Your Expert Witness Issue No. 51

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contents IN THIS ISSUE 7

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Opening Statement

NEWS When it comes to supporting the rule of law, experts matter 8 10 Expert witness conference is hailed a success 11 Detectorists convicted of stealing Saxon coins 11 Cryptoassets and smart contracts have legal status confirmed 11 Birds of a feather find common ground 12 Lawyers welcome report on justice in Wales 12 Digital forensics experts will help crackdown on prison crime BUILDING & PROPERTY ISSUES High-octane trespassers bring forth injunctions from contractors 13 13 Points to consider when procuring a construction expert witness 13 Council forces govt U-turn on housing plan ROAD TRAFFIC ACCIDENTS Government to plug mobile phone loophole 15 15 Testing regime will enhance safety of self-drive cars 15 Transport department introduces DBS checks for MOT examiners

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FINANCE & ACCOUNTANCY Family matters 17 18 The expert’s role in resolving financial services disputes TRANSLATION & INTERPRETING Speaking the language: why accuracy is essential in the legal sphere 19 19 Professional body responds to consultation

A to Z WEBSITE GUIDE 20 Our A to Z guide to the websites of some

of the country’s leading expert witnesses.

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EXPERT CLASSIFIED 59 Expert Witness classified listings 62 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 Latest MoJ report short on detail, expert complains 25 25 PI lawyers slam MoD ‘longstop’ 27 Slimming clinic prosecution serves as a warning over registration 27 Heartburn drug recalled amid cancer scare 27 Wildlife are ingesting high doses of pharmaceuticals, study finds 29 Hospital trust admits failings prior to death of its own catering assistant 29 New test can identify resistant bacteria in 45 minutes DENTISTRY & MAXILLOFACIAL SURGERY New expert witness guidance is welcomed by maxfax surgeons 30 30 Dentists decry ‘Stasi tactics’ of regulator 31 Who caused what harm to whom; what does the expert need to evaluate it?

33 The litigious patient 34 Scottish patients are waiting two years for oral surgery 34 Oral surgeon in ‘Top 1,000’ London influencers 35 Whiplash injuries need a dental assessment – even when it’s not obvious

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OPHTHALMOLOGY Poor vision can cost lives on the road 37 37 Glaucoma research grant invites applications CARDIOLOGY Persistent flu-like symptoms mask cardiac problems 39 39 Many heart failure patients had previously seen GP 39 Specialist treatment improves patient survival DEEP VEIN THROMBOSIS Deep vein thrombosis – advice on prevention 40 UROLOGY The surgeon’s guide to staying out of court 42 PSYCHIATRIC & PSYCHOLOGICAL ISSUES CQC warns of a ‘perfect storm’ in mental health care 43 45 PTSD – what is new in ICD-11?

47 Psychiatrists join the cannabis debate 47 SEND system is in crisis, says Ombudsman 49 Recommending EMDR treatment in psychological assessments

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PLASTIC, RECONSTRUCTIVE & HAND SURGERY Breast implant safety: joint guidance issued 51 51 Surgeons call for action to deter firework misuse 52 New TV series reveals all – including an on-air nose job 53 Beyond surgery: skin camouflage explained ORTHOPAEDICS BOA decries lengthening wait times 55 55 Partnership sees orthopaedic treatment going off-island PAIN When only a pain expert will do 56 OBSTETRICS & GYNAECOLOGY RCOG responds to Shrewsbury reports 58 58 Midwives ‘key’ to detection of FGM www.yourexpertwitness.co.uk

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Opening Statement [

AUTUMN IS, of course, conference season – and there are two particular conferences of note to expert witnesses of all disciplines. In November the Bond Solon Expert Witness Conference attracted a packed house, particularly fitting as it was the 25th running of that particular race. A further attraction was a desire to learn about new rules for medical experts.

• Before that, though, came the annual conference of the Expert Witness Institute. It acts as a kick-off for legal gatherings, as remarked by Elizabeth Robson Taylor of Richmond Green Chambers. Her extensive report on proceedings makes fascinating reading, for which we convey to her our thanks. One of the issues under discussion was the prospect of artificial intelligence being deployed in legal work. Ms Taylor baulked at the prospect of a row of robots in the Supreme Court.

• Robots are very much here and now, however, in the transport sphere, and the government has grasped the bull by the horns for a change and involved itself in a new regime to ensure driverless vehicles are safe on our roads.

Recent high-profile mishaps have brought the issue to the fore.

In the event of an accident causing personal injury, who would be held responsible? And who would conduct the proceedings? Maybe those robots that had worried Elizabeth Robson Taylor.

• There is no doubt about liability when it comes to accidents caused by people using mobile phones while driving.

The evolution of smart phones and the ingenuity of lawyers have, however, combined to make the prosecution of people using the devices to take photographs difficult. The government is committed to closing the loophole.

• The use of mobile phones in prisons is also banned, but prisoners have naturally found ways of secreting them.

Again, the evolution of smart phones has enabled villains to do much more than merely phone home. All manner of online crime is the target of a new crack MoJ team of digital forensics experts.

• One of the unfathomables of the digital age – and one criminals are keen to exploit – is cryptocurrencies and other cryptoassets. It is another area where the British judiciary has taken the lead. By laying down the legal basis for cryptoassets it allows them to be properly regulated and policed. Similarly with so-called smart contracts.

• While cryptocurrencies may be the money of the future, the money of the past was at the heart of a criminal trial recently. A rare hoard of Saxon coins was found by a pair of detectorists near Leominster. The hoard could have shed light on a little-known part of our history – except the pair decided to tell no-one, including the landowner, who would have shared in the reward, and sell the coins. Sadly, many of the coins have disappeared into the marketplace.

• Causing grief to site owners is just one of the problems caused by so-called ‘free-runners’ – people who break into building sites and climb up half-built structures, cranes and anything else they can grab onto.

Under the Occupiers’ Liability Acts of 1957 and 1984 the site owner or contractor is liable for their safety and can be prosecuted if they injure themselves. Exasperated site owners have taken to obtaining injunctions to deter the activity.

• Back on terra firma, courts can only function if everyone involved in a case understands everyone else. It seems obvious, but with more than 250 languages being spoken in UK courts in one year alone, the need for accurate interpretation and translation is paramount. The issue is not always one of finding someone to speak the language concerned – their knowledge of English has to be sufficient to understand what is said by the judge and lawyers. It is a skilled occupation and one that has been undervalued by successive governments. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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When it comes to supporting the rule of law, experts matter

Lord Neuberger delivered the keynote address at the annual conference of the Expert Witness Institute at Church House, Westminster in September.

ELIZABETH ROBSON TAYLOR of Richmond Green Chambers summarises the highlights.

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LOOKING BACK on autumn, lawyers will recall that it isn’t just a season of mists and mellow fruitfulness – although most do enjoy those. With predictable regularity, the falling leaves of autumn not only herald in the new legal year, they also create a really quite inspiring backdrop for fruitful new opportunities to meet, greet, network, contemplate and confer.

Yes, the season of conferences kicks off in autumn, usually commencing – as far as the legal profession is concerned – with the annual conference of the Expert Witness Institute (EWI): an event of particular interest to lawyers.

The testimony of the highly-qualified, rigorously-trained expert witness can be crucial in court across a range of cases and circumstances, as Lord Neuberger emphasised in his keynote address, and it is the primary aim of the EWI to foster and nurture this role.

As EWI Chair Martin Spencer has insisted: “It has never been more important to have a credible voice for expert witnesses highlighting the critical role they play in our justice system.”

If anything, the conference held up a mirror to the uncertainties of 2019, with its stated theme expressed as Nothing stays the same; is everything changing? Well, yes, actually – the implication being that, as moving with the times is an imperative, mental agility and a willingness to adapt to change are what you need in any profession when ‘nothing stays the same’. As Conference Chair and EWI Governor Amanda Stevens reminded the delegates in her opening address: “Change is the only constant.”

At the same time, impartiality on the part of the expert witness is also key – a point emphasised by Lord Neuberger, retired president of the Supreme Court. Experts, he said, occupied a ‘very difficult position’ in balancing their duty to the paying party with their duty to the court.

While conceding that there is ‘no perfect answer’ here, he pointed out the necessity for everyone to bear in mind their responsibilities.

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The judge needs help

“When it comes to expert witnesses,” Lord Neuberger said, “the whole point is that the judge needs help, because he or she does not know about the topic. It is almost more dangerous for a judge trying a case when they know about the topic than when they don’t.”

Lord Neuberger then addressed a number of other topical issues, covering a number of key points. He referred, for example, to the thenrecent historic decision of the Supreme Court that Parliament could not be prorogued. Also under scrutiny in his speech were the differences between ‘negligence’, ‘recklessness’ and ‘dishonesty.’

Primarily, negligence stems from carelessness; recklessness means you don’t care whether you’re wrong or not; and dishonesty is basically a deliberate lie when the liar who’s lying knows he’s lying but lies anyway.

The Attorney General’s advice relating to the above-mentioned case was therefore not ‘negligent’, merely ‘wrong’ – a controversial view if there ever was one. Referring to a specific case, Lord Neuberger stressed the importance judges assign to honesty, warning that in the event of dishonesty, ‘the law will come down on your head’.

Other issues, such as over-long documentation and contingency fees were also brought up. The former is disapproved of due to time constraints and the destruction of paper. The latter ‘make judges uneasy’ in view of the expert’s obvious financial incentives. “If you are charging on this basis, make sure the court knows,” is Lord Neuberger’s advice.

Generally, the relentlessly increasing pressures on time and costs are exacerbated by what his Lordship termed the ‘tsunami of documentation’ – a problem which might, he added, be dealt with in the future by Artificial Intelligence (AI).

Losing our jobs to robots?

Obviously, there are no ‘magic answers’ to that question as, like Brexit and its long-term effects, so much is unknowable. So the image

of a row of robots perching in a future Supreme Court is definitely in the realm of fantasy.

In the here and now, however, the future of the EWI hinges on training.

Many useful courses are available for EWI members, and certainly training is one of the benefits of EWI membership. Experts may be expert in their own respective fields – from architecture and accountancy to a range of medical specialisms – but all need further instruction on such matters as court procedure and writing expert reports. Also useful are the opportunities for networking that conferences provide.

“People who don’t come to these conferences,” observed Lord Neuberger, “are the very people who should.”

‘Boris the Spider’…and the Lady and the brooch

Certainly, if you were one of those experts who, for whatever reason, had decided not to attend the conference you’d have missed having a laugh at Martin Spencer’s reference – in his Chair’s Address to the delegates – to Lady Hale’s now famous sparkling arachnid brooch, which sparked no small amount of comment. Could this item of jewellery have been an oblique reference to The Who’s classic song Boris the Spider?

(Look, he’s crawling up my wall, etc). Considering that anything to do with Brexit has been monumentally sombre and serious, that bit of lightheartedness was to be welcomed.

In all, however, Spencer’s speech was very much on the same or similar page as Lord Neuberger’s. Focusing on the changing context for expert witnesses, he stressed that the ‘critical role the expert witness plays in the justice system necessitates their compliance with the relevant legislation and regulations’.

Quite rightly, he has taken the view that experts appointed by instructing parties will have the qualifications they say they have. A leading clinical negligence barrister from Hailsham Chambers, Spencer had some pithy things to say about experts who may be experts in their own area, but not expert in understanding their duty to the courts. “The time has come,” he insisted, “when experts are accepted only when their credentials as experts are verified.”

Discussions and speakers

Following a subsequent panel discussion chaired by barrister and professor of law science Penny Cooper, in which Martin Spencer participated, the conference featured a range of topics presented by distinguished speaker after distinguished speaker.

“I have no doubt,” Martin Spencer said in his welcome note to the delegates, “that you will leave here at the end of the day a better and in particular a more confident expert.” It is unlikely that any delegate would have disagreed with that. q • Next year’s annual conference of the Expert Witness Institute will take place on 18 September at the Cavendish Conference Centre on Duchess Mews W1. Early bird booking is now available via the website at www.ewi.org.uk.

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Expert witness conference is hailed a success [

ON 8 NOVEMBER Bond Solon held the 25th Bond Solon Expert Witness Conference at Church House in Westminster. Demand for the conference had been particularly high, leading to a fully-booked event. Nearly 500 expert witnesses were in attendance and there were over 50 expert witnesses on the waiting list.

That upsurge in demand for places was in part due to the expert witness guidance issued in May by the Academy of Medical Royal Colleges. The guidance stated that healthcare expert witnesses must undertake formal expert witness training and keep that training up to date with appropriate refresher courses and activities.

Demand was also driven by a number of high-profile cases involving expert witnesses who have had their expert witness evidence deemed inadmissible or criticised. Those cases were reviewed at the conference.

The keynote speech at the conference was delivered by Sir Peter Gross. Sir Peter’s paper addressed the issue of standards in the work of expert witnesses. Sir Peter was followed by Lord Woolf (pictured), who reflected on changes to the Civil Procedure Rules.

Other highlights included sessions on criminal law, family law and

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commercial law, as well as a judge’s view of oral evidence from experts and a justification of experts’ fees.

The conference also saw the publication of the results of The Times and Bond Solon Expert Witness Survey 2019. The survey was conducted online in September.

Over 550 experts completed the survey, making it one of the largest expert witness surveys conducted in the UK. The report can be downloaded at from the Bond Solon website at www.bondsolon.com.

Alongside the conference there was a small exhibition of goods and services. It included a stand manned by the team from Your Expert Witness, who distributed free copies of the latest issue to delegates.

Next year’s conference will be on 6 November at the same venue.

Places are already filling fast – over 160 expert witnesses have already booked their place – so early booking is recommended. q

Detectorists convicted of stealing Saxon coins [

EXPERT TESTIMONY has helped convict two metal detectorists who discovered more than 300 Anglo-Saxon coins and historic jewellery and then hid the £2.9m haul.

Layton Davies and George Powell were scanning farmland in Leominster when they struck gold, discovering hundreds of AngloSaxon coins, jewellery and ingots.

Instead of disclosing the significant treasure find to the landowner and the coroner, as the law dictates, Davies and Powell kept the haul for themselves.

Separately, the detectorists contacted the National Museum for Wales explaining they had found only one coin each, at different locations, which meant they would not have been subject to the regulations of the Treasure Act. It came to light that the defendants had started releasing coins onto the market, through specialist sellers Paul Wells and Simon Wicks.

Evidence was gathered which showed Powell and Wicks meeting at a service station to hand over the coins.

Wicks contacted a collector and sold him two coins, telling him there was more in the collection if he was interested.

Lesley Milner of the Crown Prosecution Service said: “The coins Davies and Powell found were more than 1,100 years old and bore the inscriptions of Aelfred and Ceolwulf from the Saxon-Viking period. This find had immense historical value and should have been disclosed to

Cryptoassets and smart contracts have legal status confirmed [ ON 18 NOVEMBER the Chancellor of the High Court and chair of

the UK Jurisdiction Taskforce, Sir Geoffrey Vos, launched the LawTech Delivery Panel’s Statement on Cryptoassets and Smart Contracts at the Guildhall in London.

The panel has concluded that cryptoassets – including but not exclusively cryptocurrencies – can be treated in principle as property and that smart contracts are capable of satisfying the requirements of contracts in English law and are thus enforceable by the courts.

Speaking at the launch, Sir Geoffrey said: “I believe that this morning is a watershed for English law and the UK’s jurisdictions. Our statement on the legal status of cryptoassets and smart contracts is something that no other jurisdiction has attempted.

“The objective, of course, is to provide much needed market confidence and a degree of legal certainty as regards English common law in an area that is critical to the successful development and use of cryptoassets and smart contracts in the global financial services industry and beyond.”

