During surgery on the awake patient, further consent is needed before any change in the planned procedure can be made.

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The Montgomery ruling [Montgomery vs Lanarkshire Health Board (Scotland) (2015), UKSC11] was issued by the UK Supreme Court in March 2015 following an earlier failed appeal. The ruling states that a patient has the right to expect to be given information at material times about all relevant risks associated with a procedure, and sufficient information about the alternatives to allow fully informed consent. It does not apply when urgent treatment is required or the patient is unable to make a decision, when unconscious for example. It appears to overrule the principles of Bolam [Bolam v Friern Hospital Management Committee (1957) 1 WLR 582], Sidaway [Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital (1985) AC 871] and Bolitho [Bolitho v City and Hackney Health Authority (1998) AC 232] which have guided UK medical practice in recent years. This ruling must be taken into account for medical practice in the UK from now onwards, and the principle behind it was adopted by the judge in a case, managed in 2008, which was heard in May 2015. In this case, a suture needle broke during the repair of an extension of a repeat caesarean section incision. This was recognised at the time but the 13–15 mm fragment could not be located even after further searching once the initial bleeding had been controlled. The anaesthetist's offer to convert the regional to general anaesthesia when discomfort was caused was rejected by the patient and the operation was completed. The surgeon had been anxious that continued dissection might cause further bleeding, leading to a requirement for hysterectomy; operative blood loss, although greater than average, had been controlled. Following completion of the operation, the surgeon advised his patient of the situation, recommending postoperative imaging with further advice depending on needle fragment location. It was subsequently identified in the anterior myometrial wall. An independent obstetrician giving a second opinion advised against further surgery to retrieve the needle fragment, opining that long-term harm was very unlikely, whereas further surgery risked causing excess bleeding and the need for transfusion or hysterectomy. Imaging 4 years after the operation indicated there had been no movement/migration of the needle fragment since the initial imaging shortly following the caesarean section. In finding for the Claimant, the judge ruled the patient was conscious under a spinal anaesthetic for her caesarean section and should have been consulted during the operation about the risks associated with continued attempts to retrieve the needle fragment, compared with those of a retained foreign body—infection and migration, with the need for surgery at a later date. This ruling appears to remove from the clinician the option to make a decision on management ‘in the patient's best interest’. Not only must doctors advise their patients of all therapeutic options with the associated risks when obtaining consent from them, but they must re-affirm all relevant information when an emergency occurs and then respond to the patient's wishes, even when they are potentially more harmful. The concept of ‘urgency/emergency’ needs defining. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.