On admission patient complaining of sudden onset of frontal headache yesterday evening whilst watching T.V. Associated with severe nausea and shaking. He had experienced a similar headache on the previous Saturday and had attended St. Vincent's hospital. Nothing was found there and he was discharged on analgesics. The headaches recurred on Sunday, Monday and on the night of admission to St. James's hospital. Mr. Wolfe was described as having had shaking attacks for 3 years and it was queried that these may be due to anxiety ever since he became unemployed [three years earlier]. On admission as an in-patient he was in no distress and received medication for pain and nausea. His blood pressure was again normal. He settled and slept well. On the following morning he was still complaining of headache, though not so severe. He had a comfortable day. A lumbar puncture was performed which was normal and later he was recorded as having no complaint of headache. On 17th February, having slept well through the night, he had no complaints of headache. It was also recorded that the shaking attacks which Mr. Wolfe had been having for three years were said to be associated with nausea and palpitations which the patient ascribed to anxiety since the loss of his permanent job with the Dublin Port and Docks Board. The severity of the shaking attacks were not investigated and in the light of the plaintiff's evidence it is probable that they did not become of great significance until the latter part of 1988 i.e. within a few months of his arrival at St. James's hospital for the first time.

7. After admission as an in-patient Mr. Wolfe came under the care of Doctor Keeling, director of gastroenterology at the hospital, and his team. Investigations carried out by them revealed that there was an elevated white cell blood count. The possibility of meningitis was investigated by way of a lumber puncture and urine analysis which were normal. A CT scan was also carried out which was normal and the white cell blood count reverted to normal. In Doctor Keeling's opinion these findings tended to confirm that the initial provisional diagnosis of a viral type illness giving rise to meningismus and headaches was correct. As all of the symptoms had resolved the patient was discharged home. Doctor Keeling believes that he had no reason to suspect a phaeo tumour. The raised white cell count was indicative of a viral infection. Mr. Wolfe continued to attend as an out-patient and the last entry in that regard was made on 8th March, 1989 in which it was stated that the CT scan was normal and also the full blood count. The patient was put on a diet to reduce weight. Nothing was done by Doctor Keeling and his team to check out the "panic attacks" described by Mr. Wolfe the symptoms of which he stated had been going on for three years and which had become more severe. It is not in dispute that the transient viral infection which was found in 1989 could not explain the symptoms which the patient stated he had had for the previous

8. It appears that Mr. Wolfe may have consulted Dr. Whittley, medical advisor to the Dublin Port and Docks Board, after discharge from St. Vincent's. In all events there is a referral letter from him in the St. James's hospital file dated (probably incorrectly) 19th July, 1989 in the following terms:-

9. The plaintiff stated that when her husband returned home from hospital on or about 20th February, 1989 he was symptom free for a couple of weeks. Then the headaches, pain, sweats and shakes returned as before. He attended the hospital O.P.D. on a couple of occasions. The symptoms appear to have become intermittent. The plaintiff stated that during the following two years until his return to St. James’s on 5th April, 1991

10. Mr. Wolfe came under the care of Dr. Buckley and was examined by him on 12th April. A letter dated 23rd April, 1991 to Dr, Carthy, the patient's GP, from Dr. Buckley about that examination is in the following terms:-

11. Doctor Buckley then referred Mr. Wolfe to Doctor Keeling's team for the purpose of having the proposed endoscopy and other tests carried out. These were duly performed and it transpired that the patient was suffering from a substantial interior wall peptic ulcer. This condition would have been a likely explanation of the stomach pains of which he was complaining when he returned to the hospital on 12th April, 1991. He agreed to participate in drug trials relating to that condition for a period of weeks. He did so and it appears that his ulcer was cured eventually after a relapse in course of treatment. A scar, being the residue of it, was discovered at post-mortem. The records contain a copy of the following letter dated 9th May, 1991 from Doctor Adain Quinn, Doctor Buckley's senior house officer, to Doctor Carthy:-

12. Nothing was done to check out the complaint of "panic attacks" made by Mr. Wolfe to Doctor Buckley which are referred to in his letter to Doctor Carthy. Mr. Wolfe appears to have been discharged from the care of Doctor Keeling and his team in or about June, 1991. He next attended at the hospital at 2.30 a.m. on 10th November, 1991 when brought there in a condition of terminal illness. He is recorded as having suffered a sudden onset of clotting of blood on the previous evening. He was very distressed and looked cyanosed. It is noted that there was a history of anxiety/panic attacks. Despite intensive efforts to save him he died two days later.

