Your Expert Witness Issue 55

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contents IN THIS ISSUE 7

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Opening Statement

NEWS 8

EWI conference goes virtual

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Legal services report draws Law Society response

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NI compensation lags behind rest of UK

VIEWPOINT 11

Whose fault – the expert’s or the solicitor’s?

FORENSICS 12

Security centre defends UK against 700-plus cyberthreats

FIRE INVESTIGATION 13

It takes an expert to determine the cause of a chimney fire

TRANSLATION & INTERPRETING 14

Court-based language skills feature in awards successes

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Anglophone academies call for better language learning

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Client request sets translators on path to a new hive

13 A to Z WEBSITE GUIDE 32 Our A to Z guide to the websites of some

of the country’s leading expert witnesses.

EXPERT CLASSIFIED 50 Expert Witness classified listings 53 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 17 Medical Notes

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NEWS 19 EWI gives two cheers to Family Division recommendations 19 New digital resources support trusts and GPs 21 Virtual tribunal hearings may be here to stay SINGLE JOINT EXPERTS 22 Single joint experts: what are they and how are they instructed?

UROLOGY 23 Urology medicolegal work in the COVID era: how have things changed?

ORTHOPAEDICS Keep orthopaedic ops on the list, says BOA 25 25 Research charity partners in new venture 26 Pain programme wins healthcare award 27 What is post-traumatic arthritis?

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PLASTIC, RECONSTRUCTIVE & HAND SURGERY 29 Delays in breast reconstruction cause ‘great distress’ 29 Surgeons’ body warns of a post-lockdown ‘Zoom boom’ 30 How do you assess scarring in a plastic surgery medicolegal claim?

31 BAAPS elects first woman president OBSTETRICS & GYNAECOLOGY RCOG echoes MP’s call for action on endometriosis 33 33 Woman left with perineal tear wins compensation claim CARDIOLOGY 35 Cardiac rehab participation falls during the pandemic PELVIC VEINS 36 Pelvic vein treatments DENTISTRY & MAXILLOFACIAL SURGERY 38 Online lesson in consent offers protection to junior doctors 38 BAOMS welcomes MP’s Botox bill 39 Dentists’ leaders call for PPE assurances from government 39 TMJ surgery: the developments are exciting 41 Forewarned is forearmed: how the virus affects dentistry

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OPHTHALMOLOGY 43 Cataract surgery report finds significantly better patient outcomes 44 Blurred film highlights nation’s sight issues 45 Medicolegal negligence in the telemedicine era PSYCHIATRIC & PSYCHOLOGICAL ISSUES 47 Report on child mental health raises concerns among psychologists 47 Best practice guidance issued 49 Doctors condemn out-of-area referrals for mental health patients 49 Psychiatry body responds to report on restraints in care homes www.yourexpertwitness.co.uk

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Opening Statement [ONE OF THE HIGHLIGHTS of the expert witness’s year is the annual conference of the Expert

Witness Institute in September, which is traditionally held at Church House, Westminster. That proved impossible this year, of course, so the event was held online. One eminent barrister who tuned in was Phillip Taylor of Richmond Green Chambers. His review of the event is much appreciated.

From his review we glean that, in addition to being held virtually, the conference was very much taken up with discussions around virtual conferences and hearings. His allusions to the potential for pets to disrupt proceedings and the visual backdrop to contributions reminds us all of the need to prepare ourselves properly for virtual meetings.

• The virtual world can be a hostile as well as a friendly environment – the haunt of cyber criminals.

Keeping us safe from cyber crime is one of the tasks of the National Cyber Security Centre (NCSC).

In the year to the end of August the agency detected an average of 60 attacks per month on this country’s organisations – not all financial.

The COVID pandemic has provided cyber criminals with a fertile field in which to ply their trade and the job of analysing and prosecuting the threats is one that requires a wealth of expertise.

The NCSC even found time in its busy schedule to provide technical ‘assurance’ to the Virtual Parliament.

• As the world emerges from the pandemic in the hopefully not-too-distant future, one of the issues that will be exercising the legal profession is that of access to justice for the most vulnerable in our society, whose often-precarious position has been thrown into focus by COVID. The Law Society is in no doubt where the source of improvement lies and has been pressing the case for some time now. It is, of course, in the funding of legal aid. When LASPO virtually cut off the legal aid tap, the society argues, access to justice for the least privileged also dried up. Progress on reform has been slow.

• Access to justice depends on being heard and understanding what is happening. Where the process is taking place in a language other than one’s own that understanding is lacking. It’s where the skills of the translator and interpreter come into their own. Language services in the legal sector are highly specialised and, in some cases, award-winning. Two major categories in this year’s Institute of Translation and Interpreting Awards were won for assignments in the legal field. Our congratulations go to the worthy winners in those two categories.

There has also been a campaign launched to encourage more of us to learn languages.

• Even where there is no language difference, the outcomes of justice can be very different in different parts of the same country. In Northern Ireland the level of compensation for personal injury is less than it is in other parts of the United Kingdom. The reason for that is the way compensation is calculated and there is no sign that the situation will be changing.

A member of APIL’s executive committee explained that the lower level of compensation has led to injured people taking bigger and bigger risks in investing their money to make ends meet.

• When justice doesn’t go smoothly who do we point the finger at? Experts have come in for some buffeting lately and the shortcomings of some have been exposed. But it is not always the sole fault of the expert when things go awry. Sometimes the instructing solicitor has to shoulder some of the blame.

In an entertaining piece, regular contributor Chris Makin cites some examples of both. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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EWI conference goes virtual The Annual Conference of the Expert Witness Institute (EWI) was held online for the first time on 18 September, with the theme Bridging the Gap. The conference was attended by barrister PHILLIP TAYLOR MBE of Richmond Green Chambers. His extensive review of proceedings, some of which is reproduced here, can be read on the EWI website at www.ewi.org.uk.

[THE CONFERENCE BEGAN with remarks from the chair, Amanda

Stevens. The following programme was a robust and detailed one, predominant in which was the mystique surrounding ’virtual’ or ‘remote’ hearings, which seem now to be a regular fixture for future litigation.

Phillip Taylor wrote: “We heard first from Lord Kerr in one of his last remaining duties as a Supreme Court Justice, giving the keynote address. Brian Kerr was the last of the Lords of Appeal in Ordinary and he holds a life peerage, enabling him to remain in the House of Lords on retirement. His reflections on the legal changes he has seen were fascinating, bridging the gap between the Lords as an appellate committee, to the emerging UKSC. And the remote system for the keynote speech worked well.”

The morning sessions concentrated on the increasing use of remote hearings and trials.

Phillip Taylor continued: “The chair of the Bar Council for 2020, Amanda Pinto QC, and the vice-chair of the Personal Injuries Bar Association, Sarah Crowther QC, opened an interactive session on Covid-19: How the pandemic shaped the role of technology in the courts. There was so much common sense advice on display that it is worth watching any of the available conference videos to catch the suggestions.

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“Probably the most important points which EWI members will take with them include the need for more than one computer when you undertake remote work. That is because you need one screen for the hearing itself, either via the Cloud Video Platform or similar systems such as Zoom, Skype or Teams. You then need a separate screen for the trial bundle, which you cannot turn or cross refer to in quite the same way as the paper version. Finally, always have a mobile phone as, sadly, it is common for one party or another to lose a connection during the hearing.

“To reinforce Pinto and Crowther, we were given Lessons from the courts – a panel discussion, chaired by Dr Penny Cooper, with Alexander Hutton QC, Mrs Justice McGowan and HHJ Nigel Lickley QC from the Old Bailey. Experts will notice how top heavy the conference was with barristers so far. However, they proved the justification of their invitations with some great forensic tips for our new remote age. And at no stage did any of their cats run over the keyboards of their PCs to disrupt proceedings!

“Apart from animals or others contributing to virtual chats, there were also the recurring comments on the appropriateness – or otherwise – of the backgrounds, books rather than beds being the favoured option.”

Networking and exhibitor sessions included contributions from Bond Solon, Redwood Collections and the New Law Journal.

Phillip Taylor takes up the story after lunch: “The afternoon breakout sessions covered the more ‘bread and butter’ issues, which I am sure members found useful for their professional updates, including these areas: improving practice in inquests, in arbitration and post-Brexit.

“The final panel session brought back Penny Cooper for a discussion on Lawyers and Experts: Bringing together Experts and Instructing Parties, with contributions from Duncan Hughes-Phillips, Frank Hughes, Jennifer Jones and Robert Clayton.”

He summed up the conference thus: “We did end the conference knowing how we could improve our practice and develop our skills to make us fit for the future as lawyers and experts. And I think we all now know what to expect for 2021 and that the next conference, whether it is virtual or attended, will always remain professionally rewarding for everyone at the EWI.” The EWI’s next annual conference Lawyers and Experts: Facing the Future Together will also be held online on Friday 28th May 2021. q

Legal services report draws Law Society response [

THE CENTRAL ROLE that legal services can play in the national recovery from the pandemic should be advanced by a drive for greater access to justice for the most vulnerable: that was the message from the Law Society of England and Wales in response to the Legal Services Board’s State of Legal Services 2020 report, published in November.

The Legal Services Board (LSB) report notes that, while some regulatory intervention may help, many consumers will not have the means to fund their legal services costs, no matter how competitively priced it is. That makes public funding absolutely crucial to ensure early and effective advice.

According to the Law Society, current trends show that within five to 10 years there will not be enough criminal legal aid solicitors to sustain the duty solicitor schemes in many regions.

“The crux of the legal aid problem is funding,” says the society. “There have been no rates increases for criminal and civil legal aid since the 1990s, and legal aid fees have decreased by 34% in real terms since 1998.

The Legal Aid, Sentencing and Punishment of Offenders Act 2012 (LASPO) civil legal aid cuts reduced the areas of law for which legal aid was available.”

Its president David Greene commented: “The LASPO implementation review resulted in several promising proposals to

improve civil legal aid. There is on-going work on the Criminal Legal Aid Review, with recommendations due to be published in 2021, but progress has been slow and hindered by COVID-19.”

The LSB raises the issue of clients being able to shop around for their legal representation.

“An area which is often overlooked is low public legal literacy and confidence,” said David Greene. “Making people aware of how to recognise legal issues and from whom to seek help could increase people’s access to justice and reduce unmet demand.”

The report also examined the issue of diversity in the legal profession, with the LSB arguing that a ‘step-change’ is required.

On that issue David Greene responded: “We have long recognised the need to drive greater diversity in the profession and we have been working hard to address this issue. Earlier this month, we published new research with Cardiff University on how disabled lawyers have been affected by the COVID-19 pandemic, finding that remote and flexible working with reasonable adjustments could make the legal profession more accessible.” q

NI compensation lags behind rest of UK [

PEOPLE WITH life-changing injuries in Northern Ireland are being compensated far less than those in the rest of the UK as the wait continues for a change in how compensation is calculated, lawyers have said.

Hopes for early reform were dashed in October when the Northern Ireland Assembly’s justice committee suggested there will be no change until the end of 2021 at the earliest.

“Compensation is calculated to meet an injured person’s needs,” said Oonagh McClure, executive committee member of the Association of Personal Injury Lawyers (APIL). “That calculation has not been changed in Northern Ireland for many years, which means injured people here are being paid much less than injured people in England, Wales and Scotland.

“The way the calculation is made in Northern Ireland means that catastrophically injured people have been taking, and must now continue to take, bigger and bigger risks when investing their compensation to try to make the money last to meet their needs for the rest of their lives. They face losing their money or running out of money.” q

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Whose fault – the expert’s or the solicitor’s?

By CHRIS MAKIN chartered accountant, accredited civil mediator and accredited expert determiner

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ON THESE PAGES and in my blogs I have often told lurid stories of expert evidence going wrong, the assumption being that it is the expert who wrecked the case. But is that always fair, or do you, as instructing solicitor, also bear some responsibility?

I respectfully suggest that you do have a duty, particularly in two respects: choosing the expert, and instructing him/her properly.

The expert should be chosen carefully; it is not good enough to go for the cheapest, or the one who can take up your instructions at the last minute, the implication being that they have nothing else to do. Don’t leave the job to a junior. It is usually helpful to choose your expert early, so that he can help you weed out the hopeless cases or pyrrhic victories, or help you with ADR. And it is good to have a working relationship with an expert who will look at any case without obligation, and without charge if the matter does not proceed – one of my standard terms.

But if things go wrong, whose fault is it?

Here, I look at three cases where it was the expert’s fault in criminal, civil and criminal cases, and then a case which was clearly the fault of the instructing solicitors.

The first is the well known case of R v Sally Clark, as tragic a case as one could ever meet. The expert, Professor Sir Roy Meadow, was a highly regarded paediatrician but he was on a mission: one cot death is regrettable, two is highly suspicious, and three is murder. Sally Clark was a respectable solicitor who suffered the loss of her two sons by cot death. She was tried for murder, and Professor Meadow – well outside his expertise – gave evidence that the chances of two cot deaths in the same family were 73 million to one.

