Clinical Guidelines Serve to Guide but Dunne Principles Remain the Standard of Care

A recent decision of the Irish High Court provides important clarity on the Dunne Principles in assessing whether clinical negligence occurred. It reiterates that while clinical guidelines serve as a useful guide, the Dunne Principles still rule the day. Our Medical Law team reviews the facts of the case and considers its relevance as a particularly instructive decision in medical negligence law.

What you need to know

• The medical negligence decision helpfully clarifies and reaffirms the leading principles established in Dunne v National Maternity Hospital.
• In dismissing a patient’s claim, the Judge cited the importance of clinical guidance while noting Dunne is paramount in guiding any assessment of clinical negligence.
• The patient alleged she suffered abnormal bleeding after giving birth and alleged that this was allowed to occur negligently.
• The Judge dismissed the patient’s claim with close reference to the relevant clinical guidance and the Dunne principles.

For more than three decades, the Dunne principles have set the standard for clinical negligence in Ireland. That said, however, modern medicine has changed, and obstetric care is now shaped by guidelines, escalating triggers and electronic records. Against that backdrop, the recent decision of Perez v Coombe Women and Infants University Hospital and the HSE[1] has provided valuable and timely clarification of how those familiar principles apply today.

Drawing on precedent from the earlier cases of Dunne v National Maternity Hospital[2] and Morrissey v HSE[3], the High Court explored the threshold for clinical negligence, the legal status of clinical guidelines and records prepared in acute situations.

These are not novel topics in themselves, but the judgment gives them new clarity and context, making Perez a very instructive recent decision in medical negligence law.

The claim

Ms Perez delivered her baby at the Coombe Hospital in 2017. She experienced a primary postpartum haemorrhage (PPH) immediately after delivery. This was managed conservatively with uterotonics and observation, following which the bleeding settled. After her discharge, Ms Perez attended Midland Regional Hospital, Portlaoise with sustained bleeding and was diagnosed with a secondary PPH, allegedly due to retained products of conception (RPOC). Ms Perez sued both hospitals. She alleged that there was mismanagement of the initial PPH and a failure to ensure the placenta was complete. In addition, she alleged that there was a delay diagnosing and surgically treating the secondary PPH.

Her case leaned heavily on clinical guidelines, arguing that escalation triggers were missed. Both hospitals denied negligence.

The Court’s analysis

1. Reaffirming the Dunne Principles in the era of Clinical Guidelines

The judge reaffirmed that the standard of care in clinical negligence cases is governed by the Dunne principles, which ask whether the medical practitioner was:

"Guilty of such failure as no medical practitioner of equal specialist or general status and skill would be guilty of if acting with ordinary care."

The standard of approach is assessed as a matter of fact in each individual case. It is established by reference to the medical profession’s own standards, not by judicial opinion.

Courts must rely on expert evidence to understand what an ordinarily competent practitioner would have done in similar circumstances. The judge concluded that, in this case, the care provided generally met the professional standard, despite minor departures from guidelines or shortcomings in documentation. Notably, the judge addressed the use of clinical guidelines, such as IMEWS, RCOG and NICE[4], concluding that they are guidance tools only, not mandatory rules.

While these guidelines can inform best practices, they do not determine the legal standard of care. In practice, healthcare professionals, particularly in obstetrics and midwifery, must use clinical judgment and experience to decide the appropriate care pathway based on the specific clinical circumstances.

Importantly, the judgment emphasised that:

• Guidelines are informative but not binding – they are not “tick-the-box” procedures
• Departure from a guideline is not proof of negligence if the decision remains reasonable
• Escalation of care is not always necessary if a patient is recovering well, even if certain guideline steps were not followed

2. Two schools of thought: surgical versus conservative management

Ms Perez alleged that there were issues concerning the management of the secondary PPH and early surgical intervention was required. The hospital contended that conservative management was acceptable.

Notably, both approaches were supported by expert evidence. The High Court accepted that both approaches were valid schools of thought. The hospital in question was entitled to exercise its clinical judgment in choosing conservative treatment, provided that the patient’s informed consent was obtained. The Court found that there was no indication Ms Perez would have opted for surgery if it had been presented as an alternative. The Court acknowledged that obstetric care often involves multiple reasonable options under time pressure.

3. Record keeping

The Court also considered the adequacy of medical record keeping. While the judge accepted that contemporaneous records are the “gold standard”, she warned that imperfect notes should not be automatically treated as or equated to negligence. She emphasised that courts must consider:

• The urgent demands of the clinical situation
• The impossibility of detailed note-taking during haemorrhage management
• The supporting value of later records and oral evidence

This judicial recognition of the realities of acute care gives useful guidance for future cases.

Key conclusions

The judge concluded that there was no clinical negligence on the part of either hospital involved. Although there were minor failings, such as possible underestimation of blood loss and incomplete documentation, these did not constitute a breach of the Dunne standard. In these circumstances, Ms Perez’s claim was dismissed.

This judgment reinforces several important legal principles:

• Reinforcement of Dunne – While this is not new in itself, it gains new significance when reaffirmed in the context of today’s guideline-heavy, data-driven healthcare environment
• Clinical guidelines are helpful but not binding
• Explicit judicial realism about recording keeping especially in fast moving acute scenarios
• Deviations from practice do not automatically equate to negligence
• Reasonable differences exist in clinical judgment especially in the area of obstetrics

This case shows that the courts continue to rely on professional medical standards, and that proving clinical negligence under the Dunne principles requires meeting a high bar. It also confirms that guidelines are there to assist, not to dictate, and that courts will protect reasonable clinical discretion, particularly where more than one legitimate treatment option is available.

For more information and expert advice on navigating clinical negligence claims, please contact a member of our Medical Law team.

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The content of this article is provided for information purposes only and does not constitute legal or other advice.

[1] [2025] IEHC 396

[2] [1989] IR 91

[3] [2020] IESC 6

[4] IMEWS = Irish Early Maternity Warning System; RCOG = Royle College of Obstetrics and Gynaecologists; NICE = National Institute for Health and Care Excellence