13. A major criticism of Doctor Keeling and Doctor Buckley made by the plaintiff's experts regarding Mr. Wolfe's treatment at the hospital from April to June, 1991 is that he ought not to have been discharged until his complaint about "panic attacks" and related abdominal pain and other associated major symptoms were fully investigated. It is contended that the duodenal ulcer which had been found at that time would not have been the cause of the shaking attacks, nausea or vomiting or headaches that had been described by Mr. Wolfe.

14. In course of her evidence the plaintiff stated that she had seen her husband having shakes. She was asked what would he do when the shakes and sweats came on and her reply was "he would sit there and be shaking all over, and he would go white and the sweat would be pumping all over him and trying to hold himself". The loss of colour also happened from an early stage. As to her husband’s condition from the time when he was discharged from St. James's in June, 1991 until he died in the following November, the plaintiff deposed that "he still had the shakes and the stomach and the headaches and the whole lot". The effect of this on his life was "he would not go anywhere in case he would get panicking, he thought they were panic attacks and he would not go anywhere". She also described in detail the final attack which led to his death. It included some stomach pain and "shaking all over".

15. The plaintiff deposed that her husband's death was a great tragedy for herself and her three children. The family have left their house in Clondalkin where they resided at the time of Mr. Wolfe's death and their home is now in a local authority apartment in Dublin. The plaintiff resides there with her three children and her granddaughter. Joanne, the eldest child, is almost 20 years of age; Tara is 17 and Thomas is 13 years old. Her grandchild, Cody, is 3 months old.

16. At the time of his death the late Mr. Wolfe was receiving social welfare benefit of £68.50 per week. The plaintiff was in receipt a disability benefit of £68.00 per week. The deceased gave the plaintiff the entire of his benefit. She gave him enough to buy 20 cigarettes a day and also £20 or £30 if they were going out together or about £15 if he was having a night with friends. He was a modest drinker and it seems that he had one night out a week. In addition to social welfare the deceased received £30 a night for each gig performed by his band. He was the manager and was responsible for obtaining dates. The band received £120 per night of which expenses amounted to £30 and the remainder was divided equally between the three performers. The number of gigs varied. Some weeks they had only one; other weeks there might be as many as three but sometimes there were no gigs at all. The deceased's practice had been to give the entire of his share to his wife. He had been playing in a band for about five years including one called "Brazen" which he had joined about two and a half years before he died.

17. Mr. Wolfe also provided services for the family around the home, including wallpapering, painting and work in the garden. Mrs. Wolfe stated that since her husband's death she has had to employ others to do house decorating at a cost of £30 a room. She doesn't have a garden now.

18. An additional source of family income at the time of Mr. Wolfe's death was that the plaintiff did part-time catering work in the locality for which she received £70 a week. She was working in the kitchen of the Red Cow on the Naas Road when her husband died. She had been there for 6-8 weeks at the time, having previously had other similar jobs. The plaintiff stated that the job would have continued for so long as she wanted it. She had intended to continue and would have done so but for her husband's death. She had to give up then as she had needed his help to mind the children. The plaintiff has now a children's allowance of £30 a month for one child. The present position is that having regard to the ages of her children, the plaintiff could now return to part-time catering work if she wished to do so.

