Your Expert Witness Issue No. 41

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contents IN THIS ISSUE 7

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Opening Statement

NEWS 8 Financial services position at risk, say barristers 8 Law Society to revisit CQS training 9 Environmental professionals warn over future outlook 9 All roads lead to Church House CHOOSING THE CORRECT EXPERT 11 Guidance stresses expert’s duty to the court 11 Now experts really will have their heads in the cloud!

BUILDING & PROPERTY 12 Rush to build causes nightmares for many 12 RICS issues anticipated statement on ‘double-dipping’ 13 Avoid conflict; save time and money – that’s the message of a new pledge 13 Construction disputes can sometimes be blowing in the wind

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ANIMAL WELFARE & BEHAVIOUR 14 Poll shows the UK cares about animal welfare 14 Pet insurer tightens checks to counter puppy farmers 15 Scotland set to reintroduce selective ‘tail-docking’ 15 Not all cases of ‘dog bites man’ are as they seem FORENSICS 16 Consultant warned of ransomware attack 16 Terror investigations show importance of data CULTURAL, RELIGIOUS & ETHNIC ISSUES 17 Eastern customs that may be a concern for Western courts WILLS, LEGACIES & CHARITABLE BEQUESTS 18 Legacy income hits £2.5bn milestone 19 More advisers than ever mention legacies 19 Short breaks offer a normal life and boost self-confidence 20 Vegfam – feeding the hungry without exploiting animals 20 Charity carries on the work of its founder 21 Tax changes are only good news for some 21 Help for those with failing sight 22 Seeing Dogs providing a choice 23 Probate fee changes means families may pay much more, warns solicitor 23 Legacies – the gift of life for threatened primates 24 Surgical research benefits from legacy giving 24 Enhancing lives is the foundation of their work 25 Campaign urges VAT exemption on charitable wills 25 Philanthropist leaves university’s largest-ever legacy 25 If you Will, we will 26 Horses’ plight sparked the beginning of a dream 27 Charitable giving has benefits for the donor, too

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MEDICAL ISSUES 31 Medical Notes

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NEWS 33 Paterson case prompts call for review of private sector reporting 33 Care watchdog admits to tardiness in acting 35 Opposition swells to fixed costs in negligence cases 35 Private care providers to benefit from new legal cover 36 Patients’ charity challenges ethics and independence of proposed RRR scheme 36 NHS chief Sir Bruce Keogh to step down HEARING LOSS 37 Hearing charity attacks plans to cut aid provision 37 Hearing claims on the decline PAIN 39 Removing the complexity from Complex Regional Pain Syndrome (CRPS) cases INSTRUCTING A PHYSIOTHERAPIST 41 Physios lead the way in expert assessment of mobility and soft tissue issues

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OPHTHALMOLOGY 43 Ophthalmologists respond to NICE consultation on cataracts 43 Wet AMD patients experience anxiety and depression 43 New venture brings experts together DENTAL NEGLIGENCE 44 Dental periodontal negligence claims – the expert’s role 46 Who’s listening anyway?

WRIST INJURIES 49 Wrist injuries and the scaphoid bone OBSTETRICS & GYNAECOLOGY 51 Training in heart rate monitoring must improve for midwives, say experts 51 Regulator welcomes changes to legislation

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CARDIOLOGY 52 Cardiology claims are not common, but can take years to conclude 53 Know your numbers: BUPA offers an explanation of some heart facts PLASTIC SURGERY 55 Bullies and their victims more likely to seek cosmetic surgery FORENSIC TOXICOLOGY 56 Psychoactive Substances Act: one year on 56 Investigation into rogue drug testing continues PSYCHIATRIC & PSYCHOLOGICAL ISSUES 57 A downward spiral: drugs, mental ill-health and offending 59 BPS offers advice on talking to children in wake of Manchester attack 59 Forensic psychologists convene in Bristol 60 Attachment assessment in family cases: Science not Guesswork A to Z WEBSITE GUIDE 28 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

EXPERT CLASSIFIED 61 Expert Witness classified listings 63 Medico-legal classified listings www.yourexpertwitness.co.uk

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Opening Statement [

AT THE TIME of writing the country is in a state of turmoil following the result of the General Election. Two events were due to take place on 19 June: the Brexit negotiations were set to kick off at the same time as The Queen’s Speech was outlining the legislative programme for the government – a government that has a somewhat different complexion from the one envisaged when the event was scheduled. Both events look set to be delayed.

Both will contain elements of interest to the expert witness. While any Queen’s Speech incorporates legislation that will need to be interpreted by judges and lawyers, this one will contain the Great Repeal Bill to incorporate a multitude of EU legislation into UK law following Brexit.

The Brexit negotiations, on the other hand, will determine the extent to which the UK goes its own way. Both events will cause huge headaches for those experts, such as engineers and environmental consultants, who will be tasked with understanding just what has gone and what is left.

• Another area where UK law will be taking over from EU law is that of animal welfare. It is a slightly anomalous area because traditionally UK animal welfare legislation has been ahead of the rest of Europe. Nonetheless, it is a subject about which the British public are famously passionate and most people want welfare legislation to be at least as stringent post-Brexit as it is now.

• As if to emphasise the extent to which the UK economy has become entwined with that of the rest of Europe, yet another warning has been issued against drifting too far away from the EU in the area of financial services.

This time it is the Bar Association that is keen to put its view forward ahead of Brexit talks. Other areas of concern to the barristers’ representative body are the preservation of rights of abode and employment rights.

• The election result brought with it an inevitable rethink of Mrs May’s Cabinet reshuffle. A notable casualty was Justice Secretary Liz Truss. Her replacement is David Lidington, an MP who is known to be in favour of fox hunting and opposed to gay marriage.

• Concerns about the UK’s role in Europe pale into insignificance against the growing integration of computer systems into a global network. Even the notoriously hidebound British legal system is ‘going digital’, with the e-Judiciary portal marking the gateway to cloud computing. Last November Lord Justice Fulford exhorted experts to embrace change or be left behind.

• Information technology brings with it threats as well as benefits, however. On 12 May a visit to the local pharmacy revealed frustration among staff and customers alike at an inability to access electronic prescriptions.

As the afternoon wore on it became evident that a major cyber attack had paralysed a substantial part of the NHS in the locality. As more information is unfolding regarding the background to the WannaCry worm, more evidence is emerging that the attack was foreseen. Whether it could have been prevented is another matter.

• Cyberspace is also exploited as an environment for covert communications by those who would disrupt and destroy. That fact has been brought home to us repeatedly in recent months by a series of terror attacks across Europe – culminating in the outrages in London and Manchester.

Digital communications leave behind their own trails, which are readily interpreted by a cohort of experts. The more data they have to work with, the better equipped they are to pinpoint and dismantle the threat. Even the humble dashcam is now being drafted in to add its two penn’orth to the sum total. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Financial services position at risk, say barristers [ THE UK'S TOP SPOT as the global hub for financial services is at risk unless the

Government creates a bespoke agreement with the EU to deal with the loss of the financial services ‘passport’, according to the Bar Council.

Hugh Mercer QC, chair of the Bar Council’s Brexit Working Group, said: “Financial services make up 7% of UK GDP and directly employ 1.1 million people, two-thirds of whom work outside of London. Larger firms cannot wait until the conclusion of the Article 50 negotiations to know what will happen. Many are in the process of developing their contingency plans on the basis that the UK does not remain a member of the single market and will no longer benefit from the existing passporting regime.

“Other mechanisms used by countries outside the EEA to access financial services markets, such as the equivalence regime and the emergent third country passport, will not fill the gaps created by the loss of the passport and WTO terms will not suffice.

“What we need is a bespoke agreement with the EU, replicating the status quo as far as possible and covering the gaps created by the loss of the passport regime. Any such agreement must also grant legal and other essential services sufficient rights so that they can continue effectively to support the financial services sector.”

The warning comes in The Brexit Papers, a comprehensive and easy-to-read legal guide on Brexit from the Bar Council. In it the Bar Council also tells the government it should give EU citizens unrestricted access to UK jobs, defend employment rights of UK workers, make a strategy to keep London as the global centre for financial services and write up a solid 'Plan B' in case no deal is reached with the EU two years after Article 50 is triggered. q

Law Society to revisit CQS training Financial Crime module withdrawn following CAT ruling

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THE Law Society of England and Wales has announced it is looking again at the training elements of its Conveyancing Quality Scheme (CQS), in response to a ruling by the Competition Appeal Tribunal. The tribunal found that from April 2015 the Law Society should have permitted third-party trainers to offer some of the modules for the scheme.

The Law Society pointed out that the only module giving concern to the tribunal that was still being provided was the Financial Crime module. That module has now been withdrawn.

Law Society president Robert Bourns said: “For the vast bulk of the time CQS training has been available, it has been compliant with competition rules. I am certain that in setting CQS up, the Law Society acted in good faith and in the public interest.

“The purpose of CQS – and its effect – was to ensure greater consumer choice in terms of practitioners available to undertake this important work. We note the decision and have and will take steps to avoid similar issues in the future.

“Purchasing a house is the biggest investment most people make and they need to feel confidence in the process, as do lenders. That was always our motivation: CQS has never been about profit.

“We are grateful to the tribunal for their guidance on changes to CQS that they make in their ruling and we will be looking at their comments as a matter of priority in the coming days.” q

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Environmental professionals warn over future outlook [

EXPERTS FROM THE Institute of Environmental Management and Assessment (IEMA) have expressed concern about the future implementation of European environmental standards following the UK’s secession from the EU, particularly given the uncertainty thrown up by the election result.

IEMA’s chief policy advisor, Martin Baxter, said: “The outcome of the general election raises significant challenges, from forming a government to developing and implementing a legislative programme: all against a backdrop of the UK’s Article 50 notification to leave the EU.” “IEMA members expressed significant concern in the run up to the election on a wide range of sustainability issues including air quality, climate change and circular economy.

It is vital that the short-term uncertainties are quickly resolved so that long-term challenges can be properly addressed.”

Mr Baxter was referring to the results of a poll of 669 UK environment and sustainability experts conducted for IEMA ahead of the election. Those polled gave a clear call for accelerating action to exceed carbon emissions reductions well before the target dates set out in the Climate Change Act.

The poll’s respondents also called for the next UK Government to prioritise resolving the environmental, health and well-being effects linked to air pollution. According to IEMA around 40,000 deaths each year are attributable to air pollution.

Martin Baxter said then: “It is essential that the next Government puts in place a long-term, ambitious policy framework for transitioning the UK to a sustainable economy. As we make plans to leave the

EU, high environmental quality standards must be maintained, enhanced and consistently enforced and used to create the conditions to support UK business exports.

“The UK’s sustainability experts have significant experience of delivering business and environmental performance improvement and we look forward to working with the next Government to maximise the opportunities from the transition to a sustainable economy.” q

All roads lead to Church House [ EXPERTS FROM ALL disciplines will be heading to London’s Church House

Conference Centre in September for the annual conference of the Expert Witness Institute (EWI).

The event, which includes lunch, will this year be held on 21 September under the title Upside Down and Inside Out – Experts Under Pressure and will reflect the changes to the judicial process that has resulted in experts needing to adapt their working practices.

An array of speakers have been lined up for the conference. The opening address will be delivered by Lord Justice Rupert Jackson – author of the report which led to the widereaching reforms.

The main panel session will be chaired by former Law Society president Mike Napier QC, while the conference will by chaired by Amanda Stevens of Hugdell Solicitors.

The new chair of the EWI, Martin Spencer QC, will also be addressing the conference and it is hoped Hon Mr Justice Foskett will be able to attend. q

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Guidance stresses expert’s duty to the court [ IN ITS Guidance for the instructions of experts in civil claims, the

Civil Justice Council (CJC) states: “The purpose of this guidance is to assist litigants, those instructing experts and experts to understand best practice in complying with Part 35 of the Civil Procedure Rules (CPR) and court orders. Experts and those who instruct them should ensure they are familiar with CPR 35 and the Practice Direction (PD35).”

It continues: “Experts always owe a duty to exercise reasonable skill and care to those instructing them, and to comply with any relevant professional code. However, when they are instructed to give or prepare evidence for civil proceedings they have an overriding duty to help the court on matters within their expertise (CPR 35.3). This duty overrides any obligation to the person instructing or paying them. Experts must not serve the exclusive interest of those who retain them.”

The precedence of the expert’s duty to the court over a client’s interests was taken up in an article by Jonathan Hadley-Piggin of Keystone Law. “The duties an expert witness owes to the court may sometimes conflict with those he owes to the client,” he wrote. “The most obvious example is when the expert’s conclusions contradict the client’s case. If the client seeks to put pressure on the expert to alter his report or suppress the damaging opinion, the expert witness must resist such pressure and if necessary should terminate his appointment.

“Nor should an expert witness ignore information that may come to light which is damaging to his client’s case. There is always the risk that the other side will also be aware of it. In any event, the expert’s duty to the court requires that his evidence is complete in its coverage of relevant matters.”

The point was pushed home in the case of medical experts by Dr Jan Wise, the BMA’s medico-legal committee chair.

“The expert's duty is to the court. This overrides any obligation to the person who is instructing or paying them.

This means that they have a duty to act independently and not be influenced by the party who instructs or pays them.”

He also stresses the need to stay within areas of expertise.

“The main trait of expert evidence is that it is opinion evidence. However the expert is expected to take care not to express IN NOVEMBER THE annual Bond Solon Expert Witness Conference heard a keynote opinion that strays beyond the limits of address from Lord Justice Sir Adrian Fulford, senior presiding judge for England and Wales. their personal expertise. Where opinions The theme of the speech was the increasing involvement of information technology in the cross the boundaries of expertise, the justice system, culminating in the development of the e-Judiciary. expert is expected to respect and where The backdrop to the use of technology in the courts is ‘the cloud’ – the enveloping appropriate defer to the opinions of experts environment of hyperspace containing the digital world. in those other areas of expertise.”

A reviewer for the Expert Witness Institute wrote: “That morning the orator addressed an The CJC guidance makes particular enthusiastic message: the United Kingdom is strongly and fully committed towards e-justice mention of single joint experts, stating: “The that should be quickly followed by a paperless system, which will lead to an important and CPR encourage the use of joint experts. fundamental change in the way experts testify, particularly with the increasing use of video Wherever possible a joint report should be systems to give expert evidence.” obtained. Single joint experts are the norm In his speech Lord Fulford said: “As with all great revolution, you either adapt rapidly or in cases allocated to the small claims track fade away. I am sorry to be uncompromising, but we have simply got to change; and judges, and the fast track. lawyers, witnesses and all others who use our courts in all jurisdictions and at all levels must “The parties should try to agree joint rapidly get used to the administration of justice being transferred, in large part, to the cloud.” instructions to single joint experts, but He pointed out there are practical advantages for expert witnesses. in default of agreement, each party may “As expert witnesses, you will no longer have to lug sets of papers in the boots of your give instructions. In particular, all parties cars; you will no longer have to hope that they will one day arrive in the post, but instead all should try to agree what documents should the relevant documents in the case will be accessible to you via the relevant on-line portal, be included with instructions and what onto which you will be able to upload your report. The attendant convenience and improved assumptions single joint experts should working methods are substantial and self-evident.” q make.” q

Now experts really will have their heads in the cloud! [

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Rush to build causes nightmares for many [

THERE IS CONCERN among many experts that the rush to build one million new homes by 2020 is resulting in a fall in standards and creating a crisis of substandard new homes.

