Fri 21 May 2021

When do the actions of health visitors amount to negligence?

The High Court in England recently issued an interesting judgement which considered the duty of care owed by health visitors who visit patients' homes to provide care and support.  It is significant as it is the first clinical negligence case which deals with the role of health visitors, their responsibilities and the standard of care expected of them.  In the case of XM v Leicestershire Partnership Trust QB/2017/002909, Mr Justice Stewart considered the allegations made by the claimant of medical negligence relating to the health visitor service.


The action was raised by the claimant's father on behalf of the claimant, who was born on 27 June 2012. The claimant received treatment in January 2013 for a rare benign brain tumour. The tumour caused an overproduction of cerebrospinal fluid which accumulated in the ventricles of his brain. This had the result of causing his head to grow abnormally fast. At first the elasticity of the claimant's skull compensated for the rapid increase in the size of his head. However, by December 2012, raised intracranial pressure began to cause symptoms and he was taken to an emergency walk in centre by his parents on 20 December 2012. On 3 January 2013 the tumour was successfully removed but, by that time, the claimant had sustained permanent catastrophic brain damage.

The defendants were the responsible agency for the health visitor service which had been provided for the claimant and his parents. In connection with this service a number of individuals had visited the claimant's home to check on his progress. Several had measured the claimant's weight but not all had measured his head.

The claim of negligence

A number of grounds of negligence were alleged on behalf of the claimant.

It was claimed that one of the health visitors, who had measured the claimant's head during a visit on 8 August 2012 (the August visit), should have should have noticed discrepancies between his weight gain and increase in head circumference and should have either (i) referred him to a GP or paediatrician for assessment; or (ii) monitored the pattern and rate of growth of head circumference and arranged for a further measurement to be obtained one or two weeks later. It was also said that the health visitor had (i) failed to tell the claimant's parents about the contrast between weight increase and head circumference and that this should be monitored, (ii) failed to note it in the claimant's records and (iii) failed to contact the GP to ask the claimant to be monitored when he was next seen.

Claims were made that further health professionals, who had visited after the August visit, had failed to (i) identify that the claimant had not seen a GP for a 6-8 week check, and (ii) rectify this by arranging an appointment or tell his parents to arrange this and (iii) failed to tell his parents he should have seen a GP because of the increase in head circumference and discrepancy in weight gain which had been noted at the August visit. 

The written case was amended to say that the discrepancy in the claimant's head growth should have been noted by visual inspection at visits after the August visit where the claimant's head circumference was not measured.

The decision

The defendant had admitted that it could be liable for the actions and any omissions of its health workers if there had been negligence on their part. The court case related to liability for negligence only and a large amount of evidence was presented.

When considering the duty of care which arose for a health visitor, Mr Justice Stewart noted that it was clear that the health visitor was required, in the context of this case, to obtain a head circumference measurement at the initial contact and at the 6 week contact.  Further, the health visitor is required to plot the head circumference chart, to interpret the head circumference size so as to ensure that its growth was along expected centile lines considering future growth potential and earlier growth measurements and, if there was a concern about rapid head growth, to consider hydrocephalus and urgently refer to a GP.

The judge found that there had been a breach of duty in relation to the August visit. On the basis of evidence which had been led, he was satisfied that a reasonable standard of care required that, when assessing head circumference growth, the basis of a 'red flag' of crossing two centile lines was two measurements which were 6 weeks apart. The judge was satisfied that the trajectory of the measurements which were taken of the claimant's head circumference, coupled with the fact they were over a period of 4 weeks and not a minimum period of 6 weeks, required a health professional, including a health visitor, either to re-measure such that there was a minimum period of 6 weeks between measurements or refer the claimant to a GP.There was no issue about causation in relation to this breach of duty as the defendant accepted that if a referral had been made following the August visit, the outcome would have been a re-measurement of the claimant's head, diagnosis and successful treatment.

In relation to the missed GP check there was a duty on a health visitor, in circumstances such as the present case, to remind parents about the GP check and recommend the baby undergoes it albeit late.

It was also found that there had been a breach of duty as a health visitor had failed to notice the claimant's head was disproportionately large and failed to measure his head circumference and/or refer him for medical opinion.


This case is an interesting one given that it appears to be the first case which focuses on the duty of care owed by health visitors.  It demonstrates that the acts or omissions by health visitors can amount to medical negligence.  In this case, it was made clear that the standard a competent health visitor should meet does not require a diagnosis be made, which a health visitor would likely not be qualified to provide.  A referral to a GP would have been sufficient to avoid negligent care.  Nevertheless, the court made clear that the standard to be expected of a health visitor applied regardless of the qualification or post held by the health professional responsible for carrying out the task.  That means that there is an onus on any health professional carrying out health checks, regardless of their specific role.  Whilst this is perhaps not a surprising finding, it should provide reassurance to those in receipt of services of the standards which require to be upheld.

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