Your Expert Witness Issue 56 by DMMonline

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contents IN THIS ISSUE 7

Opening Statement

NEWS EWI prepares for second virtual conference 8 8 Transparency Review makes slow progress 9 Experts will assist in legal aid scrutiny 9 Mediation scheme gets two cheers from lawyers BUILDING & PROPERTY Surveying expert witnesses have a range of specialisms 11 11 Downsizing or expanding? Make sure your lease terms are clear 11 Professional institution offers accreditation service FORENSICS Tully calls for change in final report as regulator 12 12 Commissioner issues facial recognition guidance FIRE INVESTIGATION Was the battery the cause of the fire or a victim? 13 FORENSIC ACCOUNTANCY Forensic accountants are more essential in today’s world 14 15 These experts are accountancy’s detectives 15 FCA gains approval to return investors’ funds

VIEWPOINT Can your expert truly sign the Statement of Truth? 17 TRANSLATION & INTERPRETING Do we still need humans now we have computer translation? 18 19 Fraudulent interpreter sentenced for 12 offences

A to Z WEBSITE GUIDE 30 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 21 Medical Notes

NEWS 23 Doctors fear post-pandemic claims surge 23 Guidance reflects the new reality of remote prescribing 24 Most doctors do not feel protected – BAME doctors even less so 24 Checks ensure appropriate care for discharged COVID patients OBSTETRICS & GYNAECOLOGY 25 Telemedicine abortion service is safe and effective, study finds CARDIOLOGY 27 Heart op delays cost lives, says BHF 27 Collaborative research uses new data resource PAIN MANAGEMENT 28 The role of multidisciplinary teams in chronic pain management DENTISTRY & MAXILLOFACIAL SURGERY 31 Scotland faces dental crisis, dentists warn 31 Dental regulator responds to DHSC White Paper 32 Choosing a dental expert witness – a personal perspective

OPHTHALMOLOGY 35 Lockdown leads to CBS hallucination spike 35 AMD is linked to air pollution, study finds UROLOGY 37 What are the commonest pitfalls in urological diagnosis? PSYCHIATRIC & PSYCHOLOGICAL ISSUES 39 Study charts PTSD in COVID patients 39 Guidance helps professionals working with degenerative diseases 41 Govt consults on Mental Health Act reforms 41 Effect of unemployment on mental health highlighted VASCULAR MEDICINE 42 Diabetic foot: what are the issues and how should it be treated?

ORTHOPAEDICS 45 Product recall affects orthopaedic devices 45 Latest figures reiterate impact of coronavirus 46 Fraudulent cauda equina claimant jailed 47 What is an open fracture? PLASTIC, RECONSTRUCTIVE & HAND SURGERY 49 Top plastic surgeon leaves hospital after attack 49 First aesthetics postgrad courses set to start in September 49 Entries sought for new hand surgery award

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Opening Statement [IT’S NOT OFTEN that a notorious gangster is instrumental in the development of an investigative process. In

the case of Al Capone, though, anything is credible. Capone’s ability to slip the snare of blame for his racketeering activities led the Feds to turn to accountants to prove the extent of his tax evasion. Earnings from illegal gambling is still income, and so liable for tax. The work of Frank Wilson and his team led to the birth of the term forensic accountancy – and a 10-year stretch for Capone.

• On this side of the pond fraudulent activity of another kind took place under the very noses of the judiciary when the identity of a highly-skilled court interpreter was stolen by someone with no qualifications to carry out translation and interpretation work at proceedings that included a sensitive child sex grooming trial. The perpetrator even paid someone else to do the fraudulent work for him! The body that represents public sector interpreters is unsurprisingly far from impressed that such a con could happen – laying the blame at the door of the cost-cutting exercise carried out by the MoJ some years ago. • Of course, the situation would not have arisen if computer interpretation had been adopted. That is, however, far easier to assert than to prove: computers are incapable of the nuances of human language and hopefully will continue to be so, despite the aspirations of some in the world of technology. • The subtle nuance of human thought is one of the reasons we need experts to untangle what can be complex issues, so the trust we place in them to lead us honestly to the truth demands a great deal of candour on their part. That candour has not always been forthcoming – until, that is, the immunity from prosecution of expert witnesses was swept away. To reinforce that obligation experts are now obliged to add a paragraph to their Statement of Truth to acknowledge they may be prosecuted. Regular contributor Chris Makin details what the consequences can be of not sticking to that statement. • Our confidence in the judicial system depends on justice being seen to be done. We ensure that by allowing access to the courts by the public and the press. However, in the case of the Family Court that access is to all intents and purposes denied. There is therefore a review underway to improve transparency in the Family Court, particularly via publication of hearings. Other attempts have failed and this one is being slowed up by the pandemic. • It may seem anathema to the seasoned courtroom expert, but avoiding litigation in the first place is in most cases the preferred option. That is where the expert’s role becomes that of mediator or arbitrator. Lawyers can also play their part. In the case of commercial premises Heads of Terms can help to lay the groundwork before the contract is negotiated. An experienced property lawyer explains why, with more detail online. • Diverting cases away from the courts can also ease the backlog of cases, and a pilot to do just that in housing cases via mediation has been proposed. The pandemic is again the culprit. Lawyers warn that clearing a backlog should not be the sole basis for a mediation scheme, which in the case of housing disputes could involve vulnerable people who need the protection of the court. • The retreat to the virtual world caused by coronavirus has also led to the Expert Witness Institute holding its annual conferences via Zoom. This year’s affair has been brought forward to 28 May. Among the issues under discussion will be the effect the past 12 months have had on experts and lawyers – and it only lasts one day! q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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EWI prepares for second virtual conference [THE 2021 annual conference of the Expert Witness Institute will take

place virtually on Friday 28 May. The theme of this year’s event will be Lawyers and Experts: Facing the Future Together, reflecting the changed times in which we live. The 2020 event was also held virtually. Replacing the traditional registration and coffee will be a session for signing in to Zoom, when there will be an opportunity to peruse a virtual exhibition. The sessions throughout the day will cover a wide range of issues related to the relationship between experts and lawyers. A panel discussion will reflect on practice over the past year and the long-term changes the future will likely bring. Professor Penny Cooper will chair a further panel discussion on Lessons from the Courts, while a third such session will consider Costs and Getting Paid. Throughout the day there will be opportunities for networking, while break-out sessions will cover Criminal Negligence, Commercial/ Construction, Developing Business Internationally and Legal Updates in Scotland. The keynote address will be delivered by EWI president Lord Hodge, Deputy President of the Supreme Court (pictured). Lord Hodge was appointed Deputy President of the Supreme Court in January 2020, having previously been appointed as a Justice of the Supreme Court on 1 October 2013. From 2000 to 2005 he was a judge of the Courts of Appeal of

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Jersey and Guernsey, and Procurator to the General Assembly of the Church of Scotland. The closing address of the day will be delivered by Sir Martin Spencer, Justice of the High Court, Queen's Bench Division, and chair of the board of governors of the EWI. Prior to his appointment as a High Court judge in 2017, Martin Spencer was a leading clinical negligence barrister. His practice at Hailsham Chambers involved all aspects of clinical negligence, with particular expertise in complex high quantum claims. q • For further information and to register visit www.ewi.org.uk.

Transparency Review makes slow progress [

THE FINAL PUBLICATION of the Family Division’s Transparency Review is now expected to happen in the summer. Courts have continued to operate despite the challenges of the pandemic, but there have been unavoidable delays to the timetable Sir Andrew McFarlane, president of the Family Division, had envisaged when he launched the review in May 2019. The Transparency Review is looking at the current arrangements for media and public access and reporting in the Family Courts. A panel helping the president has recently been extended to include a senior family division judge. The panel’s aim is to gather full and candid information for the review. The panel members are Family Division High Court judge Mrs Justice Nathalie Lieven, consultant child and adolescent psychiatrist Dr Eia Asen, Anthony Douglas CBE – former chief executive of CAFCASS – Clare Dyer, former legal editor of The Guardian and Nicola Shaw CBE, executive director of National Grid. More than 100 submissions were received in response to the review’s call for evidence – drawn from individuals and agencies across the world of family justice. The president and panel have now been able to meet remotely to review all submissions and consider who to hear oral evidence from. Three oral evidence sessions are being held. The first was held on 2 February and included four participants. It was conducted remotely and according to witness preference. The further two oral sessions will take place on 8 March and 17 May. The sessions will involve a range of respondents, with the logistics – including formal invitations and methodology for each participant group – currently being finalised. In each case, provisions will be made to make the content of the sessions available either at the time or later if there are sensitivities or preferences defined by the respondent. q

Experts will assist Mediation scheme gets two cheers from lawyers in legal aid scrutiny [ [

A PANEL OF EXPERTS has been appointed to support Sir Christopher Bellamy QC in examining the long-term sustainability of the criminal legal aid system. The Expert and Advisory Panel, appointed by the Lord Chancellor, will provide support by testing and challenging the review’s emerging findings and recommendations. Sir Christopher, who was appointed to chair the panel by the Lord Chancellor on 21 December, will chair monthly meetings, which began in February. He will submit his recommendations to the Lord Chancellor later this year and it is intended that the report will be published by the end of this year alongside the government’s response. The review will consider the criminal legal aid system in its entirety, specifically it seeks to ensure that it: • Provides high-quality legal advice and representation • Is provided through a diverse set of practitioners • Is appropriately funded • Is responsive to user needs both now and in the future • Contributes to the efficiency and effectiveness of the criminal • justice system • Is transparent, resilient and delivered in a way that provides • value for money to the taxpayer. It is the latest step in the Criminal Legal Aid Review, which has already led to up to £51m per year funding for the sector. It forms part of wider work to ensure criminal defence remains an attractive career for practitioners now and in the future. The Lord Chancellor, Robert Buckland QC MP, said: “I am grateful to Sir Christopher Bellamy and his esteemed panel for undertaking this vital piece of work which will play a crucial role in ensuring the long-term sustainability of the criminal legal aid market.” q

A BID TO EASE the backlog of housing cases heading for court through a mediation pilot has been greeted with caution by the Law Society of England and Wales. “Mediation has an important place in dispute resolution; however, housing is such an essential life requirement that mediation cannot replace the usual routes of access to justice through the courts or take money from schemes that facilitate that access,” said Law Society president David Greene. “Both the eviction ban and mediation have their place when people are facing homelessness in the middle of a pandemic. However, vulnerable and unrepresented tenants may feel pressured to undertake mediation and may be misrepresented, as mediators are not housing dispute specialists. “The Law Society is particularly concerned that the pilot could impact on the sustainability of legal aid, particularly the Housing Possession Court Duty Scheme (HPCDS), which provides an emergency solicitor on the day to anyone facing eviction proceedings. “The £3m allocated to the pilot would be more usefully channelled into the HPCDS and early legal advice, which ensures tenants have the access to justice and specialist legal advice that can stop them being evicted. “Despite calls from across the housing sector to the Legal Aid Agency and the Ministry of Justice to ensure the continued availability of funded legal advice, investments have not been made. “Mediation should not be seen as the whole solution to the current court delays and backlogs. Any remedy to these issues must focus on ensuring all tenants have access to courts, court services and specialist legal advice. “The mediation pilot must therefore be approached with caution and be more explicit about what it intends to do to help the public achieve justice. It must go beyond simply clearing the backlog and move forward with the struggles of the housing sector at its core.” q

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Surveying expert witnesses have a range of specialisms [FOR MOST PEOPLE probably the greatest likelihood they

have of needing the services of an expert witness is in a property dispute. For individuals there are the possibilities of border disputes, lease disputes, valuation disputes and many more. In matrimonial disputes the value of the family home is likely to be a major bone of contention. It is the domain of the expert chartered surveyor. So it is essential that the experts in question are of the highest calibre. There are a number of sources that can be consulted to adduce the competence of an expert, including those compiled by the various expert witness bodies and the professional institutions such as the RICS. Chartered surveyor expert witnesses vary widely in their expertise. Some are generalists and can offer expert opinion across a broad range of issues, from structural reports to valuation for divorce proceedings. Such is the range of expertise of David Kutner, for example. Others are large practices, such as DWD, which employ a large number of experts, each with their own particular area of expertise. Less common are those with a high level of expertise in a particular segment of the market. Quinton Edwards boasts what is probably unparalleled expertise in the field of garden centres and the horticultural market. At one step removed from the property market is the construction industry, with its own cohort of expert surveyors. Within that group there are those with particular interests. CF Associates, for example, can offer expert opinion in forensic delay analysis and quantum analysis. In addition to offering expert reports for the courts, most expert surveyors will offer expertise in alternative dispute resolution, helping to avoid the costly process of legal proceedings. q

Professional institution offers accreditation service [ONE OF THE accreditation schemes that allows peace of mind when

appointing surveying expert witnesses is that run by the Royal Institution of Chartered Surveyors (RICS). The RICS Expert Witness Accreditation Service (EWAS) was set up by the institution’s dispute resolution service (DRS) in the wake of scrutiny of the level of quality expected from expert witnesses – in particular as brought about by the case of Jones v Kaney and the Jackson reforms. It sets the standards for chartered surveyors who act as expert witnesses. The sector had previously not been subject to professional regulation. Experts in all areas of the property sector can apply for accreditation and must undergo stringent assessment and pass a number of training modules. They must also complete an ethics test and attend interview by the accreditation board. As part of the EWAS, the RICS DRS runs an Expert Witness referral service. The referral service nominates a member of the EWAS register that fits the area of expertise required by the client. q

Downsizing or expanding? Make sure your lease terms are clear KAREN MASON is a highly experienced commercial property lawyer and co-founder of Newmanor Law, a specialist real estate law firm. Here she outlines the importance of Heads of Terms in negotiating new commercial leases.