The issue was raised in an ITV Tonight programme on 8 June. New Build Nightmares looked at the building problems affecting more than 90% of new homes that reported snags or defects – according to figures quoted from the Home Builders Federation.

Reporter Jonathan Maitland revealed that, in order to address the housing shortage and ‘after years of under-building’, new homes are being built at the fastest rate for a decade.

However, the programme found that half of new-build owners experience major problems. The programme interviewed Paula Higgins from the HomeOwners Alliance.

She said: “We are getting increasingly concerned that we are building homes that are not fit for purpose; that the quality is not there. They are not even meeting minimum standards.”

They asked one owner of a new build property: “Would you buy new build again?” The agonised answer was: “God, no! Never – never again!”

The most disturbing story concerned Colin Nickless, who occupies a shared-ownership property in East London on an estate comprising a mix of social, shared ownership and private properties. He reported “…multiple leaks, roof leaks, plumbing failures, electrical issues…

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heating issues generally, build quality issues…damp and mould appear all across the estate.”

Colin’s daughter has cystic fibrosis, a chronic condition of the lungs that requires a warm, dry living environment. He said: “You are stuck in a position where you have made a decision as a parent to buy a house that is contributing to your child’s sickness…there are nights where I lay in bed awake and I cannot put that out of my mind.”

The estate – Orchard Village – was built by Willmott Dixon, who told the programme: “The problems experienced by some residents at Orchard Village are completely unacceptable, for which we sincerely apologise.

“We are determined to put this right, and we have commenced a full programme of works to ensure the remaining issues are completed to the satisfaction of residents.” q

RICS issues anticipated statement on ‘double-dipping’ [

AS FLAGGED UP in the last issue of Your Expert Witness, the RICS has issued a UK-specific Professional Statement on conflicts of interest, aimed at tightening up requirements for professionals and regulated firms working in land, property, construction and infrastructure in this country.

The UK-specific statement, published in May, follows on from its global guidelines and bans the controversial practice of dual agency - known colloquially as ‘doubledipping’. Both standards will be effective from 1 January next year.

The standard states that: “…dual agency must not be undertaken under any circumstances. For the avoidance of doubt, RICS members working within non-RICS regulated firms are subject to the same criteria as regulated firms when undertaking dual agency in the UK under any circumstances.”

The Professional Statement also covers multiple agency – where an agent has competing contractual relationships simultaneously with several buyers – and the provision of incremental advice, such as planning, building surveying or valuation related to a purchase or disposal that is incremental to an existing instruction to advise the buyer or seller. q

Avoid conflict; save time and money – that’s the message of a new pledge [THE Dispute Resolution Service of the

Royal Institution of Chartered Surveyors (RICS) has initiated a new approach to avoiding conflict in the land, property and construction industry.

It’s new Conflict Avoidance Pledge has been created in partnership with a coalition of leading construction and engineering professional bodies and two major employers in the infrastructure space. The pledge will be officially launched in London in November.

According to the RICS: “The financial cost of disputes in the construction industry is measured in billions of pounds. Conflict also causes immeasurable harm to business relationships and brand reputations, and is extremely slow and difficult to resolve. When problems occur, projects are frequently delivered behind schedule and over budget.”

The aim of the pledge is to drive behaviour change by encouraging all organisations to consider their working practices and to move away from the culture of combative and dispute-heavy business relationships to a more collaborative approach.

The other professional bodies involved are the Royal Institution of British Architects, the Institution of Civil Engineers, the Chartered

Institute of Arbitrators, the Dispute Resolution Board Foundation and the International Chambers of Commerce UK, with support from Transport for London and Network Rail. They have joined together in a ground-breaking coalition to help the industry reduce the financial and reputational costs caused by disputes.

When an organisation signs the pledge, it indicates it is committed to: • Work proactively to avoid conflict and facilitate early resolution of potential disputes.

• Develop its capability in the early identification of potential disputes and in the use of conflict avoidance measures.

• Promote the value of collaborative working to prevent issues developing into disputes.

• Work with industry partners to identify, promote and utilise conflict avoidance mechanisms.

John Fletcher, RICS’s ADR products director, said: “The ambition of the coalition is to promote greater understanding and use of conflict avoidance techniques, which help contracting parties deal with differences of opinion early and amicably, and avoid costly, slow and potentially damaging litigation.”

TfL and its contractors had already agreed a bespoke solution known as the Conflict Avoidance Panel (CAP).

This panel consisted of industry experts and professionals gathered by Direct Rail Services who would provide impartial, practicable and acceptable information and guidance to all parties involved.

CAPs encourage cooperation and resolve differences early, without the need for court, arbitration or adjudication. This process was then incorporated into standard engineering contracts.

Sue Barrett, TfL’s head of commercial procurement for stations, said: “Avoiding conflicts saves time, cost and energy that would be better served in delivering projects.

CAP helps resolve issues at the time of the event in the way the contract intended, it helps both parties.” q

Construction disputes can sometimes be blowing in the wind [

THE VERY LATEST in renewable energy technology is transforming the way we consume scarce resources, but the very fact it involves new technologies can sometimes lead to unforeseen consequences, as this case study from Scottish consulting engineers Brotchie Engineering shows.

A contractor was in a dispute with their designers relating to the defects in the foundation of a wind turbine in the west of Scotland. One foundation had failed, resulting in the tower that it was supporting breaking free from its embedment.

Engineering expert witness David Brotchie was asked for his opinion. He takes up the story: “My study of the design documentation resulted in the conclusion that the design did not comply with BS 8110 and as a result would be overstressed. In addition, the foundation would have a short design life due to fatigue loads which had not been considered in the design.”

David’s examination led to an unexpected conclusion: “Despite the undoubted shortcomings in the design calculations, I suspected that the real cause of the failure lay elsewhere. The waterproofing detail between the steel tower and the concrete base was not adequate and allowed water to penetrate this interface. The contractual complication was that the turbine manufacturer insisted that the waterproofing detail had to be adopted by the designer. As a result, contractual responsibilities were blurred.” q www.yourexpertwitness.co.uk

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Poll shows the UK cares about animal welfare [

A POLL CARRIED out by the RSPCA in January revealed that 81% of people want animal welfare laws improved or at least kept the same after the UK leaves the EU. Only 5% disagreed.

The charity’s head of public affairs, David Bowles, said: “This poll sends a really strong message to the government as they negotiate our way out of the EU that the public cares deeply about animal welfare.

“There’s no doubt that Brexit is going to be a complex issue. A lot of legislation covering farm animals in particular will need to be reviewed, but this is a golden opportunity for the government to improve welfare and also consider rewarding farmers who rear to higher welfare standards.”

The government has already said that leaving the European Union gives opportunities to update and improve animal welfare in some key areas. The RSPCA has added its own shopping list. It includes: • Requiring compulsory CCTV in abattoirs • Mandatory labelling of food according to how animals were reared • Reforming slaughter legislation to end non-stun slaughter and at • least ensure that the meat from those animals that have not been • stunned only goes to those communities exempt under the law • Changing the way subsidies are paid to farmers to encourage • those that improve animal welfare • Putting in place measures to end live exports and reducing journey • times for animals being transported • Introducing legislation for other farm animals, including ducks, • sheep, dairy and beef cattle

• Reforming the legislation on non-commercial imports of puppies to • stop it being used to evade controls • Banning the transit of whale meat through the UK David Bowles added: “Although most of the opportunities to improve welfare focus on farm animals, the government can also use Brexit to reform the way we import puppies and prevent the thousands of sickly puppies that flood into the UK at present under EU rules.” q

Pet insurer tightens checks to counter puppy farmers

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A LEADING pet insurance provider has suspended the automated registration process for its breeder scheme and introduced new measures to help ensure the authenticity of breeders. It follows allegations that puppy farmers could be using the scheme to lure buyers by offering four weeks free insurance from Petplan, which breeders on the scheme are able to offer puppy buyers.

According to a report on the website of the Royal College of Veterinary Surgeons (RCVS), six journalists from The Mail said they were able to register for the breeder scheme using false names. The newspaper also reported it had learned of at least two cases of criminal puppy farming gangs that were signed up to the scheme.

According to the RCVS report, Petplan said a full review of its registration process is underway and it had already made a series of immediate changes, including the suspension of its automated system.

There will now be a two-stage registration process whereby breeders register their interest online. Full registration will only be confirmed following a telephone conversation with a Petplan representative.

In addition, the company said it now captures additional information from breeders at the point of registration and breeders who expect to breed five litters or more per year are subject to an additional review.

A spokesperson for the company said: “One of Petplan’s key goals is to ensure that the health and welfare of pets is protected at all times, particularly during periods of high vulnerability such as the transition period as a pet leaves the breeder or rehoming centre and settles into its new home.

“Petplan provides four weeks free insurance, which includes £4,000 veterinary fee cover, to help encourage new owners to seek veterinary treatment at the earliest opportunity and to ensure they have financial help available to cover the cost of any unexpected treatment the pet needs.

“Given that this is an unregulated industry, we are taking further steps to help ensure the authenticity of breeders issuing Petplan insurance.” q

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Not all cases of ‘dog bites Scotland set to reintroduce selective man’ are as they seem [ ‘tail-docking’ [THE SCOTTISH GOVERNMENT’S Environment, Climate Change

and Land Reform Committee has voted to allow the reintroduction of so-called tail-docking for a number of breeds of hunting dogs. The proposals will allow the removal of up to the end third of the tails of spaniels and hunt point retrievers within five days of being born if they are destined to be working dogs.

The proposal will now go to a vote by the Scottish Parliament.

The docking of dogs’ tails has been banned in Scotland since 2007.

However, if changes to legislation are approved, puppies could have their tails shortened where a vet believes they are likely to be used as a working dog and are at risk of serious tail injury in later life.

The change would bring the legislation in Scotland back into line with England and Wales, which have a similar exemption. The practice is also permitted in Northern Ireland for the strict purposes of medical treatment or dogs that are intended to be used for work in law enforcement, pest control or lawful shooting of animals.

The proposals have been condemned by some animal welfare charities, including Dogs Trust, which described the move as ‘an alarming step backwards for dog welfare’.

In a statement Dogs Trust said: “Where Scotland once led the way with a complete ban on tail docking, the reintroduction of the practice is a significant step backwards for dog welfare.”

The statement continued: “This reintroduction – in theory to prevent tail injuries – could see a large number of dogs suffering unnecessary pain, and deprived of a vital form of canine expression.”

The charity was also concerned that loopholes could be exploited.

“As currently drafted, the regulations do not specify any evidence that will be required to prove that puppies will go on to be working dogs. This could lead to whole litters of puppies having their tails docked unnecessarily, when they will actually go on to be family pets.

Furthermore, the regulations do not adequately specify what will be considered to be an acceptable working activity.” q

RUTH OWEN IS an expert witness in the field of dog behaviour. She came to that role via decades of voluntary work in rescue, particularly involving owning, working with and homing ‘bull’ breeds in general.

That culminated in a BA (Hons) degree in Canine Behaviour and Training from Middlesex University and the founding of her consultancy business, Devon Dog Behaviour. Six year ago she established her own rescue centre to take in and rehabilitate dogs of all breeds with behavioural issues of all sorts – especially aggression – and ultimately place them safely in homes.

All that experience has proved to be an informative background for advising the courts on what are usually complex situations and incidents involving the public and their dogs, as this case study illustrates.

Ruth told Your Expert Witness: “At face value, the case involving the dog that bit and injured a policeman in the face when her owner opened the front door to him did not seem to hold out much hope for the defence. However, when taking into consideration the time of day the event occurred – 5 am – the vigorous nature of the banging on the door (the officer in question was seeking a previous male resident of the property who was wanted for a serious, but unrelated, offence) and the state of distress of the owner, the case looked rather different.

“The owner of the dog had herself been victimised by the man the officer was seeking. The dog had sensed her on-going vulnerability and, as a result of the failure of a double door-safety mechanism, flew out of the house to defend her owner. It is true that the officer in question was injured: the dog did bite. However, there were extenuating circumstances.

“The dog was obedient and docile when visited by myself and the owner was willing to abide by any and all safety measures that I recommended – including an ‘on-lead and muzzle’ precaution when walking in public. The case was successfully concluded and the dog was not destroyed.

“While the prosecution had requested a destruction order, the court was satisfied that the public were not at risk and the dog remains with the owner, a much loved family pet.

“The case illustrates the fact that, not only is the ability to accurately assess the nature and behaviour of a dog vital, but being able to negotiate a complex set of events and human interactions is just as important.” q

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Consultant warned of ransomware attack [

in basic infrastructure and in staff training. We need a forensic LEADING HEALTHCARE IT consultant Dr Saif Abed must have investigation into this, in part to avoid inappropriately blaming specific experienced an acute bout of déjà vu when reports of the ransomware bits of software, or people. attack on the NHS began filtering through from such disparate sources “Also, if we see this as only a technology issue, we run the risk of as hospitals, GP surgeries and even pharmacies. not seeing the situation for what it really is: a clinical risk and patient Dr Abed, a founding partner of consultancy AbedGraham, had safety issue.” q blogged back in August last year – under the chillingly prophetic title Ransomware will kill a patient – that such software was a major threat because of the procedures it could disrupt.

He wrote: “A lot of attention has been paid to ransomware and other cybersecurity attacks over the past 12 months in healthcare, especially so in the US and with a particular focus on medical identity theft and fraud.

“However, that is nowhere near being THE INCREASING IMPORTANCE of data acquisition and analysis has been thrown the biggest risk. In the UK and Ireland, into sharp relief by the police response to the terrorist outrages in Manchester and healthcare IT maturity is increasing with London. The almost immediate reaction in setting up dedicated sites to upload all manner the adoption of electronic health record of media that could aid in piecing together what had happened went hand-in-hand with systems, mobile clinical applications and swift and comprehensive acquisition of phone and computer data that could contain ePrescribing/charting.” crucial evidence.

Following the attack he called for a In a demonstration of changing trends, Greater Manchester Police specifically asked for forensic inquiry into what went wrong so the potentially useful footage from dashcams to be uploaded for officers to assess.

NHS can deal with the clinical and patient The large number of people arrested allowed police to gain access to the mobile phones risk issues it exposed. and computers of those close to the known perpetrators of the attacks in order to analyse In an interview with Building Better whether the communications data they contained could provide clues for the investigators.

Healthcare, he explained that many trusts A report in The Guardian quoted a source as saying police investigating the Manchester are still running an old operating system, attack expected to ‘amass hundreds of electronic devices’ during the investigation.

Windows XP: “It has exposed a big lack The rapid progress of investigations into all the attacks indicates that rapid action and of investment in the NHS in board-level the gathering of comprehensive data is now a crucial tool for the police. q engagement in IT issues, in IT leadership,

Terror investigations show importance of data [

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Eastern customs that may be a concern for Western courts

By DR BASHIR QURESHI FRCGP FRCPCH Hon FFSRH-RCOG AFOM-RCP Hon MAPHA-USA Hon FRSPH • Expert Witness in Cultural, Religious & Ethnic issues in Litigation • Expert Witness in GP Clinical Negligence • Author: Transcultural Medicine – Dealing with Patients from • Different Cultures.

