Paul and another v Royal Wolverhampton NHS Trust [2024] UKSC 1 (heard alongside Polmear v Royal Cornwall Hospitals NHS Trust and Purchase v Ahmed) is the most significant decision regarding pure psychiatric harm since the Alcock litigation over thirty years ago. This Supreme Court ruling reshaped the law for secondary victims, particularly in medical negligence, by introducing a strict “accident” requirement while removing several historical hurdles the court regarded as “wrong turns”.
Factual Background: Three Tragedies
The Supreme Court heard three appeals together, all involving family members who suffered psychiatric injury after witnessing the sudden, traumatic death of a loved one caused by a prior failure to diagnose or treat a medical condition.
- Paul: two young daughters (aged 9 and 12) witnessed their father collapse from a heart attack while out shopping, saw him fall and hit his head, and later witnessed paramedics performing chest compressions; he was declared dead on arrival. The Trust had negligently failed to perform a coronary angiography over a year earlier.
- Polmear: the parents of seven-year-old Esmee witnessed her death from a rare lung condition. Her father found her non-responsive at school and attempted resuscitation; her mother arrived to see those failed efforts. A doctor had negligently failed to diagnose her condition months earlier.
- Purchase: a mother found her daughter, Evelyn, motionless after she had died from severe pneumonia, and later discovered a voicemail recorded minutes before she arrived containing the sounds of her daughter’s final breaths. A doctor had failed to diagnose pneumonia three days earlier.
The Supreme Court Decision
By a 6:1 majority, the Supreme Court dismissed all three appeals. The majority (led by Lord Leggatt and Lady Rose) held that medical practitioners do not owe a duty of care to the close family members of a patient to protect them from the trauma of witnessing that patient’s death or the manifestation of a disease.
The conclusion rested on a lack of proximity: a doctor’s professional responsibility is to the patient and does not extend to family members who might be psychologically affected by witnessing the results of a failure to treat. To impose such a duty would go beyond the “nature and scope” of a doctor’s role in society.
The “accident” requirement
The most critical outcome is the reinforcement of the “accident” requirement, drawing a sharp distinction between an “accident” and a “medical crisis”.
- Definition of an accident: an external, discrete, and traumatic event caused by violent means, such as a road traffic collision or a fire.
- Medical crisis vs. accident: witnessing the manifestation of a disease or a “medical crisis” (a heart attack, a collapse at home) resulting from clinical negligence is not witnessing an accident. “No analogy could reasonably be drawn” between a car crash and a loved one suffering a medical emergency.
- The overruling of Walters: the Court overruled North Glamorgan NHS Trust v Walters, where a mother had recovered after witnessing her baby’s 36-hour decline classified as a “single horrifying event”; Paul declared Walters wrongly decided.
Clarifying the Alcock criteria: “wrong turns”
While narrowing the scope for clinical-negligence claims, the Court also simplified the law by removing requirements that had long frustrated claimants and judges:
- Removal of “sudden shock”: the requirement that injury be caused by a “sudden shock to the nervous system” was an “unfortunate wrong turn”. Claimants no longer need to prove a sudden “assault” on the mind.
- Removal of the “horror” requirement: the Court rejected the need for an event to be objectively “horrifying”, noting there is “no available Richter scale of horror”.
- Time gaps: a gap in time between the negligent act and the resulting accident does not prevent a secondary victim from claiming, provided they witness the accident itself.
Significance and Lord Burrows’ Dissent
The decision has been described as a “damage limitation” exercise similar to White. It effectively blocks off medical negligence as an area where secondary victims can recover, except perhaps in rare cases of a “medical accident” (such as a doctor injecting the wrong drug and causing an immediate, violent adverse reaction).
Lord Burrows issued a powerful dissent, arguing the law should have taken a “justified incremental step” forward, and criticising the majority for an “unwarranted backward step” in insisting on the “accident” requirement. In his view, the death of the primary victim should be the relevant event satisfying the Alcock proximity criteria; it is arbitrary to allow a daughter to recover if she sees her parent hit by a car but to deny her if she sees that same parent die from a preventable heart attack.
Despite this dissent, the majority decision stands, reinforcing the “patchwork quilt” of distinctions that define this area of law. While the NHS and its insurers likely “breathed a sigh of relief”, the decision means that for most families witnessing medical tragedies, the law of tort remains a closed door.