The Bolam and Bolitho Tests: How Medical Negligence Is Judged in the UK

The Bolam test asks whether a doctor acted in line with a practice accepted as proper by a responsible body of medical opinion. Bolitho added that this opinion must also withstand logical scrutiny. Together they are how clinical negligence is judged in the UK, and medicine interviews use them to test how you reason about blame.

I'm Dr Akash Gandhi, an NHS GP since 2012, and I teach medicine applicants at TheUKCATPeople. Medical negligence comes up in interviews more often than any other legal topic, largely because it's where law, ethics and everyday practice all meet. Our medical ethics interview guide covers the ethics that sit around all of it.

What is medical negligence?

Medical negligence is a legal finding rather than a medical one, which is the first thing worth getting straight. It means a doctor’s care fell below the standard the law expects, and that this then caused real harm to the patient.

It's a civil case, so the patient or their family are seeking compensation rather than punishment. A claim has to establish each of the following, and all of them have to be present together:

• Duty of care: once someone is a doctor’s patient, that doctor owes them a duty to take care. Rarely argued about
• Breach: the care fell below the expected standard. This is the part Bolam and Bolitho decide
• Causation: the breach actually caused the harm, rather than harm simply following it. Hardest to prove, and it defeats most claims
• Harm: the patient suffered a real injury or loss, so a near miss that leaves everyone unharmed falls outside negligence entirely

Key Takeaway: Negligence is care that fell below the standard and then caused harm, and causation is usually the part that decides the case.

Which four cases do you actually need to know?

Bolam, Bolitho, Montgomery and McCulloch between them cover everything you'd realistically be asked, and the table below is most of what you need, because one line on each is genuinely enough for any interview.

Bolam and Bolitho govern diagnosis and treatment, while Montgomery and McCulloch govern consent, which is the conversation that happens before a patient agrees to anything.

Key Takeaway: Bolam as qualified by Bolitho, Montgomery for consent and McCulloch for which options count, which is a single sentence covering the whole framework.

What is the Bolam test?

The Bolam test asks a single question: would a responsible body of doctors have done the same thing? If the answer is yes, the doctor has met the standard, even where plenty of others would have acted differently.

He 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.

The case: John Bolam was given electroconvulsive therapy, a psychiatric treatment, without muscle relaxants and without a warning about the risk of fracture, and he was injured as a result. Doctors of the day genuinely disagreed about relaxants, and the court held that following either view was enough.

• Judged against a reasonable doctor: you're compared with a competent doctor in your speciality rather than with the best in the country
• A minority view counts: the doctors backing you can be a respectable minority, and they still count
• A floor, not a target: Bolam sets the minimum the law accepts, and plenty of care clears that bar while remaining fairly mediocre

Key Takeaway: Bolam is a minimum standard, and the doctors who would have done the same only need to be a respectable minority.

What did Bolitho add to Bolam?

Bolitho added that the supporting medical opinion has to hold up logically, so a court can now set aside expert evidence where the doctors giving it are unable to show they weighed the risks against the benefits.

The case: two-year-old Patrick Bolitho was in hospital with croup, an illness that narrows a young child’s airway. A nurse twice called the registrar, who stayed away, and Patrick then arrested, suffered brain damage and died. The question became whether the registrar’s refusal to intubate would itself have been negligent.

Lord Browne-Wilkinson was clear that rejecting a genuine body of medical opinion would be rare, and in practice courts have seldom done it.

Key Takeaway: Expert opinion still decides most cases, though since Bolitho it has to survive logical scrutiny first.

Why does Montgomery treat consent differently?

Because what a patient is told about risk is now judged from the patient's point of view rather than the profession's, which was a real shift. Since the Supreme Court decided Montgomery v Lanarkshire Health Board in 2015, that conversation has sat outside Bolam altogether.

A risk is material, meaning the doctor has to mention it, in either of these two situations:

• a reasonable person in that patient’s position would be likely to attach significance to it, or
• the doctor knows or should know that this particular patient would attach significance to it, as a small risk to fine hand movement would be to a concert pianist

The case: Nadine Montgomery had type 1 diabetes and was small in stature, giving her a roughly nine to ten per cent risk of shoulder dystocia, where a baby’s shoulder sticks during birth. That risk went undiscussed with her and no caesarean was offered, and her son Sam was born in 1999 with cerebral palsy.

