Case Summary of Montgomery v. Louisiana: In 1963, 17-year-old Montgomery killed a deputy sheriff in Louisiana. ECT without the prior administration of a muscle relaxant results in muscle spasms and this has a known, although small, risk of bone fracture as a result. The relevant guidance from the GMC was reviewed and this supported the argument that it was the doctor’s role to provide a patient with all the information to allow them to make a balanced judgement between different options. This case involves a patient, Bolam, who sustained injuries during a course of electro-convulsive therapy being used as a treatment for depression. Mrs Montgomery has type 1 diabetes, which increases the risk of having But doctors should have already been following GMC guidance, which highlights the importance of communication.13. 2d 756, 762 (La. The Montgomery case was framed as a clash of values—patient autonomy versus medical paternalism. This case was brought by Mr and Mrs Pearce with regards to the obstetric advice she was given during her fifth pregnancy which ended with the stillbirth of her daughter, Jacqueline, in December 1991. Her claim was that the accident, and her injury, were the result of Hunter not exercising the usual standard of care and competence that was his duty while performing the injection. Hanley took legal action after she suffered an injury during an injection being given by her doctor when the hypodermic needle broke. Thus, although the test is focused on patients, doctors are not liable for every omission of disclosure to which a patient later objects.”25. Jones v Royal Wolverhampton NHS Trust  EWHC 2154 (QB). He did not seek treatment immediately because he had not been advised of the risk of deep vein thrombosis or pulmonary embolism or of symptoms that might indicate these. It was felt that, despite not being told of the risk of paraplegia, Mrs Sidaway had been given sufficient information to enable her to make a decision about proceeding with the treatment. It should be viewed differently from the process of diagnosis or treatment. The Montgomery case firmly rejected the application of Bolam to consent, establishing a duty of care to warn of material risks. The Montgomery case in 2015 was a landmark for informed consent in the UK. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. The court found that a doctor’s actions are not necessarily negligent if they are found to conform to a practice that is accepted as reasonable and proper by other reasonable members of the profession. Mr Afshar advised surgery on the protruding disc. Information overload is unlikely given that information should be tailored to the patient. Mrs Pearce argued that had she been informed of this risk she would have opted for a Caesarean section as this would have posed least risk to her baby. There are choices to be made, arguments for and against each of the options to be considered, and sufficient information must be given so that this can be done. The full implications of the case are undoubtedly still unknown, but Montgomery has clear relevance for medical law and ethics. Montgomery is, of course, about informed consent: warning of risks, advising of reasonable alternative treatments and obtaining valid consent. Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: AS represented the GMC in the Supreme Court in the Montgomery case. Many organisations (in particular the General Medical Council, who intervened to make submissions in the case) said that the Montgomery decision had simply enabled UK law to catch up with current GMC guidance; others hailed it “the most important UK judgment on informed consent for 30 years.”4 Doctors have expressed their concerns about its potentially radical effects on patient care and clinical practice.5 We held a public debate in 2015, including doctors, lawyers, and medical students, which showed renewed tension between the professional discretion of doctors and patients’ choices6; indeed, the verdict has been characterised as supporting patient autonomy over medical paternalism.3 7 8 9 But what are the implications for doctors’ practice and their legal liability? The law on consent has progressed from doctor focused to patient focused. It is in fact Lord Scarman that introduced the concept of ‘material risk’, 30 years before the Montgomery ruling. The risk for such surgery was held to be less than one per cent and Mrs Sidaway felt her surgeon had been negligent not to include this risk in the discussion. Sidaway v Board of Governors of the Bethlem Royal Hospital and others  871 AC. This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. Nadine Montgomery, a woman with diabetes and of small stature, delivered her son vaginally; he experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Montgomery v Lanarkshire Health Board  UKSC 11 is a Scottish delict, medical