[AS BUSINESSES RETURN to workplaces once again, many

occupiers will be looking to either renegotiate lease terms or agree new leases to redefine their situation, given a growing acceptance that remote working will form part of the working week. The question of space utilisation may lead some businesses to downsize, whilst others looking to space their people apart may ironically need bigger offices, or more locations. Different requirements will mean new agreements, requiring Heads of Terms to tie down what is being agreed, with the need to secure a good long-term deal critical for businesses in the post-COVID world. Heads of Terms provide a written record of the main terms of a deal, but critically they have traditionally been resolved before involving solicitors, which can cause problems and delays later on. Heads of Terms should provide the framework for the deal and also deal with how it should be executed. When Heads of Terms are drafted without advice from an experienced real estate lawyer, lack of detail may result in a long list of questions to answer before the deal can be delivered, leading to time wasted going backwards and forward on the terms agreed. Ensuring the Heads of Terms are not legally binding is a vital aspect of drafting them, since the detailed provisions will be included in the contract documentation. Using the phrase ‘subject to contract’ will help ensure that is the case; but in many cases the actions of the parties after the Heads of Terms are drawn up will have as much impact on whether the provisions are seen as being legally binding as the actual wording of those provisions. Heads of Terms will become increasingly important in commercial property deals, as they provide the framework for efficient and successful deal execution. It is important to understand the benefits of engaging specialist legal advisers at the outset, who recognise Heads of Terms should be all about preparing for efficient deal execution and success. q • This is an extract from an article published on the Your Expert Witness website. To read the full article visit www.yourexpertwitness.co.uk.

• To find out more about the EWAS and the referral service visit the RICS website at www.rics.org/uk/. www.yourexpertwitness.co.uk

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Tully calls for change in final report as regulator [IN HER FINAL REPORT before stepping down as the Forensic

Science Regulator, Dr Gillian Tully has warned that parts of the sector remain in a precarious position and there is an urgent need for fundamental change. The report highlighted significant improvements over the past six years – including more robust testing of methods, improved reliability of results and greater evidence of competence within forensic science. However, Dr Tully called for more scrutiny of scientific evidence in court, increased capacity in toxicology and digital forensics, and improved compliance with quality standards. The Forensic Science Regulator and Biometrics Strategy Bill is currently making its way through Parliament and could give statutory enforcement powers to the next regulator to uphold standards. Dr Tully leaves the role with a mixture of confidence in the improvements underway and concern about inexcusable pressures in the system. She said: “It is in nobody’s interest for justice to be delayed and it isn’t acceptable for forensic scientists to be instructed to review vast quantities of information in the days before a court case. A much more effective approach is needed to make the changes required across the criminal justice system. “There have been major improvements in the quality of forensic science over the last six years, but we can’t rest on that and I encourage all forensic science organisations to be innovative in their approaches. “It has been an enormous privilege to hold this role and my thanks go

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to all in the forensic science community who work so hard in the most difficult of situations.” Dr Tully stepped down from the role of Forensic Science Regulator on 16 February and a recruitment competition for her replacement is currently underway. The Home Office Deputy Chief Scientific Adviser, Rupert Shute, has been appointed to act as Interim Forensic Science Regulator until such time as the new regulator is appointed. q

Commissioner issues facial recognition guidance [IN DECEMBER the Surveillance Camera Commissioner (SCC)

Tony Porter issued best practice guidance to police forces in England and Wales on the use of live facial recognition (LFR) surveillance camera technology. The document, Facing the Camera, is the first guidance to be released since the Court of Appeal handed down its judgment on Bridges v South Wales Police in August last year – the commissioner was an intervener in the case and a key contributor. The SCC is the independent regulator of the overt use and public operation of surveillance camera systems by the police in England and Wales. That includes systems incorporating LFR. He supports the police having legitimate recourse to surveillance camera systems, including LFR where they are necessary to keep the public safe and secure, within the clear provisions of the law. Transparency of lawful use is essential to public trust and confidence in such matters. Tony Porter commented: “Over the seven years I have been commissioner I have continually said that the police should be able to use technology to keep us safe and secure, but this must be balanced against our civil liberties and the law. The High Court ruled that South Wales Police’s use of LFR was in accordance with the law, but this was later overturned by the Court of Appeal. “The guidance I’ve issued today will help forces who want to use LFR identify how to do so in accordance with the current legal framework. Where there is a proportionate need to deploy intrusive technology it is right that the police have the guidance to do that – Facing the Camera will go some way to help them before decisions are made to deploy.” q

Was the battery the cause of the fire or a victim?

[RECHARGEABLE lithium-ion (Li-ion) batteries are

commonly used in modern electrical products. With their high-energy density and light weight, they are used in various products from mobile phones to cars. There is, however, one significant disadvantage to the widespread use of Li-ion: like all alkaline metals, lithium is highly reactive and flammable. Since Li-ion batteries contain so much stored energy they are susceptible to overheating if damaged or defective. That can cause a runaway chemical reaction that can ultimately result in the battery casing catching fire or rupturing explosively. The investigators at Strange Strange & Gardner understand that there are numerous reasons why a battery may fail. They include a manufacturing defect, poor fitting, improper charging or use, or mechanical damage. SS&G’s senior fire investigation specialist Anthony Murray explained: “We are aware that, although batteries can be the source of fire ignition, they are sometimes victims of the fire. To successfully determine the cause of a suspected battery fire a proper understanding of battery fundamentals and a thorough investigation methodology are essential. “We investigate all types of battery fires and explosions that result in property damage or injury. That type of accident is becoming more common. 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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Forensic accountants are more essential in today’s world [IT’S FAIR TO SAY that the world of finance has never been so

complex. Even personal financial affairs can often require the skills of a forensic accountant – with their meticulous attention to detail, combined with analytical and interpretive skills of the highest order. DRC Forensics is a specialist forensic accountancy practice set up by David Cook in 2009 in Portishead, Bristol. Since then David and his associate Chris Gahagan have acted as expert witness in countless cases, both in the civil and criminal courts. David qualified as a chartered accountant in 1965 and became a fellow of the Institute of Chartered Accountants in England and Wales (ICAEW) in 1975. He is a member of the Institute’s Special Interest Groups for Forensic Work and Valuations. He is also a Justice of the Peace. David has a wide range of commercial and corporate expertise, particularly business advice, financial planning and taxation. He has been widely involved in valuing businesses for acquisition, disposal, management buy-outs and reorganisation, as well as in dispute situations. He is a Law Society-approved expert witness and is used to producing expert reports, giving evidence in court and acting for the prosecution/ complainant, defence or as a single joint expert. David has considerable expertise in litigation support and investigations, especially in relation to supporting lawyers on the accounting and financial aspects of business and commercial disputes, professional negligence, fraud investigations and other criminal matters. As well as work for lawyers, David has carried out assignments for the Serious Fraud Office, SOCA and the Solicitors Indemnity Fund and assignments for and claims against banks.

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Said David: “I deal with legal disputes involving money where, usually, I am instructed by a lawyer to investigate a situation, produce an independent expert’s report and, where necessary, give evidence in court. “In criminal cases I deal mainly with fraud, money laundering and confiscation under POCA. I act usually for the defence, as the prosecution these days use in-house accredited financial investigators, and I often appear in Crown Court. “In civil cases I can be a party expert for claimant or defendant, single joint expert where the court specifies it, shadow expert advising a party or independent accountant to determine a dispute. I deal with professional negligence and with shareholder, partnership, matrimonial and contract disputes. I conduct numerous valuations of businesses in dispute situations. Most civil cases are settled without court attendance, but I still give evidence sometimes.” Chris Gahagan is a chartered accountant who has a law degree and over 20 years’ experience. He qualified as a chartered accountant in 1990 and is a member of the ICAEW’s Special Interest Groups for Forensic Work and Valuations. Chris has vast commercial and corporate experience having set up a number of businesses and having been instrumental in the acquisition, valuation and sale of several companies. He has provided consultancy services on all aspects of business to national retail organisations as well as SMEs. Together David and Chris form a formidable partnership with a wealth of expertise. q

These experts are accountancy’s detectives [

A SURPRISING VARIETY of litigation may involve the work of a forensic accountant expert witness. Forensic accountants are highly-skilled financial investigators – typically chartered or certified accountants – who are engaged to analyse financial affairs when either foul play is suspected or there is a dispute regarding money. The kinds of case they can be deployed on ranges from the obvious – fraud, cybercrime, matrimonial disputes – to the unexpected, such as professional negligence, personal injury and even fatal accident cases. The profession has a long and distinguished history. Some trace its antecedence to Pharaonic Egypt, when the Pharaoh would employ scribes to keep a close check on all outgoings. The term itself was not formally defined until the 1940s, following

FCA gains approval to return investors’ funds [THE Financial Conduct Authority has obtained High Court

the work of certified public accountant Frank Wilson in the 1930s. Wilson worked for the US Internal Revenue Service investigating the affairs of infamous gangster Al Capone. Although notorious for his involvement in murder and racketeering, Capone was indicted for Federal income tax evasion. Wilson and his colleague computed that Capone owed the government $215,080.48 in tax from illegal gambling profits. He was convicted of tax evasion, for which he was sentenced to 10 years in prison. Wilson’s work resulted in him becoming known as the ‘father of forensic accountancy’. Nowadays forensic accountants work in the digital world and deal with incredibly complex technology to uncover fraudulent behaviour or reveal finances that have been concealed from the court. The Institute of Chartered Accountants in England and Wales describes the forensic accountant as the ‘detective of the financial world’. It describes the main qualities as the ability to analyse, interpret, summarise and present complex financial issues. They must also be familiar with legal concepts and procedures. In addition, in this electronic age the forensic accountant needs to have an advanced understanding of the digital programming that is central to all financial activity, although they will often work in concert with forensic technologists. q

approval to return £3.42m to compensate victims of a series of unauthorised deposit-taking and collective investment schemes. The schemes were run by Samuel and Shantelle Golding and their companies Digital Wealth Ltd, also known as Digital Wealth Society (DWS) and Outsourcing Express Limited (OEL) – also known as Kerchiing. Between 2015 and 2017 the schemes alleged to involve the online purchase of wholesale goods from China for onward sale and promised unrealistically high returns, in some cases up to 100% of the amount invested. No significant trading was conducted and the schemes relied on a continuous flow of new investors to fund existing investors’ returns. Samuel and Shantelle Golding admitted to the court they were personally involved in those contraventions. The schemes raised just over £15m from over 1,000 individual accounts. The FCA took immediate enforcement action on learning about the schemes and prevented the disposal of the remaining funds. Despite that action a shortfall of £3,285,413 was identified in the DWS deposit-taking scheme and £834,402 in the OEL collective investment scheme. The FCA has recovered £3,428,612 from various bank accounts containing the proceeds of the schemes, which will now be returned to 356 qualifying investors in the DWS scheme and 250 qualifying investors in the OEL scheme. Mark Steward, executive director of enforcement and market oversight at the FCA, said: “The FCA took action as soon as it became aware of these illegal schemes, preventing further losses to future investors who would be unable to exit the scheme before it inevitably collapsed. In this case, we managed to save some money for investors: too often it is too late. These firms were not authorised by the FCA and, as we always say to consumers, if a scheme looks too good to be true, do not invest. “We have worked very hard to identify people eligible to receive compensation from these schemes and are pleased to have been able to recover and return some of their money.” q www.yourexpertwitness.co.uk

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Can your expert truly sign the Statement of Truth? By CHRIS MAKIN chartered accountant, accredited civil mediator and accredited expert determiner

[AN EXPERT’S REPORT under CPR must conclude

with the Expert’s Declaration stating that the expert knows his duty to the court and has complied with that duty. There must then be a Statement of Truth, which used to say: “I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.” However, as from 1 October 2020 that statement was extended, with these words: “I understand that proceedings for contempt of court may be brought against anyone who makes, or causes to be made, a false statement in a document verified by a Statement of Truth without an honest belief in its truth.” It is relevant to consider why these words were added, and particularly interesting to me because it concerns a solicitor, now an ex-solicitor, in my home town of Huddersfield. The relevant case is Liverpool Victoria Insurance Company Ltd v Dr Asef Zafar [2019] EWCA Civ 392, being an appeal by LV= against a sentence of only 6 months, suspended for 2 years, on a medical expert witness on the grounds that it was unduly lenient.