What did McCulloch decide in 2023?

McCulloch settled who decides which alternative treatments a patient gets to hear about. Montgomery requires a doctor to discuss the risks of reasonable alternatives, but it left open the question of who judges what counts as reasonable.

The case: in McCulloch v Forth Valley Health Board the Supreme Court held that this is answered by Bolam as qualified by Bolitho rather than by Montgomery. Where a responsible body of doctors would regard an option as unreasonable, a doctor can leave it out.

Consent has become genuinely patient-led as a result, which is autonomy in practice. The mechanics are in our guides to medical consent, capacity and Gillick competence.

Key Takeaway: Which options count as reasonable is a Bolam question, while what the patient is then told about those options is a Montgomery question.

Does a mistake automatically mean a doctor is negligent?

No, and this is the single most useful correction to have ready in an interview. Most errors in medicine fall short of negligence, and plenty of bad outcomes involve none at all, because medicine carries risk that resists being designed out of it.

Here are three genuinely different things that routinely get called by the same name:

• A bad outcome: the treatment failed to work, or the illness simply won, and everybody involved did their job properly
• A mistake: something was done that shouldn't have been, or something got missed. Often harmless, and normally handled by reporting it and changing the system
• Negligence: the care fell below what a responsible body of doctors would accept and it caused real harm, and only a court gets to decide that

When I run practice interviews, I ask students to say which of the three they're looking at before they judge the doctor at all, because it makes the answer far clearer and it buys you a little thinking time.

Key Takeaway: A bad outcome, a mistake and negligence are three separate things, and saying which one you mean is the first move in any answer.

Are doctors sent to prison for making mistakes?

Very rarely, and it's worth being able to say so confidently, because almost all clinical negligence is a civil claim for compensation, and prosecuting a doctor over a death at work stays unusual because the bar is deliberately set high.

The criminal charge is gross negligence manslaughter, and the test comes from R v Adomako in 1994: a duty of care, a breach of it, a death caused by that breach, and conduct so bad, given the risk of death, that it amounts to a crime.

The case: six-year-old Jack Adcock died of sepsis in Leicester in 2011, and Dr Hadiza Bawa-Garba, the registrar, was covering multiple wards, short-staffed, with no working IT for test results and no consultant on site for much of the day. She was convicted of gross negligence manslaughter in 2015.

In 2018 the Court of Appeal restored her suspension after the High Court had ordered erasure. Interviewers reach for this case because of the question sitting underneath it: when is an error an individual failing, and when is it the system around them?

Our full Bawa-Garba guide covers it properly, and the same themes run through Martha’s Rule and Yaser Jabbar. The cases involving deliberate harm sit in a category of their own, namely Harold Shipman and Lucy Letby.

Key Takeaway: Prosecution is rare and needs proof beyond reasonable doubt, so treat Bawa-Garba as a system under strain as much as an individual under pressure.

What should a doctor do after something goes wrong?

You tell the patient what has happened, and you do it promptly. The duty of candour is the requirement to be open and honest when care has gone wrong, and it operates at both an individual and an organisational level:

• Professional: applies to you as an individual doctor and is enforced by the GMC, so be open with the patient, apologise, and put it right where you can
• Statutory: applies to organisations such as hospitals, regulated by the Care Quality Commission. Tell those affected in person, give a truthful account, explain what happens next, apologise, and record it

In my GP clinics this is usually a phone call rather than a formal meeting. If a result has been missed or a referral has gone astray, I say what happened, say sorry, and explain how I'm putting it right.

An apology counts as an expression of regret rather than an admission of liability, which is worth knowing. The duty came out of the Francis Reports into Mid Staffordshire, sits alongside Good Medical Practice, is overseen by the CQC, and overlaps with whistleblowing.

Key Takeaway: Make the patient safe, tell them honestly what happened, apologise and report it, remembering that saying sorry counts as an expression of regret rather than of liability.

How can I talk about medical negligence in my medicine interview?

Lead with the standard rather than with your opinion: say what a doctor is actually judged against, and then work out whether the case in front of you meets it.

