Your Expert Witness Issue No. 50

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contents IN THIS ISSUE 7

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Opening Statement

50TH ISSUE – SPECIAL FEATURE 9 Over a decade of expert comment: what’s changed and what’s stayed the same?

11 50 issues chart the changing role of the medical expert NEWS 12 Solicitors outline their wish list for Boris 12 MoJ asks lawyers for data on unused material 14 Bar Council hits out at performance of justice system 15 Conference makes sense of a changing world 15 Forensics watchdog offers anonymous whistleblowing line FINANCE & ACCOUNTANCY 17 The worst expert witness: and the winner is…

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BUILDING & PROPERTY ISSUES 18 Group calls for legislation to preserve tenements 19 Boundary dispute reform: let’s use the legislative vacuum to good effect INVESTIGATION & LITIGATION 20 New guidance for data requests 20 Bailiffs to see mandatory use of body cameras 20 CCTV systems should now be secured by default

A to Z WEBSITE GUIDE 21 Our A to Z guide to the websites of some

of the country’s leading expert witnesses.

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EXPERT CLASSIFIED 51 Expert Witness classified listings 54 Medico-legal classified listings

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 23 Medical Notes

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NEWS 25 Negligence claims remain steady despite increased activity 25 Three services in same Mews rated Inadequate 27 Outcome measures: the preferred method to monitor rehabilitation 27 GMC to regulate medical associates CHOOSING THE CORRECT EXPERT 28 Expert witness guidance follows manslaughter review ARTHROPLASTY 31 Guidance aims to help surgeons get it right first time 31 Many awaiting joint replacement suffer pain ‘worse than death’ ORTHOPAEDICS 33 MRI scan unlikely to reveal ‘missed’ scaphoid fractures 33 Orthopaedic hospital loses dance and sports service 33 Guidelines published for well leg compartment syndrome 34 Expert knowledge is enhanced by frontline experience

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CARDIOLOGY 35 Cardiomyopathy patients being failed, charity finds PLASTIC, RECONSTRUCTIVE & HAND SURGERY 37 Women begin legal action over implant-associated lymphoma 37 Plastic surgeons welcome non-surgical interventions report 37 Beware of the dog: especially when walking it!

DENTISTRY & MAXILLOFACIAL SURGERY 38 Dermal filler procedures need regulation, surgeons warn 38 Dentists claim success in fines campaign OBSTETRICS & GYNAECOLOGY 39 Women whose waters break early should be able to continue pregnancy

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OPHTHALMOLOGY 41 Complications of dermal filler injections 41 Report highlights importance of eyesight for road safety COMPLICATIONS OF DIABETES 42 What are the factors that lead to diabetic foot amputation?

PSYCHIATRIC & PSYCHOLOGIGAL ISSUES 45 Drug deaths: finger pointed at govt policy 45 Scotland’s drug deaths worst in Europe 47 ADHD in adults: diagnosis needs a different approach than with children 48 Military PTSD sufferers may need physical healing as well 49 Dementia audit finds improvements on previous report UROLOGY 50 Pitfalls in urology diagnosis www.yourexpertwitness.co.uk

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Opening Statement [IT SEEMS COUNTER-INTUITIVE that figures showing court appearances at an all-time low should trigger

consternation among the bar community. However, when that fact is put in the context of an 8% rise in reported crimes the alarm becomes thoroughly understandable.

It’s not that crimes are not being committed: they are not being detected or prosecuted. The chair of the Bar Council, Richard Atkins QC, laid the blame squarely at the feet of successive governments. Cuts in all parts of the criminal justice system have left that system ‘broken or breaking’ and every part of it needs attention.

Even the Commissioner of the Metropolitan Police Cressida Dick has alluded to a breakdown in the police’s ability to detect and prosecute crime. Mr Atkins referred to a speech she made in June in which she admitted that the courts are ‘emptying, not filling’.

• Detecting and prosecuting crime is, of course, one of the principal functions of the forensic scientist. Evidence produced by diligent forensic work can be instrumental in convicting the guilty and exonerating the innocent.

When forensic work is not carried out with the necessary rigour the resultant evidence can be tainted and justice ill-served.

Whether the shortcomings are the result of a lack of skill and/or application, or of deliberate malpractice, it can be difficult for others working in the same organisation to call out the incident. The Forensic Science Regulator has therefore set up a confidential ‘whistleblowing’ line, operated by Crimestoppers.

• An increasingly common tool for crime detection is CCTV, more correctly referred to as surveillance cameras.

Hitherto, systems have not always been as secure against cyber attack as we would like. A new ‘Secure by Default/Secure by Design’ scheme from the Surveillance Camera Commissioner allows system manufacturers to self-certificate the security of their products. It offers installers and users confidence that their system is fit for purpose when it comes to their online presence.

• Addressing the state of the criminal justice system was also one of the items on a ‘wish list’ compiled by the Law Society for incoming PM Boris Johnson. Lawyers called for investment to address a raft of issues that put up barriers to justice and undermine the reputation of the British justice system.

The society also called for investment in the civil justice system and the family courts, as well as warning of the ‘potentially devastating effects’ on the justice system of a no-deal Brexit. Without a deal British lawyers would have 31 separate legal systems to deal with.

• One of the sticking points of all Brexit negotiations has been the Irish border problem – and the so-called ‘backstop’. It is a real humdinger of a boundary dispute. And Brexit has also, ironically, been one of the factors in stalling a Private Member’s Bill in the Lords to modernise the rules governing boundary disputes of a more domestic nature.

The proposals in the Bill would replace much of the involvement of solicitors in such disputes with referral to surveyors. In practical terms it would lead to a much greater involvement of expert witnesses – particularly surveying experts – in bringing disputes to practical solution.

• Boundary disputes formed one of subjects covered in the first issue of this publication. Now we have clocked up the significant number of 50 issues – bringing news and views on all aspects of the work of the expert witness since the spring of 2007.

• This 50th anniversary issue will no doubt be enjoyed by the assembled members of the Expert Witness Institute at its annual conference on 26 September. The EWI conference is one of the highlights in the year of the Your Expert Witness team, who will be there with their exhibition stand this year as usual. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Over a decade of expert comment: what has changed and what has stayed the same?

[ THIS ISSUE MARKS the 50th edition of this publication

which first appeared in the spring of 2007. Those 50 issues have provided a dozen years of commentary on the main issues facing those brave souls who put their expertise and reputations at the service of the courts in order to aid the cause of justice.

The themes covered have been as broad as the disciplines of the experts themselves, and have reflected changing concerns of the legal community as well as of experts. The period has seen major upheaval in the way justice is dispensed and, particularly, funded. New technology has offered opportunities for advances for the legal system, for forensics practitioners and, of course, for criminals.

While there have been many significant changes to report, the striking element of the subject matter discussed back then and now is their similarity. The issues that exercised the legal and expert professions then are still of interest today.

The very first issue, for example, spent a great deal of time debating the very nature of the expert witness and the way in which their evidence must aid the court and not the party appointing them.

Subsequent issues reiterated the point, with many a treatise from experts in various fields, as well as reports on the updates to rules governing how experts should present their evidence – and for whose benefit.

The Woolf reforms came under discussion. Overhauling the complexity and cost of civil litigation has remained a running sore in the profession. Our first issue carried a review of the first 10 years of Lord Woolf’s reforms, and the following 49 issues have been similarly preoccupied with subsequent reforms – notably the Jackson reforms.

Lord Justice Jackson’s reforms of civil litigation were overarching and comprised the subject matter of much of this publication for a number of years. Their effects are still very much in evidence – allied as they were to successive governments’ determination to reduce costs in the public sector wherever possible.

Although the Jackson Review was carried out under the aegis of a previous legislation, the issue of whiplash became the nearobsession of a new one. Insurance companies were apoplectic about the level of compensation being paid out for so-called lowspeed impact claims and the government joined the crusade to

stamp them out. The row over access to justice is another topic that carries on to this day.

Property issues similarly form an ever-present in expert witness debate. The first issue carried a review of the very first building regulations – in Babylon in the 2nd millennium BC – under the grizzly headline No builders slain, but disputes still arise. In the second issue the then-editor Chris Wilson treated us to a description of his house-buying travails.

Chris wrote: “Now, the reason for my outburst…emanated from a prolonged argument about a strip of land next to the property, which may or may not have belonged to the vendor – in essence, a boundary dispute.”

In that issue the RICS offered a guide to boundary disputes and 49 issues later we have an explanation of proposed new legislation waiting to return to the Lords.

Those examples are just the tip of an iceberg that has hove into view on a regular basis over the past decade and a bit. It really is a case of Plus ça change, plus c’est la même chose.

On the following page we will turn our attention to an area of expertise that has become so ubiquitous it now occupies its own section in the pages of this publication: the medical expert. In particular we will look at the rise in medical negligence claims. q

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50 issues chart the changing role of the

medical expert [THE 12 YEARS or so during which this journal has been published

have seen an unprecedented rise in both the number of claims for clinical negligence against the NHS and the level of compensation being awarded.

Our first issue carried a small clutch of stories on the role of the psychologist – an area which has itself grown in importance, not least because of the growing recognition of PTSD as a scourge among combat veterans. And indeed, PTSD was the subject of a report in the following issue.

There was, however, no inkling of the impending deluge of cases against clinicians for compensation regarding inadequate care – indeed, the issue at the time was the difficulty in bringing claims.

An early article addressed the problems associated with what was seen as an uneven playing field in resolving medical negligence claims.

John Pickering of Irwin Mitchell noted that, despite the number of claims remaining ‘fairly static’ over the period from 2004-2007, the adverse incident rate was high, leading to the conclusion that ‘many people are not pursuing remedies for their injuries. Is this apparent reluctance a reflection of the hurdles that the injured claimant must overcome?’

That ‘fairly static’ number of over a decade ago was around five-and-ahalf thousand, according to figures from the NHS Litigation Authority. In its annual report this year, the NHSLA’s successor, NHS Resolution, also reports the number of claims as being ‘relatively steady’ – this time at a little over ten-and-a-half thousand: nearly double the previous number.

The pages of Your Expert Witness have charted that inexorable rise in

claims, together with explanations of how and why it happened.

By 2010 Medical Issues was a section within the magazine in its own right, with features explaining not only the role of experts in such cases, but also the ins and outs of the various specialties, the procedures involved and what can go wrong.

More dramatically, Your Expert Witness has joined the mainstream press in cataloguing a number – too many – of major cases of institutional failures in the NHS. There have been the scandals at Gosport, Morecambe Bay, Glan Clwyd, Southern Health and, of course, Mid-Staffs.

Of course, medical experts are not just engaged in cases involving medical negligence. They may be assessing injury caused by accidents – in the workplace, on the roads or in the street – or by design, such as cases of assault and abuse.

In the first leader column devoted to medical stories, the author noted: “In the civil sphere, medical experts are called upon to assess injury following accidents or other misadventures in order for compensation to be assessed. In medical negligence cases – either in court or in the disciplinary tribunals of the GMC – they are called upon to offer a judgement on the conduct of their peers.

“In criminal cases they may be commenting on the likely cause of injury and whether it could have been inflicted deliberately.”

Medical experts occupy a prominent place in this publication and will no doubt continue to do so. q

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Solicitors outline their wish list for Boris

[ SOLICITORS’ LEADERS have urged

new Prime Minister Boris Johnson to put the criminal justice system at the heart of the priorities of his administration.

“If you want justice you have to invest – decades of cuts to this fundamental part of our country’s infrastructure mean the whole system is crumbling,” said Law Society of England and Wales president Simon Davis.

“Every organisation has its list of asks of the new Tory leader – but few things damage the country’s health more than the undermining of our justice system.”

The Law Society is urging a series of measures to address the crisis.

Growing shortages of duty solicitors and independent experts, court closures, barriers to accessing legal aid and crucial evidence not being disclosed in court until the last minute are all features of what the society called the chronic underinvestment in justice.

“The future integrity of our justice system depends on the whole system working effectively – a poorly functioning criminal justice system will undoubtedly impact on the UK’s international reputation,” Simon Davis added.

Solicitors are also urging urgent changes when it comes to the funding of civil law – such as family issues. Access to justice is a fundamental principle that underpins British values and the rule of law; however, changes to eligibility criteria and availability of Legal Aid have left many unable to pursue civil legal cases through the courts, particularly those on lower incomes.

A third issue addressed by the Law Society president was the potentially devastating impact of a no-deal Brexit on the legal sector.

“England and Wales is one of the most respected jurisdictions in the world for its transparency, certainty and flexibility,” said Simon Davis. “English law is the most commonly used law by international business and for dispute resolution.

However, preserving the legal sector’s

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strong economic contribution will require continued close co-operation with the EU and depend on the continued ability of UK lawyers to practise there.