He was not a statistician and he had the figures wrong, but conviction was inevitable. Sally Clark was released after five years on her second appeal – but only because of incomplete disclosure at the main trial – but never recovered, drinking herself to death within months. And Professor Meadow had been on his bandwagon in the trials of Tripti Patel, Angela Cannings and others, with similar tragic results.

For a blatant example of the ‘expert’ who failed in every respect in a civil case, I turn to the case of Van Oord Ltd & Anr v Allseas UK Ltd [2015] EWHC 3074 (TCC), where Mr Justice Coulson took pains to explain the twelve – yes, twelve – respects in which an expert had failed in his duty.

They included: • not even considering or formulating the costs as incurred by the claimant • admitting in cross-examination that he did not even agree with his own report – this is amazing!

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

The third case is again criminal, but blame must be directed at both the expert and those instructing him, in this case the CPS. The case was R v Stephen Sulley & Ors, and the crux of the fraud charges was that there was no market in voluntary carbon credits, so the victims had been sold ‘investments’ which could not be realised.

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

2. He said he kept abreast of the carbon credits market, but he had not read any of the books written by Dr Frunza although they were widely

available. He had though once watched a documentary on carbon credits!

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

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

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

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

The case collapsed, and the CPS said they would have to revisit 20 previous trials where Mr Ager had been their expert. They wouldn’t be using him again.

Finally, I turn to a case where instructing solicitors were clearly to blame.

In Akebia Therapeutics Inc and Otsuka Pharmaceutical Co Ltd v Fibrogen Inc, Arnold LJ sat as a high court judge because of the shortage of judges able to hear such very complex cases concerning medical research. And he was quite scathing of the instructing solicitors, stressing many times that it is the duty of the instructing solicitor, not just the expert, to know CPR 35 and the Practice Direction, and to ensure for example that the expert attaches their CV to their report (basic!), and that there is nothing in the published literature by an expert which contradicts the opinions they express in the present case.

This was indeed a highly complex case, and there was a shortage of experts in the field, many of whom would not be familiar with CPR and litigation generally. But Arnold LJ made clear that it was the responsibility of instructing lawyers to get it right; that they need to know CPR 35 and PD35 just as thoroughly as their experts.

So what do we learn? I suggest two things. Choose your experts with great care, and make sure you instruct them properly. The morals to be drawn from the examples above could not be clearer! q

About Chris Makin

[CHRIS MAKIN was one of the first 30 or so chartered accountants to become an Accredited Forensic Accountant and Expert Witness – see www.icaew.com/about-icaew/find-a-chartered-accountant/find-anaccredited-forensic-expert.

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

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

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Security centre defends UK against 700-plus cyberthreats [ THE National Cyber Security Centre (NCSC) defended the UK

from an average of 60 attacks per month during a year which saw its resources proactively focused on the coronavirus response, the organisation’s latest Annual Review revealed. The NCSC, which is a part of GCHQ, handled 723 incidents between 1 September 2019 and 31 August 2020, with around 200 related to coronavirus.

That compares to an average of 602 per annum in the previous three years.

In a year heavily influenced by the pandemic, the review highlights the NCSC’s support for the healthcare sector, such as scanning more than 1 million NHS IP addresses for vulnerabilities – leading to the detection of 51,000 indicators of compromise – and working with international allies to raise awareness of the threat of vaccine research targeting.

With cyber criminals looking to exploit public fear over the pandemic with coronavirus-related online scams, the NCSC and the City of London Police also launched the Suspicious Email Reporting Service, which received 2.3 million reports from the public in its first four months – resulting in thousands of malicious websites being taken down.

The NCSC also provided the technical assurances during the creation of the Virtual Parliament, as well as producing a wide range of advice for businesses and individuals switching to home working as a result of the pandemic.

Its chief executive Lindy Cameron commented: “This review outlines the breadth of remarkable work delivered by the NCSC in

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the past year, largely against a backdrop of the shared global crisis of coronavirus.

From handling hundreds of incidents to protecting our democratic institutions and keeping people safe while working remotely, our expertise has delivered across multiple frontiers.

“This has all been achieved with the fantastic support of government, businesses and citizens and I would urge them to continue contributing to our collective cyber security.”

The Rt Hon Penny Mordaunt MP, Paymaster General, added: “The COVID-19 pandemic continues to affect how we live and work. In a year of complex challenges, the NCSC has continued to react to swiftly-evolving cyber threats.

“This review shows how the NCSC has taken decisive action against malicious actors in the UK and abroad, who saw our digital lifelines as vectors for espionage, fraud and ransom attacks. It is vital that cyber security remains a priority for government, industry and the public in building UK resilience to a spectrum of risks.” q

It takes an expert to determine the cause of a chimney fire

[THE LATEST STATISTICS from GOV.UK show that there are approximately 7,000 chimney fires a year in England. Chimney fires can occur when there is a build-up of soot and tar on the inner walls of the chimney, which are produced when burning wood and coal.

Fires in masonry chimneys can burn at up to 1,000ºC and may disintegrate mortar or collapse flue liners. The structural damage to the outer masonry material may provide a pathway for fire to travel to combustible wood frame components within the housing structure – often within the roof.

Along with the fire risk to the building, damage to chimney flues can create pathways for carbon monoxide to enter the home.

Why choose SS&G?

The experts at consultant forensic engineers Strange, Strange & Gardner understand that there are many reasons why chimney fires may occur. They include degradation over time, failure of components and defective chimney construction.

They also recognise that not all combustion appliances are installed correctly or follow the relevant sections of the Building Regulations. Competent fire investigation is vital in minimising loss and maximising recovery. They provide their clients with the answers they need to assess a claim or case.

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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Court-based language skills feature in awards successes [

IN OCTOBER the Institute of Translation and Interpreting (ITI) opened entries to its 2021 Awards. The ITI Awards showcase strong knowledge and skills, best practice, business know-how and excellent client relationships, as well as new ways of doing things, and significant contributions to the profession.

The 2021 Awards include a new category – the ITI Outreach Champion. The award is for an individual or organisation that has successfully promoted the value and importance of professional translators and interpreters and/or the powerful, positive impact of communicating in other languages for business and society in general, beyond the translation and interpreting sector.

The deadline for submitting entries in all categories is 15 February next year.

ITI Awards recognise and celebrate a wide range of translation and interpreting achievements. The Best Performance on an Assignment covers two categories – Translation and Interpreting. This year both categories were won for assignments in a legal setting.

The Best Performance on an Assignment – Translation category was awarded to Agata McCrindle. Agata was instructed as an expert under court order to provide translation of disclosure documents in legal proceedings. The disclosure consisted of several thousand emails and various documents, which Agata translated in batches. The assignment required excellent organisational and liaison skills and the ability to deal

with a variety of challenges; for example, accurately translating often technical content from one of the defendants who was dyslexic.

Interviewed following the award, she shared what winning the award was like. She said: “Winning the award has raised my profile, both in the business and translation community. It has given me and my business the boost of confidence. I also learned from the experience and realised that in order to succeed you need a skillset that goes beyond being good at translation – you need to be able to work with your clients by offering them solutions and alternatives, to show respect and understanding of your clients’ needs.

“Creativity, adaptability and consistency in your approach to translation are key. The assignment I was recognised for has required all those skills and since winning the award I have made sure I approach all my assignments in the same way. You win once and you will always be the winner.”

The Best Performance on an Assignment – Interpreting category was won by Lauren Shadi, whom the judges recognised for her work in interpreting between a female asylum seeker held in custody on a charge of attempted murder and a psychiatrist who was making an assessment of her mental state. Challenges included reproducing the client’s emotions, their reluctance to talk, working professionally in the face of the client’s distress and the setting – an open room where other legal visits were taking place. q

Anglophone academies call for better language learning [THE COVID-19 CRISIS demonstrates how essential foreign language

skills are to international co-operation and highlights the need for anglophone nations to step up language learning. That was the message from the British Academy, which published an unprecedented joint statement with organisations from the USA, Canada and Australia.

The Importance of Languages in Global Context was issued jointly by the British Academy together with the American Academy of Arts and Sciences, the Australian Academy of the Humanities, the Academy of the Social Sciences in Australia and the Royal Society of Canada. It calls on governments, policy makers, educators and industry to take ‘concerted, systematic and coordinated’ action to increase capacity for easily accessible education in a broad range of languages.

The academies highlight the key role that language skills play in international co-operation, especially during global crises such as the COVID-19 pandemic, when researchers, governments and healthcare workers need to share accurate information. However, anglophone nations are not producing enough speakers of languages other than English to meet 21st-century needs and are not doing enough to support those who are already multilingual to use and develop their valuable skills.

To build foreign language skills in countries where English dominates, the academies call for more language education in schools, colleges, universities and workplaces. It outlines three main goals:

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• To celebrate all languages, including those spoken by minority and indigenous populations. That means protecting against discrimination on the basis of language, preserving linguistic diversity and continuing access to education across a full range of languages • To acknowledge the English language’s position as a world language by enabling full access to literate English, recognising that it may be enhanced by awareness of other languages • To gain greater language skills by providing every student with access to learning additional languages. That will foster literacy and educational attainment, build confidence, enhance employability and help them to navigate multicultural environments.

The academies also argue that students from every socioeconomic background must have equal access to language education to reach their full potential in the 21st century.

Professor Neil Kenny FBA, the British Academy’s lead Fellow for languages, said: “Foreign language learning in the anglophone world has been in decline for too long – and the COVID-19 pandemic is a wakeup call. Anglophone nations need to urgently develop and implement language policies that are explicit, co-ordinated and comprehensive, making access to the world’s languages a core feature and indispensable part of the education of every student, of every age, beginning with valuing the languages learned at home.

“By increasing capacity for, and widening access to, language learning, anglophone nations will be able to more effectively co-operate with others and tackle the challenges of the 21st century. Right now the main challenge is COVID-19, but climate change, the growth of misinformation, threats to democracy and, indeed, future pandemics will all require fast and seamless international co-operation. To work together, the people of the world must be able to speak to each other and be understood.

“Earlier this year the British Academy and partners published a national strategy to revive language learning in the UK from early years education through to adulthood. We stand ready to assist the UK government in implementing these, or similar, recommendations. If government and civil society pull together, the UK could become a linguistic powerhouse: more prosperous, more productive, more influential and more innovative.” q

Client request sets translators on path to a new hive [ THE LANGUAGE DEPARTMENT at

Laird Assessors was rebranded around a year ago to Translate Hive, as part of their mission to shout about their translation and interpretation services.

Laird’s language team originated in 2013 after one of the company’s clients won a large contract with a Polish client. They needed to ensure the most efficient way of arranging vehicle inspections, so they decided the most simple solution was to employ a native Polish speaker.

Once word got out that they were providing Polish translations – the second most popular language after English currently spoken in the UK – other clients started asking them for other languages, mainly Indo-Aryan and European. It was clear that there was an appetite for wellorganised expert witness translations.

Managing director Nik Ellis explained: “We set about building software to control our ever-growing database of translators and interpreters, with an emphasis on – excuse the pun – clear communication.

“We found it was imperative to ensure constant updates and checks, which in turn guaranteed the smooth running of projects.

That was especially important when there were numerous parties involved – solicitors, clients, interpreters, courts and experts. Our software can spin those plates and communicate the important points to each party.

“Our ability to organise an efficient work flow attracted clients from outside our traditional legal industry, with the first being a UK manufacturer wishing to export to the EU. They tasked us with translating their instructions, terms and other documentation into over 20 languages: a mammoth task we managed to complete within a couple of weeks – to the delight of the exporter.”

That was the catalyst for changing the name and branding, to appeal to industries outside the legal world. They wanted to appeal to a wider market and indeed had no real geographical restrictions – and thus Translate Hive was born!

Nik Ellis continued: “We are sometimes asked why someone wouldn’t just use Google Translate. Computer/AI translations are quite good and will certainly help you get the meaning of the majority of texts; however, translation is one arena where AI can still not beat a human.

“There are too many idiosyncratic pitfalls, too many rules that are regularly broken, dialects and accents, meanings altered by intonation and words that mean something different from their technical translation. It’s tough, as anyone who has ever learnt a language will know. So when ‘quite good’ is too risky for something legal, important, technical or medical, then humans are still the best.

“On a final note, we’re very proud to be nominated for our first award – being shortlisted for the Supporting the Industry category in this year’s PI Awards. Thank you to all who have supported us throughout our journey.” q • For further information visit the website at www.translatehive.com

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MEDICAL NOTES [

AS WITH PRETTY MUCH every other activity, the past few months have seen the world of the medical expert turned upside down and moved into the virtual realm. While the idea of practising medicine in a virtual world may seem to be at odds with common sense, many of the more mundane activities of meetings and initial consultations can be achieved online. In some cases even assessments can be carried out via online platforms. Necessity has very much become the mother of invention.

• For some a number of positives have emerged from the move online. Where previously telephone conferences were carried out in a visual vacuum, the move to Zoom means the various parties can actually see each other. There is a more ‘natural’ feel to the event when the parties can make eye contact.

