Torts 06 Negligence V - Factual Causation
Torts 06 Negligence V - Factual Causation
NEGLIGENCE V
FACTUAL CAUSATION
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Tong Seok May Joanne v Yau Hok Man Gordon [2013]
Chester v Afshar [2005]
4.4 Negligent treatment
5 Loss of chance
5.1 Explanation
5.2 Loss of physical chance
Hotson v East Berkshire Health Authority [1987] (see 4.2)
Gregg v Scott [2005]
Armstrong v Quest Laboratories Pte Ltd [2020]
5.3 Loss of economic chance
Allied Maples v Simmons & Simmons [1995]
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1 “BUT FOR” CAUSATION
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1.3 Limitations of the “but for” test
1. Difficulties of factual verification
(a) Counterfactuals by nature are difficult to prove with any degree of certainty, as they
require the fact finder to speculate what would have happened if the ∆ had not done
what he in actual fact did
(b) Often lack the kind of precise information that could verify whether the culpable
act of the ∆ made any difference in that specific way
2. Indeterminacy of meaning in the test
(a) To make the test determinate enough to yield an answer, have to assume that those
applying the test can indeed specify a definite possible world that is “similar” to the
actual world
(b) Great vagueness, think of it as the MCU Multiverse with multiple branching timelines
– which one is the “right” one to use as comparison?
3. Overinclusive – test seems too lenient in what counts as a cause
(a) Includes all factually necessary prior conditions (mother give birth to ∆, can charge
blame mother or not?)
(b) Includes all consequences of the change in the course of events
(c) Addressed/limited by legal causation
4. Underinclusive – too stringent as what counts as a cause
(a) Scientific/medical uncertainty makes it impossible to prove cause in fact “but for”
(b) Overdetermination cases – cannot handle multiple causes and multiple
defendants properly
(i) Cases in which each of a pair of two events, c1 and c2, is independently
sufficient for some third event e. Logically, the sufficiency of c1 and of c2
entails that neither c1 nor c2 is individually necessary for e, and thus, on the
counterfactual analysis of causation, neither of them can be the cause of e
(ii) Can be simultaneous (two shotgun blasts at the same time), or temporally
ordered (∆’s fire arrives first and burns building down, another fire arrives
shortly after and would have been sufficient to burn down the building, but
the building’s already gone)
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5. Wilsher v Essex Area Health Authority [1988] AC 1074 – multiple causes
(a) Premature baby was negligently administered excess oxygen by doctors and went
bind, but was one of 5 possible causes of retrolental fibroplasia (RLF, 早產兒視網膜
病變) causing blindness
(b) Causation not proven, claimants could not prove on a balance of probabilities that the
excess oxygen was the cause
6. Cook v Lewis [1951] SCR 830 (CSC) – evidential uncertainty, not really
overdetermination
(a) Hunters accidently shot Lewis and consequently lost an eye, could not determine
which shot hit him
(b) Both hunters equally liable (joint and several), when it was impossible to determine,
onus on hunters to absolve themselves (reversal of burden of proof)
(c) Sunny Metal [2007] SGCA seemed to allow a flexible and commonsensical approach
when applying the “but for” test [73], no need to reverse burden of proof (not allowed
under Evidence Act, simple inference of causation would suffice)
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2 MATERIAL CONTRIBUTION TO DAMAGE
2.1 Explanation
1. Material contribution to the harm was an alternative test created in Bonnington as a way to
tackle indeterminate harm
(a) Material contribution needed – not de minimis
(b) An accumulation of X is the but-for cause of the injury
(i) Indivisible: accumulation of X causes injury up till a certain pint, by which
more X makes no difference (fully liable)
(ii) Divisible: the more X, the worse the injury (apportionment of liability)
2.2 Cases
2. Bonnington Castings v Wardlaw [1956] AC 613
(a) Pneumoconiosis (肺塵病) from inhalation of silica dust in course of employment, but
two potential sources: swing grinders (∆’s negligence) and pneumatic hammers,
severity of illness was in proportion to the level of exposure of dust (i.e. cumulative
illness)
(b) Held employer fully liable, material contribution to ∆’s damage was sufficient
(c) Indivisible? Divisible?
