This article was written by Liam Ryan.
The outcome of clinical negligence litigation is, more often than not, determined by the quality and cogency of expert evidence. Where the central issue is whether a clinical judgment fell within the range of responsible professional opinion, the Court’s task is not to substitute its own view for that of the clinician but to assess, with the assistance of expert witnesses, whether the relevant decision-making reflected a defensible weighing of the available evidence. The principles in Bolam v Friern Hospital Management Committee [1957] 1 WL R582 and Bolitho v City and Hackney HA [1998] AC 232 are well-established. Their application to the specific discipline of psychiatric risk assessment, however, is a more nuanced exercise, one that the High Court has now examined with considerable care in Ridge v Dorset Healthcare University NHS Foundation Trust [2026] EWHC 898 (KB).
The test in Bolam has endured for nearly seventy years as the foundational standard in medical negligence. Its familiarity, however, can obscure the genuine difficulty of its application. In no clinical discipline is that difficulty more acute than in psychiatry, where the central task of the clinician the assessment of a patient’s mental state and the degree of risk they present to themselves is by its very nature, a subjective and predictive exercise. A psychiatrist must weigh a constellation of factors, some pointing towards risk, some away from it, and reach a judgment about a future that has not yet occurred. The law accepts that reasonable clinicians will differ in such assessments. The question is where the outer boundary of reasonable clinical opinion lies.
The core facts
The factual background of Ridge was serious and harrowing. Between 1 and 27 April 2021, the Claimant had made multiple attempts on his own life, including attempting to drown himself carrying weights, trying to hang himself with a dressing-gown cord, taking hold of a knife, and on three separate occasions, climbing the electricity pylon near his home. He had tried to purchase Nembutal online and kept a handwritten diary of his suicidal thoughts.
His parents drove him to the appointment the following morning. He had packed a bag in the expectation of immediate hospital admission. Dr Trendafilov was unaware that his parents were waiting outside, that the Claimant had packed a bag, or that he had visited the pylon earlier that morning (paragraph 36 of the judgment). Following the approximately one-hour assessment, Dr Trendafilov increased Mr Ridge’s Mirtazapine dosage, prescribed sleeping tablets, and arranged a follow-up for 30 April. He did not refer Mr Ridge to the HTT — a failure the Defendant subsequently conceded was a breach of duty (paragraph 7 of the judgment). The central issue was whether the underlying risk assessment of ‘moderate’ was itself negligent, and whether the conceded failure to refer caused the harm.
On 26 April (the night before his appointment) he wrote that his thoughts had progressed from “I’m suicidal” to “I need to kill myself’”, that he was “excited to die tomorrow morning”, and that he had selected songs for his funeral (paragraph 30 of the judgment).
The Legal Framework
The applicable legal test was not in dispute between the parties at trial Bolam v Friern Hospital Management Committee [1957] 1 WLR 582, read in conjunction with Bolitho v City and Hackney HA [1998] AC 232 requried that the Claimant, in order to succeed, was required to establish three things on the balance of probabilities (para 11 of the judgment ):
Failure on any single issue would be fatal to the claim and provide a defence.
The expert evidence
The competing expert evidence was given by Dr Trevor Turner (for the Claimant) and Dr James Eldred (for the Defendant).
Dr Turner held the opinion that the act of climbing an electricity pylon as a chosen suicidal method needed to be considered in context. It was an unusual and physically demanding act, and was direct evidence of severe suicidal ideation. At paragraph 52 of the judgment, he opined, “I cannot emphasise enough the uniqueness of the climbing of the pylon. It is very significant. To go through all of those risks is a sign of the intensity of the suicidal thoughts”. His conclusion was that “no responsible body of psychiatrists would have failed to admit him” (paragraph 49 of the judgment).
However, a difficulty emerged in cross-examination. Dr Turner’s report had been written on the misunderstanding that Dr Trendafilov had the power to admit Mr Ridge directly, without reference to the HTT. He accepted that this was wrong and that the HTT was the sole admissions gateway, but acknowledged he had not updated his report to reflect this (paragraph 55 of the judgment). The fact that his opinion was built on a factually incorrect premise was understandable, but not insignificant.
Dr Eldred, who had eighteen years of experience as a Consultant Psychiatrist with an HTT, took a different view. He opined that rating the intensity of a mood disorder involved a degree of subjective interpretation by the clinician, and that Dr Trendafilov’s diagnosis “fell within the expected range of opinion of a responsible body of practitioners” (paragraph 62 of the judgment). He identified a range of positive clinical indicators that Dr Trendafilov had been entitled to weigh. This included the Claimant’s stable accommodation, supportive family, engagement with services, forward planning, range of affect, and critically, his repeated retreats from the pylon without ever touching the cables. Dr Eldred accepted that other psychiatrists might reasonably have assessed the risk as higher, but rejected the proposition that Dr Trendafilov’s assessment was outside the range of responsible professional opinion.
The Court’s findings
On the first issue, the Court found against the Claimant. It was not satisfied, on the balance of probabilities, that Dr Trendafilov’s assessment fell below the standard of a competent CMHT Consultant Psychiatrist (paragraph 96 of the judgment). The Court identified two flaws in Dr Turner’s analysis.
First, it considered that he placed too great an emphasis on the uniqueness of the pylon-climbing and too readily treated it as a direct proxy for the severity of the underlying illness without sufficiently accounting for the fact that on at least three occasions Mr Ridge had consciously resisted the impulse to kill himself (paragraph 97 of the judgment).
