The Bolam test is the standard the courts in England and Wales use to decide whether a doctor, or anyone else exercising a professional skill, was negligent. It comes from Bolam v Friern Hospital Management Committee [1957] 1 WLR 582, and in one form or another it has governed breach of duty in clinical negligence ever since. Two later cases changed how it works. Bolitho requires the supporting medical opinion to stand up to logical analysis, and Montgomery took advice about risks out of the test. For a breach of duty expert, all three decide how the opinion has to be written.
The practical bottom line
- The test. A doctor is not negligent if they acted in accordance with a practice accepted as proper by a responsible body of medical opinion skilled in that field.
- The Bolitho check. That body of opinion must have a logical basis, having weighed the comparative risks and benefits.
- Consent is different. Advice about material risks and reasonable alternatives is judged by what the patient needed to know (Montgomery), while which alternatives count as reasonable is a matter of professional judgment (McCulloch).
- The expert's job. Describe the range of responsible practice at the time, and explain why the care fell inside or outside it.
What is the Bolam test?
John Bolam was a voluntary patient at Friern Hospital who was given electroconvulsive therapy without a muscle relaxant and without physical restraint. He suffered fractures and sued. Medical opinion at the time was divided on both relaxants and restraint. Directing the jury, McNair J said that a doctor "is not guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art", and that a doctor is not negligent merely because there is a body of opinion that would take a contrary view. The jury found for the hospital.
The benchmark is the ordinary skilled practitioner. In McNair J's words, the test is "the standard of the ordinary skilled man exercising and professing to have that special skill". A doctor does not have to be the best in the specialty to meet it.
How do the courts apply the Bolam test?
Three principles from later cases shape how the test is applied:
- The standard is judged at the time. Care is measured against the knowledge and practice of the day it was given. In Roe v Minister of Health [1954] 2 QB 66, Denning LJ warned against looking at a 1947 accident "with 1954 spectacles".
- The standard attaches to the post. In Wilsher v Essex Area Health Authority [1987] QB 730 the Court of Appeal held that a junior doctor is judged by the standard expected of someone in the post they hold, whatever their personal experience.
- A judge's preference is not enough. In Maynard v West Midlands Regional Health Authority [1984] 1 WLR 634 the House of Lords held that preferring one respectable body of professional opinion to another does not establish negligence.
How did Bolitho change the Bolam test?
In Bolitho v City and Hackney Health Authority [1998] AC 232 a two-year-old boy suffered respiratory failure, a cardiac arrest and severe brain damage after a doctor failed to attend when called. The doctor said she would not have intubated even if she had attended, and the experts were divided on whether that would have been acceptable practice. The House of Lords held that the court must be satisfied that the body of opinion relied on has a logical basis. In Lord Browne-Wilkinson's words, the experts must have directed their minds to the question of comparative risks and benefits and reached a defensible conclusion.
The House of Lords also said this would rarely decide a case. In most cases, the fact that distinguished experts hold an opinion shows it is reasonable. Bolitho gives the court a way to reject an opinion that cannot be defended, and it puts the onus on every expert to show the reasoning behind the practice they support.
How did Montgomery change consent?
Montgomery v Lanarkshire Health Board [2015] UKSC 11 concerned a diabetic mother of small stature who was not told of the risk of shoulder dystocia in a vaginal delivery, or offered a caesarean section. Her son was born with severe disabilities. The Supreme Court held that a doctor must take reasonable care to ensure the patient is aware of any material risks in a recommended treatment and of any reasonable alternatives. A risk is material if a reasonable person in the patient's position would be likely to attach significance to it, or if the doctor is or should reasonably be aware that this particular patient would.
For advice about risks, the question moved from what a responsible body of doctors would disclose to what this patient needed to know. Bolam still governs diagnosis and treatment. In McCulloch v Forth Valley Health Board [2023] UKSC 26 the Supreme Court added that whether an alternative treatment is reasonable, and so has to be discussed, is a matter of professional judgment assessed under the Bolam test.
Does the Bolam test apply in Scotland?
Scotland has its own formulation, from Hunter v Hanley 1955 SC 200: a doctor is negligent only if guilty of a failure that no doctor of ordinary skill would be guilty of if acting with ordinary care. In practice the two tests are treated as equivalent, and Montgomery, which was a Scottish appeal, applies across the UK.
How should a breach of duty expert apply the test?
- Define the standard first. Name the specialty, the grade, the setting and the date. A GP's care is assessed by a GP, a midwife's by a midwife.
- Describe practice as it was. Use the guidelines and literature in force at the time, and say which ones. Guidelines are evidence of accepted practice, and the court will still ask whether departing from them was reasonable in the circumstances.
- Set out the range. Paragraph 3.2(6) of Practice Direction 35 requires the expert to summarise any range of opinion and give reasons for their own. Under Bolam, that range is the question the court has to answer.
- Frame the conclusion in the test's terms. For example: "no reasonably competent consultant obstetrician would have discharged the patient without a further scan". What the expert personally would have done is evidence of one doctor's habits and carries little weight on its own.
- Show the Bolitho reasoning. Explain the risks and benefits that made the practice defensible or indefensible, so the opinion survives logical scrutiny.
- Treat consent separately. Identify the material risks and the reasonable alternatives, and say which alternatives a responsible body of practitioners would regard as reasonable.
- Stop at breach. Whether the breach caused the injury is a separate question, often for a different expert. Our guide to factual and legal causation in clinical negligence covers it.
What mistakes weaken a Bolam opinion?
Hindsight is the most common. Knowing the outcome makes the warning signs look obvious, and a report that reads backwards from the injury is easy to attack. Others follow close behind: applying guidelines published after the events, commenting on a specialty the expert does not practise, treating a bad outcome as proof of bad care, and passing over the practice the defendant's expert relies on when the report needs to explain why it falls outside the responsible range. A chronology that records what the clinician knew, and when, is the best guard against hindsight; our guide to building a medical chronology covers how.
Bolam asks what the doctor knew and could reasonably have done at the time. An expert who reads the records in the order the clinician saw them is already halfway to the answer.
The report that carries the opinion still has to meet Part 35. Our guide to CPR 35 sets out what the court expects of it.
How ALLDOQ fits
Every Bolam opinion rests on the records: what was known, what was written down, and when. ALLDOQ puts the full bundle, the imaging and a chronology in one workspace, with every entry linked to its source page, so an opinion on breach can be traced line by line. Book a walkthrough to see it on a real instruction.
