Your Expert Witness Issue 54 by DMMonline

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contents IN THIS ISSUE 7

Opening Statement

NEWS 8

Report calls for overhaul of major disaster inquiries

PI lawyers attack high-risk compensation proposals

New wording for Statement of Truth comes into effect on 1 October

Care and supervision orders to resume digital roll-out

Sir Geoffrey Vos appointed Master of the Rolls

FIRE INVESTIGATION 11

Tumble dryers – fire cause determination

BUILDING & PROPERTY 12

Cladding forms being signed off by unqualified people, claims RICS

Council agrees to restore bat habitat

Take care when Zooming into online dispute resolution, says lawyer

Remote hearings come to the fore

FINANCE 15

Expert determination – what’s new?

FORENSICS 16

Commissioner enters AFR debate

Govt seeks new forensics regulator

TRANSLATION & INTERPRETING

Let’s talk about translation and interpreting

Linguists’ body gets new hand at the helm

Cost-cutting threatens access to justice

A to Z WEBSITE GUIDE 17 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

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

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

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MEDICAL ISSUES 21 Medical Notes

NEWS 23 Protocol sets background for COVID claims handling 23 Concerns raised over post-hospital services for frail patients 24 PHE dismantling: questions remain over replacement 25 Cumberlege report draws expressions of shock, anger and remorse REMOTE MEDICAL ASSESSMENTS 26 Remote COVID diagnosis leads to new model for clinical assessments 28 Lockdown can lead to a calmer conversation PSYCHIATRIC & PSYCHOLOGICAL ISSUES 29 Psychiatrists call for long-term investment in mental health 31 Inquiry pledge follows NI hospital abuse review CARDIOLOGY Research quantifies heart attack victims put off hospital by COVID-19 33

OPHTHALMOLOGY 35 Eye specialists create joint vision from COVID lessons 35 Ophthalmologists prepare for second COVID wave 36 Impact of sight loss to be revealed at webinar DENTISTRY & MAXILLOFACIAL SURGERY Kids’ tooth decay rates set to get worse, say experts 37 39 Corporate dentistry adrift in the doldrums 40 Medicolegal challenges of assessing patients with dental, cranial or facial conditions 41 Training director puts his own skills to the test PLASTIC, RECONSTRUCTIVE & HAND SURGERY Who decides when it’s safe to drive after hand surgery? You do! 43 43 Scarring study publishes first work UROLOGY 44 Diagnosis of prostate cancer is far from easy

OBSTETRICS & GYNAECOLOGY Maternal deaths report draws comment from royal colleges 45 VASCULAR SURGERY 46 Modern varicose veins treatments ORTHOPAEDICS 49 Acetabular fractures – simplified 50 Joint registry held up as possible model for all implants

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Opening Statement [DESPITE THE DISRUPTION to our daily lives, the work of courts must proceed. That usually means, in this day and age, going digital. In the case of the Business and Property Courts that has applied to 85% of their business since the country went into lockdown. That is a phenomenal achievement for an institution with a public reputation for being hidebound, to put it mildly. The move into the digital age is likely to become permanent, according to those involved in the process. And speed and efficiency will become even more crucial as the shake-out of the pandemic leads to more collapses and accompanying claims.

• That move to virtual hearings and digital processes was, of course, already in motion in the case of some courts. Video testimony and online documentation were becoming the order of the day. Curiously enough, the online roll-out of care and supervision applications was paused at the onset of the COVID crisis in March, and is set to resume in September. More and more functions will be carried out online, with all parties able to monitor progress. One sign that may cause some hackles to rise is the ‘transition’ of family law processes into the new Court and Tribunal Service Centres – particularly with the renewed emphasis on local delivery of services and policy. • There are elements of the digital justice system that not everyone is at ease with. In particular, the process of mediation benefits from having a face-to-face character. That is the view postulated by a leading dispute resolution and commercial litigation lawyer. And while personal contact is no longer possible, it is necessary to put into place safeguards to ensure no party is put at a disadvantage. • At the heart of mediation is trust, as it is with the testimony of an expert witness. The Statement of Truth is there to reassure everyone that the expert is acting in the interest of justice and the court. It is a source of regret that the trust put in some experts has been questioned – to the extent that an amendment to the Statement of Truth must henceforth include an acknowledgement that consequences will follow if that trust is broken. • Trust is also at the heart of the system of certification of high-rise buildings with potentially dangerous cladding. It is therefore of concern that the RICS has received reports of such certificates – the EWS certificate, which confirms whether or not there is combustible cladding present – being signed off by non-qualified persons. The scandal regarding cladding has taken many twists and turns since the awful events at Grenfell Tower, and this is just the latest. The anguish for survivors and relatives must resurface with every story. • While a faulty fridge was found to be the cause of the disaster at Grenfell, tumble dryers have equally been found to be the cause of many domestic fires. Comedian Ted Robbins famously vowed not to have another one in his house following a life-threatening fire at his home, but there are estimated to be nearly half-a-million units still in use that are subject to recall notices. Establishing whether a fire was caused by a faulty tumble dryer is a complex process – one that requires the attention of an expert. • Whatever the cause of an injury, the compensation awarded is intended to allow the victim to lead a normal life – for the rest of their life. There is therefore a great deal of anger among personal injury lawyers at proposals to include high-risk investment returns as part of the calculation. The idea of a severely-disabled person losing their livelihood because of an underperforming investment makes for uncomfortable reading. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Report calls for overhaul of major disaster inquiries [WHEN A CATASTROPHIC event or systemic

failure results in death or injury, the justice system must provide a framework to understand what happened and to prevent recurrence. A working party set up by JUSTICE, the all-party law reform and human rights organisation, has publishes a timely report, When Things Go Wrong: the response of the justice system. The report seeks to address the erosion of public trust in the response of the justice system to deaths giving rise to public concern: major incidents causing multiple fatalities or arising from a pattern of systemic failure. If it is to enjoy the confidence of the public, the report says, the justice system must provide a response that is consistent, open, timely, coherent and readily understandable. Unfortunately, the systems are too often beset with costly delay and duplication, with insufficient concern for the needs of those affected by disasters. Instead of finding answers through the legal process, bereaved people and survivors are often left feeling confused, betrayed and re-traumatised. The lack of formal implementation and oversight following the end of an inquest or inquiry makes the likelihood of future prevention limited. Having sat for a year, the report makes 54 recommendations of the working party, directed at remedying such shortcomings by building on the strengths of the present system of inquests and public inquiries, including: • The framework – the report proposes new state and independent bodies to provide oversight and facilitate information-sharing. They include a Central Inquiries Unit within government, a full-time Chief Coroner and a special procedure inquest for investigating mass fatalities as well as single deaths linked by systemic failure, able to consider closed material and make specific recommendations to prevent recurrence. • Opening investigations – greater collaboration between agencies, building a cross-process dossier, would reduce the multiple occasions that bereaved people and survivors have to recount traumatic events and ensure that they are fully informed throughout the process. • Processes for appointing inquiry chairs and panels, for establishing the terms of reference and for providing information and relevant documents to core participants need to be more structured and transparent. Drawing on previous JUSTICE working parties on accessibility, the report recommends that bereaved people and survivors are placed at the heart of the process. Aside from the legal formalities, it also calls for widespread use of commemorative ‘pen portraits’ and therapeutic spaces for bereaved and survivor testimony. • A statutory duty of candour, including a rebuttable requirement for

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position statements, would help foster a ‘cards on the table’ approach. Directing the inquiry to the most important matters early on could result in earlier findings and reduced costs. • Accountability and systemic change – the report concludes that an independent body should lead oversight and monitoring of the implementation of inquest and inquiry recommendations, whose review could aid scrutiny by parliamentary committees. Chair of the working party, Sir Robert Owen, said: “A system cannot provide justice if its processes exacerbate the grief and trauma of its participants. Our recommendations seek to ensure that inquests and inquiries are responsive to the needs of bereaved people and survivors, while minimising the delay and duplication that impede effectiveness and erode public confidence. “We think that this set of proposals, if implemented, will provide a cohesive and cost-effective system, with the prospect of a reduction in duplication and delay, and which in turn should serve to increase public trust.” q

PI lawyers attack high-risk compensation proposals [

THE Association of Personal Injury Lawyers have reacted angrily to proposals on the calculation of compensation payments. The proposals – set out in a consultation by the Department of Justice – suggest payments should be based on investment involving risk to return a lifetime amount. Severely injured people should not be forced to gamble compensation for life-changing injuries, APIL says. “The people affected by this consultation have lifelong and lifechanging injuries, which they would not have suffered were it not for negligence,” said Maurece Hutchinson, APIL’s Belfast-based Northern Ireland representative. “They are compensated to pay for their care, specialist equipment and living costs. They cannot simply earn their own money as they did before they were injured. In most cases the compensation is all the support they will ever have for the rest of their lives. “The DoJ is consulting on whether compensation should be calculated in such a way that injured people will have to take risks when investing their compensation to ensure it will stretch for the rest of their lives. “If they don’t take that investment risk, they will have to fall back on the state to pay for their needs when the money runs out. That goes against the basic principles of compensation. It is supposed to meet an injured person’s needs after serious injury which was inflicted upon them by someone else’s negligence. The state should not have to pick up the bill. “Injured people should not be forced to take risks and gamble their compensation in a bid to get by. Catastrophically injured people are vulnerable and fearful for their futures. There has been much debate about whether injured people should shoulder some risk with their investments. They are averse to taking risks with this very important money and should be allowed to invest without taking risks at all.” q

New wording for Statement of Truth comes into effect on 1 October [

EXPERT WITNESS ORGANISATIONS are drawing experts’ urgent attention to an amendment to the Statement of Truth they must include in their reports. The 122nd update to the Practice Direction for the Civil Procedure Rules makes the new wording mandatory with effect from 1 October this year. The new Statement of Truth that should be used reads: “I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer. “I understand that proceedings for contempt of court may be brought against anyone who makes, or causes to be made, a false statement in a document verified by a Statement of Truth without an honest belief in its truth.” The Expert Witness Institute recommends updating report templates now to ensure experts are ready when the change comes into force. Although it is not mandatory until 1 October, there is nothing to prevent the new wording being used immediately. According to expert training specialist Bond Solon: “This development is all in line with the process of professionalisation of the expert witness industry and the trust and reliance that the courts place on the experts who write reports.” The new wording follows the case of Liverpool Victoria Insurance Co Ltd v Zafar [2019] EWCA Civ 392, in which the Court of Appeal set out guidance for judges on how to deal with contempt of court actions against expert witnesses.

Dr Zafar had included information in his report at the request of his instructing solicitors. The information directly contradicted his actual findings on examination of the claimant and contained an opinion on prognosis, suggested by the solicitor, which was not his own. The court found that he had, at the very least, been reckless about the truthfulness of the information, if not dishonest, in including it in his report. As such, he was in contempt of court and liable for punishment by the court, either by way of a fine or by way of imprisonment. The Court of Appeal ruled that an expert witness who is found to be either dishonest or reckless as to the truthfulness of their reports should be sentenced to immediate imprisonment for one year. q

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Care and supervision orders to resume digital roll-out

[

THE NEW ONLINE SERVICE to process care and supervision applications will resume its national roll-out from 14 September, HMCTS has announced. The service allows local authorities and legal representatives to create and manage care and supervision applications under Part 4 of the Children Act 1989, or an Emergency Protection Order under section 44 of the Children Act 1989, online. It was paused in March because of the COVID-19 pandemic. Since then the project team has been improving performance of the service in preparation for the national roll-out, which will follow a phased approach beginning

with an initial eight court sites. Others will follow. The new service is aimed at improving the progression of cases to support the best outcome for the most vulnerable children by: • Allowing local authorities to create new • digital applications for care supervision • and Emergency Protection Orders • Enabling cases to be progressed by the • court, legal professionals, local authorities • and judiciary in a timely manner • Giving legal professionals, including • parents’ solicitors and Cafcass, the ability • to access cases digitally and view tasks • that need to be completed before a hearing • Allowing court users to see the status of

• their case and to progress it online • Enabling court users to upload and • access documents and evidence digitally • Enabling documents and evidence to be • added to case and court bundles which • can be uploaded, annotated, presented • in court and used in the hearings. Family Public Law will transition into Court and Tribunal Service Centres as the roll-out progresses. That means support for some administrative tasks relating to case management will move to a central function. Local courts will continue to carry out tasks such as listing and will also continue to support the offline process as they do currently. q

Sir Geoffrey Vos appointed Master of the Rolls [

AN IMPORTANT FUNCTION of the state that had to continue during the pandemic was that of judicial appointments. They included the appointment of The Rt Hon Sir Geoffrey Vos as the Master of the Rolls, effective from 11 January. The appointment will follow the retirement of Sir Terence Etherton and was approved by HM The Queen in July.

The Master of the Rolls is the second most senior judge in England and Wales after the Lord Chief Justice, and as President of the Court of Appeal’s Civil Division is responsible for the deployment and organisation of the work of the judges of the division, as well as presiding in its courts – often hearing the most complex cases across the full range of civil, family and tribunal matters. The Master of the Rolls is Head of Civil Justice, and as such is chair of the Civil Justice Council and Civil Procedure Rule Committee, with responsibility for the development and oversight of the wider civil justice system. The position dates from at least the 13th century. Reflecting the role’s historic roots, but also the on-going importance of public access to records and data for the rule of law, the Master of the Rolls is chair of the Advisory Council on National Records and Archives. Sir Geoffrey Vos was called to the Bar in 1977, and took silk (QC) in 1993. He was appointed as a Justice of the High Court, assigned to the Chancery Division, in October 2009. Between 2005 and 2009 he was a judge of the Courts of Appeal of Jersey and Guernsey, and a judge of the Court of Appeal of the Cayman Islands between 2008 and 2009. He sat as a Deputy High Court Judge from 1999 until 2009. He was the chairman of the Bar Council in 2007 and became president of the European Network of Councils for the Judiciary in January 2015. He was appointed as a Lord Justice of Appeal in 2013 and became Chancellor of the High Court of England and Wales on 24 October 2016. q

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Tumble dryers –

fire cause determination

[ IN THE LAST five years, there are estimated to have

been at least 2,661 fires where faults in tumble dryers were the source of the ignition. There are still 435,000 ‘fire risk’ tumble dryers in UK homes even though safety recalls have been issued. The costs involved in repairing damage following a fire can be enormous. The consequences for peoples’ lives can be worse. Where the cause of a fire is a dryer, it may be possible to recover the costs against the manufacturer. To do this there needs to be sufficient evidence that the machine was defective, or that the fire was a result of the manufacturer’s negligence or omission. Insurers need to prove the fire was not due to misuse of the appliance or due to another cause. Recovering the costs associated with the damage caused by a dryer fire is possible, but a proper and thorough investigation must be completed to capture the essential evidence before it becomes lost.