“Unless alternative arrangements are agreed after Brexit, UK lawyers and law firms will fall back to operating under

31 different national regulatory systems across the EU and EFTA. People and businesses will continue to operate crossborder; therefore, an infrastructure which allows them to gain fast and effective access to cross-border justice needs to be maintained.” q

MoJ asks lawyers for data on unused material [

REVIEWS INTO ISSUES involving criminal legal aid are currently being carried out by the Crown Prosecution Service (CPS) and the MoJ. The MoJ’s Criminal Legal Aid Review, which includes all the defence fee schemes, is due to report in the summer of next year.

Some issues have already been identified by the reviews and in June the government announced an accelerated package of measures. In collaboration with the legal professions, MoJ now aims to complete those areas of accelerated work by the end of November.

A government spokesperson said: “We began engaging with all levels of legal professionals several months ago as part of our review into criminal legal aid fees, and have committed to working closely with practitioners as it progresses. The CPS has also worked closely with barristers since launching its comprehensive review of prosecution fees and will continue to do so through the remainder of the review.

“It is therefore only sensible to refocus on areas where professionals have expressed pressing concerns. We understand the strength of feeling that remains, however, and are committed to working with the sector to further support and strengthen the profession, making it fit for the modern age and accessible to those who seek to join it.”

One particular area where the MoJ is seeking information from the professions is on the subject on unused material. The ministry is asking for information by the end of September.

In a joint statement, the Law Society, London Criminal Courts Solicitors Association and Criminal Law Solicitors Association said: “Some of you will have received a request from the MoJ…asking you to complete a questionnaire on unused material. This is part of an ‘accelerated work’ stream arising out of the Criminal Legal Aid Review that has been agreed with the main solicitor representative groups and the Bar Council.

“We appreciate that the completion of the questionnaire may be time-consuming, but we strongly hope that this exercise will result in additional funding for reviewing unused material. It is therefore in all of our interests that as much information as possible is provided to the MoJ.” q

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Bar Council hits out at performance of justice system [THE TOTAL NUMBER of individuals formally dealt with by the

Criminal Justice System in England and Wales is at the lowest since records began and fell 2% in the latest year. That was according to the Criminal Justice Statistics Quarterly, England and Wales, April 2018 to March 2019, published by the Ministry of Justice on 15 August.

At the same time the number of police recorded crimes rose overall by 8% – to 5.3 million offences excluding fraud – believed to be associated with improved recording among police forces and victims’ greater willingness to report crimes.

The conviction ratio for those prosecuted remained stable at 87%.

Offenders with long criminal careers account for nearly two fifths of the offending population. The proportion of offenders convicted for indictable offences with long criminal careers has increased by nine percentage points since March 2009.

There were, however, increases in prosecution for violence against the person and possession of weapons offences: 3% and 6% respectively.

The report notes: “Prosecutions for violence against the person have increased due to the introduction in November 2018 of the separate offence of assault on an emergency worker, the majority of which would previously have been recorded as ‘common assault’ in summary offences.”

The reaction of the Bar Council was scathing. Its chair Richard Atkins QC described them as ‘grim reading’. However, he pointed to recent remarks by the Commissioner of the Metropolitan Police which, taken with the MoJ figures, paint an even worse picture.

In a speech in June Cressida Dick described police detection rates as ‘woefully low’ and said the courts are ‘emptying, not filling’.

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“If crime is not detected, it cannot be recorded, investigated or prosecuted,” said Richard Atkins, “so the official figures are just the tip of an iceberg. Criminals are going about their business unchallenged: fraud goes virtually unpunished and is not even included in the statistics.

“The recent focus on the state of the criminal justice system by the government is welcome, as are the additional resources, but the whole system is broken or breaking and the focus needs to be on every part: Legal Aid and access to legal representation, prosecution, courts, forensic science and probation, as well as police and prisons.

“The Bar Council, MPs, senior judges and others have been calling out for reversal of the draconian cuts to the justice budget – the steepest cuts to any public service. Our democracy, society and our economy depend on a properly functioning, fair, justice system, that the public can have faith in. Sadly we fear that this is no longer the case.

“Criminals up and down the country will be rubbing their hands with glee, knowing that even if their crimes are detected and they are caught by the police, the chances of them being prosecuted or jailed are slim.” q

Conference makes sense of a changing world

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NOTHING STAYS the same; is everything changing? That is the theme of this year’s Annual Conference of the Expert Witness Institute (EWI), to be held on 26 September at the Church House Conference Centre in London.

Founded in 1996, the EWI is the leading membership body and training provider for expert witnesses in the UK. Its objectives are to promote excellence in expert evidence worldwide through rigorous vetting and evaluation, and to support the proper administration of justice and the early resolution of disputes through fair and unbiased expert evidence.

Its annual conference brings together expert witnesses, solicitors, barristers and eminent judges to discuss the key issues facing the expert community, with a comprehensive programme of informative legal updates, vibrant debate and case law analysis. It is an unmissable opportunity for members and others to network with fellow experts and the legal community, to strengthen their role in the legal sphere. It is also a chance to meet up with the team from Your Expert Witness at their stand.

The packed programme includes notable presentations following the theme. After the opening address by conference chair Amanda Stevens,

Forensics watchdog offers anonymous whistleblowing line

Lord Neuberger will address the conference followed by The Hon Mr Justice Martin Spencer who will focus on The Expert Challenge 2019.

The morning continues with Change is the only constant: a panel discussion considering the various factors impacting the work of Expert Witnesses, led by Dr Penny Cooper with The Rt Hon Lady Justice Nicola Davies and His Honour Judge Richard Roberts, and concludes with a presentation by Chris Easton on Single Joint Experts: making it work for experts and instructing parties.

After lunch, Governors Question Time will be fielded by Kay Linnell and Dr Thomas Walford, followed by a discussion on fixed costs by David Marshall, vice-chair of fixed costs in the EWI’s Clinical Negligence Working Group and partner at Anthony Gold Solicitors.

Two current issues of pressing importance to expert witnesses bring the debates to a close: Legal Aid and how to get paid will be presented by Kenny Shealey, national legal aid training co-ordinator and senior law costs draftsman, while New disclosure rules affecting experts and costs budgeting for experts will be explained by His Honour Judge Richard Roberts. q • For further information and booking details visit http://bit.ly/EWIAC2019

[THE Forensic Science Regulator has launched an anonymous

reporting line to allow forensic science professionals to raise concerns about service quality without revealing their identity.

Quality failures such as sample contamination or data manipulation can mean that innocent people are wrongly convicted or offenders escape justice. The Forensic Science Regulator’s anonymous reporting line aims to ensure that any serious issues are flagged to the regulator, even if an individual does not feel able to report through the whistleblowing procedures in their own organisation.

The service is run by the Crimestoppers charity, whose agents will record the information provided and pass it to the Forensic Science Regulation Unit, to determine a suitable course of action.

The service is meant to be a last resort when all other options have been exhausted. Individuals can phone 0800 917 0967 or use the online form at www.crimestoppers-uk.org/forensicregulator.

The Minister for Policing and the Fire Service, Rt Hon Nick Hurd MP, said: “Forensic science is an invaluable tool for bringing criminals to justice, but we must ensure it works to the standards that the public expects. I welcome the Forensic Science Regulator’s new anonymous reporting line. It is important we have many routes to identify and prevent any issues within the system.” q www.yourexpertwitness.co.uk

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The worst expert witness: and the winner is…

By CHRIS MAKIN Chartered Accountant, Civil Mediator and Expert Determiner

[A COUPLE OF YEARS AGO I had the doubtful

privilege of giving a blatant example of the ‘expert’ who failed in every respect. The case was Van Oord Ltd & Anr v Allseas UK Ltd [2015] EWHC 3074 (TCC), where Mr Justice Coulson took pains to explain the twelve – yes, twelve! – respects in which an expert had failed in his duty. They included: • not even considering or formulating the costs as • incurred by the claimant; • admitting in cross-examination that he did not • even agree with his own report (this is amazing!)

• and; • admitting that the views he had expressed in his • report were merely the assertions of his clients, • who themselves had resiled from such • assertions in their own cross-examination.

So with experts of such low calibre, where is the litigation lawyer to find reliable experts? Well, it seems that the Crown Prosecution Service needs help in this respect.

In May 2019, Steven Sulley and seven others were accused of fraud in selling voluntary carbon credits (and diamonds) to more than 70 victims, many of them vulnerable pensioners. Those investors lost £3.5million.

The crux of the fraud charges was that there was no market in voluntary carbon credits, so the victims had been sold ‘investments’ which could not be realised.

The expert witness for the prosecution was one Andrew Ager, who it emerged had attempted to dissuade the defence expert Dr Marius Cristion Frunza (who holds a PhD from the Sorbonne) from giving evidence. This is serious, but Mr Ager’s other failings included: 1. Having no academic qualifications. When asked about A-levels, he replied that he thought he had sat three subjects, but he couldn’t remember whether he had passed any.

2. He said he kept abreast of the carbon credits market, but said he had not read any of the books written by Dr Frunza although they were widely available. He had though once watched a documentary on carbon credits!

3. He admitted that several assertions he had made to Dr Frunza during a meeting of experts were untrue.

4. He asserted – despite it being his clear duty under CPR – that it was not part of his duty to bring facts helpful to the defence to the attention of the court.

5. He had no record of any of the material supplied to him by the police, or of any of his workings.

6. He did admit that he had been supplied with some sensitive material by the police, but it had been damaged by a leak. But not to worry; he asserted that matters were now in order, since he now kept sensitive material in a locked box on his balcony.

The City of London police, similarly, had no notes of meetings with Mr Ager and no record of the material they had passed to him. This is particularly worrying after the repeated difficulties of the CPS under Alison Saunders of failure to disclose evidence, helpful or not. The watchword of any professional, including prosecuting authorities and their experts, is: ‘Record – Retain – Reveal any evidence, helpful or not.’

This is very basic stuff, and both the police and Mr Ager had fallen far short of the standard required.

So what happened?

At Southwark Crown Court Mr Justice Nicholas Loraine-Smith directed the jury to return not guilty verdicts, and the eight accused walked free.

And the CPS said they had removed Andrew Ager from their list of approved experts. So that’s all right, then. Or is it?

Was this a victimless crime? Of course not – many of the victims had invested their life savings in a scam.

Did it end there? Certainly not. It emerges that the same expert, Andrew Ager, had been the prosecution’s expert witness in some 20 previous trials, so all of those where convictions had been achieved would now have to be reviewed. And that means that far more than the 70 victims in the current case may find that those who have taken away their savings will not be punished.

The moral is clear, and the CPS failed miserably in following it: choose your expert with care. This is an extreme example, but an inadequate expert can destroy the good work of the lawyer.

I recognise that the world may not be over endowed with experts in voluntary carbon credits, and some other esoteric subjects may cause difficulties. But for many subjects experts are readily available, and there can be no excuse for instructing professionals who may be good at their job, but who do not know how to write an expert report, hold a meeting of experts, advise on Part 36 offers, and conduct themselves correctly at court.

May I be permitted to provide the following hint?

For forensic accountants who have been vetted by ICAEW, go to www. icaew.com/about-icaew/find-a-chartered-accountant/find-an-accreditedforensic-expert. There are only about 100 of us, out of 140,000 chartered accountants, who have reached this high standard.

And for some light relief and some interesting war stories, have a look at my website – with videos! q

About Chris Makin [CHRIS MAKIN was one of the first 30 or so chartered

accountants to become an Accredited Forensic Accountant and Expert Witness – www.icaew.com/about-icaew/find-a-charteredaccountant/find-an-accredited-forensic-expert.

He is also an accredited civil and commercial mediator and an accredited expert determiner. Over the last 30 years, he has given expert evidence over 100 times on a vast range of cases and conducted over 100 mediations.

For CV, war stories, videos and much more go to the website www.chrismakin.co.uk. q

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Group calls for legislation to preserve tenements [A REPORT FROM Scotland’s Working

Group on the Maintenance of Tenement Scheme Property has called for regular building inspections, the establishment of compulsory owners’ associations and building reserve funds to be written into legislation to protect the future of Scotland’s tenement buildings.

The working group was established in March 2018 and comprises sector experts and MSPs from all Parliamentary parties. In January the group published its interim recommendations report and then formally discussed stakeholder and public responses, which were received via a consultation. Its final report was published on 4 June.

The Minister for Local Government, Housing and Planning, Kevin Stewart MSP, said: “This report brings together views from across the Scottish Parliament and housing stakeholders, and its recommendations merit serious and careful consideration.

“We welcome that it acknowledges the important action we have already taken to improve the condition of Scottish tenements, and recognises the challenges that must be met to ensure that our housing stock can

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continue to provide safe and sustainable homes for the future.”

The report’s recommendations cover three areas: building inspections, owners’ associations and building reserve funds, and how these aspects could function and be implemented.

The ‘scheme property’ of all tenements should be inspected every five years, with a report prepared that will be publicly available to existing or prospective owners and tenants, neighbours and policy makers.