The facts

On 3 December 2011 a Mr Mudassur Iqbal was in an RTA. The other driver, at fault, was insured by LV=. Mr Iqbal was examined by Dr Zafar, who ran what the Court of Appeal referred to as an expert witness ‘factory’. He was able to examine an injured person and produce an expert report every 15 minutes – he produced 5,000 reports a year and earned £350,000 for this work in addition to being a fulltime GP with the NHS. Dr Zafar did the examination 11 weeks after the accident and dictated a report, in Mr Iqbal’s presence, stating that in his opinion there had been whiplash but it had resolved one week after the accident and Mr Iqbal was fully recovered. The report, dated 17 February 2012, went to instructing solicitor Mr Khan of TKW, bearing an Expert’s Declaration and the traditional Statement of Truth. From a file note at TKW, it seems that Mr Iqbal rang the solicitor to say that he had continuing problems of whiplash. So Mr Khan said he wrote a letter (which could not now be found) to Dr Zafar asking him to produce an amended report. Communication was through an agency, Med-Admin. A secretary asked Dr Zafar if a revised report should be prepared. Dr Zafar agreed, and a report identical in all respects, but now with continuing whiplash, was produced. Now the solicitor had two versions of the same report. Regrettably for him, a paralegal put a bundle together which included the wrong, fully recovered, first report. LV=, recognising the effect on their insurance business if they were to pay out claims based on false expert opinion, sent an investigator to find out from Dr Zafar just what had gone on. Dr Zafar tried to blame others, told lies and produced a false witness statement with a Statement of Truth. LV= decided to make an example of Dr Zafar and took High Court action against him, and against the solicitor, for contempt of court. After a lengthy contested hearing, Garnham J found that ten grounds of contempt of court had been proved against Dr Zafar, and he imposed the suspended sentence mentioned above. LV= appealed because they considered it unduly lenient.

The Court of Appeal’s view

The Court of Appeal took a harsh view of the actions of both Mr Khan and Dr Zafar. Mr Khan was not involved in the Court of Appeal case; his future had already been determined. He was jailed immediately by the High Court, the Law Society intervened in his practice, and he is no longer a solicitor. End of. As for Dr Zafar, the judgment is well worth a read, and there was repeated criticism of an expert who makes a false declaration. The High Court referred to a fireman in South Wales Fire and Rescue Service v Smith [2011] EWHC 1749 who had lied about not having any earnings after his accident and was jailed. Garnham J, with whom the Court of Appeal agreed, said this: “Those who make false claims should expect to go to prison. Solicitors and expert witnesses who act dishonestly in the evidence they give to the court, whether in support of such claims or otherwise, must expect a similar outcome. Mr Khan and Dr Zafar, you must understand that the proper functioning of the court system depended on your honesty. Your conduct in this case amounts to a fundamental betrayal of the trust placed in you by the court.”

The outcome

Dr Zafar pleaded financial strain because he had lost his main income. He would clearly not be recognised as an expert again. The court was unimpressed. As for the sentence, the court did find that it was unduly lenient; 6 months suspended for 2 years should have been 9-12 months immediate. But the court contented itself with leaving the suspended sentence undisturbed, although giving guidance for such cases in future. We experts have been warned! The extended Statement of Truth obliges experts to think very carefully before signing off their reports. And now we all know the reason for this extended wording. Solicitors, when choosing experts, should be careful not to instruct experts such as Dr Zafar – and solicitors who wish to remain on the roll must not get involved in such affairs. Simples! 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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Do we still need humans now we have computer translation? By NIK ELLIS, managing director Translate Hive

[WE HUMANS MANAGED to take our

caveman ‘grunts’ and evolve them into around 6,500 languages spread throughout the planet. We went on to invent planes, trains and automobiles, making it easy to live, travel and trade with pretty much any nation. The internet simplified that and shrank our world even more. The existence of so many tongues created a problem in terms of communication and thus translation apps were developed. There are some big problems that these apps are struggling to overcome; for example, even dealing with a single language – say English – presents issues with inconsistent rules. There are loads of instances: ‘i before e except after c’ – but not for my ‘weird beige foreign neighbour’. Why is it ‘he, his and him’ but not ‘she, shis and shim’? ‘Take a bow’ sounds the same as a bough (of a tree) and also the same as cow – and so, therefore, should ‘cough’; yet that follows a different rule. Some words change meaning depending on the sentence: ‘They were too close to the door to close it’.

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So the problem for a logical, rule-based computer programmer is working out how to assign a direct translation of a fluid language into another language with a miss-matching set of rules, different sentence structures, intonation and other idiosyncrasies which alter meanings. There are plenty of translation apps around these days and some of them are really quite good. It can be quite fun to ‘roundtrip translate’, where a phrase is computer translated from one language to another and then back again. It demonstrates how meanings can start to deviate. Those apps are great to help tourists find

their way round foreign towns, order food or book trips. Perhaps some of the words aren’t quite right but they give the general meaning and normally, in those situations, good enough is good enough. What happens, though, when good enough is not an acceptable standard, when accuracy is vital and where the devil is in the detail – such as legal, technical or medical documents? In those circumstances it is imperative that the translation accurately reflects the meaning of the original language. While some ‘lost in translations’ can be funny, to a business, court or government they can be potentially disastrous. Right now artificial intelligence has helped us overcome some of our miss-translations, but to date the software still has far to go to match a human translator. While we’ve seen automation take over so many roles today, the weird and fluid guidelines governing languages mean that humans still have the upper hand in the world of translation and interpretation. q

Fraudulent interpreter sentenced for 12 offences [

A MAN WHO stole the identity of a legitimate court interpreter and provided services to the courts in 140 cases – despite having no qualifications to do so – was sentenced to two years imprisonment, suspended for two years, at Southwark Crown Court on 12 February. Mirwais Patang must also complete 300 hours of unpaid work within 24 months. Patang had previously pleaded guilty to two counts of forgery and two counts of fraud on 27 August. On 4 January, on the first day of a trial scheduled to last for two weeks, he pleaded guilty to a further six counts of fraud, one count of conspiracy to commit fraud and one count of forgery. Detective Andy Cope, from the City of London Police’s fraud team, said: “This has been a long and complex investigation, with further fraudulent activity and deceit being uncovered at every twist and turn. “The blind greed shown by Patang, and the total disregard for the implications of his actions and what it might mean for the integrity of serious criminal trials, is truly appalling. By thinking of only his own financial gain he has undermined confidence in the criminal justice system and put victims of crime through unfair stress and worry.” Patang first acted as a Pashto and Dari interpreter in March 2012, using his own name and identity to register with Capita – the company contracted by the Ministry of Justice (MoJ) – between January 2012 and October 2016. The MoJ relied upon Capita’s processes to ensure interpreters were suitably vetted and qualified. Those wishing to provide interpreting services, as self-employed individuals or contractors, would register with Capita online and then be taken through vetting, security and quality checks and finally issued a ‘tier’ reflecting their skill and experience level. Patang doctored a community interpreting certificate to prove his qualification to Capita and was granted Tier 3 status. Between March 2012 and August 2016 he worked on 88 cases, earning £35,574. In September 2014 Patang stole the identity of a legitimate court interpreter who had Tier 1 status with Capita. That status requires additional qualifications and experience and as a result Tier 1 individuals are paid more for their work. Through using this identity Patang earned just over £30,000 working on 52 cases between September 2014 and July 2015. His fraudulent activity was eventually uncovered when Capita alerted HM Courts and Tribunals Service (HMCTS) to discrepancies in timesheets submitted by Patang for his work interpreting for defendant Taimoor Khan in the high-profile Aylesbury child sexual abuse case,

when he tried to claim for an additional 93 hours of work. As a result of the incident the City of London Police’s fraud teams launched an investigation and found evidence that not only had Patang inflated his claims for this case, but he was in fact using someone else’s identity to pose as a legitimate court interpreter. Capita then confirmed he was also carrying out interpreting work in his own name and had attended 88 cases, at which point police found the qualifications he had provided to be forgeries. A review was conducted of the interpreting provided by Patang in court. After listening to audio files officers suspected that the individual interpreting at the trial of those accused in the Aylesbury child sex abuse case was not in fact Mirwais Patang. Evidence collected by the City of London Police showed Patang had paid his friend Solimann David £1,400 to attend court on his behalf and provide interpreting services for eight weeks of the trial. David also had no qualifications to act as an interpreter. Solimann David pleaded guilty on 27 August last year to a single count of conspiracy to commit fraud. He was also sentenced at Southwark Crown Court on 12 February to six months imprisonment, suspended for one year. He must complete 100 hours of unpaid work within 24 months. The case and coverage in the national press prompted the National Register of Public Service Interpreters (NRPSI) to write to the Ministry of Justice with its concerns and recommendations. The NRPSI was set up in 1994 following a recommendation by the Runciman Royal Commission on Criminal Justice. Its executive director and registrar Mike Orlov said: “This type of situation has been waiting to happen or be uncovered. It comes as no surprise to NRPSI this has occurred given the decline in standards of court interpreting that has been prompted by changes in how court interpreters are sourced by the justice sector. “NRPSI has been campaigning for some time for the Ministry of Justice's language service framework agreements, procurement practices and contracts – and the language agencies that service these contracts – not to sacrifice interpreting standards and risk public safety and the reputation of the justice sector in favour of short-term commercial considerations. The lowering of interpreting engagement fees by language agencies and, in some instances, acceptance of language speakers with no interpreting qualifications for certain grades of assignment is taking its toll on the quality of language services available to the justice sector. “NRPSI believes that only properly remunerated registered and regulated interpreters with the required qualifications and experience should be used by the public services and for court interpreting, and those in the criminal justice system in particular. Those interpreters who become registered have their credentials independently verified and are listed on the publicly-available online register of spoken word interpreters. “This database is free to access and can be used to search for an interpreter by language or location, as well as to check that they are registered and see what they look like. “Were only registered and regulated interpreters used for court interpreting, we would not be faced with the news reports of these 'fake interpreters' and the justice sector's integrity and reputation would not be threatened.” q www.yourexpertwitness.co.uk

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MEDICAL NOTES [IT USED TO BE SAID of the British that we don’t like to complain. Even when things went wrong at the hands of

clinicians it wasn’t our way to make a fuss. That has changed in recent years with the emergence of an American-style ‘litigation culture’. If something goes wrong we now expect amends to be made, while not in any way accusing anyone of deliberate wrongdoing. That change in attitudes, however, seems to have shot off at a tangent during the current coronavirus pandemic, with some patients seeming to blame the NHS and their GPs in particular for the chaos that the virus has caused. Research by the Medical Defence Union has found that over a third of GPs had received a complaint relating to the pandemic – issues such as long waiting times and remote consultation – and more than two thirds fear a surge of cases in its wake. With NHS staff working to a standstill in the face of unprecedented pressure, do we really need people carping about having to wait a little longer for routine treatment? • Where the pandemic has insinuated itself into non-COVID medicine is by diverting resources away from the everyday saving of lives. Heart surgery is an area that has felt the impact most keenly, with nearly 100,000 fewer procedures being carried out in 2020 compared to expectation.