• Much training has been able to move online, with virtual resources being made available by a host of bodies. They include NHS Resolution. Two very different resources have been made available by the organisation. A new programme has been launched for healthcare organisations to help them understand and deal with concerns about doctors, dentists or pharmacists.

The second resource is aimed at GPs and follows the bringing of general practice into the remit of its indemnity schemes.

The video will help to ensure patient safety. Both are designed to try and pre-empt any cause for complaint before it happens.

• The holding of tribunal hearings virtually is also seen as an advantage for those who fall foul of the disciplinary system.

Preliminary hearings can be less stressful – and certainly less time-consuming. Those attending such virtual hearings should be well prepared, though, and treat them as if they were physical meetings.

For complex cases, however, the need for a hearing in person remains.

• Having the patient present is also, of course, essential for any procedure, and the pandemic has wrought havoc on much elective surgery. There have been heartfelt pleas for a return to something approaching normality from a number of specialties.

Orthopaedics is a particular case in point. The BOA has pointed out that the resumption of elective surgery in that specialty was already slow, putting thousands of people in pain on a lengthening waiting list. It is keen to see that list grow smaller.

• Breast reconstruction following cancer surgery is a further example. Not being able to access reconstruction was a lottery at the best of times and has become even more difficult in the current circumstances. The result can be a complex mix of distress and low self-esteem.

• The effects of the pandemic could lead to some irrational behaviour. A rush to improve our looks could be one of them, according to plastic surgeons. One of its professional bodies has warned of unscrupulous providers offering procedures without any face-to-face consultation. Such a ’Zoom boom’ could have disastrous effects.

One of the results of any kind of surgery, plastic or otherwise, is scarring – and, indeed, scarring can be a driver towards having cosmetic procedures. A leading plastic surgeon provides us with a fascinating insight into how scarring occurs and how to minimise it.

• One area of surgery that has reported improved outcomes is cataract surgery. Results from the ophthalmology database show significant improvement in the occurrence of a major complication and similar improvement in instances of loss of acuity.

Despite improvements in one area of sight care, more of us are experiencing vision problems and not doing anything about it. To highlight the issue, the College of Optometrists have released a film which has been deliberately shot out of focus. q

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EWI gives two cheers to Family Division recommendations [THE EXPERT WITNESS INSTITUTE (EWI) has welcomed the final

report and recommendations from the Family Division’s working group on Medical Experts in the Family Courts, but has raised continued concern about how the recommendations will be delivered.

While the EWI are pleased to see the recommendations, and believe they will go a long way in strengthening the pool of experts who are willing to work in the Family Courts, they are questioning whether the recommendations risk duplication of effort and reinventing the wheel in some areas.

Launching the report, the President of the Family Division, Sir Andrew

New digital resources support trusts and GPs

McFarlane, said: “In recent years it has become increasingly difficult for the family justice system to find experts who are willing to give evidence in Family Court proceedings. The shortage has not only been of clinical experts but also allied health professionals and independent social workers.”

The report, published on 5 November, makes 22 recommendations.

They include the development of online training resources and the increased use of remote hearings.

Sir Andrew had this to say on that issue: “Helpfully the working group discerned a silver lining in the COVID-19 cloud in that remote hearings demonstrated real advantages in making attendance at court hearings less disruptive of clinical practice and also in the convening of multi-disciplinary meetings.”

In its response, the EWI says: “The recommendations place a large emphasis on the Royal Colleges developing guidance for expert witnesses and, though it is suggested that they should consider our role, they are not specifically instructed to work with the Institute – or indeed The Academy of Experts – to create the guidance. This seems a missed opportunity and there is the potential for the various Royal Colleges to create guidance where this could be co-ordinated and hosted by the Institute.”

Despite misgivings, the EWI welcomed the creation of a Family Justice Council Sub-Committee to oversee the implementation of the recommendations, but noted that members seem to be limited to those within the working group, and does not include anyone from the EWI – or any other expert witness body.

“This, once again,” the EWI concludes, “seems to be a missed opportunity.” q

[

THE Practitioner Performance Advice section of NHS Resolution is launching a new programme to support healthcare organisations in understanding, managing and resolving concerns about doctors, dentists or pharmacists. Initial work on the programme is already providing ‘useful insights into the nature of concerns reported to us by healthcare organisations at the point they make contact for advice,’ the resolution body says.

Data for the past five years shows that almost 70% of cases involved concerns associated with misconduct or other aspects of behaviour of a practitioner. Just under half of cases involved a concern about the clinical skills of the practitioner, including concerns around governance and safety. A concern around the health of the practitioner was reported in just under 20% of cases. Also of significance is that, in 30% of cases, the reported concerns related to more than one area.

NHS Resolution says: “We are here to support both healthcare organisations and practitioners where difficulties about performance arise.”

NHS Resolution has also made available new online resources for general practitioners, following the launch of its general practice indemnity schemes. The organisation has been committed to supporting beneficiaries of the schemes, including through the sharing of learning from claims.

Over the summer it completed a series of Supporting General Practice videos, aimed at sharing ‘learnings’ from claims to improve patient safety.

Each video looks at a particular area that is known to give rise to a number of claims each year and then provides advice on how to prevent such claims arising. They include advice on what to do if a GP receives a complaint or a claim.

Another video looks at how to manage clinical risk in general practice and what to do when things go wrong. To outline the parameters of the Existing Liabilities Scheme for General Practice, NHS Resolution has also launched a five-minute animation: What is the Existing Liabilities Scheme for General Practice? q www.yourexpertwitness.co.uk

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Virtual tribunal hearings may be here to stay [

DOCTORS’ DEFENCE ORGANISATION the MDU has said it believes virtual Medical Practitioners Tribunal Service (MPTS) regulatory hearings have brought benefits in some cases, which could continue in future.

As part of a panel discussing how the pandemic has changed hearings, MDU senior solicitor Ian Barker explained that virtual interim orders hearings can be more convenient and less stressful for those taking part. The same may be the case for fitness-to-practise hearings in which there is uncontested evidence.

However, in complex cases, in-person hearings may well be appropriate for all concerned.

Ian Barker explained: “The pandemic has led to a sea-change in the way hearings have been handled and some of these changes, while not being things we would all otherwise have been inclined to try, have been positive. Some forms of virtual hearings can be more convenient and less stressful, with doctors being able to take part from the comfort of their own home or workplace rather than in person. However, we still advise members to behave as they would when appearing in person.

“Virtual hearings could work well in certain cases where the facts are agreed or where a health concern has been raised, for example. They have also been a productive way of holding interim orders tribunals, which can decide whether to suspend a doctor or impose restrictions, pending a full investigation.

“However, in complex cases where the facts are contested or it is necessary to call a number of witnesses, in-person hearings may very well be fairer for all parties and should continue.

“The MDU remains very happy to continue to work with the MPTS and to feed back to them about the impact on our members of the new arrangements. The GMC and MPTS face a challenge in clearing the backlog of cases that have resulted from the pandemic. However, we welcome the strides made in adapting to the current circumstances.”

The MDU has also issued some practical tips for doctors taking part in virtual hearings: • Make sure you have all the documentation about the case to hand • and have downloaded the app necessary to take part.

• Log on in plenty of time and ensure you are familiar with the • technology, such as how to mute and unmute your microphone.

• Use a work device to take part, rather than a personal one, and • make sure it is fully charged.

• Ensure there is a suitable background and preferably choose • somewhere quiet where you won't be interrupted.

• Dress smartly – and not just your top half, in case you need to • stand up.

• Be aware of your posture and body language. Behave in the same • way as if you were appearing in a court room in person.

• Have a glass of water handy and have a comfort break before • you start.

• Speak clearly while looking at the camera. If you have to look away • to your notes, explain that's what you are doing. q

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Single joint experts: what are they and how are they instructed? [

OVER THE YEARS there has been an increasing trend towards the use of the single joint expert (SJE) in a wide range of cases.

Single joint expert means ‘an expert instructed to prepare a report for the court on behalf of two or more of the parties (including the claimant) to the proceedings’. The rationale is that it leads to less cost and potentially a speedier outcome.

According to Part 35 of the Civil Procedure Rules: “Where two or more parties wish to submit expert evidence on a particular issue, the court may direct that the evidence on that issue is to be given by a single joint expert.”

The document continues: “Where the parties who wish to submit the evidence (the relevant parties) cannot agree who should be the single joint expert, the court may: (a) select the expert from a list prepared or identified by the (a) relevant parties; or (b) direct that the expert be selected in such other manner as the (b) court may direct.”

When it comes to instruction, the Rules state: “Where the court gives a direction under rule 35.7 for a single joint expert to be used, any relevant party may give instructions to the expert.” and “When a party gives instructions to the expert that party must, at the same time, send a copy to the other relevant parties.”

When it comes to the nitty gritty – the fee – the court may give

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direction about the payment of fees and may limit the amount that can be paid to the expert.

At base, though: “Unless the court otherwise directs, the relevant parties are jointly and severally liable for the payment of the expert’s fees and expenses.”

The duty of the single joint expert is to the court, in the same way as any expert witness. The Academy of Experts has this to say: “Just like a party appointed expert, the SJE’s duty is to help the court on matters within their expertise and this overrides any obligation to the person from whom the expert has received instructions or by whom he is paid. SJEs should maintain independence, impartiality and transparency at all times.”

Where there is a single joint expert in the case, the parties may still appoint a further expert as an advisor, but they may not be able to recover their costs at the end of proceedings.

There is also scope, at the discretion of the court, for another expert opinion to be sought in addition to the SJE. Lord Woolf’s judgment in Daniels v Walker reads in part: “Where a party sensibly agrees to a joint report and the report is obtained as a result of joint instructions…the fact that a party has agreed to adopt that course does not prevent that party being allowed facilities to obtain a report from another expert, or, if appropriate, to rely on the evidence of another expert.” q

Urology medicolegal work in the COVID era: how have things changed?

The COVID-19 pandemic has seen a fundamental change of working practice for most people. In this brief article urology expert witness CHRIS DAWSON MS FRCS LLDip provides some comments on how the pandemic has changed his practice, and how things may change in the future.

[

THE MOST IMMEDIATE change came during the initial lockdown at the start of the pandemic. Prior to that, appointments for condition and prognosis reports had been simple to make and could be carried out in a timely fashion. The lockdown changed that, and forced a swift change to the virtual world of online appointments via Skype, FaceTime and Zoom.

While the online platform allows a verbal interchange and the gathering of important information from the claimant, the lack of a face-to-face environment precludes the possibility of a physical examination. In some cases that may have no detrimental effect, whereas in others some useful physical information would not be possible to gather. To date I have found most instructing parties to be very helpful in that regard. A comment in the report to the court to the effect that examination was not possible due to the COVID-19 pandemic has sufficed, along with an offer to examine the claimant at a later date, should the need arise.

On the plus side, most conferences with counsel now seem to have moved to video platforms and away from the telephone alone. The ability to see the person(s) in the conference is a definite advantage in my view, and has made the conversation seem more natural – and also more productive.

To date the amount of medicolegal work does not seem to have reduced; in fact, anecdotally there seem to be more instructions than previously. It is difficult to predict what will happen to medicolegal work as we move through the COVID era.

However, it is well known that hospital waiting lists have generally risen during the pandemic, as essential services were shut down for a while and then restarted once the initial lockdown was over. The possibility for missed or delayed diagnoses as a direct consequence of the lockdown remains, but it is perhaps too soon to see what the effects will be. Whether or not it will result in an increase in claims by patients also remains to be seen. q

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Keep orthopaedic ops on the list, says BOA, as specialty records low post-COVID take up [

THE BRITISH ORTHOPAEDIC ASSOCIATION (BOA) has issued a statement about suspensions of elective operations in some regions during the second wave of COVID-19.

The BOA says: “We are urging trusts to continue planned operations wherever it is possible to do so and for as long as it is possible to do so, but we recognise that in some areas very difficult decisions are having to be made. During the first wave we supported the principle that non-urgent services needed to be suspended in order to deal with the pandemic as it emerged; however, further suspensions to surgery will have serious consequences for the patients awaiting surgery and we urge decision-makers to consider all options in order to maintain routine services through the weeks and months ahead. Where surgery is to be cancelled we urge hospitals to ensure that this is for the shortest possible time.”

At the end of August there were almost 200,000 people in England awaiting admission for orthopaedic surgery, the BOA says, and average waiting times were at their longest for many years. Patients on the waiting lists have typically been living with very significant pain and

Research charity partners in new venture [

ORTHOPAEDIC RESEARCH CHARITY Orthopaedic Research UK (ORUK) and Embryo Ventures have announced the formation of a joint venture company, Novara Therapeutics, to commercialise a patented bone-targeting contrast agent. Novara Therapeutics will focus on pre-clinical development of the proprietary imaging and therapeutic technology to advance diagnosis and treatment of bone disease in patients.

