Your Expert Witness Issue No. 43 by DMMonline

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contents IN THIS ISSUE 7

Opening Statement

NEWS 9 Manchester to host new research body for risk and regulation 9 Crash victims’ charity wins High Court victory TREES AND THE LAW 10 Trees and the law: what is the expert’s opinion? 11 6KHI¿HOG URZ KLJKOLJKWV HPRWLRQDO LPSDFW RI WUHHV BUILDING & PROPERTY 12 New Planning Bill introduced in Scotland FORENSICS 13 3ULPHUV KHOS MXGJHV ZLWK VFLHQWL¿F HYLGHQFH 13 Jail for money launderers WILLS, LEGACIES & CHARITABLE BEQUESTS 14 Legacy income stats vary in an uncertain world 15 Law on will-making set to be modernised 15 Funding helps enhance quality of life 16 Surgery saves lives 17 Seeing Dogs providing a choice 18 Solicitors urged to raise the issue 18 Legacies – the gift of life 19 Electronic wills: the future or the present? 19 +ROLGD\V KHOS ERRVW FRQ¿GHQFH RI \RXQJ FDQFHU SDWLHQWV 19 Supporting the maritime community 20 Education through the power of play 20 Help for those with failing sight 21 If you Will, we will 21 How to support those who support victims 22 Horses’ plight sparked the beginning of a dream 23 Consortium racks up a double century 23 Tax claims: delays reported at HMRC 23 Vegfam – feeding the hungry without exploiting animals 24 Charity carries on the work of its founder 24 Charity helps kids with kidney problems 25 When the presents come from the taxman! 25 Helping the forgotten people of Zimbabwe

A to Z WEBSITE GUIDE 26 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

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Your Expert Witness

Suite 2, 61 Lower Hillgate, Stockport SK1 3AW Advertising: 0161 710 3880 Editorial: 0161 710 3881 Subscriptions: 0161 710 2240 E-mail: ian@dmmonline.co.uk Copyright Your Expert Witness. All rights reserved. No part of this publication may be copied, reproduced or transmitted in any form without prior permission of Your Expert Witness. Views expressed in this magazine are not necessarily those of the publisher. Printed in the UK by The Magazine Printing Company Plc www.magprint.co.uk

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MEDICAL ISSUES 29 Medical Notes

NEWS 31 Government consults on regulation of health professionals 31 Trust fined following fall deaths 31 APIL comments on bereavement ruling MEDICO-LEGAL REPORTING 33 The report is the centrepiece of medico-legal work CLINICAL NEGLIGNCE 34 Medical litigation: the wind of change has become a hurricane 35 The changing face of clinical negligence claims DENTISTRY & MAXILLOFACIAL SURGERY 37 Fitness to Practise: GDC publishes its data 37 Campaign highlights oral cancer scourge 38 Getting to the root of the problem 40 Dentists point the finger at ‘ambulance chasers’

BRAIN INJURY 41 Assessing brain injury is not always straightforward 41 Research set to start into football brain effects PSYCHIATRIC & PSYCHOLOGICAL ISSUES 43 Health trusts ‘restrain patients every 10 minutes’ 43 Valproate scandal: review welcomed by Royal College 45 Report reveals mental health failures in prisons 45 Campbell honoured by psychiatrists for campaigning work PLASTIC, RECONSTRUCTIVE & HAND SURGERY 47 Our hands give rise to a great many injuries 47 Children’s hand injuries can be avoided for £1, says BAPRAS 48 Plastic surgeons increasingly pick up the pieces of botched ops GASTROENTEROLOGY 49 Expert calls for minimum alcohol pricing 49 Many adults would ‘not be worried’ by cancer symptoms PAIN MEDICINE 50 We all know what pain is, don’t we? 50 Anaesthetists speak out over fentanyl fears 51 Surveillance footage needs putting into context when pain is the claim 53 Pain can be actionable of itself

OBSTETRICS & GYNAECOLOGY 54 Stillbirth trend is downwards – but still shows capacity issues 55 Endometrial cancer: early presentation can lead to good outcomes VASCULAR INJURIES 57 Common procedures may lead to unforeseen vascular consequences OPHTHALMOLOGY 59 Imposed restrictions should not restrict access to cataract surgery, says RCOphth 59 Guidance helps prevent eye problems in ICU CARDIOLOGY 60 New test could ease heart attack diagnosis HEARING LOSS 61 Hearing guidance gets mixed response ORTHOPAEDICS 63 Figures show shocking number of children requiring hip surgery 63 BOA welcomes efforts to minimise ‘never events’ www.yourexpertwitness.co.uk

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Opening Statement [NOTHING BRINGS HOME the vast plethora of ways in which we rely on the goodwill and good

deeds of others more than a survey of the many charitable organisations that perform almost miraculous work with minimal resources. Such is the result of assembling the series of features this publication has been running on the many ways in which legacies left in wills are allowing charities to perform their functions. From small, local funds helping people with specific disabilities to cross-border NGOs operating in war zones to try and preserve some kind of normal life for victims of unimaginable cruelty, the gifts left by people after their passing is helping to bring sanity in an often insane world. As we approach Christmas we can have nothing but admiration, not only for the selflessness of the people carrying out the work, but also for the altruism of those who remember others in their final act. • Some of those charities are involved in helping people who have been the victims of reckless behaviour or crime. The Christmas season brings out of the woodwork that cohort of fraudsters and scammers who prey on the unwary. A recent report in the local press named the Strangeways area of Manchester as the counterfeit capital of the UK, with around 80 stores openly selling goods which, unaccountably, shoppers know to be fake. Alongside the handbags and trainers can be found prescription drugs such as viagra. • While the purchase of a few ‘wannabe’ fashion items is seen by many buyers to be harmless, the proceeds of these purchases are part of that vast fortune of ill-gotten gains that is laundered to appear to be legitimate. They join the profits from drug dealing, weapons smuggling and people trafficking in the stock-in-trade of the serious criminal gangs. Fortunately, forensic analysis by experts is having success in identifying the trails left by such money laundering and bringing perpetrators to trial. One such success was registered in London, with the jailing of five men – one of them a bank employee. • As life becomes more complex and crime becomes more hi-tech, so the evidence needed to achieve convictions becomes more complicated and technical. In order to help judges grapple with the complexities of evidence presented to them, the Royal Societies of London and Edinburgh have joined with the Judicial College to produce a series of primers – short guides to various technical elements of evidence. The first two are aimed at interpreting DNA fingerprinting and identifying people from the way they walk. • For most people, however, the only contact they have with the judicial system is on a civil law basis. They may be unfortunate enough to have suffered an injury through the negligence of others or be involved in some kind of civil dispute. For many, that means planning disputes. In Scotland the planning system is heading for an overhaul to make it more fit for modern society. Similar upgrading has been promised for England and Wales: we shall see. • Perhaps no issue to do with property generates more heat than the felling or otherwise of trees. In Sheffield, a long-running dispute between the council and a number of residents regarding a PFI project to fell around 6,000 trees as part of a street improvement project has resulted in arrests and a suspended jail sentence, together with interventions from the likes of Bianca Jagger and Michael Gove. In most cases, however, decisions around the pruning and felling of trees are settled a tad more amicably. Just be careful where you get your Yule log from. Merry Christmas and a Happy New Year! q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Manchester to host new research body for risk and regulation [THE HEALTH AND SAFETY EXECUTIVE (HSE) and the

University of Manchester have announced a joint commitment to establishing an Institute for Risk and Regulatory Research. The new Thomas Ashton Institute will capitalise on the existing strong international credibility of both the University of Manchester and HSE. It will act as a hub for risk and regulatory excellence, reaching out globally through its educational activities and acting as an authoritative source of health and safety knowledge and expertise. The institute will deliver research, training and learning on a national and global stage, and will support HSE and the University of Manchester even further in their growing capability and expertise in the management and regulation of risk. One of the key aims of the institute’s work will be to take the lessons learned from four decades of incident investigations and research and make them accessible to industry. The work will help to make sure that mistakes are not repeated as new technologies and industries emerge. Both partners are keen to bring new technologies to fruition safely and more quickly by addressing safety, health and regulatory barriers before they emerge. HSE’s chief executive, Dr Richard Judge, said: “We are excited by the opportunities that establishing this new institute brings, and

Crash victims’ charity wins High Court victory

by the opportunity to cement and strengthen our long-running partnership with the University of Manchester. This directly supports our regulatory activities. “In creating an international centre of excellence for risk and regulatory research, we are also providing a focal point for working with others. As part of that, we will invite forward-thinking contributors to work with us on the institute’s future programmes to prevent work-related death, injury and ill health.” President and Vice Chancellor of the University of Manchester, HSE’s chief executive, Professor Dame Nancy Rothwell, Dr Richard Judge added: “This is an excellent partnership that has the ability to develop, transform and shape health and safety research, policy and expertise for years to come. Partnering with such a reputable organisation as the HSE is testimony to the university’s growing reputation in this area and is a reflection of the research expertise and practitioner-led excellence here at Manchester.” q

[THE LAW FIRM Leigh Day – on behalf of the road victims’

charity RoadPeace – have won a High Court legal challenge to the decision by the UK Government and the Motor Insurers’ Bureau (MIB) over who should receive compensation in personal injury claims involving non-road vehicles. In a judgment in the High Court, handed down on 7 November, Mr Justice Ouseley agreed that compulsory insurance cover should be extended to any use of a vehicle which is consistent with its normal function, including when motor vehicle incidents occurred on private land such as private drives and farmyards. As such, Mr Justice Ouseley considered that domestic rules should be brought into line with the EU Directive and a declaration of incompatibility should be made, with the possibility of a timetable for legislative change to follow. RoadPeace, a national charity that provides support for road crash victims, also welcomed what is said were substantial concessions by the MIB following the instigation of legal action against what it claimed were unlawful agreements by the MIB which were incompatible with EU law. The MIB exists for compensating innocent victims injured or killed by uninsured and/or untraceable drivers. It is estimated that uninsured and untraced drivers injure approximately 26,500 people every year and kill around 130. Every insurer providing motor insurance is obliged to contribute to the funding of the MIB. Rowan Smith, solicitor in the public law team at Leigh Day, said: “This judgment is a real vindication of all the effort RoadPeace, with limited means as a relatively niche NGO, has put into its long battle to bring the standards of UK compensation for victims up to scratch with the requirements of EU law. Where the High Court called for changes to the law, we will push for an ambitious timetable.” q www.yourexpertwitness.co.uk

Trees and the law:

what is the expert’s opinion? By MARK CHESTER of Cedarwood Tree Care

[AS AN EXPERT WITNESS working on tree-related commissions,

the range of scenarios I can be asked to comment on is diverse – and they often straddle different aspects of law. In one case I can be dealing with an alleged breach of the Town & Country Planning Act – which could involve criminal law – while another may relate to a domestic case and the law of trespass. Issues may be straightforward or complex, and emotions can run high; but the ability to stay focused and identify the key aspects of a case remains fundamental to the work. When trees are involved in litigation, there can be a desire for retaliation; to make the perpetrator pay for their action. That is especially true when dealing with trees that were subject to a Tree Preservation Order (TPO). However, remaining objective throughout can ensure that those seeking a successful enforcement achieve that outcome. The reverse is also true. One client I worked with faced a claim for felling a number of trees. The key issue was not whether the trees had been felled, but if they were exempt from the protection of the TPO. I was asked to provide a feasibility assessment and suggested that many of the charges could be defended. Among the plethora of charges, there was a handful for which a case could have been made. Those bringing the charge were determined to pursue it with full force – not wanting to explore other options. By the first day in court only a handful of the charges were of sufficient merit to be heard, and the barrister made short work of them as limitations were highlighted. I reflected that a more restrained, informed and focused approach may have resulted in a different outcome.

Tree safety: often a cause for concern

Tree failure rarely causes accidents, although the consequences can be very unpleasant. The application of some core principles can provide a defendable policy. I prefer to advise clients on that before an accident occurs, rather than having to deal with the aftermath. If you don’t know what trees you have, what work is required and the timescales, then it is difficult to prioritise. In my experience, not adhering to those principles, and employing people who lack the expertise to manage the resource, are the main reasons for trees to cause problems.

Valuing amenity trees

This is one of those outcomes that we instinctively know should be possible, yet seems difficult to apply. How can one place a monetary value on a mature tree that is centuries old? There are, in fact, many situations where we can attribute a value, depending on what we are seeking to achieve. That can include the cost of replacing a damaged tree, which may require planting multiple replacement specimens, and can be useful with planning applications. Valuations can help in resolving litigation, but they need to be defendable and proportionate: usually involving more than one quotation. I once reviewed a claim where the valuation was based on a single desktop quotation. The defendant felt it was excessive and disproportionate. While providing advice, I pictured myself sitting next to the claimant and explaining why the damaged trees were less valuable than anticipated. It is important to remain above the emotion and to present the issues clearly. I always seek to write in anticipation that all the parties involved will be reading and critiquing the content. That is the mindset of the Single Joint Expert, and the best way I can represent those affected. q