Key elements include: • Establishing compulsory owners’ associations are an essential element of tenement maintenance by providing leadership, effective decision-making processes and the ability for groups to enter into contracts.

• A building reserve fund should be set up, with funds used for maintenance – as defined in Schedule 1 of the 2004 Act – including repairs and replacement, the installation of insulation, cleaning, gardening, painting and other routine works, the day-to-day running of a tenement and the reinstatement of a part (but not most) of the tenement.

The issue of tenement maintenance has grown in prominence in Holyrood, with crossparty support for action to make changes to existing legislation and practice. Numerous debates have taken place in the chamber over the past 18 months, the first of which led to the establishment of the working group.

Hew Edgar, RICS interim head of policy, commented: “Following the publication of the interim recommendations report in January, the group has consulted widely on the three recommendations…and updated the final recommendations based on feedback received.

“The recommendations are interlinked, and while each recommendation has its own benefits, the required transformative change to improve the fabric of Scotland’s tenement property can only arise through the implementation of all three.

“RICS welcomes all recommendations within the report and we will continue to work with the working group, government and interested parties to help implement these robust solutions to help future proof Scotland’s historic residential property.” q

Boundary dispute reform: let’s use the legislative vacuum to good effect

by RICHARD CROW, associate director of Trident Building Consultancy

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WHO WOULD HAVE thought that Brexit – or the lack of it – would significantly affect the way in which the industry manages boundary disputes?

Two years ago a Private Member’s Bill, sponsored by Lord Lytton, received its first reading in the House of Lords. The Bill suggested that boundary issues could be better addressed by using a structure which broadly replicates the provisions of the Party Wall Act – essentially removing much of the responsibility from solicitors and handing it to surveyors. Progress of the Bill was thwarted by the general election of June 2017, and with parliamentary time apparently unavailable to advance the legislation it is yet to have its second reading in the Lords. The delay is frustrating, but it also provides some necessary reflection time.

Breaking boundaries

There is undoubtedly a need to reform legislation which can cost individuals as much as £20,000 for trimming a hedge – as well as costing them their relationship with their neighbours. And as large scale development is rushed into existence to address the housing crisis, landowners will increasingly seek boundary dispute services to maximise their landholding prior to development.

Lord Lytton’s Property Boundaries (Resolution of Disputes) Bill aims to reduce costs and expedite the resolution of property boundary disputes. Its mandatory dispute resolution scheme involves one neighbour serving a formal notice on the other, along with a plan indicating where they believe the boundary lies. If the neighbour disagrees, then a dispute is deemed to have arisen.

Either a surveyor is instructed jointly (which is encouraged to both limit costs and bring about openness), or individual surveyors are appointed by each party and a third independent surveyor instructed to make the final decision. Surveyors must be members of either RIBA, RICS or ICE and must adhere to the RICS code of conduct, regulations and RICS professional guidance regarding measured surveys of land, buildings and utilities and boundaries.

The surveyors’ findings are regarded as conclusive unless an appeal is made to the High Court within 28 days. When that period expires without appeal, both parties must inform the Land Registry.

Reservations

There are notable omissions. Not all boundary disputes are captured by the Bill – specifically leasehold land. That means two adjoining leaseholders cannot determine a boundary dispute without the authority and approval of the freeholder(s). That may not appear to be an issue at first sight; however, the freeholders may have no interest with such boundary issues or may no longer be contactable, as contact details have changed over the passage of time. If the tenant’s occupational use of the land is infringed due to encroachment, for example, who would the leaseholder turn to if they could not self-manage this process?

Furthermore, the Bill does not appear to authorise the surveyor to

instruct a landowner to remove a structure on a neighbour’s land or award compensation. As a consequence, there is an increased likelihood of aggrieved parties using the appeal route of the High Court – ironically, adding an extra layer to the process and ultimately more legal costs.

The Bill imposes criminal sanctions on those who prevent the service of the boundary dispute notices, but there is no reference to property owners who prevent surveyors from inspecting the property.

And we need more clarification on how the new procedures would work with existing rules and procedures on adverse possession or the acquisition of rights of way through the Land Registry.

Finally, due to the current system, there are very few surveyors with expertise in this area. When I undertook the RICS Expert Witness Accreditation Scheme certification recently, I was one of just three who attained the accreditation. Perhaps the lack of those suitably qualified reflects the fact that there are currently no minimum standards for boundary dispute advisors, but if the new legislation comes into effect we would require substantially more qualified experts – ideally those who combine the experience of land surveying and building surveying, as I do.

And, although the Bill aims to avoid adversarial adjudication, it requires a decision to be forced on both parties. The proposed system does not allow for the parties to mediate should they wish to do so. That can be criticised as undemocratic, with the potential to set a dangerous precedent.

Boundary disputes are a messy business – and so, it would seem, is boundary dispute legislation. I am fully in support of change and welcome Lord Lytton’s initiative, but clearly it requires further consideration before – hopefully – the Brexit cloud lifts one way or another and necessary legislation such as this is once again visible on the horizon. q www.yourexpertwitness.co.uk

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New guidance for data requests [ON 15 AUGUST the Information Commissioner’s Office (ICO)

issued updated guidance on the timescales for responding to a data subject access request (DSAR) following a recent ruling of the Court of Justice of the European Union.

A DSAR – the written request for information on what data is held by an organisation on an individual – may form part of a grievance, disciplinary or employment tribunal procedure.

Law firm Walker Morris offered an explanation of what the guidance means for private investigators and other data controllers.

“The general rule is that DSARs must be complied with without undue delay and at the latest within one month of receipt. The day of receipt of the DSAR will now be counted as day one, instead of the day after receipt. In the ICO’s example, this means that an organisation receiving a DSAR on 3 September has until 3 October to comply.

“If there is no corresponding calendar date in the following month, the date for responding will be the last day of the following month. In the ICO’s example, this means that an organisation receiving a DSAR on 31 March has until 30 April to comply. It makes no difference to the calculation as to whether the day of receipt is a working day or a nonworking day. However, where the calculated date for complying with the DSAR falls on a weekend or public holiday, the organisation has until the end of the next working day to respond.”

The statement from Walker Morris, republished by the Association of British Investigators, continues: “In light of this change, data controllers should review and revise their data protection and DSAR policies and any other documentation/notifications that reference the timescales for a response, including privacy notices. Relevant staff within the organisation will need to be notified of the change. Controllers should also review their arrangements with any data processors to ensure that the change is suitably addressed.” q

Bailiffs to see mandatory use of body cameras [

PEOPLE IN DEBT will be given greater protection from rogue bailiffs following the announcement by the government of the introduction of compulsory body-worn cameras.

While the vast majority act professionally and within the rules, the MoJ said, there are concerns that some bailiffs continue to employ intimidating tactics that put both themselves and often vulnerable consumers at risk. The government is taking decisive action and making body-worn cameras mandatory to ensure debt is collected in a fair and safe manner – with those who fail to do so being held to account.

It comes after recent moves by ministers to improve industry standards and protect vulnerable consumers better. It includes introducing a new 60-day ‘breathing space’ for people struggling to cope with debt – during which creditors will not be able to chase payments and individuals must seek professional advice.

Justice Minister Paul Maynard said: “The use of intimidation and aggression by some bailiffs is utterly unacceptable, and it is right we do all we can to tackle such behaviour. Whilst most bailiffs act above board, body-worn cameras will provide greater security for all involved.”

The announcement follows a recent government call for evidence aimed at ending intimidating practices, while better protecting vulnerable people. A response outlining its findings, including options for independent regulation and an improved complaints system, will be published after the summer following further engagement with the enforcement industry and the advice sector.

The move to make the use of body-worn cameras mandatory relates to High Court enforcement agents and certificated enforcement agents.

It does not relate to County Court bailiffs who are employees of HMCTS and who are out of scope for the review.

The Ministry of Justice said it will work with the Treasury to implement a ‘breathing space’ period where people with problem debts will be protected from enforcement action from creditors and will see their interest frozen. q

CCTV systems should now be secured by default [ON 20 JUNE – the world’s first Surveillance Camera Day – the

UK’s Surveillance Camera Commissioner, Tony Porter, launched the ‘Secure by Default/Secure by Design’ minimum requirements for manufacturers of surveillance camera systems and components.

Several high-profile and well-publicised instances of systems being compromised demonstrated that they were being left live and internet-facing in an unacceptable security configuration. Some of the compromises, like the Mirai botnet that brought down social media and financial websites across the globe, also showed the root cause was down to poor design and manufacturing.

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Driven by the need to ensure the UK’s resilience against that and other forms of cyber security vulnerability, as well as to provide the best possible assurance stakeholders, the new minimum requirements are an important step forward for manufacturers, installers and users alike.

The work has been led by Mike Gillespie of Advent IM – cyber security advisor to the commissioner – and Buzz Coates of Norbain, and developed in consultation with manufacturers.

Mike Gillespie said: “If a device comes out of the box in a secure configuration, there’s a good chance it will be installed in a secure configuration. Encouraging manufacturers to ensure they ship their devices in this secure state is the key objective of these minimum requirements for manufacturers.

“Manufacturers benefit by being able to demonstrate they take cyber security seriously and their equipment is designed and built to be resilient. Installers and integrators benefit from the introduction of the requirements by not having to know how to turn dangerous ports or protocols off during the installation. End users benefit because they know they are buying equipment that has demonstrated it has been designed to be resilient to cyber-attack and data theft.”

Manufacturers can demonstrate they meet the minimum requirements by completing a self-certification form and submitting it to the commissioner’s office for validation. If successful they will be able to list the component or system as certified by the commissioner and will be able to display his certification mark.

Tony Porter commented: “It has been an enlightening and positive experience working with manufacturers toward a common goal and it’s a genuine first and further standards will follow over the next couple of years.” q

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 Laird Assessors Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

The UK’s leading Independent Automotive Expert Witnesses. Comprehensive, clear reports backed by technical prowess

www.abc-translations.co.uk

www.laird.expert

Dr Thomas C M Carnwath

Mr Chris Makin

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

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

www.tomcarnwath.co.uk

www.chrismakin.co.uk

Mr Jeremy P Crew MA MD BChir FRCS

Mr Marcus Ornstein

Consultant Urological Surgeon Medical reports on all legal aspects of urology.

Reports in some cases based on hospital notes only.

Hon Senior Lecturer and retired Consultant Surgeon with expertise in general surgery, breast disease, hernia and abdominal trauma. T: 07713 860000 E: markornstein@gmail.com

www.oxfordurology.co.uk

www.marcusornstein.co.uk

Dr Lars Davidsson MRCPsych MEWI

Martyn Slyper

Consultant Psychiatrist and Accredited Mediator Reports within most areas of general adult psychiatry.

Specialist in PTSD, anxiety disorders & mood disorders.

Expert witness in Assistive Technology for Clinical Negligence, Personal Injury and Industrial Injury cases.

www.angloeuropeanclinic.co.uk

www.adapt-it.co.uk

Drilling Expert Legal Services

Principis Ltd

Mr Steve Devereux CEng ACIArb • Well engineering • Onshore & offshore drilling • Drilling rigs & operations

Asbestos expert witness and opinion relating to the safe management of works, regulatory compliance, disputes and exposure.

www.drilling-expert.legal

www.expertasbestos.com

Emma Ferriman Ltd

Dr Gerry Robins MBBS FRCP MD PGCLTHE

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

Consultant Gastroenterologist Full medico legal service in all cases relating to gastroenterology

www.emmaferriman.co.uk

www.drgerryrobins.co.uk

Expert in Mind

Mr Bernard Speculand MDS FDS FFD FRACDS (OMS)

Providing the legal sector with leading experts in psychiatry and psychology

Consultant Oral and Maxillofacial Surgeon. Personal injury and clinical negligence cases for claimant, defendant and as Single Joint Expert. Special interest is TMJ Surgery.

www.expertinmind.co.uk

www.birminghamtmj.co.uk

Professor Parviz Habibi MB ChB PhD FRCP FRCPCH

Target Psychology Ltd

Consultant in Paediatric Intensive Care & Respiratory Medicine.

Specialist in treating respiratory conditions and sleep disorders as well as paediatric intensive care.

Adult and Child assessments within: • Public & Private Law Proceedings • Pre-Proceedings • Immigration Proceedings • Court of Protection Proceedings • Criminal Proceedings

www.childrensrespiratorydoctor.co.uk

www.targetpsychology.co.uk

Mr Kim Hakin FRCS FRCOphth

Dr Rowland James Whale MBBS MRCP(UK)

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

Consultant Physician and Geriatrician • Elderly claimants • Medical negligence • General medical issues • Personal injury

www.kimhakin.com

www.drwhale.co.uk

The Hampden Consultancy Consulting Engineers • Mechanical & Electrical Services We can be appointed as Expert Advisers, Party-appointed Experts or as Single Joint Experts

www.thehampdenconsultancy.com

To get your website listed on this page just give us a call on 0161 710 3880 or email ian@dmmonline.co.uk www.yourexpertwitness.co.uk

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MEDICAL NOTES [CONVENTIONAL LOGIC HAS IT that the number of medical negligence claims is on an on-going upward

spiral. The truth, as evidenced by figures published by NHS Resolution, is somewhat less straightforward. The quarterly report of the body – formerly the NHS Litigation Authority – reveals the number of claims has levelled out, despite the fact that the NHS is carrying out more and more activities.