(i) Court explained in Williams v Bermuda Hospital Board [2016] that there was
no argument in HL about the injury being divisible because counsel did not
argue for proportionate liability
3. Holtby v Brigham & Cowan (Hull) Ltd [2000] 3 All ER 421
(a) Asbestosis (石綿肺, a cumulative illness) from exposure to asbestos dust (half of his
working life employed by ∆, the rest by other employers)
(b) Liability was apportioned according to time exposure to asbestos
(i) Inconsistent with Bonnington, but only because ∆’s extent of liability was not
argued there
(ii) Adopting the apportionment approach might involve less of an injustice than
the extremes of denying or allowing full recovery
4. Bailey v Ministry of Defence [2009] 1 WLR 1052
(a) Claimant physically weak after an operation, aspirated her own vomit, leading to
cardiac arrest and then brain damage, two causes of her weakness were (1) post-
operative pancreatitis (seen as eggshell rule in Williams), (2) negligent post-operative
care
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(b) Held the Ministry had made a material contribution to the weakness of her
condition, meaning “more than negligible”
5. Williams v Bermuda Hospital Board [2016] UKPC 4
(a) Had an appendectomy, but there were complications because of sepsis developed
incrementally 6 hours prior to operation, judge found culpable delay of at least 2.5
hours prior to operation
(b) Since injuries were caused by a single known agent (sepsis), and the effect on ∏’s
heart and lungs continued way longer than it should have, material contribution was
found
(c) Whether the cumulative factors occurred concurrently or successively irrelevant,
material contribution to ∆ injuries still established
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3 MATERIAL INCREASE IN RISK
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claimant may pursue an obligation against any one party as if they were jointly liable and it becomes the
responsibility of the ∆s to sort out their respective proportions of liability and payment
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(ii) [66], “it is the creator of the risk who…should bear its consequences” (Lord
Hoffman)
5. Barker v Corus (UK) plc [2006] 2 AC 572
(a) Another mesothelioma case, but first two exposures were due to breach of duty by
employers, last exposure to asbestos was ∏’s own failure to take reasonable care, ∆
held severally liable instead of joint and several
(b) Fairchild exception held applicable, meaning not all exposure incidents have to be
tortious
(c) Attribution of liability on a proportionate basis
(i) ∆ were not fully liable in this case (∆ had slipped up himself)
(ii) Since it was not proved that the ∆ had caused the harm in Barker,
proportionate liability was a way to blunt the harshness in Fairchild
(d) Limiting the Fairchild exception using the “single agent mechanism” requirement
(i) Possible causes must show “substantial similarity” to fall within Fairchild –
must be a single agent e.g. different types of asbestos
(ii) Principle cannot apply “when the claimant suffers lung cancer which may
have been caused by exposure to asbestos or some other carcinogenic matter
but may also have been caused by smoking and it cannot be proved which
is more likely to have been the causative agent” (Lord Hoffmann)
(iii) Lack of clarity as to what constitutes a single agent, lack of clarity as to the
reasons for the rule, yet followed in other Commonwealth jurisdictions
(e) Barker’s proportionate liability reasoning was legislatively overruled in UK
(Compensation Act 2006, §3) into full damages as well as joint and several liability
for mesothelioma only
6. Sienkiewicz v Greif (UK) Ltd [2011] 2 AC 229
(a) Another mesothelioma case, only one ∆ that tortiously exposed claimant to asbestos
but claimant was also at risk from non-tortious environmental exposure, material
increase in risk led to causation, full recovery of damages due to Compensation
Act
(i) Generally a lost cause for ∆ in mesothelioma cases
(a) [186] “mesothelioma cases are in a category all their own…must now
be considered from the defendant’s standpoint a lost cause, [but] there
is to my mind a lesson to be learned from losing it: the law tampers
with the “but for” test of causation at its peril” (Lord Brown)
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1. Surender Singh s/o Jagdish Singh v Li Man Kay [2010] 1 SLR 428
(a) Patient died post-op as clips securing an artery slipped loose (5 to 6 clips used, all
failed), death from haemorrhage thus suing hospital for negligence in failing to
monitor the deceased post-op, but insufficient evident concerning how the clips had
slipped off
(b) Hospital negligent in failing to monitor patient, applied McGhee but did not even use
Fairchild and Barker (why?)
(i) Haemorrhage was a big concern in the post-op period, failure to monitor
increased risk of death, leading to causation
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4 CAUSATION IN MEDICAL NEGLIGENCE
4.1 Explanation
1. In Hii Chii Kok [2017], the SGCA stated that there are three aspects of medical care:
(a) Diagnosis – misdiagnosis
(i) Performing investigations such as X-rays, CT scans, lab tests, interpreting the
results, and communicating the diagnoses to the patient
(b) Information – non-disclosure of risks
(i) Advising patients on their treatment options, and the risks and complications
associated with treatment
(c) Treatment – negligent treatment
(i) Performing surgery, prescribing medication, etc.
4.2 Misdiagnosis
1. To establish causation in misdiagnosis cases, the “but for” test is used
2. Hotson v East Berkshire Health Authority [1987] AC 750
(a) ∏ fractured his femur after falling from a tree and visited ∆’s hospital, but was not
diagnosed properly, diagnosis and treatment were delayed by 5 days, and ∏
developed hip necrosis
(b) Causation not established, “all or nothing” approach regarding damages
(i) “But for ∆’s negligent, would ∏ have developed hip necrosis?”
