Your Expert Witness Issue No.57

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contents IN THIS ISSUE 7

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Opening Statement

NEWS 8 Lord Hodge delivers EWI keynote address 8 Law Society gives evidence on Police, Crime, Sentencing and Courts Bill 9 Money Show star laments missed opportunity to target scammers VIEWPOINT 11 Beware conflicts of interest FORENSICS 12 New Forensic Science Regulator appointed 12 Cyber security body gets its ‘wings’ BUILDING & PROPERTY 13 New dispute resolution scheme will help neighbours avoid a fight 13 Construction firms need expert advice as PI cover dries up

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FIRE INVESTIGATION 14 Fire Safety Act becomes law 14 New cladding fire safety interest group formed 14 New Code of Practice published 15 Emollients: effective healthcare but beware the fire risk TRANSLATION & INTERPRETING 16 It’s the human touch that brings language to life 17 Peer calls for accreditation of court interpreters 17 ITI Awards are announced online 17 Guide helps cross-border translators in a post-Brexit world

15 A to Z WEBSITE GUIDE 23 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 19 Medical Notes

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NEWS 21 Report confirms variations in resuscitation decisions 21 GMC acts to drive out disadvantage 22 BMA chief gives two cheers to MPs’ healthcare report REMOTE MEDICAL ASSESSMENTS 25 Remote assessments: permanent adoption is the consumer’s choice 25 Not everyone can access the virtual consulting room UROLOGY 27 The surgeon’s guide to staying out of court PLASTIC, RECONSTRUCTIVE & HAND SURGERY 29 PIP scandal: latest ruling brings relief to sufferers 29 Breast surgeons respond to FDA mesh products alert 29 Carpal tunnel surgery – patient information package sought

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OPHTHALMOLOGY & OPTOMETRY 31 Better monitoring could reduce cataract surgery complication, study finds 31 Public confidence in ‘opticians’ at all-time high VASCULAR MEDICINE 32 Swelling of the leg is a common issue in litigation ORTHOPAEDICS 34 Fractures during falls continue to show poor outcomes 35 How has the issue of informed consent changed in the wake of COVID-19?

37 Patients awaiting joint ops suffer poor quality of life, study finds 37 Minister’s attendance at APPG highlights ‘significant issues’ 39 Pelvic fractures: an increasingly common feature of medico-legal cases PSYCHIATRIC & PSYCHOLOGICAL ISSUES 41 Children worst affected by COVID-driven mental health crisis 43 Mental health community welcome moves to ban conversion therapy 43 Report analyses suicide in middle-aged men

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OBSTETRICS & GYNAECOLOGY 44 COVID infection increases risks for women giving birth, but overall numbers are low DENTISTRY & MAXILLOFACIAL SURGERY 45 Developments influence updated guidance on third molars 45 Guidelines on dental aligners do not go far enough, say dentists CARDIOLOGY 49 Excess cardiac deaths are a harbinger of things to come, says BHF

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Opening Statement [AS SOMEONE WHO lives in a building containing multiple units of occupation (a block of flats, to

anyone over the age of 50) I have been bemused but reassured by recent activity to make us all safe by ramping up fire precautions. It has all been brought about by the passing into law of the Fire Safety Act. The new regulations have prompted a flurry of activity among the fire safety profession, with new codes of practice and a new special interest group.

None of this will be of any comfort, of course, to anyone who was touched by the Grenfell fire – the driver behind all the activity. Those leaseholders who saw the opportunity spurned to limit their liability for someone else’s failings will be equally unmoved.

• The inquiry into the Grenfell fire also saw an example of the way in which a conflict of interest on the part of an expert witness can lead to consequences. In that case a timely reporting of the conflict merely led to the expert being excused from taking further part in the proceedings.

In the case of a doctor writing ‘expert’ reports for his wife’s solicitors’ practice to use in dubious holiday sickness claims the sanction was more severe: he lost his appeal against being struck off the medical register.

Regular contributor Chris Makin describes these and other examples in a thoughtful exposition on what can be a thorny subject, with dire consequences for transgressors.

• Of course the best way to avoid a conflict of interest in a court case is to avoid court altogether.

The trend towards dispute resolution outside the courts moved into the world of neighbour disputes – the stock-in-trade of a number of reality TV shows – with the introduction of a new scheme by the Property Litigation Association. As a member of that august body’s law reform committee points out, people often get themselves involved in a dispute with a neighbour and then find themselves unable to extricate themselves without great expense.

• When things do get to the point where court action is inevitable, it is vital that all parties understand what is going on – and can have their evidence understood. For some time now the National Register of Public Service Interpreters has lobbied to have inclusion on its register as a given for court interpreters. The NRPSI was set up in the wake of a series of miscarriages of justice caused by incompetent or even criminal so-called interpreters – such as in the case of Mirwais Patang, which we reported on in the last issue.

• Most interpreters, of course, are diligent in carrying out their role in enabling people of different cultures to communicate, whether in the courtroom, business setting or simply exchanging information.

The Institute of Translation and Interpreting has long been a standard-bearer for language learning and the interchange of ideas between peoples with different languages.

Its annual awards are, therefore, a red-letter day in the linguist’s year. The star of this year’s awards was Daniel Hahn OBE, in recognition of a lifetime promoting the translation of literature. Every awardwinner, however, merits our congratulations.

• Which brings us to Brexit! No, the issue is not quite finished with. The convoluted terms of the Trade and Co-operation Agreement between the UK and the EU will test the skills of the most accomplished linguist, as the rush to resume trading runs up against the paperwork that only the oldest among us can remember used to exist before 1973. Plus ça change. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Lord Hodge delivers EWI keynote address [

THE Annual Conference of the Expert Witness Institute (EWI) was once again held online, on 28 May. The keynote address was delivered by Lord Hodge, Deputy President of the Supreme Court.

In the speech Lord Hodge explored the critical role of the expert witness in the administration of justice, together with judicial expectation. He also shared his thoughts on the impact of the pandemic on the courts. He said the title of the conference – Lawyers and Experts: Facing the Future Together – felt particularly apt.

Lord Hodge offered his own observation on what the court expects of a competent expert witness.

Reporting on the speech, the EWI’s Simon Berney-Edwards wrote: “Lord Hodge then turned to the expert’s co-operation with other actors and the role of professional organisations.

“Lord Hodge praised specialist organisations and institutions such as the EWI for their role in minimising the occurrence of harmful expert witnesses by advocating for high standards in expert evidence. Membership of these bodies could give credibility to an expert witness, as it showed that he or she is

taking the role seriously by signing up to a set of standards of behaviour and competence and is maintaining his or her continual professional development.”

Lord Hodge had pointed out that lawyers and instructing parties also played an important part ­not just by ascertaining that an expert did possess the necessary expertise and making them aware of their duty to the court, but by ensuring the expert was made aware of all the facts of the case, including material that did not support the client’s case.

The impact of COVID-19 on the courts was an inevitable theme.

Simon Berney-Edwards continued: “He was very much aware that life had not been easy for expert witnesses during the pandemic both in terms of carrying out physical site visits or examinations and in financial impact, be that through postponed trials, or delays in payment. However, not all consequences of the pandemic were bad.” q • To read Simon’s account in full visit www.ewi.org.uk.

Law Society gives evidence on Police, Crime, Sentencing and Courts Bill [ON 20 MAY the Law Society’s head of public law, Ellie Cumbo,

gave evidence to the Parliamentary committee scrutinising the Police, Crime, Sentencing and Courts Bill. Ms Cumbo gave evidence on the

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impact that remote hearings can have on vulnerable witnesses, the uncertain impact of remote juries on access to justice, and the society’s views on changes to pre-charge bail.

She highlighted that remote hearings can be convenient in certain cases – administrative hearings for example ­– but they can have a serious impact on vulnerable clients who may struggle to engage with the process. She called for clearer guidance for their use alongside the legislation.

The Bill will also enable changes to juries, and Ms Cumbo noted that, while the Law Society could support the inclusion of deaf jurors and British Sign Language interpreters, it does not support remote juries hearing cases. There has been little consultation in the area and it is unclear how a jury’s perception of a case could be impacted by remote observation.