The amount of compensation being paid out remains eye-wateringly high, at nearly £5bn in the past year. But things could be worse; the number of claims being settled via the body’s dispute resolution process is rising steadily, indicating a more conciliatory approach by claimants. Maybe, as claimed by many PI solicitors, the reason for bringing claims is turning towards a desire to see the mistakes learned from.

• There are areas of medical malpractice that cannot be reconciled via dispute resolution and require personal injury litigation and maybe compensation payments on a vast scale. In August the Manchester law firm Leigh Day launched legal action on behalf of a number of women who have contracted the rare form of cancer BIA-ALCL, which has been connected with textured breast implants. The original number of women was stated as being over 50 – however, a recent release from Leigh Day has indicated that the number is over 70.

• Aesthetic surgery is an issue that has probably given rise to more column inches than any other medico-legal subject. From the risks of plastic surgery tourism to the scandal of the PIP implants to the outcry over procedures being carried out by unqualified practitioners, there have been plenty of stories to fill the pages of this journal.

Now the hand-wringing and the outrage have produced a result, and new regulations will govern who can perform those parts of non-surgical procedures that involve breaking the skin. Both the British Association of Plastic, Reconstructive and Aesthetic Surgeons and the British Association of Oral and Maxillofacial Surgeons have indicated that, while the new rules are welcome, they do not go far enough.

• While the press is an invaluable messenger for uncovering scandals that might otherwise remain hidden, it can occasionally go over the top and fire at the wrong target. Orthopaedic surgeons were a little put out, as reported in the last issue of this publication, by implications drawn of the failure rate of hip and knee replacements, taken from a review in a medical journal. A collective of professional organisations issued a joint response (no pun intended) pointing out the general level of success of such operations.

While that general view of the safety and success of joint replacements continues, the specialty has published new guidance on the safe carrying out of the operations, aimed at keeping surgeons on the right side of the law.

• When doctors do stray over the line from safe practice, the consequences go far beyond those suffered by most of us. For people in most walks of life the worst that can happen is loss of job, professional opprobrium and maybe a financial penalty. If a doctor gets it wrong, somebody could die.

If that death is the result of negligent care the clinician involved in the case may face criminal sanction, including prosecution for gross negligence manslaughter. The case of Jack Adcock and prosecution of Dr Bawa Garba in just such a case led to the urgent review by Sir Norman Williams.

One section of Sir Norman’s report deals with concerns around the quality of expert witnesses in such cases, both prior to and during the prosecution. The Academy of Royal Colleges has acted on Sir Norman’s demands and issued new guidance for experts. q

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Negligence claims remain steady despite increased activity [THE Annual Report and Accounts

2018/19 for NHS Resolution, published on 11 July, shows the number of clinical negligence claims has remained relatively steady, despite rising activity in the NHS. Overall, claims are falling as a proportion of the number of treatment episodes; however, the report highlights concerns around rising costs and the need for concerted action on all the drivers of clinical negligence costs.

The specialty that attracted the most claims over the period was that of emergency medicine, at 1,409; obstetrics resulted in by far the greatest value of claims – at £2.4bn that accounts for 50% of the total.

In the legal market, there is encouraging news with evidence of an increased engagement with ways to resolve concerns which keep patients and NHS staff out of court, accompanied by a reduction in legal costs.

However, the number of cases going into formal litigation has remained stubbornly more or less the same for well over a decade.

In a statement NHS Resolution said: “We have been on a mission to change that.

We set ourselves a challenge to disrupt the traditional approach taken to clinical negligence claims, to encourage mediation and other forms of alternative dispute resolution (ADR) and to reduce the number of claims going into formal court proceedings.

“There has been a noticeable culture shift in the clinical negligence market. We are now mediating more clinical negligence cases

than ever before and these outnumber those going to trial by six to one. There is more to do, but the benefits of mediation and other forms of ADR are clear: reducing the stress and burden on patients, NHS staff and their families and giving them the time and space to explore what happened.”

The report highlights the benefits of NHS Resolution’s strategy to work more closely with partners in health and justice, using the platform of 100% NHS membership of the indemnity schemes and the lever of pricing to drive improvements in patient safety. The report gives explicit backing to the national patient safety strategy recently published

by NHS Improvement and the continued drive across the health system to improve maternity safety.

The statement continued: “We must do everything we can to learn from what goes wrong and, where there is agreement as to what needs to change, to support that through the indemnity schemes we run. Our maternity incentive scheme, which uses a bundle of ten actions informed by our research and that of our partners, makes the best use of the financial lever we have to drive investment in safer care, improve things for patients and NHS staff and ultimately reduce the costs of avoidable harm.”

In the year to March the provision for claims indemnified by NHS Resolution has increased by £6.4bn to £83.4bn. The agency received 10,678 new clinical negligence claims,

compared to 10,673 in 2017/18, representing a flattening out in an environment of rising NHS activity.

The number of mediations on clinical negligence claims increased by 119% in a single year: up to 380 from 173 in 2017/18. It exceeded the number of clinical negligence trials (62) more than six-fold.

The number of new referrals received by the Practitioner Performance Advice team relating to the performance of doctors, dentists and pharmacists within the NHS remained broadly consistent, with 925 new requests for advice compared to 919 in the previous year.

The full report can be downloaded from www.resolution.nhs.uk/corporate-reports/. q

Three services in same Mews rated Inadequate [THREE LOCATIONS ON one street in the Royal Borough of

Kensington and Chelsea – all run by the same provider – have been rated ‘Inadequate’ by the Care Quality Commission (CQC).

All have been placed into special measures following inspections in May. The three services are run by PROMIS clinics on Kendrick Mews.

While the three are registered separately, they operate as one service with the same manager and the same staff covering the three locations. CQC completed the inspection which reviewed the three registered locations.

The service provides medically-monitored alcohol and drug rehabilitation services, including a psychological therapy programme.

CQC inspectors were concerned that the provider had not full taken account of a CQC briefing (supported by Public Health England) on the quality and safety of detoxification in residential substance misuse services. It was circulated to providers of all relevant services in 2017.

The service did not provide safe care for clients undergoing alcohol detoxification. The provider accepted clients for alcohol detoxification who had a history of alcohol withdrawal seizures and delirium tremens. That carried a level of medical risk that was not fully assessed prior to admission.

Clients did not have a comprehensive assessment before commencing alcohol detoxification treatment. There was no record that clients had a physical examination, including for clients with a

reported physical health problem. This included clients with possible or actual liver disease.

Clients’ medical and mental health history was not always obtained from other healthcare professionals prior to detoxification treatment.

One of the GPs prescribing for clients undergoing alcohol detoxification treatment had not had any specific training in treatment for substance misuse.

However, people were cared for in a clean and comfortable environment and there were enough staff to meet the needs of the client group. Clients were supported and treated with dignity and respect and were involved as partners in their care. Clients were supported to understand and manage their care and treatment. The service offered family interventions and post discharge support groups.

Dr Paul Lelliott, deputy chief inspector and lead for mental health at the CQC, said: “I am placing the three services into special measures due to their failure to follow best practice for the safe detoxification of clients withdrawing from alcohol, their failure to protect their premises from the risk of fire and the lack of management oversight of safety and quality.

“The service will be kept under review and, if needed, we will take further enforcement action. We will conduct another inspection within six months, and if there is not enough improvement we will move to close the service.” q www.yourexpertwitness.co.uk

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Outcome measures: the preferred method to monitor rehabilitation [

LAWYERS MUST ADOPT a proactive approach in their on-going support of seriously injured clients, taking ownership of assessing the impact of rehabilitation.

That’s the view of Andy Shaw, partner and head of personal injury and clinical negligence at Midlandsbased law firm Higgs & Sons.

Said Andy (pictured): “Lawyers who support seriously injured clients need to ensure that case managers and therapists providing treatment for clients use outcome measures to demonstrate the value added by the treatment.”

Patient reported outcome measures, or PROMS, are an essential requirement in all areas of healthcare, in determining the impact of treatment. An outcome measure is a test that objectively determines the baseline function of a patient at the beginning of treatment and, once treatment has begun, that same test is used again to determine progress and the treatment’s efficacy. They are routinely used in treating those with long-term neurological conditions, such as stroke and traumatic brain injury.

performance across countries and services. Within the UK, the National Health Service Outcomes Framework measures NHS performance and supports quality improvement throughout the NHS. For patients who are receiving private treatment funded by an insurer under the Rehabilitation Code 2015 following an accident, it is essential that outcome measures are used to demonstrate the value of the services being provided. Without such measures, a defendant and ultimately the court may determine that the treatment provided was excessive.

Selecting the appropriate outcome measure

Guidance on how to select the most appropriate measure is provided by statutory healthcare policies and their associated outcome measure requirements. In addition, several UK rehabilitation organisations have produced specific recommendations regarding outcome measures. The British Society for Rehabilitation Medicine publishes a ‘basket’ of recommended outcome measures for rehabilitation. The UK Rehabilitation Outcomes Collaborative has also developed a national clinical database for Why use outcome measures? rehabilitation to evaluate rehabilitation inputs provided to meet needs Using outcome measures facilitates comparisons of healthcare and outcomes of specialist inpatient rehabilitation services.

Finally, there are also condition-specific recommendations for outcome measures to be considered.

Andy explained: “Having selected the appropriate measures, the second challenge THE Department of Health and Social Care has announced that the General Medical is how to gather data that is meaningful for Council (GMC) will regulate physician associates and anaesthesia associates. Associates are evaluating a service, and monitoring individual a relatively new group of medical professionals who work under the supervision of a doctor. patient progress with the patient, family and GMC chief executive Charlie Massey declared: “We are pleased the four UK governments rehabilitation staff. have made a decision about who should take this important work forward. We look forward to “There is, of course, a danger in using supporting physician associates and anaesthesia associates to maximise their contribution to outcome measures exclusively to determine the workforce, while ensuring high standards are maintained to meet the needs of patients. whether treatment should continue to be “We are now working closely with the Department of Health and Social Care to determine funded. Considerations such as the risk of timescales and costs. We have been clear that costs should not be borne by doctors. regression need to be taken into account when In accepting responsibility for regulating these professions, we will also make sure that deciding whether treatment frequency will be excellence is maintained in education for both doctors and medical associate professionals, reduced or completely withdrawn.” so that all trainees receive the time and support they need to learn and provide safe care.”

He concluded: “Lawyers must be alive to The news was also welcomed by bodies representing the two groups of associates. the need of ensuring that a client is receiving The Faculty of Physician Associates said it looked forward to working with the GMC ‘to appropriate treatment. It is simply not enough expedite the regulation process so that we can move forward to consult on prescribing to engage a case manager to manage treating responsibilities’. q therapists.” q

GMC to regulate medical associates [

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Expert witness guidance follows manslaughter review [THE Academy of Medical Royal

Colleges has published new guidance for healthcare professionals acting as a professional expert or witness.

The guidance, Acting as an expert or professional witness, follows a recommendation in Sir Norman Williams’s Review of Gross Negligence Manslaughter in Healthcare and has been endorsed by nine healthcare professional bodies on behalf of over 70 professional organisations representing doctors, dentists, nurses, midwives, pharmacists, allied health professionals, optometrists and healthcare scientists.

Importantly, the General Medical Council, Nursing and Midwifery Council, Health and Care Professions Council, General Pharmaceutical Council, General Dental Council and General Chiropractic Council have all confirmed that the advice set out in the guidance is consistent with their standards and guidance as regulatory bodies.

While the guidance was produced in response to the Williams Inquiry recommendation, there have been concerns about aspects of the role of expert witnesses for some time. Although professional bodies cannot act to regulate professional witnesses, the guidance – aimed specifically at clinical professionals who provide an expert opinion or act as professional or expert witnesses in courts or tribunals – clearly states what healthcare professional bodies expect of their members in terms of standards, training and behaviour when acting as a witness.