Why choose SS&G?

Strange Strange & Gardner understand that there are many reasons why dryers fail, and such claims often result in liability disputes. To successfully determine the cause of a suspected dryer fire, an in-depth investigation and analysis of the scene, including analysis of the individual product elements, must be undertaken. SS&G’s senior fire investigation specialist Anthony Murray explained: “We have the specific academic, professional and trade experience that is essential when determining the origin and cause of an incident. Along with our expertise at the fire scene, we communicate the conclusions in a knowledgeable and approachable way. We provide cost-effective reports promptly, and our assistance is a telephone call away.” q www.yourexpertwitness.co.uk

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Cladding forms being signed off by unqualified people, claims RICS [ THE Royal Institution of Chartered Surveyors (RICS) says it has been made aware that unqualified people may be signing off EWS1 forms – the form used by a building owner to confirm to valuers and lenders that an external cladding system on a residential building has been assessed by a suitable expert, in line with the latest government advice. The EWS1 form must be completed by a fully-qualified member of a relevant professional body within the construction industry, with sufficient expertise to identify the relevant materials within the external wall cladding and attachments – including whether fire stopping and fire resisting cavity barriers have been installed correctly.

UK banks and building societies have robust measures in place to protect people against fraud, which would pick up any EWS1 form that is suspicious; however, RICS is encouraging everyone to check the signatory on a form with the profession’s institution. In a statement, the RICS said: “RICS, UK Finance and BSA [the bodies representing banks and building societies] do not approve individual persons who can deliver the EWS1 and cannot advise on who can and cannot complete the EWS1 form/process. However, we would anticipate only qualified chartered members of the relevant professional bodies such as the Institute of Fire Engineers and RICS will have the necessary self-assessed competence and professional indemnity insurance to carry out this work.” q

Council agrees to restore bat habitat

[WARWICK DISTRICT COUNCIL has

agreed to pay a local wildlife group £1,000 and provide new hibernation boxes for bats after it failed properly to consider the impact a development might have on local wildlife when it approved a planning application. The council approved the planning application without requiring the developer to provide necessary details of bats using the site, despite the history of bats living in the vicinity. It also failed to require the developer to compensate for the bio-diverse land lost. The issue was referred to the Local Government and Social Care Ombudsman, which required the council to make the amends. When the land next to the site was approved for housing in the mid-2000s, the Secretary of State insisted a bat barn was created as part of the development, to protect the local bat population. However, in 2017 an application to build homes on fields next to the original site was approved, and before work began the developer removed a hedge and a number of trees which were important to the bats.

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Planning officers at Warwick District Council had recommended planning permission be approved, despite the concerns of ecologists they consulted. The planners failed to mention in their report to the council’s planning committee that the council’s ecologists had objected. That was because the ecologists did not have the details they needed about bats using the site to give meaningful advice. Also, the council had decided to create a Section 106 legal agreement with the developer, requiring compensation for the loss of bio-diverse land either by providing alternative land or by paying financial compensation. A Section 106 agreement creates a legally binding obligation that can be enforced in the courts. The ecologists had calculated the loss of bio-diverse land was worth the equivalent of more than £350,000. Nigel Ellis, chief executive of the Local Government and Social Care Ombudsman, commented: “When considering planning applications for particularly sensitive sites such as these, it is all the more important that planners gain the necessary information

and advice in a timely manner, to give the committees approving applications the best chance of making an appropriate decision. “Evidence of at least three different species of bats have been found at the site, and a nearby major infrastructure project had to be relocated because a rare species was found. In this case, because the necessary surveys were not conducted at the right time, we can never be sure just what impact the development has had on the local bat population. “I hope the measures the council has now agreed to take will go some way to offset the potential damage that has been done to biodiversity in the area, and the agreed improvements to the planning process will ensure decisions are made properly in future.” Following the Ombudsman’s investigation, the council has already started looking into whether it can use land it owns to offset the loss of bio-diverse land. It has also identified a woodland which is managed by a local wildlife group, which could be improved for bats by installing specially-built hibernation boxes. q

Take care when Zooming into online dispute resolution, says lawyer [ORGANISATIONS THAT ARE looking to use mediation as a way to resolve a dispute

without the need for costly litigation need to be aware of the impact that the COVID-19 pandemic will have on the process in the coming months, and the potential pitfalls and challenges. That is according to Ian Timlin, a dispute resolution and commercial litigation lawyer at Conexus Law, specialists in legal services for the built environment. Ian (pictured) cautions that the new process may not be as effective, and is also less secure unless certain measures are put in place. Ian explained: “From a practical point of view it has been relatively straightforward to bring mediation online, with Zoom for example being used as the facility for secure separate breakout rooms for separate parties, and for bringing the parties together in a plenary session. The mediator can then speak to each party separately or with the parties together, virtually switching online from room to room. “However, that does mean that things are not necessarily as secure as in a physical situation. As a result, we are advising that there is an online mediation protocol in the mediation agreement to be signed by the parties, which governs the terms of how the virtual mediation progresses and the rules that are to be adhered to. It should cover areas such as not recording the sessions, or sharing of the mediation meeting ID other than to participants involved, to ensure no one 'sits in' unannounced. “Also, each party should agree that, if for any technical reason they can see and/or hear a private conversation between the mediator and/or any other party – including error on the mediator's part in moving parties correctly to the breakout rooms – they must terminate the session at once and call or text the mediator.” However, Ian goes on to say that the biggest challenge remains the fact that it is much more difficult to establish a genuine rapport across a screen with the mediator and other parties, and this is key in mediation to gain a party’s trust and confidence. “Before people are willing to settle, they must SINCE THE UK went into national lockdown in March, the Business and Property feel that their interests are truly understood, Courts (BPC) have dealt with 85% of business – both interlocutory and final hearings – and only then can a mediator reframe problems remotely, using technology such as Skype or Cloud Video Platform. The Law Society cites and float creative solutions,” he explained. “Eye informally gathered statistics for hearings during lockdown showing that some 50% of all contact with the other side can be difficult if they BPC Rolls Building Chancery remote hearings lasted less than one hour, and 70% lasted are sitting well back from their screens and not less than two hours. in the same room, and therefore it is vital that The judiciary has determined that England and Wales is at a watershed moment in the participants show their faces and do not hide history of dispute resolution, with technology able to provide a system ideally suited to behind their name on a black screen or stock modern international businesses, helping cement its continuation as a market leader. The photo of themselves. That way each party and news comes amid the uncertain backdrop of Brexit negotiations, as the UK sets out how it the mediator can see how they are reacting to will conduct international business in the future. the points being made.” Sir Geoffrey Vos, then-chancellor of the High Court, said: “The prospect of an increase Ian also points out that, while online mediation in claims gives all of us involved in the UK’s dispute resolution process a big responsibility. is new to many organisations, eBay is a big We must make sure that our systems remain fit for purpose. Hearing cases remotely when user, and it is estimated that an incredible needs must is one thing; making sure that we have processes and rules fit for the 21st 50-plus million disagreements among traders century is another.” on eBay are resolved every year using online Law Society of England and Wales president Simon Davis added: “When the UK dispute resolution. lockdown began, the Business and Property Courts quickly moved from physical to virtual He concluded: “There is no doubt that hearings, showing that our system adapts creatively to meet the needs of businesses at virtual mediation is here to stay and is home and overseas. certainly appropriate for low-value disputes. “These courts had already taken steps to adopt new technologies, but the pandemic has However, where considerable sums are in allowed widespread adoption in a short period of time. dispute or complex issues arise, serious “Throughout this period, I have championed the role solicitors have played to keep the consideration should be given to the wheels of justice turning and these figures prove the profession can confidently represent traditional form of mediation, even in the their clients in complex business disputes remotely.” q current circumstances.” q

Remote hearings come to the fore [

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Expert determination – what’s new? CHRIS MAKIN reminds us of the versatility of expert determination, and reports on some recent developments.

[

AS A CHARTERED ACCOUNTANT (FCA) who practises exclusively in legal matters – forensic accountant, expert witness, mediator, expert determiner – my experience is that expert determination (ED) is considered by litigation lawyers too infrequently. Of course, it is common practice for company sale/purchase contracts and the like to include a dispute resolution clause (DRC), but how often would a lawyer in a contentious matter consider anything between negotiation or mediation at one end of the spectrum and arbitration or a court hearing at the other? Litigators have a duty to keep matters proportionate, and there is always the threat of a refusal to mediate, per Halsey, when costs are considered – but other options are available. As an active mediator and expert determiner, as well as my ‘day job’ as forensic accountant, I have no axe to grind; I express these views merely to help you, the practitioner.

expert determiner may be appointed. The typical DRC in a company sale/purchase contract says that, if the two sides cannot agree the completion accounts or a determiner to settle them, the president of ICAEW must make an appointment – and I was one of about 100 FCAs on that list. But the president now declines to do so, except by court order. Instead, applicants are directed to the ICAEW list of members online, where all members’ many specialisms are listed. That doesn’t work well, because any English FCA/ACA – and there are now 156,000 of us – can tick boxes of their specialisms; and no-one monitors their competence unless, as with any assignment, they get it wrong and are either sued or referred to disciplinary (or both). I have come across cases where the appointee didn’t even know that rules must be agreed, or the difference between a speaking and a non-speaking determination.

ED is versatile

The answer, I respectfully suggest, is to find your expert FCA by other means. I am not alone in being competent to do this work, but you do need someone who knows what they are doing. I have being doing EDs for over 20 years. I was in the first group of only five to be accredited at The Academy of Experts – the only professional body which awards this accolade – and I am an examiner there in ED for the full range of professionals. There is a full section on my website about ED. Other determiners, of course, are available, and my advice if you need an accountant to act as expert determiner is not to plough through the hundreds of ACAs on the ICAEW members’ list, but go to Expert Search at The Academy of Experts where you will find an expert who really knows how to do an expert determination. q

Most of my ED appointments do arise from DRCs, but direct appointments can be effective, too. Consider: • There was a dispute over how much should be paid to a retiring • senior partner of a legal practice. The partners appointed a senior • arbitrator who made an award (for a hefty fee) but only on • principles. The quantum still had to be established and I was • appointed determiner for that purpose. But the whole process • could have been done by me as expert determiner for little more • than the second fee I charged. • I was appointed SJE where a partner in a firm of chartered • accountants had left the firm, taking clients and staff. I took oral • representations from each, and got on so well with everyone that I • suggested to instructing solicitors that I was confident I could • mediate a settlement. Both sides’ solicitors were interested, but • nervous that they would have to start again if the mediation failed. • So, instead, I was appointed expert determiner and quickly • reached a binding judgment. • Two doctors were divorcing. I was asked to mediate a settlement • of their medical practice, and we settled the mediation but only on • principles. So I was appointed ED to put some binding figures on • the settlement they had reached.

And the expert determiner is versatile

It is often thought that the expert appointed can decide matters only within his expertise. That is wrong. Lord Denning in Campbell -v- Edwards [1976] 1 Lloyds’ Rep 522 said that the expert appointed must make an entire decision, because that is what he contracted to do. And in Bruce -v- Carpenter [2006] EWHC 3301(Ch), where an accountant told the court she could not make decisions because they were not of an accountancy nature, the court disagreed, and confirmed Lord Denning’s decision. In my EDs I have often had to make decisions outside my expertise, after taking advice from other professionals. The result is that the parties have a complete, legally binding decision.

So how do you find a competent expert determiner?

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

For accountants, what’s new?

There have been changes, effective 1 July, in how an accountant www.yourexpertwitness.co.uk

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Commissioner enters AFR debate [

THE Surveillance Camera Commissioner has reacted to the Appeal Court decision in the case of (R) Bridges v South Wales Police, which found that the police had acted unlawfully in using automated facial recognition (AFR) technology in Cardiff. The case was brought by a member of the public whose data was captured by the police while Christmas shopping. The action was initially lost in the High Court, which deemed the police’s actions lawful, but that ruling was overturned by the Court of Appeal on 11 August. In a statement the Surveillance Camera Commissioner Tony Porter said: “I have repeatedly called for open debate from all sides on this very important issue. If there is to be an ethical and evolutionary process for the legitimate use of automated facial recognition technology by the state then it is essential that the public have trust in the technology, its legal and regulatory controls and the honesty of endeavour by the police themselves.” He was scathing of the Home Office which, he said, had failed to update the guidance on AFR technology use contained within the Surveillance Camera Code of Conduct. “In so far as the legal deficiencies identified by the court are concerned I am sure that others will share my frustration with the Home Office,” he said. “The police worked hard to apply themselves in adhering to the Code, a statutory based document which for more than five years I have fruitlessly and repeatedly been calling upon the Home Office to update. The court opined that these deficiencies could be addressed through updating the Code and through national police guidance being issued.” A particular cause for concern with AFR technology is that it is biased against women and people of colour. The judgement found that South Wales Police did not take steps to verify that the software in question did not discriminate. q

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Govt seeks new forensics regulator [THE CABINET OFFICE is advertising for a new Forensic

Science Regulator. The post is currently held by Dr Gillian Tully, who has held it for two consecutive three-year terms. According to the job description: “The Forensic Science Regulator ensures that the provision of forensic science services across the criminal justice system is subject to an appropriate regime of scientific quality standards. They are responsible for: • Identifying the requirement for new or improved quality standards • Leading on the development of new standards • Where necessary, providing advice and guidance so that • providers of forensic science services can demonstrate • compliance with common standards.” The document continues: “The successful candidate will ideally have a substantial background in operating at a senior level in a relevant field, encompassing at least one of the following: • Leadership in a forensic, or related, scientific discipline • The development and application of quality standards in a • scientific or technical environment • The regulatory process involving scientific standards • The criminal justice system.” Applications close on 14 September and the appointment is expected to be made towards the end of the year. q

Welcome to our A to Z guide of the websites of some of the Expert Witness field’s leading players. If you are one of our many online readers simply click on any of the web addresses listed below and you will be automatically directed to that particular website. To get your website listed on this page just give us a call on 0161 710 3880 or email ian@dmmonline.co.uk Mr Kim Hakin FRCS FRCOphth Translations and Interpreting for the Legal Profession since 1997. Specialists in Personal Injury and Clinical Negligence.