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THE LAW OF ‘all or nothing’ is not strictly adhered to in countries with populations of Eastern culture, religion and ethnicities; rather they follow the principle that ‘something is better than nothing’.

Government control is shared with strong tribal authorities – more so than with their elected parliaments. The tribes provide the finance to run the countries, not individuals. Here, I describe 10 customs practised in Eastern countries, for consideration by judges, juries, lawyers and expert witnesses in Western courts.

Tribal tribunals and courts – the criminal courts hear criminal cases only. The civil courts share civil cases with local tribal tribunals, because it is cheaper for all parties and the government. Each tribunal usually has five local elders as decision makers. They are unpaid volunteers and all belong to the same tribe.

In India and Pakistan they are called Panchayt (five decision makers).

Trials are open to the public and held in tribal venues. Civil cases, such as marital and neighbourhood disputes, are dealt with by these tribunals. The losing parties can still go to the civil court if they disagree with the tribunal’s decision.

Some tribes use cultural laws and some use religious laws, such as Sharia Law for Muslims. Other religions’ laws are used by their followers. Magistrates sit in these courts without juries and there are lawyers but no barristers.

Blood money (Diyyah) instead of prison or hanging for murder – in cases of murder, the victim’s family may be given a choice: either the murderer is executed, or he pays a considerable amount of money to the victim’s family for lifetime maintenance. In Eastern countries men often financially support both their own families and disabled relatives.

Criminal courts make decisions in the interest of both parties, as they are usually part of the same tribe.

Amputation of the right hand for theft – this unique punishment is applied under Sharia Law to Muslims in some Islamic countries for the crime of theft. The amputation is performed in public to deter other possible thieves. Warnings and prison sentences will have previously been given to the thief and this punishment is the last resort. As things change over time this practice is becoming less and less common.

Public execution – this practice is still carried out in a few Eastern countries, but it is being replaced by life prison sentences. History is full of stories of hanging or shooting prisoners in public. I need not go into more detail.

Tribal ‘tit for tat’ murder – in some Eastern countries a tradition becomes established whereby two local tribes become hostile to each other. If a man from one tribe has been killed by someone from the other tribe, the murdered man’s sons and brothers have a tribal ‘prestige’ duty to kill a man from the opposite tribe.

Murder of a wife’s lover – the majority of Eastern countries follow the custom of arranged marriage. Marriage for love and courtship is strictly forbidden.

If a husband comes home and finds his wife in bed with another man, he might murder the lover. Then he would go to police station to report the crime. What happens afterwards varies from one locality to another; the husband is sometimes set free to teach a lesson to other potential lovers. He would be respected by his family and friends. Sometimes it is considered acceptable to do a bad act to achieve a good result, similar to killing four hijackers to save forty hostages.

Confession to a crime to protect a niece’s eligibility – if an unmarried woman has committed a crime, an arranged marriage within the tribe is not possible. A family meeting may take place and an older aunt may become a substitute, saying to the police that she has committed that crime. She may even be imprisoned.

By doing so the older aunt is honoured in the family. The young woman feels ashamed and hopefully will not commit another crime. The family looks after the older aunt when she is released from a prison – a kind of social security system.

Obligation to marry a woman after sexual relations – this is an interesting Eastern custom. If a young man commits a sexual act with a young woman – even though both were willing – it is considered to be rape by both families. The mother of the young woman would go to see the young man and persuade him to marry her daughter. If he declines, the young man could be beaten up by the brothers of the young woman, or worse. That is considered family honour.

Beating for rejection of an arranged marriage – this Eastern custom mostly affects ‘Westernised’ men who were born in an Eastern country and come to study and work in a Western country. When the man goes back to his home country and is offered an arranged marriage to a woman in his own tribe he may refuse it.

Such a refusal is considered a family insult and as ‘big headedness’ on the part of the man. The brothers of the rejected bride may beat him up. I knew two doctors in London who were threatened in this way when they visited their home towns. They never went back again.

Making an ‘outcaste’ of a person – a person who disobeys the rules or traditions of their extended family can be made an ‘outcaste’ and disowned by their relatives forever. Interestingly, the caste system is a Hindu custom in India and is the basis for the social class system in Britain.

Further details can be found in my book Transcultural Medicine: Dealing with Patients from Different Cultures. I have been informed that the book was read by British Army doctors in Iraq and Afghanistan when treating soldiers, prisoners of war and civilians from different backgrounds.

Governments in Eastern countries allow or practice these legal decisionmaking procedures in good faith. They may appear to Western eyes as unacceptable, nevertheless both positions are regarded as right in their own way in their respective traditions. q

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In this latest special feature on legacy giving and issues surrounding charitable bequests we have some good news and some bad news.

Income from legacies is at an all-time high, as is the proportion of solicitors and will-writers who draw attention to the possibility of leaving a legacy when advising clients. Giving to charity can also spark other acts of philanthropy and promote general good feeling.

However, no such philanthropy has as yet come from the government in terms of exempting wills from VAT, and the new Inheritance Tax allowances may not spell such good news for charities.

Legacy income hits £2.5bn milestone [

CHARITABLE INCOME FROM wills has reached an all-time high, according to a new report by experts Smee & Ford, the UK’s leading provider of legacy information. The report shows that charitable income from legacies has significantly increased – growing by 39% over the past five years to reach £2.5bn.

Of the total donor wealth distributed from wills that included charitable gifts in 2016, 15.6% went to charities, the report says.

And although the number of estates that included gifts to charities reported so far for 2016 has fallen compared with 2015 – from 37,775 to 36,197 – the report states the general trend

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over this period is that the value of bequests are steadily rising.

Indeed, Smee & Ford predict that, as data is still currently being compiled, the number will rise further.

The 36,197 charitable estates in 2016 was the third highest figure ever recorded by Smee & Ford, and 6% of the population leave a bequest in a will. The report also points out that key indicators like the housing market support the trend by positively influencing increases in the values of residual bequests.

Other key findings include the fact that the value of charitable estates has reached an all-time high of £16bn. Of that, 15.6%

More advisers than ever mention legacies [ THE PROPORTION OF solicitors and will-writers talking

about the tax benefits of legacy giving with clients has risen to an all-time high, according to new research commissioned by campaigning umbrella group Remember A Charity.

The tracking study, carried out by Future Thinking, monitors solicitors’ and professional will-writers’ approach towards legacy giving and attitudes towards working with charities.

The latest survey was conducted in December. It reveals that more than 72% of solicitors and will-writers always or sometimes advise clients about the Inheritance Tax benefits

went to charities, with a total of 121,231 bequests made in 2016.

The report estimates that 6% of the population leave something to charities in wills, of whom 60% are female. If only 1% more people could be persuaded to include gifts to charities in their wills, it would raise an additional £95m.

The report also identifies the top 25 charities which made the most significant gains in legacy income in 2016. Cancer Research UK, whose legacy income increased by £11m to £177.8m, has reported that notifications from wills shared with the charity ‘are at historically high levels’. The British Red Cross also made significant gains, increasing legacies from £22.2m to £32.6m. q

of legacy giving: up from 66% in 2015 and 61% in 2009, when the survey was first carried out.

Almost two-thirds (64%) of advisers always or sometimes proactively mention the option of leaving a gift to charity, with 38% saying they always do so. One fifth of advisers occasionally proactively mention charity, while 14% never do.

When it comes to advisers working with one of Remember A Charity’s campaign supporter firms, they are more than twice as likely to ‘always’ mention charity bequests. There are now over 1,100 campaign supporter organisations that commit to mentioning the option of charitable giving during the will-writing process.

On average, advisers report that 17% of wills contain a charitable bequest, having grown steadily from 15% in 2011.

The large majority (78%) said their firms have assisted in the administration of an estate containing a charitable legacy.

Remember A Charity’s director Rob Cope commented: “It’s great to see record numbers of advisers talking about the tax advantages of legacy giving and that our campaign supporter scheme is making a real impact here. The challenge now is to build on this momentum, working collaboratively with the legal sector to ensure that advisers are well informed and remain enthusiastic about raising the issue of legacy giving with clients.” q

Short breaks offer a normal life and boost self-confidence

“

The Youth Cancer Trust gives amazing support, love and dedication to hundreds of young adults affected by cancer, without them I truly don't think I would have become the person I am today. They have given me back my confidence and made me realise that I can live a normal life, have fun and have the most amazing experiences like other young people who haven’t had cancer.

”

[THAT QUOTE FROM Kirsty sums up the value of the work done

by the Youth Cancer Trust. The organisation provides free therapeutic activity holidays for teenagers and young adults – those aged 14-30 – from the UK and Ireland who are suffering from cancer.

The residential breaks are designed to provide a safe space for young people with cancer to be with others of a similar age going through a similar experience, thus reducing the sense of loneliness that often accompanies a cancer diagnosis during their formative years. The activities are designed to help rebuild confidence and boost self-esteem, and include horse riding, sailing and water sports.

The charity receives no government funding and relies entirely on donations, such as those from legacies, to help support the needs of young cancer patients like Kirsty. q • For more information visit www.youthcancertrust.org. www.yourexpertwitness.co.uk

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Vegfam – feeding the hungry without exploiting animals [VEGFAM ‘Feeds The Hungry Without Exploiting Animals’ by funding

sustainable, self-supporting, overseas projects – such as seeds and tools for vegetable growing, fruit/nut tree planting, irrigation and water supplies (some solar/wind powered). They also provide emergency relief in times of crisis and disaster. Such vital projects have been supported since 1963.

Vegfam is professionally operated entirely by volunteers and all funding comes entirely from supporters’ donations.

Why donations are needed

Vegfam funded projects provide food security for children and adults worldwide, improving their livelihoods and alleviating hunger, malnutrition, starvation and thirst. These people are often out of reach of the major charities. As little as £5 enables a family in India to be self-sufficient in fruit, nuts and vegetables or a family in Africa to have access to safe water.

Where donations are spent

The beneficiaries are people suffering from disease, disabilities, disasters (including flood, earthquake and drought), HIV/AIDS, homelessness, hunger, thirst and war. They include marginalised communities, orphanages, refugees, schools/colleges, trafficked women and children, villagers and tribal people. Vegfam is often their only hope of help. In the past 10 years alone, Vegfam funding has helped more than 500,000 people in over 20 countries.

Vegfam helps people to help themselves. All donations and legacies are gratefully received and make a real difference to people's lives. q • You can support this life saving work by donating online at https://www.charitychoice.co.uk/vegfam or call 01550 721197.

Charity carries on the work of its founder [

FOR OVER 30 YEARS the famous animal hospital known as Tiggywinkles has been working to rescue, treat and rehabilitate sick, injured and orphaned British wildlife. Over that time they have proved beyond doubt that most wild animal and bird casualties can be saved and returned to the wild.

Although they specialise in hedgehogs – indeed, they derive their name from St Tiggywinkles, the name of their specialist hedgehog ward, inspired by the animal character created by Beatrix Potter – their wealth of expertise in the care of a wide range of species can now be passed on to others.

In addition, their commitment to practical education plays a vital part in the conservation of wildlife. As an accredited centre, opportunities are available for students aged 16 and over to gain a City and Guildsapproved qualification via their Apprenticeship in Animal Care scheme.

Tiggywinkles was founded by Les Stocker, who sadly passed away in July. In a tribute, Les was described as ‘…a steadfast ambassador, achieving his goal to turn wildlife rehabilitation into a profession’. In another he was referred to as the ‘the spiritual heart of Britain’. He was awarded an MBE by The Queen and given the title Laureate in the 1990 International Rolex Awards for Enterprise, for his work in wildlife conservation and establishing Europe’s first wildlife teaching hospital.

More recently, he gained the prestigious Honorary Associateship of the Royal College of Veterinary Surgeons.

The charity is happy to commemorate all who generously remember the Wildlife Hospital Trust in their will by inscribing their name on a plaque in its Remembrance Garden. Gifts are also welcome in the form of a donation or by becoming a Friend of Tiggywinkles. q

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Tax changes are only good news for some [CHANGES TO THE Inheritance Tax

(IHT) framework, which came in on 6 April, could put charitable legacies at risk, according to commentators.

The introduction of a new IHT allowance, the main residence nil-rate band, will reduce the number of people who can benefit from the tax incentives for legacy giving, risking a fall in the number of charitable legacies. A worst case scenario estimate suggests that there could be 1,200 fewer people annually leaving charitable gifts as a result of the tax changes.

Tax breaks are accepted as an important factor in encouraging people to leave money to charity, with research from the Behavioural Insights Team and the University of Bristol showing that when people’s wealth lies just above the tax threshold they are more than twice as likely to leave money to charity in their will as when their wealth is below it.

Professor Sarah Smith of the University of Bristol said: “We know that the tax incentive is an important factor for people choosing to give, particularly for those just above the IHT threshold. While it is difficult to predict how legacy giving will be affected by the changes, our worst case estimate is that charities could miss out on as much as 1,200 fewer charitable estates annually. We hope the reality won’t be as dramatic as this, but the changes are certainly a timely reminder to the sector to think about how it can protect and grow legacy income.”

Rob Cope, director of Remember A

Charity, says: “Tax breaks are a natural entry point for solicitors and will-writers to raise the option of charitable giving during the will-writing process. But with the tax changes, our concern is that fewer people will be aware of their charitable options which will be a real threat to legacy giving.”

Remember A Charity has also identified some potential positives, which include the fact that the main residence nil-rate band effectively lowers the net value of the estate. This means that it may cost less for people who are above the IHT threshold to access the reduced IHT rate of 36% when donating a minimum of 10% of the value of their estate to charity.

There are pitfalls, however, and many people may need to review their wills.

Jerome Dodge, of Dorset-based law firm Blanchards Bailey, said: “While the new allowance could save people significant sums of money, the fact the legislation is full of strange anomalies, combined with the reality that most wills were drafted before the changes were introduced, may mean they will not benefit unless their wills are updated.

“It’s a common perception that the Inheritance Tax allowance is automatically increased for everyone – this is not the case and it can easily be lost without careful planning. There are ways to avoid these problems, but we would strongly recommend any individual who has assets of more than £325,000, or any couple who have assets of more than £650,000, to review their wills as soon as possible.” q

Help for those with failing sight

[

FAILING EYESIGHT is nothing short of a personal catastrophe.

Do you have a family member, friend or neighbour who is gradually losing their sight?

Reading, recognising friends and living skills are all affected as your sight is going – and it’s much harder if you live alone.

The National Federation of the Blind of the UK (NFBUK) keeps its members in touch with general information, help and updates on what’s going on.

The charity produces bi-monthly news magazines and circulars in audio, braille or electronically, which members can read independently. It also encourages blind and partially sighted people to play a fuller part in society. q

“

With the tax changes, our concern is that fewer people will be aware of their charitable options which will be a real threat to legacy giving.

Rob Cope, director of Remember a Charity

”

• For further information contact NFBUK on 01924 291313, email admin@nfbuk.org or vist www.nfbuk.org. www.yourexpertwitness.co.uk

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Seeing Dogs

providing a choice [

THE SEEING DOGS ALLIANCE has made steady progress since it started operations in 2001. It was launched, and is supported, mainly by guide dog owners who want a competitor charity – as is available to blind and partially sighted people in most developed countries. Seeing Dogs’ successful rearing and training programme continually includes several dogs either being puppy reared or receiving their ‘seeing dog’ (their term for guide dog) training.

