Applying the Bolam principle

Following a tonsillectomy at a specialist ENT unit, a 44-year old female patient was given a post-operative drug regime to control the severe pain associated with adult tonsillectomy.

The drug regime had been developed by the consultant anaesthetist involved in the surgery. He had provided written information to the patient detailing both the anaesthetic and the post-operative drugs.

The 10-day regime, which prescribed dexamethasone in combination with diclofenac, was developed based on findings reported by an ENT consultant surgeon in a research paper published some years earlier.

In the immediate post-operative period, the patient recovered well and was discharged two days after the operation. The consultant anaesthetist gave the patient his emergency contact numbers and also phoned to check on her progress at six days after the surgery.

At 10 days post-discharge the patient was admitted to her local emergency department suffering a severe rectal haemorrhage. She was found to have a caecal ulcer and underwent an emergency hemicolectomy.

The patient brought a claim for negligence against the anaesthetist, the focus of which was the postoperative drug regime. Allegations related in particular to prescribing a combination of dexamethasone and diclofenac in ‘excessive’ amounts over a prolonged period.

The MDU obtained expert opinion on behalf of the member. Initially, the expert raised concerns over the longterm use of diclofenac and dexamethasone in combination and suggested that there was no literature supporting the combined use of these two drugs for up to 10 days following this type of surgery.

Further, that unless the drug regime was also used by other practitioners at the specialist unit, then this drug regime was not capable of support.

The member identified the source of the regime as a paper on the combined use of diclofenac and dexamethasone published in 1992.

The paper commented upon the combined use of dexamethasone and NSAID’s in post-operative pain management following adult tonsillectomy and palatal surgery. The MDU contacted the paper’s authors; they confirmed the continued use of diclofenac and dexamethasone in post-operative pain management and that they had not experienced any complications such as those experienced by the patient in this case.

In fact, the MDU found on further investigation that the drug regime, or variations of it, were used by other practitioners at the specialist unit, and obtained statements to support this.

In light of this information, the expert opinion confirmed support for the member, in particular the drug regime, and the claim was discontinued.

The Bolam principle1 establishes that a professional is required to exercise the ordinary skill of a competent practitioner in his/her field. A doctor will be judged to have come up to the required standard of clinical care if a reasonable body of medical opinion, albeit a minority one, would find his/her actions acceptable.


  1. Bolam v Friern Hospital Management Committee [1957] 1 WLR 582

This page was correct at publication on 01/08/2012. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.