The statement was widely welcomed by both legal and financial communities for the clarification it provides.

Law Society president Simon Davis said: “It will increase confidence amongst law firms to adopt new technologies and among investors to invest.” q

the relevant authorities. But Davies and Powell actively hid their haul for their own selfish gain.”

An expert testified that the coins seized from Wells, Davies and Powell had come from the same source due to the rarity of the coins. q

Birds of a feather find common ground [

CHORLEY-BASED legal and healthcare outsourcing company Handl Group has continued its expansion with the acquisition of Advanced Child Care Assessments (ACCA) of Burnley: the group’s second of the year following the addition of Harrison Associates.

ACCA is a provider of independent social work investigation and assessments within court proceedings. It will remain an autonomous company within Handl Group.

ACCA founder Mark Webb commented: “We provide excellence in the work that we do and strive for the very best possible outcome in every case. Handl Group aligns entirely with our beliefs, goals and aspirations.

“We also have synergy with a number of brands within the existing Handl portfolio. Therefore, Handl Group was the obvious choice to move our business to the next level and beyond.”

Handl Group chief executive Graham Pulford added: “This acquisition will bolster and broaden our breadth of service in the legal and expert witness arenas, strengthening our strategic position in these areas.

“At Handl Group we have a strong demonstrable legacy helping brands with accelerating growth and driving quality through investment in operational transformation, so this is an exciting time for us all.” q

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Lawyers welcome report on justice in Wales [

THE REPORT BY the Commission on Justice in Wales, published in October, has drawn a cautious welcome from the Law Society – officially the Law Society of England and Wales.

“The Commission has made an important contribution with their vision for the future of the Welsh justice system,” said the head of the Law Society’s Wales office Jonathan Davies.

“As the body of Wales-specific law grows, it is important to consider the distinct needs of the Welsh public and the legal profession as they seek to ensure their businesses remain vibrant and sustainable.”

The Commission’s key recommendation was that justice be devolved to Wales; however, the Law Society stressed recommendations for continued cross-border collaboration.

“We are pleased that the recommendations advocate a shared regulator and continued openness across England and Wales,” said Jonathan Davies, “allowing solicitors to gain experience and grow their careers in both nations.”

The report also examined access to justice and the impact of the 2012 legal aid cuts in Wales.

Jonathan Davies continued: “In Wales, many areas have become advice deserts – with clients having to travel long distances to reach

their nearest solicitor. Legal services are a critical public service and we welcome this recognition of the importance of legal aid funding and access to justice.

“This is a landmark day for the future of justice in Wales. We look forward to working with Welsh government and the Commission on Justice to grow the sector, promote South Wales as a vibrant legal centre and improve access to justice.” q

Digital forensics experts will help crackdown on prison crime [

IN OCTOBER the Ministry of Justice announced the creation of a new digital forensics unit and an expanded digital investigations team to crack down on criminal activity involving devices smuggled into jails.

The unit will investigate offenders carrying out illicit communications to further their criminal operations from inside prison walls.

With strengthened security leading to a rise in contraband seizures, the MoJ says there is increasing evidence that prisoners are using advanced technology to access the dark web, encrypt their messages and use social media in jail.

Announcing the move on 28 October, Prisons Minister Lucy Frazer QC MP said: “We know that the ways in which criminals conduct their business is advancing – with prisoners harnessing new technology and the dark web to further their operations behind bars. Bolstering our powers to detect and disrupt this kind of crime is a key element of our £100m investment in prison security.”

The new technology will identify perpetrators more quickly and produce improved digital evidence that is more likely to bring a successful prosecution in court. It will also offer opportunities to gather intelligence on how phones are being used to commit crime and detect and disrupt criminal activity in the wider community.

The specialist digital forensics team is being funded from the government’s previously-announced £2.75bn package to transform the prison estate. q

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High-octane trespassers Council forces govt U-turn on housing plan bring forth injunctions [ from contractors [

ONE OF THE legal issues concerning construction companies in the age of social media is the liability conferred on contractors for the safety of trespassers on their sites, despite their best efforts to prevent so-called ‘urban explorers’ from gaining access.

The bizarre outcome is one of the unanticipated consequences of the Occupiers’ Liability Acts of 1957 and 1984. Intended to force site owners to secure sites to prevent children and innocent people from accidentally injuring themselves, it has been expanded to include injuries sustained by criminals trespassing on sites and suffering perfectly foreseeable injuries.

In some cases the trespassers have recouped substantial revenue from monetising their exploits on social media.

The response from the industry has been to take out injunctions against both known perpetrators and unknown others.

Sir Robert McAlpine took out an injunction in March to cover four sites in Manchester. The firm’s safety, security, health, environment and quality director Anna Baker said: “Our decision to take out injunctions across a number of Manchester sites was one of a number of measures we have implemented to act as a deterrent to trespassers who may be thinking about accessing a Sir Robert McAlpine site.

“We noted an increasing trend in the occurrence of urban explorer incidents across a number of our sites at the start of the year, specifically associated with climbing tower cranes.”

The response from the industry was epitomised by Construction News reporter Miles Rowland, who wrote: “The law must evolve to address the behaviour of urban explorers and provide a more straightforward way for contractors to prosecute these deliberate trespassers.

“If the government continues to ignore this issue it would indicate a disregard for both health and safety and the construction sector at large.” q

THE GOVERNMENT has revised its Housing Delivery Test result for Lewes District Council following a successful legal challenge by the local authority.

Lewes District Council issued High Court proceedings against the Ministry of Housing, Communities and Local Government (HCLG) after the publication of its annual housing delivery test results in February, which indicated that the council had only delivered 50% of the housing required under its adopted local plan over the previous three years.

The consequence of delivery falling below 85% is a requirement to add a 20% buffer to a council's five-year housing land supply. That would have resulted in the council losing its five-year housing land supply and, as a consequence, its local plan would be treated as 'out of date' and irrelevant when determining planning applications. Neighbourhood plans over two years old would also effectively become redundant.

The case was listed for a final hearing at the High Court at the end of October, however HCLG has accepted the evidence put forward by Lewes District Council and a revised Housing Delivery Test result of 86% has been issued.

Cllr Emily O'Brien, Cabinet Member for Planning at Lewes District Council, welcomed the government's change of heart.

She commented: “The decision to issue proceedings was not taken lightly, but they were necessary to safeguard our local plan.

“The revised test result means that Lewes District Council can demonstrate we have an up-to-date local plan and that planning decisions can be made in accordance with our adopted local plan, which includes the policies in our adopted local neighbourhood plans.” q

Points to consider when procuring a construction expert witness [

IT IS LIKE any other procurement: a matter of process. That is the view of Lee Morrissey of March Surveying Services (MSS).

Lee offers this 10-point guide as a tool for paralegals and solicitors who might be involved in procuring a construction expert witness in criminal or civil cases.

01: Identify the nature and scope of the proposed instruction – is 01: the requirement for an Advisory Report, an Expert Report or 01: Single Joint Expert report?

02: Request confirmation that there are no conflicts of interest.

03: Request CVs and rates from the expert, check credentials, agree 01: terms and conditions.

04: Allow yourself sufficient time, where possible, to procure your 01: expert.

05: Identify the approximate volume of information to be considered 01: by the expert so that costs and timescales can be 01: quoted and agreed to avoid surprises.

06: Prepare a brief background to the case, sufficient for the expert to 01: be able to distil the issues.

07: Identify whether or not an inspection is required.

08: Identify whether or not court appearance is anticipated.

09: Identify whether experts meetings are anticipated.

10: If necessary, request redacted reports.

For further information visit www.marchsurveyingservices.com. q www.yourexpertwitness.co.uk

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Government to plug mobile phone loophole [THE GOVERNMENT HAS

confirmed it will close a legal loophole which has allowed drivers to escape prosecution for handheld mobile phone use while behind the wheel.

At present, the law prevents drivers from using a hand-held mobile phone to call or text.

However, people caught filming or taking photos while driving have escaped punishment as lawyers have successfully argued that the activity does not fit into the ‘interactive communication’ currently outlawed by the legislation.

Transport Secretary Grant Shapps has announced that he will urgently take forward a review to tighten up the existing law. The revised legislation will mean any driver caught texting, taking photos, browsing the internet or scrolling through a playlist while behind the wheel will be prosecuted for using a handheld mobile phone while driving.

Mr Shapps said: “We recognise that staying in touch with the world while travelling is an essential part of modern day life, but we are also committed to making our roads safe. Drivers who use a hand-held mobile phone are hindering their ability to spot hazards and react in time – putting people’s lives at risk.

“We welcome the Transport Select Committee’s report, and share their drive to make our roads even safer which is why this review will look to tighten up the existing law to bring it into the 21st century, preventing reckless driving and reducing accidents on our roads.”

The latest move will see the government go further than ever to ensure the law reflects the use of devices that allow other distracting activities. The impact of the behaviour is proven: if a driver looks at their phone for just two seconds while travelling at 30 miles per hour, whether to reply to a message or send a quick snap, they will travel 100ft blind, drastically increasing the chance of an accident.

The review will be urgently taken forward, with further proposals expected to be in place by next spring making the offence clearer for drivers and police forces.

Nick Lloyd, head of road safety at the Royal Society for the Prevention of Accidents, commented: “Drivers who use their phones are up to four times more likely to crash. RoSPA highlighted this loophole in the summer and is delighted that such prompt action is being taken to ensure that all hand-held mobile phone use is to be prohibited, making our roads safer for all.”

While ministers have also announced that they will consider the current penalties in place for hand-held mobile phone use, there are no plans to ban hands-free phone use.

Chief constable Anthony Bangham, National Police Chiefs Council lead for roads policing, added: “Technology has moved on since the original offence was introduced and it’s important to ensure any distraction to a driver is kept to an absolute minimum to keep all road users as safe as possible.” q

Testing regime will enhance safety of self-drive cars [

A NEW SAFETY regime for driverless vehicles has been unveiled by the Minister of State for the Future of Transport, George Freeman. Called CAV PASS, the system is aimed at ensuring self-driving vehicles are safe and secure by design and minimising any defects ahead of their testing, sale and

wider deployment on the roads.

The minister launched the system at the official opening of the Autonomous Village – a self-driving vehicle test facility with 70km of secure test tracks, a private mobile network and a simulator suite. The new ground will allow developers to safely challenge systems

Transport department introduces DBS checks for MOT examiners [

THE Department for Transport has introduced Disclosure and Barring Service (DBS) checking for anyone who becomes authorised to carry out MOT checks on vehicles, or becomes an ‘authorised examiner designated manager’. The basic DBS check verifies the applicant’s identity and will show any unspent convictions.

Those already authorised do not need to have the check done, but the DoT will request a DBS check for any additions or changes to their authorisation, or possibly as part of an appeal against any disciplinary action that has been taken against them.

The procedure replaces the counter-signing of driving licences or passports which used to be carried out to check credentials.

The DoT said: “We’ve done this to protect the integrity of the MOT and to simplify the process for applicants.” q

and collect data, to help fine-tune software, sensors, 5G telecommunications and cyber security systems.

Joshua Harris, director of campaigns at road safety charity Brake, commented: “The technology and its potential is hugely exciting but it’s critical that these vehicles are robustly tested for safety before allowing them on our roads.”

The new safety assurance system will first focus on enabling the advanced trialling of self-driving vehicles, and aims to eventually help assure the safety and security of these vehicles for their mainstream sale and use.

Such advanced trials may include those without a human operator in the loop at all times, or the assessment of novel vehicle types such as pods and shuttles. q www.yourexpertwitness.co.uk

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Family matters

By CHRIS MAKIN Chartered Accountant, Civil Mediator and Expert Determiner

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ACCOUNTANTS are in to everything, aren’t they? And that is especially true when things go wrong. In these pages you will have read (I hope) about how an accountant can act as expert in commercial litigation, can act as mediator in commercial disputes and much else besides, can investigate fraud, and can trace and quantify the extent of the ill-gotten gains of the drug trafficker.

As if that weren’t enough, expert accountants also have a valuable part to play in family disputes. I have acted for many years as an expert in family matters, and my work falls into three main areas: as party expert, as shadow expert (or expert adviser) and as single joint expert (SJE).

An expert is allowed to act on the record only with the judge’s permission, and traditionally the party expert is involved only in the ‘big money’ cases. I have been involved in many such cases, but let us turn our attention just to one.

I acted as expert for a husband who, with his wife, had two businesses.

One was an industrial waste business – it had a fleet of skip wagons, bringing in waste from factories across Surrey to waste transfer stations where any recoverable waste was recycled and the rest went to landfill.

The other company owned a huge quarry in the greenest of Surrey green belt – quite an asset! – where gravel was extracted and the landfill was dumped. My opposing expert advised that, to achieve a clean break, the husband should take the waste company and the wife should take the quarry company. I saw that as plain daft. For what would the wife use to backfill the quarry? And where would the husband dump his landfill, in Surrey of all places?

My solution was far more sensible: let the husband keep both companies, since there was a ‘marriage’ between them, and let the wife take the family mansion and the bulk of the investments. She could live on the investments and the husband could continue his successful pair of businesses. And so it was decided, without the need for a court hearing.

There is also the need for a forensic accountant where there is deep suspicion between spouses. Two quick examples.

In one, the husband had a company selling computer hardware and all the add-one services – installation, support and training. His website preached the advantages of this comprehensive service. Then he left home and set up with a lady who had a company providing very similar services.

His company’s profits declined; he said he had had to give up many of the services because they were no longer profitable.

I took a print of the husband’s company website at an early date, and currently. He used to have a long list of services, but most had disappeared.

Yet – surprise! – a print of the girlfriend’s company website currently showed that she was offering all the services which the husband had discontinued.

Inspection of the husband’s company sales ledger showed that the regular income from his clients with service agreements had petered out. It wasn’t necessary to look at the girlfriend’s books, even if I had been allowed to.

It was obvious what had happened. The family proceedings were quickly settled on the basis of what the husband’s company would have been worth if the trade had not been diverted.

Then an example of the power of Hildebrand – remember that case?

I acted for a wife whose husband had a very large IT company. There were large amounts being paid in consultancy fees – always an area ripe for investigation. My client printed out a lot of material from the notebook computer, which the husband had left at the matrimonial home, and discovered that there were many invoices for consultancy services.

My investigations revealed that they were false: one set had been invented in the name of a relative of a junior director with an unusual name, who in fact was resident in Australia; the other set were ostensibly issued by

an Eire company which I discovered from a search at Irish Companies House had been liquidated five years earlier!

I regret the overturning of Hildebrand by Imerman, for how else could justice have been served?

To more mundane matters. These days, district judges are most unlikely to permit party experts to act, they much prefer SJEs. The reason is obvious: if there is only one expert, there will be only one valuation (or a narrow range of valuations) produced by that expert.

So the judge doesn’t have to make a decision between £1million and £nil.

I have acted in a huge number of such cases and the need for valuations of the family business is clear – with a clean break it is necessary to determine the value of probably the main asset of the marriage which only one party can take out, namely the family business. An accountant is needed not just to advise on that value, but also to advise on the tax consequences of the business being divided up or passed into the hands of just one party. And if a clean break is not possible, the court will need to know what income such a business can yield, so as to fund periodic payments.

One of the problems encountered increasingly these days is the family business which has provided the couple and their children with a good income in the past, but which may have suffered badly in the recession.

I recall one a few months ago – exceptionally for a reasonably small enterprise there were party experts. My opponent had valued the business at about £1million by stretching logic in favour of the wife (the expert’s fees were paid by a rich daddy) whereas I acted for the husband and valued the whole enterprise at £nil – I saw that it was on skid row.