Except for the highly skilled final training, the Alliance depend on volunteers. In this way, with careful monetary control, it costs them about £15,000 to train each dog and owner, about a third of what would otherwise be expected.

Seeing Dogs’ clients are usually trained in their home environment, although their target is to have a dedicated training centre. When residential training has been required, they have used hotels. Puppies remain with the puppy rearers till they are 12-14 months old, during which time they are familiarised with all the circumstances they are likely to encounter as Seeing Dogs – such as crowded streets, heavy traffic, buses, trains, cars, cafés, restaurants, stairs (although not escalators), lifts and swing doors. An allowance is available to cover the expenses of this very important pre-training work.

Seeing Dogs like their puppy rearers to take their charges to puppy training classes which helps with obedience training and socialisation with other dogs. They provide them with a reference manual and visit them from time to time to check on the puppy’s progress. They are also always at the other end of a phone to give advice or to obtain it for them.

Currently, waiting lists for trained dogs are such that some clients wait months or longer to be trained with a dog.

This is particularly serious for elderly people waiting for replacements. If they are without a dog for a period, they can lose the mobility needed to complete their training when a dog becomes available. Seeing Dogs urgently need funds to change this situation. With twenty owner and dog partnerships qualified, they have proved that they produce trained dogs to the very high standard required, at a price well below the norm. q • For further information on donating to this charity tel 01483 765556, email info@seeingdogs.org.uk or visit their website at www.seeingdogs.org.uk.

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Probate fee changes means families may pay much more, warns solicitor [

NEW PROBATE LEGISLATION, which came into effect in May, will lead to large rises in fees payable after death, affecting millions of people, according to Dorset-based law firm Blanchards Bailey.

Previously, probate fees were fixed at either £155 through a solicitor or £215 without, regardless of the worth of an estate, but that has now changed to a banded approach, proportionate to the value of the estate.

However, not all properties need to go through probate. The value of the estate below which no fee is payable rises from £5,000 to £50,000, meaning a lot more people will not have to pay fees.

Anyone with an estate worth between £50,000 and £300,000 will now have to pay £300 instead of the previous fixed fee; then the fees rise dramatically dependent on the value of the estate.

People with an estate worth between £500,000 and £1m have to pay £4,000: an increase of over 2,400%. Those with Jerome Dodge, head of estates worth between £1m wills and estate planning at and £1.6m have to pay £8,000 Blanchards Bailey in fees, while anyone with estates from £1.6m to £2m pays £12,000. Fees rise to a maximum of £20,000 for estates worth more than £2m.

“The changes to probate fees mean there is a considerable jump for those with an estate valued at £500,000 or more,” said Jerome Dodge, head of wills and estate planning at Blanchards Bailey. “But there are ways we can structure people’s assets to reduce the fees as it is only assets that pass through wills or the intestacy provisions that are subject to the fees. We can advise people on the best way forward to reduce those fees.” q

Legacies – the gift of life for threatened primates [THE RESCUE AND provision of sanctuary for monkeys who have

suffered abuse and neglect is the mission of animal charity Wild Futures.

They are also dedicated to protecting primates and their habitats worldwide.

Flora and fauna around the world are endangered by climate change, habitat destruction and the bush-meat and pet trades. For some species it is too late and the future of what remains lies in our hands, so the gift of a legacy to Wild Futures is ‘…the gift of life and a future for primates and our wonderful planet’.

The charity’s holistic approach makes it unique in providing sanctuary to rescued monkeys, supporting projects overseas, campaigning for primate welfare, educating people to protect primates worldwide and promoting a sustainability and ethical ethos. International recognition of that is demonstrated by the fact that its safe haven for monkeys – The Monkey

Sanctuary in Cornwall – is the only sanctuary in the whole of Europe to be accredited by the Global Federation of Animal Sanctuaries.

For over 50 years they have rescued monkeys suffering with psychological trauma, diabetes and metabolic bone disease. With spacious, natural enclosures, companionship of their own kind and specialist care, the monkeys learn to enjoy life again. Meanwhile, Wild Futures strives to end the cruel trade in the hope that one day their work will be done.

They receive no government funding, so the generosity of those that remember Wild Futures is essential to enable them to continue their work. A legacy can be the gift of a life worth living and a wild and safe future for all. q • Call 01503 262532, email giving@wildfutures.org or visit the webiste at www.wildfutures.org.

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Surgical research benefits Enhancing lives is the foundation of their work from legacy giving

[THE ROYAL COLLEGE OF SURGEONS OF ENGLAND (RCS) is

a registered charity and is internationally recognised as one of the world’s leading professional bodies for surgery – promoting surgical research, education and training throughout the UK. They are not part of the NHS and for over 200 years have safeguarded standards in clinical practice.

There are many reasons you might find yourself under the care of a surgeon and the work of the RCS is not limited to specific illnesses or specialties. Rather, through surgical research and education it supports better care for all ages – from minor day surgery to life-saving emergency trauma.

Although the medical profession and medical researchers continue to strive for the cure for many diseases and cancers, in many cases surgery remains the most effective treatment; and has the highest impact on cancer survival.

The RCS relies heavily on donations and legacies to develop and maintain its varied programme of clinical research, surgical education and heritage conservation. Operations are now safer, less invasive and more effective, with better outcomes. The range of procedures that can be performed safely and routinely has expanded dramatically. That would not have been possible without high-quality research.

Surgery saves lives – and a gift will help those who put theirs in the hands of a surgeon. q

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[INDEPENDENCE AND FREEDOM of choice for people with learning

disabilities are fine ideals, but they can only become a reality with the right level of support – both financial and personal.

That is where the Camphill Foundation UK & Ireland comes in. The foundation funds an ever-changing variety of projects which enhance and enrich the lives of vulnerable people with learning disabilities.

They provide the financial support to enable new initiatives to start and to help create or improve facilities and vital opportunities for creative and fulfilling work – often in areas that regular funding fails to reach.

True quality of life means combining individual choice and fulfilment with social belonging and responsibility. That’s what the Camphill Foundation aims to promote.

For further information on leaving a legacy, enabling that work to continue and to help the support of special and vulnerable people visit www.camphillfoundation.net. q

Campaign urges VAT exemption on charitable wills [A NUMBER OF charity fundraising

bodies have backed a campaign to urge the government to scrap VAT on charitable wills.

The campaign is being led by Remember A Charity and is supported by both the Institute of Fundraising and the Charity Finance Group.

Remember A Charity estimates that VAT exemption on charitable wills could double the number of people leaving a gift to charity in their will, generating a further £800m for good causes for the relatively low cost to government of £375,000.

“While this change would come at a relatively low cost to government, it could make a huge difference to charities, giving solicitors and will-writers cause to highlight the option and benefits of legacy giving with all clients,” said the consortium’s Rob Cope.

“We need to ensure that legacy giving is not just something reserved for the wealthiest in society; that it is something we are all given the opportunity to do.”

His words were echoed by Mike Smith, head of public affairs at the Institute of Fundraising.

He said: “This small change in the cost of writing a will could make a massive difference in the number of people who decide to leave a gift to charity. The government has been really supportive of efforts to increase legacy giving, and we are encouraging them to back

this small reduction in tax to help raise millions more for good causes.”

Andrew O’Brien, head of policy and engagement at Charity Finance Group, added: “Legacies are a growing and important way that the public supports good causes.

It is critical that we make giving as easy and effective as possible. So it is important

that the government does not undermine existing incentives through increasing probate fees on estates that leave money to charity which could have significant unintended consequences. The government should also align its tax policy so that unseen taxes such as VAT support the government’s objectives to increase charitable giving.” q

Philanthropist leaves university’s largest-ever legacy [EDINBURGH NAPIER UNIVERSITY has announced its largest-ever legacy gift.

Philanthropist Ian Tomlin has left £750,000 in his will to support young classical musicians, matching support through scholarships and annual donations during his lifetime.

Dr Tomlin’s support for music at the university also led to the establishment of the Ian Tomlin Centre for Music and a clinic for hearing disabilities.

The gift will be used to fund ‘the study, teaching and performance of classical music’ providing masterclasses, specialist lessons, workshops and concerts as well as investing in equipment and teaching resources.

Nicholas Ashton, co-programme leader for BMus (Hons) at Edinburgh Napier, said: “The training of these young people would not have been possible were it not for Ian’s extraordinary, selfless generosity.

“He was the epitome of the philanthropist – a man who was driven by the desire to promote the welfare of others – and we are delighted his influence will continue to be felt here as his legacy gift supports the careers of the promising classical musicians of the future.” q

If you Will, we will [LEGACIES MEAN SO much to the team at Last Chance

Animal Rescue. These wonderful gifts have helped them to rescue, rehabilitate and re-home so many abandoned, abused and unwanted dogs, puppies, cats, kittens, rabbits and guinea pigs who otherwise would have had no future.

The charity understand the wishes of its kind benefactors who have considered them in their Wills. A spokesperson said: “We know they want their generous gift to us to be used directly to save lives, provide the very best of care and to find loving homes.

“Legacies really do provide the gift of life and Last Chance Animal Rescue can now, after much planning and prudent use of funds, offer our life saving services to so many more needy pets. We are delighted to announce we now have a second rescue and re-homing centre in Kent, giving hope and a true A new friend for Alan last chance to so many.

“Sadly we cannot thank those who have enabled this wonderful achievement but are extremely grateful to all those who are currently considering helping us now and in the future to continue our work.” q www.yourexpertwitness.co.uk

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Horses’ plight sparked the beginning of a dream [

THE YEAR IS 1983 and it is the coldest winter for 20 years.

Stories of ponies and cobs being abandoned by their owners on Rainham Marshes in Essex were hitting the headlines. Doctor’s receptionist Paula Clark, who was involved in raising money for a number of sanctuaries, was sitting at home in tears after reading the story of these poor horses.

When her husband Ernie returned home from work Paula showed him what was happening and they vowed to take action and help the animals that needed them. The story of Hopefield Animal Sanctuary had begun.

They went to the marshes where 16 horses were already dead and others were starving. They took tanks of water to them, also bales of hay and feed. They even got a vet to examine some of them. Paula and Ernie started to raise money to buy the horses and move them to other sanctuaries and helped those sanctuaries to raise funds.

They then put out a call out for some land to start up their own sanctuary. A lady from nearby Pitsea had half-an-acre to offer, so Paula and Ernie started their dream: Hopefield. They began taking horses with the intention of fostering. They would bring the horses back to health and then find them nice homes.

The first horse they fostered out was Pye. Soon after they heard that the fosterers were trying to sell him, so Ernie took them to court, which cost £4,000. Ernie finally got Pye back in a terrible state, and both Paula and Ernie promised they would never rehome again: the animals had a home for life.

As the sanctuary grew Ernie and Paula both gave up their jobs to look after the animals that so badly needed them. They soon moved to a piece of land in Langdon Hills and were there for three years.

Hopefield was still growing, so they knew it wouldn’t be too long before they would have to move to an even bigger piece of land.

Paula put another call out for land and they came across the land that Hopefield sits on today. It is owned by Tesco, who kindly let Hopefield use it for a peppercorn rent. Through the years Paula and Ernie had their ups and downs, but never gave up. Their work was recognised by a number of awards, including MBEs for both of them. Their hard work has inspired many people and saved hundreds of animals’ lives.

Sadly, Paula died of cancer in September 2009. Ernie kept his promise to Paula to continue their work, but also sadly died of cancer two years later.

Since their passing the work has continued with four new trustees. They include music star Leona Lewis, as well as Paula and Ernie’s son Lee, plus David Schlaich and Nicola Carson. There is also a general manager, Lianne Angliss.

Said Lianne: “We have continued to rescue horses and farm animals, but have found that over the years the type of animals we are having to help has greatly changed, with people getting more and more into exotic species. We have opened a reptile room, which soon filled up, and have also taken in many exotic mammals, including raccoons, tanukis, a skunk, marmosets and many more. We also now have birds of prey as well.”

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Music star Leona Lewis is one of Hopefield's trustees The sanctuary is now open more to the public and has become a visitor attraction as well. That generates funds that go directly to the animals, making the future more secure. It also helps with educating people about the correct care the animals need.

Said Lianne: “We will continue to make Hopefield grow and to help as many animals that we can.” q

Charitable giving has benefits for the donor, too too [

NEARLY TWO THIRDS of people who choose to donate to a charity will go on to take additional positive actions like volunteering or signing a petition, according to research carried out by the Institute of Fundraising and YouGov. In addition, nearly half of people will actually change their behaviour or feel more positive as a result. These remarkable findings come

Daniel Fluskey, head of policy and research at the Institute of Fundraising

from the joint report Insights into charity fundraising: Changes in knowledge, attitude, and action as a result of donating. The report highlights how giving to charity can have a positive impact on the lives of people who choose to donate.

Fundraising is vital for charities – who rely on the generosity of the public – but the additional benefits of donating to charity are not well understood and are often overlooked.

Of all those donating 16% gave time as a volunteer, 22% talked about a cause or recommended a charity to friends or family, 19% looked for more information about the cause and 17% signed up for a newsletter, joined a campaign or signed a petition.

The research also found that 43% of people asked had changed their behaviour or felt more positive as a result of donating in the past. Of all those donating 24% felt better or more positive, 15% became more knowledgeable about social issues, 11% became more aware of their health risks and 10% became more environmentally aware.

Daniel Fluskey, head of policy and research at the Institute of Fundraising, said:

“Fundraising and the generosity of the public is vital for charities; but these remarkable findings show that supporting the causes we care about also has wider benefits for society and those donating. Whether going on to volunteer, signing a petition, learning about health risks or just feeling more positive, giving to a cause you care about is a good thing for those donating, as well as charities in need of support.”

The findings are the first set of results from polling conducted earlier this year. q

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Welcome to our A to Z guide of the websites of some of the Expert Witness field’s leading players.

If you are one of our many online readers simply click on any of the web addresses listed below and you will be automatically directed to that particular website.

To get your website listed on this page just give us a call on 0161 710 3880 or email ian@dmmonline.co.uk Jeffrey AC Meek LLP Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

Forensic Accounting Reports: • Personal injury • Valuations • Commercial disputes • Divorce • Fraud • Proceeds of crime • Negligence

www.abc-translations.co.uk

www.jeffreyacmeek.co.uk

Dr Asef Zafar MBBS MRCGP

Dr Joshua Adedokun

GP and experienced Expert Witness specialising in reports for clinical negligence, personal injury and accident claims

Chronic pain expert following personal and occupational injuries. Wide experience in medical negligence claims.

www.uk-doctors.org.uk

www.expertpainreports.co.uk

British Weather Services

Mr Kim Hakin FRCS FRCOphth

• Legal weather reports • Weather data • Site investigations • Expert witness in court • Call: 07860 912216

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

www.britishweatherservices.co.uk

www.kimhakin.com

Professor Charles Claoué

Mr Marcus Ornstein

Consultant Ophthalmic Surgeon • trauma • cataract • corneal and external disease • refracture surgery

Senior Lecturer (teaching) and recently retired general surgeon with expertise in general surgery, breast disease, hernia and abdominal trauma. T: 020 8423 8236 E: markornstein@gmail.com

www.dbcg.co.uk

www.marcusornstein.co.uk

Mr Chris Makin

Mr Mark Duxbury

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

Consultant Surgeon – medicolegal work relating to general and laparoscopic surgery, specialist liver and pancreatic surgery, and hernia and gallbladder surgery

www.chrismakin.co.uk

www.markduxbury.info/medicolegal

DentoLegal

MD5 Ltd

Specialising in the preparation of evidence-based Breach of Duty & Causation and Condition & Prognosis Dental Reports

Expert analysis of digital evidence stored on computers, phones and other digital devices

www.dentolegal.com

www.md5.uk.com

Expert in Mind

Medicolegal Associates Limited

Providing high quality medico-legal reports within the field of mental health

Expert Witnesses in Pain Medicine for both clinical negligence and personal injury cases acting for the defendant and claimant. T: 0207 118 0650

www.expertinmind.co.uk

www.medicolegal-associates.com

FHDI - Kathryn Thorndycraft

Mr Michael Hodge

Examining documents & handwriting – to determine authenticity • to expose forgery • to reveal aspects of origin

Maxillofacial and Oral Surgeon.