• Doctors themselves are finding themselves being sold short when it comes to protection against the virus in their workplaces. Latest figures from the monthly survey of doctors by the BMA shows that little over a quarter feel fully protected from COVID at work. Doctors from BAME backgrounds feel even less confident – an indicator that the NHS is still not an equitable place to work. • It’s not all doom and gloom, though. The pandemic brought about a shift in emphasis in abortion services to enable early abortions to be carried out at home following remote consultations and prescription. The telemedicine service has been shown to cut waiting times and allow for earlier – and hence safer – abortions. • When there has been a case of negligence, or simply a case of the wrong decision being made, identifying who to pursue is being made complicated by the increasing involvement of multidisciplinary teams (MDTs) in many areas. MDTs have brought about significant improvement in outcomes in a range of clinical settings, the management of chronic pain being one of them. Care must be taken, as with many other collaborative settings, that decision making is not only carried out correctly, but is seen to be so. • The diversity of specialisms involved in treatment is mirrored in the wide range of expertise to be found in the expert witness community. In dentistry, for example, there is a plethora of specialties who can all be loosely identified as ‘dentists’ and if you instruct the wrong one your case could go up in flames. Regular contributor Toby Talbot reveals who does what. • The litigation system is not always on the side of the complainant, however. Anyone tempted to make a false claim for damages against the NHS may find themselves in very hot water indeed. Such was the case of woman in Yorkshire who pursued a fraudulent case for cauda equina against her local trust. She was caught out by video surveillance and sentenced to six months in jail. • The whole medical community, and the plastic surgery profession, was shocked to hear of an attack on one of its most prominent members in January. Former BAPRAS president Graeme Perks suffered ‘life-threatening’ injuries during an assault in his own home. Thankfully, Mr Perks is out of hospital and we wish him a speedy recovery. q

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Doctors fear post-pandemic claims surge [A SURVEY OF 1,203

doctors by the Medical Defence Union (MDU) and GPonline found that two thirds of respondents (67%) feared facing a complaint related to the pandemic. The concern rose to 77% among GPs, and over a third (38%) of primary care doctors had already received a complaint related to the pandemic. Doctors said the commonest reasons for patient dissatisfaction were increased waiting times for treatments, delays in accessing routine screening and tests, communication difficulties and consulting with patients online. While 87% of doctors said patients had been understanding about the changes they had had to make, some doctors reported feeling that public sympathy with the difficulties caused by the pandemic was wearing thin. The survey also found that 43% of GPs and 34% of doctors overall had faced abuse from patients. The MDU reported comments from doctors surveyed, including: “At the start of the pandemic people were supportive, but as time has gone on people are becoming more frustrated. I think the claims will come as a result.” Dr Caroline Fryar, MDU’s head of advisory services, said: “Healthcare professionals are dealing with a wave of complaints from frustrated patients waiting for treatment or further investigations

because of the pandemic. The MDU has supported members with 3,500 complaints and adverse incidents since the first lockdown in March 2020. “Patients have, on the whole, been understanding, and doctors need to respond to all complaints in a thorough and compassionate way. However, with the latest NHS England figures showing that in December over 220,000 people had been waiting for more than a year to start treatment, these cases are likely to be the tip of the iceberg. “It’s concerning that many of the complaints have the potential to become claims for compensation in the years ahead, something which 60% of doctors told us they were worried about. The stress of dealing with complaints and claims far into the future could push many doctors to breaking point. It could lead to an exodus of healthcare professionals at a time when the NHS will be depending on experienced staff to get through the backlog of cases. A quarter of doctors surveyed who had been involved in a past investigation had considered leaving clinical practice or had left. “We are calling on the government to take action to shield healthcare staff from litigation against the NHS caused by the pandemic. Claims are indemnified by the state, but are still complex, time consuming and stressful for those involved.” q

Guidance reflects the new reality of remote prescribing [THE General Medical Council (GMC) has published updated

guidance on prescribing, to support doctors who are increasingly seeing patients via remote and virtual consultations. Good practice in prescribing and managing medicines and devices sets out the regulator’s standards for good practice when prescribing remotely and face-to-face, when prescribing unlicensed medicines, and for when patient care is shared with another doctor. The guidance makes clear that the same standards remain when prescribing remotely as they do when seeing a patient face to face, such as being satisfied that an adequate assessment has been made, establishing a dialogue and obtaining the patient’s consent. Key updates include new advice on prescribing controlled drugs, stronger advice on information sharing, and the importance of good two-way dialogue between patients and doctors in all settings. It also has specific advice for doctors prescribing remotely for patients in nursing homes or hospices, and patients who are based overseas. Professor Colin Melville, the GMC’s medical director and director of education and standards, said: “We understand the enormous

pressures the profession is under as the pandemic continues and the vaccination programme is rolled out across the UK. “Our updated guidance supports doctors who are navigating what for many has become a new reality of remote medicine, helping them to maintain good patient care in these incredibly challenging circumstances. It’s vital that the principles of good practice apply, whether a consultation is face to face or remote.” The updated guidance takes effect from 5 April. q

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Most doctors do not feel protected – BAME doctors even less so [THE BMA HAS REPORTED that thousands of doctors feel they

are not fully protected from COVID-19 in their place of work. And for doctors from BAME backgrounds the picture is even worse. Regularly surveys have been carried out by the BMA since April of last year, including surveying GP practices and hospitals. Doctors have been asked a range of questions, including: “Taking everything into account, do you feel safely protected from coronavirus infection in your place of work?” In April last year only a little more than 11% of doctors said they felt fully protected. The results of the survey in July saw that figure rise, but it was still worryingly low – only 41% of doctors who responded said they felt fully protected in their place of work. Since July that figure has declined steadily and in the most recent survey, conducted in February, just 2,005 doctors – fewer than 28% of those who took part – said they felt they were fully protected from the virus in their place of work. The chair of the BMA consultants committee, Dr Rob Harwood, said: “No one should have to go to work and not feel safe, but these results show that our doctors, the length and breadth of the country, seem to be doing just that – and that’s a terrible indictment. To be caring for patients, many of whom are seriously ill and need complex care, whilst anxious about the adequacy of your own protection from the virus, should not be happening in a 21st-century health service.” A report from the December survey analysed the figures for doctors from BAME backgrounds. They showed that 72% of BAME doctors said they felt only partly or not protected at all from the virus. In comparison, for non-BAME respondents that figure then was 60%. Doctors were also asked about their confidence in having sufficient and properly tested and fitted PPE during this current wave. Among BAME respondents, 16% said they were not at all confident and just under 25% said they were only partly confident. For white respondents the figures were just under 10% and just under 17% respectively. And although a little over 46% of BAME respondents say they have been risk assessed and feel confident that appropriate adjustments have been made, 14% say they have not been assessed and feel that adjustments are needed, and a further 15% say whilst they have been assessed, the adjustments now need updating. By comparison, the results for non-BAME respondents show that 55% have been risk assessed and only 7% reported that their assessments now needed updating. Chair of BMA Council Dr Chaand Nagpaul said: “These results underpin a horrible truth; we have known from very early on in the pandemic that health and social care workers of BAME background

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are more likely to become ill and die from this virus. COVID has exacerbated existing racial and cultural inequities within our health service that have contributed to this disparity.” q

Checks ensure appropriate care for discharged COVID patients [THE Care Quality Commission (CQC) is working with the

Department of Health and Social Care, local authorities and individual care providers to source safe and high-quality care in designated settings, which are part of a scheme to allow people with a COVIDpositive test result to be discharged safely from hospitals. The measure is to help prevent the spread of COVID-19 in care homes and will allow for a focus on the care that people who have contracted COVID-19 need. The government’s aim is for each local authority to have access to at least one designated setting as soon as possible. For inspections of designated settings, CQC is checking for specific elements to ensure infection control can be maintained. Using its infection prevention and control framework CQC is inspecting care locations against eight areas and reporting with ‘eight ticks’ on infection prevention control which will give the public an overview. The criteria include whether adequate PPE is available for staff and residents to control infection safely, whether staff are properly trained to deal with outbreaks and proper procedures are in place, whether shielding and social distancing are being complied with and ensuring the layout of premises, use of space and hygiene practice to promote safety. q

Telemedicine abortion service is safe and effective, study finds [

ALLOWING WOMEN to have abortions at home has provided a safe, effective and more accessible service. That is the conclusion of a study that analysed national data on early medical abortions from before and after the coronavirus pandemic. At the start of the pandemic the Royal College of Obstetricians and Gynaecologists (RCOG) urged the government to change the law so that women could access early medical abortions at home. That was approved in England in March last year and shortly after in Scotland and Wales. The largest-ever study of UK abortion care, carried out by researchers at the University of Texas at Austin, the British Pregnancy Advisory Service, MSI Reproductive Choices and the National Unplanned Pregnancy Advisory Service, has analysed the outcomes of more than 50,000 early medical abortions that took place in England, Scotland and Wales between January and June 2020 – both before the telemedicine service was introduced and after. The aim was to compare data and see how the telemedicine service compares to the service before.

Prior to the telemedicine service being approved, anyone seeking an abortion needed to attend an in-person appointment to receive an ultrasound scan and take the medication used to bring about an abortion within the clinic. Under the new guidelines, consultations were encouraged to take place by telephone or video call. The medication could be taken at home, with an ultrasound scan only taking place if needed. The key findings from the study were: • Waiting times from when the woman has her consultation to treatment improved from 10.7 days to 6.5 days • Women are able to receive care much earlier in their pregnancy – with duration of the pregnancy at the time of the abortion significantly reduced. • The effectiveness of the treatment remained the same for abortions carried out through the traditional service and the telemedicine service. • There were no cases of significant infection requiring hospital admission or major surgery. Nobody died from having an early medical abortion at home. • 80% of women said telemedicine was their

preferred option and they would choose it in the future. • None of the women said they weren’t able to consult in private using teleconsultation. The UK government’s consultation on whether or not to make the service permanent closed on 26 February. The RCOG, along with abortion service providers in the UK, has urged the government to make the telemedicine service permanently available. Prof Dame Lesley Regan, chair of the RCOG’s abortion taskforce, said: “One argument I hear time and again is that changing abortion laws makes it ‘easier’ to get an abortion and will lead to more women choosing to have one. Indeed, some may believe that keeping abortion difficult to access, more unpleasant to undergo and more dangerous, will persuade women to continue their unwanted pregnancy. “You just have to look around the world to recognise this claim is invalid. Every day scores of desperate pregnant women put themselves in extreme danger by undergoing illegal and unsafe abortion. Reducing access to abortion doesn’t make it any less common, but it does make it less safe.” q

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Heart op delays cost lives, says BHF [

NEW FIGURES SHOW the impact of the pandemic on potentially life-saving surgery and other procedures for heart patients as the NHS is pushed to breaking point by surging COVID-19 cases. Around a third fewer heart operations than expected were performed by the end of November in England, the analysis found. In total, the number of operations such as coronary bypass and heart valve surgery fell to around 25,000 from 37,000 during the same period in 2019. Other invasive heart procedures, such as fitting stents or balloons to open blocked arteries, have also been impacted. In total, around 96,000 fewer heart operations and procedures than expected took place in the year to November in England compared to the same period in 2019.