When the husband was being cross-examined, he said business was so bad that he was applying for a CVA for his company and an IVA for himself.

His arrangements failed, the company went into insolvent liquidation and he went bankrupt. Good news: I was right, the business was worth nothing. Bad news: I didn’t get paid! And this is something of which family lawyers must be acutely aware – is the business worth fighting over?

So there we are: a scamper through the need for accountants in family proceedings. I did say that accountants get involved in everything! 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 – see www.icaew.com/forensicaccreditation/register.

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

For CV, war stories and much more go to the website at www.chrismakin.co.uk – now with videos! q

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The expert’s role in resolving financial services disputes

By PAUL GRAINGER, CEO Complyport Limited

[

FINANCIAL SERVICES can appear complex and daunting to many professional advisers – and to their clients. That is why experts often play a key role in resolving financial services disputes.

The law, regulations and rules relating to financial products and the delivery of financial services runs to thousands of pages. It covers matters as diverse as insurance, consumer credit (loans, credit cards and hire purchase agreements), banking and payment services, mortgages, savings, investments, life assurance and pensions.

It also sets out the standards for disclosure of services, product features, costs, charges and financial projections of future returns. Perhaps more importantly, the conduct of business rules set out a requirement that in providing a service or product, a financial services firm must always act in its client’s best interests.

If a client is not satisfied with a financial product or service, they have the right to

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complain to the firm that provided that product or service. In many instances when clients make such a complaint, they may find the firm concerned accepts the fault or error in the service or product and provides compensation.

Where a client is not satisfied with the outcome of a complaint, he or she may be able to refer the case to the Financial Ombudsman Service (FOS) free of charge.

The FOS is an independent investigation and adjudication service. It will receive evidence from the complainant and the firm concerned and will then provide an independent judgement. If it finds in the client’s favour, it can award a compensation figure to ensure the client is no worse off and is possibly also awarded recompense for any additional cost or inconvenience.

However, since 1st April 2019 the FOS has only been able to make awards of up to £350,000 – prior to April 2019 it was just £150,000. Whilst this may sound like quite a

sizeable sum, when compared with the amounts involved over the lifetime of a long-term financial commitment, much higher sums may be needed to compensate for the loss to the client.

Those clients may then decide to instruct legal advisers who may find they are not sufficiently qualified or experienced to properly understand the product or service concerned, the degree of loss that the client has suffered, or the correct level of compensation required.

This is where an expert witness can significantly assist in providing clear advice and guidance regarding the product or service, how the client should have been dealt with by the provider and what is required to put the client back into a ‘no loss’ position.

A good expert witness can guide and inform both the parties to the dispute and the court, often speeding up the process of resolving the dispute before trial. In this way experts can play a key role in resolving financial services disputes. q

Speaking the language: why accuracy is essential in the legal sphere

by CHRISTINE BATY of Translate Hive

[THERE’S NO DOUBT that many questions surround legal interpretation and translation – and how it can assist, from the first notification of loss through to court proceedings, while remaining a disbursement. I will try and answer some of these questions here.

What is the difference between translation and interpretation?

Translation is a written text from one language to another, ensuring complete understanding in a visual format. Providing translated documents from English into a client’s native tongue prevents confusion later down the line, due to having a physical reference should any inconsistencies be raised.

Interpretation holds many meanings, but in the legal sense of the word it is recognition of understanding through paraphrasing for each individual language and dialect – legal terminology can be tricky for the unqualified and unexperienced expert.

Does your client truly understand the claims process and will the language barrier be the cause of an unsuccessful case?

If those questions aren’t pivotal at some time when accepting a brief to represent a non-English speaking client, their case is at risk. An educated

Professional body responds to consultation [

THE Institute of Translation and Interpreting (ITI) recently submitted two documents in response to the Independent Chief Inspector of Borders and Immigration’s recent call for evidence about the use of interpreters in the asylum process.

In the first, the institute made a number of recommendations, including: • Interpreters should be able to speak in the asylum seeker’s language • as competently as a native speaker, including specific dialects • Interpreters should receive adequate briefing • Interpreting should only be conducted by professional interpreters • Requirements for interpreters involved in remote interpreting – such • as qualifications, experience and briefings – should be the same as • for those involved in face-to-face interviews • Remote interpreting should only be used when the location of • participants or the lack of local interpreters with relevant qualifications • precludes the use of in-person interpreters.

As a result of a deadline extension to enable additional consultation, the institute invited members to submit their own experiences, which were then combined into a summary report. Topics raised included concern at the very long length of some interviews, leading to interpreter fatigue; unsatisfactory remuneration rates for that type of work; and the automatic assumption that interpreters were responsible for errors, which was not invariably the case.

The inspection is still listed as ‘live’ and is expected to be reported on next year. q

judge will happily throw out a case should a client seem uninformed. British judges increasingly now pay attention to foreign cases, in the hope the client isn’t being taking advantage of in any profit-earning way rather than the best interests of the client being sought as their fundamental human right.

Therefore, interpretation and translation hold a vital part in any case – but especially with personal injury cases – not only at court but at each stage of the claim, whether it be written, verbal or both, for complete understanding and for the benefit of the client and their claim.

Can anyone translate a document? What about Google Translate?

With that in mind, it is essential that experts must be listed on one of the recommended registers. That provides a safeguard regarding competence, reliability and security vetting, which along with suitable qualifications and many hours of experience at a forensic level are necessities for recognition by the court.

The use of native-speaking file handlers or family members of the client is no longer accepted as a reliable source of advice to the client. Similarly, automated translation services give a very literal translation, which often doesn’t make clear sense or may alter the meaning of the sentence just slightly. Clearly in court – and in many other areas – accuracy is paramount.

Is outsourcing the right choice?

Should your client’s claim come to the litigation stage, it is undoubtedly a view of some that outsourcing is a forbidden word. Will there be risk? Will there be excessive cost? These are valid questions, of course, however the key is to quash the scepticism, focus on the core goal and give thought to the loyalty and expertise outsourcing can bring.

While completing exceptional due diligence and analysing company and client needs are important, of prime importance is the working relationship. The need to ask questions and have them re-clarified by someone who can demonstrate a knowledgeable and consistent quality of service is paramount.

That’s one of the more important reasons why solicitors trust Translate Hive, where knowledge is at the heart of the team – not just within the legal sector, but with non-legal translation and interpretation as well.

Our stronghold of exceptional customer care team members can not only offer guidance in the unknown but also offer solutions for the most urgent of conundrums.

It’s time to future proof your firm and invest in outsourced translation and interpretation support! q

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

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

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

Emma Ferriman Ltd

Principis Ltd

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

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

www.emmaferriman.co.uk

www.expertasbestos.com

Expert in Mind

Dr Gerry Robins MBBS FRCP MD PGCLTHE

Providing the legal sector with leading experts in psychiatry and psychology

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

www.expertinmind.co.uk

www.drgerryrobins.co.uk

Professor Parviz Habibi MB ChB PhD FRCP FRCPCH

Mr Bernard Speculand MDS FDS FFD FRACDS (OMS)

Consultant in Paediatric Intensive Care & Respiratory Medicine.

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

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.childrensrespiratorydoctor.co.uk

www.birminghamtmj.co.uk

Mr Kim Hakin FRCS FRCOphth

Target Psychology Ltd

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

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

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www.targetpsychology.co.uk

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MEDICAL NOTES [THE LATEST NHS Trust scandal has arisen out of a situation which everyone thought had been rectified.

It was back in 2017 when then-Health Secretary Jeremy Hunt ordered an inquiry into the maternity services at Shrewsbury and Telford Hospitals NHS Trust. In the intervening two years Donna Ockenden has been carrying out her investigation.

The Royal College of Gynaecologists also carried out a review, at the request of the trust. It was the reference to that review in The Independent, when it broke the story of continuing failings at the trust, that has ruffled RCOG’s feathers. We have reported their response.

• As RCOG points out, they can only report within the terms of reference of their brief. Keeping to the point, or rather keeping within one’s own specialism, is also the gist of new guidance for expert witnesses issued by the Royal College of Surgeons. It comes as the result of two reviews of the law of manslaughter by gross negligence in a clinical setting, and has been welcomed by, amongst others, the British Association for Oral and Maxillofacial Surgery.

• Oral and maxillofacial surgery (OMS) is a twin specialism with dentistry – indeed, OMS surgeons are required to be qualified in both medicine and dentistry – and it is a specialty that is seeing long waiting lists in Scotland, with one patient reported to have waited nearly five years for a procedure.

The cause of the length of wait also appears to lie in both spheres. While there is undoubtedly a shortage of practitioners in the OMS specialty itself, the problem is exacerbated by the number of extractions and other dental procedures being carried out in hospitals instead of in the community – itself a result of a shortage of dentists, together with a dearth of experienced dentists able to train new entrants.

• Lengthening waiting lists are also a source of concern to orthopaedic surgeons – this time in England. The number of people waiting for orthopaedic or trauma surgery has topped half a million – by far the largest number of any specialty. As the BOA points out, such conditions as arthritis are extremely painful and debilitating for sufferers. The situation in Northern Ireland is even worse • There is one part of these sceptred isles where orthopaedic waiting lists are actually falling! That’s in Guernsey, which has found a solution to the problem by exporting it, sort of. The island’s health committee has entered into a partnership with a private provider in England to carry out procedures on the mainland. It is the latest in a series of such ventures.

• It is while in hospital that most diagnoses of heart failure are made. It is a growing problem, as the number of people suffering from heart failure seems to be on a permanent upward curve. Curiously, around four in 10 people diagnosed had attended their GP practice with symptoms in the previous five years.

GPs also don’t always spot the signs of cardiomyopathy hidden by the symptoms of flu and a lingering cold. That is, of course, when people do go to their GP. Often there is a tendency not to add to the pressures GPs are under, so the symptoms get missed until it’s too late.

• Most of us also self-medicate when it comes to tummy upsets and heartburn, and one of the most commonly prescribed remedies has also been freely available on the shelves of our supermarkets – until now. Ranitidine was withdrawn from the shelves in October over fears it could be contaminated with carcinogens. The latest information from MHRA is that the shelves are now empty of ranitidine. I can personally confirm that, in my neck of the woods at any rate, that is true. q

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Latest MoJ report short on detail, expert complains [

IN SEPTEMBER the Ministry of Justice published the results of a consultation on medical reporting within the package of whiplash and small claims track reforms – due to be implemented in April next year for road traffic cases. The consultation ran for a month in April-May, and the resultant document sets out the government’s policy choices.

It is, however – as seems par for the course in this area – very light on detail. That is the conclusion of Alistair Kinley, director of policy and government affairs at law firm BLM. “Given that the thrust of the proposals is much as was outlined in the consultation in the spring, it’s regrettable that the MoJ announcement of the measures has come in early September rather than in July as had been originally been expected,” he said.

“That delay of a couple of months surely puts further pressure on the timetable to deliver these reforms, given that the April 2020 implementation looks to be inflexible – with 1 April 2020 mentioned in the body of the Civil Liability Act 2018.”

He set out the main measures confirmed in MoJ’s post-consultation response, and the broad levels of stakeholder support: • To expand the MedCo system beyond soft-tissue injury claims to all road traffic injury claims valued under £5,000: around 75% in favour • To extend the fixed £180 cost for medical reports to non-soft tissue claims, with only GPs and A&E consultants reporting on those injuries: around 66% in favour • To develop guidance, selection criteria and service level

PI lawyers slam MoD ‘longstop’ [INJURED ARMED FORCES personnel and veterans face

being blocked from the courts in a perverse move by the Ministry of Defence, say lawyers. The proposal that has infuriated personal injury lawyers is that a ‘civil litigation longstop’ should be applied to claims for personal injury or death caused abroad.

“The Ministry of Defence wants to stop injured servicemen and women from being able to make compensation claims for injuries which they sustained more than 10 years ago,” explained Gordon Dalyell, president of the Association of Personal Injury Lawyers. “The MoD’s message is clear. Injured veterans are a burden it wants to shake off as quickly as possible.”

“These are not injuries sustained in battle; they are needless injuries which could and should be avoided, and there are many valid reasons why an injured person might wait 10 years before seeking compensation. The true damage of post-traumatic stress disorder or asbestos exposure, for example, can take years to manifest.

“There is no justification for why the MoD should be excused from its responsibilities to suffering veterans. The employers of civilians are held to account; it would be perverse for our veterans and serving personnel to be denied the same access to justice. It’s unthinkable that a wrongdoer could be allowed to say ‘that was a long time ago, you should forget about it’.

“Negligence claims are an important means of highlighting dangers in relation to training and equipment, which ultimately prevents injuries and can save lives,” he said. “But they are also crucial for the individuals involved who need compensation to put their lives back on track.” q

agreements to enable claimants in person to commission medical reports via MedCo: firm levels of support for that approach Alistair Kinley continued: “The important statutory underpinning here is Section 6 of the 2018 Act, headed Rules against settlement before medical report, which introduces the statutory ban on so-called ‘pre-medical offers’. That provision makes it a regulatory offence for insurers and solicitors to settle whiplash claims without medical evidence – much in the same way that referral fees were banned in 2013 by making such payments a regulatory offence. It therefore follows that the process for commissioning and delivering medical reports in these claims must be specified.”

That, says Kinley, will be part of the implementation of the wider whiplash and small claims reforms which, with the enabling 2018 Act now in place, will be achieved by a range of Civil Procedure Rules and pre-action protocols. He asserts that there are few clues to the detail of this secondary legislation in the material published by the MoJ. “For example,” he said, “the ministry identifies the need for ‘consistency for obtaining medical evidence in support of all claims of this nature irrespective of whether the claimant has legal representation’ but adds only that this aspect ‘will be taken forward and implemented as part of the ongoing work to draft revised Civil Procedure Rules and a new pre-action protocol’.

“That this is the approach is understandable, but surely the hope must be that the work proceeds quickly and its outputs are shared quickly with stakeholders so that they can plan properly, given that implementation is now less than seven months away?

“A final point to note is that nowhere in the new MoJ material is there any reference to increasing the small claims track limit for EL/PL claims (to £2,000) at the same time as the package of whiplash and small claims reforms in motor. Perhaps it may be that this strand of the government’s original ideas is quietly falling off the reform agenda?” q

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Slimming clinic prosecution serves as a warning over registration [PROVIDERS OF medical services have been warned over not

registering with the CQC after the owners of an Essex slimming clinic were ordered to pay a total of £36,000 when they failed to do so.

Russell and Jacqueline Eglinton, directors of Classytrade Ltd, were fined £25,000 after admitting they had failed to register the Saint James Slimming and Beauty Clinic in Brentwood. They were also ordered to pay £11,001 prosecution costs following the case brought by CQC. Joyce Frederick, CQC’s deputy chief inspector for registration, said: “Services providing medical care must register with CQC by law. When they fail to do so we cannot monitor the care being provided and that could pose a risk to people receiving treatment.”

A hearing in September was told the defendants had not appreciated that the service should be registered with CQC. They thought it was covered by the GMC registration of the doctor they employed, but it was not.

CQC received anonymous information about the service in March last year, following an advertisement which appeared in a local newspaper.

The advert said people could ‘Get Slim Fast’ and made references to a ‘sympathetic private consultation with a qualified doctor’, ‘two weeks’ supply of medicine’ and ‘carefully selected diet sheets’.

Heartburn drug recalled amid cancer scare [

THE Medicines and Healthcare products Regulatory Authority (MHRA) has issued an alert following the recall of all unexpired stock of certain batches of two types of the ranitidine medicine used to treat conditions such as heartburn and stomach ulcers.