19. Medical negligence was the subject of a comprehensive review by the Supreme Court in Dunne (an infant) -v- National Maternity Hospital [1989] I.R. 91 in which the unanimous judgment of the court was delivered by Finlay C.J. He specified six principles relating to the assessment of professional medical negligence. The first of these is pertinent to the instant case and is as follows:-

20. The other principles expounded by the learned judge do not appear to have relevance to the liability issue presently before the court, but the concluding passage from that part of the judgment is of particular importance as an exposition of judicial thinking regarding the resolution of conflict on liability in this difficult area. It is in the following terms:-

21. Applying the foregoing principle laid down by the Supreme Court in Dunne -v- National Maternity Hospital to the facts of the instant case, and having due regard to the broad parameters which are stated by Finlay C.J. to underpin the law in the area of medical negligence, it seems to me that there are two aspects of the liability issue which emerge on the evidence and which must be addressed by the court. Was Doctor Keeling and/or Doctor Buckley at fault in failing to discover by diagnosis, or in consequence of investigation of Mr. Wolfe's symptoms, that he was suffering from the phaeo tumour from which he died? If so, has it been proved on the balance of probabilities that the failure of Doctor Keeling or Doctor Buckley or either of them (including their respective teams) to diagnose or to investigate adequately or at all Mr. Wolfe's symptoms was such a failure of duty that no medical practitioner of equal status and skill would be guilty of if acting with ordinary care?

22. Two facts of major importance which have been established in evidence created particular difficulty regarding the diagnoses of Mr. Wolfe's phaeo tumour. The first was present at all material times. I accept the evidence of Professor Wass that in all probability Mr. Wolfe's tumour was a rarity within a rarity in that he remained at all times normotensive. It has emerged that he did not have an actual attack in hospital such as those described by his wife as having occurred at home. However, he was still having severe headaches in hospital which probably indicated the tail-end of attacks and he ought to have been found to be hypertensive on those occasions unless he was one of the minute number of phaeo sufferers who are normotensive. It is common case that hypertension, either continuous or during attacks, is normally the primary symptom of a phaeo tumour.

23. The second difficulty regarding diagnosis was the coincidence that when he was investigated by Doctor Keeling and his team in April/June, 1991, Mr. Wolfe was found to have a substantial peptic stomach ulcer which would have appeared to explain some of his symptoms at that time - notably abdominal pain.

24. The essence of the plaintiff's claim and the defendant's defence thereto appears to be as follows:-

25. It is submitted on behalf of the plaintiff that the evidence establishes that Doctor Keeling and/or Doctor Buckley, if acting in accordance with the standard of care laid down by the Supreme Court in Dunne (an infant) -v- National Maternity Hospital ought to have diagnosed in February, 1989 or at latest in April/June, 1991, that the late Mr. Wolfe was suffering from a phaeo tumour which, if discovered, probably would have been surgically cured, thus saving his life. Alternatively, the case is made that they should have investigated or had investigated by other experts the cause of serious abdominal pain and related symptoms suffered by Mr. Wolfe on both occasions when treated at St. James's. It is contended that the probable ultimate outcome of such investigations would have been the discovery of the phaeo tumour in time to save Mr. Wolfe's life. In brief the case made against the hospital and the consultants is:-

26. The essence of the defendant's defence in answer to the plaintiff's claim is that the evidence establishes that there was no negligence on the part of the consultants in failing to diagnose that Mr. Wolfe had the phaeo tumour which caused his death in November, 1991. As already stated it is common case that the hospital staff did their best to save him at that time but, having regard to the nature, extent and gravity of his condition, it was impossible to do so. The defendants accept that in the light of the post-mortem findings it is probable that at all material times Mr. Wolfe was suffering from a phaeo tumour.

27. The defendants rely upon the following factors which emerged from the evidence and learned medical literature.

28. Having reviewed all of the evidence, and noting in particular Mr. Wolfe's situation when he was treated at St. James's in 1989 and in April/June, 1991, the central thread which runs through the entire from first admission to hospital are the "panic attacks" with related severe physical symptoms suffered by Mr. Wolfe and which he appears to have associated with the loss of his job in 1985. These attacks were not investigated by Doctor Keeling or Doctor Buckley or by anyone else at St. James's. As Doctor Barniville stated in evidence they remained as loose ends.

29. What is likely to have emerged if such attacks had been investigated in 1989 or in April/June, 1991 or at any time thereafter prior to the fatal phaeo attack suffered by the deceased in November, 1991?

30. One of the experts who gave evidence on behalf of the plaintiff was Doctor

31. Harry Barniville who before retirement had been for many years a senior consultant general physician at the Mater hospital, Dublin.