Osteoporosis is the most common bone disease, affecting over 200 million people worldwide. The condition is characterised by a progressive reduction in bone mass and strength that results in more than 8.9 million osteoporotic fractures annually. With one in three women and one in five men aged over 50 years experiencing an osteoporotic fracture in their lifetime, the condition poses a major public health challenge that is expected to increase markedly as the world’s ageing population continues to rise.

While contrast agents are often used to improve the quality of imaging used in normative diagnosis, such agents have no tissue specificity nor have any therapeutic action. Novara Therapeutics is set to deliver the world’s first bone-targeting contrast agent for early diagnosis and intervention of osteoporotic fractures.

Dr Arash Angadji, CEO of ORUK, said: “The creation of Novara Therapeutics is the result of over a decade of solid scientific research at the University of Brighton and, proudly backed by Orthopaedic Research UK, is aiming to offer better treatment and diagnostic solutions for osteoporotic patients. We are delighted to join forces with Embryo Ventures to further develop this exciting technology and make it available for patients to enhance their quality of life.” q

increasing mobility problems for many months, and sometimes years.

With surgery only just getting started after the suspension earlier in the year, and orthopaedics undertaking less than 50% of normal levels of surgery in August, further suspensions on operating will be a significant setback in tackling the growing waiting list.

The statement came after it had emerged that orthopaedic elective surgery had achieved one of the lowest percentage returns to normal activity during August. The data from NHS England reflects the low level of prioritisation afforded to orthopaedic surgery and the treatment of chronic painful conditions compared to the surgical treatment of other diseases, the BOA says.

The figures report the situation at the end of August and reveal that, for trauma and orthopaedics, over 24,000 people had been waiting over a year and 302,426 had been on the waiting list for over 18 weeks.

The BOA said: “This situation is intolerable for patients. Further delays have an enormous impact on patients who are in pain and are increasingly disabled. Patients fear the loss of independence that severe arthritis can cause.

This also has wider societal effects, for example where they are unable to work or become reliant on the state for care and support for day-to-day life.

“We are very concerned at how long these very reduced levels of surgery have continued. It is unlikely that the NHS will return to preCOVID capacity for some time. Action is required.”

The BOA points out that some hospitals have been able to undertake elective orthopaedics at 100% of pre-COVID numbers. They are typically dedicated elective orthopaedic hospitals, which are much easier to make ‘COVID-light’ or ‘green’, so they are enabled to deliver more surgery by design and investment. They are also less affected by winter pressures.

“We believe there needs to be more investment in cold elective orthopaedic centres to address the backlog and continue to provide efficient and timely access to these procedures,” the association says. “The long-term sustainable delivery of vital, cost-effective, life changing orthopaedic surgery depends on it. It is clear that prior to the pandemic the capacity for orthopaedic surgery was not able to keep up with demand.

“It is essential that the elective surgery continues to take place to relieve pain and suffering during the second wave of COVID or further increases in waiting times and further deterioration in the health of so many will be inevitable.” q

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Pain programme wins healthcare award

[

A SELF-MANAGEMENT rehabilitation programme for osteoarthritis has won the MSK Care Initiative of the Year award at the Health Service Journal Value Awards 2020. The ESCAPE-pain programme has been awarded the prize in recognition of its outstanding contribution to delivering better services and driving better outcomes across its organisation and delivery partners over the past 12 months.

The judges felt it was an excellent initiative which enables selfmanagement for people with hip and knee pain. Clear rationale was given for the initiative with supporting evidence and references, which has led to improvement in patient care.

The citation said the team had demonstrated great overall cost saving benefits to the system in terms of total and social health, and the overall ambition to improve general health, fitness and wellbeing was commendable.

ESCAPE-pain (Enabling Self-management and Coping with Arthritic Pain using Exercise) has been running for over six years. It is an evidence-based and cost-effective group rehabilitation programme for people with chronic joint pain.

The programme integrates education, self-management and coping strategies with a personalised exercise regimen for each participant. It has been shown to reduce pain, improve physical function, improve quality of life and mental wellbeing, reduce healthcare utilisation, and is more cost-effective than usual care. And the flexibility of ESCAPE-pain means it can be delivered in a variety of locations and by a range of professionals.

Developed by Professor Mike Hurley, who is a member of the Chartered Society of Physiotherapy, ESCAPE-pain is hosted by the Health Innovation Network and supported by NHS England. q

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What is post-traumatic arthritis?

By Mr NIKHIL SHAH, consultant trauma and orthopaedic surgeon, North West Pelvic and Acetabular Fracture Service at Wrightington Hospital.

[

THERE ARE MANY TYPES of fractures and injuries that directly or indirectly cause damage to the joint, including fractures around the hip, knee or ankle joint in the lower limb, and the shoulder, elbow and wrist in the upper limb. These fractures may directly involve the joint (intra-articular fractures) or occur away from the joint (peri-articular) and affect it indirectly.

When the articular cartilage is damaged, either at the time of the injury itself or over a period of time after the fracture, it undergoes progressive degeneration. Articular cartilage does not have the property of self-healing and its condition deteriorates with time. This condition is commonly referred to as post-traumatic arthritis (PTOA).

The goals of treatment of such articular fractures is to try and reduce the fracture fragments accurately by aligning the various pieces in such a way as to avoid any irregularity or steps in the articular surface and restoring its smoothness as best as possible, holding the reduced fracture in a stable fashion with internal or external fixation using plates, screws, frames or other techniques, and encouraging early active movement of the joint to restore function.

Despite a lot of research into cartilage healing and regenerative techniques over the last two to three decades, there is no viable or reliable technique to prevent post-traumatic arthritis once the cartilage has been irreversibly damaged. The aetiology is thought to be multifactorial with mechanical, biological and structural factors playing a role in its causation. There are complex biochemical pathways consisting of the release of various inflammatory chemicals (cytokines) that cause injury to the cartilage. PTOA is also thought to occur if a long bone

fracture heals with significant biomechanical malalignment causing abnormal loading of a portion of the joint.

PTOA more commonly affects patients at a younger age than primary constitutional arthritis. These patients are generally healthier and more active, making it more challenging to treat post-traumatic arthritis. This form of arthritis can vary from a mild condition to a debilitating problem and some joint injuries are more forgiving than others. In addition to causing pain and reduced function this condition also causes a decrease in the quality of life and leads to a significant burden on the health care system.

Fractures of the acetabulum affect the socket of the hip joint and some of these fractures lead to post-traumatic arthritis.

This may happen even with appropriate surgery. Some of the factors that lead to arthritis are related to the injury itself, such as damage to the cartilage of the acetabulum (referred to as marginal impaction), dislocation of the hip joint, or injury to the femoral head. Some factors are influenced by the treatment, including whether or not the fragments can be reduced accurately enough.

The knee joint is an important weight bearing joint and is injured commonly in young patients, especially Post-traumatic arthritis of the hip athletes. Injuries to the knee joint several years after a severe joint can affect not just the acetabulum fracture bony surface and articular cartilage, but also the cruciate ligament or the meniscal cartilage.

Over a period of time these problems can lead to cumulative and repetitive cartilage injury, usually because of instability, eventually leading to post-traumatic knee arthritis.

The usual presenting features of PTOA consist of progressively increasing pain in the affected joint and reduced function. However there is usually a lag period between the injury and the occurrence of the arthritis. There is also a lag period between the occurrence of the arthritis seen on X-rays or sophisticated imaging scans, and the onset of symptoms. This interval may vary from a few months to several years, if not decades.

In many cases the symptoms can be treated with simple non-surgical measures in the early stages. Once the arthritis becomes severe and causes significant symptoms that cannot be controlled by pain management, then surgical options are considered.

One of the traditional treatments for arthritis consisted of fusion of the joint (permanent stiffening) or arthrodesis. Although this option is still implemented in certain specific and uncommon situations for some joints, it does lead to permanent loss of movement and is therefore not popular amongst patients.

The usually recommended surgical treatment for most forms of end stage arthritis is some form of artificial joint replacement. However such artificial joints have a finite life span. The longevity of an artificial joint can be adversely affected by the young age of the patient and activity.

This makes treatment quite challenging in younger patients. Long term research efforts need to better understand the aetiological factors so that preventative strategies can be developed. q www.yourexpertwitness.co.uk

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Delays in breast reconstruction cause ‘great distress’ [

CANCER CARE CHARITY Breast Cancer Now has estimated that over 1,500 women had missed out on reconstructive surgery between March, when NHS breast reconstruction services were suspended, and September, when it revealed its findings.

Not all women with breast cancer choose to have reconstruction, but for those that do, having to live with one breast, no breasts or asymmetric breasts due to lengthy delays to surgery can cause great distress.

Through its Helpline and insight work, Breast Cancer Now said that patients affected by delays to reconstructive surgery were reporting significant emotional impacts, including damaged body confidence, anxiety and depression – at a time when face-to-face support from healthcare professionals and charities was not possible.

The backlog of breast reconstruction surgery due to the pandemic has added to already extensive waiting lists for delayed reconstruction – of up to two years in many hospitals. In some areas existing delays in accessing a specific type of reconstruction, using tissue from another part of the body, are expected to worsen even further.

Breast Cancer Now called on NHS bodies across the UK to ensure that patients get the surgery they need as soon as possible.

The charity also called for reassurances from the NHS that women waiting for delayed operations will not be forgotten or prevented from having surgery due to time restrictions, after a report in 2018 revealed some clinical commissioning groups in England were only funding reconstruction within a particular timeframe.

Nearly one in three cancers diagnosed in women in the UK are breast cancers, with around 55,000 women – and also 370 men – diagnosed each year. Under normal circumstances, guidance recommends that all breast cancer patients requiring a mastectomy should be offered breast reconstruction, with the option of either having it immediately or delaying it until a later date.

Baroness Delyth Morgan, chief executive of Breast Cancer Now, said: “Reconstructive surgery is an essential part of recovery after breast cancer for those who choose it. Women with breast cancer have told us these delays are causing them huge anxiety, low selfesteem and damaged body confidence, and all at a time when the COVID-19 pandemic has denied them access to face-to-face support from healthcare professionals and charities.

“We are pleased that breast reconstruction services are starting up again, but until operations are fully resumed the COVID-19 backlog will only continue to grow, worsening

already lengthy waiting lists.

“This is why we are calling on NHS bodies across the UK to ensure that all breast cancer patients get their reconstructive surgery as soon as possible, regardless of whether the delay has been through choice or cancelled surgeries. These women have already been through the challenge of breast cancer, exacerbated by not being able to access faceto-face support. We owe it to them to end their wait for reconstructive surgery that we know for so many is critical to their recovery.”

In June the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) set out plans for reconstruction services to be restarted.

BAPRAS president-elect Ruth Waters said: “Delays in access to reconstructive surgery for breast cancer patients are a major cause of concern. For those women who decide

to undergo breast reconstruction, this is an extremely important part of their cancer treatment which can have a significant impact on their mental wellbeing and quality of life.

“We have developed protocols and procedures to enable elective surgery to be performed safely, but most units that normally perform breast reconstruction report that they are restricted to activity at 20-50% of pre-COVID-19 levels. This means we remain unable to provide a full service for women having mastectomies now, and those who were already on a waiting list have little hope of being given a date in the near future.

“Sadly, the de-prioritisation of breast reconstruction is not a new issue. Even prior to COVID-19, women in the UK faced huge variation in access to these procedures, with inconsistent guidelines around timeframes and eligibility.” q

Surgeons’ body warns of a post-lockdown ‘Zoom boom’ [UNSCRUPULOUS COSMETIC SURGERY providers are cashing in on a post-pandemic

‘Zoom boom’ by coercing vulnerable patients into ‘panic buying’ procedures as a post-lockdown quick fix, the British Association of Aesthetic Plastic Surgeons (BAAPS) has warned.

BAAPS is warning the public not to fall prey to unethical marketing tactics and has highlighted the dangers of virtual cosmetic surgery consultations.

The association, which reported seeing a ‘massive upswing’ (100%) in demand for virtual consultations during lockdown, issued the statement highlighting its concerns following its first Virtual Annual Conference, where it launched a new set of ‘Triple Lock Guidelines’ to help safeguard patients in these challenging times.

While 83% of BAAPS surgeons said they think virtual consultations are a valuable first step in the process, particularly in the current climate, the association has been extremely concerned to find that some cosmetic surgery clinics are not following safety guidelines.

In a survey of 20 non-BAAPS cosmetic surgery clinics, 75% did not insist on a face-to-face consultation with an adequate cooling off period of at least 14 days, and 85% did not insist on a cooling off period at all, despite it being a mandatory requirement of good medical practice by the GMC. Concerningly, some clinics even advocated no face-to-face contact with a surgeon before surgery.

Safety and ethical practice are always BAAPS’s number one priority and the association believes that safeguarding patients should be a number one priority for all medical professionals.