The guidance reflects good practice set out by other bodies and highlights the legal requirements of witnesses. However, the aspects which are original or have been highlighted as specific responsibilities for clinicians include:

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• Healthcare professionals giving expert evidence must hold the appropriate licence to practise or registration and be in, or sufficiently recently have been in, practice • Healthcare professionals who act as expert witnesses should undertake specific training and continuing professional development for being an expert witness • The healthcare professional must have a full understanding of the wider context of the care delivery and how it impacts on the case, including the care delivery setting – rural, tertiary care, district general hospital, independent sector, primary care – and the historical context and circumstances if relevant • Healthcare professionals should be able to describe and explain the range or spectrum of clinical and/ or professional opinion on the issue in question and indicate, with sufficient reasoning, where their own opinion fits into that spectrum • Healthcare professionals acting as expert witnesses should make a selfdeclaration as to their scope of practice, professional development, training, special interests, areas of expertise both in general

and in relation to the specific case, and any conflicts of interest that could impact on their evidence • If they are found to have provided misleading information after such a declaration, they could be liable to professional misconduct proceedings in addition to the possibility of any criminal sanction.

Professor Carrie MacEwen (left), chair of the Academy of Medical Royal Colleges, said: “Being an expert witness is an important and valuable role. It is essential that clinicians acting in these roles are properly trained, fully up to date and act with complete integrity.

“Having this guidance endorsed by such a range of professional bodies and supported by professional regulators is a significant step.

I believe it will help ensure and maintain the required standards as sought by Sir Norman Williams’s Review.” q

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Guidance aims to help surgeons get it right first time Despite a general consensus among medical professionals regarding the safety and efficacy of arthroplasty procedures, there are still fears and suspicions among the general public, following a number of press reports regarding failure rates of certain devices and the possible toxicity of a number of them. Here we look at the latest guidance offered by the medical profession to help surgeons avoid possible litigation.

[

ARTHROPLASTY IS DESCRIBED as ‘a routine operation that involves replacing a damaged, worn or diseased knee or hip with an artificial joint’. Adults of any age can be considered for a knee/hip replacement, although most are carried out on those between the ages of 60 and 80, however more people are now receiving this operation at a younger age.’

New guidance has been produced in association with the British Hip Society, the British Association for Surgery of the Knee and the British Orthopaedic Association. The guidance takes two parts: dealing respectively with the hip and the knee.

The guidance has been produced by the Getting It Right First Time (GIRFT) programme, and is aimed at providing advice on various aspects of surgery which should be available and clearly documented in a knee or hip arthroplasty operation record.

The GIRFT litigation workstream shares data on litigation costs with NHS trusts with the aim of working with clinicians and managers to determine how clinical practice could improve, reducing the potential for future litigation. Data on the surgical specialties has already been shared with trusts.

The GIRFT litigation data packs for surgical specialties encourage trusts to triangulate the learning from claims, incidents, complaints and inquests. In particular, since implementing the review of claims through the GIRFT orthopaedic visits and the litigation data packs, there has been a year-on-year fall in orthopaedic claims volume.

The documents are not comprehensive guides to knee or hip surgery; however it is hoped that surgeons will find the advice helpful. Both sets of guidance share a great deal of both general information and detail.

Kirsty Handyside of Bournemouth-based Ellis Jones Solicitors has

described the new guidance thus: “The programme is designed to improve healthcare practice, techniques and procedures for the benefit of patients.

“A series of hip and knee cases, which include claims to NHS, were reviewed and common themes concerning technique and documentation were collated and highlighted in the documents. It encourages that various components of the arthroplasty should be clearly documented to provide evidence of safe clinical practice, in addition to providing important information should a review or revision of the replacement ever be required.” q

Many awaiting joint replacement suffer pain ‘worse than death’ [

ALMOST 20% of people awaiting hip replacements are experiencing extreme pain or discomfort, a new study shows.

Researchers at the University of Edinburgh also found that 12% of patients on waiting lists for knee replacements considered themselves to be in a similarly acute state of health.

The figures, published in the Bone and Joint Journal, are worse than for many other chronic health conditions, such as diabetes, heart failure or lung diseases. The researchers say the findings disprove the perception that hip and knee arthritis only causes mild discomfort and that surgery is considered optional.

The team measured the health condition of more than 4,000 Scottish patients – half waiting for hip replacement and the other half for knee replacement – using an internationally-approved score called the EQ-5D. The rating measures a patient’s ability to perform routine activities and look after themselves, as well as their levels of mobility, discomfort and anxiety.

Of the 2,000-plus people waiting for a total hip replacement, 19% were in extreme pain or discomfort – a state defined as ‘worse than death’ by the EQ-5D. Some 12% of those waiting for knee replacements said they were in a similar condition. The scores improved dramatically following joint replacement.

Hip and knee replacements are highly cost-effective treatments with long-lasting and almost immediate relief from the pain and disability caused by arthritis, according to the study’s authors. Despite that, patients receiving those procedures are the first to have their treatment limited or cancelled.

Chloe Scott, consultant orthopaedic surgeon and honorary senior clinical lecturer at the University of Edinburgh, commented: “Given the overall high levels of pain and disability described by all patients awaiting joint replacement compared with most other illnesses, access to appropriate treatment should be free and available to all at the time of need, not limited by cost or bed availability.” q www.yourexpertwitness.co.uk

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MRI scan unlikely to reveal ‘missed’ scaphoid fractures [ RESEARCH PUBLISHED in

the journal Injury has identified that missed scaphoid fractures are unlikely to have been picked up by an MRI scan if it had been used to back-up X-ray.

The researchers, Bakur Jamjoom and Tim Davis from the Department of Trauma and Orthopaedic Surgery at Nottingham University Hospitals, reviewed 52 medical negligence cases where scaphoid fractures had been missed. It is, the researchers noted, a common cause for litigation.

The research found that most of the fractures were missed because of a ‘failure to consider the possibility of a scaphoid fracture and search for clinical signs of this injury’.

In the report’s abstract the researchers said: “Some were missed due to failure to detect (or absence of) tenderness over the scaphoid bone. As a scaphoid fracture was never considered, or excluded by clinical examination, in 49 of the 52 cases a policy of obtaining MRI for all suspected scaphoid fractures would only have detected three of 52 fractures (6%). Improved awareness through better education is required to reduce the number of missed scaphoid fractures.”

The full report was published in the July issue of Injury: the International Journal of the Care of the Injured, published by Elsevier. q

Guidelines published for well leg compartment syndrome [

THE BRITISH ORTHOPAEDIC ASSOCIATION (BOA) has endorsed new guidelines for surgeons on the prevention, diagnosis and initial management of patients at risk of well leg compartment syndrome (WLCS). Patients undergoing prolonged pelvic surgery may develop WLCS in the absence of trauma.

The condition is relatively uncommon but potentially devastating, and has been recognised for almost 30 years. Delayed diagnosis and treatment may lead to severe adverse consequences, including loss of limb and/or life following otherwise uncomplicated pelvic surgery.

A multidisciplinary team of pelvic, vascular and orthopaedic surgeons have reviewed the available evidence and recently published the clinical guidelines on behalf of the relevant surgical specialty associations. It has been produced not only to protect patients from harm, but also to reduce the likelihood of criticism – including civil claims – brought against surgeons involved in treating patients at risk of developing the condition.

The guidelines, including the relevant professional standards, have been formally endorsed by the BOA and have been made available free to download as an open access publication in the British Journal of Surgery. q

Orthopaedic hospital loses dance and sports service [THE END OF AUGUST saw the closure of the Dance,

Sports and Exercise Medicine Service at the Royal National Orthopaedic Hospital NHS Trust – several months earlier than was originally planned.

This decision for a planned closure next year was made ‘in the best interests of patients and their need to be treated in a resilient service in the medium to long term’. However, the timeline for closure had to be accelerated due to the resignation of the service’s sole consultant.

The closure is part of the configuration of services in that part of London: the intention being to concentrate specialised services in fewer centres, where more patients can be treated within a fullystaffed, sustainable service.

Announcing the early closure, the hospital said: “We appreciate that there is a limited time frame to communicate with patients in the individualised manner that we would aspire to. While this is regrettable, the above circumstances leave us with few options.

Undoubtedly a sincere apology is due to all affected parties for the distress and inconvenience this situation will cause.” q

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Expert knowledge is enhanced by frontline experience [

AN ORTHOPAEDIC TRAUMA SURGEON is uniquely placed to provide expert opinion as they have a real grasp of the complexity of injury and trauma. That means they can make accurate prognoses and recommendations based on their day-to-day experience and awareness of the latest evidence.

Mr Ash Vasireddy is a full-time fellowshiptrained orthopaedic trauma surgeon at King’s College Hospital, which is one of the busiest major trauma centres in the UK. He qualified at Guy’s, King’s and St Thomas’s Medical School and completed his orthopaedic training on the prestigious London South East Thames Rotation. He is instructed regularly as an expert witness for both personal injury and medical negligence claims.

As well as his day job at King’s College Hospital, Mr Vasireddy is one of a small group of surgeons, and is the only contemporary orthopaedic surgeon, who works as a HEMS (air ambulance) pre-hospital care doctor. That enables him to go one step further than an orthopaedic surgeon because of his experience in the prehospital environment.

He is uniquely placed to give consideration and opinion of the management of a patient’s transfer to hospital and the appropriateness of the choice of hospital in relation to the injuries sustained by the patient. He can provide a detailed review and assessment of the treatment provided both by the first responders and on admission to hospital – including, for example, key areas such as the effective management of any pain and how the fractures were initially managed.

Mr Vasireddy explained the role of the expert witness in that field: “Trauma and orthopaedic surgeons diagnose and treat all kinds of injuries affecting the bones, joints, muscles, tendons and ligaments in any part of the body – from minor fractures to severely broken bones that pose a direct threat to a patient’s life. Medicolegal cases that require a trauma and orthopaedic surgeon may involve road traffic accidents or accidents in the workplace and include patients who have sustained high-energy impact injuries.

“Medical negligence claims usually follow as a result of alleged lack of treatment or care or because of a missed diagnosis. In cases involving emergency care there are a series of key moments and decisions that may affect the outcome of the patient involved.

A trauma and orthopaedic surgeon acting as an expert witness will be able to assess the preliminary diagnosis and treatment given to a patient at the scene of the index event or accident. ”It’s worth noting that the work of an orthopaedic trauma surgeon is not only focused on the immediate treatment of a fractured bone. Specialist orthopaedic trauma surgeons are also involved in the definitive management of fractures and the follow-up care of the injured patient. For example, an assessment and opinion of whether the injured limb has regained its original strength and maximum function is another key part of their work. Factors that may have impeded recovery can also be evaluated and addressed.

Mr Vasireddy continued: “The specialist skills of a trauma and orthopaedic surgeon allow the determination of the extent to which a patient could have been expected to recover use of an injured limb vs their actual recovery. This is very important, particularly in terms of discussions of quantum and their ability to return to key aspects of their life such as employment and to what level.”

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Clients working with Mr Vasireddy have commented on the quality of the detail and analysis in his reports, his personable approach and his obvious breadth of knowledge and skills across a range of medical specialities – particularly as a highly-skilled first responder and clinician in a major trauma centre, used to treating a vast range of injuries in addition to his complex surgical lists.

Mr Vasireddy is available for instruction through Medicolegal Partners Ltd. He specialises in the management of complex open and closed pelvic, acetabular, upper limb and lower limb fractures and amputations. As a HEMS pre-hospital care doctor his unique skill-set and experience of regularly treating patients in life-threatening and time-critical situations such as road traffic accidents and construction site injuries sees him highly qualified to report on a variety of medico legal cases. q • To instruct Mr Vasireddy call 0207 118 0650 or email him at info@medicolegal-partners.com

Cardiomyopathy patients being failed, charity finds [NEW RESEARCH HAS revealed that cardiomyopathy patients are

being left at risk due to inefficient care pathways. The research was carried out for the charity Cardiomyopathy UK and reported by the British Cardiovascular Society.

The heart muscle charity has identified severe gaps in services that are leaving the lives of more than 180,000 cardiomyopathy patients and thousands of family members at risk. The new research has revealed longer waiting times and an indirect and inefficient ‘care pathway’ – the journey from diagnosis to treatment.

Cardiomyopathy is a disease of the heart muscle that affects around one in 300 people. The condition often runs in families and is the top cause of sudden cardiac death in young people. If left unmanaged, the disease can lead to cardiac arrest – making an efficient care pathway critical in order to save lives.

In the largest survey of its kind, questioning more than 590 people living with the condition, Cardiomyopathy UK found declining standards throughout that entire care pathway.

Cardiomyopathy UK’s chief executive, Joel Rose, said: “Left unmanaged, cardiomyopathy can lead to cardiac arrest, which makes efficient diagnosis and treatment of the disease absolutely critical. As such, it’s deeply concerning to see from our research that standards in the care pathway for cardiomyopathy are declining.

“Over the past 30 years, improvements in genetic screening and medicines have completely transformed the potential to diagnose and treat cardiomyopathy. And we’ve also seen that detection among GPs has improved, with numbers being immediately referred to cardiologists going up by more than 10%. But those improvements, and breakthroughs in detection, genetics and medicine, are pointless unless healthcare professionals are able to screen and treat cardiomyopathy patients and their families efficiently.