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6KHIÂżHOG URZ KLJKOLJKWV HPRWLRQDO impact of trees >THE LONG-RUNNING FURORE RYHU WKH IHOOLQJ RI WUHHV LQ 6KHIÂżHOG Âą ZLWK

interventions from such disparate sources as Bianca Jagger and Michael Gove â&#x20AC;&#x201C; has demonstrated the emotional effect the issue can have. With around 6,000 trees scheduled for destruction as part of a street improvement project and talk of a SRVVLEOH 8 WXUQ E\ WKH FRXQFLO WKH 6KHIÂżHOG FDVH LV D PDMRU QDWLRQDO QHZV VWRU\ But for most people their experience of issues relating to trees is limited to individual trees and who is responsible for their upkeep. In that respect the issues VXUURXQGLQJ WUHHV IDOO LQWR WZR EURDG FDWHJRULHV 7KH ÂżUVW FRQFHUQV ZKHQ WUHHV DUH protected and when they can be pruned or even felled; the second concerns who is responsible for any harm or damage they may cause. Several helpful guides have been published by a number of sources. On the issue of when trees can be pruned and when they are protected, the Arboricultural Association has this to say in its Guide to Trees and the Law. â&#x20AC;&#x153;There are a number of ways that trees can be protected by law within the UK. These include Tree Preservation Orders (TPOs), Conservation Areas, the Felling Licence system, Restrictive Covenants, and planning FRQGLWLRQV ZLWKLQ WKH SODQQLQJ V\VWHP ,W LV LPSRUWDQW WR ÂżQG RXW IURP \RXU local council whether any legal restrictions apply before you undertake work on your trees as you may be liable to prosecution if permission is QRW ÂżUVW REWDLQHG Â´ According to the Forestry Commission: â&#x20AC;&#x153;It is an offence to fell trees without a licence where one is required. If there is no licence or other valid permission, or if the wrong trees are felled, anyone involved can be prosecuted. â&#x20AC;&#x153;There are other legal controls on tree felling mainly covered by Tree Preservation Orders and the Hedgerow Regulations. This legislation is administered by local planning authorities. Controls also exist that apply to the movement of timber.â&#x20AC;? When the trees are home to certain species of wildlife, extra regulation is in place. Again, according to the Forestry Commission: â&#x20AC;&#x153;A European Protected Species (EPS) mitigation licence may be required from Natural England under the Habitats and Species Regulations (2010) if felling operations could adversely affect any EPS.â&#x20AC;? 7KH FRPPLVVLRQ KDV SXEOLVKHG VSHFLÂżF JXLGHV IRU YDULRXV VSHFLHV What many individual homeowners want to know is, who is responsible for the maintenance of trees and who is responsible if things go wrong? The Arboricultural Association explains: â&#x20AC;&#x153;The safety of trees is nearly always the responsibility of the owner of the land on which they grow; but there are some exceptions, such as when a rental agreement requires the tenants of a property to manage the trees. The tree owner RU PDQDJHU KDV D &RPPRQ /DZ GXW\ RI FDUH WR ÂľWDNH UHDVRQDEOH FDUH to avoid acts or omissions which they can reasonably foresee would be likely to injure their neighbourâ&#x20AC;&#x2122;. â&#x20AC;&#x153;The tree owner also has a duty under the Occupiers Liability Acts to take reasonable steps to ensure visitors or trespassers on their land are safe. In practice this means that if a tree fails and causes damage to a person or property then the tree owner may be liable.â&#x20AC;? In its guidance for customers, insurance company Aviva is reassuring, stating: â&#x20AC;&#x153;Whilst no single source of statistical information exists, the indications are that the number of instances when people are struck by falling branches or trees is low. However, there have been a small number of serious incidents and such events usually attract a high level of media attention.â&#x20AC;? The company makes a number of recommendations on measures that can be taken to ensure trees are safe, including regular inspection by a TXDOLÂżHG DUERULFXOWXUDOLVW Most guidance is agreed on the established principle that pruning of trees that overhang oneâ&#x20AC;&#x2122;s property is allowed, although care should be taken that no damage is caused. In typically quirky British fashion, the cut branches remain the property of the neighbour and should be returned! T www.yourexpertwitness.co.uk

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New Planning Bill introduced in Scotland [ SCOTLAND’S PLANNING SYSTEM

is the subject of a major new Planning (Scotland) Bill, which was laid before the Scottish Parliament on 4 December by the Cabinet Secretary for Communities, Social Security and Equalities, Angela Constance MSP. The Bill is part of a wider programme of reforms to the planning system in Scotland and follows an independent review last year and a consultation earlier this year. Among the provisions in the Bill are the removal of strategic development plans, the introduction of local place plans, prepared by community bodies, and simplified development zones. There are also proposals for an Infrastructure Levy to help fund infrastructure development.

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Minister for Local Government and Housing, Kevin Stewart, said in a statement: “Scotland’s economy needs a world-class planning system. Our planning system must take a strong and confident lead in securing the development of great places that will stand the test of time, and this Bill will encourage more people to play an active role in shaping them. “In addition to restructuring and simplifying the system to provide greater certainty for investors and communities alike, it will reflect the importance of development and infrastructure to achieve our ambitions for housing, schools and regeneration – creating jobs and generating economic growth. “Performance improvement will be formalised, so applicants can rely on

receiving a consistent service and local authorities will have greater powers to charge for their services. In short, this Bill will reduce bureaucracy so that planners are better equipped to lead high-quality developments that support the economy and enhance our communities.” Rt Hon Henry McLeish is the chair of the Scottish Alliance of People and Places. He commented: “We welcome the Scottish Government's ambition to create a more innovative and inclusive planning system that puts people at the heart of decisions about their local communities. Planning the places in which we live and work is fundamental to our social and economic wellbeing, and it is vital we reach out to communities and empower them to actively participate in the decisions that affect their lives. “This Bill represents a real opportunity to be bold and ambitious, and present a positive, forward-looking vision for our planning system, rather than simply making technical changes to policy.” The Royal Town Planning Institute (RTPI) Scotland also welcomed the Bill, while expressing aspirations for it to have gone further. Its convenor Stephano Smith commented: “We said at the outset of the planning review that it was a fantastic opportunity to realise the potential of the planning system and to highlight the important role planning had in creating the types of places we want across Scotland. “The Bill, as introduced, has the right direction of travel and will fix some of the issues faced in planning our cities, towns and villages. However, we question if it is bold enough to make the step change required for a worldleading planning system.” q

Primers help judges with scientific evidence [A NUMBER OF guides for judges – or

primers – on scientific evidence are being introduced into UK courts. The first two primers in the series – covering DNA fingerprinting and techniques for identifying people from the way they walk, as viewed on CCTV – were launched on 22 November. They are designed to assist the judiciary when handling forensic scientific evidence in the courtroom. The project is a collaboration between the judiciary, the Royal Society and the Royal Society of Edinburgh. Each primer is a concise document presenting a plain English, authoritative account of the technique in question, as well as considering its limitations and the challenges associated with its application. They have been written by leading scientists and working judges and peer reviewed by legal practitioners, all of whom have volunteered their time to the project. Supreme Court Justice Lord Anthony Hughes, chair of the Primers Steering Group, said: “These are the first in a series of primers designed to be working tools for judges. They aim to tackle the agreed and uncontroversial basis underlying scientific topics which crop up from time to time in courts. The objective is to provide a judge with the scientific baseline from which any expert dispute in a particular case can begin.

“We have been very privileged to have the co-operation in preparing them of the two Royal Societies of London and Edinburgh. We are very grateful to their eminent scientists for taking the time to put complex science into a form which addresses practical trial-related questions from judges.” While the Forensic DNA analysis primer covers an established scientific technique

used widely as evidence in UK courts and many courts around the world, the Forensic gait analysis primer considers a young, relatively new form of evidence in the UK criminal courts and advises that the scientific evidence supporting gait analysis is ‘extremely limited’. Future primers on the topics of statistics and the physics of vehicle collisions are planned. q

Jail for money launderers [FIVE MEN have been jailed for a total of 28 years for their roles in a network responsible for

laundering at least £6.9m stolen by international cyber criminals, following an investigation by the National Crime Agency (NCA). Over a three-year period the group set up and controlled around 400 bank accounts in a conspiracy which involved receiving stolen funds into one account, then dispersing it in smaller amounts to a number of other accounts. The process would be repeated several times to disguise the source of the money before it was transferred back to cyber criminals in Eastern Europe. The fifth man, a personal banking manager at Barclays, was instrumental in the opening of a large number of the accounts, known as ‘mule’ accounts, using false ID and address documents. NCA officers recovered a number of mobile phones, financial ledgers and 70 ‘mule packs’ from one flat. The mule packs contained ID and banking documents, bank cards and security information that enabled the group to access the accounts. In a search of the banker’s house officers recovered over £16,000 in cash and nine mobile phones hidden in various places around the house, including under the kitchen sink and tucked behind the sofa cushions. q

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As Christmas approaches we are all reminded of the vital part that charitable giving plays in all our lives. It is also a time of year that can be tinged with sadness for lost loved ones. The two can often come together with the thought of the lasting good that can come of a legacy. Making a will can be daunting and the law as it stands is arcane. A consultation aimed at making the process easier has just ended. It has included proposals for electronic wills, opening in the process a potential can of worms.

Legacy income stats vary in an uncertain world [PROJECTIONS OF THE VALUE of legacy giving have seen both

ups and downs over the past few months in these topsy-turvy times. In October the Legacy Foresight group was projecting a slowing of growth in legacy income as a result of the Brexit vote. As Legacy Foresight points out, gifts in wills are a vital source of income for British charities – indeed, according to the National Council for Voluntary Organisations, legacies represent 14% of all the fundraised income received by UK charities, and 5% of total income. The research group projects that legacy market growth will be considerably slower than in the five years leading up to the Brexit referendum, when annual growth rates averaged 6.5%. After taking into account rising inflation, growth in real terms will be less than 1% per annum. Chris Farmelo, director of Legacy Foresight, said “The good news is that we do not expect to see a return to the situation following the global financial crisis in 2008, when sector incomes fell and then stagnated. In fact, the number of bequests received by UK charities is predicted to rise over the coming years, due to the climbing death rate. “However, the value of those bequests will grow much more slowly than of late, due to the uncertain economic situation. From 2017 to 2021 the average residual bequest (now worth around

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£46,600) will grow by just 1.3% per annum, compared to 2.8% between 2012 and 2016.” In November, however, Legacy Foresight revised income projections upwards following publication by the Office for National Statistics of its biennial population projections, which include projected deaths to 2049/50. The figures represent a significant uplift on their previous death projections, produced in 2015. Compared to those forecasts there are now predicted to be 5% more deaths over the next five years. That means a total of three million deaths from 2017/18 to 2021/22, an increase of 140,000 over previous estimates. According to Legacy Foresight: “As part of our on-going market analysis and forecasts, we had already anticipated an upward revision in the number of deaths, but our estimates were relatively cautious, and the new ONS projections are 2% higher than our own forecasted figures. “The increase means that over the next five years both the number of charitable bequests and overall legacy income will be 2% higher than we predicted in summer 2017. We are now anticipating 640,000 charitable bequests from 2017 to 2021, worth a total of £15.6bn to UK charities. “The new figures pose vital questions about the many possible reasons why death numbers are expected to rise to this extent, which our analysts are examining.” q

Law on will-making set to be modernised [A CONSULTATION BY the Law

Commission on proposals for changes to the law on will-making closed on 10 November. Launched in July, the consultation looked at a number of areas where it was felt the law on wills did not reflect modern thinking. Launching the consultation in July, the Law Commission said that the Victorian laws are out of step with the modern world, are failing to protect the vulnerable and are not allowing others to distribute their cherished possessions after they’ve gone. With an estimated 40% of adults dying each year without a will, it’s also thought that the laws could be putting people off writing one. That means there is no guarantee that estates are distributed as the deceased intended. Law Commissioner Professor Nick Hopkins said: “Making a will and passing on your possessions after you’ve died should be straightforward. But the law is unclear, outdated and could even be putting people off altogether. “Even when it’s obvious what someone wanted, if they haven’t followed the strict rules, courts can’t act on it. And conditions which affect decision-making – like dementia – aren’t properly accounted for in the law. “That’s not right and we want an overhaul to bring the law into the modern world. Our provisional proposals will not only clarify things legally, but will also help to give greater effect to people’s last wishes.”

In its consultation paper the Law Commission proposed: • Giving the court power to recognise a will in cases where the • formality rules haven’t been followed but the will-maker has made • clear their intentions • An overhaul of the rules protecting those making a will from being • unduly influenced by another person

Funding helps enhance quality of life

[FUNDING AN ever-changing variety of projects which enhance

and enrich the lives of vulnerable people with learning disabilities is the function of Camphill Foundation UK and Ireland. The foundation provides the financial support that can enable new initiatives to start-up, help to create or improve facilities, or provide vital opportunities for creative and fulfilling work. It often provides that extra bit of help needed to enhance quality of life. Independence and freedom of choice are fine ideals, but they can only become a reality with the right level of support, both financial and personal. True quality of life means combining individual choice and fulfilment with social belonging and responsibility. The projects supported by Camphill Foundation improve and enrich that quality of life for people with learning disabilities by providing new work or social and cultural opportunities which enhance the development and wellbeing of both the individual and the community. For further information on leaving a legacy, enabling that work to continue, visit www.camphillfoundation.net q www.yourexpertwitness.co.uk

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Surgery saves lives

[SURGEONS SAVE AND improve the quality of people’s lives

• Applying the test of capacity in the Mental Capacity Act 2005 to the • question of whether a person has the capacity to make a will • Providing statutory guidance for doctors and other professionals • conducting an assessment of whether a person has the required • mental capacity to make a will • Giving the Lord Chancellor power to make provision for • electronic wills • Lowering the age at which people are able to make a will from 18 to • 16 years old The paper also asked whether the rule that marriage revokes a will should be retained or abolished. The consultation was broadly welcomed by the legal profession. In its own response, the Law Society welcomed efforts to bring the law on making a will into the 21st century, agreeing that courts should have the power to recognise and give legal effect to a deceased person’s final wishes where they have not strictly followed the formalities required to make a valid will – with appropriate safeguards against fraud. The response also recognises that adopting the test in the Mental Capacity Act will ensure the same test is applied whether a testator is executing a will, or the court is making a statutory will on their behalf. Among the bodies in the third sector that responded to the consultation was Remember A Charity, the umbrella body representing 200 charities that campaigns for legacy giving. In its submission, Remember A Charity welcomed proposals for electronic and video wills, but cited the need to balance easier willmaking with added safeguards to protect the public and minimise the risk of dispute. Its director Rob Cope said: “If the legal profession gets the balance right, this overhaul of will-writing could be crucial for growing charitable legacies. One of the biggest barriers to legacy giving is that too few people are making or updating a will and the process needs to be made simpler and easier to do, with sufficient safeguards in place to ensure people’s final wishes are met. “Wills have to be brought out of the dark ages. Introducing electronic and video wills as a means, particularly for those who can no longer write or visit a solicitor’s office, is certainly welcome. But we need to be mindful that relaxing the laws around what makes a will legally valid could create uncertainty and increase the scope for legacy disputes. This means having more accessible, regulated will-writing opportunities, while ensuring appropriate checks are in place to test mental capacity and protect against undue influence. “With contested wills on the rise, charities are keen to avoid the emotional, financial and reputational costs associated with inheritance disputes, defending donors’ wishes and their own legal obligation for funds allocated to them. We are keen to ensure that the new system provides greater protection for the public and minimises the scope for conflict between charities and any other potential recipients.” q

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every day. Patient care and wellbeing is the heart and drive of the Royal College of Surgeons (RCS). They are a registered charity, independent of the NHS, and for more than 200 years have safeguarded the standards of clinical practice. There are many reasons why you may find yourself under the care of a surgeon – few people have not benefited, either directly or indirectly, from advances made in surgery. The charity’s work is not limited to specific illnesses or areas of disease but supports better care for all ages, from minor day surgery and the removal of cancer, to life-saving emergency procedures and trauma care. In every case, the patient places their trust in the hands of the surgeon. Although this trust is well founded, there is a need to invest continually in education, research and training to ensure that surgeons – and the care they provide is – the best in the world. While the medical world continue to strive for the cure to many diseases and cancers, in many cases surgery remains the most effective treatment. 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. Surgery saves lives and a gift will help those who put theirs in the hands of a surgeon. q

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 • Seeing Dogs is a member of the International Guide Dog Federation (IGDF). 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.

www.yourexpertwitness.co.uk

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Solicitors urged to raise the issue

One in four people will have experience of mental illness, but stigma around mental health still prevents people raising it as a topic when considering their will. So how can solicitors help their clients to discuss the issue openly? DANIEL WALSHE from the charity Rethink Mental Illness considers the challenge.