• Personal Injury • Criminal Cases • Clinical Negligence

www.fhdi.co.uk

www.consultantoralandmaxillofacialsurgeon.co.uk

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Mr Michael Thompson

Mr Simon Bramhall

Specialist in bowel cancer and the effects of delay in diagnosis on survival.

Consultant General/Upper GI and HPB Surgeon. Significant medico legal work undertaken in his area of expertise.

www.expertcolorectalsurgeon.co.uk

www.simonbramhallhpbsurgeon.co.uk

Munro Consulting

Stockport Psychology Services

Expert Witness services relating to the design, construction and maintenance of highways

Specialising in Public & Private Family Law, Personal Injury, Clinical Negligence & Criminal cases

www.munro-consultants.co.uk

www.sps.uk.net

Professor Roger James

Dr Thomas C M Carnwath

Independent Health Consultant and Expert Witness in the field of cancer services.

Consultant Psychiatrist and expert witness in medical negligence and personal injury cases.

www.independenthealthconsultant.co.uk

www.tomcarnwath.co.uk

Sector Forensics Ltd

Mr William Stuart Hislop

• Computers • e-Disclosure • Compliance • Indecent Images • Mobile Phones • e-Discovery • Intellectual Property • Fraud

Consultant Oral and Maxillofacial / Head and Neck Surgeon.

Specialist in ablative and reconstructive surgery.

www.sectorforensics.co.uk

www.wshislop.co.uk

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MEDICAL NOTES [

IT IS ALMOST unprecedented for a Secretary of State for Health to personally ask NHS England to investigate the actions of an individual trust, but such has been the controversy surrounding the deaths of babies at the Shrewsbury and Telford Hospital NHS Trust that Mr Hunt felt compelled to intervene.

Over the past few months it has emerged that the apparent cause of at least some of the tragic events in Shropshire – inaccurate assessment of a baby’s heart rate – had been the subject of a coroner’s concerns in Yorkshire. What has emerged since appears to be a general lack of adequate training for midwives in this essential skill – possibly caused by a demarcation between midwifery and obstetrics.

• When there has been harm to a baby in or shortly after birth, or to a mother during childbirth, there is a universal acceptance that redress should be swift and simple. Addressing that concern was the remit of the NHS Rapid Response and Redress scheme for brain damaged babies, proposals for which have been published.

A number of patients’ charities and the Association of Personal Injury Lawyers are not entirely convinced of its adequacy. Swift and simple it may be, but those concerned with securing compensation say it is not adequate.

• Similar anger has been stoked by continued proposals to introduce a fixed costs regime into clinical negligence cases. It is being suggested that, were such a regime already in place, scandals such as the Ian Paterson case and the Mid Staffs debacle would not have come to light.

An open letter from nine charities vented opposition to the move, while APIL called for NHS Resolution – formerly the NHS Litigation Authority – to put its house in order to prevent drawn out cases.

• Where the NHS and its staff shine as a beacon is in cases of emergency or disaster. Such was the case in the recent terrorist attacks. There are numerous stories of nurses and other medics and paramedics braving attack themselves to tend the wounded, resulting tragically in one brave nurse, Kirsty Boden, paying the ultimate price.

The suicide bombing at the Manchester Arena had a particular horror as it targeted teenagers and young people. That would inevitably result in others youngsters asking questions about the attack and its motivation – questions adults would find difficult to answer. The British Psychological Society offers guidance on dealing with the issues raised, for both professionals and parents.

• In older people anxiety and depression is becoming a better understood phenomenon. Recent research has shown that those problems are likely to be experienced by patients undergoing treatment for so-called wet AMD, or age-related macular degeneration. Losing your sight can have devastating psychological consequences, made more acute by a crisis in ophthalmology in this country – a theme visited more than once by this publication.

Put simply, there are not enough ophthalmologists for the number of patients needing treatment.

As a result, follow-up treatment gets missed and there is not enough time to spend reassuring patients about their condition and prognosis.

• A side-issue connected with the problem has been a difficulty in finding expert witnesses in the field. Finding the time to comply with strict timetables while juggling busy practices is not easy.

A novel approach that offers a possible solution is for a number of experts to come together to offer a multiple array of expertise. The result is Eye-Law Chambers, a merger of four medico-legal practices. Its founder, Professor Charles Claoué, hopes it may act as a model for other specialties. q

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Paterson case prompts call for review of private sector reporting [

IN THE WAKE of the Ian Paterson case, the Royal College of Surgeons (RCS) has called for a review by the government of how safety standards and transparency can improve – particularly in the private sector.

The president and vice-presidents of the College issued an open letter welcoming the Health Secretary’s suggestion of an inquiry to understand how Ian Paterson was able to practise for so long. They say the review ‘should build on the findings of Sir Ian Kennedy’s report, as well as the independent review of the governance arrangements at Spire Parkway and Little Aston hospitals, and assess what action has been taken following those reviews.’

The RCS Council will also review the Paterson case and judgment, in particular to understand why doctors were unable to spot or unwilling to challenge Ian Paterson’s malpractice.

The RCS also called for ‘an equal focus on patient safety in both the private and public sectors’, warning in particular that there is poorer public availability of patient safety and clinical data from private hospitals. Their proposals include: • A review should be carried out into how safety standards and data transparency can improve in the private sector and not just the NHS. • The private sector should be expected to report similar patient safety data as the NHS. That should include data on unexpected deaths, never events and serious injuries.

• The private sector should be better at taking part in clinical audits – that could become a condition of all NHS and private organisations’ registration with the CQC. • Cosmetic surgery, which happens almost entirely in the private sector, needs to be better regulated. The RCS is calling for legislation to enable the General Medical Council to annotate the medical register with details of which surgeons are qualified to undertake cosmetic surgery.

The RCS stressed it is not suggesting there is evidence of less safe care in the private sector

compared with the NHS – but that it is less transparent on reporting safety incidents.

RCS president Miss Clare Marx commented: “Ian Paterson wilfully abused the trust placed in him by patients at their most vulnerable. His actions and behaviour were appalling and we must do everything in our power to prevent such a violation being repeated.

“It is important to remember that the overwhelming majority of doctors work with diligence and commitment – often under great pressure – motivated to understand and meet the needs of their patients as best they can.

Modern day medical practice – which includes annual appraisals as part of revalidation and rules around team decision-making and patient consent – means rogue doctors are more likely to be identified at an early stage and remedial action initiated.

“That said, there are still a number of areas which require urgent improvements to protect patients from harm. Robust regulation remains an important way of protecting the public.

“Patient safety initiatives have tended to concentrate on the NHS, but we also need a strong focus on the private sector, particularly in the collection and publication of patient safety data in private hospitals. We are therefore calling for a review of the sector to look at how safety standards and data transparency can improve. Similarly, regulation is not keeping pace with the booming industry of cosmetic surgery, which also largely takes place in the private sector.

“We continue to call for the General Medical Council to be given powers to annotate the medical register with details of which surgeons are qualified to undertake cosmetic surgery.” q

Care watchdog admits to tardiness in acting [THE CARE QUALITY COMMISSION (CQC) has issued a statement following the

conviction of 13 people for the ‘organised and systemic’ abuse of adults with learning difficulties at two care homes in Devon run by the Atlas Project, in which it admitted it did not act as quickly as it should have to address issues raised.

In the statement Andrea Sutcliffe, CQC’s chief inspector of adult social care, states: “When CQC inspected Veilstone in October 2011, inspectors were so concerned by the treatment they discovered that they quickly extended the inspection to all 15 of the services run by Atlas. We found serious concerns in most of their care homes, including the routine use of excessive restrictive practices, which is why we took action which led to the closure of all of these services in 2012.

“Much has changed since 2011. When these abusive practices were discovered, CQC took decisive action but we should have responded more quickly to the concerns raised earlier by someone using the service. Since then we have overhauled our regulatory approach; improved the monitoring of services and the way we respond to safeguarding concerns; introduced a new and more thorough inspection process; increased the numbers of people with learning disabilities involved in our inspections; and strengthened our enforcement processes.

“We have also worked with The Challenging Behaviour Foundation on the issue of restraint and we now subject services where staff frequently resort to restrictive interventions to much tougher scrutiny than we did five years ago.” q

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Opposition swells to fixed costs in negligence cases [AN OPEN LETTER from nine charities

representing patients and those suffering from specific conditions added to the swell of voices calling on the Secretary of State for Health to reconsider proposals on imposing fixed costs in clinical negligence cases. The letter was published in The Telegraph on 2 May, coinciding with the close of a consultation on the subject.

In the letter the signatories say: “We are jointly calling on the Secretary of State for Health to reconsider the proposals in the current consultation Fixed recoverable costs in clinical negligence. We believe the proposals are premature, poorly informed and pose a threat both to access to justice and patient safety.

“The government is proposing that some solicitors representing successful claimants would no longer be able to recover their full legal costs from healthcare providers found to have been negligent.

Some of the most vulnerable people harmed by clinical negligence would not be able to achieve justice, because they would not be able to find solicitors to represent them. Even if they did they would lose a significant amount of their damages in legal costs that would be left to them to pay.”

The signatories point out that serious cases, such as the Mid Staffs scandal and that of Ian Paterson, might never come to light if the proposals are implemented.

“The NHS would be less safe because it could not be held to account and therefore not learn lessons. Cases like those involving Dr Ian Paterson and those at Mid Staffordshire may never come to light. Older people’s cases, stillbirths, any fatal cases, and cases of people lacking mental capacity would be likely to be worst affected.”

In its response to the consultation, the Association of Personal Injury Lawyers said: “It is pointless to impose fixed costs for clinical negligence work without fixing the process first. A fixed, predictable claims process needs to be developed, rather than imposing fixed costs on the existing, dysfunctional system.

“Taking an axe to how much the Department of Health pays does nothing to tackle the factors which drive costs, such as the ludicrously long waiting times for the recovery of medical records, or arduous expert reports. We propose that a claimant should submit an abbreviated expert report early on, for example, so that NHS Resolution – as it is now called – can decide early on whether to make an offer to settle.

“The Department of Health seeks to advance its own cause, as a negligent wrong-doer, by changing the way in which injured people can succeed and the costs they can recover. It’s like a criminal dictating the length of his sentence.” q

Private care providers to benefit from new legal cover [A LEADING PROVIDER of legal assistance and expenses has launched a new product aimed specifically at the care home market.

Care Provider Legal Solutions, from ARAG, includes commercial legal protection tailored to the specific demands of the challenging and highly regulated sector, as well as enhanced ‘crisis communication cover’ to counter the heightened risk of significant and long-term reputational damage that businesses can be exposed to.

“Care provision is obviously a growing but very challenging market, in which operators face a unique array of legal and regulatory

risks,” said product development manager Lesley Attu.

“The nature and frequency of employment problems, tax and even criminal investigations can be quite specific – as is the exposure to diverse regulatory censure. Care providers come in all shapes and sizes, but any of them could face a rigorous and expensive investigation. The new product caters to all sorts of business, whether care is offered by a residential or nursing home or where individuals are cared for in their own homes.”

The new policy provides for representation at Coroners’ Courts or fatal accident inquiries,

Care Quality Commission investigations, registration disputes and Charity Commissioner appeals, plus representation out of office hours for interviews under caution. Legal defence cover includes allegations of dishonesty or violent acts.

“We already write a lot of business in this sector,” added head of sales Andy Talbot, “so we’ve been able to draw on a decade of our own claims experience and listen carefully to the brokers we work with who specialise in this market, to build a product that really addresses the specific needs that care providers have.” q

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Patients’ charity challenges ethics and independence of proposed RRR scheme [ACTION AGAINST MEDICAL ACCIDENTS (AVMA) – the charity

that campaigns to reduce the instance of clinical accidents – has called for major changes to the Department of Health’s proposals for a Rapid Response and Redress (RRR) scheme for brain damaged children in maternity cases in England, following the closure of a public consultation in May. According to AvMA: “The consultation…has good intentions, which we support, but we are concerned that the proposals have not been thought through properly and lack detail. We believe there are better ways to achieve the same objectives. Such a scheme would be unnecessary if NHS organisations investigated properly, complied with the duty of candour and settled cases early.”

AvMA identifies two elements of the scheme that it finds particularly concerning: compensation to the parents of brain-damaged children would be 10% lower than a court would award; and the scheme would be run by NHS Resolution – formerly the NHS Litigation Authority – which is responsible for defending claims against the NHS. AvMA chair of trustees Suzanne Shale said: “We broadly welcome the scheme, which certainly has good intentions, but there are many questions still to be answered. As it stands the scheme would be funded from damages that would otherwise go to children who have been brain damaged through NHS negligence. Each child stands to lose an average of £600,000. We seriously question the ethics of this approach.

“We call on the NHS to investigate these cases properly in the first place and offer a prompt settlement without depriving brain damaged children of 10% of their damages. This should be happening already!

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“If this scheme goes ahead it must be completely independent.

People will not have confidence if NHS Litigation has a role in administering the scheme; but the current proposals contain no details on how the investigators and panel members will be selected.

“Most importantly, families must be at the heart of the scheme. Yet, despite referring to legal advice for parents, the proposals give no clue as to how this will be provided or funded.” q

NHS chief Sir Bruce Keogh to step down [SIR BRUCE KEOGH, medical director of NHS England, has

announced his resignation. He will be taking up a new appointment as chair of Birmingham Women’s and Children’s NHS Foundation Trust.

Simon Stevens, chief executive of NHS England said: “Bruce has given superb medical leadership to the NHS and has been a great source of wisdom and advice to us all.”

Sir Bruce attracted much praise for his report on cosmetic surgery, which led to the Royal College of Surgeons (RCS) issuing guidelines on the practice.

RCS president Miss Clare Marx said: “In 2013, his review of the regulation of cosmetic interventions demanded much needed changes to the cosmetic surgery industry which had developed a ‘Wild West’ reputation. Patients who want cosmetic surgery are now better protected thanks to new professional standards for surgeons set by the RCS, as well as RCS certification, to help patients identify properly qualified surgeons.”