Healthcare professionals have been told to stop supplying the two products immediately. All remaining stock should be quarantined and returned without delay to the supplier.

The MHRA stresses that patients should not stop taking their medication, and a treatment review is not necessary until the next routine appointment.

The recall is a precautionary measure due to possible contamination of the active substance in ranitidine with an impurity called NDMA (N-nitrosodimethylamine), which has been identified as a risk factor in the development of certain cancers.

The MHRA is actively involved with the European Medicines Agency and other medicines regulators to determine the impact of what is an on-going, global issue. On 8 October a drug alert was also issued regarding the withdrawal of four types of prescription-only Zantac products.

Other ranitidine products have been quarantined, and the Department of Health and Social Care issued an alert on 15 October regarding shortages of the medicine and advice to healthcare professionals on alternative treatments.

Dr Andrew Gray, MHRA deputy director of inspections, enforcement and standards, commented: “We have asked companies to quarantine batches of potentially affected medicines while we investigate and we will take action as necessary, including product recalls where appropriate.

“We have also requested risk assessments from the relevant companies which will include the testing of potentially affected batches.

“Currently, there is no evidence that medicines containing nitrosamines have caused any harm to patients, but the agency is closely monitoring the situation, and working with other regulatory agencies around the world.”

In the US a lawsuit has been filed against a number of manufacturers of the drug, claiming they were aware of the potential risks and so deliberately avoided testing it. q

When inspectors checked the commission’s database no records of the provider or the service could be found. Classytrade Ltd initially disputed that the service needed to be registered with CQC. In June last year registration inspectors visited the premises, following which CQC brought the prosecution. The defendants pleaded guilty to the offence at Chelmsford Magistrates Court in July and were fined following a hearing on 6 September. The service is no longer in operation.

Joyce Frederick said: “If services are not registered with us we cannot ensure that people are being kept safe while receiving care. Owners of care services can face an unlimited fine if they provide a service without registration, and where we find services that are not registered we will take legal action such as that taken against Classytrade Ltd. “We hope that this case will serve as a warning to other slimming clinics to make sure they are appropriately registered with CQC before they carry out any services or care to patients.” q

Wildlife are ingesting high doses of pharmaceuticals, study finds [A NEW STUDY showing how fish behaviour is being changed by

pharmaceuticals entering water habitats, after being incorrectly disposed of, highlights the urgent need for research into the impact of such drugs on human health, says water purification specialists Bluewater.

“The findings are alarming as they add to growing evidence that exposure to endocrine-disrupting chemicals leaking into the natural environment can disrupt the functioning of hormones," said Bengt Rittri, founder and CEO of Bluewater.

The scientists behind the study at Monash University in Melbourne highlighted how psychoactive pollutants in particular are changing the behaviour and mood of wildlife. The research, published in the journal Biology Letters, focused on numerous pharmaceuticals such as the antidepressant Prozac.

An earlier Monash University study, published last year in Nature Communications journal, found that a number of species were ingesting a diverse suite of pharmaceuticals in six separate creeks near Melbourne, including spiders living close to the water. One shock finding was that platypuses in some of the streams were consuming almost half a human daily dose of antidepressants every day.

Bengt Rittri continued: “The latest research findings from Monash University spotlight how wildlife and humans alike are at risk from ingesting the growing amount of chemical and other contaminants being found in the water we drink. We face the worst of outcomes if we don't act to halt the toxic waste entering our water and food chains.” q

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Hospital trust admits failings prior to death of [ its own catering assistant

A HOSPITAL catering assistant died following appalling failures at the hospital where she had worked for 25 years, a report by law firm JMW has revealed.

A&E staff at University Hospital Lewisham made a catalogue of errors when Lovetta Bailey attended the department suffering from the deadly condition sepsis. They wrongly discharged her home without treatment in October 20113. Two days later 63-yearold Lovetta, who was highly regarded by her colleagues in the catering team at the hospital, had died of multi-organ failure caused by sepsis.

Lovetta’s death was completely preventable if she had been admitted to hospital and treated with antibiotics. However, warning signs were not acted on, a sepsis screening tool was not used and abnormal blood test results which revealed she needed antibiotics were wrongly reported as ‘normal’.

After seeing a television report about a similar case which had occurred at Lewisham Hospital the year before her mother’s death, Lovetta’s daughter Christine decided she wanted to hold the hospital to account and raise awareness of the consequences sepsis negligence can have.

Christine contacted the medical negligence team at JMW, who had dealt with the previous case. Following JMW’s involvement the hospital trust admitted negligence in December 2017 and specifically that a number of errors were made, including: • A failure to appreciate the significance and act • on abnormal observations, which included • low oxygen saturations and a high • temperature and heart rate – all warning • signs of sepsis.

• Failing to escalate Lovetta’s care to a doctor • or more senior nurse.

• Failing to use the hospital’s screening tool • for sepsis.

• Wrongly discharging Lovetta when her blood • test results were abnormal and IV antibiotics • were indicated.

In July 2018 the trust also accepted that its failures had caused Lovetta’s death. It has

now agreed to pay a five figure compensation settlement; however their primary motivation for legal action was to try to prevent any more deaths from a delay in diagnosis of sepsis.

Christine, who has returned to work following a long period of sickness because of the trauma, said: “The impact of what happened has been completely devastating

and I still find it very difficult to talk about it.

“She really believed in Lewisham Hospital and she had always worked very hard for them because high standards were very important to her in all areas of her life. My brother Roger and I were both born there.

She had worked there for 25 years and everyone liked her.” q

New test can identify resistant bacteria in 45 minutes [

SCIENTISTS ARE DEVELOPING a low-cost, rapid diagnostic sensor test which aims to show the susceptibility of bacteria to antibiotics within 45 minutes. NHS laboratory testing of samples can take up to two days and the test aims to allow doctors to be able to prescribe the correct antibiotic for an infection more quickly.

In a research paper published in the journal Biosensors and Bioelectronics, the team at the University of Strathclyde has demonstrated the system is capable of showing results in less than 45 minutes.

The scientists examined the difference in growth profiles between the common hospitalacquired bacterial infections – staphylococcus aureus, most strains of which are sensitive to antibiotics, and the drug resistant strain MRSA, which is resistant to several widely-used antibiotics and can be harder to treat.

Both strains were placed onto electrodes covered in a special hydrogel deposit, which monitored bacterial growth and also contained antibiotics.

Results showed that the susceptible strain can grow on electrodes modified with gel containing no antibiotic, but could not grow when the sensor was seeded with antibiotic.

However, due to its antibiotic resistance, the MRSA strain was still able to grow on the electrodes which contained clinically relevant concentrations of antibiotics.

The paper’s lead author, Dr Stuart Hannah, said: “There is a small difference between what makes an organism susceptible to an antibiotic and what makes it resistant. In real terms, we were able to distinguish between the two strains in less than 45 minutes, which is a significant improvement on the current gold standard of up to two days.

“The technology uses a low-cost, commercially-available sensor which acts like a mini culture dish that can deal with any kind of clinical sample. The system is modified with a special gel deposit so that we can identify the difference between susceptible and resistant forms of common bacteria.

“Rapid result detection means you could pinpoint bacterial versus viral infections straight away and would be able to start working on the correct treatment more quickly for patients, which is very important for particular infections.

“Antibiotic resistance is less likely to develop if you give a narrower spectrum antibiotic.” q

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New expert witness guidance is welcomed by maxfax surgeons [THE British Association of Oral and Maxillofacial Surgeons (BAOMS)

has welcomed new guidance from the Royal College of Surgeons of England (RCSEng), regarding the medico-legal training surgeons should undergo before acting as an expert witness.

The Surgeon as an Expert Witness – A Guide to Good Practice follows the publication of two independent reviews that highlight the need to improve the quality and consistency of expert witnesses in gross negligence manslaughter cases.

Ian Martin, who is a past president of the North of England Medico-legal Society and BAOMS former president, stated: “BAOMS supports the call for surgeons who act as expert witnesses to receive appropriate training. It is important that they do not stray beyond their own areas of expertise, and

Dentists decry ‘Stasi tactics’ of regulator [THE British Dental Association has expressed concern about

what it says amounts to entrapment of individual practitioners by the GDC, following revelations in The Telegraph that the regulator has spent over £17,000 a year on private investigators who have posed as patients' families.

The figures indicate that between 2017 and 2018 the GDC paid £17,064 to private detective agency Invicta Investigation to ‘…investigate complaints or information received in respect of a registrant's fitness to practise’. While the investigations are legal, the BDA described them as ‘Stasi tactics’.

On one occasion, The Telegraph reports, investigators posed as the relatives of an elderly woman. An investigation against the dentist in question that followed was ‘thrown out’, the paper said, with the GDC having to pay costs.

Dentist leaders say the regulator needs to focus on proportionate action to combat the growing threat of illegal tooth whitening providers and the increasing popularity of remote orthodontics – where braces are provided via websites without a face-to-face consultation with an appropriately qualified dentist. Both carry health risks for patients.

BDA chair Mick Armstrong said: “When illegal tooth whitening is running rampant, and braces are being flogged via websites, the GDC should be using tactics like mystery shoppers to protect patients.

“Entrapment is entirely another matter. These sorts of Stasi tactics are not a good look for a professional regulator that lists its values as fairness, transparency, responsiveness and respect.” q

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recognise the role and limitations of the expert as part of the overall judicial process, whether civil, criminal or coronial.”

According to the guidance, surgeons who act as an expert witness should: • Not give opinions to the jury upon questions that they are not entitled to answer. For example, a surgical expert would be entitled, if asked, to assert whether or not a surgeon's conduct (related to a criminal case) equated to substandard care. But whether or not that care was ‘exceptionally bad' would be for the jury to decide. While the Crown Prosecution Service might pose such a question – hoping for an affirmative reply – the expert should not answer it, since his or her role is restricted to the binary question: substandard care or not.

• Have been a consultant surgeon for at least five years.

• Only take on cases that they encounter as part of their routine practice.

For example, it would not be appropriate for a vascular surgeon to give their view on the standard of diabetic care, such as that relating to retinal surgery.

The guidance goes on to explain that: • The same applies to sub-specialisation: if the case turns on an issue lying within a surgeon's surgical speciality, but outside their own field of work, they should be wary of accepting instructions.

• Surgeons should not provide medico-legal services after three years from retirement.

• Surgeons should have indemnity: anyone who acts as an expert witness is at risk of litigation.

In England alone the cost of clinical negligence compensation for harm in secondary care for 2018/19 was approximately £9bn, and according to NHS Resolution the costs are rising despite the number of cases falling. RCSEng says that surgeons who act as expert witnesses are the key to the quick resolution of claims for medical negligence. q

Who caused what harm to whom; and what does the expert need to evaluate that harm?

DR DAVID COHEN offers an expert’s perspective on liability and causation in cases of clinical negligence in endodontics and personal injury in dentistry

[HAVING NOW PRODUCED hundreds of expert reports for

both clinical negligence and personal injury claims, I think I have developed an insight into what is needed, and the problems associated with both. I hope that this article may prove to be of use to dentists without legal training as well as to solicitors without dental training.

In both areas of law it is necessary to prove liability, and any causation flowing from the alleged liability. In order to prove liability, four conditions have to considered: duty of care, failure in duty of care, causation and harm.

Duty of care: A duty of care on the part of the defendant has to be demonstrated. In the case of clinical negligence that is a fairly simple matter: dentists have a duty of care to their patients.

In personal injury cases it is slightly more complicated, depending on the circumstances. For example, if somebody trips in the street, does the local authority responsible for the pavement have a duty of care? If somebody is hit by a car while crossing at a zebra crossing in the light, it is fairly obvious that the driver has a duty of care.

Failure in duty of care: In order to show liability it has to be shown that, although the defendant has a duty of care, the defendant has failed in that duty. For example, would a body of opinion of similar standing to the defendant have done the same, and could it be justified – that is, according to Bolam?

Causation: When it is established that a duty of care has been breached, has that caused any damage that wouldn’t have happened if the accident or incident had not occurred?

Harm: Has the damage caused any harm to the patient/claimant? If so, what sort of harm, and can it be rectified?

In my experience in endodontic clinical negligence cases, there are a number of misconceptions that have developed that don’t always fulfil the criteria outlined above.

The most regular misconception, in my opinion, is related to root canal instruments that fracture in the canal during use. Patients – and lawyers – seem to automatically assume that a fractured instrument constitutes negligence. That is certainly not the case; for example, a fractured instrument in a canal that has already been disinfected does not pose a problem, and therefore is not negligent. Failure to inform the patient of the fracture, however, may be considered negligent – not the fracture itself.

Other misconceptions include overfilled root canals, underfilled root canals and final restorations. For example, as long as a root canal is fully disinfected, a slight overfill or underfill is not negligent, as it does not cause any harm.

Once a root canal has been adequately filled, a final coronal restoration is required. Failure to provide an appropriate restoration could be considered to be negligent, especially if it later transpires that the root canal therapy has not been successful. In that case it is not the fault of the root canal, but the restoration. That is significant if the treatments were carried out by two different practitioners.

exposure to medical ones? Firstly, after compiling many hundreds of condition and prognosis reports for lawyers, I have noticed a regular tendency for me to be sent all the clinical notes relating to the client: all that is, except the dental notes.

I realise that many lawyers and agencies use a template of some sort to organise documents, but it rarely includes the clinical notes from the patient’s dentist. So I would make a plea: if you ask for a dental report on your client, please remember to include the dental notes. It is no good the expert knowing all about a female client’s gynaecological history, for example, but nothing about their dental history.

Also on the subject of dental notes, please do not send photocopies of X-rays: they are not worth the paper they are copied onto. Have them copied onto film, or digitised and emailed. And if you do send them securely, please remember to advise the expert of the password!

You would be surprised how many times I have been sent a protected disc of X-rays or clinical notes and not been told the password.

Finally comes the issue of quantum. In many cases of dental injury the teeth require substantial repair, often involving expensive crowns or bridges. It is now generally recognised that those restorations will require regular replacements over the client’s lifetime. Evidence seems to infer, for example, that crowns may need replacing every 10 to 12 years due to decay affecting them. Remember to make sure the client’s claim includes those replacements if appropriate. q

Personal injury

In personal injury cases, once liability and causation has been established, then condition, prognosis and any treatment required – both currently and in the future – have to be determined. That will obviously require a consultation with the client and most often a review of dental records.

On the subject of dental records, what should a personal injury lawyer want to know about dental cases that may be different from his regular www.yourexpertwitness.co.uk

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The litigious patient

By TOBY TALBOT BDS MSD (Washington) FDS RCS

TOBY TALBOT is a specialist in restorative dentistry, prosthodontics, endodontics and periodontics. He has over 20 years experience as an expert witness, with a specific interest in dental negligence litigation claims. In this issue he examines the tell-tale features of a claimant in the making

[

THERE IS A four-fold greater chance of litigation for any dental practitioner in the UK compared with New York. We’re no longer mimicking the US culture of litigation – we now lead the world.

Whether you’re a dentist or in the business of offering them legal representation, it’s worth understanding who is driving this financially and emotionally expensive revolution. Is there a particular species of litigious patient, and if so, what do they look like?

The answer is obviously ‘no’, but there are certainly patterns of behavior and traits of character that have become apparent to me during more than 30 years as a restorative dentist and 20 years as an expert witness.

Obviously, it’s preferable to avoid any patient-practitioner relationship developing into full-blown litigation. Complaints invariably originate from poor communication and can be provoked by what is or isn’t said.

My own audit of more than 20 years of documentation revealed the following triggers that led to the patients issuing civil proceedings – in descending order of frequency: 1. A sense of abandonment and failure to respond when problems 1. became apparent.