32. The following passage occurs at pp 18-20 in the transcript of Doctor Barniville's evidence, book 2. He was referred, inter alia, to the concluding part of Doctor Buckley's letter to Doctor Carthy dated 24th April, 1991:

33. In course of Doctor Barniville's cross-examination the following passage

34. I accept the evidence of Professor Wass, which was supported by other defence experts, that in all probability Mr. Wolfe was one of those very rare phaeo sufferers who remained normotensive during attacks. The opinion has been expressed that he was suffering the tail-end of such attacks when his blood pressure was checked in hospital and found to be normal on both occasions after his arrival there with a severe headache which had not yet subsided. In the absence of the primary phaeo symptom of hypertension on those occasions, the possibility that such a tumour may have been the cause of Mr. Wolfe's condition was too remote to be checked out by a competent clinician. I accept that opinion. Having regard to the probable normotensive nature of Mr. Wolfe's tumour, I am not convinced by the opinions expressed by Doctor Barniville and Professor Blake that the cluster of symptoms which were known to or which ought to have been ascertained by the treating doctors at St. James's hospital, including severe sweating during attacks, should have put them on notice that there was a real possibility that the cause of the deceased's symptoms was a phaeo tumour. As I have already stated, I am satisfied that the absence of hypertension when his blood pressure was checked at any time in hospital while the severe headaches were continuing would rule out in the mind of a competent clinician a phaeo tumour as a realistic possibility which ought to have been investigated. However, in my view that is not an end to the matter, I accept the opinion that a clinician of equal specialist status to Dr. Keeling if acting with ordinary care would have investigated in February, 1989 or subsequently in April/June, 1991 the so called "panic attacks". The symptoms which were known to Dr. Keeling and his team in 1989 and 1991 and to Dr. Buckley and his team in 1991 are serious and, as previously stated, included nausea, vomiting, abdominal pain, headaches, shaking and loss of normal pallor. If they had been investigated it would have been discovered (a) that the attacks also included severe sweating; (b) that they had been happening in severe form regularly since late 1988 and, crucially, (c) that they had become acute three years after Mr. Wolfe lost his permanent job in 1985. There is no evidence or expert testimony to connect the time lag between the onset and continuance of severe symptoms in 1988 and the loss of employment in 1985. In my view no clinician of comparable status and skill if acting with ordinary care would have failed to investigate "panic attacks" having such severe associated symptoms. Having done so, he/she would have contemplated at least a possibility that the attacks from late 1988 were unrelated to the plaintiff's loss of employment in 1985 and that in fact they may have been caused by an as yet unidentified abdominal ailment. Once that possibility presented itself prudence would indicate that appropriate abdominal tests should be carried out. If that had been done in the instant case Mr. Wolfe's phaeo tumour would have been discovered and surgically treated with probable success..

35. In 1989 Dr. Keeling's tentative diagnosis of a viral infection did not explain the known symptoms of the attack which the patient had suffered - far less the full nature of such attacks if investigated. In my view he or his team should have investigated the attacks and, if so, would have discovered that they were unlikely to have any connection with the patient's loss of employment in 1985 and may have had a purely physical cause associated with the abdomen. It was negligent as defined in Dunne's case not to carry out that investigation, or to have it carried out by some other appropriate expert. Likewise, when Mr. Wolfe returned to Dr. Keeling's care in 1991 the "panic attacks" from which he was suffering ought to have been investigated - all the more so as they were similar to those with which he had presented in 1989. If that had happened it would have been found that the peptic ulcer which was then discovered, though explaining abdominal pain at that time, did not explain the onset of severe intermittent attacks from 1988. The nature and severity of such attacks suffered by Mr. Wolfe since their onset in that year ought to have been investigated by Dr. Keeling and/or his team in 1991 as in 1989. That obligation is unrelated to the possibility that the patient might have been suffering from a phaeo tumour. If the so called panic attacks had been investigated by Dr. Keeling or anyone else at St. James's hospital their actual history as it has emerged in evidence at the trial probably would have been ascertained and an abdominal problem would have been suspected as a likely or at least a possible source thereof - thus giving rise to an abdominal investigation and the discovery of a previously unsuspected phaeo tumour. (That discovery would have been similar to two of the three phaeo tumours being treated by Prof. Wass at the time he gave evidence). It seems to me that no clinician of equal professional status and skill as Dr. Keeling if acting with ordinary care would have failed to investigate the purported severe "panic attacks" suffered by Mr. Wolfe - even on the basis of the information which was actually known to the medical staff at the hospital. Furthermore, it seems to me in all the circumstances that no clinician of equal specialist status if acting with ordinary care would have discharged Mr. Wolfe in July, 1991 without any follow-up arrangement and without carrying out any investigation of the so called "panic attacks". If Mr. Wolfe's subsequent history after discharge had been monitored it would have been discovered that his symptoms deteriorated still further in the ensuing months leading ultimately to the fatal attack from which he died in the following November. I cannot envisage any possible justification for leaving major so called "panic attacks" as a loose end without any investigation. In short, I find that Dr. Keeling was negligent in his treatment of Mr. Wolfe in 1989 and again in 1991.