(ii) There was a 75% chance that he would develop necrosis from the beginning
(remember the test is based on the balance of possibilities)
(c) Can he claim loss of chance instead? (see 5.2: Loss of physical chance)
(i) ∏ attempted to claim damages for his loss of 25% chance of avoiding hip
necrosis
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(ii) Nothing different – patient would have done the surgery anyway (no
causation)
Joanne Tong, [170]
Hii Chii Kok, [248]–[251]
(iii) Deferral – the patient would have deferred the option, but no evidence that
patient would take an alternative or avoid the procedure
Chester v Afshar (this is the problematic one)
3. Montgomery v Lanarkshire Health Board [2015] UKSC 11
(a) diabetic pregnant woman was not told of substantial risk of shoulder dystocia during
vaginal delivery, risk materialised and ∏’s son developed cerebral palsy, causation
found
(b) But for ∆’s failure to disclose the risk of shoulder dystocia and the alternative of a C-
section, ∏ was prevented from choosing a C-section instead of natural birth,
which would have allowed ∏ to avoid the injury to her son
(i) [103], “on that question, [the evidence showed that] Mrs Montgomery would
have elected to have a caesarean section”
4. Tong Seok May Joanne v Yau Hok Man Gordon [2013] 2 SLR 18
(a) Failure to advise patient on use of general anaesthesia for a caesarean section, caused
her to sustain a neck injury
(b) No breach of duty in the first place, but causation still considered in dicta
(c) Andrew Ang J applied the “but for” test
(i) [170], “even if ∆ had breached his duty of care to obtain ∏’s informed
consent…∏ did not give any evidence to the effect that she would have
chosen RA instead of GA if she was informed of the risk of neck injury
and/or the alternatives to GA. Instead, ∏’s evidence was that she would
have been content for the anaesthetist to make the choice of anaesthesia
based on what was best for her…”
5. Chester v Afshar [2005] 1 AC 134
(a) Patient was undergoing spinal surgery, there is always risk of paralysis, evidence was
that patient would have deferred and explored other options, no firm finding that she
would have refused the operation after being informed, causation established
(b) What if the claimant would have gone ahead with surgery, only at a later date or
with a different surgeon? (HL decision was 3-2)
(i) Majority – doctor negligent in omitting to warn the ∏ about the risks, even
though there was no evidence that the patient would avoid the procedure
entirely
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Premised on doctrine of informed consent and right of autonomy and
dignity [24] (UK Human Rights Act 1998)
(ii) Minority – immaterial that claimant would have deferred the operation, as she
would still have been subjected to the same 1-2% of complications at a later
date/under the hands of a different surgeon
(c) Chester does not represent the law in Singapore (Joanne Tong)
(i) [172], “I agree [that autonomy within the meaning of the Human Rights Act
has no application in Singapore], and also decline to apply Chester. The effect
of Chester is to found liability purely on the basis of a breach of duty
infringing the right of a plaintiff to choose for herself. This entirely sidesteps
any enquiry of factual causation. I agree with Lord Hoffmann’s dissenting
opinion in Chester (at [31]) that the relevant question is ‘whether one would
have taken the opportunity to avoid or reduce the risk, not whether one would
have changed the scenario in some irrelevant detail’”
4.4 Negligent treatment
1. To establish causation in negligent treatment cases, the “but for” test is used
(a) Surgeon leaves a surgical instrument in his patient’s body after an operation, patient
subsequently develops an infection. Did the surgeon cause the infection?
(b) Counterfactual – if the doctor never left the surgical instrument in the patient’s body,
would the patient still have had an infection?
(i) If yes, then there is no causation
(ii) If no, (based on balance of probabilities), factual causation is established
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5 LOSS OF CHANCE
5.1 Explanation
1. Refers to a percentage reduction in the prospect of obtaining a favourable outcome, or
avoiding a negative outcome. Courts may be wary of deciding in favour of “loss of chance”
cases as they may sidestep issues proving causation, and recognising that ‘chance’ is an
actionable type of harm – chance has value.