When asked about the society’s concerns around pre-charge bail, Ms Cumbo raised the long time periods that the bill allows a suspect to be bailed for, and noted the Law Society would prefer that shorter timelines with judicial oversight at an earlier point were put in place.

The Bill will now continue its committee stage, with MPs scrutinising it line-by-line in the coming weeks. The Law Society says it will continue to work with Parliamentarians to shape it. q

Money Show star laments missed opportunity to target scammers [TV CONSUMER CHAMPION Martin Lewis

has responded to The Queen’s Speech by reiterating the call for online financial scams to be included in the Online Safety Bill – the government’s flagship legislation for tackling online harm.

The founder of the Money and Mental Health Policy Institute and MoneySavingExpert.com had previously joined with a coalition of other organisations to call on the government to include online scams in the Bill, to ensure consumers are better protected against those crimes.

Martin Lewis (right) said: “The Queen read that ‘My government will lead the way in providing internet safety for all, especially children’. Yet the government has stumbled at the first fence by not including scams in the Online Safety Bill. We live in a world where the policing of scams is dangerously underfunded, leaving criminals to get away with fraud with impunity. This was a chance to at least deny them the ‘oxygen of publicity’ by making big tech responsible for the scammers’ adverts it is paid to publish.

“By not doing so the government has failed to protect millions, in the midst of a pandemic, from one of the most damaging online harms to their financial and mental health. My slim hope is, as prior reports hinted, the door is ajar for scams to be added to the Bill at the committee stage. And we will continue to expose this gap, and push ministers to put in place proper consumer protections against scams.”

In their letter to the Home Secretary and Digital Secretary, the 17 organisations wrote: “Online platforms play a pivotal role in

enabling criminals to reach and defraud internet users through the hosting, promotion and targeting of fake and fraudulent content on their sites, including adverts that they make significant profits from. Yet platforms have very little legal responsibility for protecting their users, despite often being the best placed to tackle harmful content.

“While we recognise there are initiatives being progressed by the government designed to tackle aspects of online fraud, there is a growing risk that current plans for future regulatory frameworks are not taking a comprehensive approach to the threats faced by consumers and do not reflect the extent or urgency of the problem.”

According to the Money and Mental Health Policy Institute, scams have escalated in the past 12 months, with figures showing that £1.7bn was reportedly lost to scams in the past year. Action Fraud estimates that in the year to June 2020, 85% of all fraud was cyber-enabled.

The actual financial losses are likely to be much higher and do not capture the devastating emotional impact on victims. The Money and Mental Health Policy Institute quote one victim, a 63-year-old teacher, who said: “I felt completely sick. I’m overall better now but often I get flashbacks of certain events and that upsets me a lot. I usually get them at night when I’m in bed and when that happens, it sets the tone for a bad night’s sleep.”

Research also shows that vulnerable people, including those experiencing mental health problems, are more at risk of falling victim to those online crimes. q

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Beware conflicts of interest

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

[AS I WRITE THIS David Cameron is getting into

increasing difficulties over his relationship with the failed financier Lex Greensill; there are problems over senior civil servants having paid jobs in the private sector; and even Matt Hancock has problems over his family connections with a firm which provided PPE to the NHS. And then we have Sir James Dyson apparently asking Boris Johnson for special tax treatment for his employees who produced ventilators in the early days of Covid.

There’s a pattern here: actual or perceived conflicts of interest can be fatal to one’s case. And that of course is important with your choice of expert in litigation.

Let’s bring this down to my level. Some years ago I acted as mediator in a landlord and tenant dispute over a cottage way out over the Yorkshire moors. I found that the owners of the cottage were the parents of a young lad who used to play the cornet in a youth brass band which I conducted for many years. Now, this had nothing whatever to do with the dispute or with my competence as a mediator, and I hardly knew the parents; but just think how fatal to the process it would have been if the other party had discovered that connection during our deliberations. So I did the obvious: I declared a tenuous conflict to the other party and his counsel – they were happy, we got on with the mediation and we achieved a settlement.

Moral: if there is any doubt at all about one’s independence, bring it out early and place it on record. Sadly, that didn’t happen with a case recently.

This was Bux v The General Medical Council [2021] EWHC 762, an appeal heard in the High Court by Mr Justice Mostyn (with whom I worked when he was at the bar) where Bux was appealing his removal from the GMC register.

The Medical Practice Tribunal (MPT) had ‘made findings of fact that the appellant had acted in a state of conflict of interest, dishonestly and for financial gain’. They listed the reasons thus: i) That the appellant acted in a state of conflict of interest by accepting instructions (through an agent, Medico Legal and Litigation Services Ltd) to prepare medico-legal reports in respect of holiday sickness claims, from a firm of solicitors (AMS Solicitors Limited) in which his wife, Mrs Sehana Bux, was a salaried partner. ii) That in one case he gave a deliberately false answer (in a reply endorsed with a statement of truth) to questions posed to him as an expert under CPR 35.6. iii) That he made diagnoses without proper evidence, without identifying the existence of a range of opinions, and had in his reports failed to follow the requirements of CPR Part 35. iv) That he improperly performed a circumcision procedure in the community and in so doing failed to recognise or advise in terms of the risk of doing so.

Mostyn J summarised: “In my judgment the MPT was correct to reach the conclusion that it did. I reiterate: a conflict of interest will arise when an expert witness’s opinions are actually influenced, or are capable of being influenced, by his personal interests…… In this case the MPT had abundant evidence which demonstrated the following facts: i) As an expert witness the appellant owed to the court a duty of independence and objectivity. ii) On the other hand, the defendant had a personal interest in keeping up to speed the lucrative throughput of medical reports – the benefit from which accrued not only to himself but also to his wife. She was a coshareholder in the company to which the proceeds of the work were paid, and was a partner in the firm of solicitors providing him with the work.

iii) In 2016 it was abundantly clear to the appellant that he had to disclose his marital relationship not only to the defendant’s insurers but also to the court. This was clear to the appellant not only from the terms of the codes of guidance to which he was subject, but also as a result of the letter written in 2011 by the MDU. But he made no disclosure. iv) The appellant had on 12 May 2017 signed replies to CPR 35.6 questions, endorsed with a statement of truth, which were completely false.

“In such circumstances, in my judgment, it would have been perverse and wrong for the MPT to have decided anything other than that the appellant had an actual, serious conflict of interest of the first type. I am satisfied, notwithstanding the presence of some linguistic confusion, that this is what the MPT decided.”

To repeat his lordship: “A conflict of interest will arise when an expert witness’s opinions are actually influenced, or are capable of being influenced (my emphasis), by his personal interests.”

With another case I can be brief, though the message is just as powerful – and the case is just as emotionally powerful as the George Floyd/Derek Chauvin murder trial. An expert witness to the Grenfell Tower public inquiry is advising on how the council landlord handled fire risk when it is learned that his own son works for the council as its head of fire safety.

This was addressed properly, according to a statement from the enquiry: “Colin Todd informed the inquiry of his son Keith Todd’s intention to take up employment with RBKC at an early stage. Keith Todd will not be involved in any way in advising RBKC regarding evidence it gives to the inquiry about the Grenfell Tower fire and… Colin and Keith Todd will not discuss in any way fire safety matters relating to RBKC.” This was the correct action, and it should see an end to accusations of conflict. No guarantee, but those involved did declare a potential or perceived conflict at the earliest opportunity. Similarly for your experts, being seen to be whiter than white is a basic requirement. 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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New Forensic Science Regulator appointed [THE HOME SECRETARY has appointed Gary Pugh OBE as the

new Forensic Science Regulator. He took up his post on 16 May and will carry out the role for three years, taking over from the Interim Regulator Rupert Shute.

The Forensic Science Regulator ensures that the provision of forensic science services across the criminal justice system complies with an appropriately high standard of scientific quality and is carried out with objectivity and impartiality.

A former director of forensic services at the Metropolitan Police Service, Gary Pugh (pictured) is a forensic scientist of over 40 years standing, with experience of leading national governance boards and operations.