36. The situation regarding Dr. Buckley's possible liability is different. He first encountered Mr. Wolfe in April, 1991 but had the benefit of the hospital notes relating to the patient's treatment there in 1989. As recorded in his letter to Dr. Carthy of 24th April, 1991 Dr. Buckley was told by Mr. Wolfe about his recurring "panic attacks" with associated abdominal discomfort. He decided to send the patient to Dr. Keeling and his team to carry out tests and to postpone investigation of the "panic attacks" until the result of the tests was available. We now know that an apparent cause of the patient's abdominal pain was discovered i.e. the peptic stomach ulcer which was duly treated and cured by medication. It seems to me that Dr. Buckley acted reasonably in taking that course. It appears that he intended to review the situation including the "panic attacks" after Dr. Keeling's tests were completed. In the event Mr. Wolfe passed into the care of Dr. Keeling and his team. It seems that Dr. Buckley did not see him again. However, his senior house officer, Dr. Quinn, wrote to Dr. Carthy, on 12th May, 1991 on Dr. Buckley's behalf as follows:-

37. Before writing that letter the S.H.O. may not have averted to Dr. Buckley's letter of 24th April to Dr. Carthy. He does not seem to have realised that it was Dr. Buckley's stated intention to investigate Mr. Wolfe's situation, including the panic attacks, after Dr. Keeling's tests were completed. The S.H.O. ought not to have discharged the patient to the care of the G.P. and Dr. Keeling's team but should have referred him back to Dr. Buckley as the latter intended. A practical difficulty in a major public hospital like St. James's, one of the largest in Ireland, is that they are very busy institutions with many patients. Medical consultants are obliged to rely on their senior house officers to assist them with their workload and to take many routine decisions on their behalf. It would be quite unreal to expect that a busy consultant like Dr. Buckley should personally follow-up all of his patients. It was reasonable (and indeed probably inescapable in practical terms) to rely on his S.H.O. to assist him in that regard and it seems to me that he had no obligation in law to check out all routine work done for him by a senior member of his team. If Mr. Wolfe had been referred back to him as he intended, it might well have emerged that Dr. Buckley would have investigated the "panic attacks" (which seems to have been what he had in mind) and would have learned their true history and significance, thus leading to an abdominal examination which would have revealed the phaeo tumour. Even if he did not go that far, Dr. Buckley might have arranged to see Mr. Wolfe as an out-patient from time to time in subsequent months to monitor his situation and, if so, he would have learned about the further aggravation of the alleged "panic attacks". In that event abdominal investigation may have followed. I am not satisfied that the plaintiff has established a case in negligence against Dr. Buckley.

38. There is a substantial case to be made that Dr. Buckley's S.H.O. was negligent in not referring Mr. Wolfe back to the specialist as the latter intended, thus rendering the hospital vicariously liable as his employer. However, having already found that the hospital is liable to the plaintiff in negligence on other grounds, it is unnecessary to pursue that issue.

39. The evidence is insufficient to complete the assessment and further information is required.