"There is no such thing as virtual aftercare in the event that intervention is needed”, said new BAAPS president Mary O’Brien. “It’s very important, when a patient chooses a surgeon, that the hospital is accessible so that high-quality postoperative care can be provided. BAAPS has warned against cosmetic surgery tourism for this very reason. The danger of virtual consultations is that the patient may not realise that travelling a long distance for a surgical procedure in the UK can compromise aftercare.”

The new BAAPS Triple Lock Guidelines are: • A face-to-face consultation involving a thorough clinical and psychological evaluation is • essential before you have surgery. Virtual consultations should only be used as an introduction.

• Time for reflection, or what is known as a cooling off period, is essential for a minimum of • 14 days.

• Aftercare – ensure you have made appropriate provision to access your aftercare. q

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How do you assess scarring in a plastic surgery medicolegal claim?

By Mr PUNDRIQUE SHARMA Consultant Plastic Surgeon at Medicolegal Partners Limited

[SCARRING IS AN entirely normal physiological process

evolved over millions of years to heal wounds. It is an inevitable consequence of injuries, whether they be deliberate and necessary – following an operation, for example – or unintended, such as following an accident.

But what actually is a scar? A scar is a wound that has healed in a way that is non-identical to the neighbouring tissue – that is to say it is identifiably different from the tissue it’s replacing and next to it, and it is that difference that makes it apparent. A scar can technically refer to any tissue that has healed ‘imperfectly’, from heart muscle to tendons – and even, on a metaphorical level, to psychological wounds. In general though, when we talk about scars, particularly in plastic surgery, we mean skin scars.

This definition of a scar, then, itself raises two questions: why is the healed skin different from the neighbouring tissue and what is the practical result of those differences? To answer those questions it is important to understand the actual components of the skin.

The skin is composed of two layers – the epidermis on the outside and the underlying dermis on which it sits. The epidermis is very thin and is primarily made of epithelial cells that multiply very rapidly.

It forms a waterproof barrier to the outside world, protects from infection and also protects from ultraviolet light – largely thanks to the melanin in it that comes from special cells called melanocytes and gives the colour to the skin. It is extremely thin and relatively flimsy, so much so that if one were to lift it off the dermis it would be almost see-through.

The dermis is much thicker and tougher (animal dermis is the main component of leather) and is mainly composed of a strong fibrous protein called collagen and an elastic one called elastin. It also contains hair follicles and nerve cells so you can feel, sweat glands, a large blood supply – allowing body temperature to be regulated – and sebaceous glands, which keep the skin moist.

When an injury occurs the epidermis basically heals perfectly, but the dermis heals imperfectly. It contains a different, weaker collagen and less elastin, so is more prone to stretching.

There are changes in the nerve cells, so it could be less or more sensitive, initially more blood vessels (so redder) and later fewer (so paler), and no hair follicles, sweat glands or sebaceous glands. It is those differences within the dermis that are primarily responsible for the ‘scar’.

Collagen forms the basis of scar tissue. At first it is laid down in a disorganised way within a highly vascular environment. Over time most of the collagen is reabsorbed and the remainder is remodelled. At the same time the vascularity of the site reduces.

Thus, all scars start the healing process with a red and raised appearance, but over the course of about 6-12 months that changes to leave a pale, flat scar.

Every wound will heal with a scar, but it is the surgeon’s aim to leave the patient with a mark that is as fine as possible. A surgeon can do this in several ways – for example by planning to place the scar in a less visible place, aligning it so there is less tension across it, using careful tissue handling, using the appropriate stitches, being mindful to reduce the risk of infection and giving advice as needed.

However, in some cases the scar becomes a problem, and depending on its location that can have psychological effects on the patient. Furthermore, there can also be functional problems with a scar, for example a contracture of a scar that crosses a

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joint or a natural crease can restrict the range of normal movement or distort appearance. In extreme cases, where the parts of the joint are drawn into abnormal positions, it can even lead to musculoskeletal issues such as dislocation or growth restriction. Complications regarding scarring are extremely common in medicolegal cases involving plastic surgery and it has been estimated that nearly three quarters of all cases require an expert opinion on the issue.

There are basically four groups of ‘poor scarring’ that we think of: • Atrophic scars, where the scar is very thin (sometimes so thin that it actually ends up breaking down into a wound or ‘ulcerates’ with slight trauma) and prone to stretching.

• Stretch marks (striae distensae), where the skin has been rapidly stretched and thinned almost like a rubber band that has been stretched beyond its elastic limit.

• Hypertrophic scars may occur following healing under significant tension or some post-injury/post-operative issue such as delayed wound healing or infection. The scar is raised and often red and itchy. While they may settle, they do not always do so.

• Keloid scars share some similarities with hypertrophic scars, but are usually much more lumpy, spread beyond the boundaries of the original scar and can in fact keep on growing unchecked.

In theory they can be classified as ‘tumours’, though they are not cancers. They do not pose a danger to life or limb and do not spread. They are much more common in darker skinned people.

The final appearance of a scar is dependent on many factors.

The surgical factors have already been mentioned, but some other factors – such as age, ethnicity and hereditary disposition – are related to the patient and cannot be controlled by the surgeon.

Even so, a history of keloid or hypertrophic scar formation should be a signal that the patient will require close follow-up and possible early intervention, should any complications occur.

The best time to influence the eventual appearance of a scar is at the time of initial wound repair. That is partly because, once a scar has matured, the options for improving its appearance are limited. That is particularly true for hypertrophic and keloid scars, where excision may actually result in an even larger and more unattractive scar. The application of steroids, either through intralesional injection or applied as a topical cream, can improve itching and hyperpigmentation.

Topical pressure, through the use of elasticated garments, speeds the maturation of collagen and flattens the scar; but while this treatment generally has few complications, there have been reports that in children, use of the garments on the thorax may interfere with the growth of the spine and result in scoliosis. Recent advances in laser technology may also offer new treatments for scar correction.

However, for many scars the best treatment is simply to wait: facial scars in particular often improve so much spontaneously that after 12 months there is no need for surgical revision.

The assessment of scarring for medicolegal purposes can be difficult and can be broken down into three aspects: the descriptive appearance of the scar, the functional result of the scar and the psychological effect of the scar.

The appearance and nature of the scar can be described relatively objectively in various ways, such as by using the Vancouver Scar Scale, as can the functional effects of a scar.

However, assessing the psychological impact is much more challenging and sometimes counterintuitive: a study at the

University of Liverpool in 2008 showed that some facial scars can make men more attractive to the opposite sex rather than less.

Aesthetic damage often does not entail an economic loss to the patient, but disfigurement can be psychologically traumatic.

Compensation in those cases is based purely on the subjective opinion of a medical expert and thus is not an exact science.

Although there are various tools available to assess the visual characteristics of scars, they cannot measure subjective factors such as pain and itching, and those factors often have the greatest impact on a patient’s quality of life.

While the public perception tends to be that plastic surgeons can produce invisible scars, that is not actually the case. Every wound will heal with a scar: the aim is to make it as small as possible. While many factors that influence scar healing and formation are outside the control of the surgeon, good planning and technique will help to minimise the chances of an adverse outcome. Furthermore, open communication with the patient should lead to realistic expectations of what can be achieved and what complications might occur. q • Mr Pundrique Sharma BSc MBBS FRCS (Plast) PhD is a consultant plastic surgeon. He accepts instruction as an expert witness in adult and paediatric cases involving general plastic surgery, reconstruction and burns surgery. He has a special interest in limb reconstruction and nerve injuries, including those following trauma and obstetrical brachial plexus injury.

He has also set up a hand fracture clinic at Alder Hey Children’s Hospital, particularly dealing with finger and thumb fractures, as well as metacarpals, and has published papers on the subject.

Mr Sharma can also act as an expert in cases involving cosmetic surgery across a variety of aesthetic procedures, including breast surgery and body contouring such as abdominoplasty and liposuction.

For more information visit www.medicolegal-partners.com/sharma.

BAAPS elects first woman president [MARY O’BRIEN has been named the first-ever female president of

the British Association of Aesthetic Plastic Surgeons (BAAPS), marking a new chapter for the respected, but previously male dominated, organisation. Despite the fact that 90-92% of people having cosmetic surgery in the last 15 years have been women, BAAPS has always been led by men, a trend reflected across all surgical specialties.

Figures from the Royal College of Surgeons show that, between 1991 and 2020, the number of consultants who are female has risen from 3% to 13.2%. Women are now represented in all 10 surgical specialties and at all levels within a surgical career. Plastic surgery has the second highest female representation of approximately 21% – the first being paediatrics.

Commenting on her new role, Miss O’Brien said: “I remain in full-time NHS reconstructive plastic and hand surgery practice, while spending some of my time working with a fantastically motivated group of plastic surgeons elected by the association membership who form the council.”

Leading BAAPS is an exciting new challenge for Miss O’Brien, who as the figurehead of the association will continue to spearhead its mission to promote safety and tighter regulation within the sector. One of her main concerns is the ‘trivialisation’ and ‘glamorisation’ of both surgical and non-surgical aesthetic procedures.

She says: “Cosmetic tourism, unscrupulous advertising and marketing, irresponsible agencies that sell surgery targeting vulnerable groups, and the promotion of unrealistic expectations all concern me.

We live in a society that increasingly connects via a virtual world, and Instagram posts don’t always represent reality!” q

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

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

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

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

RCOG echoes MP’s call for action on endometriosis [

THE Royal College of Obstetricians and Gynaecologists (RCOG) has issued a response to the findings of the All-Party Political Group (APPG) of its inquiry into endometriosis. The inquiry surveyed over 10,000 people with endometriosis, interviewed healthcare practitioners and those with the condition about their experiences.

The Executive Summary of the report states: “The APPG on Endometriosis found that those with endometriosis are waiting an average of eight years for a diagnosis, despite over 58% visiting their GP ten or more times with symptoms, 53% visiting A&E

with symptoms, and 21% seeing doctors in hospital ten or more times with symptoms.”

The APPG has called on all governments in the UK to commit to a series of support measures for those with endometriosis, including a commitment to reduce average diagnosis times to four years or less by 2025, and a year or less by 2030.

Dr Edward Morris, president of the Royal College of Obstetricians and Gynaecologists, said: “This report is vital in understanding how women living with endometriosis in the UK continue to be let down when it comes to their diagnosis, treatment and the support they

receive to manage their condition.

“While endometriosis costs the UK economy billions of pounds per year in treatment, loss of work and healthcare costs, the impact on women's wellbeing and mental health is much greater.

“The long diagnosis times and poor patient experience could be attributed to the significant gap in data when it comes to women and girls. What the RCOG would like to see is medical research in this area prioritised to ensure they get the advice and treatment that's right for them so they can lead happy and healthy lives.” q

Woman left with perineal tear wins compensation claim [A WOMAN who was left with a fourth degree perineal tear following

childbirth has settled her medical negligence case for more than £600,000.

The woman – referred to by lawyers as ‘Margaret’, although it is not her real name – suffered further problems when the tear was not promptly diagnosed and more difficulties resulted.

Margaret was admitted to hospital in 2015 for an induction of labour when she reached her due date. It was decided that a ventouse cup should be used to deliver the baby, but that didn’t work and forceps were used.

The baby was delivered without an episiotomy being carried out and what was thought to be a second degree tear was repaired in the delivery room.

A few days after she was discharged, Margaret started to experience leakage of faeces through her perineum. It was only on her second return to hospital that the fourth degree tear was recognised. She underwent a series of different repair operations before a fistula was diagnosed and Margaret then had to undergo yet another repair operation.

She is left with symptoms including incontinence of flatus and occasionally faeces, urgency, difficulties with toileting and sexual dysfunction. She has also suffered a psychiatric injury requiring treatment.

Medical negligence solicitor Kelly Lawford of Leigh Day secured a settlement of over £600,000 for Margaret after arguing that an episiotomy should have been carried out and that the obstetrician

delivering the baby should have controlled the delivery of the baby’s head so as to prevent the tear.

While the NHS Trust accepted that the extent of the tear should have been diagnosed and repaired, it denied that the tear itself was the result of inadequate care. q

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Cardiac rehab participation falls during the pandemic [

THE NUMBER OF PEOPLE who have been taking part in cardiac rehabilitation in the UK fell by around a third as the COVID-19 pandemic first hit.

According to the British Heart Foundation’s National Audit of Cardiac Rehabilitation 2020, there were 52,625 people taking part in the programme – which normally takes place in a group setting – from August 2019 to January 2020. However, as the pandemic took hold the figure dropped dramatically to 35,500 during the following six months, from February to July 2020.

There are a number of reasons for the drop in participation. The pandemic resulted in fewer people attending hospital with heart attacks and thousands of surgeries being postponed. A reduction in referrals to rehabilitation services, coupled with social distancing measures and the redeployment of healthcare professionals, may have also contributed to this decrease.

Worsened inequalities

People of Asian and Asian British backgrounds experienced the largest drop in participation during that timeframe, falling 45% overall.

Similarly, people of Black, African, Caribbean and Black British backgrounds experienced an overall 44% drop in participation.