2. Miscommunication with an English-speaking patient due to 1. clinician’s mother tongue not being English.

3. Failure to identify that the clinician is out of his/her depth and a 1. referral to a colleague clearly indicated.

4. Absence of the usual clinician, causing the patient to attend 1. another practitioner who makes a negative comment about their 1. dental state.

5. Failure to adhere to well-established clinical protocols, with specific 1. reference to alternative therapies with no scientific/clinical support.

6. Failure of treatment with unsuccessful efforts to resolve the 1. problems.

7. Clinician was too brusque and/or rude and appeared in a hurry.

8. Patients reporting that the clinician lost his cool/patience and/or 1. shouted at them.

Often the ‘offending’ practitioner has chivvied a patient into making a choice, using demanding or dictatorial language, real or perceived.

A recent review carried out by a leading indemnity insurer found that over 70% of complaints were attributed to poor communication, highlighting indelicate vocabulary, manner of delivery and body language and lack of ‘feeling’ or compassion.

Moreover, and in a great many cases I’ve encountered, clinicians abandon the patient by not responding to letters of complaint or phone calls. An apology, an expression of regret, and an assurance that the problem will be rectified, is often all that is needed to prevent the patient taking their grievance further.

Unfortunately, clear communication sometimes falls on deaf ears.

When financial compensation is unlikely, I’ve observed that writing to

governing authorities can become the means by which some patients aim to ‘get back’ at the clinician.

I am confident that patients prone to this course of action have an identifiable character profile. Patientes Litigiosum is almost inevitably female and over 50. Before I’m accused of sexism, my own audit revealed that 90% of those bringing formal suits against my own clinic were female. This can be explained by the higher percentage of female patients with long-standing prosthodontic issues referred to the clinic. A review of referrals to me as expert witness involving litigation against general dental practitioners over the past three years, revealed a 60% female bias.

Our litigant is invariably living alone or estranged from partner or family. If married, their relationship has become unfulfilling. It is likely they are possessed of a history of anxiety and depressant illness previously treated with medication and/or CBT. Expect a high display of emotion during a consultation.

One will also observe multiple functional disorders including gynaecological complaints, chronic fatigue syndrome, IBS and other ailments that long-suffering GPs have failed to ‘put their finger on’.

Multiple visits to the GP for exhaustion and irregular sleep patterns are common.

The problem is that the busy clinician, understandably focusing on his/her anatomical area of interest, can easily miss these traits.

The Western approach is disease focused, whereas the old Greek physician's philosophy of ‘Don’t tell me about the disease in the man, but about the man with the disease’ could not be closer to the truth.

An interview technique that subtly explores personal, social and professional history is essential in gathering information necessary to identification of this high-risk group.

Once identified, it's then a matter of explaining the interaction of stress and depression upon the immunological competences of the patient, and their ability to cope following stressful surgery. It allows you to share with the patient the responsibility of healing.

I have learnt that if a patient can readily connect the dots between their mental and physical health then all is well. However, if the patient vigorously denies any connection between the two, then I consider they are assuming no responsibility, and refer the patient elsewhere.

The logic behind this approach is that I now accept that I cannot possibly connect with all patients all the time. Where I fail, another clinician may succeed. However, I always pass on this vital piece of information to the referred clinician.

Fair’s fair. q • Toby Talbot is clinical director at the Talbot Clinic. Over the last twenty years, Toby has established a professional fast-track service for the legal community, helping courts, counsel and judges make accurate and well-informed decisions. www.yourexpertwitness.co.uk

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Scottish patients are waiting two years for oral surgery [

FREEDOM OF INFORMATION requests undertaken by the Scottish Liberal Democrats have revealed waits of over two years in some cases for inpatient oral and maxillofacial treatment – covering diseases affecting the mouth, jaw, face and neck.

One patient in the NHS Grampian area waited 243 weeks for an outpatient procedure. The Scottish Government operates a 12-week target for surgery.

The figures include procedures that can restore the functionality and appearance of a patient's mouth following oral cancer – which ranks among Scotland's fastest growing cancers – or serious injury.

BDA Scotland says the government must take responsibility and tackle the issue. It has pointed to huge problems filling consultant vacancies and continued underfunding of both primary and secondary dental services as key factors driving waiting times.

It says hospitals are facing an increasing number of referrals for tooth extractions owing to the lack of support for senior clinicians in high street practice to supervise and train younger and less experienced dentists. That adds to surgical waiting times.

David McColl, chair of the British Dental Association’s Scottish Dental Practice Committee, said: “Patients shouldn’t be waiting eons for life-changing surgery. These

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procedures can help restore both functionality and appearance to a patient's teeth and mouth after cancer or serious injuries.

“Years of underinvestment and failure to

support high street practice are heaping huge pressures on our hospitals. Ministers can’t go on treating dentistry as an optional extra in Scotland’s health service.” q

Oral surgeon in ‘Top 1,000’ London influencers [BAOMS vice-president Rob Bentley

has been named in the Evening Standard’s top 1,000 influential people in London, for the work he has done on delivering the capital’s first 24-hour medical emergency helipad.

Progress 1000, the paper’s celebration of the people changing London’s future for the better, was revealed in October.

Rob Bentley was named alongside his colleague at the King’s Trauma Centre Duncan Bew. Rob said the recognition represented “…the continued development of our Major Trauma Centre at King’s, and in particular the trial of our 24-hour helipad – the first for London and the South East.

“It’s been a fantastic team effort involving patients, staff and charities who have worked tirelessly to help realise and reduce transfer times from two hours to just 25 minutes, 24-hours a day.” q

Whiplash injuries need a dental assessment – even when it’s not obvious PROFESSOR PAUL TIPTON outlines the consequences of whiplash from a dental viewpoint

[MOST SOLICITORS will be surprised

to learn that, besides direct dental injuries, whiplash victims may develop symptoms that are dentally related. Those symptoms may contribute to a victim’s suffering and can be diagnosed and treated by a suitably trained dentist, restorative dentist or prosthodontist.

Rear-end collisions now account for over one third of urban accidents and nearly 40% of those produce whiplash injuries. The sudden forward acceleration of a car results in a backwards thrust of the head – on the relaxed musculature of the neck – thus causing a violent hyper-extension of the head and neck.

It is a rebound injury that often damages the temporomandibular joints (TMJs), leading to a diagnosis of temporomandibular joint dysfunction (TMD).

Trauma to the TMJs resulting from direct blows to the face and jaws – due to impacts with hard structures such as steering wheels, dashboards, windscreens and airbags – are well documented; however, TMJ symptoms are also a common finding in motor accident patients with cervical whiplash.

The presence of TMJ dysfunction after cervical whiplash injury was first recorded

by Frankle in 1965. That relationship has now been verified with magnetic resonance imaging (MRI) in individuals who presented with TMJ symptoms following an accident, but had sustained no direct trauma to the face, head or jaw and had no TMJ complaints prior to the accident.

At the TMJ and facial pain clinic at UCLA in California, approximately 700 new patients a year are treated for TMD, with almost one third having suffered major trauma resulting mainly from car accidents. A comparable group of non-TMD subjects reported an incidence of only 13% involvement in major trauma from car accidents. An examination of the TMJs should therefore become an integral part of any comprehensive evaluation of post-motor vehicle accident cervical whiplash victims.

An orthopaedic surgeon is routinely instructed by most solicitors to report for accident victims with whiplash injuries.

Their report is essential and will evaluate the musculoskeletal aspects of the client’s disability. However, there may be additional dental disorders that a dental specialist could diagnose, if instructed in addition to the orthopaedic surgeon, which could substantially affect the quantum of the claim if lengthy and

expensive dental treatment is required.

It is in the best interest of a client to recommend they seek appropriate treatment as soon as possible and it is important that any treatment provided prior to examination by an expert is well documented. A dental expert can refer to those records later when the client is examined.

Delay in treatment is a common problem.

A number of our clients could have benefitted greatly from early treatment; however, many simply stated that they had been waiting for months for their solicitor to arrange an appointment for them. Inappropriate management can lead to unnecessary tooth loss, extensive bone damage due to infections that complicate future treatment, extended treatment times, increased costs and may have the potential to cause osteoarthritic change in the TMJs. The cause of claims for TMD in individuals with whiplash include jaw pain, jaw joint clicking, pain in and around the ears, headaches, pain on chewing, jaw joint dislocating, tenderness in the muscles around the head, changes in the bite and in some cases tinnitus.

Accident victims are generally in pain and distress and report genuine symptoms, and pre-accident sub-clinical problems can become clinical after an accident. Clients may not regard these problems as new, or relate them to the accident – especially if the problems develop some time after the accident (late whiplash syndrome). In many patients, however, the signs and symptoms of the whiplash injury go undiagnosed as there

are often greater problems that have occurred as a result of the road traffic accident.

Many researchers have also described the relationship between stress and increased jaw muscle activity, called bruxism. Bruxism – or night-time tooth grinding – becomes elevated in times of stress and can cause muscle pain, tooth pain and jaw joint tenderness, which if pre-existing can exacerbate the cervical whiplash injury.

An examination of the TMJs should therefore become an integral part of any comprehensive evaluation of post-accident cervical whiplash victims. The fact that most solicitors fail to refer their car accident whiplash injury victims to dental specialists means this very painful and prolonged problem goes undiagnosed, creating misery for many patients.

Treatment is aimed initially at treating the TMD in a conservative manner by occlusal splint therapy. The success rate is expected to be in the region of 85% or more. Greater relaxation and pain relief may be gained from occlusal adjustment (reshaping of the teeth to create a better bite) and sometimes further restorations or full-mouth construction with crowns, to stabilise the bite. That final treatment modality is time consuming and technically demanding, and claims in the region of £50,000 or more are not uncommon.

In extreme cases surgery may be involved.

Claims of TMD in individuals with whiplash can also be expensive for solicitors, as failure to refer a whiplash injury to the correct restorative dentist or prosthodontist could result in a claim for malpractice against the solicitor, or class action, if dental whiplash is not part of a claim. q • A highly respected specialist in prosthodontics, Professor Paul Tipton has published over 100 scientific articles in the dental press and is an expert lecturer in his field, with training academies in Manchester, London and Dubai (www.tiptontraining.co.uk). He is currently Professor of Restorative and Cosmetic Dentistry at the City of London Dental School and BPP University, and president of the British Academy of Restorative Dentistry (www.bard.uk.com).

He is one of the UK’s most successful dentists (www.drpaultipton.com), with specialist clinics in Manchester and London (www.tclinic.co.uk), and regularly appears in the Dentistry Top 20 UK Dentists poll. www.yourexpertwitness.co.uk

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Poor vision can cost lives on the road [SOMEONE IS KILLED or seriously

injured on a British road every 20 minutes – and a major cause of casualties on the roads is poor vision.

Ahead of Road Safety Week in November, vision health specialists Optical Express issued a warning to drivers and other road users of the dangers of poor eyesight.

The company stressed that, although there is a basic sight exam as part of the UK practical driving test, there is no later assessment to ensure that drivers still maintain the same level of vision in the long term as when they passed their test. Poor vision means that drivers are far slower to recognise and anticipate hazards on the road or the mistakes of other drivers, which can lead to devastating consequences.

Optical Express revealed that three in five glasses or contact lens wearers said they had driven without the correct eyewear, which is an offence that could result in prosecution as it disregards the Driver and Vehicle Standards Agency (DVSA) regulations.

The DVSA states that you must wear glasses or contact lenses every time you drive if you need them to meet the ‘standards of vision for driving’, as driving without them can endanger yourself and others.

National guidance states that people should

get their eyes tested at least once every two years, although 15% of us fail to do so, and 6% of us claim to have never had an eye test.

Optical Express’s clinical services director Stephen Hannan said: “Good eyesight is an essential requirement for safe driving, as drivers with poor vision increase their risk of collisions due to not seeing hazards and their inability to react in time to dangers on the road.

“It is imperative that members of the public

who hold a driving licence have a regular eye examination, whether they wear glasses and contact lenses or not, in order to make sure they meet the necessary requirements, as passing the sight test when you first passed your driving test doesn’t necessarily mean your sight is still up to standard.

“It is a very important public safety matter in the interest of the individual driver and the general public, as well as being a legal requirement before driving a car.” q

Glaucoma research grant invites applications [

THE Royal College of Ophthalmology and the International Glaucoma Association (IGA) have issued a call for applications for the £100,000 Ophthalmology Research Award, which is run in partnership by the two organisations with the funding provided by the IGA. According to the RCOphth, there are 700,000 people in the UK living with glaucoma, an eye disease that without treatment typically causes loss of vision. Over the next 10 years the number of cases is predicted to rise by 22% and over 20 years by 44%.

The research award has been running for nearly 20 years and has funded research projects ranging from prospective stem cell treatments to the use of big data in patient risk stratification.

The IGA encourages patient-orientated research directly concerned with the improvement of glaucoma management. Applicants may be trainees seeking support for a fellowship or senior researchers seeking a grant for a project.

Last year’s successful applicant was Dr Victor Hu of the International Centre for Eye Health at the London School of Hygiene and Tropical Medicine, for his project Detecting glaucoma using a combination of low-cost, portable and easy-to- use tests.

Chair of the IGA Professor Philip Bloom said: “The importance of research awards in the field of ophthalmology cannot be understated.

Research has led to improved technology and innovative methods of service delivery that are helping to improve the way we deliver care.

We’re proud to have played a role in this, and we’re excited to see what new studies will be proposed in this grants round.” q www.yourexpertwitness.co.uk

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Persistent flu-like symptoms mask cardiac problems [A SURVEY OF over 2,000 people

earlier this year found that 95% are unaware that persistent flu-like symptoms can be signs of cardiomyopathy and myocarditis. Lack of awareness means the majority of people would not visit the GP with lingering flu-like symptoms.

The issue becomes more pertinent during winter, when people with lingering flu-like symptoms are 59% less likely to visit the GP compared to the summer. If people feel unwell during ‘flu season’, they think serious symptoms are just a bug ‘going around’ and not something to bother the doctor with.

The research was carried out by the charity Cardiomyopathy UK, which runs

the Every Heart Matters campaign aimed at encouraging people to seek help if they have persistent flu or flu-like symptoms, breathlessness, chest pain, palpitations, swollen ankles or dizziness. It is also urging GPs to check that flu-like symptoms are not masking a more serious problem.

As part of the campaign, people with myocarditis who were originally told they had the flu will be sharing their stories with the media.

The charity relates the story of Carolyn, a district nurse who was diagnosed with dilated cardiomyopathy in 2017. Soon after starting a new job she developed a cough and phlegm which lasted for about a week. Carolyn visited

Many heart failure patients had previously seen GP

her GP, who confirmed a viral chest infection and advised rest.

When Carolyn's symptoms persisted, she was admitted to hospital. Following a blood tests and an ECG, she was told she had heart failure, and an echo test showed she had dilated cardiomyopathy.

Cardiomyopathy UK chief executive Joel Rose said: “During the winter flu season it’s important that people recognise the signs and symptoms of cardiac diseases such as cardiomyopathy and myocarditis. With cases of flu and the common cold rife, people must listen to their body and ‘think heart’. If concerned, they should visit, or revisit, the GP as soon as possible.” q

Specialist treatment improves patient survival

[RESEARCH SUGGESTS that nearly eight in 10 people with

heart failure are diagnosed after a hospital admission, even though four in 10 had visited their GP in the previous five years with symptoms such as breathlessness, swollen ankles and exhaustion.