[THE SAD FACT IS that people with severe mental illness die,

on average, 20 years earlier than the rest of the population, and are often dependent on family members as long-term carers. So clients with mental illness in the family may be thinking about how they will support a loved one after they die. If the subject of mental illness does crop up, be prepared to talk about it openly. It may be a difficult topic for your client, too, at first; but our experience shows that, once in the open, it can be a huge relief to talk about it. When writing a will, the priority for most people will always be to take care of their family, friends and other loved ones. It’s at that point that more people are considering leaving a gift to a charity to which they have a personal connection. Gifts in wills are one of the most important ways people can show their support for an issue that matters to them. Although the numbers are rising it’s often an opportunity which is overlooked. Often it’s simply a case of solicitors’ clients not realising that it’s an option. That is where the legal profession can play a vital role. While solicitors are prevented from suggesting that a client leave specific gifts in their will,

research released in October 2016 by Remember A Charity showed that over two thirds of people responding to an online survey said that they would be happy to have a solicitor mention charitable giving during the will-writing process and almost half said that solicitors have ‘a duty’ to make clients aware of the option of legacy giving. So if you find yourself in a situation with a client whose family has experience of mental illness, remember these words from our supporter Ernestine: “I am leaving a legacy to Rethink Mental Illness. I know that many people find the idea a bit daunting, as I did. But its much easier than you think, and your mind is so much calmer after; you can just get on with you life. I feel if I leave what I have to Rethink Mental Illness they do have the determination, the expertise and the perseverance to fight in order to get mental illness the attention that it needs.” q • For further information contact Daniel Walshe, High Value and Legacy Manager at Rethink Mental Illness – www.rethink.org, email daniel.walshe@rethink.org, tel 020 7840 3032.

Legacies – the gift of life [ANIMAL CHARITY Wild Futures rescues

and offers sanctuary to monkeys who have suffered abuse and neglect. They are dedicated to protecting primates and their habitats worldwide – they are endangered due to climate change, habitat destruction and the bush-meat and pet trades. For some species, it is too late. The future of all that remains lies in our hands, so leaving a legacy to Wild Futures is the gift of life and a future for primates and our wonderful planet. Wild Futures’ holistic approach makes them unique – providing sanctuary to rescued

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monkeys, supporting projects overseas, campaigning for primate welfare, educating to protect primates worldwide and promoting a sustainability and ethical ethos. 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 • For more information call 01503 262532, email giving@wildfutures.org or visit the webiste at www.wildfutures.org.

Electronic wills: the future or the present? [ONE OF THE POTENTIALLY game-changing aspects of the Law

Holidays help boost confidence of young cancer patients

“

For me the charity has not only allowed me to rebuild the loss of confidence but has enabled me to do so in a safe and homely environment with like minded peers – that has a support group effect

”

Commission’s consultation on the law regarding will-making is the introduction of electronic wills. It is also the one that attracted most comment from respondents. On the issue the Law Society said in its submission: “To encourage the take up of wills, we recognise that there is a need to improve the methods available to approach the issue. We are therefore not opposed to the possibility that wills may, at some point, be made electronically. “However, we urge caution against proposals to usher in fully digital processes for making wills at this point in time. Without access to a detailed proposal of how a digitalised system might operate in practice and guidance to accompany such, it is difficult to picture how this could be implemented. We strongly recommend that, should the infrastructure for electronic wills become available, a comprehensive consultation exercise should be carried out to assess the need for such, as well as the risks and benefits it presents.” Its president Joe Egan said: “We support efforts to simplify the process of making a will and we acknowledge the need to start looking at technology to support existing practice. There are issues we will need to work through to ensure wills made online can be proven valid, but it is an area for further debate.” For the Institute of Legacy Management (ILM), however, the issue is more pressing. The ILM raised concerns that the consultation fails to pay sufficient attention to the increasing impact of technology on will making.

[THIS QUOTE FROM Dave sums up the value of the work undertaken by the Youth Cancer Trust. The organisation provides free therapeutic activity holidays for teenagers and young adults – those aged between 14 and 30 – from the UK and Ireland who are suffering from cancer. The young people who stay at the Trust are often depleted and lacking in confidence from the effects of cancer and its treatment. The service helps promote well being and encourages independence – which in turn helps boost self esteem. Being with other people of a similar age, who understand what it’s like to have cancer, helps reduce the sense of isolation which often accompanies a cancer diagnosis as a young person. 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 Dave. q • For more information visit www.youthcancertrust.org.

Supporting the maritime community [SEAFARERS UK has been helping people in the maritime

community for 100 years, providing vital support to seafarers in need and their families, as well as to those in education or training who are preparing to work or serve at sea. They do this this by giving grants to organisations and projects that make a real difference to people’s lives, across the Merchant Navy, Fishing Fleets, Royal Navy and Royal Marines. Last year they gave grants totalling £2.5 million to over 70 maritime welfare charities. Seafarers UK receives no government funding and is heavily dependent on public donations and legacies to maintain its grant-making. q • To support Seafarers UK or to find out more about their work, visit www.seafarers.uk or email seafarers@seafarers.uk www.yourexpertwitness.co.uk

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In its own response, the ILM said the growing trend towards writing wills through the use of technology was already affecting the probate process, but that the consultation failed to acknowledge that – and the issues it may cause. Its chief executive Chris Millward said: “The consultation seems to defer all conversation on technology in the will process, suggesting it’s a future problem. But we know that people writing wills online is having an impact now and requires considerable consideration, fast.” The consultation proposes that the Lord Chancellor is given the power to introduce fully electronic wills by statutory instrument, without specifying a timeline or the level of public consultation this would involve. The time for action, however, is now, said Millward. “Our members are already seeing the consequences of wills made online, and as we become more reliant on technology, this is likely to increase. There is a risk of badly drawn-up wills resulting in donors’ final wishes being frustrated, and failing: meaning charities and their beneficiaries miss out on vital support. The introduction

of fully electronic wills would complicate the process further. “The law needs to catch up quicker with the changing way people are writing wills. We can embrace technology while retaining essential safeguards and standards to make sure such wills are legally robust and

Education through the power of play

[ACTION FOR SICK CHILDREN is currently focusing on its two

main projects – Dental Playbox and Magical Power of Play Appeal. The Dental Playbox project is a preventative programme to educate the under fives, through the powerful medium of play, in the importance of good oral hygiene, sensible eating and drinking – along with visiting the dentist on a regular basis. In this, its 10th anniversary year, the aim is to educate at least 10,000 children! The Magical Power of Play Appeal supports the invaluable work of health play specialists by providing play resources for hospitals across the UK. These resources help to improve the hospital journey for sick children through distraction and recovery. 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 • For further information contact NFBUK on 01924 291313, email admin@nfbuk.org or vist www.nfbuk.org.

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vulnerable people are protected. Tighter regulation and standardisation of online willwriting platforms would help achieve this. “We encourage the Law Commission to revisit the issues around online wills as a matter of urgency, and would welcome the chance to discuss this with them further.” 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

How to support those who support victims [ THE LEADING independent charity

in England and Wales for people affected by crime and traumatic incidents is Victim Support. Last year the service offered support to nearly a million victims of crime: victims whose lives had in many cases been torn apart by the crime they’d experienced. In 2016-17 Victim Support also helped over 1,200 witnesses through their court experience. But its work doesn’t stop there – they continue to help victims rebuild their lives once the court process is over until they no longer need support. Victims and witnesses often report that giving evidence in court is both ‘re-traumatising’ and ‘terrifying’. Victim Support has supported children as young as three in preparing to give evidence in court and continues to work with families and other professionals. They support young witnesses in a range of ways: pre-court visits, offering practice on live video links, setting up meetings with judges and advocates and using stories, games and activities to help children build up their confidence and self-esteem. That combination of practical and emotional support ensures that children are fully prepared for the court process and have the best chance of giving their very best evidence. 17-year-old Lara said: “Vanessa from the witness service was brilliant, going above and beyond what I expected. She provided support throughout my court case, starting from her giving me and my family details of what would happen in court, right over to her helping me to write my statement. As well as the emotional and practical support, just having a familiar face was really reassuring.” 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

Consortium racks up a double century [ REMEMBER A CHARITY has

announced a new milestone in its development, with the 200th charity joining the consortium in October. Shine supports those with spina bifida and hydrocephalus. Its chief executive Kate Steele highlighted the importance of legacy fundraising for the organisation. “By being part of the Remember A Charity campaign,” she said, “Shine will be part of a movement to grow our legacy giving now and into the future, working alongside fellow charities to raise awareness and promote the importance of gifts in wills to our supporters and the wider public. “Shine is delighted to be recognised as the 200th member. Such high membership is testament to the faith that the third sector has in the work of Remember A Charity, and recognition of the importance and potential to grow legacy giving for the benefit of so many.” By focusing on what no single charity can do alone, the consortium enables the sector to collaborate with one clear voice about the importance and impact of gifts in wills. Remember A Charity delivers high impact public awareness campaigns, lobbying government and the legal sector

to help make legacy giving become a social norm. Remember A Charity’s membership and supporter development manager, Emma Bockhop, added: “The size and diversity of the consortium’s membership are critical success factors for the campaign. “A broad base brings a wide range of insights and experiences and makes our collective voice more powerful. Crucially, it also extends the reach and relevance of our messages and influencing work, bringing us ever closer to achieving our

goal of normalising legacy giving. We thank all our members for their support and encourage other charities to come on board to help achieve our shared goal even more quickly.” q

Tax claims: delays reported at HMRC [IN NOVEMBER the Institute of Legacy Management reported delays experienced

by its members with the processing of claims by HMRC. HMRC confirmed to the ILM that there was a delay of around 6-8 weeks in terms of standard processing times. They explained that it is for two reasons: • A backlog from earlier in the year due to the increased volume of submissions as a result of the proposed increase in probate registry fees • The introduction of a new process/scanning system, which means all correspondence must be scanned when received. That caused delays in terms of when cases can be assigned to officers. They confirmed that more people had been taken on to deal with the backlog but that it will take some time to clear. q

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. www.yourexpertwitness.co.uk

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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 2016. 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

Charity helps kids with kidney problems [FOUNDED IN 2000, Kidney Kids Scotland supports children

with renal illness and their families and is the only Scottish charity specifically set up to do so. The main aim of the charity is to enable children to receive treatment as close to home as possible, thus minimising disruption to the family unit. To do that Kidney Kids Scotland works closely with consultants and other medical and welfare personnel, relying on their expertise to identify where help is most needed. In addition, the trustees believe that no family should have to worry unduly over financial problems while also worrying about a sick child, and they do their utmost to support those families in any way they can. The charity principally supports the Royal Hospital for Children in Glasgow, which is the only centre in Scotland where children with end-stage renal failure can be treated with haemodialysis or receive a transplant. Kidney Kids Scotland has also been instrumental in setting up the first-ever home haemodialysis service in Scotland, also based at the Glasgow centre, and is funding a nurse to set up the new service. A pilot is underway and the first family is currently undergoing the training needed to carry out the treatment at home. Haemodialysis provides greatly improved health and quality of life. Children can participate fully in family life and have flexibility as to when and how often to dialyse. They can also partake of a more enjoyable diet. Patients feel better both physically and emotionally, and achieve better clinical outcomes such as reduced medication and improved blood pressure. q

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When the presents come from [ the taxman! IN THE LEAD UP to Christmas, lawyer Nicola Waldman – a partner in Hodge, Jones and Allen LLP – explains why bequeathing money to charity in a will can actually increase what is left to family members. “Without wanting to quash the sentiment that we in the UK are a generous bunch,” says Nicola, “inheritance tax (IHT) advantages introduced in 2012 are likely to have encouraged charitable bequests. If you leave 10% or more of your estate to a UK registered charity, not only is the amount you give to charity free of IHT, but the IHT on the rest of your estate is 36% instead of 40%.” She cites the fictitious example of Scrooge, who has an estate of £500,000 and (somewhat surprisingly!) leaves it all to Bob Cratchit. After deduction of his nil-rate band (£325,000) his estate will pay IHT of £70,000. However, had Scrooge left 10% of his estate to a UKregistered charity, the tax bill would have been £56,700 – saving £13,300. Nicola continued: “The other point to bear in mind is, for those who want to give to charity anyway, the ‘cost’ of a 10% legacy to non-charity beneficiaries, such as the family, is the same as the cost of a 4% legacy. “In other words, let’s say Father Christmas has an estate of £950,000 and was going to leave 4% to the Charity for Retired Reindeer and the rest to his niece and nephew. As the charity gift is less than 10%, the original 40% rate of IHT is still payable on the rest of his estate. That means the charity gets £25,000, the IHT is £240,000 and the children get £685,000 between them.

“Had Santa been more generous and given 10% to the charity, the 36% rate of IHT would apply. The charity would now get £62,500, the IHT would be £202,500 and the children would still get £685,000 – no difference to the children, the charity gets more and HMRC pays the difference!” In addition, says Nicola, it often makes sense to make a bigger charitable gift from an estate you’ve inherited. A gift of 4-10% of that estate actually costs the non-charity beneficiaries more than a gift of 10%. She cited an example from an actual case: “Two brothers wanted to give money to the RSPCA from their mother’s estate. She had left everything to them in her will. They told their lawyer they wanted to do a deed of variation to the will, leaving what amounted to 9% of the estate to charity and keeping the balance. “In the estate of £1,200,000, that would have meant a gift to charity of £78,750 and a tax bill of £318,500, leaving the brothers with £802,750. Instead, their solicitor advised them to give 10% of the estate to the RSPCA. It then received £87,500; the tax bill was reduced to £283,500 and the brothers received £829,000 – a net saving to them of £26,250, achieved by leaving a bit more to charity.” The moral of the story is clear: in certain cases, the more you give, the more you save. Merry Christmas! q

Helping the forgotten people of Zimbabwe [ZANE: ZIMBABWE A NATIONAL EMERGENCY is a UK registered

charity working to help the most destitute, vulnerable and impoverished people in Zimbabwe. It is the largest supplier of financial aid to elderly people in Zimbabwe who lost their life savings and pensions in the economic collapse and subsequent hyper-inflation. This includes over 600 frail veterans and their widows who fought for the Crown but have been left destitute and surviving on one meal a day. ZANE assists with rent, medical bills and food – and, crucially, also provides comfort, advice and support. In addition, ZANE funds a clubfoot correction programme, successfully treating over 2,600 children to date. It funds the provision of prosthetic limbs for victims of landmine explosions and assists people with hearing loss. ZANE also funds education programmes including the provision of pop-up classrooms in high-density townships for children who would otherwise not receive an education. It runs creative therapy workshops for women living in extreme poverty who are victims of political violence and trauma. Whilst a change in leadership brings hope of a brighter future, it will take years, if not decades, to recover from the economic and social devastation of the last 30 years. In the meantime, ZANE will continue to provide aid and comfort to those who need it most. q • To find out more about the work of ZANE visit www.zane.uk.com www.yourexpertwitness.co.uk

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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 Mr Jeremy P Crew MA MD BChir FRCS Translations and Interpreting for the Legal Profession since 1997. Specialists in Personal Injury and Clinical Negligence.