While emerging evidence suggests that people of White British background have had higher cardiac rehabilitation participation rates during the COVID-19 pandemic, the report also found that the on-going health crisis has worsened inequalities for already underserved people.

The reasons for that are complex, says the BHF. It could be due partially to availability and accessibility of cardiac rehab, and also to the healthcare services that refer it. Cultural and societal barriers may also play a part – although more data will indicate whether that is a longterm concern.

Sally Hughes, head of health services engagement at the BHF, said: “It is extremely concerning to see such a sharp fall in the number of people participating in cardiac rehabilitation. The COVID-19 pandemic has created staff shortages and restrictions on health services, as well as highlighting how urgent innovation is.

“As a result, a lot of programmes have had to adapt their services by offering alternative assistance through virtual and online classes and support. In response the BHF has fast-tracked the development of new online information and support resources, cardiac rehabilitation at home, on exercising safely, healthy eating and medicines to support this.

“Someone’s need for aftercare after something as life-changing as a heart attack does not go away because we are in a global pandemic. As we build back NHS services, we should continue to reimagine rehabilitation services, making them more appealing and effective for people.”

Vital part of recovery

Cardiac rehabilitation is a vital part of the recovery process following a cardiac event, which helps people get back to as full a life as possible following a heart event such as a heart attack or bypass surgery. It can also support people who have other cardiac conditions.

Research has shown that cardiac rehabilitation reduces the risk of premature death by a quarter and lowers hospital admissions by around a fifth, as well as reducing the chances of experiencing further serious heart-related illnesses.

To innovate and help support people doing cardiac rehabilitation while at home, the BHF has recently moved all its resources online. That means that people who have been advised to join a cardiac rehab programme can take part in one without leaving their house.

While that helps make cardiac rehab more accessible, it is important to remember that it is not the equivalent to a health professional or clinician-led rehab programme. q

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Pelvic vein 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

[

TECHNOLOGY FOR TREATING problems with the arteries and veins of the body has seen massive advances in the last 20 years. Minimally invasive methods have been developed for treating blocked arteries by endovascular methods, conducted though catheters threaded along the arteries from a needle puncture in a vessel some distance from the problem point. Arteries can be reopened with the help of ‘stents’ – metal supports to keep vessels open.

In the venous system, varicose veins are widely treated with endovenous techniques using a long catheter threaded along the length of the troublesome vein.

No longer are incisions required to treat varicose veins which are completely reabsorbed following successful treatment.

Pelvic veins

foam commonly used to inject varicose veins in the legs are also used.

The clinical data which supports the use of this treatment is somewhat limited. A number of clinical series have been published which report greatly improved symptoms following pelvic vein embolisation. However, no randomised clinical trial has confirmed the impression from the case series. Despite this, pelvic vein embolisation has become fairly widely used in the management of pelvic congestion syndrome and is considered acceptable practice amongst vascular surgeons.

Adverse events after minimally invasive treatment

The route taken by the catheters employed to embolise the pelvic veins is via the neck veins. This has the potential for damage to veins or other vessels along the route of the catheter on its way to the pelvis, but such complications are rare. The coils used to block the pelvic veins should remain in the pelvis once delivered to their intended location, but that is not always the case.

Some coils have been shown to migrate locally, potentially causing damage to nearby structures in the pelvis. Others have been known to travel via the veins to reach the right side of the heart and the lungs. Some coils may be retrieved by interventional radiologists although no long-term harm appears to arise from the misplaced coils. However, the migration of the pelvic coils causes considerable alarm and anxiety in some patients.

In the light of these significant adverse events, patients should receive detailed information concerning the possible risks of treatment as well the likely benefits in accordance with the recently published advice from the General Medical Council on the subject of consent.

A complication of embolisation of pelvic veins. The embolisation coil has travelled to the lung

A problem which has now fallen into the field of expertise of vascular surgeons is the treatment of pelvic varicose veins. These veins lie deep in the pelvis and may give rise to pelvic pain. This subject usually lies in the field of practice of a gynaecologist since there are many causes of pelvic pain and it takes the expertise of a gynaecologist to investigate and identify the precise problem in each case. Pelvic varicose veins are a common finding in female patients who have delivered a child but mostly give rise to few symptoms.

However, in a limited number patients, ‘pelvic congestion syndrome’ is associated with the pelvic varicose veins. These veins can be seen on ultrasound imaging of the pelvis. Symptoms of this condition include dull, aching or ‘dragging’ pain in the pelvis or lower back, particularly on standing and worse around the time of the menstrual period.

Many treatments have been tried for this condition. One of the earliest treatments was open surgical ligation of the ovarian veins which appear to ‘feed’ the pelvic varicose Pelvic veins and leg varicose veins. Since the veins development of modern The pelvic varices may communicate endovascular treatment, with varicose veins in the leg. This has ‘embolisation’ of the led some surgeons and radiologists veins has been done. to undertake pelvic vein embolisation In this treatment a in order to treat varicose veins in the needle is inserted into legs. In cases where pelvic congestion a vein in the neck of syndrome is present, this the patient and passed is probably acceptable though the heart to management. However, reach the inferior vena it is often the case that cava in the abdomen pelvic varices lead to no and then the pelvic symptoms but varicose veins. The troublesome veins are present in the veins are blocked-off legs. Some surgeons by depositing platinum have concluded that coils inside the varices treatment of pelvic veins which leads to the veins is required for successful becoming permanently management of leg Varicose veins in the legs arising from varicose veins in the pelvis (left) and X-ray of pelvic varicose veins joining to leg varicose veins (right) occluded. Sclerosant varices.

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In general, the literature on the treatment of varicose veins shows that treatments conducted entirely within the legs is effective for such veins.

Modern vein treatments lead to satisfactory resolution of varicose veins and considerable improvement in leg symptoms. The role of pelvic vein embolisation in the treatment of leg varicose veins remains unclear.

Several differing opinions appear in the medical literature but no clinical trial has been done to establish the role of pelvic vein embolisation in this context. My own informal survey of the views of European and American vein specialists indicates that most prefer to treat the leg varices by minimally invasive treatments (heating the veins and/or sclerotherapy with foamed sclerosants) as the first line of treatment. Where this fails some would consider pelvic vein embolisation.

Pelvic vein embolisation carries a number of potentially severe complications and its use in a non-life threatening condition, such as varicose veins in the legs, bears careful consideration with the patient during the consent process in order to comply with the General Medical Council guidelines on consent. In my view, failure to inform patients of the differing views of specialists in this field may comprise substandard care. Adverse events arising from pelvic embolisation in the treatment of varicose veins of the leg may be considered to be substandard care since less invasive methods with established efficacy are available.

Conclusions

Pelvic vein embolisation is a useful treatment in some patients in order to address pelvic congestion syndrome. Evidence for use of the treatment comes from limited clinical series and no randomised clinical trial is available to demonstrate efficacy of this treatment. Significant complications may arise from this treatment and patients should receive full information concerning these prior to undergoing treatment.

The use of pelvic vein embolisation in the management of varicose veins in the leg is not supported by any clinical series or trial. Most vascular specialists would prefer treatments with established efficacy for the management of varicose veins in the leg. q

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Online lesson in consent offers protection to junior doctors [A NEW E-LEARNING MODULE on consent has gone live as part

of the British Association of Oral and Maxillofacial Surgeons and Health Education England e-Learning for Healthcare (HEE e-LfH) e-FACE project.

The 12th module in the programme is designed to tackle the limited consent knowledge many young trainees have.

The sessions have been developed to demonstrate best practice, and are aimed at dental core trainees (DCTs) and specialty registrars in oral and maxillofacial surgery (OMFS).

Loz Newman, the consultant maxillofacial/head and neck surgeon who conceived the module, said that consent is always important to surgeons, increasingly so in light of the 2015 Montgomery v Lanarkshire Health Board case.

He explained that the module came about following a talk he gave at the Royal College of Surgeons of England.

“We were all concerned that young trainees are often sent to seek consent from patients inappropriately, for procedures where they have limited knowledge,” he said. “We felt that not infrequently they were ill prepared for the task. Consent is barely taught in the undergraduate curriculum and there is little in the post graduate curriculum.”

He said that the idea is to provide consent process training for DCTs that offers them some form of protection, with a certificate awarded once the module is complete.

“This shows that they had had some formal training in consent that relates to specific surgical interventions in addition to aiding their learning.

“We thought it would be sensible to write clinical scenarios that would be more relevant and easier to digest than the more dry,

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legalese textbook approach to consent.”

The new e-FACE module includes: • An introduction to consent that discusses the key principles of the • consent process • A series of short clinical scenarios that focus on commonly • performed procedures.

It is the third phase in the development of bespoke e-FACE sessions.

The modules are a blend of curated sessions from existing HEE e-LfH programmes and new bespoke sessions. e-FACE clinical project lead Jason Green – a consultant oral and maxillofacial surgeon – commented: “It is really exciting to see new modules go live that will facilitate DCT induction. It has been especially pleasing to see how this collaborative approach has delivered e-learning content perfectly pitched at a level for new starters in OMFS and other healthcare professionals.” q

BAOMS welcomes MP’s Botox bill

[

THE British Association of Oral and Maxillofacial Surgeons (BAOMS) has welcomed the Private Members bill that would make it illegal to give Botox or dermal fillers to anyone under 18 for cosmetic purposes. The Botulinum Toxin and Cosmetic Fillers (Children) Bill 2019-21, brought by Laura Trott MP, went through Committee Stage in the House of Commons in November.

Caroline Mills, BAOMS lead on facial aesthetic/cosmetic surgery and consultant maxillofacial surgeon at Great Ormond Street Hospital, said: “BAOMS is pleased that Health Minister Edward Argar has given his backing to this bill, and for his department’s commitment to explore increased oversight of aesthetic practitioners.

We want this to be the first step towards wider regulation across the industry to protect anyone in the UK undertaking non-surgical cosmetic procedures.”

She explained that the possible complications from Botox or dermal filler injections are significant and can cause blindness, severe allergic reactions, chronic on-going infection and deformity: “These procedures can have significant life changing side-effects and require the competency to administer emergency medical treatment. It’s recognising and managing these problems that is so important, and where patient safety may be compromised.” q

Dentists’ leaders call for PPE assurances from government [THE BRITISH DENTAL ASSOCIATION (BDA) has welcomed

the National Audit Office’s latest report on procurement during the COVID pandemic and called for real clarity on the long-term supply and distribution of personal protective equipment (PPE).

The NAO found that, in the period up to 31 July, over 8,600 contracts related to government’s response to the pandemic were awarded, with a value of £18bn. While ministers placed a stated emphasis on speed, deliverability and technical compliance, the watchdog noted widespread concerns over transparency and lack of appropriate safeguards.

PPE availability was the number one brake on capacity for practices in England when they resumed face-to-face care in June and is still cited by more than a third (35%) of practices UK-wide as having a high impact on their ability to increase patient access.

Dentists alerted the authorities to chronic shortages in early February, when many practices were set to ‘down drills’ as primary supply routes from China faced significant disruption. The NAO report suggests a surge in procurement in response to COVID did not begin until March.

Lack of PPE appears to have been a decisive factor in the move to a limited urgent care service during lockdown, which reduced patient

numbers by nearly 98% by May. At the time there were even reports of centres using scuba gear in the absence of necessary masks.

Industry sources have estimated that the cost for an aerosolgenerating activity – routine care involving the use of high-speed instruments – increased from £1.13 pre-COVID to £11.83 post-COVID: a more than 10-fold increase. While NHS practices have been granted access to the government’s NHS portal, private practices – which represent the majority of spending on dental care in the UK – do not, and have faced further hikes in costs since VAT was restored to PPE at the end of last month.

BDA chair Eddie Crouch said: “Every health professional requires assurances that processes are now in place to ensure low-cost, highquality kit makes it to the front line.

“PPE shortages have dogged dental services since the outset of the pandemic. The huge backlog we face is a testament to a failure to plan and procure equipment needed to protect patients and staff.

“Issues were identified with supplies in early February, but the message from government was keep calm and carry on. We are still living with the consequences.” q

TMJ surgery: the developments are exciting

By Mr ROBERT HENSHER, consultant maxillofacial surgeon

[

THE INCIDENCE OF DISORDERS of the temporomandibular joint (TMJ) in the UK is estimated to be between 5% and 15%. Most authorities agree that their management should begin with conservative measures and that surgery as an initial treatment – excluding direct traumatic damage and severe anatomical disruption as the presenting problem – is possible but very rare. Surgery is indicated when the noninvasive treatment fails and imaging reveals abnormal anatomy.

The advent of MRI scanning and expert radiological help has made diagnosis easier and replaced earlier techniques such as arthrography – making them of historical interest only.

Reflecting the cascade of management, much surgical treatment is minimal and blends with diagnostics. Arthrocentesis (washout) and arthroscopy are two examples. The latter also permits minor surgery, for instance debridement and even repair by virtue of miniaturised instrumentation. That, however, can have limited success and is highly operator sensitive.