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

www.abc-translations.co.uk

www.kimhakin.com

Mr Ashok Bohra MS MPhil MFSTEd FRCSEd FRCS(GenSurg)

Mr Chris Makin

General & Laparoscopic Surgeon taking instructions on behalf of either claimant or defendant or as a Single Joint Expert.

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

www.surgeonexpertwitness.co.uk

www.chrismakin.co.uk

David Bunker Arbitrator & Mediator

Mr Stephen McCabe MBChB FRCS FRCEM

Disposal & acquisition of businesses, management buyouts, shareholder & partnership disputes, employee disputes and taxation enquiries.

Consultant in Emergency Medicine taking instructions on behalf of either claimant or defendant or as a Single Joint Expert.

www.david-bunker.com

www.mccabemedicolegal.co.uk

Dr Thomas C M Carnwath

N-Able Services Ltd

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

• Chronic pain • Brain injury • Spinal injury • Children & young people • Neurological conditions • Amputations • Complex orthopaedic multi-trauma

www.tomcarnwath.co.uk

www.nableservices.co.uk

Dr Lars Davidsson MRCPsych MEWI

Dr Gerry Robins MBBS FRCP MD PGCLTHE

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

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

www.angloeuropeanclinic.co.uk

www.drgerryrobins.co.uk

Chris Dawson MS FRCS LLDip

Mr Sameer Singh MBBS BSc FRCS

Consultant Urologist with over 16 years experience of medico legal report writing and expert witness work in personal injury and clinical negligence cases.

Consultant Orthopaedic Surgeon • All aspects of trauma – soft tissue and bone injuries • Sports injuries • Upper and lower limb disorders and injuries • Whiplash injuries Clinic locations – London, Milton Keynes and Bedford

DentoLegal Ltd – Gary M Simon

Dr Elizabeth J. Soilleux MA MB BChir PhD FRCPath PGDipMedEd

DentoLegal specialises in the preparation of evidencebased Breach of Duty & Causation and Condition & Prognosis Dental Reports on the instruction of solicitors.

Expert Witness Pathologist with a particular interest in haematopathology. Short reports on specimens, full court compliant reports and expert biopsy reporting.

www.chrisdawson.org.uk

www.dentolegal.com Emma Ferriman Ltd

www.orthopaedicexpertwitness.net

www.expertwitnesspathologist.co.uk

Mr Bernard Speculand MDS FDS FFD FRACDS (OMS)

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

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.emmaferriman.co.uk

Yvette Young (Secretary) T: 0121 605 1884 E: info@medsecadmin.co.uk www.birminghamtmj.co.uk

FHDI - Kathryn Thorndycraft-Pope

T Clinic Dental Legal Experts

Examining documents & handwriting • to determine authenticity • to expose forgery • to reveal aspects of origin. Electro Static Detection Apparatus and Mi-Scope used.

Professor Paul Tipton is a specialist in Prosthodontics and Professor of Cosmetic and Restorative Dentistry and one of the UK’s leading dental expert witnesses. E: experts@tclinic.co.uk

Professor Parviz Habibi MB ChB PhD FRCP FRCPCH

Target Psychology Ltd

Consultant in Paediatric Intensive Care & Respiratory Medicine. Specialist in treating respiratory conditions and sleep disorders as well as paediatric intensive care.

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

www.childrensrespiratorydoctor.co.uk

www.targetpsychology.co.uk T: 0161 425 1826

www.forensichandwriting.co.uk

www.tclinic.co.uk/legal-reports/

www.yourexpertwitness.co.uk

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Let’s talk about translation and interpreting [TRANSLATION ENABLES effective

communication between people around the world. It is a courier for the transmission of knowledge and understanding, a protector of cultural heritage – thus providing localisation in areas of indifference – and essential to the development of a global economy via businessto-business reach. That definition encapsulates the benefits of working with a professional translation company such as Translation Hive. Its languages manager Christine Baty explained: “Studies have shown that the internet is used by 3.2 billion people, which is nearly half the world’s population! As a business your goal is expansion, and more than likely that’s on a budget. “So I can tell you this for free: machine translation is cheaper and potentially faster, but does the machine care about your company brand or reputation? Does the speed outweigh the damaging and somewhat embarrassing mistakes in the vocabulary and localisation? Both are surely rhetorical questions. “Machine translators have come a long way in a short period, but they are still lacking in certain aspects. Those are the aspects that make a translation effective for day-to-day and business use; and that is where human translators beat the machines. As the saying

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goes, ‘pay cheap and you risk paying twice’. “Would you put your company’s ethos, approach and promises in the hands of a hopeful attempt at automation? That applies to several industries, such as legal, digital reach and websites, e-commerce, marketing, food and beverage, finance, hospitality, manufacturing, tourism and leisure – the list is endless.”

Does interpretation get lost in translation?

Interpretation also centres on the same factors. It is tempting to use a family member or friend, as it can be comforting if someone is in an unfamiliar or uncomfortable situation. However, if someone needs to respond to questions or provide information involving authorities or for business interaction, unqualified and unexperienced aid may have unwanted personal and emotional attachments. Friends or family usually do not want to confuse or upset a person close to them;

however, there is the added risk of inaccurate interpretation having serious consequences in legal matters or business transactions. Where language puts up a barrier for communication, adding emotion or inexperience could be costly. Christine Baty continued: “Should cost saving be the deciding factor when choosing an interpretation or translation service? Case studies carried out by Translation Hive have proven that a reliable and professional outsourced solution can maintain a business brand and, more importantly, ensure delivery of what is promised, as it is aimed at business continuity, brand and reputation. “So how is that translated into a sustainable and reliable business opportunity? Automation works; it gets so far but, as with a business plan, with marketing or continuity strategy would you rely solely upon automation rather than on a person, hoping it translates or interprets close to your business ethos? If the answer is no, an outsourced interpretation and translation service which is accurate, reliable and ultimately much more effective should be your first option. “Translate Hive is experienced in providing such services at the highest level to meet the requirements of any industry.” q • For further information visit the website at www.translatehive.com

Linguists’ body gets new hand at the helm [THE Chartered Institute of Linguists is

to have a new chief executive. John Worne (pictured) will join the institute in mid-October. He joins CIOL following five years in senior leadership roles in higher education at the Royal College of Art and King’s College London. Prior to that he was director of strategy at the British Council – the UK’s official body for international education and cultural relations. An experienced spokesperson, public speaker and writer, John regularly represented the British Council and promoted the value of languages and UK and international culture in print, online, on TV and radio. Speaking about CIOL, John said: “The combination of CIOL’s authoritative voice for languages, along with its role in promoting the professional status of linguists and supporting high-quality examinations, qualifications and assessments, is hugely powerful. Having had the fortune to work in many different countries, I could not be more passionate about the value and joy of languages and language learning – and all the richness of human culture which is embodied in them.” Before the British Council, John worked at the heart of UK Government in the Cabinet Office and Department of Health, following more than a decade working around the world in marketing, advertising and business development. That included five years living and working in Paris. John speaks French, is progressing in Italian, has some Spanish and a little Cantonese. Judith Gabler, chair of CIOL council, and Bernardette Holmes MBE, chair of the trust board, both expressed their delight, adding: “Quite apart from the invaluable skills and experience John brings to CIOL, he is also passionate about helping others – both professionally and personally – to share the joy and practical benefits of speaking, writing, working in and simply loving languages. “We look forward immensely to working with John to make CIOL the very best professional body it can be for language practitioners around the world.” q

Cost-cutting threatens access to justice [ONE OF THE PRINCIPALS of modern society is that the justice system should be

accessible to all. That access is jeopardised when there is a language barrier. Writing in a blog on LinkedIn, Mike Orlov, executive director of the National Register of Public Service Interpreters, argues that a lack of proficiency in English can prove a barrier to many citizens in their dealings not just with the justice system, but also with medical services and all public services. That hindrance is more acute today with the COVID-19 emergency making many people’s dealings with authority more complex. Further, he argues that cost-cutting is exacerbating the problem by driving many professional interpreters and translators away from working in the public sector. Orlov writes: “While state resources are clearly not limitless, it is nevertheless critical to set public sector funding priorities on the basis of commitments to quality principles, not just supply and cost considerations; especially when lives are at stake. The pressure to save money or recoup costs should not be allowed to insidiously undermine the principle of nondiscriminatory access to public services and should certainly not hinder access to justice for all and free and clear access to medical services.” When people who do not speak English have dealings with authority, he says, they need access to a professional, trained and qualified interpreter. That, he says, is “particularly relevant when focusing on access to advice regarding protection through this COVID-19 crisis.” Many professional interpreters, however, have left the profession, to be replaced by those without the requisite qualifications. “No amount of oath-swearing in the court or deep affection for a loved one in a doctor’s consulting room can guarantee the requisite quality of accurate interpreting from a pseudo or ersatz interpreter who does not have the necessary competency.” q

www.yourexpertwitness.co.uk

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MEDICAL NOTES [ANY ANALYSIS OF the societal effects of the COVID-19 pandemic will point to the rapid adoption of remote working practices – a change that is set to become permanent as the pandemic recedes. An early manifestation of that change was in the move to remote consultations by medical professionals. GP surgeries were no-go areas for those without a specific invitation, with telephone and video the preferred methods. So it has evolved with medical assessments for personal injury and negligence claims. Legal firms have adapted to the procedure and are able to offer advice to clients. At least one expert witness has identified positive benefits in terms of efficiency.

• Remote medical assessment also forms one element of a protocol that has been put together by organisations representing three strands of the negligence claim process. The protocol identifies ways in which those representing claimants and the NHS bodies against whom claims are directed can co-operate to ensure the process continues during the COVID emergency while allowing the NHS to operate at full capacity and without disadvantaging those involved. • Online working has also become the norm for training and research purposes. And the format of the webinar will be the vehicle for the launch of a new report on the effects and cost of sight loss in the UK. It is a sobering fact that over two million people are living with sight loss in the UK, and ophthalmology has the highest number of out-patients of any specialty. • Ophthalmology has a high proportion of its practitioners from BAME communities, and it is known that those communities are suffering disproportionately from the pandemic. When the added risk of pregnancy is factored in, the effects can be devastating. A review of deaths involving COVID, mental ill-health or domestic violence against pregnant or post-natal women found that, of the eight women who died as a direct result of COVID infection during the review period, seven were from BAME backgrounds. Professionals involved in maternity care are calling for extra care to be afforded to the vulnerable groups. • The pandemic is also having an indirect effect on people dying from heart attacks, according to research from Leeds University. It has become an all-too-familiar story: during the depth of the crisis hospitals were stretched to breaking point and were caring for many people with the disease. Someone suffering the symptoms of a heart attack, who in normal times would have called an ambulance, delays taking action. They may be heeding the ‘stay at home’ message of the government, or are fearful of contracting the disease. • Indecision over whether to call 999 or not is just one facet of the mixed messages the public have been peppered with over the past few months. The organisation which has borne the blame for that confusion, rightly or wrongly, has been Public Health England. Now its pandemic response function has been taken over by a new agency. Some have detected a blame-shifting exercise, while others have criticised the method of announcing the move. • Before the arrival of COVID-19 on these shores there was another cause of misery and pain for many women – one that was largely unreported to the population at large. That is, until a small number of campaigners on three seemingly unconnected causes brought to public attention the effects of two drugs and one surgical device that were wreaking havoc. To his credit Jeremy Hunt, then Health Secretary, ordered a review of the unintended consequences of medicines and devices, focusing on the three main offenders – Primodos, sodium valproate and surgical mesh. The results of that review are now known, and the extent of the suffering has staggered even the most hardened commentators. q