Shrinking waiting lists

Paradoxically, surgery and treatment waiting lists are shrinking at the same time as operation and procedure numbers are falling. There were 39,067 fewer people on waiting lists for heart operations and

Collaborative research uses new data resource

[

A LINKED health data resource covering 54.4 million people – over 96% of the English population – has become available for researchers from across the UK to collaborate in NHS Digital’s secure research environment. The resource is enabling vital research to take place into COVID-19 and cardiovascular disease, with the aim of improving treatments and care for patients. This work has been led by the CVD-COVID-UK consortium in partnership with NHS Digital. The CVD-COVID-UK consortium is a collaborative group of more than 130 members across 40 institutions, working to understand the relationship between COVID-19 and cardiovascular diseases. The consortium is managed by the British Heart Foundation Data Science Centre, led by Health Data Research UK. The new resource links health data from GP records, hospital data, death records, COVID-19 laboratory test data and data on medications dispensed from pharmacies, and is accessible to CVD-COVID-UK consortium researchers in NHS Digital’s Trusted Research Environment (TRE) Service for England. q

procedures at the end of November in England compared to February. It bears out a fear expressed by the British Heart Foundation (BHF) that, despite the NHS working all hours to prioritise the sickest patients, a lack of available non-COVID care means that fewer people are being added to waiting lists. Many of those on waiting lists are having to wait longer. The number of people waiting more than a year in England has soared to 2,800 – 100 times as many as there were in February last year. A spokesperson for the BHF said: “We believe the latest figures are just the tip of the iceberg, with a hidden, larger backlog of heart care left unaccounted for. We have warned that more disruption for heart patients is yet to come, resulting in heart surgery and procedures being paused. “We have said that as soon as the current crisis eases, it is vital that heart services are prioritised, protected and expanded to address the significant backlog of people awaiting treatment.”

Delays to care

Long waits to have or be referred for surgery or treatment can lead to more unnecessary deaths and ill health. Latest figures show there have been more than 5,000 excess deaths from heart diseases and stroke in England since the pandemic began, and delays to care have likely contributed. Dr Sonya Babu-Narayan, BHF’s associate medical director and a consultant cardiologist, said: “The NHS is working on overdrive to prioritise all urgent COVID and non-COVID care. At the same time, we must not lose sight of people with heart conditions whose planned treatment has been delayed. Surgery and other invasive procedures to treat heart disease are not luxuries that people can easily go without – delaying them can cost lives.” q

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The role of multidisciplinary teams in chronic pain management DR CHRIS JENNER MB BS FRCA FFPMRCA, Consultant in Pain Medicine and experienced expert witness, discusses the use of multidisciplinary teams in managing pain, explores the patient benefits and also looks at the medicolegal challenges of a multidisciplinary approach.

[

CONDITIONS SUCH AS chronic pain can be extremely complex and may require input from a number of different specialties in order to diagnose patients and provide effective treatments. As a result, there has been an increase in the use of multidisciplinary teams (MDTs) in the management of patients with pain. However, the expertise on offer can vary considerably, and while the use of MDTs is often beneficial to patients, not all teams are completely integrated. There are also unresolved issues surrounding liability, should a problem with a patient’s care subsequently lead to litigation. There is no fixed composition of a MDT, but a typical team will include practitioners from many medical disciplines. By incorporating a wide range of specialties, patients benefit from the integration of various areas of expertise and the different treatments they offer. In addition, the team will be better placed to assess and manage the multiple physical, psychological and social aspects of chronic pain. Thus, the core members of a team will usually include practitioners from three or more of the following medical specialties: Pain medicine physicians. As well as carrying out interventional procedures, pain medicine physicians are vital in the pharmacological provision of adequate pain relief, leading to improvements in sleep, mood and exercise tolerance. Neurologists. As pain management is now recognised as a subspecialty of neurology, neurologists are increasingly likely to be involved in MDTs treating patients with non-cancer pain. These doctors are experienced in the treatment of patients with chronic pain arising from inflammatory diseases of the musculoskeletal system and connective tissue, degenerative conditions of the joints and spine and soft tissue disorders. Orthopaedic surgeons. Surgical intervention may be an option in some cases. Orthopaedic surgeons often perform functional assessments of patients. Psychologists/psychiatrists. Many patients with chronic pain suffer from psychological/psychiatric symptoms – such as anxiety, depression and post-traumatic stress disorder – and can benefit from appropriate psychological/psychiatric treatment. There may be psychosocial barriers to recovery which can be improved by programmes such as cognitive behavioural therapy that increase psychosocial well-being by helping to change a patient’s thoughts, feelings and beliefs about their pain. Physiotherapists/physical therapists. Chronic pain often leads to the avoidance of physical activity, either due to the fear of reinjury or because it makes existing pain worse. Physical therapy, which aims to target the musculoskeletal conditions which cause or result from pain, is important in the treatment of many complex pain conditions. Nurses also play an important role in most MDTs. Coordination of care is often their responsibility: they will be called upon to assess

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patients and supervise medication regimes, and to conduct nonpharmacological interventions such as relaxation and other strategies. Additional team members come from a wide range of non medical fields, many of whom practise in the community and will work to support the patient in various aspects of daily life. Practitioners might include pharmacists, occupational therapists, complementary therapists, dieticians and educational therapists. As well as specialist practitioners, the patient’s primary care provider often plays a central role in the MDT. He or she is responsible both for the long-term management of the patient according to the suggested treatment plan and also for referring the patient for additional assessment and treatment if and when this is required. Therefore, good communication between the MDT and the primary care provider is as important as the collaboration between the team members themselves. Surprisingly, not all MDTs include a pain medicine physician. While usually coming from a background in anaesthesia, pain medicine physicians have undergone extensive further training in order to gain specific knowledge of the evaluation, diagnosis and treatment of different types of pain. Thus, they have in-depth knowledge of pain physiology and can evaluate patients with complex conditions. Much of the patient’s experience of pain is subjective and there are no tests available to prove its existence. This means that diagnosis can be difficult and a number of different diagnoses may be made to explain the same set of symptoms. As pain medicine is a specialist field, only a pain medicine physician will have the necessary experience and proficiency to provide an accurate diagnosis. Pain medicine physicians can be particularly useful in litigation, as chronic pain cases are often dependent on the plausibility of expert witnesses. They are able to offer an opinion on causation, treatment and prognosis, and thus provide input to help guide the legal teams in determining an appropriate level of compensation. The benefits of MDTs for patients have been consistently demonstrated. As well as a reduction in pain intensity, patients show improvements in physical functioning, quality of life and psychological factors. A meta-analysis of 65 studies of multidisciplinary treatment for chronic back pain showed that patients treated in this way reported lower subjective ratings of pain than those receiving conventional unimodal treatment or no treatment at all. Additionally, patients in the MDT group reported a lower use of the healthcare system and were twice as likely to return to work as patients in the other two treatment groups combined. MDTs work because there is a continuity of care, which can be delivered to the patient in a coordinated treatment programme. This avoids duplication of investigations and also ensures that treatment failures can be identified quickly.

However, while an MDT offers input from several different disciplines in the same location, this does not always mean the patient’s condition is treated in an integrated manner. It is common for some of the members of the team to be involved on a part-time basis only and this may be particularly frequent in smaller practices who do not see enough patients to justify a permanent full-time team. In addition, although teams should hold regular meetings in which cases are discussed, not all of them do so. A study in Canada found that less than 80% of teams held such meetings, and only about a quarter of teams held a weekly meeting. Problems can also arise if communication within the team is not open and free from animosity. If an overbearing individual dominates the team, true collaboration cannot take place and the team becomes dysfunctional, to the possible detriment of patient safety. Perhaps a bigger problem is the question of liability in the event of harm to a patient as the result of a decision or treatment recommendation made by an MDT. In medical law, responsibility lies with individuals and not with groups. Unlike a corporation or statutory body, an MDT has no official legal identity. Instead, any decisions made by the team are considered to have been made on the basis of the individual opinions of the doctors present at the meeting. However, each doctor can only be held responsible for the part of the decision that lies within their area of expertise. Furthermore, the soundness of the decision relies upon all of the relevant information having been made available to the MDT. It is the responsibility of the primary clinician, who may be a part of the team or the patient’s primary care provider, to ensure that this happens and that all of the information provided is accurate. Once a recommendation has been made by an MDT, it should be explained to the patient so that he or she can make an informed decision. It is particularly important that any disagreements within the MDT team, along with the reasons for them, are also communicated to the patient. Disagreements can occur in MDT meetings but are not always formally recorded, despite the fact that documentation of dissent would obviate the personal responsibility of that particular clinician should the MDT later be found liable. Likewise, if the referring clinician decides to depart from the conclusions reached by the MDT, this should be explained to the patient. The doctor must consider the implications of deviating from the MDT’s plan without justification, and should therefore provide clear documentation of their reasons for doing so. Without such explanations, any consent given by the patient may well be considered invalid. Additionally, if the patient becomes aware of disagreements after an incident of alleged harm, it is more likely that he or she will seek recourse through litigation. Thus, where significant changes to treatment are made after the MDT discussion, it may be prudent to inform the team of this and invite a new discussion, in case the clinical decision is later challenged in court. Chronic pain is a complex condition, often affecting the physical, psychological and social well-being of the patient. The MDT is considered to be the optimal treatment modality for many forms of chronic pain. However, it is unclear where liability lies in the event of a patient coming to harm as the result of an MDT decision and as yet this situation is untested in UK courts. As litigation levels continue to rise, it seems inevitable that MDT decision making will be examined in the future.q • Dr Chris Jenner is highly regarded for his extensive experience and skill across the range of medico legal cases involving pain, particularly complex cases which less experienced experts find challenging. Dr Jenner is based at Imperial College NHS Trust and is clinical director of a private practice in London. He has 15 years’ experience as an expert witness. His expertise includes neuropathic pain, chronic widespread pain, fibromyalgia, complex regional pain syndrome (CRPS), phantom limb pain and post-mastectomy pain syndrome, as well as multidisciplinary pain management. Read his biography and CV on the website at www.medicolegal-partners.com/jenner www.yourexpertwitness.co.uk

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Welcome to our A to Z guide of the websites of some of the Expert Witness field’s leading players. If you are one of our many online readers simply click on any of the web addresses listed below and you will be automatically directed to that particular website. To get your website listed on this page just give us a call on 0161 710 3880 or email ian@dmmonline.co.uk Mr 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 17 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.

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www.yourexpertwitness.co.uk

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

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

Scotland faces dental crisis, dentists warn [THE British Dental Association Scotland has called on all

political parties in the devolved administration to set out an effective response to the crisis facing dentistry as new data reveals the collapse in attendance during the COVID pandemic. While registration rates remained high and broadly stable – owing to lifetime registration – data indicates the number of children seen between May and December was around a quarter of the 2018-19 average due to the pandemic. Between September and November the number of adults seen was around a third of the 2018-19 average, before falling to 28% of the 2018-19 average in December. The traditional measure of ‘participation’ – capturing attendance at an NHS dentist in the past two years – has less meaning in the context of COVID, the BDA says, as the full impact of the pandemic has yet to filter through. Those in more deprived communities have traditionally experienced lower levels of participation and the latest data shows

that in 2020 children and adults from the most deprived areas were less likely to have seen their dentist within the past two years than those from the least deprived areas – 73.5% compared to 85.7% of children and 55.9% compared to 67.1% of adults. The BDA has warned lower levels of participation will inevitably translate into a higher disease burden. Early signs of decay and oral cancers are picked up at routine check-ups, and delays will mean both higher costs to the NHS and worse outcomes for patients. Robert Donald, chair of the British Dental Association’s Scottish council, said: “These numbers underline the scale of the challenge ahead. Millions have missed out on dentistry. Problems that could have been caught early, from decay to oral cancer, have been missed. “Scotland’s huge oral health inequalities cannot be allowed to widen. Every party heading into May’s election now has a responsibility to set out how they will ensure families across Scotland can get the care they need.” q

Dental regulator responds to DHSC White Paper [

THE CHIEF EXECUTIVE and registrar of the General Dental Council, Ian Brack, has responded to the Department of Health and Social Care’s White Paper, Integration and Innovation: working together to improve health and social care for all. The White Paper, published on 11 February, set out the department’s legislative proposals for a Health and Care Bill. It aims to build on ‘the incredible collaborations we have seen through COVID and shape a system that’s better able to serve people in a fast-changing world’. Building on the NHS’s Long Term Plan, the document sets out three main priorities: removing the barriers that stop the system from being truly integrated; using legislation to remove much of the transactional bureaucracy that has made sensible decision-making harder; and ensuring a system that is more accountable and responsive to the people that work in it and the people that use it. In a statement Ian Brack said: “We very much welcome the government’s renewed commitment to regulatory reform, something for which we have been making the case for some time. The General Dental Council continues to operate within the limits of outdated and restrictive legislation which, in many instances, prevents a flexible, efficient and proportionate approach to regulation. “While we have made improvements within the current framework, further progress without legislative change will be limited and so we look forward to continued collaboration with the department towards the shared aim of achieving as rapid a solution as possible.