The Court preferred Dr Eldred’s more nuanced position: that one had to weigh the inherent risk of the act against the equally significant fact that on at least three occasions Mr Ridge had consciously resisted the impulse to kill himself and had retreated (paragraph 98 of the judgment). The Court found support for this approach in the evidence of Helen Green, the Occupational Therapist who chaired the MDT meeting on 28 April. Though not a psychiatrist, she had considerable experience of risk assessment. Her view was clear: “The mere fact that someone embarks on an inherently risky process, such as climbing a pylon or a high building, does not necessarily mean that they want to kill themselves. If they retreat each time, e.g. because they have other things to look forward to, that will be a matter that will be taken into account when assessing the risk that they will, in the future, take their own life. Risk assessment is a subjective process that involves taking into account all relevant information about past behaviour and future plans etc, and using one’s judgement to reach a conclusion. (paragraph 68 of the judgment)”.
Second, it found that Dr Turner had placed insufficient weight on the positive features of Mr Ridge’s presentation: his engagement with services, his forward-planning, and his range of affect (paragraph 99 of the judgment). The Court’s most striking finding was how it interpreted the Claimant’s diary entry for 27 April, written after the meeting with Dr Trendafilov to validate the clinical assessment. The entry referenced plans for Italy, volunteering abroad, “a fun summer”, and the purchase of running shoes. The Court concluded: “Those diary entries show that Dr Trendafilov’s assessment of the positive aspects of the Claimant’s presentation on 27 April was not misplaced” (paragraph 100 of the judgment). The clinician’s judgment was, in effect, corroborated by the patient’s own words on the day in question.
On the second issue of whether the HTT would have recommended immediate inpatient admission, the Court again preferred Dr Eldred. His eighteen years of HTT experience gave him authoritative insight into the criteria actually applied in such assessments, which included home treatability, the patient’s willingness to comply, the suitability of the home environment, and the risk profiles of patients already on the HTT’s list. The Court was satisfied that had a referral been made, the HTT would not have recommended immediate admission, and that in so deciding it would have reached a defensible Bolitho-compliant conclusion (paragraph 106 of the judgment).
On the question of the failure to take a corroborative account from Mr Ridge’s parents, the Court was equally unpersuaded by the Claimant’s case. It noted that Mr Ridge had himself confirmed in evidence that he had not told his parents about his suicidal thoughts or his visits to the pylon. In those circumstances, it was far from clear that consulting them would have materially altered the clinical picture before Dr Trendafilov. The Court preferred Dr Eldred’s approach, while it may often be desirable to seek such a corroborative account, it cannot of itself be considered negligent not to do so at a first appointment (see paragraph 102 of the judgment).
On the third issue, the evidence of James Smith (the nurse responsible for bed allocation) showed that there were no suitable beds within the Trust’s area on 27 or 29 April, and only one potentially suitable bed on 28 April, for which two other patients with earlier referral dates and comparable presentations were already waiting (paragraph 94 of the judgment). Immediate bed-finding was reserved for patients assessed as “very high risk”; the highest Dr Turner placed Mr Ridge was “severe or high” (paragraph 107 of the judgment). The Court concluded that it was no more than possible that a bed would have been allocated to Mr Ridge which fell “a long way short of it being more likely than not” (paragraph 110 of the judgment).
Conclusion
Ridge is not a case that rewrites the law, but for those practising in the field of clinical injury, it is timely and important. The up-to-date clarity it provides at the intersection of Bolam and Bolitho tests when dealing with psychiatric risk assessments is important, with four practical points arising for practitioners to be aware of.
First, the judgment reinforces that a psychiatric risk assessment is an inherently subjective clinical exercise that does not yield a single defensible answer. The fact that one psychiatrist would have assessed the risk differently, or that serious harm subsequently occurred, does not of itself establish negligence. The Court’s finding at paragraph 101, that Dr Trendafilov’s assessment was “not outside that range or fell short of the standard reasonably to be expected of a competent psychiatrist,” underlined this. It is a high threshold to overcome.
Second, the Court’s willingness to treat the Claimant’s own contemporaneous diary as corroboration of the clinical judgment under attack is significant. Where a Claimant’s own words, written on the day in question, reflect the positive features identified by the clinician, those words will carry evidential weight. Claimant practitioners should scrutinise such contemporaneous material with care before framing their expert’s instructions.
Third, the judgment clarifies that causation remains a bulwark for Defendants in situations where the HTT operates as a gatekeeper to inpatient admission. A negligent failure by a CMHT Consultant to refer to the HTT will not generate liability if the HTT, when applying its own criteria and its own judgment, would not in any event have recommended admission. The structural separation of roles between CMHT and HTT is not merely a clinical distinction but of legal significance.
Fourth, the granular bed-availability evidence placed before the Court by Mr Smith illustrates how a well-prepared defendant can defeat a claim at the causation stage even where breach might otherwise have been established. Trusts facing comparable litigation would be well advised to obtain and preserve contemporaneous bed-allocation records at an early stage.
Finally, this case is a reminder of what is at stake in psychiatric negligence litigation. The Claimant’s injuries are catastrophic and permanent. He is a young man of considerable intellectual ability, a First Class graduate, a performer, a writer who now lives with the lifelong consequences of a fall from a pylon. The legal answer was that the Trust was not liable, but whether that answer is also the right one in human terms is a question that the law, at present, does not ask. That tension between legal principle and the reality of lives broken by failures in psychiatric care will continue to generate challenging litigation for years to come.