Consultant Urological Surgeon Medical reports on all legal aspects of urology. Reports in some cases based on hospital notes only.

www.abc-translations.co.uk

www.oxfordurology.co.uk

Mr Antony M. Visocchi

Dr Joshua Adedokun

Independent Dental Expert Witness • Emergency care • Diagnosis and treatment planning • Issues of consent • All routine treatment

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

www.dentalexpertwitness.co.uk

www.expertpainreports.co.uk

Mr Chris Makin

Dr Lars Davidsson (LSM) MRCPsych MEWI

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

Consultant Psychiatrist and Accredited Mediator Reports within most areas of general adult psychiatry. Specialist in PTSD, anxiety disorders & mood disorders.

www.chrismakin.co.uk

www.angloeuropeanclinic.co.uk

David Berry PhD FRC Path MFSSoc MRSC

Mr Marcus Ornstein

Independent Toxicology Consultant Specialist in toxicology with particular emphasis on drugs (both prescribed and illicit) and alcohol.

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.toxicologyservices.co.uk

www.marcusornstein.co.uk

Dr David Usher BSc DPhil FCIEHF

Mr Mark Duxbury

Consultant Ergonomist: Identifying ergonomic issues behind work-related injuries. Assessing the equipment provided and the risk management system in place.

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

www.interactionofbath.com

www.markduxbury.info/medicolegal

Emma Ferriman Ltd

MD5 Ltd

Consultant Obstetrician and Fetal Medicine Specialist • Prenatal diagnosis • Obstetric ultrasound • First trimester screening • Multiple pregnancy and high risk obstetrics

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

www.emmaferriman.co.uk

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 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

Sector Forensics Ltd

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

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

www.expertcolorectalsurgeon.co.uk

www.sectorforensics.co.uk

Dr Nigel Kellow MB BS FRCA MBA

Mr Simon Bramhall

Consultant in Anaesthesia & Pain Medicine • Spinal cord and nerve injuries • Complications relating to anaesthesia • Fibromyalgia • CRPS • Back & neck pain

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

www.kellow.com

www.simonbramhallhpbsurgeon.co.uk

Premex Group Ltd

Stockport Psychology Services

A leading provider of independent medical reports Choose from a panel of experts providing national coverage in every specialism

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

www.premex.com

www.sps.uk.net

Robert Hensher FRCS FDSRCS

Dr Thomas C M Carnwath

Consultant Oral and Maxillo-Facial Surgeon Subspeciality interests: • Dental Implantology • Salivary Gland Surgery • Temporomandibular Joint Replacement

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

roberthensher@gmail.com

www.tomcarnwath.co.uk

www.yourexpertwitness.co.uk

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MEDICAL NOTES [LIKE ALL FOLLOWERS of football (and one who sustained a cruciate injury during a game

in the 1960s, before anybody had cruciate injuries), I have been saddened by the stories of the dementia suffered by heroes of my childhood – Jeff Astle of England and The Baggies and World Cup-winner Nobby Styles, among others. A recent TV programme by Alan Shearer brought into sharp focus the stresses exerted on the brains of footballers when they head the ball. It’s something that we’ve taken for granted for generations, but which is now the subject of research to be carried out by a team appointed by the FA. Brain injuries sustained by sports players has come more to the fore recently, with rugby forwards and American football players being seen as more obvious sufferers. The more delicate art of heading a soccer ball puts the issue into a more stark contrast. • Mental illness is still not considered as serious as physical illness, despite promises by successive governments to address the problem. In particular, people in prison or in detention in police stations are unlikely to have their mental health problems addressed by those holding them. When it comes to people with mental health problems in prisons, it seems the government doesn’t even know who they are. A damning report by the National Audit Office finds that the government is failing miserably to fulfil a promise made to address the issue of mental health in prisons – and the situation is getting worse. • The problem is not confined to the prison service: latest figures on those we entrust to care for people with mental health issues – the mental health trusts – show they are restraining people on average every 10 minutes. That flies in the face of Department of Health guidelines. It seems we have not progressed as far from the 18th-century concept of Bedlam as we thought we had. • If you are elderly the risk of being mistreated is amplified. A NHS Trust in Shropshire has been fined one third of a million pounds over its failures of care regarding five elderly patients who died while in its care. Of course, the fine will be paid by: oh, yes; the taxpayer, who will have to cover the shortfall. The individuals responsible for the scandal will escape, as usual, scot-free. • Another problem experienced by elderly patients is that of failing eyesight. It is also one which can be addressed by those caring for them without any need for expensive equipment. Where there is a potential problem of eye damage in intensive care units, a set of guidance notes can help front-line staff avoid future problems by protecting the eye while carrying out treatment. • Of course, while we are in hospital or at our local GP surgery, we can be pretty certain that the people treating us have the appropriate qualifications and are subject to the correct regulation. But what if they are treating us privately, from their own offices or even in our own homes? The regulation of healthcare professionals has been the cornerstone for making sure people offering healthcare services are who they say they are. However, a residual confusion has resulted in a consultation on an overhaul of the regulation. It ends on 23 January. q

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Government consults on regulation of health professionals [A CONSULTATION IS currently underway looking at the regulation

of health care professionals, based on recommendations from a 2014 report by the UK Law Commissions. The Regulation of Healthcare Professionals proposed major changes to the way in which health and social care professionals are regulated in the UK. Its reforms are aimed at consolidating and simplifying the existing legal framework, while imposing greater consistency across the regulators in some areas, such as the conduct of fitness to practise hearings. The report’s key recommendations included: • New powers for the regulators to make their own rules • A new barring scheme to prevent certain professionals who have • committed serious crimes from practising • Greater use of mediation in fitness to practice proceedings • Consistency across the regulators in the way that fitness to practise • hearings are conducted

• Enhanced duties on the regulators to consult the public and work • collaboratively • Less government interference in the rule making process and the • appointment of the regulators/PSA boards The Government has responded with a consultation to bring forward the recommendations. At the same time, Health Minister Jackie DoylePrice issued an interim response to the 2016 Mental Capacity and the Deprivation of Liberty report. In a written ministerial statement, she said: “I welcome the publication of the Law Commission’s report, which we are carefully considering and thank them for their careful and considered work. We will now engage with a range of stakeholders to understand in greater detail how these changes can be implemented.” The current consultation ends on 23 January and the Government has promised a final response in the spring. q

Trust fined following fall deaths [SHREWSBURY AND Telford Hospital NHS Trust has been fined a third

of a million pounds, and ordered to pay £130,000 costs, following a series of HSE investigations into the deaths of five elderly patients. Stafford Crown Court heard that the patients, aged between 72 and 92, sustained fatal injuries as result of falling while being cared for in hospitals run by the trust. The deaths took place between June 2011 and November 2012. The HSE investigations found that fall prevention measures, including close supervision of those in a confused mental state, were not properly applied. That was made worse by poor consideration and communication of measures to protect against falls arising from each patient’s particular frailties. In a statement, Lucy Anderson Edwards – a great niece of Edna Evans, one the patients who died – said on behalf of the family: “I am just thankful that after today’s events myself and the rest of her remaining family can finally have some closure and move on from the somewhat horrifying past events and undignified circumstances in which Edna passed away. “Nothing will ever rectify, and nothing will ever justify, the tragic events that led to Auntie Edna’s death, but today I am grateful for the Shrewsbury and Telford Trust’s open admittance to fault and I can only hope that bringing my aunt’s case to light will go a long way in preventing such catastrophic future errors.

“My thoughts are with fellow families and friends of other loved ones who also fell victim to a failure of care from the Shrewsbury and Telford Hospitals Trust. Finally as a family we’d like to thank the Health and Safety Executive for pursuing this investigation, as well as its impeccable support and professionalism throughout the whole lengthy case in aim of achieving the best justice possible.” q

APIL comments on bereavement ruling [APIL has reacted to the judgement by the Appeal Court in

the case of Jacqueline Smith – the Lancashire woman awarded bereavement damages following the death of her partner John Bulloch, with whom she had lived for 11 years. Its president Brett Dixon said: “Ms Smith’s case highlights an area of our justice system about which we should be ashamed. The law on bereavement damages in England and Wales is desperately out of touch. The price of a life is valued at an arbitrary figure and anyone other than a spouse or civil partner and some parents of under-18s are not deemed close enough to the deceased to make a claim for their loss and suffering. Let’s not forget that their loved ones would still be alive were it not for the negligence of others. Bereaved families deserve better.” q www.yourexpertwitness.co.uk

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The report is the centrepiece of medico-legal work [THE FOCAL POINT of an expert

“

in areas such as whiplash instead witness’s contribution to a case is of orthopaedic consultants – most the expert witness report. In the case specialise in a particular field of of a medico-legal expert that will medicine. In general GPs are able usually be based on a combination to comment on areas of medicine of medical reports and possibly an normally dealt with in the GP’s examination of the claimant. surgery. A GP expert will also According to the British Medical comment on cases involving GP Association: “A medico-legal clinical negligence. expert’s report is a vital element in More specialist areas of practice litigation. It must be clear, succinct, will normally require reports from independent and well presented. consultants in their field. Your “Reports are seen by many Expert Witness routinely carries professionals during litigation and articles from experts in their often new instructions are received specialties intended to explain the from opposition lawyers. Many issues to lawyers. medico-legal experts create their own Dr Zafar also offers useful advice report writing style or adopt other that solicitors can pass on to their people’s generalised formats, having clients if they are required to attend Civil Procedure Rules (35.3) rarely received constructive feedback a medico-legal examination: “It is from lawyers on what is required important that they spend a few from their medico-legal reports.” minutes beforehand making a The two main types of case that mental note of approximate dates involve a medico-legal report are those involving personal injury and ways in which they have been restricted. This will save a lot of and clinical negligence claims. time spent trying to remember in the examination.” q According to Dr Asef Zafar, a GP who acts as an expert witness in both types of case: “Both types of medico-legal cases require a slightly different skill set, but often have a large crossover in terms of what the medico-legal expert is looking for. Medico-legal reports have to adhere to a certain standard of quality, so that the court is able to fully understand its implications.” He goes on to describe a number of different cases that may require a medico-legal expert’s report. “This can be as simple as producing a medico-legal report on a car accident and as complicated as building a full medico-legal court case. When dealing with medico-legal matters, it is equally important to consider both the medical and health aspects of a situation as well as the potential for any legal claims.” The base from which an expert report is written is the overriding duty of the expert to the court, rather than the party engaging the expert. That is put succinctly in the Civil Procedure Rules (35.3): “It is the duty of experts to help the court on matters within their expertise. This duty overrides any obligation to the person from whom experts have received instructions or by whom they are paid.” The role of the expert witness in medico-legal cases was summed up as long ago as 1953 in Scotland. The comments of Lord Justice-Clerk Cooper at the time are still as relevant today: “Expert witnesses, however skilled or eminent, can give no more than evidence. They cannot usurp the functions of the jury or Judge sitting as a jury any more than a technical assessor can substitute his advice for the judgment of the court. Their duty is to furnish the Judge or jury with the necessary criteria for testing the accuracy of their conclusions, so as to enable the Judge or jury to form their own independent judgment by the application of these criteria to the facts proved in evidence. The scientific opinion evidence, if intelligible, convincing and tested, becomes a factor (and often an important factor) for consideration along with the whole other evidence in the case, but the decision is for the Judge or jury.” While a number of experts operate in the field of general practice – and there is evidence that GPs are being instructed increasingly

It is the duty of experts to help the court on matters within their expertise. This duty overrides any obligation to the person from whom experts have received instructions or by whom they are paid.

”

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Medical litigation: the wind of change has become a hurricane 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 • Expert Witness in Community Paediatrics and Clinical Public Health

[WHEN I STARTED my first house job at Whipps Cross Hospital,

London, in September 1964, all NHS doctors had state-backed indemnity. There were no complaints from patients, so it was hardly ever used. My consultant would be invited by the relatives of a deceased patient, who had been under his care, to attend the funeral. The senior registrar, registrar, senior house officer and myself – the houseman – managed to do daily ward rounds. There was an enormous amount of money in the NHS at that time due to political gains. Geriatric and long-term patients’ wards in hospitals were extended to make free care homes. The registrar prescribed expensive medication, if needed, and I prescribed cheaper ones. No-one, but no-one, went without medication – no matter how expensive. I was backed by the ward sister and staff nurse. They would even set up a drip for a patient, when needed, if I went to the dining room for lunch or dinner: real team work. I used to prescribe sleeping tablets – usually Welldorm – for most patients, as there was no pressure to send them home. Good sleep was a bonus. A young diabetic patient would go to work during the day and come

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back to his hospital bed at night to have his insulin injection. A male nurse advised me that if I let the patients sleep then they would not call me at night. Those were the days! One evening recently, after attending a meeting at the Royal Society of Medicine, I was advising a young doctor that she must consider writing at the end of every set of consultation notes: ‘advised to seek further medical help if needed’. That would protect her if there were a complaint against her. As an expert witness in GP clinical negligence, I am witnessing a big change in British culture. Nowadays, the relatives of a deceased patient go to the GMC, solicitors and the courts to pursue action against their GP. They do not seek a meeting with the GP – or their Medical Defence Union, who now have to pay a lot of compensation claims. I am afraid the state-backed indemnity promised recently by Jeremy Hunt , Secretary of State for Health, is essential; but that alone cannot guarantee the survival of the National Health Service in the UK. The winds have changed to hurricanes and there is more to it than meets the eye. Let us do something together to help doctors in this expanding complaints culture – and not blame each other. q

The changing face of clinical negligence claims [LAW FIRMS in the clinical negligence sector in 2017 must look back

