Williams v Betsi Cadwaladr University Local Health Board [2022] EWHC 455 (QB)

In Williams v Betsi Cadwaladr University Local Health Board [2022] EWHC 455 (QB) following her husband’s suicide after a relapse in his psychiatric condition, the Claimant brought proceedings on behalf of her deceased husband’s estate and herself as a secondary victim against the Defendant local university health board.

The facts

Mr Williams had a diagnosis of schizo-affective disorder and had suffered from the condition since 1990. He had been admitted to hospital on many occasions. His last admission prior to his death was in December 2010 until March 2011. He was discharged to community psychiatric care and was reviewed by a consultant psychiatrist and had his Care and Treatment Plan (“CTP”) reviewed annually.

On the morning of 9 February 2014 (a Sunday), the Claimant phoned the Defendant’s Heddfan psychiatric unit at Wrexham Maelor Hospital (where Mr Williams was a former patient) reporting a relapse in his symptoms. She was put through to Nurse Freestone, a senior nurse at the unit. The Claimant said Mr Williams needed to come to hospital. When asked if he was suicidal, the Claimant responded that he could be. Nurse Freestone said that this was not possible and signposted the Claimant to Accident and Emergency or an out-of-hours GP. The Claimant explained that Mr Williams would not want to attend A&E and would not speak to a GP he did not know. Nurse Freestone reminded the Claimant that she could phone emergency services if she was concerned about the safety of Mr Williams or others. Nurse Freestone suggested contacting the Community Mental Health Team the next morning, and the Claimant said that she thought she could cope until then, when asked. Nurse Freestone did not speak to Mr Williams.

Tragically, approximately 7 hours later Mr Williams took his own life.

Liability  – Failure to refer

The Claimant’s case was that Nurse Freestone failed to ensure that she was appropriately signposted to sources of help for an urgent psychiatric assessment, and that Nurse Freestone had a discretion to allow Mr Williams to attend the Heddfan unit to be seen by the psychiatric liaison team (“PLT”) if necessary, so this should have been offered.

Jim Duffy, Counsel for the Claimant submitted that the Court should view the telephone conversation between the Claimant and Nurse Freestone as one involving the provision of advice about risks, thereby falling within the remit of the Supreme Court’s decision in Montgomery v Lanarkshire Health Board [2015] UKSC 11. Accordingly, it was submitted that Nurse Freestone should have offered alternative referral options in light of Mr William’s reluctance to attend A&E for assessment or speak to an out of hours GP.

However, in cross-examination, the Claimant’s expert in psychiatric nursing failed to identify and maintain clear criticism of Nurse Freestone’s advice [55]. Nurse Freestone’s evidence about what the out of hours service was and how it should operate was consistent with the CTPs provided to Mr Williams, and with expert evidence from both sides [57]. The Court considered that this, along with various reassuring factors including that the Claimant confirmed that she felt able to manage Mr Williams until the following morning [53], meant that what Nurse Freestone offered and advised was appropriate.

Availability of the CTP

Mr Williams’ last CTP was dated 13 January 2014. It included a risk assessment form detailing a past risk but no present risk to himself and an out of hours crisis plan which broadly replicated the advice given by Nurse Freestone over the phone [9].

The Claimant criticised the Defendant for having failed to distribute the care plan to her, such that she was not sure who to contact for assistance [11]. The Judge made a number of factual findings on this point to conclude that even though it was likely that the Claimant was not able to retain her own copy of the CTP, this was unlikely to have made any difference to the events of February 2014 [19]. The Court concluded that regardless of what the crisis plan said, the Claimant would have rung the Heddfan Unit because that is where Mr Williams wanted to go [17].

The Claimant alleged that the Defendant was negligent by not having the CTP uploaded and accessible by Nurse Freestone in the electronic system [32]. At the time, there was an electronic system of sorts in operation, but this was confined to very limited documents [30]. Instead, Mr Williams’ CTP was held in paper form ½ mile away from the Maelor Hospital. Counsel for the Claimant submitted that, in reference to the decision in Bolitho, regardless of the views of the experts on common practice in 2014, it was illogical not to have the CTP available in the electronic system, however rudimentary [61]. Having contextualised the limited nature of the electronic system that was in place in 2014, the Judge rejected the Claimant’s analysis and concluded that it was not illogical for the Defendant to try new electronic systems whilst maintaining an underlying reliance on a reasonable paper system [62].


Despite finding against the Claimant on either route to liability, the Court addressed causation, specifically whether direct contact with the PLT would have resulted in a different outcome either with or without electronic access to the CTP.

The Judge held that had Mr Williams and the Claimant spoken to the PLT, their first response would have been to suggest attendance at A&E. The Claimant argued that had the PLT spoken to Mr Williams directly and had access to his CTP notes they had a degree of flexibility to allow for a mode of assessment that avoided A&E. However, the Judge held that this presumes that sufficient information would have been gleaned to cause the PLT to provide out of hours assistance beyond their normal practice. The Judge concluded that it was likely that the Claimant would have given similar reassurances as she did to Nurse Freestone about coping overnight; he was satisfied that it would have required something very unusual for the PLT to depart from normal practice [74]. Access to Mr Williams’ CTP would not have materially altered Nurse Freestone or the PLT’s approach [76].

Finally, the Court considered whether the Claimant could establish that if an assessment was undertaken, Mr Williams would have been admitted to the Heddfan unit. Both experts felt they could not express a clear view based on what information they had of Mr Williams’ presentation and state of mind without the benefit of hindsight. As such, the Court was reluctant to speculate on what would have happened had Mr Williams been assessed that day [78].