“We also note the proposed creation of new powers for the Secretary of State to remove professions from regulation and abolish individual regulators. We understand that the government does not have any specific plans to use such a new power, which in any case is dependent on Parliament approving the necessary legislative change. In the meantime, our primary focus as ever remains on maintaining public protection and confidence in dental services.” q

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Choosing a dental expert witness – a personal perspective By TOBY TALBOT BDS (Sheff) MSD (Washington) FDS RCS (Eng) Specialist in Restorative Dentistry

[IT IS HELPFUL for counsel to understand the

‘variety’ of dentists in the market for providing expert reports. General dental practitioners, like our medical counterparts, are ‘jack of all trades; master of none’. They have a very good all-round view of the business of dentistry, but are rarely up to date with the clinical literature – confining themselves to reading from the British Dental Journal and a few other general publications that are offered to the profession. The oral and maxillofacial surgeon will also have a dental degree, and his medical background and hospital appointments will give him the added expertise regarding greater injuries to the face and jaws following severe trauma and an insight into those cases related to detection and treatment of oral cancer in a timely manner – and the devastating consequences if overlooked. They are also experts in developmental anomalies of the face and jaws such as cleft palate and lip. Orthodontists also have dental degrees, but with added specialist knowledge and training to carry out finelycontrolled movements of teeth that are often causing the patient cosmetic embarrassment. ‘Rabbit’ teeth or crooked teeth where the teeth cannot fit in the available jaw space can all lead to patient concerns or, in the case of many children, parental concerns. However, as children are continuing to grow the teeth will often move readily with the most subtle ‘nudging’ – and quite rapidly when compared with the adult. More and more ‘adult orthodontics’ is being carried out, not only by orthodontists but also by general dental practitioners who have a special interest in the subject. Adults are far more demanding when it comes to having their teeth re-aligned than children, who just want to be ‘out of their braces’ as quickly as possible once the novelty wanes. If treatment is offered on the NHS with no money involved in the transaction, the bar tends to be set lower by these young patients and parents alike. Adults rarely qualify for orthodontic treatment on the NHS unless in conjunction with abnormal jaw developments. Orthodontics will normally involve considerable cost to the patient. Therefore, many general dental practitioners are opting for brief courses in new methods of ‘invisible orthodontics’ when they may lack the basic three-year intensive training of the true specialist practitioner. My advice to counsel is to engage the expertise of an orthodontist if their clients are complaining about the outcome of orthodontics and not a generalist, even if the ‘failed treatment’ was carried out by a general dental practitioner. The other specialist fields of dentistry include: • Prosthodontists who specialise in the replacement of lost teeth. • Periodontists who are specialists in gum disease issues. It is a common factor that can be easily overlooked by the busy generalist who may fail to diagnose the disease process in a timely manner until it becomes too late to save the teeth. • Endodontists who are specialists in infected root canals and their treatments. It may surprise the reader that the long-term success of root canal treatments carried out by generalists may be only 50% whereas the endodontist is likely to preserve over 90% of treated teeth in the longer term. • Paediatric dentists who confine their services to children. • Restorative dentists who encompass all three fields of prosthodontics, periodontics and endodontics. They are able to handle the complex cases where more than one of the fields is involved, associated with multidisciplinary cases that do not fit neatly into one single field. • Implantologists don’t exist, except by self-promoting practitioners who are wishing to tap into a lucrative market. Dental implants come into the remit of the prosthodontist, who will often work closely with the maxillofacial surgeon to combine their respective areas of expertise. Many general dental practitioners with a special interest in the field provide a service. Weekend courses held in airport hotels are commonplace, whereas the dedicated three-year training programmes underpinned by formal teaching institutions

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are a very different matter. My advice to counsel dealing with failed implant treatment is that you do your homework with regard to whom you seek expert advice from when faced with failing implants. To avoid many pitfalls for the office of counsel, I recommend due diligence is conducted by the solicitor’s office to ensure that the selected expert can deliver the goods. If the case is simple and straightforward, and thus wholly within the remit of a general practitioner, you can commission a general dental practitioner. But if you require to consider a specialist dental expert: • A maxillofacial surgeon can give you a critical appraisal of a wholly surgical issue. They should not give a dental opinion that can be relied upon – even though they often do. Their dental knowledge is often little more than what they retain from their dental undergraduate days, which reflects their need to focus on their postgraduate surgical training. • If the problems relate to periodontal/gum disease, find yourself a periodontist. • If the problems relate to failed root canal treatments, find yourself an endodontist. • Failed denture or crown and bridgework? Get yourself a prosthodontist. • If the case is multifactorial and covers a broad range of dental problems, get yourself a specialist in restorative dentistry. They are all dentists – but they’re all different creatures. In addition, check out whether the expert is still active at the coalface. I attended a professional meeting in London and met a colleague who was very proactive as an expert witness. He had just celebrated his 85th birthday, having retired as a clinician 20 years ago. How on earth can counsel expect him to be up to date? He will invariably find himself before a judge – in all probability and ironically of advanced years – giving evidence, only to be publicly humiliated when asked the ultimate question by the opposing QC: When did you last undertake a similar procedure? The reader is reminded of the influence of the Wolfe Report a few years back. Partisan conduct, whereby former practitioners would consider it their mission to protect colleagues, has been stopped to reflect professional transparency and candour. Likewise, those colleagues who considered ‘protecting the patient’ as a crusade will find themselves outed. Gone are the days when senior retired medical/dental colleagues can dabble in report writing for a bit of pocket money without finding themselves humiliated in court, outed for being out of touch with current clinical practice. Court immunity has now become a thing of the past, resulting in a considerable reduction in our numbers. Professional training and registration of expert witnesses has culled the amateurs.

A personal footnote

It is noted that many solicitor firms engage agencies for the management of medicolegal cases. The agencies will have built up over the years a large database of experts with a multitude of expertise, in order to act as facilitators to collect the reports and act as an intermediary for fee collection. The contract of engagement with the expert is kept at arm’s length from the solicitor’s firm and may allow the solicitors to delay payment until the conclusion of the case – alleviating cash flow issues. Although that may appear on the surface as a favourable thing, I have yet to conclude that the intermediaries add any real value to the proceedings. I much prefer to establish dialogue directly with Counsel to get things done. If the ‘weight’ of delaying financial settlement is considered greater than the establishment of a relationship between myself and Counsel, then I regret it. I am unable to build a relationship with a faceless clerk in an institution handling over 300,000 cases a year, as I do when I am dealing directly with a solicitor who perhaps may be dealing with 1-200 cases a year. I consider the engagement of intermediary agencies means we are all missing out. I invite the reader to reflect. q

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Lockdown leads to CBS hallucination spike [

THE Royal National Institute of Blind People (RNIB) is warning that on-going lockdown and coronavirus restrictions could be causing a spike in hallucinations due to sight loss. The hallucinations, known as Charles Bonnet Syndrome (CBS), are caused when the brain attempts to fill in gaps in visual information with invented images or patterns. The visions vary from person to person and range from simple lights or patterns to complex images. They are often distressing. Over the past 12 months the number of people calling RNIB’s Sight Loss Advice Service to report CBS has increased – with sharp peaks in calls corresponding with coronavirus restrictions. In January the number of calls about hallucinations increased by 67% compared to January 2020 and accounted for more calls than any other condition, including common

AMD is linked to air pollution, study finds

complaints such as cataracts and age-related macular degeneration (AMD). Although there is little research into the condition, it is widely believed that at least a third of all people with significant sight loss experience the symptoms – meaning that it could affect more than 100,000 people – but it is often under-reported. Dr Louise Gow, specialist lead for eye health at RNIB, said: “The increase in calls and emails we have received about CBS during lockdowns has been dramatic. And the visions that are being reported are much more vivid than usual, which has left many people feeling particularly distressed – describing their hallucinations as ‘out of control’. “It’s as though the stress and anxiety of coronavirus, and the resulting restrictions, has had an impact on people’s symptoms. Although there is currently no research to confirm such a link, it would seem stress and lack of stimulation can increase symptoms. “With the rise in calls we are seeing, it is very worrying that awareness of CBS remains low, even among health and care professionals. We have heard of several instances where GPs have mistakenly referred patients to mental health services, rather than directing them to information about how to cope with CBS and ensuring that they see an eye health professional. If this happens, it is possible that the underlying vision issue causing the CBS is not treated and could worsen, resulting in further avoidable sight loss.” The rise in the condition has even sparked interest from Britain’s longest running soap, Coronation Street. A new storyline shows Weatherfield resident Johnny Connor begin to hallucinate cockroaches, cats and people. Although his symptoms are caused by sight loss, they are initially misidentified as a psychiatric issue. In response to the issue, RNIB has launched a Talk and Support service specifically for people experiencing CBS. Created with CBS specialists Esme’s Umbrella, the service involves small groups of blind and partially sighted people regularly meeting by phone or online for peer support. q

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AIR POLLUTION is linked to a heightened risk of developing age-related macular degeneration (AMD), according to a new study. The findings, published in the British Journal of Ophthalmology, revealed that people living in the most polluted areas were at least eight per cent more likely to report having AMD. The research drew on data from 115,954 participants in the longterm, community-based UK Biobank study, which involves more than half a million people. All the participants were aged 40-69 at the start of the study with no eye problems, and were asked to report any subsequent diagnosis of AMD by a doctor. The study also estimated pollutants such as PM2.5, nitrogen dioxide and nitrogen oxides, which largely come from vehicle engines, to calculate the average annual air pollution at people’s home addresses. Just over 1% of the overall group – 1,286 people – were diagnosed with AMD. Once other factors such as lifestyle and underlying health conditions were taken into account, participants exposed to higher levels of concentrations of PM2.5 were found to be 8% more likely to report they had been diagnosed with AMD. As it was an observational study, researchers themselves have said this alone does not prove that pollution caused sight loss. However, the findings add to the growing evidence of the damaging effects of outdoor air pollution on our eye health. Geraldine Hoad, research manager at the Macular Society, said: “While this is an interesting study and adds to a body of growing evidence that pollution is bad for our health, there is not yet enough evidence to conclude that it increases our risk of developing AMD. The risk of developing AMD is down to your genetics as well as your environment and lifestyle. A healthy diet and not smoking are important ways in which everyone can reduce their risk of developing AMD.” q www.yourexpertwitness.co.uk

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What are the commonest pitfalls in urological diagnosis?

There are a number of regular themes in medical negligence work in urology. In this brief article consultant urologist CHRIS DAWSON MS FRCS LLDip shares his experience in writing reports on the subject over the past 15 years.

[

CASES INVOLVING testis torsion feature regularly in urology medical negligence claims. Following the onset of pain – due to twisting of the testicle around the spermatic cord – early intervention is required to prevent ischaemia, and the loss of the testis. The condition can be difficult to diagnose. In my experience, most claims result where the torsion is misdiagnosed as infection (epididymo-orchitis or epididymitis) and the claimant sent home, before representing with continued pain later – by which time the testis is beyond salvage and requires surgical removal. That is a frequent precursor to allegations of negligence in young men. Testis torsion usually presents with sudden onset of pain. It may wake the patient from sleep or start after exercise or minor trauma to the genitals, or after sexual activity. Epididymo-orchitis most commonly occurs in men aged 18-35 years. Although it can occur at any age, it is uncommon in prepubertal males. Patients with epididymitis usually present with pain of gradual onset. Where diagnostic uncertainty exists the affected scrotum should be explored surgically urgently, and that should not be delayed while imaging is requested – not least because imaging is often delayed in out-of-hours situations. Ischaemia to the testis can occur as soon as four hours after the onset of torsion, with the potentially devastating outcome of loss of the testis. In one study investigators quoted a testicular salvage rate of 90% if detorsion took place within six hours from the onset of symptoms. That fell to 50% after 12 hours, and to less than 10% after 24 hours.