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Protocol sets background for COVID claims handling [ INTERESTED PARTIES in the management of clinical negligence claims during the on-going COVID situation have devised a new protocol for handling claims during this period. The patient safety charity Action against Medical Accidents (AvMA), NHS Resolution – which handles all claims against the NHS in England, now including GPs – and the Society of Clinical Injury Lawyers (SCIL) have come together to sign up to the new protocol. Peter Walsh, chief executive of AvMA, said: “On behalf of people affected by avoidable harm in healthcare we welcome this protocol, which should provide assurance to those with a potential clinical negligence claim while also acknowledging the severe pressure which the NHS is under as a result of the pandemic.” The protocol is wide-ranging, covering: • A moratorium upon time limitation until three months after the • protocol ends • Making use of email to serve and receive documents on the • default position • Encouraging much more innovation, for example online • examinations of clients for medical expert reports • Encouraging more co-operation in the progress of claims, • and in particular interim payments of damages and costs to avoid • unnecessary court hearings • Settlement meetings and mediations to take place remotely • wherever possible • Consideration of whether costs budgeting needs to take place • initially, or can be requested to be adjourned in order to save court • and other resources. Paul Rumley, chairman of SCIL, said: “This is a very welcome development for everyone involved in clinical negligence claims, and shows what all parties involved in this area of law can do when they collaborate together. It is an ambitious protocol, and reflects many

weeks of hard work and necessary compromise by everyone involved in it. Particularly useful is the moratorium upon limitation to save unnecessary work and costs issuing cases which are simply not ready to proceed during this time, and equally the explicit acknowledgement echoing the calls of the Lord Chancellor and Lord Chief Justice at this time that claims do still need to progress even though all parties face challenges in doing so at this time.” Of particular note, and in contrast to other claims protocols to cover the current situation, is that the agreement continues in place indefinitely, until one of the parties gives notice to end it. The provisions are also subject to review, and possible refinement, every eight weeks to continue to respond to the challenges of the current situation. Paul Rumley continued: “The protocol is a brave and significant step forward, continuing as it does to be applicable unless or until it is ended by one of the parties, instead of having to be renewed every few weeks as is the case with the other injury protocols agreed at this time. “It is good news first and foremost for injured patients who wish to progress their claims at this time, and also for the claimant and defendant lawyers alike involved in these claims. It can, and will be refined, on an on-going basis to continue to respond to the challenges posed by the on-going coronavirus situation.” Simon Hammond, director of claims management at NHS Resolution, added: “The protocol provides some certainty to those who are handling clinical negligence work, while balancing the need to protect frontline staff’s time during the pandemic and recovery period. It shows how the industry is working collaboratively to find solutions around any challenges and it is hoped such collaboration continues post the termination of the protocol.” q

Concerns raised over post-hospital services for frail patients [ THE MAJORITY OF PEOPLE who stayed as an in-patient

in hospital were happy with the care they received, had confidence in the doctors and nurses treating them and felt their fundamental needs were met, according to a national survey from the Care Quality Commission (CQC). However, survey respondents were less positive about arrangements and information received when leaving hospital, and access to support and further services once at home. That was a particular concern for people who self-reported as being frail. The results of the 2019 adult in-patient survey reveal what almost 77,000 adults who had stayed in hospital for at least one night during July last year said about the care they received. The survey has been conducted annually since 2004. In 2019, new analysis was undertaken to better understand how supported frail patients felt after leaving hospital. For patients with a planned admission to hospital, more experienced a change to their scheduled admission date compared to last year. A fifth (21%) reported that their

admission date had been changed by the hospital at least once, and 5% reported two or three changes. A third of frail people responding to the survey said the care and support they expected was not available when they needed it after leaving hospital. That is significantly higher than the 20% of non-frail patients who said that. Professor Ted Baker, chief inspector of hospitals, said: “Most people continue to report positively about their interaction with staff and their overall experience as an in-patient – reflecting the significant efforts of healthcare professionals working tirelessly to provide care in hospitals across the country. However, I am disappointed to see some people describing a poorer experience in accessing in-patient services in the first place, and further problems when leaving hospital. “This year’s results indicate that people are facing longer discharge delays and reveal continued concerns around the quality of information provided when they are ready to return home. It is particularly worrying that for people who self-report as being frail, the difficulties in accessing support after leaving hospital were even greater.” q www.yourexpertwitness.co.uk

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PHE dismantling: questions remain over replacement [ THE ANNOUNCEMENT OF the ‘axing’

of Public Health England and the merging of its COVID-19 response function into a new National Institute for Health Protection (NIHP) has drawn as much criticism for the way it was announced as for the move itself – as well as for what are seen to be less than honourable motives for its execution. Expert comment has come from both the public health community and the medical profession. Christina Marriott, chief executive of the Royal Society of Public Health, declared: “To undertake such a shake up during the midst of a pandemic, and before the full inquiry promised by the Prime Minister, seems risky and a questionable use of resources. It risks the loss of experienced and dedicated staff and demoralising those who remain. “It risks system-wide disruption – previous top-down reorganisations have shown us that these take years to work through the system – and, most importantly, it risks not addressing the real issues of the failure of England’s response to the pandemic. We

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are an international outlier in the number of people we have lost to COVID-19 and we must learn the lessons quickly and before any subsequent wave. Reorganising public health is a distraction. “The lessons we need to learn are about disinvestment in public health – and the upcoming Spending Review is the ideal opportunity for the government to properly and securely fund public health. We need to learn lessons about how we commission private sector organisations to ensure they fit within the public health system. And we need to understand what went so very wrong in England.” The president of the Faculty of Public Health, Professor Maggie Rae, echoed the concerns. “With a huge strain already placed upon the public health system, the leaked announcement over the weekend has caused further stress and uncertainty for an already exhausted workforce,” she said. “With Matt Hancock today officially announcing the formation of the National Institute for Health Protection, we hope that the successful aspects of PHE’s response

to COVID-19 are retained and strengthened, that public health leaders will be at the centre of shaping the forthcoming reforms to the public health system and that public health will now face investment rather than the cuts of the past decade.” The British Medical Association addressed its concerns to the centralisation of the new institute’s function, and the allocation of its resources to private sector contractors. BMA chair of council, Dr Chaand Nagpaul, said: “We are concerned that it will report directly to the Secretary of State and his department, especially given that the public needs to have confidence that they are receiving expert information and advice. The institute also needs devolvement at a local authority level, working with local Directors of Public Health, who must equally be regarded as being independent.” He continued: “It’s important that the NIHP does not seek to outsource large amounts of its work to private providers because of the lack of accountability of private contacts on value for money and ability to deliver results.” q

Cumberlege report draws expressions of shock, anger and remorse [

THE SHOCK EXPRESSED by politicians at the outcome of the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege, was echoed not only by the medical profession but by the review chair herself. The review was set up in 2018 by former Health Secretary Jeremy Hunt to investigate how the healthcare system responds to reports from patients about harmful side effects from medicines and medical devices – specifically the hormone pregnancy test Primodos, anti-epileptic drug sodium valproate and surgical mesh. The report, First Do No Harm, sets out nine major recommendations to bring much-needed help and support to those who have suffered as a result of those interventions, and to reduce the risk of avoidable harm from medicines and medical devices in the future. The review team travelled across the UK to listen to hundreds of affected patients and their families, and received written evidence from many more over its two-year investigation. The team heard from people, mainly women, whose lives had been catastrophically affected and whose families had suffered terribly as a consequence. The sheer scale and depth of suffering of those affected drew an almost unprecedented expression of commiseration from Baroness Cumberlege. Speaking on the publication of First Do No Harm, she commented: “I have conducted many reviews and inquiries over the years, but I have never encountered anything like this; the intensity of suffering experienced by so many families, and the fact that they have endured it for decades. Much of this suffering was entirely avoidable, caused and compounded by failings in the health system itself.” Explaining the title of the report, she continued: “The first duty of any health system is to do no harm to those in its care; but I am sorry to say that in too many cases concerning Primodos, sodium valproate and pelvic mesh, our system has failed in its responsibilities. We met with people, more often than not women, whose worlds have been turned upside down, their whole lives, and often their children’s lives, shaped by the pain, anguish and guilt they feel as the result of Primodos,

sodium valproate or pelvic mesh. It has been a shocking and truly heart-rending experience. We owe it to the victims of these failings, and to thousands of future patients, to do better.” The medical profession was quick to express contrition. Charlie Massey, chief executive of the General Medical Council, said: “The harrowing experiences of patients detailed in today’s report are a sobering reminder of the life-changing harm and side effects suffered from the use of these medicines and devices. Where things have gone wrong, patients have not always felt listened to by those in charge of the health system, and that is not acceptable.” While offering no immediate comprehensive response to the recommendations, Health Minister Nadine Dorries expressed both shock and anger at the findings. Herself a former nurse, Ms Dorries told MPs: “I have watched and read some of the testimonies. They left me shocked, but also incredibly angry. And most of all determined to make the changes that are needed to protect women in the future.” Jeremy Hunt, who as Health Secretary commissioned the report and who now chairs the Health and Social Care Committee, was equally forthright. “I commissioned this report because I knew that many lives have been ruined because we didn't act quickly enough to deal with problems in these three areas, but I have to say the results are far more shocking and disturbing than I ever imagined,” he said. Perhaps most telling is the fact that Baroness Cumberlege was moved to reflect nearly three weeks after the report’s publication. Addressing the victims directly, she wrote: “It was harrowing but you were inspirational. We are hugely grateful to all of you who met us, conscious that for many of you it was not easy either physically or emotionally. And we are acutely aware and saddened that many wanted to meet us but were too unwell to do so. “Please take it from us – your bravery, dignity and tenacity in the face of the terrible harm you have suffered makes you truly extraordinary people. “We listened to you, and our report is a reflection of what we heard and learned. It is as much your report as it is ours.” q

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Remote COVID diagnosis leads to new model for clinical assessments CHRIS STOKES looks at remote medical assessments for clinical claims – and asks whether it is likely to become the new norm

[ONE OF THE ELEMENTS of the protocol arrived at by

bodies involved in the management of clinical negligence claims during the COVID-19 crisis is the online examinations of clients for medical expert reports. The significance of the inclusion of that innovation is that it is endorsed by a number of parties to the claim process. One of those bodies, the Society of Clinical Injury Lawyers (SCIL), sets out in its guidance for lawyers on the circumstances behind recommending medical examinations remotely. “It is inevitable in the current circumstances that face-to-face examinations will be difficult to arrange and undesirable given the government’s guidance for travel,” says the SCIL. “Parties should not attempt to pressure claimants to attend such appointments, for example by refusing to agree to an extension for service of any expert report. “Both parties should consider and promote the use of remote/virtual examinations wherever possible to ensure cases proceed. If both parties are intending to call upon the evidence of an expert of like discipline, then unless otherwise agreed both examinations should take place utilising the same basis to facilitate the examination: face-to-face or remote/virtually.

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“The parties should cooperate to ensure, where necessary, a patient’s medical records and imaging are shared electronically to avoid any delay in the resolution of the claim.”

The claimant’s perspective

Personal injury specialists Minster Law have advice aimed at claimants themselves. Their advice is: “A central part of your personal injury claim is a medical report from an independent expert which examines your injuries, treatment options and predicted recovery time. Providing this appointment, which usually involves a face-to-face examination, has become more difficult as a result of current travel restrictions and social distancing measures. “In response to this, and to prevent any unnecessary delay in your claim, medical agencies are now able to conduct these appointments remotely, rather than face-to-face.” Minster Law have no doubt about their embracing of the new reality. “As your legal representatives in your personal injury claim, we are advising our customers to agree to a remote examination to avoid delays to your claim and the risks of travelling to and attending a face-to-face examination.” They do, however, sound a note of caution when the case is subject to an insurance claim. “There is a chance that the insurance company responsible for paying any compensation due to you may challenge a report based only on a remote examination. In some circumstances, this could result in the need for a further report at a later stage, when a face-to-face examination can be arranged. Rest assured that in that unlikely event, any additional costs incurred will not impact the compensation you receive.” There is no doubt that the new reality of remote examination where possible has been embraced by most medical experts. It follows on from the now-familiar remote diagnoses most GPs carry out as a matter of course. That process itself followed on from the need to remotely assess patients for COVID-19 in the early days of the pandemic, as recommended in an article in the BMJ Online by a team from Oxford University and encapsulated in the flowchart illustrated on the right.

Every cloud

There is, however, an area of medical expertise that is not only taking remote assessment in its stride, but finding positive advantages for both the expert and the claimant. Consultant forensic psychiartrist Dr Nikki de Taranto points out on the following page that not only is there a time and expense saving to be had in her area of expertise – the trauma arising from both clinical negligence and child abuse – but the remote interview can act as a relief from the trauma itself of reliving the victim’s experience.

working in the sphere of medical assessments imposed by the COVID virus will also find their way into the new normal – and whether that will lead to a more efficient way of assessing medical negligence and personal injury claims. Watch this space. q

Is this the new norm?