So how does the BMS Funding model work? “Essentially, we have access to over £100m through partnerships on the pre-Jackson Reforms days of 2013 and earlier, and wonder what with trusted funders, and we are able to use this to support clinical they ever had to worry about back then. negligence litigators,” Tony enthused. “We will meet with the law The changes in this arena may not have been as dramatic as they were firm, and once we establish that the scheme is going to benefit all for the personal injury practitioners, but with clinical negligence cases parties involved, we are able to finance the disbursements. Equally continuing to be extremely lengthy and difficult – not least because they importantly, the firm then has access to the UK’s leading ATE insurer involve two sets of equally eminent experts presenting opposing views – a products specifically designed for BMS firms and their clients, triage huge impact has been felt in clinical negligence firms across the UK. providers and bespoke medical reporting organisations’ solutions.” Despite the challenges faced by clinical negligence solicitors, the Tony added: “We are often asked: ‘but what is in it for BMS?’, well-documented changes introduced by Lord Justice Jackson in 2013 which is a fair question and one which is simple to answer. We have forced personal injury firms – desperate to ‘de-risk’ their exposure select the best organisations in the business to partner with and to the RTA market – to move into that territory, increasing competition then receive small commissions for offering the services to our for cases several-fold. There have been further negative impacts on clients. What this means is that the cash flow as a result of changes to the claimant can be assured that they are payment structure and enforcement of in the best possible hands, not only proportionality and budgets. with a professional legal team on their The proportionality issue is one that side but with access to the country’s has hit firms particularly hard, especially experts in the field. when they are dealing with extremely “The law firm benefits from financial complex cases – which by their nature security and the knowledge they can require a lot of time and therefore continue to build their business without financial commitment, but do not often, tying up capital in lengthy cases, and by the same token, generate the large BMS Funding receives moderate potential success fees. With average commissions to ensure the whole cash costs of £20,000 to £30,000, firms model is benefitting all involved, not are really having to debate which cases just financially but to ensure the health to take on: a problem which is only going of the claimant is paramount and that to get worse with ever-rising court and they have the best possible chance of expert reporting charges. justice being served.” Added to all of this is the fact that, So what about the future for the while in theory an average case could be clinical negligence sector? The next resolved within 18-24 months, many more significant change in this area will have complex medical negligence cases go BMS Funding director Tony Sullman just as large an impact as the Jackson on for three, four or even five years. That Reforms did in 2013, should it go is another factor which has a particularly ahead. The change referred to is, of course, the one of fixed costs negative effect on a firm’s cash flow and appetite to take on new cases. regimes: a subject which was first mooted in 2015 and is still being It has been a tough few years for the clinical negligence side of many discussed in Westminster nearly three years on. law firms. Even before Jackson cases were tough on cash flow, simply The premise is that it would be a positive step for the industry because of the length of time involved in so many lawsuits. But for the past to limit the amounts that can be claimed. The NHS alone paid three years it has been a lot worse. Firms feel the pressure not only from out nearly £1.5bn in clinical negligence claims in 2015/16, and increased court costs but also, because the NHS is under such financial understandably the public is reported to be strongly in favour of strain, settlements are taking longer – so cash flow has never been so implementing fixed costs to ensure any NHS funds can be deployed severely affected. more effectively. It is against this ever-worsening backdrop that in 2015, Midlands-based However, there is strong opposition from law firms, who argue BMS Funding was established specifically to help firms in the personal that the premise that lower value cases are less complex is not injury and clinical negligence markets. necessarily true; and also that NHS Resolution (formerly the “Our model allows firms to release cash from their business so that they NHSLA) should focus more on the underlying causes of the rising can profitably manage their clinical negligence case load,” explained Tony numbers of medical negligence cases rather than taking the ‘horse Sullman, director of the litigation funder. “It allows the law firm to increase has already bolted’ approach of discussion on case fees. marketing spend to attract the right cases, and also to have the necessary Whatever the outcome of this latest debate, one thing is clear; finance to take the case on – ultimately allowing our clients to gain volume unfortunately there will always be clinical negligence claims and we efficiencies and grow their businesses.” need firms who are financially able to provide access to justice for Tony continued: “We first brought the funding solution to the clinical all and not just the few. q negligence market early in 2017, initially working with two to three firms. Nearly 12 months on we have been able to fund dozens of cases and not • BMS Funding is working to become the leading fund provider for only help ensure the future growth for many law firms, but also ensure small and medium-sized law firms and ABS businesses in England claimants have the best possible support in terms of triage assessment, and Wales. For more information visit www.bmsfunding.co.uk, medical expertise and medical reporting in court. It is a well-used phrase, email info@bmsfunding.co.uk or call 0333 212 7151. but the BMS model genuinely offers a win-win result.” www.yourexpertwitness.co.uk

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Fitness to Practise: GDC publishes its data [THE General Dental Council (GDC)

has published an analysis of its fitness to practise (FtP) case data – compiled by an independent organisation – and its policy response to the findings. It is the first time that the GDC has carried out such an in-depth statistical analysis of its FtP data and marks the first step in a programme of work aimed at assisting with reforms towards making it a better, fairer and more efficient regulator. In January the GDC launched Shifting the Balance, which set out its proposals to reform dental regulation. It aims to work collaboratively with partners to develop a model of ‘upstream regulation’ that involves professionals and the regulator working together in the interests of patient safety and public protection. According to the GDC: “As part of this reform programme, we have committed to improving the collection, analysis and use of data and intelligence, and to work with partners and the profession to understand what it tells us. Improved data analysis will enable the GDC to develop an intelligence-led approach to upstream regulation.” That, says the GDC, can be used to identify potential problems and enable it, together with its partners and the wider profession, to take steps to address them, reducing the risk of harm. In its response to the publication of Shifting the Balance, the British Dental Association said: “The BDA continues to receive highly critical comments about the level of knowledge and expertise of those working on FtP cases – including case workers, case examiners, legal advisers and expert witnesses – including recent as well as historic cases. While the focus on upstreaming and defining ‘seriousness’ is welcomed, there is still more work to be done to improve the detailed work in the FtP section when cases are handled.” The report, published in November, reveals some important insight into the types of cases and dental professionals that appear in the FtP data.

The findings include: • Male dental professionals were more likely than female dental professionals to have been involved in an FtP case • Dentists were significantly overrepresented at all stages of the FtP process, compared to all other registrant groups • Dentists that came onto the register by taking the Overseas Registration Exam were less likely to be involved in an FtP case compared to their UK-qualified counterparts • Dentists coming on to the register having qualified in an EEA country were overrepresented in FtP cases • The odds of having been involved in an FtP case were 22% higher for dental professionals identifying as Asian or Other, compared to those identifying as White The GDC points out that there are significant gaps in the data, as it is provided by dental professionals on a voluntary basis. The council will be considering how to encourage dental professionals to provide voluntary information, so any analysis can provide better insight.

It is also just one source of information in a complex landscape, the GDC says, and is not on its own able to establish the factors that are causing the findings. Jonathan Green, executive director of Fitness to Practise at the GDC, said: "This is a major step towards improving our use of data and intelligence to inform upstream regulation initiatives – to improve patient protection, ensure the public maintains confidence in dental services and to better support professionals. "We made a commitment within Shifting the Balance to use data and intelligence to inform our approach to regulation, and this statistical analysis of our fitness to practise data is one of the ways we are working to fulfil this. We have already started to use the findings to feed into our on-going work to deliver our commitments. We will continue fulfilling our commitment to better share data and intelligence with the dental sector by developing a 'state of the nation' report, to be published at the beginning of 2019.” q

Campaign highlights oral cancer scourge [NOVEMBER saw a month-long campaign by the Oral Health Foundation to raise

awareness of mouth cancers. Oral cancer kills nearly 2,000 people in the UK every year and many of those deaths could be prevented with early referral and diagnosis. Chi-Hwa Chan leads the oncology sub specialty interest group of the British Association of Oral and Maxillofacial Surgeons. He said: “Raising the public’s awareness of the signs that could indicate oral cancer – and early referral and diagnosis by clinicians – are essential to avoid aggressive, lengthy and life-altering treatment.” According to the latest figures for the UK (Cancer Research UK, 2014) the number of mouth cancer cases has increased dramatically by 39% in the last decade, and by 92% since the 1970s. “Anyone can be affected by mouth cancer,” said Chi-Hwa Chan, “but it is more common in people over 40, particularly men. Worryingly, recent research has shown that it is now becoming more common in younger patients and in women. “Public awareness of what to look out for is not as good as it could be,” Chi-Hwa Chan explained. “This is why the Oral Health Foundation campaign is so important. People should look out for mouth ulcers, whether they are painful or not, or any unusual lumps or swelling, and consult their dentist or GP.” q

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Getting to the root of the problem 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 VSHFL¿F LQWHUHVW LQ GHQWDO QHJOLJHQFH OLWLJDWLRQ FODLPV In this issue he argues that, regrettably, government policy has been a major factor in increasing his workload.

>MEDICO-LEGAL CASES involving dentistry in the UK have been

rising exponentially over the last 20 years, to the point that we now rank second in the world after Israel for litigation in this area. In fact, a dental practitioner in the UK is now four times more likely to face civil action than a dentist in New York. I was fortunate enough to work in the US in the early 1980s and then returned to the UK to watch things unravel. Our profession is failing to live up to patient expectations and as a consequence we are increasingly being held to account. There are several contributing factors that have led to this more litigious culture, and they are largely a consequence of government policy. Firstly, the new dental contract conceived by the Department of Health, for general dental practitioners providing care under the NHS, LVQ¶W ¿QDQFLDOO\ YLDEOH LI \RX DSSO\ LW OLWHUDOO\ 7KH FRQWUDFW QRZ SD\V D practitioner the same if a tooth is extracted as it does if it is preserved with complex root canal treatment. The former may take as little as 10 minutes, the latter 3-4 hours of treatment time. As a result, there has been a 40% increase in extractions, particularly in children. After 35 years in practice, I still require an hour to conduct a FRQVXOWDWLRQ DQG H[DPLQDWLRQ RI D SDWLHQW ZKHQ , ¿UVW VHH WKHP 7KH NHS dentist is now expected to do the same and include x-rays, oral hygiene instruction, dietary advice and carry out a scaling – all for £18.50. Assuming the clinician needs to see 7-8 patients per hour to cover costs, that leaves 7 minutes for an initial assessment. This inevitably means missed diagnoses and errors with treatment planning, and thus legal action. I believe that NHS dentistry has actually held back the development of good practice, leading to a loss of skills and the need for practitioners to cut corners. The rise of mixed dental practices, where both NHS and private services are delivered, only makes the situation worse. Quite rightly, the public will wonder why on earth the profession signed up to such an agreement. Regrettably, the profession is represented by the British Dental Association (BDA), which has always had a cosy, and some might argue unhealthy, relationship with the Department of Health. It can’t help when senior members of the BDA are referred for annual honours for their support of government SROLFLHV DQG WKH FKLHI GHQWDO RI¿FHU PLJKW EH VHHQ DV D FDUHHU

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politician, cautious about supporting his colleagues at the coalface lest he rock the party boat. Secondly, the advent of recognised ‘specialties’, endorsed by the General Dental Council, has resulted in an explosion of specialist practitioners on the high street that were previously only found in the university and hospital sectors. Whereas maxillo-facial surgeons and orthodontists have been around for over 50 years, you will now find: restorative dentists who rebuild/restore teeth; prosthodontists who replace lost teeth; periodontists who treat gum disease; and endodontists who provide root canal treatments. Furthermore, as dental research has progressed, ‘implantology’ now allows teeth that have been lost to be fixed to the jaw with greater predictability. With these sophisticated treatment options come greatly elevated expectations from the recipients. Patients have never paid more for their dental treatment and, quite understandably, they expect a lot more for their money. And what happens when they don’t get it? Legal action.

I’ve worked in the public hospital and university sectors, general practice and the private sector. I’ve been a medico-legal expert witness for 18 years, and have observed a huge increase in civil actions as a result of the above changes in UK dentistry. I believe the general public is getting a raw deal from the public sector. Cynics will say this has been centrally orchestrated to encourage the private sector to unburden the public purse, much in the same way that optician services have largely become privatised on the quiet. Of course it hardly needs to be said that the comments and views expressed in this article are mine and not necessarily shared by the profession, but I would welcome an open debate, and, ironically, a future with less work as an expert witness. q • All the views and opinions expressed by the author are personal. For further information visit www.tobytalbot.co.uk

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Dentists point the finger at ‘ambulance chasers’ [FIGURES FROM THE dentists’ defence organisation Dental

Protection show that a dentist in the UK is nearly twice as likely to receive a claim for clinical negligence as was the case just 10 years ago; and a full-time dentist can now expect to receive two claims over a typical career. In a survey of over 1,500 dentists published this summer, 94% said they feel it has become easier to bring a claim for clinical negligence than ever before and 90% said they are increasingly fearful of being sued. In response to the figures, the British Dental Association (BDA) has called for a crackdown on no-win, no-fee lawyers, who they say are targeting the profession. The BDA points to Care Quality Commission reports, which continue to demonstrate that dental patients are at lower risk than those seen by any other UK health provider. The association says that a failure to tackle US-style 'ambulance chasers' is now putting health services under strain. According to the BDA, indemnity costs for dentists have increased by over 400% in the past decade, while earnings have fallen by nearly 35% in real terms. A report from the Centre for Policy Studies found that the medical-legal bill is now £24 per person, more than twice the £9 per person in the United States, despite that country's more litigious reputation. BDA chair Mick Armstrong said: "Every official report over the past decade shows our patients are receiving low-risk, high-quality care. All that's changed are the hyper aggressive tactics of these ambulance chasers. "Dentists are already feeling the squeeze on declining pay and skyrocketing expenses. Our patients do not expect to see funds

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desperately needed for investment lining the pockets of voracious no-win no-fee lawyers." In June Dental Protection backed moves towards a fixed recoverable costs scheme for clinical negligence claims up to a value of £250,000, together with an increase in the small claims track threshold for clinical negligence claims up to £5,000. It also called for a minimum threshold for cash compensation relating to claims for minor injuries, to reduce the cumulative cost of damage pay-outs where only very minor injuries are sustained. Its dental director Raj Rattan said: “It is important that there is reasonable compensation for patients harmed following clinical negligence, but a balance must be struck. The rising cost of clinical negligence is impacting on dentists: when the cost of clinical negligence increases, the cost of professional protection must also increase to reflect this – and we recognise the pressure this places on our members. “Dental Protection believes that a package of legal reforms to help tackle the rising cost of clinical negligence – and the challenging claims environment for dentists – is long overdue. We are calling on the government to take urgent action.” q

Assessing brain injury is not always straightforward [A BRAIN INJURY can change lives in an instant. That is the start

point for any case of brain injury for Headway, the charity set up to support people with all kinds of injury to the brain. According to Headway, many people report difficulties in receiving a diagnosis for their brain injury, particularly if they are suffering from persistent and lingering problems as a result of a minor head injury. “The issue can often be compounded if the effects of the person's brain injury are largely hidden,” the charity says. “The cognitive, emotional and behavioural and psychological effects of brain injury can be difficult to detect by those who are not neurological experts. This can leave people without a diagnosis – and without a reason for their ongoing difficulties.” That problem was highlighted by consultant clinical neuropsychologist Dr Linda Monaci, writing in this publication just a year ago. Dr Monaci wrote: “Any event which involves trauma to the head, such as a road traffic accident, may result in a brain injury causing cognitive, emotional and physical symptoms. The severity of a brain injury is usually graded as mild, moderate or severe – and this can help provide guidance on recovery and the rehabilitation required.” In cases where the brain injury is severe and relatively easy to attribute – such as road traffic injuries, blunt force trauma or military action – there is an established (if often contested) route to follow when claiming compensation. However, in the words of Dr Monaci: “To complicate matters, there are also cases in which a very minor blow to the head can cause persistent cognitive and emotional symptoms, even though any brain injury is arguably very unlikely.” In such cases an expert assessment is essential. q