Home Secretary Priti Patel said: “Ensuring that the UK remains at the cutting edge of forensic investigation is vital and Gary Pugh brings a wealth of experience to the role of Forensic Science Regulator. Working for many years at the top of his field, he will ensure police are working to the very highest scientific standards when investigating crimes, pursuing criminals and seeking justice for victims.

“So much progress has been made in implementing quality standards, but science is constantly evolving and the Forensic Science Regulator plays a vital role in setting those standards.”

His appointment coincides with the coming into law of the Forensic

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Science Regulator Act 2021, which provides the regulator with statutory powers.

Gary Pugh said: “I am very pleased and delighted to be appointed to the post of Forensic Science Regulator. Over my 40 years in forensic science I have seen the development of quality systems and standards, and the consequences of quality failures. I look forward to building on the solid work of my predecessors and working with the team that support my role to ensure the effective operation of forensic quality standards. The recent Royal Assent for the Forensic Science Regulator Bill will put my role on a statutory footing recognising the importance of forensic quality standards and their critical contribution to delivering justice.” q

Cyber security body gets its ‘wings’

[ THE UK CYBER SECURITY COUNCIL – the self-regulatory body for the cyber security education and skills sector – has completed its Formation Project and has officially become an independent entity, accountable to its trustees.

The council’s role is to champion the cyber security profession across the UK, providing broad representation for the industry, accelerating awareness and promoting excellence in the profession. It will do that by delivering thought leadership, career tools and education resources to the cyber security sector and those seeking a career in the industry, alongside helping influence government, industry and academia with the aim of developing and promoting UK cyber security excellence globally and growing the skills base.

Government funding for the council came from the Department for Digital, Culture, Media and Sport, while members of the Cyber Security Alliance supported the formation of the council with ‘countless hours’ of unpaid work.

Speaking at the announcement of the completion of the Formation Project, the council’s chair Dr Claudia Natanson said: “The next few months will be especially busy; we are now able to hire and start work on gaining traction and momentum across and beyond the profession.

“We’ll also be engaging with government to ensure the delivery of the standards and governance needed to ensure a strong cyber security profession now and in the future. The trustees assure all those involved in the council to date of our maximum efforts to take their work forward.” q

New dispute resolution scheme will help neighbours avoid a fight [A NEW SERVICE that aims to help neighbours resolve boundary

disputes without resorting to court action has been launched by the Property Litigation Association (PLA) and the Royal Institution of Chartered Surveyors (RICS). The Boundary Disputes Mediation Service comprises a mixed panel of mediators, lawyers and surveyors – all experienced in boundary and neighbour disputes – who can provide a quicker and cheaper alternative to litigation.

Solicitors report that neighbourhood disputes have increased during the pandemic as people have been confined to their homes. Quarrels over apparently minor issues such as who owns a fence, unkempt hedges, party walls or use of driveways can swiftly escalate and are often slow to resolve.

Construction firms need expert advice as PI cover dries up

The new mediation service, when adopted early, can break a deadlock and help people avoid expensive and protracted court action, which often costs more than the value of the matter in dispute.

In the worst-case scenario litigation can result in the loss of a home, but even more straightforward cases can cost each party anything from £10,000 to £250,000 excluding VAT. Using the new service, parties can retain control of the negotiation process and deal with key issues in a positive, proactive way, while a neutral mediator aims to reach an outcome that is satisfactory to all.

Jacqui Joyce, an experienced mediator who sits on the PLA’s law reform committee, said: “People at the heart of neighbour disputes can rapidly get themselves into a fight, but few know how to then get out of it. Mediation gives people an opportunity to exit the fight without the courts being involved, avoiding the stress, risk and huge expense that this may entail.”

The new service, supported by the Civil Justice Council (CJC), has been created in response to the government and judiciary exploring ways of resolving boundary disputes without recourse to litigation. That includes guidance published by the CJC encouraging alternative dispute resolution mechanisms.

John Fletcher, director of dispute resolution services at RICS, explained: “The government and judiciary are keen to encourage disputing neighbours to avoid litigation, which often results in immense financial and personal cost for all sides. This new service offers neighbours an opportunity to get their views across and achieve an agreed outcome quickly and more cheaply.”

RICS will administer the Boundary Disputes Mediation Service and the application form will sit on its website. Anyone interested in using the service can apply via www.rics.org/bdms. q

[CONSTRUCTION PROFESSIONALS are being urged to get

expert advice when buying professional indemnity insurance in the face of rising premiums and potential claims associated with building cladding. Stephen Ward (pictured) from RAW Insurance – which specialises in the construction sector – said safety concerns following the Grenfell fire have had a knock-on effect on the insurance market, with many insurers unwilling to cover cladding deemed to be a fire risk.

Stephen said: "Many cladding specialists who designed, supplied and/or installed ACM run a huge risk of having professional indemnity claims brought against them due to the high fire risk this material brings with it.

“With properties now in the process of being stripped of this type of cladding and reinstated with fire-safe material, the cost is more often than not being covered by the professional indemnity policy of whoever was responsible for the design. There is more pressure on the insurance market, with premiums increasing and fewer insurers offering cover than ever before.

“While businesses with previous claims are being hit the hardest, even companies with no claims can expect a big increase in premium.”

Stephen said contractors involved in cladding projects should take steps to find the best policy for their business.

“With fewer insurers in the market, I would recommend asking only one or two brokers to provide quotes because they will be approaching the same insurers,” he said. “Too many brokers asking the same limited number of insurers for quotes is counterproductive.”

Cumbrian-based RAW Insurance is an independent commercial insurance broker with vast experience in the sector. q www.yourexpertwitness.co.uk

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Fire Safety Act becomes law

[ ON 29 APRIL the Fire Safety Bill

received Royal Assent and became law in England and Wales. Intended to ensure ‘a tragedy like that at Grenfell Tower can never happen again’, what is now the Fire Safety Act amends the Fire Safety Order 2005 to clarify that the order applies to the building’s structure, external walls and common parts and all doors between domestic premises and common parts. It also clarifies that references to external walls includes doors, windows, balconies or anything else attached to the exterior.

The Act also gives powers to the Secretary of State to make further changes through secondary legislation – for example by extending the scope of the Act to include other types of buildings. It is also

expected that regulations affecting approved inspectors to include plan certificates will also be amended.

In his closing remarks to the House of Lords prior to it becoming law, Fire and Policing Minister Lord Greenhalgh said: “The government are, and always have been, committed to implementing the Grenfell Tower Inquiry Phase One recommendations.

The Fire Safety Bill is the first legislative step in this process and, as I have stated before, we are committed to delivering the Grenfell recommendations through regulations following the fire safety consultation.

“Although this is a short, technical Bill, it is important to ensure we get the legislative sequencing right.” q

New cladding fire safety interest group formed [ THE Institution of Fire Engineers (IFE) and Fire Industry

Association (FIA) have joined forces to launch a new Special Interest Group (SIG) focussing on façades and external wall fire safety issues. The SIG features members from both organisations, along with additional co-opted membership from the Centre for Window and Cladding Technology, the RICS, the Ministry of Housing, Communities and Local Government and the National Fire Chiefs

Council. Co-chaired by Jon Pagan and IFE Fellow Adam Monaghan, the SIG held its inaugural meeting in April.

Co-chair Jon Pagan, who is a director of International Fire Consultants Ltd, said: “It is essential the fire industry takes more ownership of helping to deal with fire safety issues concerning façades and external walls. We created this SIG to raise awareness of the issues and to provide support to the many fire engineers who work in this area.

“It will be the SIG’s responsibility to identify and monitor research and guidance and to take part in related industry consultations. One of the main focusses of the SIG will be ensuring that both the IFE and FIA members are kept up to date with the various on-going activities which are occurring in this key area so that they benefit from the work that we do.” q

New Code of Practice published [ THE SECOND EDITION has been published of the Code of

Practice for Investigators of Fires and Explosions for the Justice Systems in the UK, jointly prepared by the Institution of Fire Engineers, the National Fire Chiefs Council and UK Association of Fire Investigators.

Each organisation consulted its members on how the original Code had been received and implemented by the fire investigation profession. Comments were used as the basis for proposed updates, which were then issued for consultation again before the Code was finalised in its second edition. It therefore represents the current knowledge and understanding of fire investigation practice. It came into effect in April.