Prostate cancer

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

an MRI of the prostate to look for targetable lesions, followed by a transrectal ultrasound of the prostate. The majority of urological claims in this area arise when cancer is not detected. That is a frequent occurrence and both tests mentioned above have an appreciable false negative rate. Patients must be counselled that, while no cancer has been detected, it does not necessarily mean that cancer is absent, and further monitoring is therefore appropriate. In one case recently submitted to me the patient was not appropriately counselled, nor were specific follow-up instructions given to the patient’s GP with regard to PSA monitoring after the initial tests were negative. As a result the patient was not properly followed up over the next five years, and returned at that time with a significantly raised PSA and metastatic – and thus incurable – prostate cancer. The defendants were advised that the case could not be defended.

Bladder monitoring after surgical procedures

Urinary retention (failure to pass urine leading to a distended bladder) can occur after surgical procedures. Transient filling volumes between 500mls and 1,000mls do not appear to be harmful to the bladder if treated within 1-2 hours. However, prolonged overdistension of the bladder often results in failure of the bladder muscle to contract properly, and an inability to empty the bladder. Patients in that situation often require management, with on-going clean intermittent self-catheterisation to ensure that the bladder is emptied. That involves passage of a catheter into and out of the bladder several times a day. Claims in that area invariably stem from a failure of medical staff to properly document that a patient is voiding urine well after a surgical procedure, and that the bladder is not retaining excessive amounts of urine. A common theme in those cases is a desire to discharge the patient home speedily. q www.yourexpertwitness.co.uk

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Study charts PTSD in COVID patients [

MORE THAN ONE THIRD of COVID-19 patients put on a ventilator experience extensive symptoms of post-traumatic stress disorder (PTSD), according to research by Imperial College London and the University of Southampton, published in the Royal College of Psychiatrists’ BJPsych Open. The findings came as the numbers of COVID-19 patients in hospital reached a record high in the UK, far exceeding the numbers in May when the study was conducted. The researchers documented symptoms of PTSD in over 13,000 UK patients with experience of confirmed or suspected COVID-19. Extensive symptoms of PTSD were found in 35% of patients put on a ventilator and 18% of patients hospitalised without requiring a ventilator. They also found lower levels of extensive symptoms of PTSD for patients given medical help at home (16%) and patients who required no help at home but experienced breathing problems (11%). The symptoms of PTSD can start immediately or after a delay, but usually within six months of the traumatic event. A traumatic event is one where you see that you are in danger, your life is threatened, or where you see other people dying or being injured. Without timely treatment, PTSD symptoms can continue for years and prevent people from moving on with their lives. The most common PTSD symptom experienced by COVID-19 patients was intrusive images, sometimes known as ‘flashbacks’. For example, it

could be intrusive images of the ICU environment, ICU doctors wearing full PPE or other patients in the ICU. Dr Adam Hampshire, from Imperial College London, commented: “The data collected from our online studies is helping to provide insights into the psychological impact of COVID-19. We can see that the pandemic is likely to be having an acute and lasting impact, including for a significant proportion of patients who remained at home with respiratory problems and received no medical help. This evidence could be important for informing future therapy and reducing the long-term health burden of this disease.” The researchers adapted a clinical questionnaire, selecting 10 questions on symptoms of PTSD most relevant to COVID, including intrusive images, trying to ‘erase’ memories and being easily startled. While 35% of patients put on a ventilator experienced all 10 of these symptoms, 41% of all COVID patients experienced at least one to an ‘extremely’ high degree. Dr Adrian James, president of the Royal College of Psychiatrists, said: “It is clear that COVID-19 can have serious mental health consequences. This virus isn’t just a threat to our physical health; it also poses significant risks to mental health during and following the illness. “Effective and joined-up follow-up care must be provided after discharge and mental health services must be adequately expanded to treat increasing numbers of people with PTSD symptoms.” q

Guidance helps professionals working with degenerative diseases [NEW GUIDANCE from the British

Psychological Society provides psychologists and other health professionals with evidencebased recommendations for providing psychological support to people living with four motor neurodegenerative conditions: Huntington’s disease, Parkinson’s disease, motor neurone disease and multiple sclerosis. Following a review of the current literature the guidance gives evidence of the effectiveness of psychological interventions for each neurodegenerative condition. It also categorises them by type of psychological outcome and by type of psychological intervention. Psychological interventions for people with Huntington’s disease, Parkinson’s disease, motor neurone disease and multiple sclerosis

is the result of Minds & Movement – a joint initiative developed by health researchers from Lancaster University, the BPS Division of Clinical Psychology and the BPS Faculty for the Psychology of Older People. Jane Simpson, Professor of the Psychology of Neurodegenerative Conditions at Lancaster University and co-author of the guidelines, said: “We are delighted that this guidance is now available and are extremely grateful to all those health professionals and groups and charities supporting individuals living with these conditions for sharing their own work and patient experiences. “While we are able to make some useful recommendations regarding what therapies can be effective for different psychological

difficulties, we have also been struck by both the lack of research – especially for people with motor neurone disease and Huntington’s disease – and the lack of accessible psychological services for many in the UK. “We hope that our guidelines will add to the voices of patients and supporting associations for more funded research and more support for these essential psychological services. “Living with the physical challenges of these conditions is undoubtedly difficult but we also need to make sure we are looking to support the mental health and well-being of the hundreds of thousands of individuals in the UK affected by these conditions.” The guidance is free to download from www.bps.org.uk/topics/neuropsychology. q

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Govt consults on Mental Health Act reforms [ THE Department of Health and Social Care has launched

a White Paper detailing proposals to reform the Mental Health Act in England and Wales. The White Paper builds on the recommendations made by Prof Sir Simon Wessely’s Independent Review of the Mental Health Act in 2018 which set out what needed to change in both law and practice in order to deliver a modern mental health service that respects the patient’s voice and empowers individuals to shape their own care and treatment. The government’s proposed reforms aim to tackle the racial disparities in mental health services, better meet the needs of people with learning disabilities and autism and ensure appropriate care for people with serious mental illness within the criminal justice system. The government will consult on a number of proposed changes, including: • Introducing statutory ‘advance choice documents’ to enable people to express their wishes and preferences on their care when they are well, before the need arises for them to go into hospital • Implementing the right for an individual to choose a nominated person who is best placed to look after their interests under the Act if they aren’t able to do so themselves • Expanding the role of independent mental health advocates to offer a greater level of support and representation to every patient detained under the Act • Piloting culturally-appropriate advocates so patients from all ethnic backgrounds can be better supported to voice their individual needs • Ensuring mental illness is the reason for detention under the Act, and that neither autism nor a learning disability are grounds for detention for treatment of themselves

• Improving access to community-based mental health support, including crisis care, to prevent avoidable detentions under the Act. That is already underway backed by £2.3bn a year as part of the NHS Long Term Plan. q

Effect of unemployment on mental health highlighted [A NEW REPORT published by the Mental Health Foundation

and Cochrane Common Mental Disorders has warned that rising unemployment and job uncertainty during the COVID-19 pandemic will have a profound effect on mental health at a countrywide level. With the UK unemployment rate rising – according to the figures from the ONS – the Mental Health Foundation is calling on both local and national government to put practical and emotional support in place for the hundreds of thousands of people struggling with unemployment. The report, State of a Generation: Upheaval, uncertainty, and change: themes of adulthood, examines different life transitions that have an impact on our mental health. The foundation conducted a review of existing research, surveyed 3,879 UK adults aged 18-64 with Deltapoll, and worked with Citizen’s Advice Wandsworth to host an in-depth discussion with a group of women about their experience of unemployment and job loss. The report finds that the impact of increasing unemployment and job uncertainty on mental health is manifold. Increased job insecurity, for example, has been found to increase risk of depressive symptoms and unemployment has been found to negatively affect self-esteem and increase feelings of distress. q

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Diabetic foot: what are the issues and how should it be treated? 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

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DIABETES AFFECTS about 3.9 million people in the UK at present and leads to about 9,000 lower limb amputation per year, according to Diabetes UK. Diabetes occurs in two forms: Type 1, in which the pancreas fails to make sufficient insulin, usually presents in early adult life and requires treatment with insulin injections; Type 2 usually arises in later life and is associated with obesity. In Type 2 the pancreas continues to produce insulin, but the body does not respond correctly to the insulin – leading to high glucose levels in the blood. Treatment usually starts with a combination of diet and oral medication; some patients also require treatment with insulin. That type of diabetes is the most frequent, accounting for 90% of patients with diabetes. The number of people with Type 2 diabetes continues to grow.

have been shown to be associated with increased cardiovascular risk and poor outcomes in patients with diabetes. Regular clinic reviews allow advice to be offered concerning better diabetic control, adherence to the dietary regime with weight loss and exercise.

Diabetic foot problems

In general, a combination of problems gives rise to ‘diabetic foot’. The main issue is damage to the nerves of the leg, which reduces sensation in the foot. Reduced sensation in the foot can give rise to inadvertent damage to the foot, for example when wearing new shoes or walking without shoes. Damage to the nerves also affects the nerves which regulate the circulation of the limbs as part of the autonomic nervous system. That system ensures that sufficient blood flow reaches all parts of Complications of diabetes the skin and tissues, but we are Diabetes gives rise to a number not aware of its function – except of complications, whether arising when our fingers and toes go cold from Type 1 or Type 2 diabetes. when we go outside during frosty They include damage to the nerves, weather. Failure of that system leading to loss of sensation or leads to the skin becoming much unpleasant feelings – especially in more susceptible to damage and to the legs. In turn, loss of sensation poor healing. A diabetic foot after surgical resection of all necrotic tissue, leaving a in the feet can lead to diabetic Loss of a region of skin (an large defect in the foot foot ulcers, which may lead to ulcer) following a minor injury can uncontrolled infection in the feet and the need for an amputation. allow the entry of bacteria. Diabetic patients are at increased risk of Diabetes may also lead to damage to the retina in the eye, resulting infection, so it can swiftly lead to extensive and destructive infection in loss of vision. The kidneys may also be damaged, leading to renal advancing within the foot. For that reason, national guidelines failure with the need for dialysis and renal transplantation. Finally, provided by NICE advise urgent assessment of any new diabetic foot diabetes increases the risk of arterial disease, which may affect any ulcer by a diabetic foot multidisciplinary team. or all of the blood vessels in the body. Vascular surgeons often see Admission to hospital and treatment with intravenous antibiotics patients with lower limb ischaemia arising from diabetes. The risk of is required when evidence of significant foot infection is present. heart attack and stroke is also increased. Delayed treatment of a diabetic foot infection may lead to the need Overall, diabetic patients experience a loss of life expectancy for extensive and destructive removal of dead tissue from the foot or of about a decade, principally attributable to the increased risk of even a below-knee amputation. cardiovascular disease. Lower limb arterial disease is common in diabetic patients, as I have noted above. Any patient – especially diabetic patients – who present Prevention of diabetic foot problems with a foot or leg ulcer should have an assessment of the circulation All complications arising from diabetes are minimised when good of the leg. The simplest evaluation is to palpate the ankle pulses, but diabetic control is achieved. Patients are encouraged to measure their a Doppler ultrasound probe is more reliable at assessing the pulses. blood glucose levels regularly and to attend diabetic review clinics, Measurement of the ankle blood pressure using Doppler ultrasound where all aspects of their care can be reviewed. A measure of the will help in evaluating the circulation where impairment is suspected. quality of diabetic control is a blood test to measure the extent to which In patients with blocked blood vessels consideration of angioplasty to glucose had become bound to the haemoglobin in the blood. The improve blood flow to the leg is necessary to facilitate healing of a foot measurement is known as HbA1c. Raised levels of that parameter wound. Again, that treatment needs to be provided expediently before

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extensive damage to the foot has arisen. As with much of vascular surgery, expedient treatment of limb ischaemia-associated diabetic foot problems is essential if major amputations are to be avoided.