“It’s clear that we need to work together to ensure cardiomyopathy patients are receiving the right tests, treatment, specialist care and support, which could save lives. A diagnosis of cardiomyopathy can be life-changing. But with the right treatment and support most cardiomyopathy patients can live full and active lives.”

Dr Gerry Carr-White, consultant cardiologist at Guy’s and St Thomas’s Hospital, added: “It’s clear where we are falling down in treating cardiomyopathy patients, and we need to work in a different way to improve outcomes for these patients and their families. We have to work across networks, train more specialists in inherited cardiac disease and improve education across both primary and secondary care. Those issues can only be addressed by appropriate funding and national prioritisation.” q

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Women begin legal action over implant-associated lymphoma [LEIGH DAY have confirmed that they are

taking legal action on behalf of 20 women who have developed breast implant-associated lymphoma linked to textured breast implants manufactured by Allergan. According to the law firm, over 50 women have been diagnosed with the cancer in the UK, and it is believed that there have been hundreds more diagnosed worldwide.

One of those taking the legal action is Linzy Bromfield (pictured), who had breast implants in 2005. She developed a rare lymphoma 13 years after breast implant surgery. She first noticed that her right breast had become so swollen she was unable to wear her bra. She was later diagnosed with implantassociated lymphoma. Linzy had both of her implants removed and has been free of disease since the procedure.

The Medicines and Healthcare products Regulatory Agency (MHRA), which regulates medical devices in the UK, is currently collecting data on women affected by breast implant associated-anaplastic large cell lymphoma (BIA-ALCL).

Nigel Mercer, a plastic surgeon and chair of an advisory group of surgeons monitoring cases of the cancer for the MHRA, told the BBC: “The same type of implant has been around for 30 years but we only started seeing this as a disease recently, so it looks like it's a genuinely new disease.”

However, Sarah Moore from Leigh Day, who is part of the team representing the women, disputes that. She said: “The first instance

of BIA-ALCL was recorded in the academic literature in 1997, and between 1997-2010 there were 20 different academic articles published referencing the fact of BIA-ALCL and alerting surgeons and regulators to this issue.

“Both the MHRA and NHS Data – the body responsible for monitoring the Breast Implant Registry – recognise that there has been no comprehensive facility for the collection of data concerning instances of BIA-ALCL in the UK and that many clinicians have not had the knowledge to provide clear advice and diagnostic confirmation to patients.

“In that context – what we are seeing is perhaps not a ‘genuinely new disease’ but the moment at which regulators and clinicians are acknowledging the fact of a man-made disease that has gone underdiagnosed and underreported for too long.”

The women are taking legal action against surgeons and manufacturers.

They want recovery for the costs of the implants and their removal, and compensation for personal injury, distress and any potential financial loss they suffered.

Manufacturer Allergan has said that patient safety was a priority and it would support informative labelling ‘to promote and advance the safest use of breast implant products’. It has issued a voluntary worldwide recall of Biocell saline-filled and silicone-filled textured breast implants and tissue expanders. q

Plastic surgeons welcome non-surgical interventions report [THE British Association of Plastic, Reconstructive and

Aesthetic Surgeons (BAPRAS) has expressed its support for the Royal Society for Public Health’s call for greater regulation of procedures that compromise the skin barrier, as outlined in its Skins and Needles report, published in June.

In particular, its surgeons endorse the call for non-surgical interventions to be restricted to over-18s, unless the individual has a medical or reconstructive need, as determined by a properly qualified and registered medical practitioner.

However, in a statement BAPRAS said: “While we of course recognise the importance of age restrictions and the need for infection control, we would suggest that the recommendations of the Skins and Needles report do not go far enough. The

risks associated with cosmetic fillers are far-reaching and, if not administered correctly, the complications can be severe and even life-changing.

“Practitioners must be fully qualified to not only prevent infection, but also ensure that only a regulated, high-quality filler product is administered to patients that have been made fully aware of the risks of their procedure. There is a need for fillers to be scrutinised and regulated more formally by bodies such as the Cosmetic Practice Standards Authority (CPSA) and the Joint Council for Cosmetic Procedures (JCCP), as this is currently not the case.”

The statement echoed a similar opinion expressed by the British Association of Oral and Maxillofacial Surgeons regarding the remote prescription of dermal fillers. q

Beware of the dog: especially when walking it!

[ANALYSIS OF hand clinic referral

figures from Royal Cornwall Hospitals NHS Trust showed that there were 30 serious hand injuries caused by dog lead or collar misuse in the county in just one year.

According to the British Society for Surgery of the Hand (BSSH), the figures point to a huge number of people across the UK who could be experiencing serious but simplyavoidable hand injuries.

The hand injuries were largely caused by the sudden movement of a dog after the walker had wrapped the lead around their wrist, hand or fingers, or hooked their fingers under the dog’s collar. The abrupt force can cause friction burns and tissue loss, as well as fractures and ligament injuries.

The BSSH also warns that catching a lunging or twisting dog by hooking your

fingers under its collar can cause serious finger injuries, including fractures. Even with expert medical care, these injuries can cause long-term stiffness and loss of function.

Mrs Rebecca Dunlop, consultant surgeon with the BSSH, said: “Having seen many serious injuries caused by dog leads and collars, I want dog lovers to be aware of the simple steps they can take to avoid severe damage to their hand.

“Hand injuries can be very costly for patients and the NHS – especially through time off work and medical costs. We want to ensure that dog owners are able to carry on enjoying time with their dogs without risking damage to their hand and time in hospital.”

While most injuries occur to the dogs’ owners, those working for dog walking agencies or kennels are also at risk.

According to the former Department for Business, Innovation and Skills: “Animal care and service workers are employed in a variety of settings, including kennels… and workers risk injury when caring for animals.” q www.yourexpertwitness.co.uk

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Dermal filler procedures need regulation, surgeons warn [ORAL AND MAXILLOFACIAL surgeons

have welcomed the publication of new guidance from the Joint Council for Cosmetic Practitioners (JCCP) on the remote prescription of medication for non-surgical cosmetic treatments such as dermal fillers, but have argued it does not go far enough.

Caroline Mills, the British Association of Oral and Maxillofacial Surgeons (BAOMS) lead on aesthetic and cosmetic surgery and a consultant maxillofacial surgeon at Great Ormond Street Hospital, said: “While BAOMS agrees with the introduction of guidelines for remote prescription of dermal fillers and other medications for high-street beauty salon

practitioners, we want to see regulation of the industry in line with European Union rules.

“The new JCCP guidance to curb remote prescribing will provide some protection for patients, but it does not go far enough. In the EU practitioners have to have a medical licence to inject fillers, and we need similar regulation in the UK. “Even with the new guidelines, where the prescriber will assess the patient’s suitability for treatment, there is still the risk of serious medical complications because the regulations allow non-medical staff to give non-surgical injectables.”

Ms Mills explained that patients can

suffer vascular occlusion, possibly leading to blindness, or severe allergic reactions – both of which require emergency medical treatment.

“It’s recognising and managing these problems that is so important and where patient safety maybe compromised,” she said.

The NHS faces increasing costs to treat the high street procedures that go wrong, says BAOMS, but without NHS coding for non-surgical treatment problems the scale of emergency treatment and corrective surgery remains unknown.

“We need regulation in the UK to protect patients properly,” Caroline Mills concluded. q

Dentists claim success in fines campaign [THE BRITISH DENTAL ASSOCIATION is celebrating success in

its bid to transform the NHS fines regime that it claims has hit millions of innocent and often vulnerable patients with penalty charges.

Senior health officials in England and Wales have acknowledged they will be abandoning the 'fines first' policy when entitlements to free care are in doubt. Rather than sending a penalty charge notice to patients as a first step, officials pledged to adopt the ‘three stage process’, which operates in Scotland and Northern Ireland and removes the presumption of guilt that operates in England. Patients are given the benefit of the doubt with an initial letter, inviting them to document their entitlement or pay if they have made an honest mistake.

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The concession was made in an appearance before the Commons Public Accounts Committee (PAC). The BDA has been pressing the NHS to make the change, which in Scotland raises more revenue than follow up fines.

Brendan Brown, director of citizen services at the NHS Business Services Authority, confirmed that: “There has been a proposal which has been agreed to move to a three stage process. That proposal will be implemented in the coming months.”

Dentist leaders have been deeply concerned by the lack of awareness of the impact of fines on patient behaviour and clinical time. The policy has been linked to a 23% fall in attendance among patients entitled to free care.

MPs mocked the fact that the ‘Easy Read’ guide to completing the notoriously complex two-page dental claim form itself runs to 21 pages.

Charlotte Waite, chair of the BDA's England community dental services committee (pictured addressing the PAC on 1 July), said: “Dropping the presumption of guilt will at a stroke prevent hundreds of thousands of people being wrongly labelled as fraudsters when they claim the care they are entitled to.” q

Women whose waters break early should be able to continue pregnancy, says new guidance [

PREGNANT WOMEN whose waters break early from 24 weeks, but do not go into labour, should be offered the choice to continue with the pregnancy until 37 weeks of gestation – as long as there are no signs of infection or complications. That is the recommendation of revised clinical guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG).

Continuing with the pregnancy closer to term could reduce the risk of the baby being born prematurely, which is linked to problems with breathing, feeding and infection, and being admitted to a neonatal unit.

A woman and her baby should be monitored closely for signs of infection and her individual circumstances and preferences taken into account, say the guidelines. If there are signs of infection or complications, it may be safer that a woman gives birth straight away.

When a woman’s waters break early, but she does not go into labour before 37 weeks of gestation, it is known as preterm prelabour rupture of membranes (PPROM). PPROM is a rare condition, affecting up to 3% of pregnancies, and is associated with 30-40% of premature births in the UK. Sometimes the baby is born soon afterwards: around 50% of women will go into labour within the first week after their waters break. But frequently it is possible to continue the pregnancy for weeks, or even months after the membranes have ruptured.

Every woman with PPROM should be offered antibiotics to reduce the risk of infection, such as sepsis, and to help the pregnancy continue, the guidelines recommend.

The revised guidance covers the diagnosis, assessment, care and timing of birth following waters breaking early from 24 weeks and until 37 weeks of gestation.

Other new recommendations in the guidance include: • Where possible, a baby should be born in a unit with appropriate neonatal staff and facilities, and the woman and her partner offered the opportunity to meet a neonatologist to discuss their baby’s care • Additional emotional support should be offered to a woman and her partner during complicated pregnancies and after birth • In subsequent pregnancies, women should be cared for by an obstetrician with expertise in preterm birth • In some circumstances a woman may be cared for at home, while others may be best suited to be in a maternity unit – that should be considered on a case-by-case basis.

Dr Andrew Thomson, consultant obstetrician and author of the RCOG clinical guidelines on PPROM, said: “PPROM is an uncommon, but potentially serious condition with significant health risks to a woman and her baby. Evidence shows that waiting for labour to begin may be the best option for a healthier outcome, unless there is a reason for the baby to be born immediately. Every pregnancy will be different,

and each woman’s individual preferences need to be considered when deciding on the timing of birth.

“All maternity units across the country are encouraged to follow these guidelines which should improve health outcomes for both mother and baby.” q

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Complications of dermal filler injections

By BRIAN LEATHERBARROW BSc MBChB DO FRCS FRCOphth, Consultant Ophthalmic & Oculoplastic Surgeon, Manchester

[DERMAL FILLER INJECTIONS have grown in popularity over the

course of the last 15 years – that popularity being particularly driven by social media – and as the number of injections performed globally has steadily increased, so has the incidence of associated adverse events, some of them serious.

Complications

Blindness can occur from inadvertent injection into a facial blood vessel that anastomoses with the ophthalmic artery and its branches that supply the retina. No area of the face is safe from such a complication, although the risk is much higher with injections given into the glabella and around the nose. Although rare, blindness is an underreported devastating complication of a treatment provided purely for aesthetic reasons.

Vascular occlusion with secondary skin necrosis, infection and severe facial scarring can also occur following such injections. GPs, dermatologists, A&E practitioners, nurses and many other clinicians now need to be aware that patients presenting with unusual facial swellings, skin erythema and blistering, unexplained subcutaneous lumps and bumps, and skin discolouration may have had dermal filler injections and should be questioned accordingly. In some patients, complications may not become apparent for a number of years. They also need to be aware of the treatment options and their associated risks.

Many patients are wholly unaware of the precise nature of the dermal filler that has been injected, and are often unaware of the status and qualifications, training and experience of the ‘aesthetic practitioner’ who has provided the injections, often with no aftercare instructions or emergency contact details. Many practitioners are very poorly qualified and unable to prevent, recognise or manage subsequent complications.

standards or an accepted code of practice. This is in total contrast to the guidelines that all doctors registered with the GMC must abide by.