negligence and English tort law case on doctors and pharmacists that outlines the rule on the disclosure of risks to satisfy the criteria of an informed consent. The practice of medicine has moved significantly away from the idea of the paternalistic doctor who tells their patient what to do, even if this was thought to be in the patient’s best interests. Although upset, Mrs Pearce accepted this advice. But doctors must judge what is appropriate for each patient and how their exercise of judgment might be assessed by the courts. Judgment (PDF) Press summary (PDF) Judgment on BAILII (HTML version) He began to worsen and Dr Horn was called but did not attend. The test of materiality defined in the Montgomery ruling was whether “a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.”1 The solicitor representing Montgomery spoke of the decision as having “modernised the law on consent and introduced a patient focused test to UK law.”16. A further judgment was issued in this case on appeal which refused the amendment. Mr Afshar had a duty of care to warn Miss Chester of this risk but he did not. By referring to the importance of the accepted practice of other doctors, the Trust used the Bolam test. Montgomery v Lanarkshire Health Board  SC 11  1 AC 1430. If the action of a doctor was found to be an illogical course of action then they could be found to be negligent despite having a group of doctors who would have acted in the same way. The Supreme Court of the UK announced judgment in her favour in March 2015. One such attempt in Scotland has, so far, been unsuccessful.20 Two English cases have allowed consent claims to be added after the Montgomery decision.21 22 Some cases have succeeded on a Montgomery basis23; we (AA) understand that others have settled before litigation ever started or was concluded, as the claims were unanswerable in the light of Montgomery. A patient was to be informed of any common or serious potential consequences or complications and the determination of what was deemed common or serious was for the doctor to decide, not the patient. In this case, the assertion that Dr Horn would not have intubated Patrick if she had been present was felt to be a logical one and, therefore, not negligent. Petitioner Montgomery was 17 years old in 1963, when he killed a deputy sheriff in Louisiana. The case was found for the defence and the ruling introduced a legal test that a claimant would need to satisfy in order for medical negligence to be proved. Training and educational materials must be fit for purpose. Healthcare policy should cover, for example, which treatments should be available and how consent procedures should be handled.17 The doctor’s duty is simply to treat patients according to their interests, which might include being given more information than usual. All were in agreement that there was a body of medical opinion the supported the use of ECT without relaxants and without physical restraints as it was thought these could compromise the airway or increase the chance of injury. The doctor’s normal practice was to give ECT without a relaxant and without any physical restraints; the doctor would support the patient’s chin and shoulders while nurses stood at either side of the treatment couch to prevent the patient falling. Montgomery was 17 years old at the time of the crime. The case of Montgomery v Lanarkshire Health Board appeared to make further inroads into the traditional approach as applied to the provision of information to patients of the risks involved in a procedure. He died seven years later. Shaw v Kovac (October 2015)24 concerned a patient who died in 2007 after a transaortic valve implantation, which was then still the subject of clinical trials and not fully approved. 11 Mar 2015. Consequently, he was born with a dyskinetic form of cerebral palsy. These summaries are the opinion of the author/s, not the court, and may contain errors. This case was brought by the mother of Patrick Bolitho, a young boy who died following a cardiac arrest in hospital that resulted in severe brain damage. Post navigation. Montgomery was retried. The consultant stated that the risk of shoulder dystocia occurring in a woman with diabetes was 10% but that the risk of a serious consequence from said shoulder dystocia was 0.2% for a brachial plexus injury and less than 0.1% for hypoxic injury. Sundar S. Case based laws are turning into “emperors new clothes.”