There has been much written about the ‘new reality’ – whether the new ways of working during the pandemic will be leading to permanent changes to our working lives. That possibility seems to have spooked politicians to the extent they are offering bribes and threatening sanctions against those who are resisting the return to previous working patterns. The genie seems to be out of the bottle, however, and remote working is set to become more important than ever before – on a permanent basis. It seems timely to ask, then, whether the new ways of www.yourexpertwitness.co.uk

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Lockdown can lead to a calmer conversation Dr NIKKI DE TARANTO MBBCh LLM MRCPsych finds there are some positive aspects to remotely conducting psychiatric assessments in medico-legal post-traumatic cases

[AS A FORENSIC PSYCHIATRIST who acts as an expert

witness, one of my areas of interest is personal injury cases involving trauma, including historical child abuse and clinical negligence. In such cases the examination process can be challenging or even deeply distressing for the client. I have for years offered a few examinations over remote platforms, in cases where the person cannot physically get to a meeting because of distance or disability. However, my default arrangement has been seeing the client in person. At the start of lockdown in the UK I moved my medico-legal practice entirely online, using Skype, FaceTime or more recently, after some security issues were sorted out, Zoom. I conduct the interviews from my locked study at home, using a headset so the client’s voice is not being broadcast over speakers. Prior to the interview I ask the solicitor to explain that to the client to reassure them. I had a fairly neutral attitude to the change initially, although I realised early on that the lack of travel had immediate benefits. I was saving hours of time, was never late for a meeting and was always in a calm and focused mental state – not having had to negotiate

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roads or trains, look for parking or worry about finding the venue. The case was completely fresh in my mind as, directly before the start of the interview I had been reading the paperwork in the comfort of my own study. As time went on I started hearing from clients directly how they too were finding this way of working to be positive. The most common starts to interviews in the pre-COVID era were the client saying: “Doctor, I very nearly didn’t come,” or “I was so scared about coming.” What I now started to hear was: “I was so relieved when my solicitor told me I could do the meeting by Skype.” The experience of working in this way has continued to a positive one for both me and most of my clients. From a financial and environmental point of view the benefits are obvious, as they have been to everyone in the world now adjusting to increased remote working. I have, however, with the aid of feedback from clients, found that there are for many of them definite psychological and mental wellbeing benefits: • They feel that they were less anxious in the run-up to the remote • meeting than they would have been before a face-to-face meeting. • They have none of the stress of travel, finding the venue or worrying • about being late. • There is no sitting in a waiting room in an anxious state, and the • meeting always starts on time. • They are in the comfort of their own space – one lady was in bed, • hugging a pillow! • They can have unlimited refreshments with them or can go to fetch • them at any time. • They can smoke during the interview. That has been an unexpected • one. I have had several clients smoke through the interview to • manage their stress level. Clients could of course, in face-to-face • interviews, ask for a cigarette break; but that is not the same as • being able to smoke at leisure. • They can ask for a short break, or to resume later in the day, which • would not have been possible when working in the old way, with • a booked consulting room and travel involved. Of course clients • have always had the opportunity to discontinue a meeting if they • cannot cope, but that would then have meant having to come back, • with all the stress of travel etc, perhaps weeks later. Now the • meeting can easily be broken into as many parts as the client • requires, and a number have requested just that. • If an interview runs over time and I have another commitment • directly afterwards, I no longer have the difficult choice between • letting the next commitment – which may well be another anxious • client – wait, or requiring the current client to travel to come back • again another time. The nature of these interviews means that clients frequently become distressed, and that cannot always be avoided where you are addressing post-traumatic issues. Of course I would always try to ensure that the client is reassured, and allow them time to compose themselves; but that is not always possible in face-to-face interviews, when the next client may be waiting outside, or the room is booked for someone else. It means that sometimes a client who is visibly upset or crying has had to walk through a waiting room and then drive, or travel on public transport, to get to the solace of their own home. All of that is now avoided. q

Psychiatrists call for long-term investment in mental health [THE Royal College of Psychiatrists has

called for a ring-fenced investment of an additional £3.3bn at the next spending review, to significantly improve mental health facilities. COVID-19 exposed the danger of years of under-investment in unsafe and not fit-forpurpose mental health buildings as a disaster waiting to happen, says the RCPsych. Old and overcrowded mental health wards increase the risk of infection and have contributed to the deterioration of patients' mental health. New research by the college reveals that a third of clinicians in England feel that the quality of mental health buildings has compromised care for patients during the pandemic. It is essential that patients with the virus are isolated away from other patients, says the college, but 38% of psychiatrists report that mental health buildings are unsuitable for safely separating patients with suspected or confirmed COVID-19. A senior source at one hospital trust is quoted as saying: “Old and overcrowded buildings are simply not fit for infection control and the danger of cross infection is very high. Our patients are seriously mentally ill people who need to be treated in hospital, yet we were constantly

having to make the judgement: where would it be safer for them to be; on a ward struggling to manage COVID cross infection or back at home where their mental state might get worse? “Time and time again mental health has been completely left out of the hospital rebuilding programme. We can’t keep treating people with mental illness as second-class citizens. If government is serious about addressing the needs of those with mental health problems, we need investment for our estates. We simply can’t go on for much longer without it.” Funding for mental health facilities is long overdue, says the RCPsych. Mental health providers often receive a disproportionately lower amount of capital funding compared to other providers. A report published by the college reveals that trusts are struggling even to complete very high-risk repairs where there is a danger of catastrophic failure of care or serious injury. RCPsych president Dr Adrian James said: “COVID-19 brutally exposed the years of neglect that left some mental health services struggling to control infection. The Prime Minister’s recent announcement of investment

is timely, but we need an urgent and immediate injection of cash to prepare buildings for the next COVID-19 wave – followed by substantial long-term investment.” Among other proposed investments, the college is specifically calling for: • £376m (25%) of the Prime Minister’s recently announced £1.5bn of NHS capital funding for 2020/21 to be ring-fenced for mental health NHS trusts • A £1bn building and redevelopment programme to enable 12 major mental health projects to be completed by 2030 • £950m to improve the therapeutic environment of mental health and learning disability/autism inpatient services by completing the elimination of dormitory wards, eliminating mixed-sex accommodation, procuring en suite facilities for all existing single rooms, minimising the risks of harm through innovative safety improvement projects and making the estate more suitable for people with disabilities • £450m for new building and redevelopment schemes for community mental health facilities as part of the significant expansion of services outlined in the NHS Long Term Plan. q

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Inquiry pledge follows NI hospital abuse review [NORTHERN IRELAND’S Health Minister Robin Swann has pledged

to establish an inquiry into events at Muckamore Abbey Hospital (MAH), following publication of an independent review of the leadership and governance there and at Belfast Health and Social Care Trust, which runs the hospital. The review was itself established to build upon the Serious Adverse Incident (SAI) review into the hospital. MAH provides in-patient assessment and treatment facilities for adults with severe learning disabilities and mental health needs, forensic needs or challenging behaviour. The latest review concluded that, while the Belfast Trust had appropriate governance structures in place – with the potential to alert the executive team and the trust board to risks pertaining to safe and effective care – those systems were not implemented effectively and senior staff did not use their discretion to escalate matters. It found that the trust board and executive team rarely discussed MAH and the focus of the trust leadership was on delivering resettlement targets. Its report also concluded that the annual Discharge of Statutory Functions reports provided by the trust did not provide sufficient reassurance and were not sufficiently challenged at trust, Health and Social Care Board or departmental level. The review team confirmed the conclusions of the previous SAI report that MAH was viewed as a place apart which operated outside the sightlines and under the radar of the trust. Responding to the latest report, Health Minister Robin Swann said: “I can confirm that it is my intention to establish an inquiry on Muckamore.

Thanks to this report, we now know more about why the appalling failings at the hospital occurred. This will help me determine the nature and scope of a future inquiry, which must focus on the questions that remain unanswered and the crucial issue of how we stop this happening again.” The Royal College of Psychiatrists in Northern Ireland welcomed the review and the pledge to establish an independent inquiry. In a statement, a spokesperson said: “The college welcomes Minister Swann’s intentions to establish an inquiry and would advocate for speedy implementation of this work. We support a new regional plan to modernise the workforce, develop community care and provide specialist training for frontline staff. “Robust day care opportunities should be in place for all people with learning disabilities and we will continue to ask for greater investment in this area. “Compassion focused care needs to be at the heart of all training and care provision and the current delivery and role of in-patient services will have to be reviewed. “The biggest challenge will be to change the culture to a situation where people with learning disabilities receive the best possible care in the community and only when necessary in hospital, for the shortest time possible. “As psychiatrists, we are keen to provide expertise and help find solutions to develop community-based services. Human rights must be protected. We must ensure that the most vulnerable in society receive the best possible quality of care.” q

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Research quantifies heart attack victims put off hospital by COVID-19 [

THE DEATH RATE for patients who experienced what is normally a lower-risk heart attack rose sharply during the peak of the COVID-19 pandemic, according to an analysis of NHS data. In comparison, the death rate for people who had a more severe heart attack fell. A study led by a research team from the University of Leeds also revealed a substantial drop in the number of patients who were arriving at hospital with a heart attack. At its lowest point, hospitals were treating just over half the cases they would normally expect to see. Although the number of people seeking medical help did rebound, they had not returned to their pre COVID-19 levels by 22 May, when the study period ended. The reduction in patients seeking timely help is likely to have resulted in people dying at home or developing chronic heart problems. Despite the pressures on the NHS from COVID-19, the study showed that hospitals were able to maintain their emergency cardiac services in the vast majority of cases and adhere to best-practice clinical guidelines.

STEMI vs NSTEMI

reduction. Over the subsequent four weeks, it increased slightly to 8.3%. Chris Gale, Professor of Cardiovascular Medicine at the University of Leeds and senior author of the study, said: “This national picture provides evidence for the devastating impact that the COVID-19 pandemic has had on people’s lives. The inflation in deaths among people attending hospital with heart attack is very likely an early signal of the mortality and morbidity that is yet to be observed. “Notably, we have not seen a return to the normal rates of admissions with heart attack. This means that people may still be delaying seeking help.” The statistical analysis revealed that significantly fewer people were attending hospital with a heart attack. NSTEMI cases were down by 49% and STEMI by 29% on what hospitals were expecting to see. Professor Gale added: “It was not the case that people were not having heart attacks – they were deciding not to go to hospital. Some were undoubtedly heeding the message to stay at home, others might have been afraid of picking up the virus in hospital or were trying to shield because they had other conditions.” q

The analysis looked at two types of heart attack: 17,246 people who had a STEMI heart attack and 33,443 who had a NSTEMI heart attack. A STEMI – ST-segment elevation myocardial infarction – heart attack is where there is a complete blockage of one of the blood vessels that takes oxygen to the heart. An NSTEMI heart attack – where the ST-segment is not elevated – is less serious and usually happens when there is a partial blockage to one of the blood vessels supplying the heart. The decline in patients attending hospital started in early 2020 as China implemented lockdown measures and the World Health Organisation announced a public health emergency. And that decline continued through the early part of the lockdown in the UK. In the month after lockdown started, the proportion of patients who had an NSTEMI heart attack and died within a month went from 5.4% to 7.5%, an increase of 39%. It dropped back to 5% over the following four weeks. During the same period, for patients who had a STEMI heart attack, the 30-day mortality figure dropped from 10.2% to 7.7% – a 25%

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Eye specialists create joint vision from COVID lessons [THE College of Optometrists and The Royal College of

Ophthalmologists have developed a joint vision for the two professions to continue to work together to support the delivery of safe and sustainable eye care services in England. The vision sets out three key principles and recommendations for the development and governance of high-quality eye care services that involve other key policy and commissioning organisations, including NHS England and NHS Improvement. Those three key principles are: • Balancing visual loss due to delays in appointments against the risk • of acquiring COVID-19 infection. • Decision making about the most effective patient care being made • by the appropriate clinician, supported by senior decision makers in our aim is to establish similar frameworks for the other nations.” • optometry. Bernard Chang, president of The Royal College of Ophthalmologists, • All pathways to be underpinned by the highest standards of joint added: “Crucially, from the start of the COVID-19 pandemic both • optometry and ophthalmology clinical governance. colleges responded by developing a joint strategy agreeing principles Importantly, the vision ensures that the eye sector will take forward and pathways. Significantly, this collaboration will continue to lead the the new ways of working – developed during the restrictions placed on development of eye services in the community and secondary care services during the COVID-19 pandemic – as a framework for the future settings as we enter the restoration and recovery phase. delivery of primary and secondary eye care services in England. “We must continue to do more to increase capacity to help prevent The vision ensures integrated eye care pathways between secondary, avoidable sight loss. This vision for England will be a start of more community and primary care optometry, and builds on the established collaborative work across all four nations in the future. Our colleges COVID-19 urgent eye care services (CUES). Co-ordinated services are focusing on urgent care, cataract, glaucoma, AMD and diabetic for more eye health conditions will see extended collaboration between eye disease pathways initially. The emphasis will be on delivering safe, the hospital eye service and primary care, enabling a greater role for high-quality care in the right setting, by the most appropriate trained independent prescribing (IP) and highly qualified (HQ) optometrists. The professional, ensuring patients are confident in accessing the joined-up wider multidisciplinary team is key to delivering the vision. It includes care they deserve.” ophthalmologists, nurses and orthoptists, dispensing opticians, contact Both colleges are involved in the Eye Care Restoration and lens opticians, service managers, GPs and patients, working with Transformation Steering Group, as part of NHS England and commissioners, local eye health networks, local optical committees and Improvement’s National Outpatient Transformation Programme. It brings the hospital eye services. together key stakeholders to develop and support the delivery of a The vision makes a series of recommendations, including integrated shared vision and plan for the delivery of eye care services across the pathways and services, with long-term commissioning plans put entire patient pathway. It will work across organisational boundaries to in place, together with agreed risk stratification models across develop practical guidance, tools and resources, remove long-standing primary and secondary care and optometrists with IP and other barriers to change and work directly with systems to implement change higher qualifications able to work with a greater degree of autonomy. by building on the pathway redesign principles of CUES and the colleges’ Importantly, funding models and pricing should not lead to any perverse new joint vision. q incentives or inconsistent payments for the same work and resource use across organisations. Although the vision is initially for England only, the aim is to develop joint frameworks, pathways and guidance for all UK nations by both colleges. Colin Davidson FCOptom, president of the College of Optometrists, said: “In the grip of the pandemic, we worked very quickly with THE ROYAL COLLEGE OF OPHTHALMOLOGISTS has begun preparing its members the RCOphth to develop joint management for a second wave of COVID-19 infections this autumn and winter. principles and pathways that minimise the risk Its president Bernard Chang said in a message to members in August: “We continue of vision loss. Having established CUES, we to work in uncertain times and the threat of a ‘second wave’ of the pandemic remains a – working with NHS England and key sector possibility. We also know that this is likely to be compounded by the winter pressures placed bodies – need to build on these advances and on the system. We all have to be vigilant, be prepared and support our services to the best go much further, in the interests of both of our of our capabilities.” professions and patients. He particularly referenced the disproportionate effect of the COVID infection on BAME “We see this as the start of the conversation communities. that will allow optometrists to be recognised “Our membership data shows that BAME make up over 36% of ophthalmologists. We now and enabled to do more, in line with their skills, know of the disproportionate effect the pandemic has had on both BAME patients and the so that optometrists can routinely provide workforce. We must ensure that appropriate measures and support are put in place, working services including minor eye conditions with your trusts, infection control teams and hospital managers. We need to protect all staff services, CUES, glaucoma triage and pre and and ensure they work in appropriate and safe settings should a second wave occur.” q post-operative cataract assessments. While this vision is for England as a starting point,