The field is awash with practitioners who use the terms ‘industry’ rather than ‘profession’ and ‘clients’ rather than ‘patients’. Many oneday courses promise the title of ‘aesthetic practitioner’ – a term that is very misleading. Unregulated clinics are regularly appearing with ‘aesthetic practitioners’ who are self-proclaimed ‘experts’ and who describe themselves as ‘advanced’, ‘leading’, ‘renowned’ or ‘award winning’ – terms that are also very misleading.

Consent

Informed consent for dermal filler injections is often inadequate and fails to include an explanation of the serious risks. Most practitioners fail to document a past ophthalmic history or perform a basic eye examination before proceeding with the injections. Blindness of an only seeing eye – for example in a patient with profound amblyopia of the fellow eye – would be even more of a devastating complication.

Blindness following dermal filler injections is very rarely amenable to any treatment.

Litigation

Inevitably, as the number of complications increases, so will the number of patients who instigate legal proceedings against practitioners. Unfortunately, despite the findings of the Keogh Report in 2013, little progress has been made in the regulation of dermal filler injections, putting patients, particularly vulnerable patients, at risk of harm. q

Regulation

Unfortunately, the field of non-surgical aesthetic practice has a serious lack of any regulation and is not governed by professional

Report highlights importance of eyesight for road safety [THE Royal College of Ophthalmologists (RCOphth) has welcomed

a report from the Department of Transport – The Road Safety Statement 2019 A Lifetime of Road Safety – which highlights the importance of good eyesight for road safety and the value of assessing reductions in visual function. Changes to vision, for drivers of all ages, should be identified as quickly as possible because this can pose a risk to road safety for all road users, the RCOphth says.

However, more research is required to understand the extent to which vision issues pose a risk to road safety. In particular the college welcomed the department’s decision to launch a research programme and literature review to assess how far poor vision is or may become a road safety problem in the UK, and if there is a requirement for a new vision test to identify drivers who pose a collision risk.

Prof Ian A Pearce, RCOphth’s Driving Standards Representative to the DVLA, said: “It will be important to analyse the results of such research to assess whether there may be a case for mandatory eyesight tests at 70 and at three-year intervals thereafter, to coincide with licence renewal.

“The preservation of vision is fundamental to secure an independent lifestyle, and we need to recognise how driving provides this, together with the ability to work and care for dependents. It is therefore very important not to unnecessarily restrict the eligibility to drive unless there is robust evidence of a safety issue.” q www.yourexpertwitness.co.uk

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What are the factors that lead to diabetic foot amputation?

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

[

ABOUT 3.5 MILLION PEOPLE in the UK have diabetes, amounting to about 6% of the population.

That figure has grown from 1.4 million in the past 30 years. Two types of diabetes are present in the UK population: type 1 diabetes develops in young people and is attributable to a failure to produce insulin in the pancreas, while type 2 diabetes normally develops in older people and is strongly associated with obesity. In that condition the body becomes resistant to the effects of insulin.

A considerable increase in type 2 diabetes largely accounts for the growth in the numbers of diabetics, which parallels the rise in prevalence of obesity.

The management of diabetes involves careful regulation of the balance between intake of carbohydrate foods, exercise and the dose of blood glucose lowering drugs. It is important for the avoidance of complications that the blood glucose levels are maintained within the normal range or close to it. The patient must test their blood glucose levels regularly and adhere to a diet with an appropriate amount of carbohydrate in order to regulate blood glucose levels.

Complications of diabetes most commonly occur in those patients who fail to control their diabetes adequately. The quality of diabetic control is measured for clinical use by assessing the levels of glycated haemoglobin, which gives an indication of the blood glucose levels over the preceding 2-3 months. That is done by measuring the haemoglobin A1c (HbA1c) in the blood – in most patients 2-3 times per year.

Complications of diabetes and the vascular surgeon

Persistently high blood glucose levels lead to damage to several organs, including the eye – where diabetic retinopathy may lead to blindness – and the kidney, where diabetic nephropathy many lead to renal failure. Diabetic patients are much more likely to develop atherosclerosis, leading to coronary heart disease, strokes and lowerlimb arterial disease.

In the leg, the distribution of arterial narrowings is often in the calf, which may lead to ischaemia of the foot. A further problem which commonly affects the lower limb is diabetic neuropathy, which reduces the ability of the patient to detect minor injury to the foot due to loss of sensation there.

Damage to motor nerves which control muscle contraction may cause incoordination of the muscles, which is essential for the maintenance of normal foot shape and function. Deformity of the foot may arise, increasing the risk of damage to the skin leading to a foot ulcer.

The nerve problems often affect those nerves which regulate the distribution of blood flow to the tissues. Diabetic patients usually have warm peripheries due to that issue, and that can cause oedema (waterlogging) of the tissues. The immune system is often less efficient in diabetic patients, leading to increased risk of infection.

The combination of all those factors may lead to minor damage to the skin, in which a blister develops. Ill-fitting shoes can rapidly cause a blister in diabetic patients, which can lead to loss of the skin and an ulcer through which infection may enter. Reduced immunity to infection

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can allow severe infection to run rapidly through the foot, spreading swiftly from the foot to the leg. The only solution to an extensive major infection is a below-knee amputation.

Controlling diabetic foot problems

NICE has published advice on the prevention and management of diabetic foot problems in great detail in its document NICE NG19. The aim is to ensure that medical practitioners and healthcare workers provide rapid treatment for patients with diabetic foot ulceration. NICE advises that a diabetic patient presenting with a new episode of foot ulceration should be referred to the local multidisciplinary foot care service – which includes specialists in diabetology, podiatry, diabetes specialist nursing care, vascular surgery, microbiology and others.

The referral should be made within 24 hours and the patient should be seen by the diabetic foot care service within a further 24 hours.

As I have noted above, delays in providing such an assessment may permit uncontrolled infection to invade the foot, necessitating an amputation below the knee. Where a physician or nurse has failed to make such a referral, substandard care may have been provided.

Strategy regarding diabetic foot ulceration

The management of a diabetic foot ulcer includes a number of components: ‘offloading’, control of foot infection, control of ischaemia, wound debridement, wound dressings. Offloading of the ulcerated area of the foot using a plaster cast prevents further damage to the foot.

Antibiotics are useful in order to treat the infection, if present.

The vascular surgeon can investigate and treat limb ischaemia due to atherosclerosis, although that may be technically difficult or infeasible, since the affected arteries in the leg and foot are not easily reopened or bypassed due to their small size.

Wound debridement is effective in removing dead tissue in order to gain control of infection. The debridement may have to involve removal of the toes or the forefoot (pictured) and is usually done by a vascular surgeon.

The aim is to avoid a major amputation: if most of the foot is retained that is a far better outcome than a below-knee amputation. Diabetic patients are often treated by a series of ‘debridement’ procedures in which small sections of dead tissue are excised in an attempt to avoid a more major amputation.

Litigation concerning diabetic foot

With the increasing population of diabetic patients the number of cases where I have advised concerning diabetic foot problems has increased. In the light of the advice from NICE on swift referral of patients to the multidisciplinary diabetic foot care service, delays in referral may be considered to be substandard management.

However, such cases are usually defended on causation. It may be difficult to show that loss of one or two toes could have been avoided where minor delays in referral have been made. On the other hand, if a significant delay in referral has occurred, and the immediate treatment

required as a result is a below or above-knee amputation, the claimant may argue that it was avoidable with more expedient care.

In patients with limb ischaemia due to arterial disease, the efficacy of vascular surgery to improve blood flow may be limited by the distribution of the narrowed arteries in distal parts of the limb, where modern vascular surgery is less effective. Claimants may consider that, where vascular surgery has been done, it should have avoided a limb amputation. However, the defendant would probably argue that the surgeon’s ability to improve the blood flow was prevented by the severity of the arterial disease. The limb may have been lost because of the severity of the arterial disease in combination with diabetes.

In a number of cases of limb amputation in diabetic patients, the clinical notes show that the claimant was morbidly obese and there was failure to control the blood glucose levels over many years. The claimant has frequently disregarded medical advice concerning weightloss and adherence to the correct dietary regime in order to control the diabetes. In such cases, much of the responsibility for an amputation may lie with the claimant and the defendant may argue that in such circumstances loss of the limb was inevitable.

Even in cases where the claimant does succeed, the defendant is likely to assert that several factors may lead to loss of life expectancy.

Diabetes and morbid obesity each lead to a loss of life expectancy of about a decade. The occurrence of severe limb ischaemia (from diabetes or other cause) leads to an observed life expectancy of about four years. The value of such cases may be greatly eroded by considerations of life expectancy.

In conclusion, there has been a large increase in the number of patients with diabetes in the UK and worldwide in recent years. That has led to many cases of diabetic foot disease – often leading to the need for an amputation. Loss of the limb can be avoided by expediently delivered good quality care from a multidisciplinary team. However, although failure to provide such treatment may comprise substandard care, there are several factors which may limit the likelihood of success of clinical negligence litigation. q

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Drug deaths: finger pointed at govt policy [THE PUBLICATION on 15 August by

the Office of National Statistics (ONS) of figures relating to drug-related deaths drew agonised responses from a number of quarters. The report showed that there were 4,359 deaths related to drug poisoning in England and Wales in 2018 – the highest number and the highest annual increase (16%) since the series of reports began in 1993. Two-thirds (2,917) of those deaths were related to drug misuse, accounting for 50.9 deaths per million people in 2018.

According to the ONS: “Drug poisoning deaths involve a broad spectrum of substances, including controlled and noncontrolled drugs, prescription medicines (either prescribed to the individual or obtained by other means) and over-thecounter medications.

“As well as deaths from drug abuse and dependence, figures include accidents and suicides involving drug deaths is further confirmation that our policy-makers do not have poisonings, and complications of drug abuse such as deep vein the best interests of people dependent on drugs in mind, or those thrombosis or septicaemia from intravenous drug use. They do not of the communities around them. Unfortunately, the figures are as include other adverse effects of drugs, for example anaphylactic predictable and avoidable as they are tragic. Countries that have shock, or accidents caused by an individual being under the taken public health approaches to drug policy, like Portugal, have influence of drugs.” seen plummeting death rates, and the evidence for harm reduction The figures show that, between 2017 and 2018, there were interventions is now inarguable. increases in the number of deaths involving a wide range of “The case for a more compassionate harm-reduction approach has substances, although opiates such as heroin and morphine continued now been clear for years – and yet the government has continued to be the most frequently mentioned type of drug. Deaths involving to lead with tough rhetoric around law enforcement, all the while cocaine doubled between 2015 and 2018 to their highest ever level, presiding over sustained cuts to local authority budgets, undermining while the numbers involving new psychoactive substances (NPS) their ability to deliver effective drug treatment services. returned to their previous levels after halving in 2017.

“This outlook is increasingly at odds with the public and the health Responding to the report, Dr Emily Finch, the vice-chair of the community, among whom there is now a growing consensus that Addictions Faculty of the Royal College of Psychiatrists, said: “The criminal justice approaches to drug harm have failed, and that we highest-ever recorded number of people dying through drug-related must start treating drugs first and foremost as a health issue.” q deaths in England and Wales should serve as a wake-up call to the government that their approach to addiction services is putting people’s lives at risk.

“National decision makers need to wake up to the fact that swingeing cuts to services, disconnecting NHS mental health services from addiction services and shifting the focus away from harm reduction to abstinenceTHE FIGURES FOR drug-related deaths in England and Wales were published just a based recovery is destroying lives and month after National Records of Scotland published figures for that country, showing a 27% fuelling the increase in drug-related deaths.” increase there from 2017. The 1,187 drug-related deaths registered in Scotland in 2018 was The pointing of the finger of blame at the largest number since the series of reporting began in 1996 – and more than double the government policy was echoed by the Royal figure for 2008.

Society for Public Health (RSPH), which Scotland’s figures imply a drug-death rate that is nearly three times that of the UK as a pointed out that the rate for England and whole. It is also higher than that reported for any other EU country. However, countries differ Wales is more than double the European in how deaths are recorded and coded, and there may be under-reporting in some cases. average and over 12 times that of Portugal.

In tune with findings for England and Wales, the report showed that opiates or opioids, such The RSPH particularly highlighted the as heroin, morphine and methadone, were implicated in or potentially contributed to 1,021 facts that cocaine use doubled from 2015 (86%) of the total number in 2018. Benzodiazepines such as diazepam and etizolam were to 2018 and that deaths from NPSs has implicated in, or potentially contributed to, 792 deaths (67%). The overlap demonstrates the returned to the level it was before they tendency for drug-related deaths to involve more than one drug. were banned in 2016.