[electronic response to Sokol DK. See: He also added that if a patient asked a question then it should be answered. The pain could be severe and she had experienced episodes of being unable to walk or control her bladder. Patrick deteriorated and suffered a cardiac arrest from which he was resuscitated but he had sustained significant brain damage. He finally appealed to the House of Lords. The test of materiality is whether in the circumstances of the particular case the court is satisfied that a reasonable person in the patient’s position would be likely to attach a significance to the risk. In these cases it is reasonable to not discuss risks but these circumstances are, as already said, rare. 817 F.3d 12 (1st Cir. She has type 1 diabetes and was concerned during her pregnancy that the size of her baby might lead to difficulties with a vaginal delivery. The competence of the surgery itself was never in doubt. In making their ruling, the different Lords had differing opinions of the case and what the duty of a doctor was in terms of discussion and consent. In 1999, Nadine Montgomery was pregnant with her first child, Sam. Clark v Greater Glasgow Health Board  CSOH 25. New users must create a login. In Spencer v Hillingdon NHS Trust (April 2015)23 the patient had bilateral pulmonary emboli after a hernia operation. Expert witnesses, representing either side, gave evidence that there are a number of different techniques used when administering ECT: some use muscle relaxants, some don’t; some use restraints, some don’t; some use manual control only, some don’t. Lord Scarman, however, expressed a different and more patient-centred opinion but, as his was a minority view, it did not affect the overall rejection of the case. Nadine Montgomery gave birth to her son, Sam, on 1 October 1999. Bolam v Friern Hospital Management Committee  1 WLR 582. Bailii, Bailii Summary, SC Summary, SC, WLRD Scotland Citing: At Outer House – Montgomery v Lanarkshire Health Board SCS 30-Jul-2010 Outer House – The pursuer sought damages for personal injuries to her son at his birth, alleging negligence by the … 59 results for maddox v montgomery case brief. Montgomery v Lanarkshire Health Board UKSC 11 is a landmark decision, in which the UK Supreme Court has found in favour of informed consent on the part of a patient who is considering, or being advised, to undergo medical treatment. The Bolam test was affirmed in Sidaway v Bethlem Royal Hospital Governors and others,2 although the ruling was not unanimous, with judges placing different weight on the patient’s right to make informed treatment decisions versus the doctor’s professional judgment in disclosing information. Making sure that patients understand all the information they need to make a decision will inevitably take longer. vLex Rating. Even if the risk be material, the doctor will not be liable if upon a reasonable assessment of his patient’s condition he takes the view that a warning would be detrimental to his patient’s health. Miss Chester had the spinal surgery and suffered a worsening in her symptoms. In keeping with general practice Dr McLellan would customarily offer a caesarean section to diabetic mothers where the estimated birth weight is 4.5 kilograms. This test has three parts which, as stated by Lord Clyde, must be met: First of all it must be proved that there is a usual and normal practice; secondly it must be proved that the defender has not adopted that practice; and thirdly (and this is of crucial importance) it must be established that the course the doctor adopted is one which no professional man of ordinary skill would have taken if he had been acting with ordinary care. UKSC 2013/0136. When she was raped, Ellen thought it was the worst thing to ever happen to her. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Directed by Boris Sagal. Today’s patients can expect a more active and informed role in treatment decisions, with a corresponding shift in emphasis on various values, including autonomy, in medical ethics. Medical staff performed the appropriate manoeuvres to release Sam but, during the 12-minute delay, he was deprived of oxygen and subsequently diagnosed with cerebral palsy. He appealed to the Louisiana Supreme Court, and his conviction was overturned because of community prejudice. The risk of shoulder dystocia (the baby’s anterior shoulder becoming stuck behind the mother’s pubic symphysis) occurring was not discussed and a plan was made for vaginal delivery. Supreme Court decision changes doctor-patient relationship forever. This practice refers back to the ruling of Lord Diplock in Sidaway who advised that if a specific question was asked, it should be answered. In his ruling, Lord Hope stated: The injury was intimately involved with the duty to warn. 1966). A man who was punched in the face and then kicked by a Montgomery County sheriff’s deputy following a police chase has sued two deputies, the sheriff and the county in federal court. The involvement of seven justices in this final appeal is of particular importance as this is the number of justices required to change or overrule a previous House of Lords ruling; in this case, the ruling in Sidaway. As a result of an occlusion of the umbilical cord caused by shoulder dystocia, Sam's