Bolam Test CASES
In English clinical negligence, the Bolam test asks whether the clinician acted in accordance with a practice accepted as proper by a responsible body of medical opinion. If so, the court will normally find no breach, even if other bodies of opinion would have acted differently. The test addresses professional skill and judgement in diagnosis and treatment, not the separate duty to inform patients about risks and options.
Definition and principles
The standard of care for professionals is objective and rooted in professional practice. A claimant must show that the defendant fell below the standard of a reasonably competent practitioner in the relevant field. Under Bolam, it is a defence that a responsible body of opinion would regard the conduct as proper – provided that body’s views withstand logical scrutiny (the Bolitho qualification).
The Bolitho qualification (logical analysis)
The court does not abdicate judgment to experts. Where competing schools of thought are presented, the judge must be satisfied that the body of opinion relied on has a reasoned, internally coherent basis that engages with risks, benefits, and data. A conclusion that is a mere assertion, or that ignores obvious risks, may be rejected as illogical even if some experts support it.
Consent and information (Montgomery distinction)
Bolam governs clinical skill and therapeutic choices. The duty to advise patients of material risks, reasonable alternatives, and reasonable variants is different. For consent, the modern test is patient-centred: a risk is “material” if a reasonable person in the patient’s position would likely attach significance to it, or if the doctor is or should be aware that the particular patient would do so. Professional opinion does not set the threshold for materiality.
What counts as a responsible body?
A responsible body is not a majority vote or a handful of outliers. The court looks for a recognisable, respectable body of practitioners with relevant expertise, whose reasoning reflects current knowledge, guidelines, and experience. Local custom, habit, or resource constraints do not, without more, define the standard. Guidelines (e.g. from royal colleges) are influential but not conclusive; experts must explain any departure or adherence by reference to the patient’s situation.
Common examples
- Diagnosis and investigations: the choice and timing of tests are assessed against responsible professional practice, with Bolitho scrutiny of why a proposed pathway was rational in light of presenting features.
- Treatment choices and technique: selection between recognised treatment options, or execution of a procedure, is judged by whether a responsible body would have acted similarly and whether that view is logically defensible.
- Care pathways and monitoring: frequency of observations, escalation thresholds, and discharge decisions must align with defensible practice tailored to the patient’s risk profile.
Evidence and experts
Expert evidence is central. Experts should be properly qualified, impartial, and engaged with the full record. The court expects clear reasoning, engagement with guidelines and literature, and explanation of risks, benefits, and alternatives. Bare conclusions carry little weight. Contemporaneous notes, objective data, and multidisciplinary records often decide whether the practice was truly responsible and logically defensible.
Legal implications
- Skill vs consent: use Bolam (with Bolitho) for diagnosis and treatment; use the patient-centred Montgomery test for risk disclosure and alternatives.
- Guidelines and resources: professional guidance informs but does not fix the standard; resource limits may explain choices but cannot justify unsafe practice.
- Causation and scope of duty: even where breach is found, the claimant must prove causation and that the loss falls within the scope of the duty breached.
Practical importance
For claimants, focus on why the defendant’s approach lacked a logical basis in the patient’s presentation, guidelines, and risks, and marshal experts who explain that analysis. For defendants, show that the practice reflected a coherent, risk-aware professional rationale supported by credible expertise and the records. In all cases, separate the consent analysis from the skill-and-judgement analysis to avoid talking past the real issue.
Relevant cases:
See also: Standard of care; Professional negligence; Bolitho (logical analysis); Montgomery (consent); Clinical guidelines; Causation; Scope of duty.
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A patient suffered paralysis following a spinal operation. She sued for negligence, arguing the surgeon failed to warn her of this small risk. The House of Lords held the surgeon was not negligent, applying the 'Bolam test' to risk disclosure. Facts The appellant, Mrs Amy Sidaway, suffered from persistent pain in her neck, right shoulder, and arms. She was referred to Mr Falconer, a senior neurosurgeon at Bethlem Royal Hospital. He diagnosed a problem with her cervical spine and recommended a laminectomy operation. The operation carried a small inherent risk of damage to the spinal cord, estimated at less than
A patient suffered fractures during electro-convulsive therapy (ECT) and sued for negligence. The court found the hospital was not liable as the doctors followed a procedure accepted by a responsible body of medical opinion. This case established the 'Bolam test' for professional negligence. Facts The claimant, John Hector Bolam, was a voluntary patient at Friern Hospital, a mental health institution managed by the defendants. He was suffering from depression and agreed to undergo electro-convulsive therapy (ECT). During the procedure, Mr Bolam was not administered any muscle relaxant drugs, nor was he physically restrained, apart from a nurse supporting his shoulders
A doctor failed to warn a diabetic mother about the risk of shoulder dystocia. The baby was born with severe disabilities. The Supreme Court ruled doctors must inform patients of all material risks of a treatment and any reasonable alternatives, establishing a patient-centred test for informed consent. Facts The appellant, Mrs Montgomery, was a woman of small stature and a type 1 diabetic. During her pregnancy, it was known that the baby of a diabetic mother is often larger than normal, which carries a 9-10% risk of shoulder dystocia during vaginal delivery (where the baby’s shoulders become stuck after the
A doctor failed to attend a two-year-old child in respiratory distress who later died. The House of Lords clarified the Bolam test, ruling that a court can find a doctor negligent if their supporting expert opinion is not logically defensible. Facts Patrick Bolitho, a two-year-old child, was admitted to hospital suffering from croup. He was looked after by two nurses and was under the care of a senior paediatric registrar, Dr. Horn. On two separate occasions, Patrick suffered brief episodes of respiratory distress from which he appeared to recover. On both occasions, the nurses telephoned Dr. Horn, who did not
