Bolitho v City and Hackney Health Authority [1997] UKHL 46

A two-year-old boy suffered brain damage after cardiac arrest caused by respiratory failure. The doctor negligently failed to attend when called but argued intubation would not have been performed anyway. The House of Lords clarified that expert medical opinion must be logically defensible to satisfy the Bolam test.

Facts

Patrick Bolitho, aged two, was admitted to St Bartholomew’s Hospital suffering from croup. After discharge and readmission, he experienced two episodes of acute respiratory difficulty on 17 January 1984. Sister Sallabank, concerned about his condition, telephoned Dr Horn twice requesting attendance. Dr Horn failed to attend on either occasion, and neither did Dr Rodger. Shortly afterwards, Patrick suffered complete respiratory failure leading to cardiac arrest. Although resuscitated, he sustained catastrophic brain damage and subsequently died.

Admitted Breach of Duty

The defendants accepted that Dr Horn was negligent in failing to attend Patrick or arrange for a suitable deputy to attend after receiving Sister Sallabank’s telephone calls describing the child’s respiratory distress.

Issues

The central issues were: (1) What would Dr Horn have done had she attended? (2) If she would not have intubated, would that failure have been negligent? The appeal raised questions about the application of the Bolam test to causation in medical negligence cases.

Judgment

Causation and the Bolam Test

Lord Browne-Wilkinson, delivering the leading judgment, held that the Bolam test has no application to the first question of what the doctor would actually have done. The judge had properly accepted Dr Horn’s evidence that she would not have intubated. However, the Bolam test was central to the second question of whether failing to intubate would have been negligent.

Logical Basis for Expert Opinion

The House of Lords clarified that courts are not bound to accept expert medical opinion simply because it is honestly held by competent practitioners. Lord Browne-Wilkinson emphasised that expert opinion must have a logical basis:

The use of these adjectives – responsible, reasonable and respectable – all show that the court has to be satisfied that the exponents of the body of opinion relied upon can demonstrate that such opinion has a logical basis.

However, Lord Browne-Wilkinson also cautioned:

I emphasise that in my view it will very seldom be right for a judge to reach the conclusion that views genuinely held by a competent medical expert are unreasonable.

Application to the Facts

The court found this was not a case where the expert opinion could be dismissed as illogical. Dr Dinwiddie, a distinguished expert, reasonably concluded that Patrick’s symptoms did not indicate progressive respiratory collapse, and that intubation carried significant risks as an invasive procedure.

Implications

This case represents an important refinement of the Bolam test. While professional medical opinion remains highly significant in determining the standard of care, it must be capable of withstanding logical analysis. Courts retain the ultimate authority to assess whether expert opinion is reasonable and responsible. The decision confirms that the Bolam test applies to questions of breach of duty, not to factual questions of causation regarding what a doctor would have done.

Significance

Bolitho is frequently cited alongside Bolam as establishing the ‘Bolam-Bolitho test’ for medical negligence. It ensures that medical professionals cannot escape liability simply by producing expert witnesses who approve their conduct if that opinion lacks logical foundation.

Verdict: Appeal dismissed. The defendants were not liable because, although Dr Horn was negligent in failing to attend, the claimant failed to prove on the balance of probabilities that this breach caused the injury, as the evidence established that intubation would not have occurred and the failure to intubate was supported by a responsible body of medical opinion with a logical basis.

Source: Bolitho v City and Hackney Health Authority [1997] UKHL 46