Males accounted for 72% of the deaths, while 66% were of people aged between 35-54. q Its chief executive, Shirley Cramer CBE, declared: “This latest rise in drug

Scotland’s drug deaths worst in Europe [

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ADHD in adults: diagnosis needs a different approach than with children In children, ADHD is conceptualised as being at one end of a normal distribution curve: that is, children who are the least attentive and those who are the most hyperactive are considered to have ADHD. Adult ADHD, however, cannot be diagnosed in that way. In adults ADHD presents as a syndrome of extremes: in addition to inattention there is hyper-focusing, which is when an emotion is attached to a task at hand. There is both procrastination and impulsivity; hyperactivity and hypoactivity; disorganisation and perfectionism. The main feature of adults with ADHD is their variability.

In this article, leading London consultant psychiatrist Dr UTPAUL BOSE explains how adult ADHD presents in both men and women and the negative effects that it can have on people’s behaviour if left untreated.

IF YOU ASKED most general adult psychiatrists about the most inattentive patients they have seen in their clinic, they would think of patients who are floridly psychotic and paying more attention to their inner world than the psychiatrist’s questions. In addition, if you ask the same question about who their most hyperactive patients were, they would think of patients who were in the middle of a manic episode.

[

impatience, like missing a train or the person in front of them spending too long in a queue. The focus on negative behaviours because of the emphasis on childhood ADHD overlooks the fact that all emotions are uncontrolled. Therefore, those with ADHD can also suffer with poor regulation of positive emotions: many individuals who never lose their temper, but have an abnormally loud laugh, suffer with ADHD as well.

Childhood ADHD has a history

Does ADHD have a negative effect on people’s behaviour?

Childhood ADHD had a 60-year head start over adult ADHD (1935 compared to 1995). Unfortunately, children to at least the age of 10 cannot give a good description of their mental state. Children do not usually refer themselves to child psychiatry clinics but are usually referred by other people, for example parents and/or teachers, and are more likely to be referred for externalising symptoms – that is, behavioural problems – than for internalising symptoms, for example anxiety, mood and low self-esteem.

However, children with ADHD actually suffer with both internalising and externalising symptoms. It is the ones with externalising symptoms that get noticed because the adults can see them, and the ones with negative externalising symptoms, which impinge on others, are likely to be referred the most. Thus, the sample of children with ADHD that are diagnosed with the condition is an extremely biased one.

It misses a lot of children who predominately suffer with mood swings and emotional incontinence: they burst into tears when a classmate says they don’t like them or they run around the playground a hundred times after scoring a goal.

It also misses out on all the ‘space cadets’ (usually girls) who do not have any observable behavioural problems but daydream all day long.

How does ADHD affect people’s behaviour?

Adult ADHD is not predominately a behavioural disorder – as opposed to childhood ADHD. Not all people with ADHD suffer from temper outbursts; in fact, some spend all of their mental energy trying to control their tempers, with the odd occasional leakage. When temper outbursts do occur, they are usually because of frustration due to

Individuals with ADHD are impulsive; that is, they prefer smaller immediate rewards rather than larger long-term benefits. Therefore, they have financial difficulties, together with problems organising themselves and with household tasks such as running a family.

They are also particularly prone to compulsive behaviours, which can involve shopping, masturbating, knitting exercises and risktaking behaviours such as gambling, extreme sports, risky sex, risky driving (speeding) and shoplifting. Some of them self-medicate with illegal drugs.

It can be managed with ADHD medication, life coaching or cognitive behavioural therapy (CBT). The benefits of treatment for ADHD are often much more dramatic than with other psychiatric disorders.

There is a trend amongst women for more internalising symptoms such as anxiety, depression and low selfesteem. However, these symptoms can be very prominent amongst men and there are also many women who are sensation-seeking risk-takers.

How do you assess someone for adult ADHD?

As children cannot tell you how their brain works, childhood ADHD is diagnosed based on their behaviours. General adult psychiatrists, however, use the mental state examination to diagnose mental disorders. It is therefore appropriate not to use specialised checklists that were designed for children, but to diagnose it primarily from the way the individual describes their mood, thinking, behaviours and sleep. q • Dr Utpaul Bose is a member of the expert witness panel of Expert in Mind. www.yourexpertwitness.co.uk

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Military PTSD sufferers may need physical healing as well [

WAR VETERANS with severe post-traumatic stress disorder (PTSD) exhibit a range of physical symptoms that current treatments do not address, new research has found.

Those veterans were found to be more likely to develop physical symptoms including headaches, tremors, stomach and muscle pain, indigestion and shortness of breath – in addition to common mental symptoms.

The research, presented at the Royal College of Psychiatrists’ International Congress in Edinburgh at the end of June, calls for new interventions to treat the physical and psychological symptoms, which could include a combination of physiotherapy and psychotherapy.

Professor Edgar Jones of King’s College London, who led the research, spent three years examining case notes from the 1940s-1990s on the mental health of over 500 British veterans from the Second World War, all of whom received pensions for a psychological illness.

Professor Jones, an authority on the psychological effects of modern war and conflict, said: “It may be that individuals who experience severe or prolonged trauma also suffer from bodily symptoms that inhibit their recovery process or serve to sustain post-traumatic illness.

These findings may serve to design new interventions or improve existing ones for veterans.

“Improved services would be clinical interventions, possibly involving multi-disciplinary approaches – such as a combination of physiotherapy and psychotherapy to deal with both psychological and somatic symptoms, or occupational therapy and psychotherapy.”

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Professor Neil Greenberg, lead for military and veterans’ mental health at the Royal College of Psychiatrists, commented: “Armed forces personnel are at risk of experiencing mental health problems as a result of their military service. Unfortunately, conventional treatments for PTSD such as trauma-focused cognitive behavioural therapy and eye movement desensitisation and reprocessing appear to work less well for military personnel.

“This research suggests that healthcare professionals who provide care to veterans who present with inexplicable physical health symptoms should sensitively ask about a history of trauma.”

A recent review of service personnel and veterans with PTSD found symptoms subsided after undergoing cognitive processing therapy and prolonged exposure therapy, but 60% to 70% continued to meet the criteria for PTSD. q

Dementia audit finds improvements on previous report [

THE NATIONAL AUDIT OF DEMENTIA (NAD) has published its fourth national report based on data received from 195 acute general hospitals in England and Wales. NAD looks at the quality of care received by people with dementia in general hospitals.

Dementia is the term used to describe a range of symptoms caused by diseases which damage the brain, such as Alzheimer’s disease, or a series of strokes. Symptoms vary extensively, but may include memory loss and difficulties with thinking, language and problem solving, as well as changes in mood and behaviour.

The National Audit of Dementia examines aspects of the care received by people with dementia in general hospitals in England and Wales. It is managed by the Royal College of Psychiatrists’ Centre for Quality Improvement.

The latest report details improvements since the Round 3 report in 2017. Those improvements include the fact that 96% of hospitals have signed up to ‘John's Campaign’, advocating the right for people with dementia to be supported by family carers when in hospital.

In addition, only 10% of staff said that they had not received dementia training at the hospital, compared with 17% in Round 3, and 51% of carers said that staff were well informed and understood the needs of people with dementia (up from 47%).

Two thirds (66%) of staff felt encouraged to accommodate the individual needs of people with dementia (up from 61%).

The latest report did identify priorities for improvement, including: • Delirium – only 58% of notes of people with dementia admitted to hospital showed that an initial assessment for delirium had taken place

on or during admission. People with dementia are at increased risk of developing delirium during an admission, which results in worsened health outcomes.

• Using information about the person to provide better care – 61% of case notes showed that some personal information had been collected; however, that often excluded information about any factors that might cause distress to the person with dementia or that might help them if they did become distressed. For people with dementia, an admission to hospital can increase disorientation and confusion. Staff can provide better care if they have access to information about what causes distress, as well as preferences and care needs.

• Training records – 89% of staff surveyed said that they had received some dementia training. However, that could not be compared across hospitals, as only half of the hospitals kept consistent records on staff training: important information to evaluate training strategies and outcomes for patient care.

• Trust boards examining outcomes for their patients did not always review data on people for dementia. The proportion of people with dementia could be identified by 64% of trust boards looking at inpatient falls, 40% of boards reviewing delayed discharges, and 37% of boards reviewing readmissions.

Overall, results show slight improvements from those reported in Round 3 – although many were significant. The audit’s expert Steering Group recommends that trusts work to implement its recommendations

by World Alzheimer’s Day on 21 September next year. They should also publish progress made on implementing dementia recommendations in an annual trust statement on dementia care and include other dementia-friendly hospital initiatives, such as self-assessment based on the National Dementia Action Alliance 2018 Charter. q

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Pitfalls in urology diagnosis [THERE ARE A number of regular themes in medical negligence work

in urology. Here, consultant urologist Chris Dawson MS FRCS LLDip shares his experience of writing reports in this area over the past 15 years.

Testis torsion

One issue that features regularly in urology medical negligence claims is testis torsion. Following the onset of pain, due to twisting of the testicle around the spermatic cord, early intervention is required to prevent ischaemia and the loss of the testis. The condition can be difficult to diagnose.

Where diagnostic uncertainty exists the affected scrotum should be urgently explored surgically, and that should not be delayed while imaging is requested – not least because imaging is often delayed in outof-hours situations.

In my experience most claims result where the torsion is misdiagnosed as infection (orchitis) and the claimant sent home, before representing with continued pain at a later time – by which time the testis is beyond salvage and requires surgical removal.

Ischaemia in the testis can occur as soon as four hours after the onset of torsion, with the potentially devastating outcome of loss of the testis. In one study investigators quoted a testicular salvage rate of 90% if detorsion took place within six hours from the onset of symptoms. That fell to 50% after 12 hours and to less than 10% after 24 hours.

Prostate cancer

Localised prostate cancer does not usually cause any symptoms. Men presenting with symptoms due to a benign prostatic enlargement will often undergo a prostate specific antigen (PSA) blood test. If that is raised, then referral to a urologist normally follows.

The usual investigations for suspected prostate cancer include an MRI

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of the prostate to look for targetable lesions, followed by a transrectal ultrasound of the prostate. The majority of urological claims in the area arise when cancer is not detected. That is a frequent occurrence and both tests have an appreciable false negative rate.

Patients must be counselled that, while no cancer may have been detected, it does not necessarily mean that cancer is absent, and further monitoring is therefore appropriate.

In one case recently submitted to me the patient was not appropriately counselled – nor were specific follow-up instructions given to the patient’s GP with regard to PSA monitoring after the initial tests were negative. As a result the patient was not properly followed up over the next five years, and returned at that time with a significantly raised PSA and metastatic (and thus incurable) prostate cancer. The defendants were advised that the case could not be defended.

Bladder monitoring after surgical procedures

Urinary retention (failure to pass urine) leading to a distended bladder can occur after surgical procedures. Transient filling volumes between 500ml and one litre do not appear to be harmful to the bladder if resolved within 1-2 hours.

Prolonged overdistension of the bladder often results in failure of the bladder muscle to contract properly, and an inability to empty the bladder.

Patients in this situation often require management with on-going clean intermittent self-catheterisation – the passage of a catheter into and out of the bladder several times a day – to ensure that the bladder is emptied.

Claims in this area invariably stem from a failure of medical staff to properly document that a patient is voiding urine well after a surgical procedure, and that the bladder is not retaining excessive amounts of urine. A common theme in these cases is a desire to discharge the patient home speedily. q

ACCOUNTANCY

AGRICULTURAL CONSULTANTS

ANIMAL BEHAVIOUR

BUILDING, PROPERTY & CONSTRUCTION

COMPLIANCE CONSULTANTS

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COMPUTER & MOBILE FORENSICS

ERGONOMICS

FINANCIAL SERVICES

CUSTODY & CHALLENGING BEHAVIOUR

FORENSIC SERVICES

EMPLOYMENT CONSULTANTS

ENERGY CONSULTANTS

ENVIRONMENTAL HYGIENE

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GEOTECHNICAL CONSULTANTS

MECHANICAL & PROCESS ENGINEERING

HEALTH & SAFETY

WOOD & TIMBER

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MEDICO-LEGAL EXPERTS ACCIDENT & EMERGENCY MEDICINE

ANAESTHESIA

CARDIOLOGISTS & CARDIOTHORACIC SURGEONS

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DENTAL & ORTHODONTIC EXPERTS

GENERAL SURGEONS

ENT CONSULTANTS

HAEMATOLOGY

HAND SURGEONS

GASTROINTESTINAL & COLORECTAL SURGEONS

LIVER SURGEONS

NEUROSURGEONS

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NURSING & REHABILITATION CONSULTANTS

OBSTETRICS & GYNAECOLOGY ORAL & MAXILLOFACIAL SURGEONS

OCCUPATIONAL THERAPY

ORTHOPAEDIC SURGEONS

OPHTHALMIC SURGEONS

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PHYSICIANS

PLASTIC SURGEONS

PAEDIATRIC SURGEONS

PATHOLOGY

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PSYCHOLOGISTS

PSYCHIATRISTS

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SPEECH & LANGUAGE THERAPY

TOXICOLOGY

TRICHOLOGY

UROLOGICAL SURGEONS

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