Ophthalmologists prepare for second COVID wave [

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Impact of sight loss to be revealed at webinar [

SIGHT LOSS CHARITY Fight for Sight is set to publish a landmark report highlighting the social and economic impact of sight loss in the UK. It will also unveil a costing tool to demonstrate the current and future costs of sight loss, and how investment in eye research could benefit both individuals affected by sight loss and wider society. Fight for Sight is inviting people with sight loss, funding bodies, stakeholders and other players in the field of ophthalmology and public health services to an interactive webinar to launch the report, Time to Focus, on 16 September, from 3.30pm to 5pm. At the beginning of this year Fight for Sight carried out one of the largest surveys of people with sight loss and blindness to understand the personal impact. The Time to Focus report will reveal the findings of that research. It will also include economic and bibliometric data from peer-reviewed research conducted by academics at LSE and other partners. The charity has revealed that, in the UK today, there are twoand-a-half million people living with sight loss – more than half of which is avoidable. That number is set to grow exponentially by 2050. Meanwhile, ophthalmology has the highest number of

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outpatients of any medical specialty and even prior to COVID-19 was under pressure with an existing backlog of patients. In spite of that, says Fight for Sight, currently only 1.5% of national research funding is invested in eye research. The report launch will see keynote speaker Professor Sir Peng Tee Khaw, professor and consultant ophthalmic surgeon at Moorfields Eye Hospital and UCL Institute of Ophthalmology and director of the UK NIHR Biomedical Research Centre in Ophthalmology, come together with other leading scientists, partners and supporters to discuss the report’s findings. Chief executive of Fight for Sight, Sherine Krause, said: “Our report will demonstrate the impact of sight loss and how potential investment in research now could transform people’s wellbeing and reduce the huge economic and social costs. “These issues are more important than ever in a post Brexit and COVID-19 landscape. We’re encouraging members of the government, health services, industry, charities, researchers and those impacted by sight loss to join us for the launch of our report on 16 September.” q

Kids’ tooth decay rates set to get worse, say experts [NEARLY 45,000 tooth extractions were carried out on children in

hospitals in England last year, according to latest data from the NHS. The figure was highlighted by the Local Government Association (LGA), which said the stark numbers highlight the dangers of too much sugary food and drink in youngsters’ diets, as well as poor oral hygiene. That is likely to have worsened during the past few months, while children and teenagers have been stuck indoors. In all, there were 44,685 multiple extractions of teeth in under-18s in England in 2018/19 – at a cost of £41.5m, according to latest NHS spending data. That is equal to 177 per working day and an increase of 17% compared to the 38,208 extractions in 2012/13, which cost £27.4m. The vast majority were due to tooth decay and the severity of the decay meant that the treatment had to be undertaken in a hospital under general anaesthetic, rather than at a dentist’s surgery. Tooth decay has been the number one reason for hospital admissions among young children. Previous public health research has revealed nearly one in four of five-year-olds in 2019 have had dental decay, while children from more deprived areas are more than twice as likely to have dental decay compared to those from less deprived areas (34% compared to 14%). Nursery and school closures have led to the loss of supervised brushing time and fewer opportunities to educate young children and parents about good oral health. Councils, schools and other educational settings are keen to restart supervised brushing schemes and scale up their oral health work, to avoid an increase in tooth decay and extractions, but need additional funding and capacity to help do so. Meanwhile, 70% of families with children under five are also reporting more snacking in the household during the lockdown – more than double compared with those who are not living with children. Cllr Ian Hudspeth, chairman of the LGA’s community wellbeing board, said: “These latest figures demonstrate the damage which can be done to young people’s teeth through too much sugar intake. The fact that, due to the severity of the decay, 177 operations a day to remove multiple teeth in children and teenagers have to be done in a hospital is concerning and also adds to current pressures on the NHS. “We need to do all we can to reduce how much sugar our children eat and drink, including investing in oral health education so that everyone understands the impact of sugar on teeth and the importance of a good oral hygiene regime. Untreated dental care remains one of the most prevalent diseases affecting children and young people’s ability to speak, eat, play and socialise.” The concerns were echoed by the British Dental Association (BDA), which warned that the figures on tooth extractions for children will only get worse, as the pandemic exacerbates the deep oral health inequalities.

Dentist leaders have said the government has a responsibility to double down on the prevention agenda in response to the pandemic, and not let it lose priority following the abolition of Public Health England. The BDA has called on ministers to build on the recent obesity strategy – with extension of the successful sugar levy and a swift implementation of an energy drinks ban for kids – and follow up on policies that were championed in 2019’s green paper on prevention, including supervised brushing in schools. BDA chair Mick Armstrong said: “It's inevitable these figures will go from bad to worse, as lockdown diets, the suspension of public health programmes and the collapse in access take their toll. Government cannot remain a passive observer. “Any retreat from public health activity will hit England’s most deprived communities. Ministers must ensure the prevention agenda does not become another casualty of this pandemic.” q

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Corporate dentistry adrift in the doldrums 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 mourns the passing of the golden age of dentistry and a looming spectre of lower standard.

[GONE IS THE TRUSTED, reassuring warmth of the local dentist – the

pillar of the community, the comfort through the pain. He’s been bought out, and his community practice consolidated and sold on to yet another City business. Instead of the family dentist, patients are confronted with the impersonal sterility of dental corporations, with tens or even hundreds of chains across the country, run by businesspeople who know nothing about dentistry, whose employees are mainly high-value foreign migrants with variable fluency in English. How did that happen? What does it mean for our future?

The perfect storm

It all started when the General Dental Council (GDC) relaxed its former rules that restricted private partnerships from hiding behind the corporate pennant. One day, medical and dental practices were run by registrants directly accountable to their governing bodies, who divvied up the roles of chair, CEO and directors of finance, marketing, operations and HR. The next day, the suited City spivs had moved in, taking over established practices with steady revenue streams and valuable property assets. This was swiftly followed by corporate executive diversification whereby cash rich institutions were looking out for new opportunities.

Land and expand

Boots, which had already acquired many of the independent chemists to establish its solid pharmacy base, suddenly expanded into dentistry. They messed up, but Specsavers quickly spied an opportunity and landed a bargain deal. BUPA did the same before they got entirely out of providing medical and dental care and became what they are today: an insurance company with zero healthcare responsibilities. Individual entrepreneurial practitioners also started acquiring multiple practices, and vertical integration even saw dental corporates acquiring dental suppliers. Then three significant factors created the perfect storm that would shipwreck the Cutty Sark of dentistry and leave a giant fleet of cold steel ocean liners in its wake: • The introduction of the Care Quality Commission In the late noughties, the Department of Health set up the Care Quality Commission (CQC) to regulate and inspect health and social care services in England. Suddenly, vulnerable senior practitioners had to switch from thinking about retirement, helping out the kids with their first home deposit and tax planning schemes for their inheritance, to instead investing heavily in new, best practice protocols and administration. The financial and cultural impact of the CQC was the first wave to crash over the small practitioner’s bows. • The global financial crash It was around the same time that the bankers got caught with their pants down and needed the taxpayer to bail them out. The crash would scar the face of dentistry forever. Suddenly, overdrafts were reduced or called in with a few days’ notice. The hoops and obstacles of loans and mortgages put paid to the days when a young associate of five or so years could go it alone. However, the City was awash with private investors looking for new ways to get a decent return when interest rates plummeted. They had the cash to clean up and buoy senior dental practitioners down a fairer course. One over-generous cash offer for their practices and some three or fiveyear contracts later, and the dentists found themselves unburdened of the responsibility for the new regulations. It also meant that the City now controlled 10-20% of the market.

One fundamental conflict was that the dentist was no longer captaining his ship. He was an employee, a deck hand; carrying out duties at the command of a captain of business. With the wind out of their sails, previously motivated dentists who would work late into the night to get the paperwork done now had a clinical director calling the shots, steering the ship through the rocks of corporate governance and protocols. Patients noticed the culture change immediately. The grumpy old man was now just counting the days to retirement. • Foreign imports, cheaper cargo and linguistic whirlpools The opening of Europe blew many to the shores of the UK. First from the West, and then came the economic refugees from the former Eastern Bloc: dentists, doctors and nurses who were well-educated, with an ambition to work hard whatever the circumstances, whatever the pay. At a time when British graduates were sparse, the European migrants filled the void at lower cost.

Squalls at sea with GDC sanctions

The GDC set a language test to a standard so low that it seemed only to qualify these brave, new professionals to be able to buy a loaf of bread in a shop. Valuing the skill sets and economics, the corporates were nevertheless quick to recruit from that group. The repercussions of language barriers can cost patients dearly. If you don’t even understand the difference between could, should and would, how can you communicate clearly with your patients? As an expert witness, I recently dealt with a medico-legal case in which the patient claimed the Spanish dentist did not explain the destructiveness of veneers beforehand. However, on examination I discovered the patient to have severe cognitive impairment. And when I read her dental notes, they clearly documented conversations about veneers over three appointments, with all the risks and benefits clearly recorded in detail before the treatment was carried out. My report concluded that our Spanish colleague had not grasped the mental limitations of the patient due the low level of English set by the GDC. It was the GDC who sanctioned his registration, so it was the GDC who is to blame. Not keen to pursue a no-win, no-fee battle against the GDC, the lawyer dropped the case.

Sink or swim: the Big Five fish of the corporate sea

But whether we like it or not, the corporates are here to stay. In 15 to 20 years I expect they’ll have scooped up more than 50% of dental practices. The health authorities will have to negotiate contracts with very powerful bodies. Consolidation of the market will invariably lead to the ‘Big Five’ – just like our supermarkets. And the flare’s in the sky already. One of the world’s largest private equity firms, Carlyle, last year looked to float the UK’s Integrated Dental Holdings (IDH) on the stock market for £1bn. Senior corporate managers were anticipating a £150m pay-day. These new supercruisers will hold all the ropes before the box-ticking public authority servants realise what’s happening. The British Dental Association (BDA) will become a total irrelevance in the negotiating arena, although most of us have realised that’s already the case. The cosy relationship between the DoH and professional bodies will become irrelevant. Contracts will be controlled by tough business negotiators with MBAs and law degrees. The average public servant won’t stand a chance. I am one of the lucky ones. I have practiced in the golden era of dentistry. My ship has sailed. q www.yourexpertwitness.co.uk

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What are the medicolegal challenges of assessing patients with dental, cranial or facial conditions? In common with most fields of medicine, litigation involving oral and maxillofacial surgery (OMFS) is increasing, as is the amount paid out in compensation – although OMFS claims result, on average, in the lowest amount paid per claim of all the surgical specialties. According to the NHS Litigation Authority (now NHS Resolution), between 1995 and 2010 a total of 318 claims relating to OMFS were registered with them and a total of £5m in compensation was paid out. Here, Consultant Oral and Maxillofacial Surgeon Mr ZAID SADIQ discusses the challenges of assessing patients with dental, cranial or facial conditions.

[MOST CLAIMS RELATE to dentoalveolar surgery and minor oral

surgery such as third molar extractions, which is not entirely surprising considering the high volume of patients treated. The most common complications of that type of surgery are lingual nerve damage, postoperative infection, wrong site extractions and – in rare cases – death. Many factors influence the incidence of complications after third molar extraction; they include age, medical history, poor oral hygiene, smoking status, type of impaction, surgical and/or anaesthetic technique used and the experience of the surgeon. Therefore, all those factors need to be taken into account when assessing the suitability of the patient for surgery. Other procedures commonly cited in litigation include dental implant surgery, rhinoplasty and orthognathic surgery to correct dentofacial discrepancies, with most complaints centring around infection, implant failure and poor aesthetic results. Traumatic injuries to the face and mouth area can cause pain, functional impairment and aesthetic issues, and lead to physical, emotional and social consequences both for the patient and for their family. Therefore, when presented with such an injury, a physician should aim to limit the consequences by undertaking a thorough clinical assessment, from which correct treatment can then be planned. Careful initial assessment is paramount, as for some injuries the prognosis is very dependent on early diagnosis and correct management. That is particularly true of dental and facial fractures, as well as tooth avulsions. The main goals of treatment are to avoid or limit complications and to restore function and aesthetic appearance. Furthermore, physicians must take into account the psychological distress caused to the patient by injuries to the facial area and the ensuing anxiety which follows, as this may have some influence on treatment. It can be clearly seen that, in traumatic orofacial injuries, the initial physical examination is extremely important. As well as the examination of clinical signs resulting from obvious trauma, such as bruising, the facial bony and soft tissue structures must also be evaluated. The victims of such injuries must also be examined for any signs of head injury which could affect brain and spine function. That should include an assessment of the occlusion, as that could be the result of problems with the temporomandibular joint (TMJ) – such as fractures, effusion and/or bleeding into the joint space. Issues with the TMJ are a frequent finding in cases of facial trauma, but they can be difficult to diagnose as the symptoms are heterogeneous, often multifactorial in origin and can fluctuate over time. However, missed TMJ fractures are problematic for the patient, particularly in younger patients, as they may result in abnormal or asymmetric facial growth and a reduction in the size of the lower jaw. It may predispose to arthritis of the jaw joint in the long run and the number of claims relating to TMJ damage is rising. For that reason, radiological examination should always be performed. Furthermore, intraoral radiography will expose root fractures and tooth displacement or avulsion, while radiography of the soft tissues may identify foreign bodies that are present in wounds. Prompt detection and removal of tooth or bone fragments can be crucial in reducing the risk of subsequent infection. Dental and facial trauma occurs frequently in children and adolescents,