Here's a sequence you can work through in roughly two minutes:

1. Name the standard. Would a responsible body of doctors have done the same, and does that view stand up logically?
2. Say which of the three you mean. A bad outcome, a mistake or negligence, and saying which one early keeps the whole answer honest
3. Look at the system as well as the person. Staffing, handover, IT, supervision and fatigue all shape what happened
4. Say what happens next. Be open under the duty of candour, apologise, report it, and change what allowed it

Here's what the interviewers in front of you are actually listening for:

• whether you can tell a bad outcome, a mistake and negligence apart
• whether you look at the system and the individual rather than only one of them
• whether you can talk about blame without becoming defensive or harsh
• whether you would be honest with a patient after getting something wrong

You don't need a clinical example for any of this, and most applicants already have something usable. If you've watched a team run a checklist on placement, sat through a safety briefing at work, or been warned about risks before signing a consent form, then you've already seen it.

Key Takeaway: Standard, then which of the three happened, then the system, then what happens next: those four moves fit almost any negligence station you'll meet.

What interview questions could come up on this?

You are unlikely to be asked any of these word for word, and you do not need a prepared answer to each one. Use them to check your understanding: if you could speak for a minute on most of them, you know this topic well enough for whatever the interviewer actually asks.

Questions to get you thinking

1. What is the Bolam test, and is it still the law?
2. Bolam and Bolitho are usually mentioned together. What did Bolitho change?
3. How does a court decide whether a doctor has been negligent?
4. Should doctors be prosecuted when a patient dies because of a mistake?
5. Who should decide which risks of a treatment are worth mentioning, the patient or the doctor?
6. You are a medical student on placement and you see a doctor give a drug at the wrong dose. The patient is fine and nobody noticed. What now?

Harder questions to stretch you

1. Bolam has been criticised for letting the profession mark its own homework. Is that criticism fair?
2. What did McCulloch add to Montgomery, and why does it matter?
3. Does the fear of being sued make doctors better or worse at their job?
4. Should a doctor’s written reflections ever be used as evidence against them?

Model answer: "Should doctors be prosecuted when a patient dies because of a mistake?"

I would start by separating out what actually happened, because a bad outcome differs from an error and an error differs from negligence. Patients sometimes die even where everyone involved has done their job properly.

Where a real mistake has caused a death, I think prosecution should be available but rare. The case I would use is Dr Hadiza Bawa-Garba. Six-year-old Jack Adcock died of sepsis in Leicester in 2011, and she was convicted of gross negligence manslaughter in 2015.

She was covering several wards, short-staffed, with the IT for test results down and no consultant on site for much of the day. Prosecute the person at the bedside, change nothing about the rota, and the next child is no safer.

I can see the other side. Families are entitled to accountability, and some conduct falls so far below any reasonable standard that compensation would not answer it. Proof beyond reasonable doubt is a high bar, and I think it sits about right.

So accountability and a learning culture can sit together. What worries me is that a doctor who is open about an error could end up easier to prosecute than one who says nothing.

I am in no position to judge any individual verdict. I would want to train somewhere that reports errors openly, because that is what makes the next patient safer.

Why this answer works:

• It defines before it argues. Bad outcome, mistake, negligence. That is the distinction the whole topic turns on
• It uses one case properly. Jack Adcock, Leicester, 2011, convicted 2015. Specifics give the argument something to stand on
• It gives the counter-argument fairly. Conceding that families deserve accountability makes the position sound reasoned
• It is honest about competence. Refusing to second-guess a verdict is right for a school leaver, and it still takes a position

There is a great deal more practice material in our 360 MMI and medical school interview questions. The wider framework sits in the four pillars, with non-maleficence most in play. To rehearse an answer like this out loud, we run one to one interview coaching.

Key Takeaway: Define your terms, use one case in detail rather than four in passing, give the other side, then take a position.

What should I take into the interview room?

One line on each case is enough to let you say something precise about the standard a doctor is held to, rather than falling back on the observation that they should have been more careful.

Related topics: our GMC guide covers the regulatory side, and the Bawa-Garba case is the negligence story panels return to most.

Key Takeaway: Say what standard the doctor was held to before you judge them, and the rest of the answer follows on its own.