Following the Supreme Court judgment addressing the secondary victim claims, the primary clinical negligence claim in Paul v The Royal Wolverhampton NHS Trust proceeded to trial at the Royal Courts of Justice in December 2025. HHJ Glen (sitting as a Judge of the High Court) dismissed the claimant’s claim for damages arising out of the death of her husband. 

Browne Jacobson instructed Helen Wolstenholme on behalf of NHS Resolution and The Royal Wolverhampton NHS Trust.

Overview

The case arose from the management of a presentation of acute coronary syndrome (ACS) against a background of advanced chronic kidney disease (CKD). The claimant alleged that the Trust was negligent in adopting a conservative approach to her husband’s care, when it ought instead to have pursued angiography and potential revascularisation, and that this had deprived her husband of a kidney transplant and materially longer life.

A reminder of the Bolam test

The judgment is a reminder that the Bolam test does not demand that all or most clinicians would have acted as the defendant did - only that a responsible body of medical opinion supports the approach taken. HHJ Glen commented that he was left with the impression that the claimant's expert was applying a higher standard than Bolam requires: 

“Unfortunately, the real difficulty with Dr McCance’s evidence was that I was left with the impression that he was in fact applying a higher standard than the Bolam test that I have already enunciated.  I was left with the impression that what Dr McCance was telling me was what he thinks he would have done rather than what others might have done.”

Clinical guidelines inform judgment, they do not replace it

HHJ Glen also commented on the role of clinical guidelines in the assessment of individual patient care. These are not conclusive and merely form part of the background knowledge.

This was not a case in which the clinical team ignored applicable guidance. All of the steps recommended by the ESC guidance - troponin testing, GRACE scoring, ECG monitoring, and echocardiography - were taken by the defendant. 

“The one area of common ground between both experts is that clinicians treat the individual patient in front of them. There is no checklist. They do not hold the ESC Guidelines or the American Guidelines in one hand as they decide how to treat an individual patient. Those guidelines are not conclusive as to how to treat any individual. They are just part of the background knowledge that informs clinical judgment. I remind myself of course that Mr Paul’s treatment was strictly in accordance with the NICE Guidelines. I note and agree with Dr McCance’s evidence that I have already read, and I will read again; “CKD patients are difficult and the guidelines are not very clear about what should be done. Individual decisions have to be made.”

The nub of the matter 

In short summary, there will always be a variety of approaches that are possible.

“Picking bits and pieces from guidance and criticism of the adequacy or otherwise of notes is not always terribly helpful. It is clear to me that the Defendant did treat Mr Paul as an ACS risk patient. It is clear to me that they did have in mind his various risk factors. The Claimant fails to satisfy me on a balance of probabilities that Dr Khogali did not belong to a body of responsible clinicians practising at the time who would probably have taken the same approach.

“Even if Dr McCance is right that the vast majority of treating clinicians would not have taken the course that the Defendant took, that of course does not exclude the possibility that a significant minority might well have done. That would be sufficient to satisfy the Bolam test.”

Our expertise

This article is intended as a general overview only and does not constitute legal advice, nor does it intend to take away from the very real sadness and loss suffered in this case. 

Our clinical negligence team acts for NHS Trusts and other healthcare providers across the full range of complex, high-value and multi-expert clinical negligence litigation, including cases with secondary victim elements and multi-jurisdictional procedural histories. 

If you would like to discuss any aspect of clinical negligence litigation, trial preparation, or risk management strategy, please do not hesitate to get in touch with our specialist team.

The judgment can be accessed by logging into Westlaw UK.