Operations on the joint – arthroplasty, disc repair and repositioning, or discectomy (with and without autografting, including local flaps) – are true open operations, the aim of which is broadly to restore anatomy if possible, improve function and reduce pain.

When the joint is irreparably damaged, either by perhaps hereditary disease, trauma (including failed surgery) or arthritic

disease, then autograft total joint replacement may be considered. That is not a new idea: since the 1920s use was made of costochondral (rib) grafting. It is mostly an option in children, where the cartilaginous tip of the transplanted rib might produce a growth centre. On occasion it may dissolve, overgrow, become arthritic (like the excised joint) or fuse with the skull base. Autografts can also include other joints (sternoclavicular, toes) or microvascular grafts (fibular).

Alloplasts, or mechanical devices, are a further option and have arisen parallel to general orthopaedic practice. They also are not new.

In the early 20th century mandibular reconstruction after removal for malignancy sometimes used primitive metal ‘joints’ as part of the plating device retaining bone grafts.

Specific alloplasts began development in the USA in the 1960s. Since then several types have emerged, mainly American but also from other countries. First as off-the-shelf models, it is now generally accepted that bespoke joints are preferred, allowing shorter surgical time, offering ease of positioning and conferring ability to correct jaw positions.

They also take account of the high tolerance demanded by the dental occlusion (bite).

Not surprisingly, the necessary expertise and back-up means dedicated surgeons, anaesthetists, radiologists and physiotherapists in designated units due to the relatively low referral rate. Nonetheless, in the right patient, in the right place – in every sense – these devices are currently the gold standard, with data emerging of functional ‘lifetimes’ of 15 to 20 years.

All TMJ surgery has complications. Specific to it include facial palsy, sensory impairment and facial scarring. It is not easy to perform and best restricted to those who frequently undertake it.

The development of TMJ prostheses has been long – and sometimes colourful – but the future is more exciting. There are now advancing tissue engineering techniques, particularly from the USA and Japan, which may make TMJ tissues and even total joint growth possible.

The American physician Alfred Stille wrote: “Medicine, like all knowledge, has a past, a present and a future and in that past is the indispensable soil out of which improvement must grow.”

We may, for example, reflect on how our erstwhile surgical treatment of TB was replaced by medical prescription. Perhaps the TMJ surgeon of the future will take a similar backward glance: I hope so. q

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Forewarned is forearmed: how the virus affects dentistry A personal perspective on COVID-9 from an expert witness and specialist in restorative dentistry.

By TOBY TALBOT BDS MSD (Washington) FDS RCS

[

WE BEGAN TO HEAR of the coronavirus pandemic in Wuhan Province in China in early January 2020.

Rather than wait for formal advice from our authorities, I contacted a colleague working in Hong Kong, who was well acquainted with the effects of the SARS outbreak in 2003, a variant of coronavirus. A similar pandemic of MERS that had followed in the Middle East in 2012 led me to contact colleagues in the Emirates. They kindly passed on the protocols that were adopted by them at that time for me to implement immediately in my own clinic.

A year’s supply of personal protective equipment was ordered, which remained in plentiful supply at that time.

This is a letter that was sent to all our patients: Due to the pandemic of COVID-19, our lives have changed. This has particularly affected our protocols when seeing our patients. To minimise the potential transmission of the coronavirus we have adopted the following protocols that now become a long-term feature in how we operate.

When a patient contacts us to arrange an appointment we will ask a number of questions that can be responded to by email or phone before your attendance.

1: What is the problem? When did it start? If you have pain, what score would you give it out of 10 – 0 is no pain, 10 is agony.

2: Do you have any medical history, including the names of any medication.

3: The name of your dentist if this is your first visit to our clinic. When was your last dental visit? Was it for treatment or a general review?

4: Whether you may have had or have symptoms of COVID-19, including a temperature, headache, cold symptoms, a dry cough, loss of smell or general fatigue. If so, when did symptoms start? When did symptoms end?

It is to be noted that we will make every effort to delay a visit to our clinic for four weeks after any symptoms have occurred.

5: If you have had a diagnostic test, whether for the antigen or antibody, what were the results? When was the test carried out?

6: Have you come into contact with anyone who was subsequently unwell with the above symptoms or have been diagnosed with the disease? When?

To prepare yourself for your visit to us, we politely request that you wear a mask or face covering. Kindly remain in your car upon arrival. We will come to you with a medical history form to be completed and a review of your symptoms. We will take your temperature. We kindly request that all accompanying persons wait in the car and do not enter the clinic. There will be no waiting area provision within the clinic during this time. If you require a parent or guardian to accompany you, then we will discuss the protocol with you and them.

When you are escorted into the clinic you will place overshoes over your own shoes before entering the clinic and use the hand sanitiser before entry.

You will be escorted directly to the prepared surgery. You are respectfully asked not to touch anything upon entry.

Appointments are scheduled with a 30-minute gap before and after your appointed time so that you will not make any close contact with another patient to reduce risks of transmission.

The surgeries have filtered laminar air flow that changes in the room up to 20 times each hour. The surgeries are disinfected before and after your visit.

We will be wearing personal protective equipment (PPE) that may seem a trifle distressing, for which we apologise but it is for all of our protection.

Gowns, masks and face shields with gloves will feel understandably distancing but essential. Your safety and comfort is our priority.

We had the required scientific information when a formal review of the subject of SARS in 2015 and MERS in 2016 was considered by academics, with their conclusions readily available. In summation, the pandemic indicated quarantining patients affected, isolation of ‘at risk groups’ such as the elderly and those with underlying medical conditions, and amassing a stockpile of PPE for healthcare workers. It also advised the universal

‘

’

wearing of face masks for everyone.

It also concluded that to curtail travelling, especially on public transport systems including trains and air, was advised. Mass meetings of people were cancelled. Subsequent studies have shown that PPE stocks can be kept for over 10 years without deterioration.

Acquiring a stock of diagnostics for testing large population groups was indicated, to measure the incidence of the disease and to identify ‘hot spots’.

I have just recently taken a business trip to Jersey in the Channel Islands.

We were proactively encouraged to have antigen PCR tests 72 hours before entry; if you failed to do so, a PCR antigen test was carried out upon landing.

You would then be effectively ‘confined to barracks’ for 12 hours until the results were texted to your phone.

The entire population were wearing face masks and it was ‘business as usual’ in the shops, bars and restaurants. Before the reader announces how much easier for it is for an island to comply with this protocol – for those who may have forgotten, we are an island.

Politics aside. How do I see the pandemic affecting the expert witness in dentistry?

Dentistry involves drilling teeth with high speed tools that create an aerosol effect. In other words, when we drill teeth the air expelled from the mouth disseminates all the micro-organisms throughout the surgery thus ’spreading’ whatever bacteria and viruses are present throughout the premises. If a patient has had coronavirus, even if blood tests indicate negative with the antigen, the saliva continues to be positive with antigens for four weeks after their recovery.

To contain that effect, high volume changes of the air within a surgery need to be carried out, with filtered laminar air flow directed from ceiling height and out at floor level. That is routinely installed in all operating rooms in hospitals to create a sterile environment.

Advice given to dentists indicates testing themselves for antigens or antibodies for the virus. The former indicates you have the disease; the latter indicates you have had the disease with a possible element of immunity, although that has yet to be scientifically established. I have my staff and myself tested for the antigen on a regular basis.

Now I would like the reader to imagine the dentist attending 30 to 40 patients per day. Does the practice find itself in a green, amber or red zone?

What are the demographics of the attending patients? Different age groups in social groups 1 and 2 are more likely to comply with self-isolation and social distancing than social groups 4 and 5 or young adults who like to party at weekends. Or is the practice located in a metropolitan area with larger elements of social deprivation or multi-generational households? Many practices may have several dentists working in the same building.

How is social distancing going to be managed effectively when over 100 patients are coming through a door in a day? Imagine, if that practice is on the high street without its own car parking facilities, how do you control people entering and leaving the premises maintaining social distancing? Does the entrance provide adequate ‘distancing’ in the hallway or on the stairs?

Assuming that a fallow period is assigned between patients to allow for thorough disinfection of the surgeries and premises, how many patients can actually be seen in the day? Productivity is inevitably going to diminish. Will the business remain viable? Will the commercial pressures of maintaining the business lead to an element of compromise? Over time, will there become an element of ‘battle fatigue’, with a lapse of established protocols, or will the ‘new world order’ remain sustainable?

Will the entire national population just drift into a state of herd immunity for the immunological competent to become ‘the survival of the fittest’? I invite readers to express their thoughts.

And when will we hear of a patient claiming that a visit to a dentist has led them to acquire the virus? q www.yourexpertwitness.co.uk

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Cataract surgery report finds significantly better patient outcomes [THE Royal College of Ophthalmologists (RCOphth) has released

its annual report for the National Ophthalmology Database (NOD) Audit 2018-2019. Since its inception the NOD audit has been assuring high-quality cataract surgical services for patients. The annual report finds a 40% overall reduction in the posterior capsule rupture (PCR) complication rates and a continuing decline in the number of surgeries affected by loss of visual acuity since 2010.

With approximately 452,000 cataract operations undertaken in England and 20,000 in Wales in 2018-19, the NOD enables contributing cataract surgeons to compare their performance against that of their peers nationally, ensuring a continued improvement in surgical outcomes and learning. It is a vital safeguard of patient safety and a promoter of best practice, potentially eliminating unwarranted variation in the provision of cataract surgery and patient care.

The fourth prospective national annual report continues to indicate clearly that high quality surgery is being delivered to NHS patients.

In the 2018-19 reporting period, 1.14% of operations were affected

by PCR, compared to 1.91% in 2010-11. In the same period 0.51% of operations were affected by visual acuity loss, compared to 0.91% in 2010-11. Those reductions in PCR complications and visual acuity loss since 2010 equates to around 3,500 fewer complications annually across the NHS, representing a cost saving from avoided PCR complications alone of about £2m per annum.

The audit achieved 100% data completeness for PCR outcomes, currently a compulsory field in electronic patient records.

In order to ensure the improvements continue, the report also lists recommendations for patients, cataract surgery providers, commissioners and regulators, as well as providing a concrete set of next steps to ensure NOD’s remit expands, including further development of patient reported outcomes for cataract surgery to ensure that patient views of their vision are considered.

continued to develop the NOD as a world-leading audit. The findings once again highlight how the collection of data is so important to continuing to deliver high-quality surgery and reduce the burden of complications on patients and the NHS, improving both patient choice and outcomes significantly. The prospect of what a future age-related macular degeneration national audit will do for the medical retina subspecialty patients is very exciting.”

The Royal College of Ophthalmologists is working with the NHS, trusts, providers and industry to find sustainable ways to fund both audits. Continued data collection through audits like the National Ophthalmology Database Audit has a significant positive impact on patient care quality, human resources and NHS finances.

Based on the NOD findings, RCOphth estimates a financial saving of £2m for the NHS per year by avoiding complications and associated costs of postoperative visits and further treatment. q

Next steps

Next year the fifth prospective audit period will move to align with the NHS year – April to March. That will aid centres with the planning of services and align the national cataract audit to other reporting services that report on the NHS year.

Electronic data collection for cataract surgery is being implemented in Northern Ireland, whose members wish to participate as a region in future audit years.

The RCOphth NOD is committed to further developing the collection of the existing patient reported outcome measure for cataract surgery, with the aim of including it in the national cataract audit.

Initial steps have been taken towards establishing a national audit in wet age-related macular degeneration and it is anticipated that this will commence within the next two years.

Speaking on the report findings, RCOphth president Bernie Chang praised the findings, but called for greater participation in NOD by trusts and private providers to ensure continued improvements in cataract surgery and patient choice.

He stated: “Professor John Sparrow and the NOD team have www.yourexpertwitness.co.uk

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Blurred film highlights nation’s sight issues

[

THE FIRST EVER completely blurred film, Focus on Life, has been produced to promote a campaign by the College of Optometrists to highlight the issue of Britons’ worsening eyesight and its impact on our lives.

The college has teamed up with BAFTA award-nominated director Mark Nunneley from the Ridley Scott Creative Group to direct a film that people can’t actually see – because it has been shot entirely out of focus.

According to new research two-thirds (66%) of British adults admit to experiencing blurred vision and over a third (35%) believe their vision has markedly deteriorated in the past two years.

The research also reveals that 18% of Britons admit to struggling with everyday tasks due to their eyesight. Of those that have had an eye test, one in five admit their eyesight test results were worse than they expected. It also shows that, worryingly, over one in ten UK adults would rather sit closer to the TV than get their eyes tested.

Similarly, 17% would rather make the text bigger on their phone when reading messages than get an eye test. One in 10 of those that have never had a sight test admit they believe their eyes are fine and 6% confess to being too lazy to book one.

The five-minute film captures idiosyncratic life memories from the perspective of those who struggle with blurred vision. It features little things that those with good eyesight may take for granted, from a walk along a beach to fishing from a boat.