The Code of Practice has been developed to support and provide guidance to organisations and individuals engaged in the examination of fire and explosion scenes within the framework of the criminal justice systems of the UK. It has been published free of copyright, with users free to use anything contained within it. However, they are reminded of the need for any excerpted materials not to be presented or used out of context.

Compliance with the Code of Practice does not of itself confer immunity from legal obligations. q

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Emollients: effective healthcare but beware the fire risk

[ MANY OF US have skin creams in our homes containing

emollients. They are an effective treatment for dry skin conditions; but how many of us are aware of the hazards they pose? They often contain paraffin, petroleum or natural oils – all of which are flammable.

Problems arise when dried emollient contaminates clothing or bedding. When it is introduced to a naked flame that fabric can catch fire, resulting in injury or death.

Healthcare professionals are trained to recognise the risks, but the general public needs to be aware that regular use of emollients increases the risk of fire and injury.

The latest statistics from GOV.UK show that, since 2010, 56 deaths and serious injuries have been linked to fires following the use of emollients.

The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended that labelling and product information for emollient products should include a warning about the fire hazard, with clear advice not to smoke or go near naked flames. Properly written and designed warnings on labels and in product instructions help keep people safe.

However, what happens if the labelling fails to emphasise the fire potential of the product?

The experts at Strange Strange & Gardner are aware of the potential hazards. In any fire investigation they look for evidence of fire spread by those means and report on the adequacy of any warnings. Their expertise allows them to examine every aspect of risk in a potential product liability case and provide their clients with the answers they need to assess a claim or case.

SS&G’s senior fire investigation specialist Anthony Murray explained: “The increased fire risk brought about by longterm emollient use is little known by the public and leads to many deaths and injuries every year. We always consider this as a possible cause of fire spread and report on whether suitable preventative measures were taken. Along with our expertise at the fire scene, we communicate the conclusions in a knowledgeable and approachable way. We provide costeffective reports promptly and our assistance is a telephone away.” q www.yourexpertwitness.co.uk

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It’s the human touch that brings language to life [WHETHER WE like it or not, it is a well-established fact that

across all walks of our business and private lives we need a variety of documents provided in a multitude of languages.

Machine translation is improving every year and technology companies are constantly telling us that AI algorithms are close to replacing human translators. It is true that artificial intelligence has changed the nature of machine translation – turning it into a tool that can improve and learn by itself.

Before recent breakthroughs in AI technologies, such as deep learning and neural networks, machine translation algorithms had to be manually created, tested and managed every step of the way. Minor improvements required hours, days and even years of programming labour, by…you guessed it: humans.

In reality, we’re a long way from algorithms replicating complex cognitive behaviour – such as the decision-making processes made in translation – without any human input.

Google Translate can be helpful, but has numerous shortcomings.

Another option might be someone in the office who speaks one or two of the languages required. A law firm or any of the various business sectors may be inclined to use the services of in-house staff because it’s the cheapest and most available option. However, what is often overlooked is the complexity and subtleties of each language.

Language is vibrant, colourful, exuberant, vivid and concise. Each language has its own shades of nuances which enhance how we experience what we read or hear. Not only can well-written language provide pleasure, as with fiction, but more importantly it provides clarity and precision – and those qualities are essential in any professional setting.

Rather than risk the potential legal liability, it pays to engage the services of a professional translator.

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Idioms

An idiom is defined as: a group of words established by usage as having a meaning not deducible from those of the individual words. Put another way, idioms are sentences that sound ridiculous to everyone but the native speakers who use them.

The French idiom ‘avoir la moutarde qui monte au nez’ literally translated is ‘to have mustard up your nose’. What it means is ‘to lose one’s temper’. Similarly with the Lithuanian idiom ‘lyja kirviais’: the literal translation is ‘it’s raining axes’; what it means is ‘it’s raining cats and dogs’ – whatever that means!

The same applies to proverbs – for example the Portuguese proverb ‘quem não tem cão, caça com gato’. The literal translation is ‘he who doesn’t have a dog hunts with a cat’; what it means is ‘you make the most of what you’ve got’.

To be able to accurately convey the sense of the idiom is one thing; finding an equivalent phrase in the target language which also reflects the original tone and sentiment presents more of a challenge.

It is for those reasons that human analysis of language is imperative.

Human translators will either be native speakers or at the very least fluent in the target language.

Professional linguists are highly-qualified specifically in the field of translation and they often work in their chosen fields in translation-focused roles. That means that their formal and technical styles of translation are far superior to anything that can be produced by machine. That is particularly evident where machine-based translators leave the words or phrases in the original language if they cannot find a suitable translation.

The way to genuinely achieve quality, reliability and accuracy in translation is not through shortcuts, but through the experience, knowledge, skill and technique that comes with a highly-qualified translator who has a professional eye and a rigorous knowledge of the subtleties of language. In that case there is no substitute for human intervention. q

Peer calls for accreditation of court interpreters [THE inclusion of the Police, Crime,

Sentencing and Courts Bill in the Queen’s Speech offers the opportunity to include a requirement for court interpreters to be included on the National Register of Public Service Interpreters (NRPSI). The call came in a speech in the Lords by Baroness Coussins, the vice-president of the Chartered Institute of Linguists, during the Queen’s Speech debate.

Baroness Coussins said: “In a nutshell, the problem is that the chaotic system used by the MoJ and the Courts & Tribunals Service allows far too many cases of unqualified or underqualified, inexperienced pseudointerpreters to do such a bad job that, quite

apart from damaging the reputation of properly qualified linguists, it can cause mayhem in the courts, resulting in miscarriages of justice, adjourned hearings, defendants remaining in custody and an undermining of trust in an important public service.”

She continued: “I suggest just adding a new, simple clause to provide for spoken-word interpreters to be appointed only from the national register in order to raise standards, improve justice and save public money. It is ironic that one clause in the Bill creates a new offence for a BSL interpreter intentionally or otherwise to influence the jury. I contend that to continue to allow incompetent, unqualified

spoken-word interpreters in our courts is itself, by default, a serious way of influencing the outcome of proceedings in the most negative way possible.”

The Baroness held up as an example of a system that works the Police Approved Interpreting and Translation (PAIT) scheme. It was an example referenced by Mike Orlov, the executive director and registrar at NRPSI, in a blog post.

Orlov wrote: “The National Register (NRPSI) is looking forward to continuing to work with PAIT and play its part in helping the police create a really effective model for the courts, as outlined by Baroness Coussins.” q

ITI Awards are announced online [ON 13 MAY, during the online conference of the

Institute of Translation and Interpreting, the winners of the 2021 ITI Awards were announced.

The prestigious John Hayes Memorial Prize was awarded to Daniel Hahn OBE (pictured). The award is judged by the current and two previous chairs of ITI. In its citation the ITI said: “Daniel Hahn was awarded an OBE for services to literature in 2020.

He has been a leading advocate for both writing and translation, working as a translator and writing about translation across many platforms over a great many years. He has been the foremost voice in the promotion of translated children’s writing and has been a leading mentor, as well as supporting mentoring, for people entering the world of literary translation.

“Within the wider community, Daniel is recognised and known for his work in translation, which in turn has raised awareness of our

profession among people who otherwise wouldn’t have given it a second thought.”

The John Hayes Prize for Excellence in Translation was won by Hayley Wood and the Best Performance in an Interpreting Assessment went to Ewa Jasinska-Davidson.

In the Open Awards, the Best Student Research winner was Helen Wagner, the Best Newcomer – Freelancing was Hannah Lawrence and the Outreach Champion was Claire Storey.

The Best Performance on a Translation Assignment had joint winners: Emma Mandley and Kim Sanderson, while Best Performance on an Interpreting Assignment went to Mike Downey, Salima Garti and Sean Davidson. The Corporate Member of the Year was Atlas Translations, Mentor of the Year was Lynn Urch and the winner of the Network Events and Initiatives Award was Polish Network. q

Guide helps cross-border translators in a post-Brexit world [BREXIT AND THE Trade and Co-operation Agreement between

the UK and the EU have changed the landscape for language service providers in the UK. New rules govern the cross-border provision of services, VAT, business travel, owning and managing companies, data protection, accounting, immigration and internships.