Research set to start into football brain effects [THE FOOTBALL ASSOCIATION and the Professional Footballers’

Association have appointed Dr William Stewart and colleagues at the University of Glasgow and the Hampden Sports Clinic to lead an independent research study into the incidence of degenerative neurocognitive disease in ex-professional footballers. Following two years of research and development, the FA and the PFA have now confirmed the next step in their commitment to commissioning an evidence-based study into the long-term effects of participation in football. This new study, Football’s Influence on Lifelong Health and Dementia Risk (FIELD), is scheduled to start in January. It is designed to look at a wide range of physical and mental health outcomes – including neurodegenerative disease – in approximately 15,000 former professional footballers and compare these results to matched general population health data. “In the past decade there have been growing concerns around perceived increased risk of dementia through participation in contact sports; however, research data to support and quantify this risk have been lacking,” said Dr Stewart, consultant neuropathologist at the Queen Elizabeth University Hospital in Glasgow. The announcement follows public concern regarding prominent exfootballers, including Jeff Astle and Nobby Styles, who have developed dementia at a relatively early age – concerns brought into the spotlight by Alan Shearer. Peter McCabe, chief executive of brain injury charity Headway, said: “We hope that this research will finally provide some answers to families who for too long have been fighting to gain a better understanding of whether or not their loved ones’ dementia was caused by heading a football.” q

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Health trusts ‘restrain patients every 10 minutes’ [ACCORDING TO FIGURES published

by the BBC on 16 November, mental health trusts in England are restraining patients on average every 10 minutes. The figures, obtained by former Health Minister Norman Lamb MP under the Freedom of Information Act and passed to the BBC, show the number of incidents of restraint has increased each year since 2013. They are based on information from 40 mental health trusts in England and revealed that patients were restrained 59,808 times in 2016-17, equivalent to between six and seven incidents an hour. That compares with 46,499 times in 2013-14. However, use of the most extreme restraints – where patients are forced to the ground – fell 9% across 33 trusts. Mental health trusts say they have improved their reporting of their use of restraint, which may have contributed to some of the rise. Physical restraint is classed as ‘any direct physical contact where the intention is to prevent, restrict or subdue movement of the body (or part of the body) of another person’. The Department of Health says there must be ‘a real possibility of harm to the person or to staff, the public or others’ for restraint to be used.

Responding to the figures, Vicki Nash, head of policy and campaigns at Mind, said: “Physical restraint can be humiliating, terrifying, dangerous and even lifethreatening. Mind has been campaigning for a reduction in how much it is used. Prone restraint, when a person is pinned face-down on the floor, can be particularly dangerous. “This doesn’t have to happen. If mental health settings are safe and therapeutic, with enough well-trained staff, we can significantly reduce the need for restraint and other restrictive practices. “These data show that, in many trusts, the use of restraint has increased, which is worrying but not surprising. When we

collected our own data in 2013 we found lots of trusts hadn’t even recorded it properly. It’s essential that trusts record and publish this data, without someone having to obtain it under FoI. It’s really important that we keep up momentum for change and make sure every trust is working towards ending the use of restraint, and especially dangerous deliberate face-down restraint. “There is currently a Private Members’ Bill going through parliament which, if it becomes law, has the opportunity to increase transparency and accountability around the use of force in mental health settings. We want to see people in crisis treated with care and compassion – this Bill will build on the good guidance already in place and make for safer environments for people experiencing a mental health crisis.” In its report the BBC describes the experience of one female patient. “I don't know why they felt the need to do it,” said the 46-year-old from Essex. “I wasn't throwing things around; I wasn't being abusive or anything like that. “They actually hurt me, which wasn't very nice. I had six people holding me down on a crash mat. They pulled down the side of my knickers and injected me.” q

Valproate scandal:

review welcomed by Royal College [THE ROYAL COLLEGE OF PSYCHIATRISTS has welcomed

the announcement by the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee of a review of the use of sodium valproate for pregnant women. The drug, used as a mood stabiliser in the treatment of bipolar disorder and as an anticonvulsant in the treatment of epilepsy, can sometimes be prescribed to pregnant women, with potentially harmful consequences for the foetus. According to the RCPsych, many of the children born to mothers taking sodium valproate in pregnancy will never live independently. In a statement, the college said: “In the treatment of bipolar disorder, sodium valproate is not a first-line treatment and NICE guidance recommends that sodium valproate should not be offered to women of childbearing age due to the adverse effects on a developing foetus/infant. “Sodium valproate should only be prescribed for women of childbearing potential in exceptional circumstances. In those cases, women must be counselled on the risks of both teratogenicity and adverse neurobehavioural outcomes; they must use effective contraception and the treatment must be reviewed regularly.” Speaking following a debate in the Commons in October, Liberal Democrat MP and mental health campaigner Norman Lamb said: “It is estimated that 20,000 babies have been born with birth defects or developmental problems. Mothers have been left distraught and suffering guilt when they themselves are the victims. They deserve an apology and a financial support package. There also needs to be

an inquiry or Hillsborough-style panel to get to the bottom of how this massive failure can have happened.” According to campaigners, a decision was made by regulators back in 1973 to keep information on the dangers of the drug from women ‘…as it may give rise to fruitless anxiety’. Although the Committee on Safety of Medicines recommended that prescribers should be informed of the risks, it advised that these warnings should not be included in packaging leaflets ‘…so that there would be no danger of patients themselves seeing it.’ The Medicines Healthcare Regulatory Association (MHRA) has now developed a Communications Toolkit to aid prescribers in counselling women on the risks of sodium valproate. A Patient Safety Alert was released by the MHRA in April calling for all organisations to undertake systematic identification and review of women and girls prescribed sodium valproate. The RCPsych continued: “It is the view of The Royal College of Psychiatrists that psychiatrists must work with local pharmacy departments and general practitioners to identify all women of child bearing potential who are prescribed sodium valproate, to ensure that the drug is prescribed only to those women where no other treatment is effective and to ensure that those women are fully informed of the risks and are using effective contraception.” The RCPsych also supports the proposal to establish a Clinical Expert Panel to collaborate with the European Medicines Agency to determine whether there is an on-going role for sodium valproate in the treatment of bipolar disorder in women of childbearing age. q www.yourexpertwitness.co.uk

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Report reveals mental health failures in prisons >THE GOVERNMENT does not know how many people in prison

have a mental illness, how much it is spending on mental health in prisons, or whether it is achieving its objectives, according to a report E\ WKH 1DWLRQDO $XGLW 2IÂżFH 1$2 According to the report: â&#x20AC;&#x153;It is therefore hard to see how government can be achieving value for money in its efforts to improve the mental health and well-being of prisoners. â&#x20AC;&#x153;Her Majestyâ&#x20AC;&#x2122;s Prisons and Probation Service (HMPPS), NHS England and Public Health England have set ambitious objectives for providing mental health services but do not collect enough or good enough data to understand whether they are meeting them.â&#x20AC;? In 2016 there were 40,161 incidents of self-harm in prisons, the equivalent of one incident for every two prisoners, while there were 120 VHOI LQĂ&#x20AC;LFWHG GHDWKV LQ SULVRQ DOPRVW WZLFH WKH QXPEHU LQ DQG WKH highest year on record. NAO head Amyas Morse commented: â&#x20AC;&#x153;Improving the mental health of those in prison will require a step change in effort and resources. The quality of clinical care is generally good for those who can access it, but the rise in prisoner suicide and self-harm suggests a decline in mental health and well-being overall. The data on how many people in prison have mental health problems and how much government is spending to address this is poor. Consequently government do not know the base they are starting from, what they need to improve, or how realistic it is for them to meet their objectives. Without this understanding it is hard to see how government can be achieving value for money." In 2016, the Prisons and Probation Ombudsman found that 70% of prisoners who had committed suicide between 2012 and 2014 had mental health needs. The Ministry of Justice and its partners have undertaken work to identify interventions to reduce suicide and self-

harm in prisons, though these have not yet been implemented. While NHS England uses health needs assessments to understand need, these are often based on what was provided in previous years and do not take account of unmet need. The NAO estimates that the total spend on healthcare in adult prisons in 2016-17 was around ÂŁ400m. HMPPS does not monitor the quality of healthcare it pays for in the six privately-managed prisons it oversees. Commenting on the report in its Legal Newsletter, campaigning charity Mind said: â&#x20AC;&#x153;Because funding is being cut there are less staff, which means prisoners spend more time in their cells. This can have a QHJDWLYH LPSDFW RQ WKHLU PHQWDO KHDOWK DQG LW PDNHV LW PRUH GLIÂżFXOW WR see healthcare staff. There is a programme of change but it is not clear how they will meet these targets. â&#x20AC;&#x153;The report makes some recommendations which include improving information so that government departments know more about the mental health needs of prisoners. Objectives should be changed so they relate to providing mental health services and make sure that they are value for money and that the organisations provide the services needed.â&#x20AC;? T

Campbell honoured by psychiatrists for campaigning work >DOWNING STREETâ&#x20AC;&#x2122;S IRUPHU Âľ.LQJ RI 6SLQÂś $ODVWDLU &DPSEHOO has been awarded an honorary fellowship by the Royal College of Psychiatrists (RCPsych). Tony Blairâ&#x20AC;&#x2122;s former press secretary was recognised for his achievements in reducing the stigma attached to mental health and encouraging people to talk more about their own experiences. Fellowship of the RCPsych is awarded as a mark of distinction and recognition of contributions to psychiatry and mental health. On being awarded the fellowship, Alastair Campbell said: Âł:LQQLQJ WKH EDWWOH IRU GH VWLJPDWLVDWLRQ LV ÂżQH EXW RQO\ LI LWÂśV accompanied by services and support that people can rely on when they need them and when they can admit they need them. Iâ&#x20AC;&#x2122;m not undermining or diminishing anything that doctors or surgeons in physical illness do, but in a way they have so much more to go on. â&#x20AC;&#x153;Psychiatry is that very interesting mix of medical and more broadly human understanding of experience. The need for good psychological support services and clever young people going into psychiatry is greater than ever. I've been very lucky to have good psychiatrists at different times in my life: the guy who has been helping me for the past 12 years or so and the guy who helped me when I cracked up in Glasgow in the 1980s.â&#x20AC;? T

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Our hands give rise to a great many injuries [ IT IS THOUGHT that as many as 25%

of the injuries presented at A&E departments are injuries to the hand. That is not exactly counter-intuitive – we use our hands to investigate, to protect, to manipulate (by definition) and to exert pressure. It is no wonder that our hands are subject to a plethora of injuries and wounding. Hand injuries generally involve a conjunction of two medical specialities: orthopaedics and plastic surgery. The effects themselves also tend to fall into two categories – cosmetic and functional. Claims in the area can be of a personal injury or medical negligence nature. Indeed, in the examples of expert witness reports on his website, hand surgeon Mr Richard Milner gives examples of both. The British Society for Surgery of the Hand (BSSH) describes hand surgery thus: “Hand

surgery is surgery of the hand, the wrist and the peripheral nerves of the upper limb. It also encompasses reconstructive surgery that improves upper limb function. “A typical hand surgery operation is performed as a day case under a regional anaesthetic – injected in the armpit or above the shoulder, to numb the entire arm. The patient is awake or lightly sedated, according to preference. General anaesthesia and/ or overnight stay in hospital are unusual, but are required for some operations on the hand, such as in children or when surgery is prolonged. A few operations can be performed under local anaesthesia, injected beneath the skin at the site of surgery.” The BSSH was founded following a series of events over the 1950s and 60s. After the Second World War a number of surgeons perceived that the older specialty

of orthopaedics and the younger discipline of plastic surgery had a great deal to offer when jointly applied to surgery of the hand. In 1952, the Hand Club was formed by members of both specialties at a meeting at The Atheneum. The Hand Club would not admit new members, so in 1956 – with typical medical humour – the Second Hand Club was formed. In 1968 it became the British Society for Surgery of the Hand, with a formal constitution. The first president was Guy Pulvertaft, the sole member of the original Hand Club to take part in the formation of the new society. Since then, the BSSH has grown to 270 full members, 76 overseas members, 36 honorary members, and 260 associates and companion members. Earlier this year the process used by BSSH to produce clinical guidelines was accredited by NICE. q

Children’s hand injuries can be avoided for £1, says BAPRAS [THE British Association

of Plastic and Reconstructive Surgeons (BAPRAS) has called for parents and carers to routinely use doorstoppers in an effort to cut the estimated 50,000 children and toddlers each year whose hands and fingers are crushed by closing doors. Fingertip injuries are the most common hand injury seen by plastic and reconstructive surgeons, with toddlers most at risk. Most parents present at A&E, which can mean lengthy waits, at least one x-ray and consultation with specialist consultants. Many require multiple procedures, with one in six injuries resulting in an amputation. Such injuries can leave children with lifelong disfigurement, pain and even depression. Figures collected in just one London hospital reveal that crushing accidents resulted in 630 nailbed injury operations last year, 40% of which were paediatric cases. Yet, says BAPRAS, routine use of door safety catches that cost a little over £1 can guard against injury to little fingers. The BAPRAS spokesperson on the issue is Ms Anna De Leo, a surgeon at the Royal Free Hospital in London. She explained: “It’s easy to underestimate how important your hands are to doing everyday tasks. Injuries to fingers and hands mean tying your shoe laces, typing, holding a mobile phone or eating become a lot more challenging. And this is nothing compared to the impact of a finger amputation. Fingertip injury alone can result in 20% loss of hand strength and can prevent people from pursuing their chosen career.” One proposed solution to combatting the increase in hand trauma is the use of doorstoppers – in particular, small ‘C’ shaped foam/ rubber products which are designed to be placed over the door to prevent it slamming on children’s fingers. Every year, according to

RoSPA, 30,000 children trap and seriously crush their fingers in doors at home, school, nursery or shops. More than 1,500 of these children will need surgery, sometimes requiring ongoing reconstructive surgery. Ms De Leo commented: “People joke that it is just a finger injury, but the reality for people who sustain those injuries is significant. More likely than not, they will live with an impairment for the rest of their lives. The injuries are so serious that the patient would need to undergo a clinic appointment, an X-ray, day surgery, a follow-up nurse appointment and possibly physiotherapy.” q

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Plastic surgeons increasingly pick up the pieces of botched ops [THE British Association of Aesthetic Plastic Surgeons (BAAPS) has unveiled worrying new data which shows a whopping 80% of its members have recently experienced a steep rise in requests for ‘revisional’ work – that is, fixing botched procedures. The figures were revealed at the BAAPS Annual Scientific Meeting in London in October. The poll also discovered that some members spend as much as a third of their own practice just fixing other people’s mistakes, while others avoid taking up the cases and decline treating them, as the problems are often unsolvable. Surgeons identified the reasons for the revisions as falling into three main areas. Two out of five (40%) cited patients being incorrectly selected for the initial surgery – they had been medically or psychologically unsuitable for a particular procedure, yet it was performed nevertheless. Nearly a third (30%) stated the original procedure had clearly been carried out by someone with dangerously inadequate training, and a similar proportion (30%) were stuck picking up the pieces from cheap deals abroad.