In 2015 Sir Bruce was attacked by junior doctors following an intervention in their dispute with Health Secretary Jeremy Hunt in which he was accused of suggesting they would not be able to respond to a Paris-style attack within one hour. q

Hearing charity attacks plans to cut aid provision [THE LATEST INSTANCE of a Clinical Commissioning Group (CCG)

“They not only directly contradict and overlook NHS being attacked for so-called rationing of healthcare involves plans by England’s Commissioning Framework – the official guidance on Enfield CCG in Middlesex to introduce cuts to hearing aid provision, commissioning services for adults with hearing loss – they also which could affect thousands of people in the area, according to hearing misrepresent what other CCGs have done. Contrary to some of charity Action on Hearing Loss. the rationale given by Enfield CCG for exploring cuts to hearing According to the charity – formerly RNID – Enfield CCG is undertaking aid services, South Norfolk CCG decided against them following a public consultation on a range of proposals that include plans to cut a thorough review of the evidence and Stoke-on-Trent CCG also hearing aid provision for people with mild hearing loss aged 50 and decided against restricting access.” q above, and to require that people with moderate hearing loss go through an eligibility test before receiving them.

Paul Breckell, chief executive of Action on Hearing Loss, said: “Hearing loss currently affects one in six of us.

We are deeply opposed to Enfield CCG’s plans to deny people with mild hearing loss the hearing aids they need, and to force people with AN ESTIMATED 20,000 people working during the past year moderate hearing loss to go through suffered from noise-induced hearing loss caused or made worse an unnecessary and inappropriate by work, based on data from the Labour Force Survey and quoted eligibility test. by the HSE. That figure includes new as well as longstanding “Ironically, despite Enfield CCG cases and equates to a rate of 62 cases per 100,000 workers. naming this consultation Adherence The Industrial Injuries Disablement Benefit scheme had 100 to evidence based medicine, they new claims in 2015, compared to 130 and 120 in 2014 and appear to have completely overlooked 2013 respectively. the wealth of compelling and robust The number of claims has declined over the past decade. evidence that shows both the Of the 1,630 new claims in the last 10 years, only 10 were importance and the effectiveness of female claimants. q hearing aids while putting together these proposals.

Hearing claims on the decline [

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Removing the complexity from Complex Regional Pain Syndrome (CRPS) cases

By DR CHRISTOPHER JENNER MB BS FRCA FFPMRCA, Consultant in Pain Medicine at Medicolegal Associates Ltd and Imperial Healthcare NHS Trust

[

COMPLEX REGIONAL PAIN SYNDROME (CRPS) is one of the most painful types of pain known. Medico legal cases involving chronic pain (pain that lasts for three months or more) is challenging for both the claimant and the defendant to prove or refute because of the subjective nature of pain. This is especially true for cases involving CRPS, partly due to the condition itself but also because the pain that follows the injury is not usually reflective of the original injury sustained and often far worse. Hence the complex disputes that arise regarding causation, liability and prognosis.

The common triggers of CRPS include fractures, sprains, soft tissue injuries such as burns, surgical procedures and limb immobilisation from a cast, splint or brace. It commonly affects a single limb, but other limbs can become involved. CRPS is essentially an abnormal neurological pain response that magnifies the effects of an injury.

CRPS is caused by damage or dysfunction of the peripheral and/ or central nervous system and an inappropriate neuroinflammatory response. More than 80% of cases are caused by an accident, injury or surgical intervention and these are the cases where a medico legal claim is often made.

Symptoms of CRPS include severe stabbing or throbbing pain, burning or pins and needles, sensitivity to light touch (allodynia), changes to skin temperature or colour (mottled or discoloured), swelling, stiffness, alteration in hair and nail growth, decreased mobility, contractures and muscle spasms.

Steps to simplify CRPS cases

There are three imoportant steps to take to simplify CRPS cases.

Firstly, ensure you engage appropriate experts; secondly, obtain a clear diagnosis and prognosis; and finally, engage and obtain a report from a consultant in pain medicine who specialises in diagnosing and treating CRPS. • Engage the appropriate expert witnesses Engaging with the relevant expert witnesses ensures the patient is appropriately assessed and an accurate and authoritative diagnosis is given. Given the complexities of CRPS, the multitude of symptoms and the overlap of medical expertise required, engaging the correct experts

will enable the identification of an appropriate multi-modal treatment package. Instructing a multi-disciplinary team is not only best practice, but will also help reach a fair settlement figure.

In CRPS cases these experts may include a: • Consultant in pain medicine – to diagnose, provide a prognosis, • identify and evaluate the effect on the claimant’s life and provide a • multidisciplinary treatment plan • Rheumatologist – to aid in the diagnosis of CRPS • Orthopeadic consultant – if orthopaedic injuries were sustained prior • to onset • Psychiatrist – to assess the claimant and rule out any psychiatric/ • psychological issues • Occupational therapist – to identify care needs • Obtain a clear diagnosis A fundamental part of any CRPS case is securing a diagnosis from an expert consultant in pain medicine who is a specialist in diagnosing and treating CRPS and who has extensively reviewed both the patient and their medical records.

The Budapest Criteria is the internationally recognised criteria for the diagnosis of CRPS and should be used in the assessment of the claimant. CRPS cases should command the same consideration as other severe injuries such as spinal cord or brain injuries.

If there is any dispute over the diagnosis of CRPS, then the focus should shift from the CRPS diagnosis to the pain itself. Ultimately, pain is pain. What is important is how severe the pain is, how long it will continue, and how it affects the claimant’s life. It is the expert in pain medicine who has the expertise and responsibility to acknowledge these points for the court.

• Engage an expert in pain medicine Medico legal cases involving CRPS are complex – the condition is, as its name implies, ‘complex’. Therefore it is essential to use a specialist consultant in pain medicine with proven experience in diagnosing and treating CRPS as a clinician and reporting on it as an expert witness.

The pain expert will consider several points when assessing a claimant: • Medical history • Severity of pain • Impact of symptoms on claimant’s life, ability to function and need • for support • Effect on claimant’s ability to work • The requirement to take medication to control symptoms and • consideration of how the medications will impact the claimant’s daily • functioning • Multi-modal treatment that has been undertaken or can be in the future • Prognosis CRPS cases can be challenging to prove and quantify. Any steps taken to simplify facts and present them to the court in a practical and useful way will benefit a case. A report lost in unnecessary information and medical complexities will not assist the court in reaching a judgement. Presenting succinct information from a multi-disciplinary team of experts improves the potential to achieve a fair settlement for both parties. q www.yourexpertwitness.co.uk

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Physios lead the way in expert assessment of mobility and soft tissue issues [

IN MANY CASES involving soft tissue injury – including the much-maligned ‘whiplash’ – the most appropriate place to turn for an expert opinion could well be a physiotherapist. Indeed, there is a distinct specialism within chartered physiotherapists offering specific medicolegal services.

The Medico Legal Association of Chartered Physiotherapists (MLACP) is a professional network for chartered physiotherapists and others who have a special interest in medicolegal work.

According to the MLACP: “An understanding of medicolegal matters is required in all areas of physiotherapy practice and at all stages of career progression. For example, all physiotherapists must understand how key legal concepts such as consent to treatment, confidentiality, duty of care and duty to report affect the way in which they work with patients.

“Some physiotherapists will choose to develop particular expertise in medico legal work and may undertake to write medico legal reports which can be used for a range of purposes.”

The association explains to its members the three main roles in which they may be required to act as experts: • Witness of Fact – they may be asked to provide information for one of their patients who is involved in a civil litigation process, usually a personal injury or clinical negligence claim. A physiotherapist who is a witness of fact is required to comply with an appropriate request to provide the patient’s physiotherapy records and/or a report.

The physiotherapist cannot decline to cooperate with the request, although for many employed physiotherapists, a dedicated person within the hospital/clinic will deal with the request. No specific training is required, and the solicitor in charge of the case would be expected to provide appropriate support and information, should the physiotherapist need to be directly involved.

• Expert Witness – physiotherapists who have developed expertise in a specific area of practice, as well as the legal litigation process, may choose to undertake expert witness work. These physiotherapists are wholly independent of the patient and have never been involved in their treatment. This work involves preparing reports, joining conferences and giving evidence during a legal case for compensation following an accident or injury as part of a personal injury or clinical negligence claim.

It can also involve work in the criminal courts. Not only must they be a recognised expert in their clinical and/or practice area, but must also have specific training in the expert report writing process and Civil/Criminal Procedure Rules and maintain their fitness to practise in that area.

• Coroners Witness or Interested Person – they may be asked to assist in a coroner’s inquest in order to determine the cause and circumstances of a person’s death. A physiotherapist may be asked to give factual or opinion evidence depending on the coroner’s investigation. No specific training is required.

A person who is called to give evidence as a ‘witness’ is not entitled to be legally represented whereas a person who has been given the status of ‘interested person’ by the coroner is entitled to be legally represented and have questions asked on his or her behalf. The definition of an ‘interested person’ is someone whose act or omission may have caused or contributed to the death of the deceased.

Physiotherapy has been a fully autonomous diagnostic profession since 1977. The titles ‘physiotherapist’ and ‘physical therapist’ are protected by law and only those listed on the relevant register held by the regulator may practise using a protected title. The statutory regulator for physiotherapists is the Health and Care Professions Council (HCPC).

Some physiotherapists may also prescribe prescription-only medicines for their patients, including some controlled drugs. A physiotherapist prescriber must have an additional annotation against their HCPC registration.

In addition to acting as experts in the sphere of litigation, physiotherapists are also at the forefront of a campaign to promote rehabilitation as a crucial element in coming back from injury.

Its #Backing Rehab campaign states: “If you’ve fractured a hip, had a stroke or are coping with a long term condition, getting rehabilitation once you’ve left hospital makes the difference between regaining health and independence or having a lasting disability and failing health.”

A leading provider of expert witness services in the specialism – White House Medico Legal Services – describes the role of the expert physiotherapist thus: “Physiotherapists are clinically effective and cost effective at managing and treating patients with musculoskeletal disorders and when treating neurological disorders.”

A veteran physiotherapist and regular blogger on the site of the Chartered Society of Physiotherapists, Joyce Williams, puts the point much more succinctly. She describes physiotherapists as: “…the experts at identifying, assessing, treating or preventing problems of human movement.” q

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Ophthalmologists respond to NICE consultation on cataracts [

THE National Institute for Health and Care Excellence (NICE) is running a consultation on a draft guideline for cataracts in adults. The consultation closes at 5pm on 23 June.

The guideline covers managing cataracts in adults aged 18 and over.

It aims to improve care before, during and after cataract surgery by optimising service organisation, referral and surgical movement, and reducing complications.

It further aims to improve the availability of information for people with cataracts before, during and after cataract surgery.

A cataract is defined as any opacity in the crystalline lens of the eye. It can affect one or both eyes. Cataract surgery is the most common operation performed in the NHS, with an ever growing need as the population ages.

According to the consultation document: “Guidance on appropriate referral criteria for cataract surgery is needed to address patient need and to optimise the allocation of NHS resources. In addition, an understanding of the most clinically and cost-effective methods for undertaking cataract surgery, and recommendations to minimise complications

and surgical errors such as wrong intraocular lens implants, are needed to further improve patient care.”

The draft recommendations cover issues related to referral for cataract surgery, preoperative assessment and biometry, intraocular lens selection and surgical timing and technique, in addition to recommendations on anaesthesia, preventing and managing complications and postoperative assessment.

The Royal College of Ophthalmologists’ Scientific Committee is co-ordinating a response to the consultation. q

Wet AMD patients experience anxiety and depression [A NEW STUDY has revealed high levels

of undiagnosed depression and anxiety among patients undergoing treatment for wet age-related macular degeneration (AMD), the Macular Society reports.

The research was conducted at Manchester Royal Eye Hospital and published in the American Journal of Ophthalmology. It involved 300 patients receiving anti-VEGF treatment for wet AMD completing standardised questionnaires to quantify clinically significant levels of anxiety and depression.

The Manchester researchers say that the findings demonstrate the value of human interaction between clinician and patient in offering reassurance around the efficacy and safety associated with anti-VEGF injections.

The main sources of anxiety were fear of going blind from the injections and concerns about treatment effectiveness, rather than trepidation around pain.

Dr Tariq Aslam, senior lecturer in ophthalmology at the University of Manchester and a consultant ophthalmologist at Central Manchester University Hospitals NHS Foundation Trust, was the lead author of the study. He said: “There have been amazing scientific achievements in diagnosing and treating serious eye diseases such as AMD which have revolutionised our ability to reverse life-changing vision loss.

“However, we must not forget the human element when applying all this to ensure all our patients can reap the full benefits of this cutting-edge science.”

The research found that 17% of patients showed clinically significant levels of anxiety and 12% had clinical levels of depression, with 56% of patients reporting anxiety related

to anti-VEGF treatment. The study also found that 89% of patients who showed anxiety and 91% who showed depression were not receiving appropriate psychological and psychiatric treatment.

Cathy Yelf, chief executive of the Macular Society, said: “This report is very welcome, although it is shocking that there is such a high level of anxiety and untreated depression in patients with macular degeneration. We know that this is a devastating condition even for those who can be treated. People are extremely afraid of

sight loss and emotional support at the time of diagnosis and after is vital.

“Macular degeneration is increasing as we live longer, so this problem must be addressed. We understand the NHS is under huge pressure and we are here to help with our free advice line and counselling service.

We urge patients and eye care professionals to use these services to help alleviate patients' distress.”

This study was supported by the National Institute for Health Research. It was also funded by a grant from Bayer. q

New venture brings experts together [

A NEW VENTURE promises to offer a new way of looking at the provision of expert witness services in the field of ophthalmology and optics.

Eye-Law Chambers was founded in January by Professor Charles Claoué as a merger of existing medicolegal practices in the specialty. Currently comprising five partners, Eye-Law Chambers provides expert opinion on all aspects of eye and vision-related matters.

In a recent interview with Lawyer Monthly, Professor Claoué explained that ophthalmology is a specialty with a small number of practitioners in great demand. As a result it is difficult to commit to medicolegal work. By bringing together a number of partners it is possible to work to specified deadlines.

The company’s experts have assisted in the courts of England and Wales, Scotland, Northern Ireland and also the Republic of Ireland, mainland Europe, Africa and Asia. Their expertise is of use in both the civil and criminal courts and in tribunals.

Professor Claoué sees great potential for the new venture, which he hopes will be producing up to 500 expert reports per year by 2020 – a date whose significance is not lost on a consultant ophthalmologist! q www.yourexpertwitness.co.uk

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Dental periodontal negligence claims – the expert’s role

By PHILIP R. GREENE BDS FDSRCPS CUEW JP Specialist in Periodontics

[DENTAL PERIODONTAL NEGLIGENCE claims are increasing

exponentially because, until recently, periodontics (problems related to the gums) was a ‘Cinderella’ subject for dental practitioners.

Symptomless for the most part, patients are unlikely to complain about their gums even when disease is present – and in most cases the disease can only be discovered by exploring beneath the gum margin with a blunt, round-tipped probe or by examining X-rays for signs of bone loss between the teeth.

Treatment usually involves removal of debris from around and beneath the gum margins, together with meticulous oral hygiene by the patient; and the achievement of these two elements can be both tedious and time consuming.

Nevertheless, failure to diagnose and treat periodontitis can lead to loosening and eventual loss of the teeth, so the consequences

Periodontal probing

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for the patient can be devastating. The general dental practitioner (GDP) therefore has an absolute duty to examine thoroughly, and having done so, advise the patient accordingly.

The life history of periodontitis is 30-40 years in most cases, however a small proportion of patients are affected earlier and more aggressively, and these cases can progress to tooth loss in 20-25 years. So even in the aggressive cases there are many opportunities for a dentist seeing a patient for check-ups once or twice a year to pick up the disease and take appropriate action.