That new environment has prompted the Association of Translation Companies (ATC), in collaboration with the Institute of Translation and Interpreting (ITI), to publish a new Post-Brexit Guide for Language Service Providers, aimed at UK-based language service companies and freelance translators and interpreters.

The guide has been created by ATC’s CEO Raisa McNab and industry expert Doug Lawrence, with review by ITI translator members Emma Gledhill and Kim Sanderson.

Each section of the guide has a short summary for the most important topics, relevant links to authoritative resources online and considerations around implications of the new rules for language service providers.

ITI chief executive Paul Wilson commented: “Companies providing cross-border services have been largely forgotten in the rush to

keep goods moving. Guidance to language service providers has at best been scant and at worst non-existent or misleading. It’s been a challenge at times to make sense of the new rules from the point of view of our industry, but we owe it to our members to interpret what’s out there, and I’m glad we’ve done it with the Association of Translation Companies.” q

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MEDICAL NOTES [NO-ONE COULD BE UNAWARE of the significance of the ruling of the Paris Court of Appeal regarding the liability

of TUV Rheinland for its part in the accreditation of PIP implants – leading to the CE marking of the implants and the widespread harm it caused.

The firm argued – and many would have some sympathy with the view – that it was pursued because it was the only company connected with the scandal that was still solvent and trading. The court in Paris disagreed, as did the lawyers and the organisation representing the many women who had been victims of the scandal.

Another potential scare for those with breast implants could be on the horizon, following a safety communication from the FDA regarding acellular dermal matrix (ADM) products used in implants. Watch this space!

• Regulating the latest trend in tooth aligning via at-home moulding will, it is hoped, prevent an epidemic of serious dental problems in the future. Adverts on TV and internet come-ons are promoting a DIY version of what the GDC has categorised as the ‘practice of dentistry’ – ­ which the BDA says should be regulated in just the same way as traditional dentists’ practices.

• DIY prescribing is nothing new to the optometry profession. Opticians are fighting back, however. The General Optical Council’s annual survey of how people view opticians – a catch-all term used to refer to optometrists and dispensing opticians, a distinction most people don’t make ­– shows increasing confidence in their eye specialist.

In particular, more than nine out of 10 people were happy with the measures put in place to deal with COVID risk.

• Not surprisingly, the COVID pandemic has cast a pall over pretty much all medical activity. In some cases the effect is being claimed to have led to some potentially dangerous practices. The CQC has found some worrying discrepancies in people’s experiences of ‘do not attempt cardiopulmonary resuscitation’ decisions – commonly known as DNRs. Worryingly, while most healthcare providers claim not to have been aware of ‘inappropriate DNACPR decisions’, those using the services see things differently.

• The long arm of COVID has also had a dreadful effect on women giving birth. Figures from the National Maternity and Perinatal Audit show a definite correlation between COVID-19 infection and birth problems, including stillbirth. Although the raw numbers are small, every occurrence is a tragedy for a woman and her family. Even more worryingly, the instance of COVID infection in pregnant women was more prevalent in ethnic minority communities.

• The effects of COVID-19 have also spread beyond childbirth into childhood. Another study – this time by researchers at King’s College, London and the universities of Liverpool and Reading – found a distinct spike in instances of depression and PTSD among youngsters aged 11-12 years during the pandemic.

We’ve all seen the disruption to normal routines caused by the lockdowns, whether that is the lack of contact with friends or with family. What we don’t know is to what extent the spike represents a real increase in cases or a bringing forward of problems that would have presented later.

• A similar picture has emerged regarding patients awaiting joint replacements. As people waited longer and longer because of the delays to operations caused by the pandemic, the worse the quality of life became for those unfortunate individuals stuck in the queue. While routine orthopaedic procedures may not seem to be a top priority to the layman, to people living with pain they are a lifeline.

• One feature of the pandemic that appears at first sight to have become permanent is the issue of remote consultation. Some legal authorities don’t appear to see things that way, but the weight of public opinion is against them. q

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Report confirms variations in resuscitation decisions [

A NEW REPORT from the Care Quality Commission (CQC) has found worrying variation in people’s experiences of ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) – commonly known as DNR – decisions during the pandemic.

While there were some examples of good practice, CQC also heard from people who were not properly involved in decisions, or were unaware that such an important decision about their care had been made.

Among its recommendations, the report, Protect, respect, connect – decisions about living and dying well during COVID-19, calls for the establishing of a Ministerial Oversight Group that would work with partners in health and social care, local government and the voluntary sector to take responsibility for delivering improvements in what is a vital and sensitive area.

The Department of Health and Social Care asked CQC to conduct a rapid review of how DNACPR decisions were used during the coronavirus pandemic, building on concerns that they were being inappropriately applied to groups of people without their knowledge.

An interim report published in December found that a combination of unprecedented pressure on care providers and rapidly developing guidance may have led to decisions concerning DNACPR being incorrectly conflated with other clinical assessments around critical care.

This latest report also drew on fieldwork in seven Clinical Commissioning Groups, responses to a national information request to providers of adult social care, a national public survey and on-going engagement with voluntary sector organisations working in the area.

While most providers of adult social care, primary care and secondary care reported they were not aware of inappropriate DNACPR decisions, or DNACPR decisions

being applied to groups of people, CQC received feedback from stakeholders, people who use services and their families and carers that ‘blanket’ DNACPR decisions had been proposed at a local level. The regulator also heard examples of these being quickly challenged and retracted.

Rosie Benneyworth, chief inspector of primary medical services and integrated care at the CQC, said: “Personalised and compassionate advance care planning, including DNACPR decisions, is a vital part of good quality care. Done properly, it can

offer reassurance and comfort for people and their loves ones – before and during difficult times.

“COVID-19 has brought this to the fore, but these are not new issues. While this rapid review was not asked to make judgments on how decisions might have impacted individual cases, we have to take this opportunity to address these problems.

We need to make sure that people have the opportunity to discuss their wishes about care and treatment in a compassionate and person-centred way.” q

GMC acts to drive out disadvantage

[THE GENERAL MEDICAL COUNCIL has set new targets to eliminate disproportionate

complaints from employers about ethnic minority doctors and eradicate disadvantage and discrimination in medical education and training. The targets, to be met by 2026 and 2031 respectively, focus on areas where clear evidence of disproportionality has been seen over time.

GMC research and analysis on fairness in referrals and differential attainment has demonstrated the sustained nature of those issues and provided insights on their causes and impacts.

Doctors from ethnic minorities are twice as likely to be referred to the GMC by their employers for fitness-to-practise concerns than white doctors, and the referral rate for doctors qualifying outside of the UK is three times higher than that for UK doctors.

In education and training, exam pass rates reflect a 12% difference between white and BME UK graduated trainees – rising to more than 30% for overseas graduates.

The chief executive of the GMC, Charlie Massey, said: “Sadly it is clear that unacceptable levels of inequality exist in the health system. Change to eradicate the disadvantages many doctors face is long overdue. Setting ourselves these specific targets will drive us to effect real change, which we can hold ourselves to account for. It will require close working with employers, regulators, education and training bodies and many other stakeholders to achieve these goals.

“Our goals are ambitious but achievable – inequality is something we need to be impatient about. We are committed to deliver change and achieve these much needed improvements.” q

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BMA chief gives two cheers to MPs’ healthcare report [THE CHAIR OF the BMA council, Chaand Nagpaul, has issued a

statement welcoming the report by the Commons Select Committee on Health and Social Care on the Health and Care White Paper – but says its falls short on private provider reform.

Dr Nagpaul (pictured) said: “The legislation must be grasped as an opportunity to guarantee to our already understaffed workforce, exhausted from the pandemic, that the government will take accountability for ensuring staffing levels are safe and provide whatever funding and resourcing this requires. We also share the committee’s concern that plans for social care reform must not be delayed and are integral to improving healthcare delivery.