The fact emerged from figures published by the British Heart Foundation (BHF) showing that hospital admissions for heart failure have reached record levels in England, rising from 65,025 in 2013/14 to 86,474 in 2018/19: an increase of 33%. That is three times as fast as all other hospital admissions, which have risen by 11% in the same period.

The rise in hospital admissions is reflective of an increasing number of people living with heart failure in the UK. The BHF estimates that around 920,000 people have the condition and it’s placing a greater burden on the health service than the four most common cancers combined. With heart failure patients staying in hospital for around 10 days – double the average of five days for all diagnoses – that is putting immense pressure on the NHS, the charity says.

It cites several factors that could be contributing to the rise in people living with heart failure: an ageing and growing population, growing numbers of heart attack survivors and stubbornly high rates of people living with heart failure risk factors such as high blood pressure and diabetes.

The BHF is warning that the figures highlight the significant challenge the currently-incurable condition poses to the NHS, and says improved ways of detecting, diagnosing and managing heart failure are urgently needed along with more innovative models of care.

The charity has also called for greater access to specialist blood tests and heart scans for GPs to help diagnose heart failure earlier.

Professor Sir Nilesh Samani, BHF’s medical director, said: “Heart failure poses a growing and increasingly complex challenge, not only for people living with the condition, but for those who care for them too. It’s concerning to see yet another increase in hospital admissions – an indication that how we diagnose, treat and care for these patients could be far better.” q

[

THE National Heart Failure Audit was established in 2007 to monitor the care and treatment of patients in England and Wales with acute heart failure. The audit reports on all patients discharged from hospital with a primary diagnosis of heart failure, publishing analysis on patient outcomes and clinical practice.

Audit findings can be used to measure the implementation of contemporary guidelines for the clinical management of heart failure from the National Institute for Health and Clinical Excellence and the European Society of Cardiology Heart Failure Association.

The audit has consistently shown that specialist cardiology input and the prescription of recommended treatments are associated with prolonged survival and better outcomes for heart failure patients.

Audit data is used by a number of national groups, including the NHS Information Centre and the Care Quality Commission.

The British Society for Heart Failure provides clinical input and strategic direction to the National Heart Failure Audit. The audit is managed by the National Institute of Cardiovascular Outcomes Research, now posted at St Bartholomew’s Hospital. It is commissioned by the Healthcare Quality Improvement Partnership. q www.yourexpertwitness.co.uk

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Deep vein thrombosis – advice on prevention

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

[

DEEP VEIN THROMBOSIS (DVT) is a common adverse event that can arise following treatment in hospital. The consequences of this condition, in which a blood clot forms in the leg veins, range from modest, permanent swelling of the leg to persistent leg ulceration. A clot may break free from the leg veins and form a pulmonary embolism when it reaches the heart and then the lungs. This is an unpleasant and potentially fatal condition.

Treatments provided in hospital which may give rise to deep vein thrombosis include almost any surgery to the abdomen and lower limbs, although hip and knee replacement operations carry the greatest risk.

Patients being treated for medical conditions such as heart attack and stroke are also at risk of DVT. These days, many operations are done as day cases, but the risks of this treatment causing DVT are similar to those incurred by inpatient treatment. The complications may arise long after the patient has left the hospital.

National guidelines on DVT prevention

The National Institute for Health and Care Excellence (NICE) has published detailed guidelines over the years on the prevention, diagnosis and treatment of DVT. The most recent publication on this subject is NICE Guideline 89 (NG89) which provides extensive advice on the prevention of DVTs following a wide series of hospital treatments which may be completed during inpatient and outpatient stays.

NICE insists that all patients admitted to hospital, whether for day care or inpatient treatment, are evaluated for their risk of DVT. Several patient factors are listed in the Department of Health VTE risk assessment tool recommended by NICE – including patients with cancer, those over the age of 60 years, with morbid obesity or with a family history of venous thrombosis.

NG89 takes into account a wide range of reasons for admission to hospital with different recommendations depending on the known likely risks of post-treatment DVT. The methods of treatment include the use of mechanical methods of DVT prevention such as compression stockings and intermittent pneumatic compression sleeves for the legs.

These are largely used during hospital admissions. The use of low dose anticoagulant drugs is widely advoked. These are used at a dosage aimed at prevention of venous thrombosis rather than at a full treatment dose which would incur higher risks of bleeding.

The duration of preventive treatment with anticoagulant drugs is noted to necessitate at least one week’s medication or continuation of treatment until reduced mobility has resolved following surgery.

This means that in many instances, the anticoagulant treatment must be continued beyond the patient’s discharge from hospital in order to be effective. Where heparin injections have been prescribed, it must be given by either the patient or nursing staff and this may lead to organisational difficulty in arranging the treatment after hospital discharge. NG89 also discusses the use of more modern drugs which

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A pulmonary embolism removed from the pulmonary artery in the lung at post-mortem examination can be taken orally. These have proven efficacy in preventing DVT and are more easily managed by patients than injections.

Failure of preventive treatment

It has been found in clinical trials that modern anticoagulant drugs reduce the risk of DVT following general surgical and orthopaedic operations by 50-90%. So in general these medications offer considerable protection against this complication, however they are not completely effective and, in some patients, a post-operative DVT may arise despite appropriate preventive treatment.

As not all DVTs that arise following treatment in hospital will be prevented by current prophylactic regimes, patients undergoing treatment should be aware of this potential complication when undergoing surgery, placing them at risk of DVT. Amongst the cases in which I have provided advice, the most common treatment failure leading to the occurrence of a DVT is failure to consider or prescribe appropriate preventive medication. It appears that either the VTE risk assessment was not done, or the conclusions from this analysis of risk factors did not result in prescription of appropriate anticoagulant drug treatment. Failures of this type leading to an avoidable DVT may amount to substandard treatment.

NG89 considers that some types or surgery are ‘low risk’ and many patients may not need pharmacological prophylaxis. However, in these cases, NICE advises that patient risk factors are considered when deciding on the need for pharmacological preventive measures.

This additional step may not be done, leading to patients not receiving the correct preventive treatment. Where this leads to a postoperative DVT, failure to provide the correct treatment may amount to substandard treatment.

NICE has identified the need to extend prophylaxis during the postoperative period following discharge from hospital. In some instances, it has been common practice to provide one injection of heparin following day surgery as the sole preventive measure. Reference to the literature underlying the clinical trials of the drugs used to prevent DVT shows that the period of treatment studied was usually at least one week’s medication. The efficacy of a single dose of heparin is unknown and probably of little use.

I have come across a number of cases in which treatment was not extended into the post-operative period, either for at least one week or until lost mobility due to surgery resolved, and this led to a DVT. Such cases may be considered to comprise substandard treatment.

In general, when failure to prescribe pharmacological treatment has led to the formation of a DVT, it can usually be shown that appropriate treatment would have been effective since the reduction in risk achieved by pharmacological prophylaxis for many indications is substantial. The same is not as clear when it comes to omission of mechanical methods of prevention. It has been shown that graduated elastic compression stockings reduce the risk of DVT in general surgical patients, but far fewer patients have been studied than for the drug treatments. There may be difficulty in proving causation if only antiembolism stockings have been omitted, especially for the prevention of pulmonary embolism where no satisfactory efficacy data exists.

In conclusion, hospital patients – whether treated as inpatients or day case patients – remain at risk of deep vein thrombosis unless appropriate measures are taken to prevent this. A clear regime of prevention is set out in NICE NG89 which all hospitals should comply with. Failure to comply with this regime might lead patients to be unnecessarily exposed to the risk of DVT leading to fatal pulmonary embolism. Should a DVT arise when the NICE guidelines have not been complied with, substandard treatment may be considered to have been provided. q

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The surgeon’s guide to staying out of court There are a number of regular themes in medical negligence work in urology. In this brief article, consultant urologist CHRIS DAWSON MS FRCS LLDip shares his experience of writing reports in this area over the last 15 years.

[WHILST A LOT of reports in medical negligence work are due to

a clear breach of duty, in my opinion many are not. In many instances patient dissatisfaction can quickly turn from a hospital complaint to a civil claim. So how can this chain of events be broken?

In many cases the problem – if there is going to be one – starts with the initial doctor-patient consultation. This will often get off to a good start if the surgeon greets the patient with a smile and a handshake, and asks how their journey to the hospital went.

Whilst this might be just another busy day for the surgeon, for the patient it is possibly their one opportunity to get across their version of events. It is important for them to be heard, and therefore vital that the clinician listens with empathy and, most importantly, without interruption.

When it is the surgeon’s turn to speak, it is important to communicate in clear, simple language and to allow time for questions from the patient. Use of patient information sheets is highly recommended, particularly when it relates to an explanation about a forthcoming surgical procedure.

If an operation is scheduled, then best practice suggests that consent should be taken in the outpatient clinic. However most clinicians will recognise that this is often not possible in the context of a busy outpatient clinic.

The letter to the GP is a vital part of the communication process. It is imperative from the surgeon’s perspective that the letter contains all details of the conversation that took place with the patient. If a surgical

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procedure is planned, then a record of the discussion with the patient about the risks of the procedure should be part of the clinic letter. This acts as an important record source should there be a later medical negligence claim relating to the consent process.

The case of Montgomery v Lanarkshire in March 2015 changed the law of consent. Much has been written on this subject and the author recommends that all surgeons make themselves aware of the ramifications of the judgement in this case. The Royal College of Surgeons guidelines on consent are a good starting point.

One of the most important points about consent is that it should be written and recorded. Most available consent forms need to be filled out by the surgeon, and it is vital that all material risks are recorded in the relevant section. Too often in medical negligence cases this section has been left blank! The use of procedure specific forms, such as those produced by the British Association of Urological Surgeons, are helpful in this regard.

Evidence suggests that doctors who explain things clearly, give plenty of information, are caring and kind, and who spend time with their patients, are less likely to be the subject of a complaint by a patient.

When a complaint does occur it is important that surgeons remember that the GMC has a professional duty of candour.

Having an open and honest conversation with the patient at an early stage, and apologising where appropriate, is therefore good practice.

It may lead to the resolution of a complaint before it escalates into court action. q

CQC warns of a ‘perfect storm’ in mental health care [THE Care Quality Commission’s annual

assessment of the state of health and social care in England was published on 15 October. This year’s State of Care report considers the pressures faced by health and social care as a whole – but focuses particularly on inpatient mental health and learning disability services, the area where CQC is seeing an impact on quality.

While the overall quality picture for the mental health sector, which includes community mental health services, remains stable, the report says, it masks a real deterioration in some specialist inpatient services.

Since October last year 14 independent mental health hospitals that admit people with a learning disability and/or autism have been rated ‘inadequate’ and put into special measures. Two of those services have since improved, three are now closed and one is still registered but is closed to new

admissions with no people resident.

The report says that, although inspectors have seen much good and some outstanding care, they have also seen too many people using mental health and learning disability services being looked after by staff who lack the skills, training, experience or support from clinical staff to care for people with complex needs.

In the majority of mental health inpatient services rated ‘inadequate’ or ‘requires improvement’, a lack of appropriately skilled staff was identified as an issue in the inspection report. That reflects a national shortage of nurses in those areas of practice, with 8% fewer learning disability nurses registered with the Nursing and Midwifery Council in 2019 than 2015.

CQC chief executive Ian Trenholm commented: “In this year’s State of Care we have highlighted mental health and learning disability inpatient services because that’s where we are starting to see an impact on quality – and on people. There has been a deterioration in ratings in these services – and our inspection reports highlight staff shortages or care delivered by staff who aren’t trained or supported to look after people with complex needs, as a reason for this.

“Increased demand, combined with challenges around workforce and access risk creating a perfect storm – meaning people who need support from mental health, learning disability or autism services may receive poor care, have to wait until they are at crisis point to get the help they need, be detained in unsuitable services far from home, or be unable to access care at all.

“We are strengthening our approach to how we look at these services, and how we use the information that people share with us, so that we can act more quickly to spot and act on poor care. But having the

right staff to deliver good care is crucial to turning the tide – as are better integrated community services to prevent people ending up in the wrong place. We’ve seen some excellent care where services collaborate and we want to see more local services working together.

“While we’ll continue to call out staffing issues at provider level when these have an impact on care, we’re also calling for system-wide action on workforce planning which encourages more flexible and collaborative approaches to staff skills and career paths. The ambitious plans to expand the mental health workforce to meet an increase in demand must be accelerated.

“We’ll continue to celebrate the providers – like those highlighted in this report – who are thinking beyond barriers to work together in new ways that not only improve quality but give their teams more development opportunities and flexibility to work across different settings, supporting them to deliver great care.” q

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PTSD – what is new in ICD-11?

By DR STEPHEN DAVIES Consultant Psychiatrist in Private Practice in South Wales

[

PSYCHIATRISTS DON’T MAKE it up as they go along. Psychiatric diagnoses are standardised in two international manuals known as the Diagnostic and Statistical Manual for Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classification of Diseases (ICD), published by the World Health Organisation.

DSM is preferred by some psychiatrists as it is more detailed and prescriptive. DSM-5, its fitfh incarnation, was released in 2013. As pointed out by Chris Brewin (BMJ Oct 2018) the section on post-traumatic stress disorder (PTSD) in DSM-5 is the most complex in the entire manual, consisting of a possible 20 symptoms arranged into four clusters along with four additional criteria. It has been claimed that there are several thousand possible combinations of symptoms that could qualify for a diagnosis of PTSD in DSM-5.

Expert reports and cross examinations about PTSD can therefore become very technical. The issue of whether the claimant has a recognised psychiatric disorder can turn on whether, for example, following a car accident a person when driving develops vigilance, hypervigilance or the required ‘hypervigilance…. occurring as a marked alteration in arousal’.

Likewise whether a claimant shows the required ‘irritable behaviour and angry outbursts with little or no provocation’ or merely feelings of irritability that are justifiable.

ICD is more commonly used in European and British healthcare settings than DSM. Most contemporary British psychiatrists will have grown up with ICD-10, which was first published in 1990. The 11th version has long been overdue. A release version was recently approved for implementation from January 2022 and is already influencing diagnostic thinking. So, what are the main ways in which ICD-11 will alter the opinions that psychiatric experts give to the courts about PTSD? Firstly, a wider definition has been adopted for the type of stressful incident for which a diagnosis of PTSD is permitted. ICD-10 required a stressful event that is ‘exceptionally threatening or catastrophic in nature and likely to cause pervasive distress in almost anyone’. ICD-11 specifies only ‘an extremely threatening or horrific event or series of events’. The requirement that to qualify an event need only be perceived as horrific, opens up the entry criteria wider than previously in ICD-10 and wider than DSM-5.

The new ICD-11 definition would not rule out witnessing traumatic events through electronic media and television in situations which are not work-related (DSM-5 rules this out as a qualifying event for PTSD). Arguably, the definition could encompass illness which is not life-threatening (such as episodes of psychosis) and occasions where there is a perceived rather than objective threat of injury (for example use of a spinal board or air ambulance as a precaution following an accident), as well as emotional abuse or workplace bullying – all of which might be seen as excluded under DSM-5 and ICD-10. The issue would depend on the way the subject experienced the event (or reports that they experienced the event) at the time rather than the event itself and how others might see it.

Moving on from the stressor, the second difference is in terms of the clinical features which characterise the condition. The symptom profile needed for a diagnosis of PTSD is provided succinctly in ICD-11 as requiring each of three types of symptoms: (1) re-experiencing, for example vivid intrusive memories, flashbacks or nightmares; (2) avoidance of thoughts and memories about the event or avoidance of activities, situations and people reminiscent of the event; (3) persistent perceptions

of heightened current threat as indicated by hypervigilance or enhanced startle reaction. It is also a requirement that the symptoms persist for at least several weeks and cause significant impairment in one or more areas of functioning.