A typical scenario is the patient who changes dentist, for a variety of reasons, and is told that he is suffering from advanced gum disease, with the possible loss of some of his teeth. The patient then complains to his former dentist and, if not satisfied with the response, consults a solicitor, who then instructs an expert to advise on Breach of Duty, Causation and Condition & Prognosis. If not done already, a letter before action is issued at this stage.

The expert will then usually produce a draft court-format report, because it will be needed for service if court proceedings are issued. However, a report on BoD and Causation is not normally needed until a later stage, so a simpler Advice Report can be provided dealing with these issues to enable solicitors to justify their client’s claim and perhaps negotiate an early settlement.

In my experience, a full court-format Causation & Liability Report is rarely actually needed.

By this time the defendant will have alerted his indemnifiers, who will also commission an expert report.

The use of single joint experts is still unusual in these cases, despite the potential savings in time and costs.

There usually follows a protracted correspondence that can go on for months, sometimes years, until proceedings are issued and the court begins to direct the timetable.

The expert is consulted throughout this process, commenting on correspondence, assisting with and advising on responses, until eventually the court directs that the experts must meet and produce a report narrowing the issues. This usually leads to a settlement, at any time up to the day of the trial. In over 25 years I have not yet had to appear in a trial, although one matter was settled at the courtroom door!

Of course, as lawyers have always known, situations alter cases and it is often not clear from the records whether there is really a case to answer. There may have been some references indicating that the patient’s condition was recognised, and that some information and advice was given to the patent. Yet the dentist may still have been negligent. This is where a screening report can be very helpful – saving time, costs and much anxiety in situations where there has been no negligence.

So who should provide this initial report, often referred to as a

Screening Report? I am frequently asked to provide such a report and I am happy to do so. At this stage I can tell from the records whether the defendant dentist has examined thoroughly, advised the patient appropriately, and provided the correct treatment or referral for specialist help. There is also a body of opinion that says that Breach of Duty is best assessed by a GDP expert, because he is in a better position to understand the standards expected of a GDP than a specialist would be. Some judges have expressed a preference for this.

I am often asked to provide an opinion on Causation following a Breach of Duty Report by a GDP expert. This works well because I am best placed to advise on the patient’s periodontal prognosis at the outset, and at various stages during the relevant period of care, and therefore to say whether or not the GDP’s management has caused the claimant to be in their present position.

What to look for when assessing a periodontal claim – PG’s top tips • At the first visit was there a basic periodontal exam (BPE)? It looks • something like this:

• If there is a BPE score of 3 or 4 (4 is the maximum) in any box, • is there a more detailed chart in the notes?

• Are there X-rays from the first or second exam, or a panoramic • X-ray? Do they show large gaps between the teeth? Are such • findings documented?

• Are there follow up X-rays at regular intervals throughout the • care period?

• Are there references in the notes to risk factors for periodontitis • such as smoking or diabetes?

• Do the notes contain references to personalised advice given to • the patient about the disease and its consequences, oral • hygiene instruction or demonstrated use of interdental • plaque removal aids?

• Has deep scaling, root surface debridement or root planing • been provided? Scaling and polishing is not the correct • treatment for periodontitis.

• Has there been a re-evaluation, with periodontal data, after this • initial course of treatment to assess the effects of the treatment • that has been provided?

• Has referral to a specialist periodontist been considered? What • was the outcome of the discussion?

All the above is, or ought to be, within the ability of a competent GDP. So the next time you encounter a potential periodontal negligence claim, the first decision is this: is the negligence clear, or do you need a Screening Report? q • Philip Greene is a specialist in periodontics practising in Central Manchester with over 25 years experience as a dental expert witness. Email Philip at perioexpert@gmail.com or visit the website at www.effectiveperio.co.uk

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Who’s listening anyway?

By TOBY TALBOT BDS MSD (Washington) FDS RCS

TOBY TALBOT is a specialist in restorative dentistry, prosthodontics, endodontics and periodontics. He has over 20 years experience as an expert witness with a specific interest in dental negligence litigation claims.

In this issue he considers how poor communications break the circle of trust between patients and healthcare providers and can result in litigious complications.

[

IT IS A TOOTH universally acknowledged that a single failure in good communications can land a dentist in want of a lawyer.

Yes, I’m in Jane Eyre country and during my 20 years of practice in Bath, and as an expert witness for medico-legal reports, I’ve learned that poor communication is the Northanger Abbey of reasons for patient litigation.

In fact, more than 70% of complaints can be attributed to poor communications, according to a review by a leading UK dental defence indemnity insurer. Their report highlights indelicate vocabulary, brusque delivery and a poor chairside manner as key pointers towards a lack of compassion for the patient. And with our medical litigation rates knocking the stars and stripes off North America’s figures, this is a very serious matter for me and my fellows in the UK. Here, medical and dental practitioners have a four-fold greater chance of litigation compared with practitioners in New York.

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However, communication is a two-way street. And effective communication begins with listening. And listening opens the door to understanding and trust, which is a great start to resolving any cracks that might appear.

Trust me, I’m a dentist

Yet while the charnel house of healthcare litigation is piled high with the complaints of patients unhappy with the quality of care, when it comes to the clinching question of trust, things don’t seem quite as gloomy for dentists as they do for doctors.

Research conducted for the British Dental Health Foundation uncovered the warming news that people have more trust in dentists than doctors. 88% of people surveyed claimed a very high degree of trust in their dentist, more so than in their doctor. Twice as many people (19.7%) value their relationship with their dentist over their doctor (9.9%).

So why is it, then, that so many patients fail to act on our advice?

I am too often riled when I’m asked to assess a patient for a medico-legal report, only to find that they are suing their dentist for negligence, while at the same time neglecting themselves when it comes to the very basics of dental hygiene – like brushing their teeth regularly. And not smoking.

The case of the missing gum disease

In one particular case I advised on, a lady was suing her dentist after 30 years of routine care. Finding herself needing emergency treatment, she attended a different dentist, who diagnosed advanced periodontal bone loss and imminent loss of several teeth. The unfortunate woman reported she was wholly unaware of the disease, which is when she commissioned a lawyer to sue for breach of duty for the costs of remedial dental treatment. This would include implants and crown work, which would likely total a five-figure sum.

When I examined the patient, it was clear the disease was at an advanced stage and we discussed treatment options of removable and fixed prosthodontics. The patient was very distressed about losing her front teeth. Both parents had worn complete dentures, which she had been determined to avoid during all those years of giving up smoking. Unsuccessfully. Cigarettes were her comfort for the stresses of life.

When writing my reports as an expert witness, it is part of my protocol to ask for the patients’ medical and dental records – including all dental practitioners before, during and following treatment by the defendant. This gives me the entire story.

Regrettably, records showed the defendant was a little too economical with his notes. Although his 2011 – 2014 notes made references to ‘ANUG’ – Acute Necrotising Ulcerative Gingivitis, a serious infection of the gums that causes ulcers, swelling and dead tissues in the mouth – gingivitis, heavy calculus deposits and level three gum disease, there was no reference to pocket charting, bleeding indices or plaque scores. Schoolboy errors.

Notably, our defendant had specifically recorded gaps between the front teeth that were causing the patient concern. He had clearly instructed her on oral hygiene repeatedly, and performed scaling. At her last visit to him, he again recorded her poor oral hygiene and bleeding.

What he seemed to have missed, however, was the diagnosis the second dentist discovered: advanced periodontal disease.

This second dentist referred her to his hygienist for full pocket, plaque and bleeding indices before embarking on a programme of oral hygiene, scaling and root planning. At this point, dear reader, you may well point your finger and shake your head at the initial practitioner. The indemnity insurers will reach for their cheque books. Settlement figures will be high.

Listen… with your eyes

But I had yet to examine her medical records. They made for difficult reading, uncovering a history of long-term depression with anti-depressant medication prescribed over 30 years. The

patient had suffered breast cancer with surgery, radiotherapy and chemotherapy in 2011. Her separation from her husband in 2012 quickly led to divorce. Within the year her son would die in a motor bike accident and her daughter would be diagnosed with drug dependency.

And yet after all this, when I examined her, she still had plaque covering all her teeth even after she had been repeatedly warned of the causes of her periodontal disease. My report ended with conclusions that the patient had continued to ignore oral hygiene instructions by both dentists even after she had been informed about the disease. In all probability, the deterioration of her periodontal disease was inevitable due to poor compliance.

Pointing the finger of blame to the first dentist due to her own failings was noted. The case was dropped.

This is why the author never accepts desktop commissions only and demands that the patient/claimant is examined on every report commissioned. q • All the views and opinions expressed by the author are personal but I would welcome public debate on all the issues included. For further information visit www.tobytalbot.co.uk.

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Wrist injuries and the scaphoid bone

By FRANCIS MORRIS, Consultant in Emergency Medicine Of all the 206 bones in the human skeleton none is as well-known as the scaphoid.

The scaphoid bone is just one of eight small carpal bones that, along with the forearm bones and the hand metacarpals, make up the complex joints of the wrist.

The scaphoid is the most commonly fractured of all the carpal bones and if not identified or managed appropriately can give rise to long term pain and disability.

This article provides the reader with the current standard of care for the assessment and management of wrist injuries in the emergency department.

[ WRIST INJURIES are extremely

common and are typically sustained by a Fall On the Out Stretched Hand or FOOSH injury. A FOOSH causes hyperextension of the wrist and can be responsible for one of three common injuries – a fractured distal radius and ulna, a fractured scaphoid and a wrist sprain.

Each of these conditions may give rise to a painful swollen wrist with limited movement and diminished grip strength.

The clinical approach adopted to differentiate between these three common diagnoses is to look for evidence of bony injury over the distal radius and ulna and over the carpal scaphoid bone.

The bony landmarks of the distal radius and ulna are usually readily appreciated, even in a patient with a swollen wrist, and evidence of bony tenderness at this site would indicate a fracture of the underlying bones, and wrist X-rays (two views) are indicated. The bony landmarks when looking for a scaphoid fracture are the anatomical snuff box (ASB), the scaphoid tubercle (ST), and on axial compression of the thumb.

The current accepted minimum standard of care involves palpating for scaphoid tenderness in the anatomical snuff and over the scaphoid tubercle in all wrist injuries to rule in or rule out clinical evidence of a scaphoid fracture.

The presence of scaphoid tenderness mandates that scaphoid X-rays (four views) are requested. It is widely recognised that between 3 and 4% of patients who fracture their scaphoid may have normal initial X-rays.

Scaphoid X-rays provide the viewer with three good views of the scaphoid bone as opposed to wrist X-rays which only include one good view of the scaphoid.

Increasing the number of views of the scaphoid improves the diagnostic accuracy of X-rays. When scaphoid X-rays do not reveal an obvious fracture, it is mandatory to immobilise the wrist with a recognised form of splintage and either review them at 10 to 14 days or request another imaging modality such as an MRI or CT scan.

Currently it is widespread practice in emergency medicine to review patients with suspected scaphoid fractures at 10 to 14 days to allow a reassessment of their symptoms and to re-X-ray the scaphoid bone. The service providing this follow-up care varies from hospital to hospital but typically will be by either the orthopaedic clinic team or the emergency department team in the returns clinic.

Patients who remain symptomatic and in whom there is ongoing concern of a scaphoid fracture and who have a normal second set of X-rays should then undergo another imaging modality such as CT or MRI scanning. Increasingly however many hospitals have now cut out the 10 to 14 day wait and provide alternative forms of imaging in patients with suspected scaphoid injuries within days of their initial presentation.

Patients with wrist injuries who have neither clinical or radiographic evidence of a fracture of the distal radius and ulna or scaphoid are managed as a wrist sprain.

The emergency department approach to a wrist sprain is similar to that of an ankle sprain, where the patient is treated symptomatically with the expectation that their symptoms will be short lived and self-limiting.

It is not standard or routine practice for the emergency department to arrange MRI scanning for patients with soft tissue injuries to their wrist to help identify those few patients who will not settle in the short term with symptomatic treatment. Such patients are typically referred back to the community with the advice that should their symptoms not significantly improve with time and settle within three months, they should present to their general practitioner for a review. q www.yourexpertwitness.co.uk

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Training in heart rate monitoring must improve for midwives, say experts [

IN THE WAKE of a number of tragic incidents involving the death or severe disability of babies, experts have warned that the training of midwives in interpreting baby heart rates and contractions must improve.

The issue relates to the ability of NHS staff to properly understand cardiotocograph, or CTG, readings of a baby’s heart rate and mother’s contractions.

The issue was thrown into focus by high-profile cases at an NHS trust in Shropshire – which has led to a number of inquiries – although the issue has been raised elsewhere in the country.

An article in the Nursing Times of 24 May stated: “According to analysis by Health Service Journal, there are hundreds of NHS negligence claims each year showing a failure to properly monitor and respond to warning signs in foetal heart rates.

“Data from NHS Resolution – formerly the NHS Litigation Authority – shows there were almost 300 clinical negligence claims between 2011

Regulator welcomes changes to legislation [ON 31 MARCH changes to the legislative framework of the

Nursing and Midwifery Council (NMC) came into force. The changes modernise midwifery regulation by separating statutory supervision from legislation. The changes also mean that the NMC will no longer be required to maintain a statutory Midwifery Committee.

Describing the changes as ‘important’ and ‘long-awaited’, the NMC said in a statement: “The separation of supervision from regulation comes after a number of critical incidents and independent reports which confirmed the existing arrangements for midwives were not appropriate for public protection.”

Its chief executive and registrar Jackie Smith said: “I’m pleased to see these important changes finally take effect. I have maintained for a long time that our legislation in his area was out of date and in need of reform. These changes will, for the first time, ensure that we are fully responsible for all aspects of the regulation of midwives, helping to ensure safe and effective practice with regulation of midwifery that is proportionate, fair and focused on public protection.” q

and 2016 where the primary cause of the injury was a failure to respond to an abnormal foetal heart rate.”

In March, West Yorkshire Coroner David Hinchliffe called for improvements in midwifery training after finding ‘significant failings’ in the death of Billy Wilson, who died three days after being born in November 2013.

According to the Nursing Times: “The midwife admitted at the inquest that she did not understand the CTG and claimed not to have been properly trained to interpret it at university. She had also yet to complete online training about CTG interpretation.”

Obstetrics expert witness Professor Philip Steer told the inquest such problems were ‘commonplace’ and that student midwives can qualify and become registered ‘without this essential training’.

A spokeswoman for the Nursing and Midwifery Council said: “We have recently commenced a wholesale review of our pre-registration midwifery standards and will be developing new standards of competence for future graduate registered midwives.”

Eddie Morris, vice president for clinical quality at the Royal College of Obstetricians and Gynaecologists, urged greater integration between obstetrics and midwifery. “There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery,” he stated.

The issue is one that has been pursued by Eddie Jones, head of clinical negligence at JMW Solicitors in Manchester.

“It’s a huge concern to us that the same mistakes continue to be made in this area when the lives of whole families are being ruined because of avoidable errors in the use of this equipment,” he blogged.

Referring to the West Yorkshire case, he said: “Over the last few days we have learned why this may be the case. According to an article in The Telegraph a senior coroner has warned that it is commonplace for midwives to qualify without training in the use of foetal heart rate monitors.