“To truly reform the NHS towards a more collaborative, joined-up system that delivers the best possible patient care, these changes must be accompanied by long-overdue investment in the NHS, clinical leadership and robust protection from fragmentation and unnecessary competition, and we would have liked to see this raised by the committee.”

The BMA chair was sceptical, however, about the report’s conclusions on private contracts.

“While the report notes that the legislation will remove wasteful rules that require the NHS to put contracts out to competitive tender, as called for by the BMA and others, the BMA believes the report should have gone further and called on the government to make the NHS the default provider for delivering NHS contracts. Without this crucial amendment there is a risk contracts will be awarded without scrutiny to private providers at huge expense to the taxpayer – as we have seen

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all too recently with the procurement of personal protective equipment and test and trace during the pandemic.

“The committee highlights the significant concerns raised by the BMA on the impact of rushing through legislative changes at a time when healthcare workers are under unprecedented strain, and calls for local NHS leaders to have a role in setting the pace of implementation to ensure changes do not adversely impact an area’s COVID-19 response or recovery. It is critical that clinicians, who know their communities best, are given the chance to lead changes to the benefit of both staff and patients, and this must include formalised roles for primary, secondary and public health doctors at every level of integrated care systems.

“Government must now listen to the committee’s recommendations and our further calls for change. Without these significant amendments we will miss an opportunity to ensure reform supports the creation of a sustainable, collaborative health and care system in the interest of both healthcare workers and patients.” q

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

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

To get your website listed on this page just give us a call on 0161 710 3880 or email ian@dmmonline.co.uk Mr Kim Hakin FRCS FRCOphth Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

www.abc-translations.co.uk

www.kimhakin.com

Mr Ashok Bohra MS MPhil MFSTEd FRCSEd FRCS(GenSurg)

Mr Chris Makin

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

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

www.surgeonexpertwitness.co.uk

www.chrismakin.co.uk

David Bunker Arbitrator & Mediator

Mr Stephen McCabe MBChB FRCS FRCEM

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

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

E: davidalbunker@outlook.com T: 07831 784006

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.

www.forensichandwriting.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/

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Remote assessments: permanent adoption is the consumer’s choice [A GREAT DEAL of debate has taken place regarding the desirability

“Not only is this proving much more convenient for customers, but it is also reducing the instances of missed appointments and saves or otherwise of extending the practice of both remote consultation/ the customer time and money as they no longer need to arrange examination and remote assessment of injury beyond the constraints travel to a GP. of the COVID pandemic. One psychologist has recounted how remote “COVID-19 has released the ’virtual claims management’ genie assessments have enabled patients to feel more relaxed during the from the bottle and there will be no going back.” process – in addition to the savings in time and expense of travelling to That was also the opinion of barrister Giles Eyre. Writing on the appointments – and remote assessments have become the norm during MAPS Medical Reporting website, he said: “While some of us may the lockdowns. be nostalgic for the face-to-face meetings which have always been When MedCo – the system for sourcing medical reports in soft tissue part of our lives until March 2020, the advantages in convenience, injury claims under the Pre-Action Protocol for Low Value Personal Injury time-saving and cost-saving of remote meetings, as well as in Claims in Road Traffic Accidents – first agreed to the suspension of the reducing the risk of infection, are such that it seems overwhelmingly need for an in-person examination in March last year the measure was likely that they are now a part of our lives, whether for business meant to be purely temporary. meetings, GP consultations or family reunions – and medico-legal At the time MedCo said: “Having considered a number of issues examinations. which have been raised by our users in recent weeks, together with Mr Eyre offered comprehensive guidance on how and when such the rapid development of government policy and advice, the MedCo assessments should be conducted. board has decided to introduce temporary measures during the current When it comes to detentions under the Mental Health Act, the COVID-19 pandemic.” use of remote assessments in any circumstances has become the In July an update again stressed the temporary nature of the subject of legal wrangling. suspension – even looking forward to a situation when face-to-face Richard M Jones of Blake Morgan offered an insight into the issue examinations could be resumed – followed by a further update in in his description of the case of Devon Partnership NHS Trust v November, at the beginning of the second ‘lockdown’.

SSHSC [2021] EWHC 101 (Admin), in which the trust asked for The latest update in March, although dealing principally with issues a determination of whether a remote assessment could meet the surrounding remote assessments carried out from outside the UK (they requirement of the MHA for a person to be ‘personally seen’. are not allowed), again looks forward to the return to ‘normal’.

Despite the NHS’s own guidance suggesting a remote assessment The real experiences of people involved in the process are at odds with could be used, the court refused to make such a determination. q that view, however. As early as July last year there were indications that the online experience was proving a hit. A survey by Minster Law revealed that 78% of clients who had attended a medical assessment previously and 82% of those who WHEN IT COMES to remote consultations to diagnose or assess the need for a personal consultation, the attended an assessment for the first move to the virtual norm has become more pronounced – indeed the NHS had begun to move in that direction time said they were ‘satisfied’ or before the pandemic. However, the BMA has detected a way in which the move to the virtual world has excluded ‘very satisfied’ with the appointment. a substantial part of the population – and possibly one that needs more help than others.

Three quarters of both groups were A report by the BMA’s Seren Boyd examined ways in which doctors’ connection to some of their patients ‘satisfied’ or ‘extremely satisfied’ has been broken by the pandemic. She quotes GP Aaminah Verity, whose GP practice suddenly saw most of with the advice given and nearly its footfall disappear. The majority of people making virtual appointments were young people with less serious nine out of 10 said the appointment conditions than the ones she was used to seeing. was ‘easy’ or ‘very easy’.

Ms Boyd wrote: “A year on, the benefits and challenges of this ‘digital-first’ approach are crystallising.

Minster Law claims director There are concerns the new virtual NHS is inadvertently shutting out certain groups of patients.”

Marcus Taylor said: “If customers The main issue is that not everyone is digitally included. Figures from the ONS show that 10% of the adult UK are telling us that they like using population are classed as ‘internet non-users’ – and it’s not only older people. technology for remote medical There was a more upbeat view when it comes to hospital consultations. Latifa Patel, a paediatric respiratory assessments, our industry has a trainee, found that the shift to digital technologies has brought significant benefits for patient and clinician. Not responsibility to respond, look to having to attend in person has meant huge savings in time and money for patients: a hospital visit usually meant digitise this and other parts of the an early start, time off work and school, long journeys and costly car park fees. claims journey. Nothing should be To read the full article visit www.bma.org.uk. q off the table.

Not everyone can access the virtual consulting room [

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The surgeon’s guide to staying out of court by consultant urologist CHRIS DAWSON MS FRCS LLDip

There are a number of regular themes in medical negligence work in urology. This brief article shares the author’s experience in writing reports in the area over the past 17 years. While a lot of reports in medical negligence work appear due to a clear breach of duty, in the author’s opinion many are not.

[

OFTENTIMES PATIENT DISSATISFACTION can turn from a hospital complaint onwards towards a civil claim. How can that chain of events be broken?

In many cases the problem – if there is going to be one – starts with the initial doctor-patient consultation. That will often get off to a good start if the surgeon greets the patient with a smile (and prior to COVID-19 a handshake!) and asks how their journey to the hospital went.

While it might be just another busy day for the surgeon, for the patient it is possibly their one opportunity to get across their version of events.

It is important for them to be heard, and therefore vital that the clinician listens with empathy and, most importantly, without interruption.

One pearl of wisdom gained by the author from a course on preventing litigation was: “Patients don’t care how much you know, until they know how much you care.”

When it is the surgeon’s turn to speak it is important to communicate in clear simple language, and to allow time for questions from the patient. The use of patient information sheets is highly recommended, particularly when it relates to an explanation about a forthcoming surgical procedure. Clear contemporaneous notes are a vital source of information when it comes to defending a claim.

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

The letter to the GP is a vital part of the communication process. It is imperative from the surgeon’s perspective that the letter contains all

details of the conversation that took place with the patient. If a surgical procedure is planned, then a record of the discussion with the patient about the risks of the procedure should be part of the clinic letter, and acts as an important record source should there be a later medical negligence claim relating to the consent process.