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According to BAAPS president Simon Withey, whose own practice sees a large proportion of revisional work: “Patient selection is one of the key issues to consider when considering who is appropriate for a procedure. I have seen many people who were clearly not appropriate for surgery – ranging from unrealistic expectations to the more extreme body dysmorphia – and including those on contraindicated medications, smokers and patients with pre-existing medical conditions which should have ruled them out. And yet unscrupulous practitioners have endangered their health entirely for profit. “There is currently a measure of financial uncertainty in the UK. Thus, affordability is one of the biggest drivers in the rise of ‘cosmetic medical tourism’ deals offering all-inclusive package holidays and the promise a high-quality service at heavily discounted rates. However, these promotions

conveniently gloss over the increased risk of complications post-surgery due to travel, less robust regulations and credentialing, as well as a lack of consistent follow up. “That has directly led to an increase in the number of reported cases of people returning to the UK with serious complications after receiving cosmetic surgery abroad. Consequently, many patients are being treated in the NHS for complications. A study in one hospital alone pinpoints the average cost of each patient at a staggering £13,500 – a total of over £282,000 just for 21 patients!” BAAPS president-elect Paul Harris added: “Cosmetic surgery has seen a major change in the way providers communicate with prospective patients. Much of it is now internet based and not regulated – indeed, many studies have highlighted the unethical ways cosmetic surgery is marketed, including via social media. Interestingly, by analysing search engine data another study showed that the UK has more interest in aesthetic treatments than even our counterparts in the US.” q

Expert calls for minimum alcohol pricing [ A LEADING EXPERT WITNESS in gastroenterology has declared his support for the introduction of minimum unit pricing (MUP) for alcoholic drinks. Dr Michael Glynn has praised a leader in The Guardian denouncing the government’s record on reducing liver disease deaths and advocating the immediate introduction of MUP. He pointed to the Lancet Commission on Liver Disease in the UK, which in conjunction with many other institutions and charities involved in liver and alcohol research have produced data showing that, over five years, more than 63,000 people will die and more than £16bn of NHS money will be spent on alcoholrelated liver disease. Said Dr Glynn: “MUP is a carefully targeted measure that only affects those that drink alcoholic drinks that are designed to be cheap but alcohol rich, especially the very strong lagers and ciders. It will have no effect on the average pub beer drinker or home wine drinker.” q

Many adults would ‘not be worried’ by cancer symptoms [ SURVEY RESULTS RELEASED by Pancreatic Cancer UK show

that 35% of adults in the UK would not be worried if they had a few of the potential symptoms of pancreatic cancer, such as tummy pain, indigestion, unexplained weight loss and floating faeces. The charity is concerned it could mean that people would not take the symptoms seriously if they had them, and may not report them to their GP. That, in turn, could delay diagnosis and treatment for a disease with a shocking 93% five-year mortality rate. The survey also found that 20% of UK adults thought a pancreatic cancer patient was likely to survive for five years or more, while more than a quarter said they did not know how likely people were to survive for that time. Pancreatic Cancer UK says this shows a worrying lack of understanding of the seriousness of pancreatic cancer. The charity is concerned this could also mean people may put off visiting their GP if they were to spot a few of the potential symptoms. Chief executive of the charity, Alex Ford, said: “We must all be aware of the possible signs of pancreatic cancer, and of the devastating impact this disease can have, because 93% of people diagnosed will not live beyond five years. This is in large part due to 80% of patients being diagnosed at a late stage, when treatment options are very limited. If people would not be concerned if they spotted a number

of the possible symptoms, and at the same time not understand the seriousness of pancreatic cancer, they may not take action quickly enough, which could then delay diagnosis and treatment.” q

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We all know what pain is, don’t we? [ONE OF THE MOST ephemeral of the consequences of injury that

in celebrating its 10th anniversary and describes its anniversary thus: needs to be assessed by medical experts is that of pain. Everyone “In the great scheme of human endeavours, we are finishing primary knows what pain is; what it feels like; the consequences of being in school and getting ready to don uniforms for secondary. It makes us pain. But the explanation of what causes pain and its treatment is a three years older than the Faculty of Intensive Care Medicine and 502 specialism that is akin to alchemy. years younger than the Royal College of Surgeons of Edinburgh.” q In legal terms, compensation for pain is grouped with ‘suffering and loss of amenity’ when assessing compensation. As a physical symptom, however, pain is very much a MISUSE OF PAIN MEDICINES has long been a subject of legal argument, both in the UK and real entity and its treatment is elsewhere in the West. In recent years the supplementation of natural opiates with artificial opioid now the subject of a medical products – more potent than previously-available products and often derived from veterinary drugs – specialism. The Faculty of Pain has led to a new blossoming in misuse. Medicine is the professional Where the escalating use of opioids can be associated with reckless over-prescribing there is body responsible for the always a possibility of negligence. training, assessment, practice The recent public outcry over the misuse of the highly-potent opioid fentanyl led to the Royal and continuing professional College of Anaesthetists and the Faculty of Pain Medicine issuing a statement expressing their development of specialist concern over misinformation in recent news reports regarding fentanyl. medical practitioners in the The statement said: “The recreational use of fentanyl, often mixed with other illicit drugs, is a management of pain in the UK. serious concern and we support all efforts to eliminate the misuse of this drug outside of a clinical It is an academic institution setting. However, we want to reassure patients of the safety of fentanyl when prescribed by their within the Royal College of doctor or administered by an anaesthetist in a hospital. Anaesthetists and supports a “Fentanyl is a unique and highly-effective medication which is well-established in the management multi-disciplinary approach to of complex pain problems. Fentanyl is also commonly used in anaesthetising patients undergoing a pain management, informed by surgical procedure. Patients who have been prescribed fentanyl to manage pain or who are about to evidence-based practice and undergo surgery have no reason to be concerned.” q research.

Anaesthetists speak out over fentanyl fears [

The faculty is currently involved

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Surveillance footage needs putting into context when pain is the claim By DR CHRISTOPHER JENNER MB BS FRCA FFPMRCA, Consultant in Pain Medicine at Medicolegal Associates Ltd and Imperial Healthcare NHS Trust

[PROVIDING SURVEILLANCE EVIDENCE can be key in turning

a case in favour of either claimant or defendant, if accompanied by the expertise of the right medico-legal expert witness. Examples of both outcomes can be seen in the following case studies.

Debility is a matter of degree

Mr X slipped and fell hard on an icy surface while exiting a company vehicle. It left him in on-going pain and with a limp. In surveillance footage taken after the incident, Mr X was seen at various times walking, pushing a wheelie bin to the kerb, taking public transport and on one occasion driving. He was even seen gardening and putting up a fence. However, despite that, the expert witness did not alter his opinion upholding Mr X’s claim. That was for two pertinent reasons: • Mr X had been encouraged to exercise and liked to keep busy • Mr X had initially stated that he could walk for up to 30 minutes before • his leg began to hurt and then for a further 15-20 minutes but with a • slight limp. There was no footage showing Mr X walking for any • extended period of time or on any particularly steep gradient. In this case the expert witness was able to put the surveillance evidence in context and show that a conclusion against the claimant could not be drawn, as the evidence did not, in fact, have any relevance to the particular debility the claimant experienced as a result of his accident. In the next case study the evidence goes in favour of the defendant due to the ability of the expert witness to analyse the surveillance evidence for the court, enabling reasonable conclusions to be drawn.

The expert witness came to the conclusion, after reviewing the surveillance footage, that there was no evidence of pain, disability, restriction of movement or other abnormalities regarding Ms Y’s left upper limb. Ms Y lost her claim. While it can be thought that surveillance footage is evidence in itself, that is very seldom the case – especially in claims involving on-going pain with little to no observable cause. The right expert witness will be able to objectively and precisely demonstrate how the presentation of behaviour seen in the evidence relates to the claim being made. An expert witness who has a clear and detailed understanding of all aspects of the claimant’s medical history will be able to assist the court, as they can be relied upon to translate surveillance evidence soundly, precisely and without bias. q • Chronic pain is a complex and often wholly subjective condition that requires an expert in pain medicine with the correct specialism to establish cause, impact and optimum treatment requirements either when defending or bringing a claim. Dr Jenner has extensive experience of treating these conditions successfully and has been preparing medico legal reports for both claimant and defendant for the past 14 years.

Miracle or deceit?

Ms Y slipped on a wet floor while she was in a bar at the Ascot races. She landed on her left arm while trying to break the fall. The pain and swelling were such that she was taken to a hospital and underwent an X-ray of the wrist, revealing a fracture. She spent a number of days in the hospital and received physiotherapy after being discharged. As Ms Y’s pain did not seem to diminish and made day-to-day tasks extremely difficult, she was further diagnosed with neuropathic pain. In her witness statement she said her left hand was, as a result, almost nonfunctional. That was supported by the expert clinician who examined her. However, surveillance footage showed Ms Y performing everyday tasks without any signs of a struggle. She was seen driving her car to the shops and swapping shopping bags between her left and right hand while attending to her hair – without any discernible abnormalities. Surveillance clearly showed Ms Y functioning normally, entering shops and paying for goods while on her phone, and managing payment dexterously using both hands. She was also recorded carrying her handbag hanging from her left elbow while holding a diary in her left hand – again with no sign of a struggle. The surveillance footage raised questions around Ms Y’s presentation to the expert in contrast to her claim. There were a limited number of possible explanations: • Ms Y’s pain had significantly improved, allowing her to use her left • upper limb with normal function • Ms Y had experienced a spontaneous recovery in her left upper limb • Ms Y was consciously exaggerating for the purpose of the • medicolegal process www.yourexpertwitness.co.uk

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Pain can be actionable of itself [ACCORDING TO Jenny Jones, a senior

litigator with Quittance personal injury solicitors, chronic pain is defined by the Health and Social Care Information Centre as ‘pain or discomfort that troubles a person all of the time or on and off for longer than three months’. “It is pain that has not been relieved by treating the cause, if known, or by trying to relieve the pain itself, and can be mild or much more severe. In some cases it may be constant. Symptoms include shooting, burning or aching sensations in the area affected, or feelings of soreness, stiffness or tightness.” The prevalence of chronic pain increases with age, with 53% of men and 59% of women aged 75 and over being affected. Moreover, the stress of being in pain may be associated with a number of negative outcomes, including depression, job loss, reduced quality of life, impairment of function and limiting daily activities. Ms Jones points out that a person whose chronic pain is the result of a work accident, road accident, trip or slip or military accident may be able to bring a claim for personal injury compensation. “As well as an award of damages for pain and suffering, compensation may include

a claim for care given by a relative and the costs of any treatment required as a result of the injury,” she explains. “The costs of physiotherapy, rehabilitation treatment and specialist items of equipment are usually recovered. Loss of earnings may also be

claimed if the injury has affected, or will affect, earnings. “Chronic pain claims are particularly complex and specialist and the extent of the compensation varies with the assessment of individual cases.” q

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Stillbirth trend is downwards – but still shows capacity issues [FIGURES PUBLISHED on 27 November show that stillbirth and

neonatal deaths in the UK have more than halved since 1993: from 0.62 to 0.28 per 1,000 total births, representing a fall of around 220 intrapartum (term) deaths per year. Led by the National Perinatal Epidemiology Unit at the University of Leicester, the MBRRACE-UK report looked at the quality of care for stillbirths and neonatal deaths of babies born at term (after 37 weeks), who were alive at the onset of labour and who were not affected by a major congenital anomaly. That type of death occurred in 225 pregnancies in 2015. The analysis aimed to identify potentially avoidable failures of care during labour, delivery and any resuscitation, which may have led to the death. A key finding was that capacity issues were a problem in over a quarter of the cases. The majority of staffing and capacity problems were related to delivery suite, with the remaining issues relating to neonatal care provision.

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Furthermore, in 80% of the stillbirths and neonatal deaths analysed, improvements in care were identified which may have made a difference to the outcome of the baby. Commenting on the findings, Professor Lesley Regan, president of the Royal College of Obstetricians and Gynaecologists, said: “For the vast majority of women and their babies, the UK is a safe place to give birth. However, despite the fall in stillbirth and neonatal mortality, these deaths remain a major cause for concern. “The finding that for 80% of babies, different care may have led to a different outcome, echoes the findings from the RCOG’s Each Baby Counts programme. The report also highlights that the majority of these deaths were attributable to multiple factors rather than a single cause. It is crucial that lessons are learned from each death and that front-line staff are given the resources they need to deliver safe care to every woman and baby.” Gill Walton, chief executive and general secretary of the Royal College of Midwives (RCM), commented: “It is concerning that the report found that staffing levels and capacity contributed to some of the poor outcomes, particularly around the time of labour and birth. The increasing complexity of women being cared for in our maternity services exacerbates this issue. We must ensure we have enough midwives and obstetricians to provide safe care throughout the maternity pathway and adequate facilities in all birth settings. “The RCM believes that there needs to be a supernumerary labour ward co-ordinator in place in every single maternity service to have a ‘helicopter view’ of birth activity in all settings, and we have already begun leading on work in partnership with NHS Improvement. “This report clearly shows that improvements to the quality of investigations are needed. It is only through thorough investigation and implementation of recommendations that lessons can be learned from these tragic events. We must do everything possible to prevent them, and improve care and safety.” q

Endometrial cancer: early presentation can lead to good outcomes By JEREMY TWIGG MD FRCOG, Consultant Gynaecological Oncologist at the James Cook University Hospital, Middlesbrough

[ENDOMETRIAL CANCER (EC) affects

approximately 6,000 women per year in the UK. The incidence is rising as levels of obesity in the population increase and people live longer. The prognosis for endometrial cancer is usually very good, as the majority of patients diagnosed with the condition present post-menopausally and early to their GP with bleeding. However, endometrial cancer is not just a condition of the post-menopausal woman. The commonest form of endometrial cancer comes from the lining of the womb (endometrium). Microscopically it appears similar to the endometrium and is termed â&#x20AC;&#x2DC;endometrioid typeâ&#x20AC;&#x2122; endometrial cancer. It is a slow growing tumour, low risk and outcomes are good as it is often diagnosed in its earliest stage. One of the recognised risk factors for EC is a condition called atypical endometrial hyperplasia (AEH). Patients diagnosed with this condition have up to a 50% chance of having endometrial cancer. The condition can be found in women

presenting with abnormal periods in the latter parts of their reproductive lives. Doctors have been provided with guidelines by the National Institute of Health and Care Excellence and the Royal College of Obstetricians and Gynaecologists on which symptoms indicate the possibility of AEH or EC being present, and how to manage women in those circumstances. Risk factors include being over 45 years of age, having pain or worsening of the menstrual flow. In such circumstances an ultrasound and endometrial biopsy to exclude EC are mandated. Similarly, any woman undergoing any form of destructive procedure on the endometrium, such as endometrial ablation, should have a biopsy from the lining of the womb to exclude EC. If diagnosed, the standard for care for EC is hysterectomy and removal of the tubes and ovaries. On many occasions the procedure can be carried out through keyhole surgery. With early surgery the prognosis can be excellent. q

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Common procedures may lead to unforeseen vascular consequences By PHILIP COLERIDGE SMITH DM MA BCh FRCS Consultant Vascular Surgeon, Medical Director of the British Vein Institute and Emeritus Reader in Surgery at UCL Medical School

[ MANY OPERATIONS AND treatments of different types are

performed to address a wide range of medical conditions. In general the benefits greatly outweigh the risks, but occasionally operative treatment leads to damage to large blood vessels. Vascular surgeons are called to treat the consequences of such vascular injury; however, these are often major operations. Patients who have suffered extensive surgery in addition to their planned treatment often allege that they have received substandard treatment. There are many examples of this type of problem where I have personal experience or have advised in cases.