“Heart rate monitoring is one of the most important tools the health service has for checking the well-being of the baby in the womb and it is extremely worrying that this lack of training has come to light.” q

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Cardiology claims are not common, but can take years to conclude [MEDICAL NEGLIGENCE CLAIMS in

cardiology are relatively uncommon compared with other specialties, although the nature of the practice means they can be among the most serious. That can include in some cases the death of the patient.

In 2014 the deputy head of claims at the Medical Defence Union (MDU), Dr Sharmala Moodley, reported in its journal on research carried out into 67 claims against its members that were either settled or defended over a 10year period.

Although some were ‘statute barred’ – lodged after the statutory three-year time limit following the point at which the problem became apparent, a number still related to procedures or treatments carried out many years previously.

Dr Moodley said: “We have represented members in cases where the claimant brought their action many years after the date of the incident. In some cases, the member had been entirely unaware of any damage to the patient at the time of the incident.”

Even when a case is brought, many years can elapse before it is settled. Of the cases reported on by Dr Moodley the longest took

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eight years from the time of notification.

“The oldest case in this series arose from a patient who developed a stroke following a failure to anticoagulate appropriately. The incident took place in 1992 and was not notified until eight years later. This case was settled four years after it was notified – 12 years after the incident had occurred,” he said.

Most claims alleged a failure to assess, diagnose or treat appropriately, including alleged failure to assess suitability for procedures such as angiography and coronary bypass.

Said Dr Moodley: “Others claimed that there was a failure to make a diagnosis or a delayed diagnosis of conditions such as endocarditis and atherosclerosis. Claims were also notified by patients who alleged that the treatment they received for hypertension, angina and valve disease was inadequate. There were also cases where the claimant alleged that test results such as ECGs and angiograms were negligently interpreted.”

The MDU recommends that cardiologists and surgeons minimise the risk of being subject to a claim by taking a number of steps.

They include ensuring that they document the discussions with patients pre-operatively and complete the consent form. Giving patients written information and documenting that this has been given, says the MDU, may also help reduce the risk of a claim.

The advice continues: “Consideration should be given as to whether a patient is at particular risk of a complication. Advise the patient of the risks and benefits of the procedure, possible alternative treatments, as well as the option of no treatment, and the complication rates – and document this.

“Ensure that the patient is aware of the possible post-operative complications and knows what steps to take if problems arise after discharge from hospital.

“If a complication does arise, the patient should be advised what has happened as soon as possible and, if appropriate, an apology should be offered in accordance with GMC guidance. An appropriate apology is not an admission of liability.”

Finally, the MDU points out that it is ‘not necessarily negligent to fail to make or delay in making a diagnosis’. q

Know your numbers: BUPA offers an explanation of some heart facts [

ALMOST A THIRD of people with high blood pressure are unaware of it and this can lead to an increased risk of heart attack, stroke and other health issues. On World Hypertension Day in May the cardiology advisor for Bupa UK, Dr Yassir Javaid, explained what health numbers are important – such as blood pressure and heart rate.

Blood pressure

Blood pressure is the force of blood against the artery walls every time the heart beats. Raised blood pressure puts extra strain on the heart and blood vessels, increasing the risk of a heart attack, stroke, kidney disease and some forms of dementia.

A normal blood pressure reading should be less than 140/90.

The top number (systolic pressure) is the pressure within the arteries when the heart contracts and the bottom number (diastolic pressure) is the pressure when the heart is between beats.

Cholesterol

Cholesterol is a type of fat made in the liver. The body needs cholesterol to make certain hormones; however, too much bad cholesterol (LDL-cholesterol) increases the risk of heart disease, particularly in people with other risk factors such as high blood pressure.

Ideally, you’d want LDL-cholesterol level to be under three, however if you have a history of heart-related issues such as angina or had a previous heart attack, then you should aim for an LDL of less than two.

Waist measurement

Body shape is probably more important than BMI in terms of influencing blood pressure and heart health. Fat around the abdomen is an indication that a person is likely to have fat coating major organs such as the heart, kidneys, liver and pancreas and that type of fat is associated with developing diabetes and heart disease.

Ideally, waist circumference should be no more than 94cm for men and 80cm for women. q

Heart rate

Heart rate is usually measured at rest. That is because the heart rate can fluctuate throughout the day. The normal resting heart rate for adults can range from 60 to 100 beats per minute, though many fit people can have a normal resting heart rate of below 60. Anything higher than 100 beats per minute at rest should be checked by a GP.

BMI

The Body Mass Index (BMI) is an indication of whether someone’s weight is right for their height. Being overweight puts extra pressure on the heart and, more often than not, people who are overweight also have high blood pressure. A healthy BMI range is anything between 18.5 and 24.9. Again, a healthy diet and exercise is key to staying in the healthy BMI range.

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Bullies and their victims more likely to seek cosmetic surgery [REMARKABLE FINDINGS FROM

research carried out at the University of Warwick have indicated that school bullies and their victims are more likely to want cosmetic surgery.

Professor Dieter Wolke and colleagues in the Department of Psychology and Warwick Medical School have discovered that teenagers who are affected by bullying in any way have a greater desire than others to change their bodies by going under the knife.

Their research paper, Adolescent Desire for Cosmetic Surgery: Associations with Bullying and Psychological Functioning, was published in the journal Plastic and Reconstructive Surgery.

Almost 2,800 adolescents aged 11-16 were screened for their involvement in bullying, through self and peer assessment. From them a sample group of around 800 adolescents – including bullies, victims, those who both bully and are bullied, and those who are unaffected by bullying – was analysed for emotional problems, levels of self-esteem and bodyesteem, and the extent of their desire to have plastic surgery. They were asked to complete

established questionnaires, such as the Strengths and Difficulties Questionnaire and the Acceptance of Cosmetic Surgery Scale.

The results showed that adolescents involved in bullying in any role were more interested in cosmetic surgery compared to those uninvolved in bullying. Desire for cosmetic surgery was highest in victims of

bullying, but was also increased in bullying perpetrators.

The research found that 11.5% of bullying victims have an extreme desire to have cosmetic surgery, as well as 3.4% of bullies and 8.8% of teenagers who both bully and are bullied. That compares with less than 1% of those who are unaffected by bullying.

The researchers reason that perpetrators of bullying want to have plastic surgery to improve their appearance and increase their social status, whereas victims of bullying want to go under the knife because their psychological functioning is affected by being picked on: giving them lower self-esteem, more emotional problems and a desire to change their appearance.

The researchers commented: “Being victimised by peers resulted in poor psychological functioning, which increased desire for cosmetic surgery. For bullies, cosmetic surgery may simply be another tactic to increase social status…to look good and achieve dominance. The desire for cosmetic surgery in bullied adolescents is immediate and long-lasting.” q

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Psychoactive Substances Act: one year on [IN MAY LAST YEAR the Psychoactive Substances Act came

into force. One year on there have been a number of articles published reflecting on the Act and its effectiveness, particularly with reference to the availability of new psychoactive substances, or so-called ‘legal highs’ as they were termed prior to the Act. In April Home Office Minister Sarah Newton reacted to criticism from some quarters of the legislation.

“We have known about the devastating consequences of Spice for some time,” she wrote, “and we have acted to give police the powers they need to take action, making third generation synthetic cannabinoids Class B drugs on a par with ketamine and amphetamines. We will continue to monitor its impact and if we need to do more, we will.”

Marking the first anniversary of the passing of the Act, Detective Chief Inspector Warren Stevenson of West Yorkshire Police said: "Being unable to access these substances has had a significant positive impact on our communities. Previously, shops selling these substances were also often the epicentre of anti-social behaviour and officers were often being called to the locations following concerns. This has completely stopped, with the high street shops in West Yorkshire either closing, or no longer selling psychoactive substances.”

The legislation has not been a complete success, with seeminglydaily stories of the devastating effects of new psychoactive substances in prisons.

A blog on the Mentor website warned: “Many of the significant harms among the homeless and prison populations have yet to be addressed, with some local services struggling. But often the impact of synthetic cannabis or ‘spice’ on these groups appears to be the only measure portrayed on the relative success of the

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Act. Its use is not spreading across into the wider population. The media concern for the human cost of taking spice would be all the more convincing if these most vulnerable people were not termed ‘zombies’.” q

Investigation into rogue drug testing continues [

RANDOX TESTING SERVICES has published an update on its investigation into the manipulation of toxicology data at its laboratories in Manchester and Crumlin.

The statement says: “RTS itself uncovered what it believed was evidence of data manipulation in January 2017 when it acted as whistleblower in reporting its suspicions to the police. The subsequent police enquiry into practices at RTS laboratories and those run by other companies has led to the arrest of two people.

A criminal investigation into their alleged activities is on-going.”

The statement goes on to detail the scale of the problem.

“As a result of its own investigation, RTS is not currently satisfied that the results of in excess of 6,000 positive toxicology samples are sufficiently reliable. All relevant parties have been informed. Retesting is underway and the police forces continue to identify those samples they wish to be retested.”

Head of toxicology at RTS, Dr Mark Piper, said: “We regret the concerns that these developments will inevitably cause. We are taking all possible responsible actions to allay them.

“RTS are closely engaged with all related police forces, and the process of retesting samples at an appropriately accredited external laboratory is underway. RTS will manage this stage and cover all associated testing costs.

“We have been unrelenting in our commitment to uncover the extent of this data manipulation. The police have our full support in whatever actions they take in resolving this matter and in dealing with the consequences of any criminal activity.”

According to the company’s statement, accreditation for liquid chromatography mass-spectrometry testing – a common method used in drug toxicology testing in forensic laboratories – has been suspended at both RTS Manchester and Crumlin until further notice. Accreditation for other methods of testing at RTS Crumlin is unaffected. q

A downward spiral: drugs, mental ill-health and offending

[

THE Royal College of Psychiatrists has produced a document – aimed primarily at the public – explaining the connection between mental illness, offending and substance abuse.

The document describes what is meant by mental disorder, offending and substance misuse and how often they are seen together. It examines whether people with mental illness are more likely to commit violent crimes.

Studies have found that mental health problems are much more common in prisoners than in the general population, the document points out. As many as 90% of prisoners report some kind of mental health problem and the most commonly reported symptoms in prisoners are sleep problems and worrying.

According to the RCPsych: “The types of crime committed by people with mental illness are no different from the crimes committed by people who do not have mental illness. Mentally disordered offenders still go through the criminal justice process as anyone else would. However, there are measures in place to help people with mental illness. There are assessments to identify people who would

be best helped in hospital. The courts can also ask for a psychiatric report to help them decide on the best course of action.”

The document describes what is meant by a ‘dual diagnosis’ – when someone has a mental illness along with a substance misuse problem.

The causal relationship may be in either direction or, more commonly, a spiral where one feeds the other.

“Research shows that substance misuse may cause or increase symptoms of mental illness. On the other hand, mental illness may lead someone to abuse substances. They may want to block out their symptoms or the side-effects of medication. They may have difficulties in sleeping, feel lonely or simply wish to boost their self-confidence.

“People with a dual diagnosis have other problems, including being lonely, homeless, having a history of abuse and are more likely to get into trouble with the police.

“Unfortunately, dual diagnosis is often seen in people in prison. The criminal justice system tries to help people with drug problems through prison-based drug treatments and community punishments which include drug rehabilitation programmes.” q

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BPS offers advice on talking to children in wake of Manchester attack [

IN THE WAKE of the Manchester outrage, targeting as it did teenagers and young people, the British Psychological Society (BPS) issued a statement aimed at advising people on how they should talk to children about traumatic events.

BPS president Nicola Gale said: “Because of the target of this outrage, many parents and carers will be asked about it by their children.”

She referred people to the ‘good advice’ given by chartered member Emma Citron when talking to BBC News.

Said Emma: “Give children basic facts; tell them what it is they want to know; ask them what they would like to know and then give them access to that. Support them and comfort them and be there for them, hug them, cry with them if they're crying, just respond to how they're responding emotionally. Take the lead from them – we need to know what it is they want answers to.”

A group of psychologists led by Richard Meiser-Stedman has put together a single page giving brief information on supporting children and young people involved in major trauma. It includes a valuable link to a longer document produced by the Norwegian Centre for Crisis Psychology.

The BPS’s own Crisis, Disaster and Trauma

section offers advice to those caught up in such incidents. It includes: • During the first few days people need time • to get over the shock of what happened • Trying to get back to a normal routine is • helpful – for example, children going back • to school

• Take gentle exercise and eat little and • often • Flashbacks, bad dreams and jumpiness • are very common in the first two weeks • after which they tend to fade • Try to spend time with the people you • love and who care about you. q

Forensic psychologists convene in Bristol [THE ANNUAL CONFERENCE of the Division of Forensic Psychology of the British

Psychological Society took place from 13-15 June at the Mercure Bristol Grand Hotel.

Among the subjects discussed was how press reporting of heroic acts following a terrorist attack can help to allay public anxiety. Another presentation described how campaigns against knife crime can by more effective if they focus on the risk of injury rather than death or imprisonment.

The opening keynote address was by Prof Cathy Widom, on Does violence really cycle?

The second day of the conference saw the presentation of the division’s two prizes. The Award for Distinguished Contributions to Professional Practice in Forensic Psychology went to Ruby Fisher, professional lead for forensic psychology at Tees Esk & Wear Valleys NHS Foundation Trust, while the Junior Award in Forensic Psychology went to Helen Thomas, a chartered forensic psychologist with the Public Sector Prisons Psychology Service. q

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Attachment assessment in family cases

Science not Guesswork

By MELANIE GILL, Specialist Assessment Psychologist and Forensic Consultant

[

THE FAMILY JUSTICE SYSTEM deals on an everyday basis with the tragic failures of families and parenting – within relationships often involving anger, violence, drugs and alcohol, emotional abuse, mental illness and severe animosity between separated parents.

Within private law specifically, the nature of parental conflict reflects one of the most emotionally damaging environments a child can suffer and also highly specific patterns of parental psychopathology such as narcissism, Munchausen by Proxy (contemporary type), and entrenched negative personality traits.

False accusations of child sexual abuse and domestic violence are common. Unfortunately, this continues to be poorly understood within the family law system and the belief that children who present as happy are happy condemns some of them to significant risk of mental disorder as they mature.

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In the last decade scientific knowledge of child development has grown and is still growing, but the administration of family law has come under increasing pressure. The challenges related to care proceedings, and to parental separation and divorce, are constantly on a collision course. The need to be aware of the research, especially from attachment science, is urgent, in order to divert those collisions and make recommendations that actually have a chance of working.

Attachment is the main organising mechanism for all human emotional and behavioural functioning, so the assessment of attachments is of particular significance when decisions are made about children involved in court proceedings as a result of maltreatment or parental conflict. In private law cases it gives a high level of insight into how parents in extreme and conflicted proceedings actually think, no other form

of assessment can offer such accurate understanding.

A greater understanding of attachment, at every level of family court work, not only helps to improve everyday practice, streamline case management and illuminate the often complex needs of families, but most importantly ensures that the voices of children are heard accurately through evidence based assessment.

I have had extensive training in evidence based attachment assessments for all age groups in combination with specialist training in the accurate analysis of parental alienation and its impact on specific children. The forensic analysis used in such assessments ensures that the full ‘back’ story of why and how conflict has arisen, and continues in these cases, is understood and leads to the right recommendations and interventions for the unique aspects of each family. q

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