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

One of the most important points about consent is that it should be written and recorded. Most available consent forms need to be filled out by the surgeon, and it is vital that all material risks are recorded in the relevant section. Too often in medical negligence cases that section has been left blank!

The use of procedure specific forms, such as those produced by the British Association of Urological Surgeons, are helpful in that regard.

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

When a complaint does occur it is important that surgeons remember that a Professional Duty of Candour exists – visit www.gmc-uk.org.

Having an open and honest conversation with the patient at an early stage, and apologising where appropriate, is therefore good practice, and may lead to a resolution of a complaint before it escalates into court action. q www.yourexpertwitness.co.uk

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PIP scandal: latest ruling brings relief to sufferers [ THERE WAS GREAT RELIEF among

women who had been victims of the defective PIP breast implants when the Paris Court of Appeal ruled that German certification company TUV Rheinland was liable for the damage and hurt caused by the implants, as its certification allowed the French company Poly Implant Prosthese (PIP) to apply a CE mark to the products.

PIP was dissolved in 2010 and its founder Jean-Claude Mas was jailed for four years.

He died in 2019.

In a statement following the judgement, PIPA – the body representing victims internationally – said: “The companý founded by Jean-Claude Mas marketed breast implants filled with industrial silicone for 10 years. The certification issued by the German group TUV Rheinland allowed PIP to affix the CE mark to the adulterated products and thus market them worldwide.”

Olivier Aumaître, lawyer for many of the victims, commented: “We are delighted with this outcome, which puts a definitive end to doubts about TUV’s responsibility.”

Law firm Slee Blackwell represents many of the UK women who have suffered effects from the defective implants.

In a statement following the ruling

the firm said: “There had previously been doubts about TUV’s legal liability, especially after a setback in the Aix-enProvence Court of Appeal some years ago, which left victims worldwide worried that they might not be able to recover compensation. However, the ruling now gives British women the opportunity of claiming compensation for the injuries and distress they have suffered as a result of receiving PIP implants.

“Compensation will be evaluated individually, on a case-by-case basis. It is anticipated at this stage that affected women can expect to receive between €20,000-70,000. A first judgment on the amount of compensation to be paid is expected later this summer.”

The statement added that the impact of the implants on the heath of children who have been breastfed with TUV-certified silicone is also under consideration.

The firm is also urging women who have not received compensation to come forward and join the next group of cases being presented to the court.

The firm’s specialist lawyer Oliver Thorne, who has acted for the women, told the BBC that many women still had

Breast surgeons respond to FDA mesh products alert [

A STATEMENT HAS BEEN RELEASED on behalf of the joint Association of Breast Surgery (ABS) and British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) mesh-assisted breast reconstruction guideline writing group regarding acellular dermal matrix (ADM) products used in implant-based breast reconstruction. It follows the safety communication released by the US Food and Drug Administration on 31 March.

According to the statement: “Multiple studies have reported variable complication rates associated with mastectomy and mesh assisted implant-based breast reconstruction. The 2017 systematic review concludes that there remains a need for well-designed studies to evaluate the impact of mesh use on the clinical and patient-reported outcomes.”

Based on analysis of the latest scientific evidence and on expert clinical opinion, the members of the joint ABS and BAPRAS ADM guidelines writing group has made a number of recommendations for clinicians and for patients.

Breast cancer and breast reconstruction experts from across the UK have been working together to review the literature and provide updated joint ABS and BAPRAS guidelines for biological or synthetic mesh-assisted breast reconstruction procedures, which will be released shortly.

If patients are worried following their breast implant surgery they should contact their surgical breast care team. That is particularly important if they notice swelling around their implant, discharge from the wound, redness of the skin, a fever, discoloured skin or new lumps. q

their PIP breast implants in place because they did not have the money to get them replaced, and that is why it is so important they receive compensation. q

Carpal tunnel surgery – patient information package sought [

THE British Society for Surgery of the Hand (BSSH) has commissioned four awards to support the development of an information package for patients undergoing surgery for carpal tunnel syndrome. The project is being run jointly by the BSSH’s Education and Training and Communications Committees, also collaborating with the British Association of Hand Therapists (BAHT).

The awards comprise one £500 video award for BSSH member/associates covering one of four areas of patient information, one £500 award for BAHT members covering post-operative care and two £250 awards for infographics or posters to augment the information sheets.

All submissions for the awards should feature patients where possible and where patient images or videos are included express consent will need to be given for publication in the public/internet domain.

The BSSH will assume that consent has been obtained by all entrants and entrants may be asked to provide evidence of written consent to publication.

Submissions are being encouraged using all media formats to convey the message in the most accessible format and submissions should be aimed at the lay viewer/reader. q www.yourexpertwitness.co.uk

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Better monitoring could reduce cataract surgery complication, study finds [

NEW ANALYSIS of over 600,000 cataract operations suggests that there is considerable potential to reduce instances of the post-operative surgical complication known as posterior capsular opacification (PCO).

Cataracts are treated by surgery, during which the cloudy lens is removed and replaced by an artificial lens. The artificial lens is known as an intraocular lens (IOL).

PCO is a complication which can occur months or years after cataract surgery. It occurs when a cloudy layer of scar tissue forms behind the lens implant and can cause blurred or hazy vision or glare from lights. PCO is estimated to occur in roughly one in five eyes that have cataract surgery and is usually treated by Yttrium Aluminium Garnet (YAG) laser surgery.

An analysis of the RCOphth National Ophthalmology Database (NOD) Cataract Audit dataset revealed vast variation in observed post-cataract PCO rates between different contributing centres and different IOL materials and designs, such as the higher observed

Public confidence in ‘opticians’ at all-time high

PCO rate in IOLs with a hydrophilic component.

Although there were multiple surgical and ocular factors found to influence the risk of PCO YAG, none of them alone can account for the vast variation in observed PCO rates the research found.

However, better monitoring of performance of IOLs to reduce complications could result in fewer clinic visits by patients, freeing up resource in the ophthalmic workforce.

The research suggests it is a false economy for NHS providers to opt for less expensive IOLs with higher rates of PCO, given the negative effects on patients (who are often elderly) and the average cost to the NHS of the YAG laser capsulotomy needed to correct PCO. John Buchan, NOD Cataract Audit Clinical Lead and consultant ophthalmologist at Leeds Teaching Hospitals NHS Trust, was one of the report’s authors. He explained: “The extent of variation that we found suggests that there could be substantial benefits to patients and to the NHS from further work to identify the IOLs or other modifiable risk factors that impact PCO rates in individual centres. Reductions in the incidence of PCO YAG could benefit thousands of patients, by avoiding YAG laser surgery thus reducing hospital visits, improving patient outcomes and liberating NHS resources.”

The report recommends that individual eye care centres should compare PCO rates for different IOLs utilised within the same centre to identify IOLs (and other modifiable risk factors) which minimise the rates of PCO. They should also investigate measures to improve data collection, including the utilisation of electronic medical records across their whole eye service, including any community-based follow-up. q

[THE GENERAL OPTICAL COUNCIL (GOC) has published its

2021 public perceptions research, which seeks to understand the public’s views and experiences of opticians across the UK. Over 2,000 members of the public responded to an online survey as part of the research. More than 90% responded favourably to three key questions: satisfaction with their last visit to an optician (96%), confidence in the standard of care (94%) and satisfaction with the coronavirus measures in place (97%).

A new high of 30% of respondents said they would speak to an optician first if they woke up with an eye problem – an 11-percentage-point increase since 2015 – while over a third (35%) said they perceive opticians to be solely a healthcare service, which has increased by four-percentage points since 2019.

The term ‘opticians’ was used throughout the research to avoid confusion, on the assumption that the public do not clearly distinguish between ‘optometrists’ and ‘dispensing opticians’, although questions about the understanding of those terms were included as part of the research.

Marcus Dye, acting director of strategy at the General Optical Council, said: “We’re extremely pleased to see that confidence in the professions remains high, especially during the COVID-19 pandemic. We’d like to thank our registrants for their hard work during these difficult times to ensure the public could still receive eye care and feel safe doing so.