Film-maker Mark Nunneley commented: “Lockdown gave me the

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opportunity to reflect on how to approach this project, and how to capture this out-of-focus world. Sight and focus are crucial for me to tell stories as a filmmaker, from the creative to the direction and cinematography. I hope that our simple, life-affirming message will connect with the viewer as we invite them to pause and reflect on their own lives and the importance of focus.”

The launch of the short film is being supported by reality TV stars Theo Campbell – who was left blind in one eye after a freak accident – and Georgia Harrison, who feels passionately about the cause.

Daniel Hardiman-McCartney FCOptom, clinical adviser for the College of Optometrists, said: “It’s shocking that people struggle with their eyesight, but do not get their sight tested until they have a big problem. We’re committed to encouraging people to get their sight checked regularly and educating people on the importance of looking after our eye health. The launch of our short out-of-focus film today is a testament to this and we hope to get people thinking about their vision and booking an appointment with their optometrist as a result.

“For a large number of people, unless they address issues with their eyesight, the future really will look as blurred as depicted in Mark’s film. That impacts not only health, work and safety issues, but our ability to seeing the everyday things we truly love – whether it’s our children, nature, sport or simply the latest episode of Love Island. Making an appointment today could be the first step to seeing the future as it should be and living without regret.” q

Medicolegal negligence in the telemedicine era

By BITA MANZOURI consultant ophthalmic surgeon and expert at EYE-LAW CHAMBERS

[FOR OPHTHALMOLOGISTS the year 2020 has not only been

the year of sight but the year of insight. With the global rise of the COVID-19 virus and the implications for the ability of healthcare systems to cope with the pandemic of infected patients, the medical world has had to rapidly implement technological ideas for the management of patients with non-Covid related morbidities, thereby continuing to provide care but keeping patients away from healthcare institutions.

It can be said that the year 2020 has been the dawn of the telemedicine era. Previously, worldwide, telemedicine had already been used to great advantage for patients who live in very rural areas far from healthcare providers, in developing countries where access to healthcare was difficult, and in developed countries as a way of professionals in different areas communicating with each other on the management of a particular patient case or seeking a second opinion.

These have all formed the tenets of good medical practice.

In ophthalmology telemedicine has several areas of application. In diagnosis, telemedicine is already in usage for the screening of patients with diabetic eye disease and in the screening of premature babies with retinal problems such as retinopathy of prematurity (ROP).

Indeed, imagebased diagnosis and management are a reliable, accurate and cost-effective way of treating these potentially blinding conditions. The use of electronic prescriptions in telemedicine avoids errors – such as the name, dosage and duration of a medication due to the illegible writing of the prescriber.

With the advent of the COVID-19 virus, the AttendAnywhere platform has gained greater usage, thanks to the two-way communication technologies emerging in clinical institutions, and aims to mimic how face-to-face consultations work. Governments have also been driven to provide better and more effective health care for their citizens, and part of this includes an investment in telemedicine.

Among the commonly acknowledged driving factors behind this include, firstly, citizens and patients becoming more consumer focused with respect to healthcare systems and professionals, exercising their inherent right to choice, coupled with a demand for the best care available, and intolerance of inequality of access based on geographical location – so-called ‘postcode lotteries’; secondly, the need for radical improvements in healthcare productivity despite limited budgets; and finally the need to manage the increasing complexity of healthcare processes and the resulting huge quantities of information.

However, with greater use, telemedicine raises a number of ethical and legal issues. These include the responsibilities and potential liabilities of the health professional, the duty to maintain the confidentiality and privacy of patient records, and the jurisdictional problems associated with cross-border consultations. For example, when health workers from different countries collaborate – ‘crossborder telemedicine’ – on the care of a patient, there is no consensus on the language to use in data recording in the patient’s notes, especially if the consultation was in a language not native to the origin of the patient. Telemedicine requires the transmission of health information from one place to another.

From a legal point of view, the quality of the information on which a health professional bases an opinion or diagnosis raises an important question about the division of responsibility between the healthcare professional and the provider of the telemedicine service. It is important for healthcare professionals using such a service to recognise, for instance, when clinical information is and is not of appropriate quality to make a diagnosis.

The final example relates to patient confidentiality: patients have a fundamental right to have their medical records kept confidential.

Telemedicine relies heavily on the video and audio transmission of data through telecommunication networks. Secure access to the network and data transmission is essential for the confidentiality of personal and medical data. The promise of this network is that patient information will be electronically available to authorised personnel but, as has been seen with the NHS – BBC News reported that NHS data breach affects 150,000 patients in England – telemedicine can impinge on this inherent right due to the vulnerability of data lines to security breaches despite encryption of data and authentication checks.

In the UK, one of the first attempts to describe the legal framework for telemedicine was that of Brahams, who stated that ‘unforeseen medicolegal implications of telemedicine will be revealed by litigation as it arises’. These questions about the legal and ethical aspects of telemedicine will remain to be answered definitively; in the meantime, healthcare professionals are advised to act with prudence to minimise these medicolegal challenges. q • For further information contact Eye-Law Chambers on 020 8852 8522, email eyes@dbcg.co.uk or vist the website at www.eyelawchambers.com www.yourexpertwitness.co.uk

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Report on child mental health raises concerns among psychologists [THE BRITISH PSYCHOLOGICAL SOCIETY (BPS) has raised

concerns about the findings of a new report from NHS Digital about the mental health of children and young people in England. The report found the proportion of children experiencing a probable mental disorder has increased over the past three years – from one in nine in 2017 to one in six in July this year.

It looked at the mental health of children and young people in England in July 2020, and how it has changed since 2017.

Experiences of family life, education and services, and worries and anxieties during the coronavirus pandemic are also examined.

Dr Vivian Hill, chair of the BPS’s Division for Educational and Child Psychology, said: “These findings highlight the disproportionate impact of the COVID-19 pandemic on more vulnerable populations including those with pre-existing mental health needs, those living in low income families and those exposed to overcrowding, family conflict and domestic abuse. For children and young people with an underlying mental health need, the pandemic has exacerbated these needs.

“There is a complex interaction between these factors, for example poor sleep and feeling lonely can be both a cause and a consequence of declining mental health and well-being. They are also adaptive responses to a life-threatening pandemic.

“It is important not to pathologise these young people. What is clear is that mental health resources need to be more strategically targeted to at-risk populations. This study highlights the urgent need for easilyaccessed community-based mental health services and increasing the supply of educational psychologists working in schools as we enter the second wave of the virus would help to provide timely, readily-accessed mental health support to those who need it most.

“The study also highlights the pervasive influence of poverty, at individual and community levels, both in terms of risk factors and diminished access to support. The evidence is clear: there needs to be urgent targeting of financial and mental health support to our most vulnerable communities. The BPS Poverty to Flourishing campaign is working hard to highlight these needs and to promote equitable access to resources and support.”

The concerns were echoed by the society’s vice chair of the Division for Educational and Child Psychology, Dr Gavin Morgan.

He said: “We are very concerned about the findings of this new report. The current generation of children and young people have faced a decade of austerity cuts to local and health authorities, which has affected access to support from mental health and psychological services. This has been further exacerbated by the coronavirus pandemic and the incremental impact upon the mental health of children.

“This report shows yet again the need for educational psychologists to be working in schools and supporting the needs of children as we continue to respond to the consequences of austerity, school closures and the resulting impact upon mental health.

There will be long term effects that educational psychologists will be supporting for a considerable amount of time.” q

Best practice guidance issued [COVID-19 HAS PRESENTED new practical and ethical

challenges for psychologists undertaking research, not least because the need to rapidly generate evidence must be balanced with the realities of the situation we are in.

New best practice guidance from the British Psychological Society, Ethics best practice guidance on conducting research with human participants during COVID-19, outlines the considerations and aims to assist researchers in recognising ethical practice issues during these unique circumstances.

Dr Lisa Morrison-Coulthard, head of research and impact at the BPS, said: “We know the COVID-19 pandemic has affected many research activities; however it’s so important that now, more than ever, we are able to work safely and ethically with people to both understand the psychological impact of the pandemic itself, whilst also continuing to deliver unrelated research projects.

“This guidance outlines the key considerations researchers need to bear in mind when embarking upon research with human participants during the pandemic, within a best practice framework.” q www.yourexpertwitness.co.uk

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Doctors condemn out-of-area referrals for mental health patients [ AN INVESTIGATION BY the BMA has

found that thousands of acutely ill mental health patients are still being sent miles from where they live for treatment, despite the government pledging to end the ‘harmful and destructive’ practice by April next year.

The new findings come more than two years after the BMA first revealed how record numbers of ill patients were separated from families and local support services due to a lack of available beds in their local area.

The new analysis by The Doctor magazine found that, of the trusts in England with comparable data between 2018 and 2020, 47% had sent patients to what is termed ‘out-of-area’ beds 100 times or more in the 12 months up to August this year. At least 11 trusts doubled their number of out-of-area placements in the 12 months to August compared with the same period in 2017/18.

While there were some decreases across trusts, the number of ‘inappropriate’ outof-area placements – those made because there was no bed locally – increased in 38% of the 40 trusts with comparable data between 2018 and 2020.

The findings from Freedom of Information requests also revealed that very few of the clinical commissioning groups which fund, and therefore set, bed numbers plan to increase local bed capacity – something which is very much needed if patients are to stop being sent miles from home for care, the BMA says.

Now the BMA estimates that at least 1,000 extra beds for mental illness are needed in order to end the worrying practice, with concerns that the impact of COVID-19 will only increase demand for beds. ​Commenting on the findings, BMA mental health policy lead Dr Andrew Molodynski said: “We are seeing nowhere near enough progress in ending the harmful and destructive practice of sending mental health patients out of area for treatment.

This unacceptable and unnecessary practice causes distress to some of the most vulnerable in society, increases the risk of suicide and separates people from their friends and family when those bonds are most needed.

“Despite mental healthcare leaders and providers all calling for an end to this practice for years now, the failure to invest in mental health beds and in good-quality community care means the situation is as bad or even worsening in many trusts.

Addressing this is even more urgent given the impact of the COVID-19 pandemic

and the recession on the mental health of the population, alongside an inevitable squeeze on public finances.

“It is absolutely crucial that the government recommits to ending this practice by delivering on the much-needed extra beds and ensuring the optimum coordination of services before this spirals any further out of control. A moratorium on further bed cuts, given the damage done by reductions in recent years, is now essential alongside reprovision of both inpatient and community services where there are gaps.”

As well as increasing the number of mental health beds, the BMA is calling for a credible plan to recruit and retain more staff to build up the capacity of mental health services across the country, and for stronger support for community mental health services.

There must be greater analysis of high out-of-area placement use areas to inform the urgent development of CCG-level plans to both increase capacity and strengthen community services.

The president of the Royal College of Psychiatrists, Dr Adrian James, added his voice to the calls. He said: “People are much more likely to recover from their illness if they are treated close to home

and near their family and friends. The government is likely to miss its target of ending the practice of sending patients inappropriately out-of-area, but because of the pandemic we may not know how much they fall short by.

“NHS England deprioritised the collection of out-of-area data after the onset of COVID-19, meaning we currently do not know how bad the number is. The NHS must take action: make this data collection mandatory and ask those trusts failing to share their numbers to do so.

“In the short term, areas with consistently high rates of inappropriate out-of-area placements should be given the resources they need to invest in beds that are properly staffed. In the longer term, community mental health services must be improved so that more patients can be treated in line with the commitments made in the NHS Long Term Plan.”

The findings come a year after the BMA revealed how NHS mental health rehabilitation wards have all but disappeared from many clinical commissioning groups and NHS trusts in England, leaving as many as five million people in those areas effectively ‘warehoused’ in out-of-area private-sector provision. q

Psychiatry body responds to report on restraints in care homes [THE ROYAL COLLEGE OF PSYCHIATRISTS has responded to BBC Radio 4’s File on 4

programme on the escalation of restraint used on people with intellectual disabilities, aired on 10 November.

The programme followed up on a previous report in 2018 on the treatment of a teenage patient with autism, Bethany. In the programme it was stated that there were more than 38,000 reported incidents of restraint of people with intellectual disabilities in 2019: an increase on data gathered in 2017.

In response, RCPsych’s chair of the Faculty of the Psychiatry of Intellectual Disability, Dr Ken Courtenay, said: “It’s of great concern to see a rise in the use of restraint in 2019.

Psychiatrists understand the shortcomings of the system that has led to such practices.

“Restraint of all forms should be avoided. In extreme situations restraint must only be used as part of a robust care plan agreed with the person with the aim of preventing harm.”

The programme found that the circumstances for Bethany had improved dramatically.

Dr Courtenay continued: “File on 4 highlights how people’s lives can be transformed with the right support delivered by caring staff with the skills and knowledge to support people effectively in specialist services or in their homes. Unfortunately, such support is not currently available to many people with intellectual disabilities and autistic people. We agree with the Rt Hon Harriet Harman MP that radical change needs to happen to avoid perpetuating the current system of hospital care instead of good community support.” q www.yourexpertwitness.co.uk

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