Litigation arising from diabetic foot

As I have noted above, about 9,000 patients per year undergo amputations as a result of diabetic foot problems. Some patients consider that the amputation should have been avoided; however, not all patients are diligent with their diabetic control or adherence to the diabetic regime, including the correct diet. Poor diabetic control greatly increases the risk of amputation and, since many of the cases are defended on causation, it may be the case that the amputation would have been required in any case as a result of poor patient compliance with treatment. In some instances, substantial delays in management between the onset of a foot infection and the instigation of appropriate treatment lead to a major amputation. In such cases it may be possible to show that rapid and severe infection progressed in an uncontrolled manner, leading to loss of the limb before appropriate management was instigated. Where more minor amputations have occurred, such as loss of toes, that may have been the outcome even with a good standard of treatment and proving causation is likely to be difficult. Claimants who have concealed their symptoms from their medical advisors or treated themselves without seeking medical advice may also find that proving causation is difficult. In summation, diabetic foot problems, including infection and ulceration – perhaps leading to a major amputation – are common events. Where it can be shown that the treatment provided did not comply with national guidelines, or that needless delay in referral and treatment occurred, claimants may have a case. However, those with a substantial history of poor control, despite having received medical advice on management of their diabetes, may find that proving causation is a difficult task. q

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Product recall affects orthopaedic devices [

ON 20 JANUARY the Medicines and Healthcare products Regulatory Agency (MHRA) issued a notice regarding the product recall of a range of the PRECISE System family of orthopaedic devices by manufacturer NuVasive Specialized Orthopaedics, Inc (NSO). In its notice the MHRA states: “NSO has undertaken voluntary action to recall and suspend the supply of all PRECICE Systems to the UK, while they are in the process of addressing the safety concerns identified by MHRA. These devices, therefore, will remain unavailable for supply until further notice. “The long-term safety of the PRECICE System family is unknown. Several biological endpoints have not been adequately assessed and others have failed to be considered, including chronic, reproductive and developmental toxicity, and carcinogenicity. “The manufacturer has been made aware of several adverse incidents potentially related to biological safety for the PRECICE STRYDE. This includes reports of pain and bony abnormalities at the interface between the telescoping nail segments. The manufacturer is investigating the issue and the root cause has yet to be confirmed.” The MHRA also noted that there had been widespread use of the devices in children and adolescents, for which the PRECICE System has not been validated for use. The notice continued: “MHRA does not believe the indications and contraindications provided by the manufacturer are suitably clear. The wording of the manufacturer’s instructions for use could lead to inadvertent off-label use of this family of devices.” The MHRA’s recommendations are that none of the affected PRECICE System devices should be implanted in the UK and any devices remaining on site should be removed from stock and returned to the manufacturer. A link to the MHRA notice can be found at the British Orthopaedic Association website at www.boa.ac.uk. q

Latest figures reiterate impact of coronavirus [

THE LATEST DATA for elective surgery in England, published on 10 December, once again shows trauma and orthopaedic surgery is the specialty worst affected by the coronavirus pandemic, with 35,000 people who have waited more than a year and 244,536 who have waited more than 18 weeks. It follows a similarly gloomy picture painted by the figures released in October, reported in the last issue of Your Expert Witness. The data also showed that between April and September 212,000 (73%) fewer operations occurred last year than in the same period the previous year. In October in England, the number of patients admitted was 63% of normal. That was the lowest percentage of any surgical specialty. Bob Handley, president of the British Orthopaedic Association, commented: “We are hearing countless distressing stories of patients awaiting surgery such as hip and knee replacement experiencing relentless pain. Orthopaedic patients are now marooned on the waiting list with a severely impacted quality of life and the prospect that surgery to relieve their pain and restore their mobility is getting further from their reach. “They will have the sympathy of anyone who has themselves lain awake at night in pain.” q

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Fraudulent cauda equina claimant jailed [

AT A COMMITTAL HEARING on 11 February, Ms Linda Metcalf was sentenced to six months in jail for deliberately attempting to defraud the NHS in excess of £5.7m. In addition, Ms Metcalf was ordered to repay the costs of the committal hearing within 28 days, amounting to £23,000. NHS Resolution pursued committal proceedings on behalf of

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Calderdale and Huddersfield NHS Foundation Trust, in line with its strategy to combat and deter fraud by dishonest claimants. The court concluded that Ms Metcalf was fundamentally dishonest for grossly exaggerating the effect of injuries sustained from a delay in diagnosing spinal cord compression (cauda equina syndrome) and that she deliberately and fraudulently claimed compensation in excess of £5.7m against the NHS. Ms Metcalf has repaid the interim payment of £75,000 that she received for her injuries. Video surveillance of Ms Metcalf showed that, while she claimed to be severely disabled, she only used her wheelchair and crutches for medical appointments. In his remarks, The Honourable Mr Justice Griffiths said: “She gave a completely stage managed appearance about her disability. “On July 23rd 2018, she was interviewed at her parents’ house when she said that she could not get in or out of her car without someone to help her. She was misleading, and that was shown on more than one occasion.” Jailing her, he stressed how the losses would have impacted on the NHS, stating: “It was not a one-off; it was a course of conduct which was sustained relentlessly over a course of years.” Helen Vernon, chief executive of NHS Resolution, said: “This case highlights the very serious consequences of submitting a dishonest and exaggerated claim against the NHS where we will not hesitate to pursue a custodial sentence.” q

What is an open fracture?

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

[

PREVIOUSLY also referred to as a compound fracture, an open fracture basically is any fracture – or for that matter a dislocation – where there is a break in the skin and soft tissue envelope surrounding a fractured bone. As a result there is direct communication between the broken ends of the bone and the external environment. That is a serious injury with a high risk of infection due to contamination of the fracture with debris and organisms (various types of aerobic or anaerobic bacteria) from the environment. Such fractures are usually associated with severe soft tissue damage and there can also be injury to the nerves or the vascular structures, which can cause permanent neurological deficit or life-threatening/limb-threatening vascular compromise. Another risk of an open fracture can be a compartment syndrome. It is often erroneously believed that compartment syndrome cannot occur in an open fracture, but that is not true. Most open fractures are caused by high-energy mechanisms such as motor vehicle accidents, industrial injuries, crush injuries in parts of machinery, farmyard injuries, falls from height or motorcycling accidents. It can, however, also result from relatively lower-energy incidents such as simple falls at home – usually in elderly patients – or a sports-related injury. Often there are other serious injuries to the patient, such as head or chest injuries, spinal or pelvic fractures or injuries to the internal organs. Those injuries can also be life-threatening. An open fracture requires prompt emergency attention to manage it appropriately. In a modern trauma care set-up in the UK the injured

patient usually gets transferred to a major trauma centre where multidisciplinary and expeditious expert management is available. Early management usually focuses on diagnosing and treating life-threatening injuries and resuscitation of the patient according to advanced trauma life support guidelines. The management of the open fracture is ideally performed by a multidisciplinary team that includes orthopaedic surgeons and plastic surgeons, along with vascular surgeons in specific cases where an arterial injury is suspected. This is referred to as orthoplastic care. The principles of immediate management include a thorough assessment of the limb for neurovascular injuries, realigning and splinting the bone to relieve pressure on neurovascular structures and the skin, early administration of intravenous antibiotics as per the local guidelines, removal of gross contamination and covering the wound before proceeding to more formal surgical debridement in the operating theatre by a team of expert surgeons. The formal management revolves around a thorough surgical debridement of the wound – a procedure where dead or devitalised tissue and contamination are removed by meticulous surgery, and the wound washed out with saline and anti-septic solutions. That is probably the most important part of the whole management and is ideally performed jointly by orthopaedic and plastic surgeons. A fasciotomy (decompression of a limb compartment) may be required for compartment syndrome in a long bone fracture. Once the debridement has been achieved the team will decide on the most appropriate further management, which includes stabilising the fracture either provisionally with an external fixator or definitively with internal fixation. That depends upon the specific situation, facilities and expertise available, the type of fracture and condition of the patient. Modern management includes early definitive soft tissue coverage of the open wound using plastic surgical techniques such as skin grafting or soft tissue flaps. Sometimes a limb with an open fracture cannot be salvaged, even with expert reconstructive surgery, owing to the mangled extremity. In such cases an early primary amputation may be considered and may actually give the best result in terms of rehabilitating the patient. The most significant risk is the development of an infection. Bone infection (osteomyelitis) is very challenging to treat and often results in poor functional outcomes. In extreme cases where the infection cannot be cured an amputation may be necessary. Even with good treatment, sometimes the long-term functional outcome may not always be excellent and there are recognised long-term risks of pain, reduced movement, deformity and functional problems. In the UK there are robust guidelines, referred to as BOAST guidelines, to help guide the standard of care in the management of open fractures. q www.yourexpertwitness.co.uk

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Top plastic surgeon leaves hospital after attack [FORMER PRESIDENT of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS)

Graeme Perks (right) has left hospital after being treated for stab wounds inflicted during an attack in his home in January. Mr Perks was attacked in the early hours of 14 January after going to investigate the sound of breaking glass at his home in Nottinghamshire. He was stabbed in the chest and abdomen and left ‘fighting for his life’ when he was rushed to hospital. In a statement, Nottingham University Hospitals NHS Trust, where Mr Perks had been head of the Department of Plastic, Reconstructive and Burns Surgery, said: “Graeme Perks has now been discharged from hospital and is rehabilitating slowly and satisfactorily.” Fellow plastic surgeon Jonathan Peter Brooks has been charged with attempted murder, as well as three counts of attempted arson with intent to endanger life and possession of a knife in a public place. He is in custody and is due to appear in court again in May. BAPRAS president and consultant plastic surgeon Ruth Waters said: “It has been my good fortune and honour to know Graeme for many years. I have benefited from his kindness, generosity and extensive knowledge throughout my career in plastic surgery.” q

First aesthetics postgrad courses set to start in September [THIS SEPTEMBER will see the world’s first postgraduate

degrees in aesthetics being taught at UCL in London. Two courses, Aesthetics (Aesthetic Surgery) and Aesthetics (Minimally-invasive Aesthetics) are offered at either Masters or Diploma level. The courses are designed to offer a ‘…rigorous education in clinical skills, contemporary best practice, and evidence-based principles in aesthetics to ensure an optimal outcome for the patient and practitioner.’ The Aesthetics (Aesthetic Surgery) course is open to medical graduates with a minimum of two years of training in general surgery, plastic surgery or dermatological surgery. The Aesthetics (Minimallyinvasive Surgery) course is open to the same applicants and also those who hold an undergraduate BDS qualification in dentistry, an advanced nurse practitioner qualification and who are registered with NMC, or a prescribing pharmacist registered with GPhc. The courses are supported by the British Association of Aesthetic Plastic Surgeons (BAAPS), whose council member Professor Ash Mosahebi is the course leader. The courses’ external examiner is BAAPS president Mary O’Brien.

Professor Mosahebi is quoted as commenting: “As this sector of medicine is outside of the NHS in the UK, its governance and standards of care have been the focus of much debate over recent years. “In an attempt to put some rigour into this area, there is a growing push to fully legitimise this sector of medicine, with The British Association of Aesthetic Plastic Surgeons advising patients to ensure that their surgeon or practitioner is fully licensed and accredited – and they are in full support of the UCL programme.” q

Entries sought for new hand surgery award [

THE COUNCIL OF the British Society for Surgery of the Hand (BSSH) has recently approved a new award of up to £2,000 to support proposals for research projects that can utilise existing and future data collected through the UK Hand Registry (UKHR). The aim is to support research that uses the UKHR or the data it contains and is of clear value to NHS hand surgery. It may also involve additional non-NHS hand surgery. Successful applications should demonstrate how they align with the priorities, needs and realities of the NHS. The process aligns with the Eligibility Criteria for NIHR Clinical Research Network Support, published in May 2019. A standardised entry form is available on the BSSH website at www.bssh.ac.uk. It should be completed and submitted along with a letter of support from the head of department, an itemised funding request breakdown and a two-page CV of the lead applicant, as a single PDF document. The deadline for entries is midday on 15 March. Successful projects will be listed on the BSSH website, with a plain English summary of around 200 words outlining the project. q www.yourexpertwitness.co.uk

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