brain was starved of oxygen for some 12 minutes. Many doctors have questioned the implications that the recent Supreme Court judgement of Montgomery – v Lanarkshire Health Board1 will have for the way they obtain consent from patients. Summary of Montgomery v Lanarkshire Health Board This Supreme Court judgment is required reading for all medical professionals, because the Supreme Court has made clear that the doctrine of informed consent is now part of English (and Scottish) law. The Case. Montgomery a caesarean section. She argued that had she been warned of the risk of this happening she would have taken longer to consider and reach her decision to have the surgery. Planning for labour emergencies is essential, so that the doctor and patient can discuss the patient’s wishes if an emergency should arise. Obstetricians urgently need guidance. Doctors may have been treating patients as they understood the law to be, as in the Sidaway case, but the Supreme Court has told us that this was wrong3 and that anyone who practised according to Sidaway was also wrong. 1999 - Nadine Montgomery pregnant with 1st child Concerned regarding difficulties with delivery due to size of baby. ... We encourage you to double check our case summaries by reading the entire case. The perpetrator, Lisa Marie Montgomery, then aged 36, … Nadine Montgomery, a woman with diabetes and of small stature, delivered her son vaginally; he experienced complications owing to shoulder dystocia, resulting in … When the new pain developed, her surgeon suggested that a cervical cord decompression would alleviate her symptoms. As seen in clinical practice, it was acknowledged that some patients will express a wish to not be told of the risks of a treatment or procedure or to not make a decision. Log in using your username or email address. The critical limitation is that the duty is confined to material risk. The Montgomery v Lanarkshire case of March 20151 drew fresh attention to informed consent. The jury returned a verdict of "guilty without capital punishment," which carried an automatic sentence of life without parole. A patient is autonomous and should be supported to make decisions about their own health and to take ownership of the fact that sometimes success is uncertain and complications can occur despite the best treatment. He also suffered an avulsion of the brachial plexus, rendering his arm useless. A patient, Miss Chester, was under the care of a neurosurgeon, Mr Afshar, for a 6-year history of back pain and she had been shown to have a vertebral disc protrusion on an MRI scan. These issues are not always pursued, but obstetric litigation practice has noticeably changed, making professional training and clarity with respect to guidelines an even higher priority. The Montgomery decision redefined the standard for informed consent and disclosure. In his appeal to the House of Lords, Mr Afshar focused on the grounds of causation as Miss Chester was likely to have consented for the operation and that the operation would have carried the same risk, even if it had been performed at a later date. The court rejected this, holding that the Montgomery ruling did not create a right to informed consent as an independent cause of action, but simply set a new legal standard for the duty to disclose. The judge in the first case found on behalf of Miss Chester. maddox v montgomery case brief. You can also use your College Personal ID (PID) if you have one. Looking at some of the cases in which the Montgomery ruling has been considered tells us about its interpretation to date. The appellant, Nadine Montgomery, gave birth on 1 October 1999 and, as a result of complications during delivery, her son was born with cerebral palsy. Login Montgomery and informed consent: where are we now? 2783, 171 L.Ed.2d 637 (2008). It was argued by his mother that there had been negligence in his care as, had Dr Horn come to review her son and had he been intubated, then his brain damage and death could have been prevented. The House of Lords ruled for the Health Authority in this case and within the ruling they applied a further element to the Bolam test: that of logic of a medical opinion. Judgment details. Rather it shows that the communication process has a strong influence on how patients understand, remember, and evaluate information—all of which are essential to informed consent. But this is a false dichotomy—the idea of a fully autonomous patient making choices completely independent of the doctor’s input does not reflect the complex reality of medical decision making, nor does the caricature of a paternalistic doctor riding roughshod over patients’ objections. This would mean that a patient who asked specific questions would potentially be given more information than a patient that did not ask questions. During her son’s delivery, shoulder dystocia