reasonable anaesthetist would have stored the anaesthetic differently, it was inappropriate to hold the hospital management liable for failing to take precautions. That the profession had changed its practice in the light of experience proved that the profession was responsible in its self-regulation. In 1954, anaesthetists coloured the phenol with a dye. If a vial became contaminated, the dye showed inside the vial. These vials were then discarded. But, given that the hospital was applying the best practice of the time, there was no negligence. Somervell LJ. "It is now clear that phenol can find its way into an ampoule of nupercaine stored in a solution of phenol through cracks which are not detectable by the ordinary visual or tactile examination which takes place in an operating theatre — these cracks were referred to in the evidence as "invisible cracks" — or through molecular flaws in the glass. The attention of the profession was first drawn to this risk in this country by the publication of Professor Macintosh's book on Lumbar Puncture and Spinal Anaesthesia in 1951. In 1947 the general run of competent anaesthetists would not appreciate this risk. (Dr Mcintosh, Day 3, 18, 19, 42-E; Dr Organe, Day 8, 61; Dr Cope, Day 9, 25). Dr Graham certainly did not appreciate this as a risk. I accordingly find that by the standard of knowledge to be imputed to competent anaesthetists in 1947, Dr Graham was not negligent in failing to appreciate this risk and a fortiori the theatre staff were not negligent." Morris LJ "It is now known that there could be cracks not ordinarily detectable. But care has to be exercised to ensure that conduct in 1947 is only judged in the light of knowledge which then was or ought reasonably to have been possessed. In this connection the then-existing state of medical literature must be had in mind. The question arises whether Dr Graham was negligent in not adopting some different technique. I cannot think that he was" References See also Bolam v Friern Hospital Management Committee List of cases involving Lord Denning English tort case law Lord Denning cases 1954 in British law Court of Appeal (England and Wales) cases 1954 in case law Negligence case law Medical lawsuits Medical malpractice Department of Health and Social Care Anesthesia