While these changes should in theory set a lower threshold for a diagnosis of PTSD, one preliminary study comparing ICD-10 to ICD-11 criteria among patients (mostly from road traffic accidents) found PTSD rates of 13% under the new criteria compared to 25% under the older ICD10 criteria. The authors concluded that the new criteria could miss milder cases of PTSD. But the study applied the criteria retrospectively to data from older research, up to 19 years old, and did not use the criteria as part of a direct clinical assessment.

Research on use of the new criteria in clinical situations is awaited and will, I suspect, give a different result. It seems likely that the simple and succinct symptom profile will be easier for the courts to understand and easier for claimants to demonstrate or report.

The third main difference, and arguably the most radical one, is the introduction of a new sub-category of complex post-traumatic stress disorder (cPTSD). This term has been used among clinicians previously, in various ways – for example for the cumulative effects of multiple traumatic incidents leading to a variant of PTSD. In ICD-11, the term complex PTSD will define patients who meet the above main criteria for PTSD but who also have problems with emotional regulation, a negative view of themselves (eg with guilt and shame), and problems sustaining relationships.

Interestingly, ICD-11 allows that complex PTSD may follow exposure to a single event of an extremely threatening or horrific nature, but says that it will occur more usually after prolonged or repetitive events from which escape is difficult or impossible – such as torture, slavery, genocide, prolonged domestic violence, and repeated childhood sexual or physical abuse. It seems very likely therefore that this variant of PTSD will be acknowledged to be a more severe condition, conferring higher levels of compensation.

It will be interesting to see whether the courts can be persuaded that an injury which is the subject of litigation can turn what would have been standard PTSD into complex PTSD – ie a distinct diagnosis rather than an exacerbation of a pre-existing condition. q

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Psychiatrists join the cannabis debate [

THE Royal College of Psychiatrists has issued a position statement on cannabis-based medicinal products (CBMPs), adding its voice to the debate currently raging around the issue. With press coverage painting pictures of parents desperate for the medication for their sick children in the face of official intransigence, it adds an element of clarity to the debate.

The statement begins by admitting the lack of good-quality research.

Adrian James, registrar of the RCPsych said: “There is a paucity of high-quality evidence supporting the use of CBMPs for any medical indication, as is reflected in the current NICE guidance.”

The statement continues: “When considering psychiatric indications, we are aware of the suggested potential for cannabidiol to have some utility in treating psychosis, certain anxiety disorders, post-traumatic stress disorder and addiction to certain substances, but evidence is scarce. We welcome evidence of the potential benefits of CBMPs but caution that most of it comes from small-scale studies and the low rate of use worldwide means that the side effect and risk profile is not adequately evidenced.

SEND system is in crisis, says Ombudsman [

CHILDREN WITH special educational needs and disabilities (SEND) are increasingly being failed by the system designed to support them, the Local Government and Social Care Ombudsman has found.

In its latest report about the education, health and care (EHC) plan process, the Ombudsman has revealed it is now upholding 87% of cases it investigates – compared with its uphold rate of 57% across all cases it looks at outside of SEND cases.

The new report, Not going to plan?, looks at the common problems the Ombudsman is finding when investigating parents’ concerns.

Serious issues include severe delays of up to 90 weeks when issuing a plan – and frequently more than a year – not anticipating local needs, communication and preparation for meetings, and a lack of oversight by senior staff.

The knock-on effect is that many children, often the most vulnerable in society, are not getting the right support at the right time, which is having a significant impact on their education and attainment.

The Ombudsman is now investigating more complaints than it has ever done before. In 2018-19 it received 45% more complaints and carried out 80% more detailed investigations about EHC plans than in 2016-17.

Ombudsman Michael King explained: “We are now upholding almost nine in 10 investigations we carry out about education, health and care plans. That is exceptional and unprecedented in our work. Two years ago, when the system was bedding in, we were concerned we were upholding around 80% of investigations. That we are investigating and upholding significantly more complaints two years later suggests a system in crisis.

“I am now particularly concerned some authorities may be putting in place extra barriers to ration scarce resources, rather than basing support on children’s needs. While I can empathise with the difficulties authorities face, there can never be an excuse for failing to meet the statutory rights of children.”

The report highlights a number of case studies from real investigations the Ombudsman has carried out in the past two years since the EHC plan system came into force, and offers councillors and senior council staff guidance and suggested ways they can scrutinise the services they offer families and the complaints they receive about those services. q

“There is a pressing need for more high-quality research examining the efficacy of these substances for specific psychiatric indications. Key organisations must act to reduce the barriers that exist to this research.

In addition, given the potential adverse psychiatric consequences of CBMPs with tetrahydrocannabinol as an ingredient, the potential adverse consequences of the mass-prescription of cannabis products must be explored.

“Data from countries that have already allowed mass prescribing of cannabis or CBMPs will be crucial. If use of CBMPs is to become widespread, clinicians need guidance on how to prescribe these products effectively and safely.

“We have received anecdotal claims of a gap between the understanding of the current evidence by some prescribers and patients, which leads to challenging clinical encounters. Without adequate guidance and public education, this gap is only likely to grow and become more common.” q

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Recommending EMDR treatment in psychological assessments of parents and children

By DR LOUIS MONACO BSc PsyD, clinical and forensic practitioner psychologist, chartered psychologist and member of the Expert in Mind expert witness panel.

[

EYE MOVEMENT desensitisation and reprocessing (EMDR) has long been recognised as an effective treatment for post-traumatic stress disorder (PTSD), sexual assault, domestic violence and road traffic accidents. In addition to these, more common occurrences including humiliation, rejection, separation and loss can also be significant traumatic events. If they are experienced by a parent, they may negatively affect parenting capacity.

A parent who has experienced trauma may find it difficult to appropriately attend to the emotional needs of their child, which can create distance in the parent-child relationship. Other common reactions might include reacting to their child’s needs with anxiety, fear, anger, sadness or distress. As a result, the child is then likely to experience emotional and psychological consequences and create challenging behaviour at various ages and stages of development.

During psychological assessments of parents who have a history of traumatic events and/or disturbing experiences that remain ‘unresolved’ or untreated, it may become clear that emotional and physical associations to these events have become triggered whilst they are carrying out daily caregiver functions.

The seemingly sudden re-experiencing of their own childhood and/or other significant trauma can cause them to have responses of fear, physical or emotional distress, and/or physical pain, which can cause the parent to become too distracted and internally unavailable to adequately attend to their child’s needs.

The reprocessing of these memories during EMDR treatment can help the parent identify the details of targeted memories and reprocess

them, as part of a treatment plan to strengthen their resilience and develop the necessary resources to regulate themselves. Further, these learned skills can also assist the parent in helping their children improve the way they deal with their own thoughts and feelings.

In many cases, parents who are participating in psychological assessments due to their involvement in court proceedings may only come to realise that their own childhood experiences have impacted them as adults after professionals have identified these issues.

Therefore, interventions using a comprehensive EMDR treatment plan can also include internal resource development, increasing coping skills, enhancing their capacity for attachment to their child, empathy, positive affective communication and setting boundaries.

Making recommendations that bring awareness to the impact of a parent’s personal history, and referring them to treatment which will increase their ability to develop coping skills and maintain boundaries, is imperative, as they should be able to recognise their own limitations in order to have the ability to teach their children the same skills.

Therefore, a treatment plan which includes EMDR is an invaluable tool for parents to reprocess their own adverse or traumatic experiences, with the hope they will be better positioned to increase their parenting capacity and better attend to their child’s evolving needs. q • If you need a psychiatrist or psychologist to provide a high-quality report for your case, contact the team at Expert in Mind who can recommend experienced experts in the field of mental health. Call 01424 44130 or email enquiries@expertinmind.co.uk www.yourexpertwitness.co.uk

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Breast implant safety: joint guidance issued [

IN THE WAKE of press and public concerns over the safety of breast implants, following the PIP scandal and recent reports relating implants to cancer, three bodies representing breast surgeons have issued a joint statement giving advice to patients concerned about breast surgery.

The statement, from the Association of Breast Surgery, the British Association for Aesthetic Plastic Surgery and the British Association for Plastic, Reconstructive and Aesthetic Surgery, outlines two main areas currently of concern for patients with, or considering having, breast implants inserted for either cosmetic or reconstructive reasons.

One concern is about breast implantassociated anaplastic large cell lymphoma (BIA-ALCL). The World Health Organisation defined BIA-ALCL as a disease in 2016 and current information suggests that BIA-ALCL happens with one in every 24,000 implants inserted in the UK. Athough it is not yet known exactly why, significant variations in incidence rates are being reported between countries who have reported cases of BIA-ALCL. By comparison, breast cancer, which is not related to having breast implants, occurs in one in eight women in the Western World.

BIA-ALCL typically presents on average 8-10 years after breast augmentation, with visible, painless swelling of a breast over a period of a few weeks due to fluid accumulation called

a seroma; or less frequently with a lump in the scar tissue (capsule), which can develop around any breast implant.

In July 2018 the MHRA advised that the very small risk of BIA-ALCL should henceforth be discussed with all patients considering having breast implants for either cosmetic or reconstructive reasons.

BIA-ALCL is usually treatable and curable with surgery, although other treatment may be required.

The statement says: “Whereas BIA-ALCL continues to be a rare disease in the UK, we are monitoring both UK and international events closely with the UK regulator, the Medicines and Healthcare products Regulatory Agency. The full clinical details are only known in approximately one third of BIA-ALCL patients worldwide.

“Advice for clinicians and patients in the UK on BIA-ALCL has been published by MHRA, produced with the help and advice of world renowned, independent experts, including toxicologists, bacteriologists, material scientists, lymphoma specialists, radiology specialists, representatives of breast cancer charities and surgeons from our associations.”

Current advice from MHRA and all regulators worldwide is that those patients who have breast implants do not need to have them removed, as the risks associated with surgery to remove implants and

capsules outweigh the risks of potential disease. However, should patients develop any breast symptoms, such as swelling, lumps or pain they should seek immediate advice from their family doctor and/or operating surgeon and should be referred for assessment.

Another concern is whether implants can make some people ill. Breast implant illness (BII), or autoimmune syndrome induced by adjuvants (ASIA), is a collection of multiple symptoms, most of which are common in the general population who do not have breast implants. BII/ASIA is not a WHO recognised disease, but there is much on-going work and an enormous amount of data being collected and analysed internationally to establish if BII is a classifiable disease or not.

BIA-ALCL and BII/ASIA are believed to be two separate and unrelated entities.

The MHRA is looking at the published literature on both BIA-ALCL and BII. The expert advisory group for plastic and reconstructive surgery, PRASEAG, will review the literature to build on the knowledge already gained as part of the Independent Review Group’s report, which was commissioned by the Chief Medical Officer in the 1990s.

The IRG published its report in 1998, finding there was no evidence of a link between silicone breast implants and the symptoms reported at that time. q

Surgeons call for action to deter firework misuse [SURGEONS HAVE CALLED for urgent action to reduce the

number of injuries caused by firework misuse, which often require costly and complex reconstructive surgery. They called for mandatory graphic warning images and plain packaging for fireworks to warn individuals against misuse.

The call, made in November prior to Guy Fawkes Night, came from a coalition of surgeons from the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), British Society for Surgery of the Hand (BSSH) and the British Burn Association (BBA).

It was in response to figures showing that, in the 12 months to November, 1,936 people visited A&E departments due to injuries caused by fireworks. Children under the age of 18 made up 31% of hospital admissions necessitated by firework-related injuries. Injuries peak in the winter months, when fireworks are more readily available in supermarkets and stores.

BSSH president David Newington commented: “Hand surgeons see devastating injuries caused by fireworks throughout the winter months, with people often losing large portions of their hand. Providing warnings on all firework packaging would serve as a graphic reminder of the severe yet avoidable damage they can cause. Even sparklers – which are often thought of as safe – can present a significant risk unless used carefully, as they burn at such high temperatures.”

It was the second year in succession that such a demand was made. Last November BAPRAS spearheaded a campaign to raise awareness of firework misuse as a cause of avoidable reconstructive surgery. Then, BAPRAS recommended that graphic warning labels similar to those on cigarette boxes should be introduced on firework

packaging – a change that almost 70% of parents polled said they would support.

Legislation introduced in Northern Ireland in 2002 requiring an individual to obtain a license to purchase Category 2 or 3 fireworks was followed by a significant drop in the number of injuries reported: from 136 in 2001 to 38 in 2002. As an interim solution, BAPRAS, BSSH and BBA believe mandatory graphic warning images and plain packaging for fireworks will help warn of potential injuries at the point of use and discourage misuse. q

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New TV series reveals all – including an on-air nose job [

IN A GROUNDBREAKING series of programmes BBC One is showing cosmetic surgery being carried out on patients in real time via video link, to a group of people who have expressed a desire to have the procedure done themselves.

The first episode of Plastic Surgery Undressed was screened on 26 November at the suitably late time of 10.45pm and concerned rhinoplasty – nose surgery.

In the studio watching the operation being performed were four young people and their partner/parent. They were invited to question both the surgeon involved, Sultan Hassan, and another plastic surgeon in the studio on various aspects of the procedure and its safety, as well as being asked to explain their motives in seeking surgery. None had sought counselling prior to embarking on their searches.

As well as the surgeons and presenters, studio guests included those who had had the operation – one successfully in Turkey and another waiting for a third after two did not go to plan.

At various points in the operation they were asked if they had changed their mind about wanting the surgery. All confirmed they still wanted to continue until the final part of the operation. That was when the surgeon broke the patient’s nose with a chisel in order to reshape it. It literally proved the crunch point for one ‘surgery seeker’, who admitted to having changed her mind.

In a statement, Sultan Hassan explained how the series works: “Each episode concentrates on one of the most popular cosmetic surgery procedures in the country and informs patients considering cosmetic surgery about what to expect through the journey and how to make a

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safe and informed decision about undergoing surgery. Patients get to watch live surgery via a video feed in real-time, as it happens!

“They have the unique opportunity to ask the surgeons questions and clarify any uncertainties. With an ever increasing number of patients seeking cosmetic procedures it is commendable that the BBC have produced such a programme to help patients make informed decisions about cosmetic surgery.”

According to the BBC: “It comes at a time when 18-30-year-olds have never felt under more pressure to have a certain physique: a BBCcommissioned poll of that group revealed that 55% felt reality TV and social media have had a negative impact on their body image.”

The second episode featured liposuction and the third involved breast surgery, including implants. All three episodes are available to view on the BBC iPlayer and there will be further episodes screened in the New Year. q

Beyond surgery: skin camouflage explained Do you work with clients who have been scarred and who are now left with a permanent reminder of a traumatic event? Surgically, they may be at the end of the road and the solution could be skin camouflage. Here BABS FORMAN of Skin Confident offers a five-step explanation of the skin camouflage medico-legal report 1. What is skin camouflage?

Skin camouflage products are paramedical products whose purpose is rehabilitative rather than cosmetic. They have been designed specifically for scars and are: • Waterproof • Longlasting – up to 16 hours continuous wear • Highly pigmented • Designed for men and women of all ethnicities • Quick and easy to apply – generally around 10-15 • minutes per application Skin camouflage products can also be combined with silicone scar management products to assist the healing process and in fact improve the appearance of scars in a more permanent manner.

2. When can skin camouflage be used?

In short, skin camouflage can be used whenever there is any discolouration or pigmentation visible. Most commonly that is after road traffic accidents, accidents at work, public place injury and medical negligence cases.