occurred and, despite the best efforts of the obstetric team, there was a twelve minute delay between the delivery of his head and his shoulders. Since the Montgomery ruling, several attempts have been made to introduce a consent based claim to cases that were under way before the decision. The case was made that as the consultant had not discussed the risk of shoulder dystocia, the potential significant consequences of it occurring and the alternative option of a Caesarean section that negligence had occurred as far as consent is considered; Mrs Montgomery was not able to make a fully informed decision without full information on all the options. This case was heard at the UK Supreme Court in July 2014 before seven Justices following failed appeals in the Court of Session and the Inner House. Previously, the Bolam test14 in England and the Hunter v Hanley test15 in Scotland were used to determine what should be disclosed. We (ESC) have noticed that a considerable proportion of cases of obstetric negligence raised since Montgomery involve consent in addition to standard complaints of substandard care. The case was brought by Henry Montgomery, a Louisiana inmate who challenged his sentence for the killing of an East Baton Rouge sheriff’s deputy in 1963, when Montgomery … He was convicted and received a mandatory life-without-parole sentence. Lord Neuberger, Lady Hale, Lord Kerr, Lord Clarke, Lord Wilson, Lord Reed, Lord Hodge. We do not capture any email address. The risk of shoulder dystocia (the baby’s anterior shoulder becoming stuck behind the mother’s pubic symphysis) occurring was not … A second concern was that the ruling would encourage “defensive medicine,” shifting the focus from helping the patient to protecting the doctor. To the extent that I have indicated I think that English law must recognise a duty of the doctor to warn his patient of risk inherent in the treatment which he is proposing: and especially so, if the treatment be surgery. You can also use your College Personal ID (PID) if you have one. The duty was owed by the doctor who performed the surgery that Miss Chester consented to. The claimant alleged that the trust was negligent in failing to advise of this possibility. If these feelings are explored and the patient genuinely wishes no information or would prefer the doctor made the decision, then discussions should be documented and treatment proceeded with if that is felt to be appropriate. Involving a patient in their care and adopting a collaborative approach, as well as complying with the law and GMC guidance, can also result in a more positive, satisfying experience for patients and clinicians alike. Despite expressing concern to her consultant about whether she would be able to deliver her baby vagi… The discussion and involvement of the patient in the planning of their care mirrors the approach of shared decision making. The argument in this appeal was that is not appropriate to use the accepted practice of a body of reasonable medical practitioners when consent is considered. A further challenge is that the risks of birth can change dramatically and quickly, making detailed discussion and informed decision making difficult. In making this ruling, the Bolam test was applied which meant that as the usual practice of a body of reasonable doctors in the field of neurosurgery was to not have mentioned this less than one per cent risk. The Montgomery test was defined in the case 1of Montgomery v Lanarkshire Health Board. Summary: Justin reviews the issues of consent in clinical negligence cases in, and subsequent to, the case of Montgomery. On 2nd December her daughter was found to have died in utero. She has type 1 diabetes and was concerned during her pregnancy that the size of her baby might lead to difficulties with a vaginal delivery. Spencer v Hillingdon Hospital NHS Trust  EWHC 1058 (QB). Material risk is a risk that is deemed to be of significance by an individual patient rather than by a body of doctors. Patient consent: do doctors really know best? If you are unable to import citations, please contact Over this time the blood flow through the umbilical cord was compromised and Sam suffered a significant hypoxic injury which resulted in brain damage and cerebral palsy. Doctors at the coalface have received little official direction on how their practice should change in light of the ruling. View Essay - Case Brief - Maddox v. Montgomery from CJAD 405 at Columbia College. Assessed by the Supreme Court ’ s difficulty in providing guidance perhaps reflects the unique nature obstetrics—essentially... ; externally peer reviewed making difficult American woman found murdered in her home in Skidmore Missouri...: your email address, but Montgomery has clear relevance for medical law and ethics few completed! 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