Laparoscopic procedure causing vascular injury

During laparoscopy, long slim metal instruments are inserted via the abdominal wall to provide high-resolution images of the abdominal contents and to undertake surgery to many organs. It was a technique originally used by specialists in gynaecology to treat problems affecting the uterus, fallopian tubes and ovaries. For the last 30 years, however, general surgical operations – including cholecystectomy (gall bladder), appendicectomy, large bowel resection and many other procedures – have been done via a laparoscopic approach. It is now an essential technique for modern vascular practice; however, problems may be encountered when the laparoscope or instruments are inserted into the abdomen. The abdominal cavity is first inflated with carbon dioxide gas. It should then be possible for the long metal instruments to be inserted without complication. However, recognised complications include damage to intraabdominal organs. Vascular surgeons become involved when injuries to arteries and veins occur. The intra-abdominal arteries are very large and bleeding may be rapidly fatal unless immediate open surgery is done to control the bleeding. Even when an immediate fatal outcome is avoided, severe consequences of massive blood loss may ensue, including multiorgan failure affecting lungs, heart, liver and kidney. Protracted intensive care treatment is required, in addition to a large abdominal incision to rectify the injury.

Operations on the lumbar spine

Problems with the lumbar spine, leading to back pain, sciatica and related symptoms, may be addressed by surgery on the spine which is undertaken by orthopaedic surgeons and neurosurgeons. That can lead to the rapid relief of symptoms, but large arteries and veins lie immediately in front of the lumbar spine – at the back of the abdomen. One of the more frequently performed procedures is ‘microdiscectomy’, in which the contents of the lumbar disc are removed: since it is this material which leaks out and compresses the nerves to the lower limbs, causing sciatica symptoms. The operation is done from the back, so the deepest part of the operation, where the arteries lie close by, cannot be readily seen by the surgeon. A sharp instrument passing beyond the limits of the lumbar disc may damage the large arteries or veins lying in front of

the vertebrae, leading to massive haemorrhage or other damage to the vessels. Open abdominal surgery may be required to prevent a fatal outcome.

Endovascular procedures

Interventional radiologists perform many operations using long catheters inserted into arteries and veins. In general, these are carried out in patients with arterial or venous disease where there are well-defined risks of damage to the vessels, such as occlusion or rupture. However in obstetric practice, complex births – where severe haemorrhage may arise following delivery – are sometimes managed with the assistance of an interventional radiologist. Catheters equipped with inflatable occlusion balloons are positioned in the vessels which supply the uterus. These can be inflated to stop blood flow if very severe haemorrhage arises following delivery. However, damage to the lower limb arteries appears to be relatively frequent following that type of treatment. Bleeding or arterial occlusion may occur, leading to cessation of blood flow to one or both legs. Vascular surgical intervention is required to repair the damaged vessels.

Outcome of damage to arteries and veins

It is usually possible to control bleeding from damaged arteries and veins, but not all vessels are restored to normal function. I have advised in a number of cases where previously normal arteries or veins remained blocked despite attempts at repair. In patients with permanently blocked arteries in the leg, very limited exercise tolerance is inevitable, including limited walking distance. Occluded veins in the leg lead to permanent swelling of the limb, combined with the risk of leg ulceration. Litigation in those cases may arise, since the vascular complications of the elective surgery treatments mentioned above are uncommon and patients may not have been aware of them prior to their surgery. The recovery period after treatment for significant vascular injuries may be protracted and long-term disability may be significant. Often, the operation which led to the vascular damage was routine surgery without clear risk of a major complication. The case of Montgomery v Lanarkshire Health Board makes it clear that the possibility of remote but serious complications should be explained to patients who consider that they require such information. In the examples I have given, the risks of iatrogenic vascular injury is usually a known risk of treatment and techniques to avoid such injury are recognised by specialists undertaking these treatments. The occurrence of a vascular injury is usually regarded as attributable to substandard treatment by experts from the relevant specialism. The vascular expert’s task is most commonly to evaluate the immediate and long term consequences for the claimant. q www.yourexpertwitness.co.uk

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Imposed restrictions should not restrict access to cataract surgery, says RCOphth [CATARACT SURGERY IS the most common operation in the UK

– with around 400,000 performed each year – and it has enormous benefit for patients and their quality of life. It is crucial that patients who will benefit from cataract surgery are able to access it, whether for their first or second eye operation. That was the view put forward by the Royal College of Ophthalmologists (RCOphth) recently, as it announced a survey of ophthalmic clinical leads to understand how the current situation of visual acuity thresholds and other imposed restrictions are affecting access to cataract surgery. According to the RCOphth, restrictions or delays to access cataract surgery can limit people’s ability to lead independent lives and care for others. They are twice as likely to have falls and can have significantly

Guidance helps prevent eye problems in ICU [NEW GUIDANCE HAS been produced which provides advice

for clinical staff involved in eye care in intensive care units. Issued jointly by the Royal College of Ophthalmologists and the Intensive Care Society, Eye Care in the Intensive Care Unit is primarily intended to help non-ophthalmic ICU staff to protect the eye in vulnerable patients, identify disease affecting the eye and deliver treatment to the eye when it is prescribed. It concentrates on the common problems of the eye surface, but also touches on other less common conditions. As such, it should also be helpful to those ophthalmologists asked for advice about ICU patients. The health of the front surface of the eye, particularly the cornea, depends on the ability to produce tears, to blink and to close the eyes with rest or sleep. Those functions can be impaired on ICU, whether by disease or treatments such as the drying effects of gas flows from CPAP or oxygen masks. In particular, muscle relaxants reduce the tonic contraction of the orbicularis muscle around the eye, which normally keeps the lids closed, and sedation reduces blink rate and impairs or can eliminate the blink reflex. Whatever the cause, those unable to close the eye for themselves, or in whom blinking rates are substantially reduced, are at increased risk of damage to the front of the eye, and this risk is higher in those mechanically ventilated. q

reduced quality of life, with increased levels of depression and anxiety. All have a long-term financial and resource impact on primary, social and community care systems. The college points to recently-released NICE guideline for the management of cataracts in adults, which demonstrates that the use of visual acuity thresholds for referral or surgery which restricts access is not justified based on a review of available evidence and a de novo economic model developed by NICE. NICE makes the recommendation not to restrict access to cataract surgery on the basis of visual acuity. The decision to refer and then to perform surgery should only be based on shared decision making with patients and their families or carers – taking into consideration the clinical situation, including symptoms, effects on activities and quality of life, as well as the risks of surgery. The survey carried out by RCOphth concluded that the use of visual acuity restrictions to accessing cataract surgery places an unnecessary burden on the NHS, creates barriers for patients and clinicians and is not justified as the restrictions do not seem to achieve the aim of limiting surgical numbers. q

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New test could ease heart attack diagnosis

[A NEW BLOOD TEST for detecting heart

attacks has been developed by a team from King’s College London. The test, developed as a result of research funded by the British Heart Foundation, could speed up diagnosis and save the NHS millions of pounds every year. It is estimated that over two thirds of people who attend A&E complaining of chest pain have not had a heart attack. However, all receive two tests: an electrocardiogram (ECG) and a blood test to measure the levels of a protein called troponin. Under current guidelines, people suspected of having a heart attack

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are tested for high blood troponin levels as soon as they arrive in an A&E and again after three hours. Depending on the type of troponin test used, up to 85% of people will need to remain in hospital for further tests in order to rule out a heart attack. The new test uses similar technology to the troponin test, but analyses the level of a protein called cardiac myosin-binding protein C (cMyC). Levels of cMyC in the blood increase more rapidly after a heart attack, and to a higher extent than troponin, meaning the test can rule out a heart attack in a higher proportion of patients straight away. Professor Sir Nilesh Samani, medical director of the British Heart Foundation, explained: “Big heart attacks are often easy to diagnose with an ECG, but smaller heart attacks – which are more common and also life-threatening – are more challenging. The troponin test has been used for around 20 years and is currently the most powerful tool we have for diagnosing such heart attacks, but there is always room for improvement. “These initial results with the cMyC test look very promising for patients, who could be more quickly diagnosed and treated or reassured and sent home. However, further research is necessary before it can be recommended as a replacement for the troponin test.” Professor Simon Ray, president-elect of the British Cardiovascular Society, added: “Unlike currently available blood tests, which need to be repeated at least three hours after pain, it looks as though a single test is enough to make a confident decision on whether a patient has or has not suffered a heart attack. Not only can it be done earlier after the onset of symptoms, but it also seems to be better at discriminating between heart attacks and other causes of chest pains. This is very important.” q

Hearing guidance gets mixed response [ON 27 NOVEMBER the National Institute for Health and Care

Excellence (NICE) released the draft of its long-awaited guidance on the assessment and management of hearing loss in adults. If people have hearing difficulties that are not caused by earwax or an infection and are presenting for the first time, they should be referred to an audiology service for an assessment regardless of their age, the draft guidance states. It also recommends that hearing aids should be offered to adults whose hearing loss affects their ability to communicate. Early and appropriate management of hearing difficulties is also important. Particular reference is made to those with learning or cognitive difficulties such as dementia who may not be aware of their hearing problems. For someone with sudden hearing loss where the cause is not obvious, they should be referred immediately to a specialist service or to an emergency department, if appropriate. Professor Mark Baker, director of the centre for guidelines at NICE, said: “Our draft recommendations can help improve care for people with hearing loss through better management of earwax and referring people with symptoms to the right service at the right time. We encourage those working in primary and specialist services, patients and stakeholders to comment on the proposed advice.” Action on Hearing Loss stated that it will be submitting a formal response to the

guidelines and want to ensure that people with deafness and hearing loss have their voices heard. In the meantime, the charity issued an initial statement about the draft guidelines. “The development of the new NICE guidelines has come at a critical time for people with hearing loss,” the statement said. “Over recent years, we have seen budget cuts to audiology services and proposals to ration hearing aids across England. This has resulted from huge misconceptions about the impact of hearing loss and about the use and benefit of hearing aids. “Clear and robust evidence, including the highest level of evidence from randomised control trials, demonstrates that hearing aids are beneficial for people with hearing loss and provide a lifeline for many who seek help. Moreover, hearing aids are the primary form of clinical management for people with hearing loss and they are cost effective. “Action on Hearing Loss is very pleased to see that the draft NICE guidance recognises this evidence and recommends hearing aids are issued to all those who would benefit from them. “We are hugely concerned about the inequality in access to hearing aids across England – in particular in North Staffordshire, where a threshold has been introduced restricting access to many who could benefit from their use. These guidelines will help us to ensure that such rationing is prevented.” q

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Figures show shocking number of children requiring hip surgery [CHILDREN AS YOUNG as 10 are undergoing hip replacements,

according to figures reported by national press, based on information published by NHS Digital. The reason is reported to be the scourge of obesity among children. According to a report in The Telegraph, 10 children aged 10-19 have had hip replacements since 2014. The cause is reported to be a condition termed slipped capital femoral epiphysis (SCFE). Research from the University of Liverpool, published in the journal Archives of Disease in Childhood, showed a strong link between childhood obesity and hip diseases in childhood. According to researchers, significant hip deformities affect around 1 in 500 children and SCFE is the most common hip disease of adolescence. The condition always requires surgery, can cause significant pain, and often leads to a hip replacement in adolescence or early adulthood. The researchers continued: “Children with SCFE experience a decrease in their range of motion, and are often unable to complete hip flexion or fully rotate the hip inward. Unfortunately many cases of SCFE are misdiagnosed or overlooked, because the first symptom is knee pain, referred from the hip. The knee is often investigated and found to be normal. Early recognition of SCFE is important as the deformity may worsen if the slip remains untreated.”

BOA welcomes efforts to minimise ‘never events’ [THE BRITISH ORTHOPAEDIC ASSOCIATION (BOA) has

issued a statement on the issue of so-called ‘never events’ in surgery, in response to the publication of provisional figures by NHS Improvement on the occurrence of such events between April 2016 and March 2017. During the period, there were 424 reported ‘never events’, including 178 operations on the wrong body part or patient, 109 foreign objects left inside patients after operations and 49 wrong implants or prostheses – of which 24 were incorrect hip or knee implants. In the statement the BOA said it takes the issue of never events ‘very seriously’, evidenced by the fact it has a representative on the CORESS Advisory Committee – an independent charity which aims to promote safety in surgical practice in the NHS and the private sector. The statement continued: “The BOA welcomes all efforts to improve patient safety and to encourage a culture of safety in our hospitals and operating rooms. We believe that an improving safety culture is reflected in increased reporting of incidents, and that this leads to learning and ultimately safer services. “We encourage all parts of the health system to take responsibility for delivering the highest quality care and learning from incidents when they occur. In order to achieve this there needs to be embraced a ’just culture’ environment, ensuring that those instigating reports are not regarded by the institution in which they work as the cause of the problem.” q

Daniel Perry, honorary consultant orthopaedic surgeon at Alder Hey Children’s Hospital, said: “This is the best evidence available linking this disease to childhood obesity – which makes this condition one of the only obesity-related diseases that can cause life-long morbidity starting in childhood. “A significant proportion of patients with SCFE are initially misdiagnosed and those presenting with knee pain are particularly at risk. Ultimately this study helps us to better understand one of the main diseases affecting the hip in childhood. Whilst we confirm a strong association with obesity, we are still unable to say that obesity causes this disease.” Nevertheless, Tam Fry, chairman for the National Obesity Forum said: “Though numbers are seemingly small, they hide the certainty that they, too, will escalate with years to come. “It is truly saddening that adolescents are requiring hip and knee surgery, and the threefold increase in three years may also hide the fact that some of these children may not have fully completed their growth and, without the surgery, would be crippled for life.” q Image: Anatomography (CC BY-SA 2.1 JP)

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