Examples of the types of skin conditions that skin camouflage typically works well for are accident scarring, surgery scarring, burns scarring (fire, liquid, electrical), self-harm scarring, dog bite scars, post-inflammatory hyperpigmentation or vitiligo (loss of skin pigment).

3. What can it achieve?

The purpose of skin camouflage is to enable clients to live their lives to the fullest despite the visible difference that they now have.

Not only do clients have to deal with their own feelings about their altered appearance, but they may also be facing intrusive questions, stares or judgments from others.

They may have lost confidence, developed social anxiety, become socially reclusive or have more clinical manifestations of anxiety or depression.

Skin camouflage can give clients the freedom to go on holiday, to wear clothing unrestricted by considerations of length and coverage, to go to Laceration before (left) and after the gym or for a swim. In more

extreme cases it may give them the confidence simply to leave the house.

In the words of one serious road traffic accident victim: “Your work has helped to give me a lot of confidence. I'm not exaggerating when I say it's been life-changing for me.”

4. What is in a skin camouflage medico-legal report?

The aim of a skin camouflage report is to illustrate to the judge the cost of the on-going use of skin camouflage over the course of a claimant's lifetime.

Scars are generally permanent and do not change significantly once they hit maturity at around two years. The need for products can therefore be deemed to last until the end of the claimant's life.

The report will set out precisely which products are recommended for scar management, the skin camouflage itself, removal and hygiene, and sun protection. It will also include costings for relevant accessories, such as application tools and sponges.

As well as the relevant costings, the medico-legal report will set out the general suitability of skin camouflage in each particular case, including photographs showing the injuries before and after the application of skin camouflage.

5. How expensive is it?

There are several different skin camouflage brands, and each claimant will require a different product combination tailored to their particular concerns, so it is difficult to state as a hypothetical.

However, based on my experience, the monthly expense of buying all requisite products and accessories tends to lie roughly between £20 and £80 per month, for the rest of the claimant's life. That can quickly add up to a significant sum. q • For more information call Babs Forman on 07864 293247, email babs@skinconfident.uk or visit londonskincamouflage.co.uk

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BOA decries lengthening wait times [ THE BRITISH ORTHOPAEDIC ASSOCIATION has

expressed concern over a further deterioration in waiting times that patients endure for trauma and orthopaedic surgery.

“Our specialty has the largest total waiting list and our patients are therefore particularly affected by lengthening waits,” the BOA commented.

The figures for September reveal that 525,801 patients in England are waiting for trauma and orthopaedic surgery – up from 498,488 last September.

The BOA continued: “It is now five years since the waiting time targets were last met for the T&O specialty, in which 92% of patients should commence treatment within 18 weeks of referral.”

It president, Don McBride, declared: “These ever-growing waiting lists and waiting times cannot be allowed to continue.

Each of these people awaiting treatment is an individual

experiencing pain, limited mobility or other effects on their dayto-day functions.

“Many patients suffering with arthritis and other musculoskeletal conditions are in significant pain, which severely affects their quality of life and their ability to perform the simple activities of daily living. Leaving patients waiting in pain for treatment longer than is clinically necessary is not acceptable.

“Arthritis is common and often dismissed; but it is life changing, threatening patients’ independence and their ability to earn a living and care for their loved ones.”

The BOA also highlighted that fact that the situation is even more acute in Northern Ireland, where over 11,000 people have been waiting over a year for a first consultant-led outpatient appointment, while 16,916 patients are waiting for an inpatient procedure – of whom nearly 7,000 have been waiting over a year. q

Partnership sees orthopaedic treatment going off-island [AN ON-GOING INITIATIVE to reduce orthopaedic waiting times

for patients on the Channel Island of Guernsey has seen the island’s Committee for Health and Social Care (HSC) establish a partnership with private provider Ramsay Health Care UK to enable more than 60 patients to have treatment at the company’s New Hall Hospital in Salisbury.

The move takes the number of patients given the offer of treatment offisland to nearly 200, and HSC are continuing to identify further patients for whom off-island treatment could be an option.

The HSC is already claiming progress: at the end of September there were 410 patients on the orthopaedic inpatient waiting list – down from 522 at the end of last year.

HSC have also worked closely with local private provider the Guernsey Therapy Group, which has ensured pre-op care is in place for patients travelling off-island, and post-op physio appointments are booked before their surgery takes place.

The Medical Specialist Group – the main supplier of health care on the island – is ensuring any unused theatre lists are used by orthopaedic surgeons, resulting in a small increase in the number of patients that can be seen per week on island.

All patients who have received treatment as part of the initiative have received a customer feedback questionnaire in which they have been asked their opinions, from first contact to the pre-assessment clinics, the travel to the UK and their surgery.

Earlier this year the island’s Policy and Resources Committee agreed to provide a total of £1.5m from its Budget Reserve to fund the work. Up to the end of September £900,000 had been committed with a review of providers scheduled to assess the most effective use of the balance.

HSC president, Deputy Heidi Soulsby, said: “Orthopaedic services account for over 25% of all planned surgical interventions and this figure is rising. Analysis has shown increasing demand which, in common with many areas of health and care, can be attributed to the needs of our ageing population.

"Many patients have waited longer than they should have to, and for those who are still waiting, we are sorry. HSC is working hard with all of its partners to respond to these issues and we thank all those involved for their work.” q

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When only a pain expert will do

By DR CHRIS JENNER MB BS FRCA FFPMRCA, consultant and expert in pain medicine at Medicolegal Partners.

[THE International Association for the Study of Pain defines pain

as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’. Pain is always subjective and we learn to apply the word to experiences related to injury in early life.

Pain, therefore, is an experience that we associate with actual or potential tissue damage. While it is a physical sensation experienced in a specific part of the body, it is also always unpleasant and thus there is often an emotional element to the condition.

The concept of pain actually covers a wide spectrum of disorders, including acute pain, chronic pain and cancer pain, or a combination of any of these. It can arise for many reasons, including injury, nerve damage, surgery and metabolic problems such as diabetes. Sometimes there is no obvious cause.

A pain expert is a doctor who has undergone further training in order to gain a specialised knowledge in the evaluation, diagnosis and treatment of all different types of pain. In the UK, this training is provided by the Royal College of Anaesthetists. A pain expert will have an in-depth knowledge of the physiology of pain and be able to evaluate claimants, either for their own case or for the defendant, especially in the case of complicated pain conditions.

In recent years, there have been many advances in the understanding of pain and an expert in pain medicine may be able to diagnose and explain a claimant’s pain condition in layman’s terms, providing an explanation for symptoms that have previously been viewed as arising from exaggeration, functional overlay and a desire for secondary gain. This level of knowledge and insight is particularly helpful for legal teams and ultimately the court in reaching a judgement.

Along with an understanding of the specialised tests available to diagnose painful complaints, a pain specialist is able to prescribe appropriate medication and skilfully perform complex procedures – such as nerve blocks, spinal injections and other interventional techniques – which together may form the treatment plan for a patient suffering with pain. He or she is also responsible for coordinating any additional care to support the patient, such as physical or psychological therapies, and rehabilitation programmes, so that claimants receive a comprehensive and effective treatment plan for their condition.

Medicolegal cases

When acting in a medicolegal case the pain specialist is able to offer an opinion on causation and prognosis to assist the legal team in reaching decisions on quantum. The value of litigation cases is generally dictated by the type of injury suffered by the claimant and this can usually be determined by objective means. However, this is not true of pain conditions. As already discussed, pain is a subjective experience and there are no reliable tests to determine its presence or quantify it.

Usually, the only way a doctor can gauge the severity of a claimant’s pain is by assessing the impact it has on their functionality.

Furthermore, pain conditions such as complex regional pain syndrome (CRPS) are very rare and it is possible that courts may be unaware or sceptical of their existence. For a non-medical person, it can be difficult to believe that a seemingly innocuous accident or injury can cause such potentially devastating symptoms as happens in cases involving CRPS. Many cases may be dismissed if the court believes that the claimant is exaggerating or fabricating their condition without input and explanation by an expert in this specialist area of medicine.

Medical causation is critical in these cases and, as the legal teams involved obviously do not have the medical expertise to answer or resolve the complex issues, an expert witness is needed. However, it is important to remember that the role of the expert witness is to provide a

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neutral opinion and this overrides any duty to the instructing party.

In a simple case where a complete recovery is expected in a relatively short time, a report from a GP or orthopaedic surgeon may be sufficient to allow a settlement to be made. However, in many cases the continuation of pain is difficult to explain or becomes confounded by psychological factors to such an extent that the original cause is less significant. At this point, it is prudent and often necessary to call upon the expertise of a pain consultant.

In pain-related cases much of the available evidence is subjective and based on the claimant’s own statements about their condition.

Diagnosis of the symptoms can be difficult and subject to a wide range of medical opinions, and any particular diagnosis may be controversial.

In the past, chronic pain was often viewed as a psychological condition, but nowadays cases with a purely psychiatric origin are thought to be extremely rare. There may, however, be accusations of exaggeration of symptoms or malingering.

Given that pain management is a narrow and specialist field, it is likely that only a pain expert will have the sufficient expertise, and be familiar enough with the supporting medical literature, to provide an accurate diagnosis and present a compelling case both in their report and in court. However, due to the complicated nature of such conditions, it is likely that the pain expert will be only one part of a team of experts – including disciplines such as orthopaedics, rheumatology and psychiatry – that is required to obtain an accurate picture.

Instructing an expert

By instructing an expert witness, any party involved in litigation can ‘test the evidence’, which normally takes the form of a meeting between the client, expert, solicitor and barrister. This procedure can give a better awareness of the strengths and weaknesses of any particular case and may help to uncover any other existing medical issues which could have a bearing on the case. It can be especially helpful in allowing the legal teams to satisfy themselves that the claimant’s current symptoms can indeed be linked to the original accident or injury.

The pain consultant will therefore play a crucial role in this process. The parties should then be able to focus on the disputed aspects of a case and negotiate a fair settlement.

Once a pain expert has been selected, he or she will need to examine all of the claimant’s medical records before an opinion on causation can be offered in the case. While the claimant may feel that the problems they are experiencing result solely from the disputed incident or injury, careful analysis of the medical records may elicit other potential causes for the symptoms. The claimant’s medical history before the index event or injury can be vital in reaching a conclusion.

For chronic pain cases, any entries indicating previous episodes of longer-term pain will be of particular interest – especially if there is no obvious reason, such as infection in a wound, why the pain persisted for longer than would normally be expected for the type of injury.

The expert will also be looking for any other information which will help them to form an opinion about the causation and prognosis of the symptoms. This might include reference to a wide range of previous conditions which have the potential to influence how an individual responds to pain. In particular, any indication of somatisation, which reflects a tendency for stress to manifest as physical symptoms and illnesses, may be particularly relevant. This can be particularly important for a defendant, such as an insurance company, who is only

required to compensate for the effects of an accident or injury. If a court decides, based on the evidence of a pain expert, that the claimant would have suffered similar problems in any case, the compensation payable will be limited.

This point is illustrated by the findings of a review and analysis of judgements in pain-related cases undertaken in Korea. One important reason for the court to attribute a low degree of disability and thus reduce the compensation was that the causal relationship between the injury and symptoms could not be completely proven due to the presence of pre-existing conditions. In one reported case, the court chose to place more weight on one expert’s report than another’s because ‘it made a more objective evaluation of the claimant’s physical condition, including calculation of pre-existing conditions attributing to the loss of the ability to work’.

Claims involving chronic pain conditions are often more complex and difficult than other cases involving serious injury. In addition to lengthy and expensive treatment, this type of claim can include future loss of earnings for years to come, often forming the largest part of any compensation awarded. Chronic pain cases are critically dependent on the skill and plausibility of the expert witnesses and the outcome of a case can hinge on whichever expert’s view is accepted by the court. Thus, the selection of the correct expert from the outset of a case is crucial. q • Dr Chris Jenner MB BS FRCA FFPMRCA is a Consultant in Pain Medicine and leading expert witness in all medico legal cases which involve pain. Since 2001 he has been practising at Imperial College NHS Trust as a Consultant at St Mary’s in Paddington, London and is an Honorary Clinical Lecturer for the Trust.

He has a Pain Clinic at Charing Cross Hospital in London. Dr Jenner founded The London Pain Clinic in Harley Street, London, where he is Clinical Director. He can be instructed through Medicolegal Partners Limited on 020 7118 0650, at info@medicolegal-partners.com or via www.medicolegal-partners.

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RCOG responds to Shrewsbury reports [THE Royal College of Obstetrics and Gynaecology (RCOG)

has responded to references in media reports to an assessment it carried out into maternity and neonatal services at Shrewsbury and Telford Hospitals NHS Trust (SaTH). The reference is contained in coverage of the leaked interim report by Donna Ockenden, obtained

by The Independent.

A RCOG spokesperson said: “The death of every mother and baby is a devastating tragedy and we offer our heartfelt condolences to any family that has suffered such a loss.

“Following a CQC review, in July 2017 the RCOG were commissioned by Shrewsbury and Telford Hospital NHS Trust to assess their maternity services of as part of a non-regulatory and advisory review. The review was conducted by an independent team of assessors with expertise in maternity care and safety, in line with The Academy of Royal Medical College’s framework of operating principles for managing invited reviews within healthcare.

“The review was commissioned to focus on the current maternity and neonatal practice at the time, following concerns over higher than average perinatal mortality rates. The review did not focus on individual deaths retrospectively – those were the focus of other independent investigations.

“The final report was submitted to SaTH in December 2017 and it made 37 recommendations to drive improvements. At the request of the trust, the RCOG held a follow up meeting – a table top exercise – in April 2018 during which feedback was heard about improvements that had been made since the RCOG conducted its review.

“A summary of the April 2018 meeting, in which the RCOG stated that there was still work in progress to ensure maternity services were meeting the needs of women and babies, was shared with the trust who published it as an addendum to the full 2017 report. The initial report

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and the addendum were published together by the trust in July 2018.

“The RCOG regrets that the trust did not accept its initial report and waited six months to publish it alongside the addendum. The RCOG has subsequently performed a review of our invited reviews service and have made improvements, including reporting directly to the CQC at the same time that we submit a review to a trust. We will continue to review the process to ensure that the service remains accurate and responsive to the needs of maternity services as any learning organisation should.

“The RCOG remains fully committed to making improvements in maternity care and we will continue to work with the Ockenden Review and other key partners to ensure the highest standards in maternity care for women and babies.” q

Midwives ‘key’ to detection of FGM

[

MIDWIVES ARE THE key healthcare professionals who can identify female genital mutilation in the UK, according to a report by the Royal College of Midwives (RCM). It follows publication by the NHS of figures on the prevalence of the practice in the three months to September. The figures show there were more than 2,000 woman and girls being cared for in the NHS who had undergone FGM, including nearly 1,000 new cases.

Janet Fyle, professional policy advisor at the RCM, commented: “There were 940 newly identified cases of FGM, and compared with the same quarter in 2018 there has only been a small decrease in cases recorded, which is disappointing and shows there is a need to do more to tackle this.

"What is alarming is that there were 15 cases recorded of British girls under the age of 18 years and this is truly shocking.

“We are failing British born children if we do not tackle what is essentially a crime against children. It has to start from within communities where this practice is sometimes seen as a cultural norm, despite it being illegal here in the UK. We must step up our efforts and be clear to those who carry out FGM on girls and women that we will not tolerate such abuses.

“Midwives are one of the key frontline healthcare professionals who can identify and prevent female genital mutilation, due to the fact that most survivors of FGM are usually identified when they are pregnant, but all healthcare professionals must remain vigilant in identifying girls at risk.”

She called for psychological support for the victims, and urged the NHS to invest in support services. q

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