PPX v Aulakh

Current suicidal ideation and planning indicate a high risk of self-harm and ordinarily require urgent referral to a crisis team. Past ideation and planning generally indicate lower risk, although “current” includes the patient’s wider recent mental-health state and ordinary fluctuations. Suicidal ideation alone does not mandate referral; the decisive issue is the clinician’s assessment of imminent risk. Psychosocial stressors may explain suicidal behaviour retrospectively, but they cannot, without more, establish that a particular patient was probably suicidal at an earlier consultation. Causation requires proof that the proposed intervention would probably have prevented the particular claimant’s self-harm.

PPX, who suffered serious neurological injury after attempting suicide by hanging, brought a clinical-negligence claim against his general practitioner, Dr Aulakh. He alleged that, at a consultation on 25 April 2012, she should have made an urgent referral to mental-health services and arranged earlier follow-up. The trial was limited to breach of duty and causation, with contributory negligence arising only if both were established.

The central factual issue was whether PPX had reported current, rather than past, suicidal ideation and planning. The court also considered whether an urgent referral would probably have prevented the later attempt.

1. Claim dismissed. The claimant failed to establish breach of duty and causation.
2. The agreed expert position was that current suicidal ideation and planning indicated high risk and mandated urgent referral to the crisis team. Past ideation and planning ordinarily indicated lower risk. “Current” was not confined to what the patient expressed in the consulting room, since apparent improvement during the consultation might be temporary. It concerned the patient’s wider mental-health state, allowing for ordinary fluctuations.
3. The consultation note was capable of bearing either interpretation, but its use of the past tense, read with the surrounding evidence, supported the conclusion that the suicidal thoughts and planning were historical. The defendant’s written account was consistent with her stated standard practice, the note, the lay evidence and the expert evidence. The claimant had not shown current ideation or planning on the balance of probabilities.
4. The alternative case based on psychosocial stressors also failed. Such stressors may have general predictive value or explain suicidal behaviour in hindsight, but they cannot, without more, establish that a particular individual was probably suicidal at the relevant time.
5. Causation was not established. Even assuming an urgent referral would have produced assessment, monitoring, therapy and support, the claimant had to show that it was more likely than not that intervention would have prevented his attempted suicide on 20 May 2012. The evidence did not permit that conclusion, since suicide and impulsive self-harm remained difficult to predict.
6. The criticisms of note-taking and the one-month review interval were rejected or left without a finding. The proposed contributory-negligence issue therefore did not arise. Had it arisen, the court would have assessed the claimant’s contribution at 25 per cent, applying the guidance in Corr (Administratrix of Corr deceased) v IBC Vehicles Ltd [2008] 2 All ER 943.