(a) Relives the ∏ of burden of proving that the harm itself (or lost benefit itself) occurred
2. Notion that chance has value is based on the idea that even <50% of a cure from a fatal
disease, of winning a lawsuit, or of getting land rezoned is something of value that a people
will still be willing to pay
3. Chance is a concept that arises out of a lack of information, so if the ∏ still obtains the benefit
after a percentage reduction (due to ∆’s act or omission), that chance loses its value and
therefore no action can be made against the ∆ for loss of chance
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(a) Negligent delay by ∆ doctor to diagnose lymphoma ( 淋巴癌 ), 42% survival odds if
diagnosis was timely (survival = remission for 10 years), but reduced to 25% due to
delayed diagnosis
(b) Sued for loss of 17% chance of remission for 10 years, but by the time the case
reached HL, he had already been in remission for 8+ years
(c) “Loss of chance” claim brought forward as his initial chance of survival was below
50% to begin with, meaning ∏ had a less than even chance of surviving for 10 years,
even if he had received a timely diagnosis and treatment
(i) “But for” test applied on balance of probabilities; case doomed to fail if he
sued for negligence causing himself to not be ‘cured’
(d) Majority rejected claim (3-2, Baroness Hale, Lord Hoffman)
(i) Traditional “all or nothing approach” should still be used for physical injury,
e.g., [223] my negligence probably caused the loss of your leg, I pay you the
full value, or my negligence probably did not cause the loss, I don’t pay you
anything…
(ii) Compare this to loss of chance approach: my negligence probably caused a
reduction in the chance of you keeping the leg, I pay you the value of the loss
of the leg, discounted by the chance that it would have happened anyway
(iii) [224] “Almost any claim for loss of an outcome could be reformulated as
a claim for loss of a chance of that outcome”, floodgates of litigation will
open
(e) Minority (Lord Nicholl)
(i) Fairness argument: if patients not allowed to sue for loss of chance of being
cured, patients would be unfairly discriminated
(ii) For example, two patients unknowing have HIV+ and due to misdiagnosis,
both develop AIDS, but first patient had 45% of avoiding developing AIDS,
whereas second patient had 55% chance of avoiding it
(iii) Using the “but-for” test, on a balance of probabilities the doctor did it, the
second patient (55% chance) would claim full recovery, whereas the other
patient could claim nothing, 50% cut-off is irrational and indefensible (if we
allow it for economic claims, why not for life?)
(iv) Counter – chance does not work with deterministic forces (Hotson)
Statistics are estimates, either people can be cured or they cannot
42% chance should be seen as statistically, out of 100 people, 42 of them
could be cured, and the rest could not be cured no matter how much
treatment they receive
5. Armstrong v Quest Laboratories Pte Ltd [2020] 1 SLR 133
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(a) Delayed diagnosis of cancer case, ∏ died of melanoma ( 黑 色 素 瘤 ), but dispute
centred upon the credibility of medical expert evidence and not whether the Estate
had a claim for loss of chance
(b) SGCA preferred Estate’s expert evidence (could survive for 10 more years if
diagnosed timely, compared to ∆’s argument of 8 years), applied “but for” test and
found that Estate could prove its claim for loss of 10 years survival on a balance of
probabilities [192], no need to recourse to “loss of chance” doctrine
(c) Choo J (HC) in obiter agreed with dissenting judges in Gregg v Scott, question to be
decided in a future case
5.3 Loss of economic chance
1. Generally no difficulty in principle (courts easily grant partial recovery), examples include
lost chances to:
(a) Negotiate liabilities out of a contract
(i) Allied Maples v Simmons & Simmons [1995] 4 All ER 907
(b) Detect a rouge director’s misappropriation of company funds
(i) JSI Shipping (S) Pte Ltd v Teofoongwonglcloong (a firm) [2007] 4 SLR(R)
460
(c) Pursue litigation
(i) Kitchen v RAF Association [1958] 1 WLR 563
(d) Achieve a better outcome in litigation or accept a settlement offer
(i) Sports Connection Pte Ltd v Asia Law Corp [2015] 5 SLR 453
(e) Be hired by a prospective employer
(i) Spring v Guardian Assurance plc [1995] 2 AC 296
Note that this was not characterised as a lost chance in Ramesh v AXA
Life Insurance Singapore Pte Ltd [2017] SGHC 197
2. Allied Maples v Simmons & Simmons [1995] 4 All ER 907
(a) Solicitors negligent in failing to advise the claimant, who was buying certain
properties belonging to a vendor’s subsidiary (3P), to approach the vendor to retain a
contractual clause, subsidiary released from outstanding liabilities in respect of
properly and ∏ had to pay instead (PEL)
(b) Loss of chance found, successful recovery
(c) What kind of situation is this? (based on Stuart-Smith LJ’s tripartite framework at
1609-11)
(i) If the outcome depends on actions or decisions by third parties (like this
case), it is a true loss of chance situation
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∏ simply needs to show that there was a real (non-negligible) chance of a
favourable outcome with the 3P, no need to prove based on balance of
probabilities
(ii) If the outcome depends on action or decision by P or D, or the occurrence of
natural events, it is not a true loss of chance situation
Balance of probabilities needed
(d) Framework adopted by SGCA in:
(i) Asia Hotel Investments Ltd v Starwood Asia Pacific Management Pte Ltd
[2005] 1 SLR(R) 661
(ii) JSI Shipping (S) Pte Ltd v Teofoongwonglcloong (a firm) [2007] 4 SLR(R)
460
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