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and the prevalence of this type of injury has risen over recent years. That is due to the increased involvement of children and adolescents in play activities and competitive sports, more widespread usage of motorised vehicles by teenage children and an increase in the number of families keeping pets at home, especially dogs. However, the treatment of dental and facial injuries in children and adolescents presents some additional challenges. Any failure to provide adequate treatment may result in functional deficits and aesthetic issues, which can have long-term effects in patients who are still growing. Assessing those injuries can be more difficult though, particularly in very young children who may not be able to describe their symptoms very well. Another issue to consider is the possibility of non-accidental injury, such as child abuse or self-inflicted injury. It has been estimated that up to 50% of all the physical injuries associated with child abuse occur in the head and neck area. A study of cranio-maxillofacial trauma in children showed that, overall, around 4% of cases were due to violence, while it has been reported elsewhere that nearly 20% of injuries to the TMJ are non-accidental. TMJ fractures relating to acts of violence are often located in a different area to those resulting from road traffic accidents, so an injury in that area should always raise the possibility of a non-accidental origin. Any injury which leads a clinician to suspect child abuse must always be followed up, as there is a legal obligation to report such abuse. Typical signs might include bruising and abrasions which do not correspond to bony prominences, those which have been caused by recognisable objects such as bites or burning by cigarettes, and lesions which are clearly of different ages and therefore must have occurred at different times. Any discrepancy between the trauma history provided by the parent and the injuries found on examination, differences in the story given by each parent or a delay in presentation should also arouse suspicion. While claims relating to cancers of the head and neck (HNC) are relatively rare, the amounts awarded in compensation can be substantial. That is due to the cost of care, the potential for pain and disfigurement and the negative impact of the disease on quality of life. The most common complaint is of missed or delayed diagnosis. The epidemiology of HNC and oral cancer among younger patients is changing, due to increases in certain forms of the human papilloma virus and immunosuppression, and the presentation and risk profile of the disease have altered. Often, patients are younger than would have been seen previously, and therefore a clinician’s expectation that a younger patient has developed the disease may be lower than if presented with an older patient. Furthermore, HNC may be difficult to diagnose, as in the early stages the tumours are associated with no or few minor non-specific symptoms, which may be overlooked by both the patient and health professionals. Mucosal lesions may mimic benign conditions and even advanced-stage cancers can have minimal signs. It is important to remember then that a delay in diagnosis, or even misdiagnosis, may not necessarily reflect a breach of the standard of care given by the doctor or dentist. Diagnosis of the condition requires accurate testing and interpretation of the results. Despite that, it has been reported that in approximately half of HNC cases which resulted in litigation, it was alleged that a biopsy was indicated but not

performed. A delay in diagnosis may lead to progression of the disease and a poorer outcome, which in turn may increase the likelihood of litigation for alleged malpractice. However, outcome is also closely linked to the biology of the tumour, so a poor result does not necessarily indicate negligence by the healthcare team. While every surgical procedure carries a risk of complications, OMFS may be particularly prone to claims of negligence due to the aesthetic implications of many of the procedures carried out. Fortunately, serious complications are relatively rare, and although claims for minor complications are fairly common, the level of compensation awarded per incident is comparatively low. However, that should not stop an OMFS specialist from carrying out a thorough assessment of each patient and providing a full explanation of the potential risks of the procedure to be carried out. In cosmetic procedures, the patient should be given realistic expectations of the likely aesthetic outcome. For any procedure, the patient should, if necessary, be referred to a more experienced or specialist dentist or doctor, in order to minimise the risk of a claim occurring. q Mr Zaid Sadiq BDS MFD SRCS MB BS MRCS FRCS (OMFS) is a consultant oral and maxillofacial/head and neck surgeon at the Queen Victoria Hospital, East Grinstead, prior to which he worked for many years at other leading hospitals, including University College London Hospital and Great Ormond Street. Mr Sadiq is qualified in both medicine and dentistry. He completed higher surgical training in oral and maxillofacial surgery in the London KSS region. He completed a head and neck reconstruction fellowship in Edinburgh and is accredited by the Royal College of Surgeons of England. He is an honorary lecturer at University College London. Mr Sadiq has a keen interest in cancer, reconstructive surgery and tissue engineering, as well as providing a spectrum of oral and maxillofacial practice. He can be instructed as an expert witness via Medicolegal Partners at www.medicolegal-partners.com/sadiq.

Training director puts his own skills to the test

[THE TRAINING PROGRAMME DIRECTOR for dental

core training (DCT) in oral and maxillofacial surgery (OMFS) in Sheffield, Muzzammil Nusrath (pictured), has kicked off a campaign to encourage dental students to aim for a career in OMFS by highlighting the support available. “Oral and maxillofacial surgery is the exciting surgical interface between medicine and dentistry,” he explained. “Degrees in both disciplines are required to enter OMFS training. Many students are put off doing this because of the time taken to qualify and the expense of self-financing their second degree. “But there is a lot of help available from the British Association of Oral and Maxillofacial Surgeons (BAOMS), including bursaries from BAOMS and the NHS to support students to take their second degree. Further financial support is available through regular and locum work in OMFS units that is prioritised specifically for trainees pursuing second degrees.” The BAOMS quoted dually-qualified Thomas Howe, who has developed a leaflet targeted at dental core trainees who are considering a career in OMFS. He says that he has been fortunate to have had support throughout his training from Muzzammil Nusrath, “who helped me to develop my skills and fire my enthusiasm”. Mr Nusrath was himself in the news earlier this year when he led a team to reconstruct the jaw of a woman following the removal of a rare tumour. Her jaw was reconstructed with bone from her fibula by the surgical team at Sheffield Teaching Hospitals NHS Trust. The operation took 13 hours to remove the non-cancerous ameloblastoma and reconstruct Gillian Wood’s jaw with a ‘fibula free flap jaw resection’. The local primary school teacher is recovering well four months after the operation, and has praised the skill of the Sheffield surgeons. Mr Nusrath explained the surgical challenges he faced: “Gill was diagnosed with a fairly large ameloblastoma – which is a benign but aggressive tumour – that had already invaded the soft tissues of the floor of her mouth and the back of the tongue area. I needed to remove the entire affected lower jaw together with a 1cm margin of healthy bone and soft tissue to minimise the risk of the tumour coming back.” The fibula and its blood supply can be removed safely for transplant. The leg bone blood vessels are ‘plumbed into’ the vessels of the neck with microvascular reconstruction. The muscle and soft tissue are used to build the inside of the floor of the mouth and back of the tongue/cheek area. Mr Nusrath added: “I am so glad that all aspects of the surgery went well and Gill has made such a good outcome and wonderful recovery. In the near future I plan to carry out her dental rehabilitation by inserting one to two implants into the new jaw.” q

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Who decides when it’s safe to drive after hand surgery? You do! [ONE OF THE COMMONEST questions that spring to mind after

any surgery is “When can I drive?”. When that surgery is hand surgery, the question takes on a more obvious element. Use of the hand is fundamental to driving a car. The answer to the question is not, however, as readily available as it may seem. The legal position on driving, at least as far as DVLA is concerned, puts responsibility firmly on the driver to be their own expert – or at least the driver and his doctor. According to the DVLA website: “Any decision regarding returning to driving must take into account several issues. These include recovery from the surgical procedure, recovery from anaesthesia, the distracting effect of pain, impairment due to analgesia (sedation and cognitive impairment), as well as any physical restrictions due to the surgery, underlying condition or other co-morbid conditions.” Tellingly, DVLA take no responsibility for deciding what the ‘correct’ decision is. “It is the responsibility of the driver to ensure that he/she is in control of the vehicle at all times and to be able to demonstrate that is so, if stopped by the police. Drivers should check their insurance policy before returning to drive after surgery.”

Scarring study publishes first work

Some hand surgery clinics attempt to clarify the position, but come up against the same brick wall. Reading Hand Surgery can only reiterate the DVLA position. “The law is quite clear that following any surgery the key emphasis is that you are safe to drive. It is your responsibility to satisfy that requirement, not only because it is the legal duty but also because if you do drive and are not safe then your insurance company are likely to invalidate your policy.” A review of perceptions among surgeons in both the UK and the Republic of Ireland was published by researchers at the Department of Plastic Surgery, Cork University Hospital. When do we think it is Safe to Drive after Hand Surgery? – Current Practice and Legal Perspective found similar confusion among the profession. An eight-question survey looking at various aspects of clinical practice was circulated to consultant and trainee plastic and orthopaedic surgeons in Ireland and the UK. Of the 89 surgeons who replied, 53% felt the decision when to drive was the patient’s, compared with the insurance company (40%) and the surgeon (7%). Four fifths advised patients to contact their insurance company, while 87% were unaware of current regulations or guidelines. The authors said: “National guidelines were vague and left the decision with the treating doctor. Similarly, major insurers advise patients to contact their doctor for advice. From a legal standpoint, the patient has a duty of care to other road users to be in full control of his vehicle prior to driving, regardless of any advice received.” q

[A MAJOR PROJECT from The Scar Free Foundation

Centre for Conflict Wound Research, aimed at supporting veterans with appearance-altering injuries, has reached a major milestone with the publication of an important output from the early stages of the research. The Understanding Needs and Interventions for the Treatment of Scarring (UNITS) study is a three-year study exploring the experiences of military personnel and veterans who have sustained appearance-altering injuries during military operations or training since 1969 and their family members. The project sets out to understand the role of appearance and body image in their psychological wellbeing and to develop tailored support for those affected by appearance-altering injuries. The study includes a literature review, a series of interview studies, a questionnaire study and a final study to develop future support. Excitingly, the team have now officially published their first literature review which lays an important foundation for research into the nature and prevalence of body image and psychosocial concerns among veterans with appearance-altering injuries. Professor Diana Harcourt, director of the Centre for Appearance Research at the University of the West of England (Bristol), who is leading the research, pointed to the significance of the review. She said: “The review highlights why the UNITS research programme is so important. The previous research in this area consisted of only small studies; we are carrying out a much bigger study which will mean we can have more confidence in the results and use this knowledge to guide the future provision of support for those affected. The limited research that has been carried out also indicates that veterans whose appearance has changed due to combat injuries may experience psychological distress, such as depression, anxiety and social anxiety, highlighting the importance of developing proper support.” q www.yourexpertwitness.co.uk

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Diagnosis of prostate cancer is far from easy In this brief article, consultant urologist CHRIS DAWSON MS FRCS LLDip details the difficulties in the diagnosis of this specifically male cancer. The case described is fictitious, but based on the author’s clinical experience.

[KEVIN, aged 56, presented to his GP with some difficulties passing

urine. For about three months he had noticed a slight hesitancy before passing urine and a reduction in his urinary flow. He had also started to get out of bed once or twice at night. His GP listened to the story and arranged for a blood test for prostate specific antigen (PSA). PSA is an enzyme found in the blood of men, and has a role in male fertility. He did not examine Kevin’s prostate at that initial consultation. The PSA value came back at 4.2ng/ml, which is slightly raised for a man of Kevin’s age. By then Kevin’s symptoms had improved on the medication given at the initial consultation, so the GP arranged to see Kevin again in six months time. Unfortunately, because of work commitments Kevin did not make the appointment and it was nearly a year before he saw his GP again. His symptoms had begun to deteriorate by that time, so the GP retested the PSA – but did not examine Kevin’s prostate. The PSA by that time had risen to 8.3ng/ml. Alarmed by the change in the result the GP referred Kevin urgently to the local urologist for an opinion. Kevin was seen two weeks later – in line with national guidelines. Examination of his prostate showed a firm left side of the prostate with a hard nodule. The urologist arranged for an urgent MRI, followed by a prostate biopsy. The MRI confirmed abnormalities in the left side of the prostate gland, corresponding to the rectal examination findings, and the biopsies showed moderately aggressive cancer. Kevin was seen urgently by the urologist and offered treatment with

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either surgery or radiotherapy – eventually opting for radical prostatectomy surgery to remove his prostate. Kevin and his family were devastated by the diagnosis of cancer and concerned at what they believed to have been a delay in diagnosis by the GP. A review of the notes by an expert witness concluded that Kevin’s initial PSA was raised above the age-specific reference range and that alone should have led to a referral to the urologist for consideration of a biopsy. The expert was also critical of the fact that the GP did not examine Kevin’s prostate, as that may well have shown changes that would have reinforced the need for an urgent referral. It was therefore concluded that a breach of duty had occurred in Kevin’s care. However, the expert also pointed out that the cancer was found to be organ confined on the specimen removed at surgery and that Kevin’s chance of complete cure remained high. Moreover, given that his cancer was moderately aggressive on biopsy it was felt that an earlier biopsy would have led to the same treatment options as Kevin was given when his cancer was diagnosed. Prostate cancer is notoriously hard to diagnose in some men. A raised PSA is not diagnostic of cancer; nor is a palpable abnormality in the prostate. Nevertheless, either abnormality should be followed by an urgent urology referral for advice. The usual response would be, as in Kevin’s case, an MRI scan of the prostate and a biopsy, after appropriate counselling. Furthermore, a negative MRI scan and negative biopsy results, while obviously good news for the patient, do not exclude the diagnosis of prostate cancer, and urology monitoring is usual practice in such cases to determine if further investigations are required. q

Maternal deaths report draws comment from royal colleges [THE TWO ROYAL COLLEGES

representing midwives, obstetricians and gynaecologists have stressed how vital it is that all pregnant women admitted to hospital with COVID-19 have multi-disciplinary maternity care from the start, and that the information given to pregnant women must be accessible to all. The statement came in response to the report from the MBRRACE-UK Confidential Enquiry into Maternal Deaths. The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists also stated the need for special attention to be paid to those at higher risk, including black, Asian and minority ethnic (BAME) women, including providing access to an interpreter where needed. The report reviewed the care of 16 pregnant and postnatal women who died with COVID-19, from mental health-related causes or due to domestic violence between 1 March and 31 May. During the period, 10 women died with COVID-19 infection – eight directly related to COVID-19 and two from other causes – four died by suicide and two due to domestic violence. During the three months covered by the report over 160,000 women gave birth in the UK. The study found that, of the eight women who died as a result of COVID-19, seven were from black, Asian or minority ethnic backgrounds. The report made a number of new recommendations and suggested a number of improvements to existing guidance. Dr Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, commented: “Every one of these deaths is a tragedy and our thoughts are with the families of the 16 women who died. It is crucial that we learn from the findings of this rapid report to help prevent future deaths. “Through our collaborative working with the MBRRACE team throughout the pandemic, the clinical recommendations have already been incorporated into our guidance for women and healthcare practitioners. “The guidance makes clear that pregnant women admitted to hospital with COVID-19 must have multi-disciplinary maternity care and states there should be a low threshold for review of pregnant black, Asian and minority ethnic women with COVID-19.”

His conclusions were echoed by the CEO of the Royal College of Midwives, Gill Walton. “While this is a small study,” said Ms Walton, “it sadly indicates that many of the women who died from COVID-19 were from black, Asian or ethnic minority backgrounds. That further emphasises the need for clear information to be given to these women so that they are better able to manage their health appropriately. Ensuring that those at higher risk are supported by a multidisciplinary team – and that they see the same professionals over time - is key to tackling and improving outcomes for women with high risk pregnancies.” Dr Morris added: “Addressing health inequalities is a key priority for the college, and we established a Race Equality Taskforce earlier this month to focus on reducing adverse outcomes in BAME women. This report highlights that we must also ensure that services are fit to support vulnerable women who are victims of domestic violence or abuse. “Future pandemic planning should ensure that the care of pregnant women is not compromised by redeployment of maternity staff and that access to face-to-face antenatal and postnatal care for women who need support with their mental health is prioritised.” q

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Modern varicose veins treatments 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

[

VARICOSE VEINS SURGERY was the traditional way of removing varicose veins. Treatment was performed under general anaesthesia and led to significant post-operative pain and a recovery period of about one month. The long-term outcome of treatment was satisfactory. In the last 20 years several new methods of treatment have been introduced which can be accomplished under local anaesthetic. These include thermal ablation methods where a tube is Combined treatment for varicose veins by laser ablation and ultrasound guided foam sclerotherapy passed along the diseased vein for the surrounding tissues from the heat applied to the vein and affords a a distance of 20-50 cm. The tube is used to contain a heating method degree of protection against skin burns. which may be a laser fibre optic, an electrically heated catheter or Care must be taken to separate the skin and the nearby vein. Failure a tube delivering super-heated steam. The vein is anaesthetised by to observe good practice may lead to a linear burn in the leg 10 or injecting local anaesthetic around the vein and heat applied to destroy it 20 cm in length. I have advised in a case where such a burn arose without removing the vein. necessitating excision of affected skin, leaving a long scar in the leg. An improved method of injecting varicose veins known as ‘ultrasound The claimant settled a claim against the surgeon following my advice. guided foam sclerotherapy’ has been popularised. In this method, Sensory nerves lie close to the saphenous veins, especially below injections of foam created from a sclerosant drug are made into the the knee in the lower two-thirds of the calf. Inadvertent heating of a diseased saphenous veins and associated varices under ultrasound sensory nerve may lead to loss of sensation in the affected region of guidance. Local anaesthesia is not required for this treatment except at the leg but may also produce neuropathic pain. The nerve regenerates the site of injection. to some extent but then causes pain or unpleasant sensations in the innervated region that are very troublesome and long-lasting. Adverse events after minimally invasive treatment The medical literature on this complication is very limited but patients In general, the frequency of adverse events arising from treatment should be made aware that heating treatments for varicose veins may are substantially reduced compared to those which were caused by lead to loss of nerve function or neuropathic pain. Failure to warn of this surgical techniques. Since large incisions in the leg are usually avoided, complication could comprise substandard management. wound healing problems are minimised but a number of additional problems may arise. Problems with ‘phlebectomies’ Thermal methods of treatment only destroy the main longitudinal Thermal injuries veins on the surface of the leg, whereas the varicose veins usually The veins on the surface of the leg may lie close to the skin and arise in tributaries of these veins. Additional treatment can be provided to cutaneous nerves. Both of these structures may be damaged by by sclerotherapy or foam sclerotherapy in order to destroy the varicose heating the adjacent vein leading to undesirable outcomes. One of veins themselves. Some surgeons like to use ‘phlebectomy’ to treat the methods used to abolish pain during treatment is to inject a large residual varicose veins after thermal ablation. This treatment involves volume of dilute local anaesthetic around the varicose vein. This allows making a small incision in the skin and using a vein hook to pull out the the vein to be heated painlessly if the anaesthetic is injected correctly troublesome veins. Wound healing problems are uncommon since the under ultrasound guidance. The anaesthetic fluid thermally insulates incisions are small but damage may also arise to nerves and lymphatic vessels lying close to the veins. I have advised in one case where a long section of cutaneous nerve was removed at the ankle leading to a large area of loss of sensation on the top of the foot combined with neuropathic pain in the leg. In a further case, damage to lymphatic vessels arose in the calf leading to the accumulation of lymphatic fluid in a cyst. This reached about 5 cm in diameter at one stage, much to the dismay of the patient. The cyst was successfully managed by ultrasound guided sclerotherapy. The use of phlebectomies is still regarded as acceptable medical practice despite the alternative of sclerotherapy being just as effective. Patients should be made aware of the possible complications of phlebectomy as part of the consent process. Failure to complete this step may comprise substandard medical practice. The injection of local anaesthetic during the thermal ablation methods The results of inadvertent injection of a small volume of liquid usually causes only minor bruising or no bruising. However, on rare sclerosant into a tiny skin artery. The inflammatory process resolved occasions more severe bleeding may occur from small arteries lying without leaving any visible damage to the skin

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near the veins. I have advised in one case where a patient receiving warfarin anticoagulation developed a large haematoma after laser ablation of varicose veins which required surgical drainage. The local anaesthetic solution normally contains adrenaline which minimises any bleeding but on this occasion the warfarin levels in the blood had not been checked preoperatively. An expert in haematology advised that this was substandard practice. Foam sclerotherapy The modern vein treatment of ultrasound guided foam sclerotherapy, in which the main surface vein is injected with a sclerosant foam that immediately destroys the vein, has become standard practice. This is a very effective treatment in skilled hands and requires no surgical incision to complete. The main structure which should be avoided in such treatment is any artery in the leg. Ultrasound imaging is used to guide the injections and vascular surgeons should be able to identify and avoid the arteries. Inadvertent intra-arterial injection can cause severe damage to the skin and subcutaneous tissues. I have advised in one case where a major artery at the ankle was injected, leading to a below-knee amputation. The defendants admitted liability having reviewed my report. Lesser damage may be done to skin by injecting excessively strong solutions or excessive volumes. The consent process should include mention of these potential problems which only occur on rare occasions.

Conclusions

In the UK there has been a change in practice towards minimally invasive methods of treatment for varicose veins as advocated by NICE. These treatments lead to more rapid recovery with equivalent efficacy to surgical treatment. The complications seen following surgical treatments are usually avoided, but a new selection of adverse events may arise. Surgeons undertaking the newer treatment should be aware of the potential post-operative problems and discuss these with their patients. q

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Acetabular fractures – simplified by Mr NIKHIL SHAH, consultant trauma and orthopaedic surgeon, North West Pelvic and Acetabular Fracture Service at Wrightington Hospital.

[THE ACETABULUM is the socket of the

hip joint, located within the innominate bone of the pelvis. Fractures of the acetabulum tend to occur after high-energy injuries such as motorcycle or other vehicle accidents. They may also occur after falls from height and sometimes after sporting injuries. In recent years there has been a steady rise in the number of acetabulum fractures in elderly patients due to osteoporosis. This latter group of fractures are often lowenergy injuries that occur after falls from standing height. A 3D CT scan showing a posterior wall fracture (left) and a more complex type of fracture The acetabulum takes part in forming decisions are not straightforward: in many such cases it is known that the the hip joint. The function of the hip is to transfer weight during walking or natural history of non-surgical management is also quite good. standing and facilitate movement. Fractures that disrupt the joint surface Surgery may be required when those criteria are not met. Surgical can lead to damage to the cartilage of the joint or may heal with residual treatment traditionally has involved open reduction and internal fixation incongruity (a step or roughness in the smooth surface of the joint). Such (ORIF) with plates and screws, using one of the specialised techniques intra-articular fractures run the risk of developing secondary arthritis in the described by Letournel. With the advent of sophisticated intra-operative long term. imaging and a better understanding In simple terms the acetabulum can be conceptualised into different of the anatomy, some of the fractures parts that are referred to as columns and walls. The columns form can be treated with less invasive or the supporting pillars of the dome-shaped or hemispherical-shaped percutaneous methods using wellacetabulum and the walls form the rim of the hemisphere, providing planned keyhole surgery. stability to the hip joint. Classification of those fractures into subtypes There are some fractures in revolves around identifying which column or wall is fractured and how elderly or older patients where that will affect the stability or the smoothness of the hip joint. That in turn the joint is irreversibly damaged helps in planning treatment. and non-operative treatment or The French surgeons Letournel and Judet are regarded as pioneers just performing ORIF may not be in describing the principles of treatment that govern the management successful. Those fractures can of these complex injuries. Their work in the 1970s describing the be treated by what is referred to detailed concepts and techniques of surgical management and their as the ‘combined hip procedure’ or long term studies are still considered the gold standard. ‘fix and replace’ – where not only The anatomy and location of the acetabulum within the pelvis is is the fracture fixed but also a total complex and access to it during surgery is not easy. It is surrounded by, hip replacement implanted into the and lies in close proximity to, important structures such as nerves, blood hip joint after stable fixation of the vessels and other organs within the pelvis. Hence, treatment of such columns. They are complex and fractures can be quite challenging. Not only is the access difficult, but the Surgical treatment using plates and screws evolving techniques and require vital structures that surround the acetabulum can be at risk of injury by experience not just of managing the fracture itself or during surgery. Such injuries can be recognised as trauma but also of performing joint replacement. non-negligent complications. Such fractures figure prominently in personal injury medicolegal cases Often those fractures occur in a multiply-injured patient. There can be relating to trauma. The considerations in the early phase have to address associated fractures that involve the hip joint itself (femoral head, neck of whether a patient will make a good recovery or have residual symptoms femur), the shaft of the femur or a dislocation of the hip joint. of pain, stiffness or a limp, despite appropriate management. Return to A typical mechanism would be a direct head-on RTA collision. The knee work is an important consideration, as is the risk of long-term deterioration joint hits the dashboard and the femur is subjected to an axial force. That due to secondary post-traumatic arthritis, which may then necessitate a drives the femoral head into the back of the acetabulum, fracturing the delayed total hip replacement. They also figure in clinical negligence cases posterior wall and leading to a hip joint dislocation. The same mechanism for various other reasons, such as missed injuries or complications during can also lead to damage to the sciatic nerve located behind the hip joint. treatment. There may be damage to the blood supply of the hip joint, which can The prognosis depends upon a number of factors, the foremost of lead to a long-term risk of developing a condition called avascular necrosis, which is the nature of the injury itself. But it also depends upon a good where the bone of the femoral head undergoes cell death due to loss of standard of treatment and avoidance of complications. A multi-disciplinary blood supply. Those factors add to the challenges of treatment. team approach is required including specialist nurses, physiotherapists, Treatment of those fractures is a specialist area of practice. It must be occupational therapists, pharmacists and many more. With effective appreciated that many of the fractures can be appropriately managed specialist treatment in experienced tertiary units, good medium to long-term without surgery – especially when the hip joint is stable, the fracture is outcomes can generally be achieved, as is shown by long-term studies. undisplaced or minimally displaced and the articular surface remains Because of those challenges, it is considered a specialist form of trauma congruent in the weight-bearing zone. surgery. Within the UK, treatment of those injuries is offered by specialist In many elderly patients the fracture can be treated without surgery after teams of pelvic and acetabular surgeons with the appropriate training and careful consideration of the risks and benefits of major surgery to an elderly experience, working out of regional trauma centres to which the fractures patient – who may also have other medical problems – against the expected are referred for their management. q natural history of such treatment or the disadvantages of recumbency. Those www.yourexpertwitness.co.uk

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Joint registry held up as possible model for all implants [THE British Orthopaedic Association (BOA) has responded to the

report from Baroness Cumberlege and the Independent Medicines and Medical Devices Safety Review. Although the report, First Do No Harm, did not deal with issues surrounding joint replacement, the BOA’s view was that it ‘demonstrated the impact on the physical and mental health of patients when implants fail’. In particular, the BOA welcomed the recommendation for the establishment of more National Implant Registries.

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In its response, the association stated: “The BOA supports the highest quality surveillance of implants and the need for registries to track the patients in whom they are used. Registries are important tools in monitoring and understanding the performance of all implants and they have been used in orthopaedic joint replacements since 2003. When established, they rely on complete data capture, combined with clinical interpretation, to set standards and review outcomes in order to detect failure and prevent harm to patients. “The UK already has a highly-successful National Joint Registry (NJR), holding details of over three million joint replacements. Established in 2003, the NJR collects comprehensive details of hip and knee, shoulder, elbow and ankle implants and analyses and disseminates data across England, Wales and Northern Ireland, with a separate system in Scotland. This is complemented by the Orthopaedic Device Evaluation Panel, which assesses whether individual implants have reached a satisfactory benchmark and produces standards that are now used worldwide. “Alongside the NJR, trauma and orthopaedics has a strong track record in collection and use of data, with the National Hip Fracture Database, Trauma Audit Research Network, the British Spine Registry and the Scottish Arthroplasty Project already being well-established and further registries in development across the trauma and orthopaedics field.” The BOA says it would welcome the opportunity to share its knowledge and expertise to help develop a comprehensive system to ensure patient safety and follow up all healthcare implants. q

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