“It’s also positive to see that the perception of opticians as a healthcare service has increased to over a third, and more respondents than ever say they would speak to an optician first if they had an eye problem. We look forward to continuing to see these numbers increase and we hope registrants and the wider sector will find the report to be helpful in improving optical care practice.”

The full report is available on the GOC website at www.optical.org. q

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Swelling of the leg is a common issue in litigation

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

[LEG SWELLING is a common symptom in patients and arises from a number of conditions. Claimants may suffer lower limb swelling following injuries to the lower limb and the question often arises as to the causal relationship between the injuries sustained and the prognosis.

In clinical negligence litigation, deep vein thrombosis may occur when preventative measures are omitted following hospital treatment.

That can leave claimants with long-term swelling of the leg. A number of less common diagnoses may lead to leg swelling accompanied by diagnostic confusion.

Causes of leg swelling

A number of conditions may give rise to a generalised tendency to swelling of the body, although it most commonly affects the legs. Heart failure, liver failure and kidney failure all fall into that category, but are not usually in the realm of the vascular surgeon.

Leg swelling is commonly due to the presence of oedema; that is, accumulation of water in the tissues. It occurs following any injury, operation on the leg or inflammatory process and usually resolves as the original injury or operation heals. General measures such as elevation of the leg or the use of compression stockings will help. That leaves conditions which cause swelling of the main tissues of the leg, which are the subcutaneous fat and the muscles of the leg.

leg via much smaller alternative (collateral) routes of venous drainage.

They are less effective than the normal veins, which are large in diameter.

Persistently blocked main veins commonly give rise to swelling of the leg. The whole limb may be affected when the femoral vein in the groin is affected or the veins above that level.

Another problem that gives rise to leg swelling is loss of the venous valves. These are often irreversibly damaged following a deep vein thrombosis. The purpose of the valves is to ensure that blood in veins flows only towards the heart. When the valves are damaged following deep vein thrombosis, blood flows back into the leg and leads to high pressures in leg veins. The calf muscle expands to try and expel blood from the leg. The calf increases in size, which patients find uncomfortable and unsightly.

The main problem with high pressures in leg veins is that they lead to skin damage and leg ulceration – chronic, non-healing wounds of the leg – resulting in a lifelong requirement for care and treatment. The cosmetic problems, discomfort, pain and suffering, and the treatment required for those conditions, are cost elements in claims following deep vein thrombosis in the leg.

Lymphoedema

The lymphatic vessels are an extensive set of vessels that drain extracellular fluid (fluid outside blood vessels which bathes the cells of the Deep vein thrombosis body) from the limbs. They are small and fragile vessels which are easily In this condition the main veins of the leg become blocked with blood damaged. The superficial lymphatic vessels lie near the great saphenous clot. That may occur following lower vein, which runs the length of the limb injuries, especial where operative leg up the inside of the limb. Where treatment is required. In fact, any lymphatic vessels are damaged the hospital treatment gives rise to an syndrome which results is known as increased risk of deep vein thrombosis, lymphoedema. even when surgery to the leg has not In this condition fluid accumulates been done. Prompt anticoagulant within the subcutaneous tissues of the drug treatment is effective in resolving leg, leading to swelling of the limb. The the condition. Delay in diagnosis and worst affected region is the foot, where appropriate treatment leads to a much swelling begins, and is most prominent worse outcome. on the top of the foot. With worsening I have advised in several cases of lymphoedema, the swelling involves where claimants have alleged that the ankle and calf. In severe cases, the delayed start of anticoagulant drugs whole limb may be affected. led to permanent leg swelling, with The most common causes of the risk of leg ulceration in the future. lymphoedema are severe bacterial Often the claimant has succeeded infections of the lower limb and in those cases. In one case, delayed cancer surgery. Tumours may spread treatment led to cessation of blood via the lymphatics and sections of flow in the leg, with gangrene and the the lymphatic system are removed need for an amputation. That claimant during cancer surgery. Patients successfully argued that appropriate should be warned of the likelihood of treatment would have avoided the need lymphoedema affecting the upper or for amputation. lower limb, depending on the region Some patients who have of surgery. Bacterial infections may experienced a deep vein thrombosis enter the lymphatic vessels, which have troublesome swelling of the leg. form part of the body’s defence system That appears to arise from two sources. for infections. Cellulitis affecting the Where the main veins from the limb lower limb may lead to persistent Lymphoedema of the left lower limb following an episode of severe are blocked the blood has to leave the cellulitis which occurred following a minor injury to the limb lymphoedema of the foot or leg.

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Litigation in cases of lymphoedema usually arises from trauma to the limb. I have advised in cases where regions of tissue loss in the lower limb included the main lymphatic system leading to lymphoedema of the limb below the level of injury. Old fashioned varicose vein surgery involved dissection in the groin, a region though which the main lymphatic vessels pass. I have come across several cases in which substandard varicose vein surgery has led to lymphoedema affecting much or all of the lower limb. I have advised a number of litigants in such cases.

Fortunately, varicose vein surgery has largely been abandoned in favour of more modern and much less invasive techniques, which avoid this potential complication.

Lipoedema

Lipoedema is a congenital condition which involves swelling of the lower limbs due to preferential deposition of subcutaneous fat. As a result of the condition the legs become large, but there is no substantial accumulation of fluid. Ultrasound imaging shows a subcutaneous layer which is thicker than would be expected, but contains no excess of fluid – in contrast to lymphoedema. Another factor distinguishing this condition from lymphoedema is that the feet are not affected and have normal, minimal amounts of subcutaneous fat. The increased fat deposition extends to the calf and thigh and may also include the hips.

Patients with the condition tend to accumulate fat preferentially in the lower limbs when they put on weight. In a small number of cases where I have advised it has led to claimants assuming that leg swelling was due to injuries sustained in road traffic incidents. In those cases it is likely that the lipoedema has been emphasised after the claimants put on weight in the aftermath of the incident. The lipoedema was present prior to the incident.

To sum up, personal accident and clinical negligence litigation may involve the subject of swelling in the leg. Several different causes of swelling may arise and the success of litigation depends upon detailed evaluation of the circulation of the limb to determine the causation. q

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Fractures during falls continue to show poor outcomes [ FALLS ARE THE MOST common incident affecting

hospital inpatients, and one of their most serious consequences is a hip fracture. A report published by the Royal College of Physicians – National Audit of Inpatient Falls interim annual report – covers 2020 audit data from England and Wales facilities and is supported by National Hip Fracture Database (NHFD) clinical audit data from 1 January to 31 December.

Many healthcare professionals had to focus on the COVID-19 response in 2020, and in response, NAIF extended its clinical audit deadline to the end of 2020.

As a result, the report focuses solely on facilities data and a further clinical data report will be published in the autumn.

In total, 74% of eligible trusts and health boards took part in the facilities audit, reduced from 77% last year.

The numbers are still encouraging in the context of the challenges posed by COVID-19.

The report shows that hip fractures sustained in an inpatient setting continue to be associated with poorer outcomes including a two-fold increase in 30-day mortality. The findings also show that fewer organisations claim to report all inpatient hip fractures as serious harm – 70% compared to 76% in 2019 – which is a recommendation in the report.

NICE guidelines advise against the use of fall risk screening tools, instead recommending a multi-factorial risk assessment for all inpatients over the age of 65. Despite that, the report found

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there was a small increase in the proportion of organisations using the screening tools.

Summarising its recommendations, the report states: “In our 2020 report we highlighted that inpatient hip fractures were associated with a greater risk of institutionalisation and higher mortality compared to hip fractures sustained out of the hospital; reflecting the fact that inpatients tend to be frailer or more acutely unwell. However, better post fall management could improve outcomes for this patient group.”

The report was commissioned by the Healthcare Quality Improvement Partnership. q

How has the issue of informed consent changed in the wake of COVID-19?

Obtaining informed consent from patients has always been a crucial and necessary procedure before surgery is performed; however, the COVID-19 pandemic has radically altered care pathways and introduced new elements into the consent procedure. It is vitally important that patients are made aware of the implications of those elements, so that they can make proper decisions about their care. Here, Consultant Orthopaedic Trauma Surgeon MR ASWINKUMAR VASIREDDY discusses the importance of obtaining informed consent in the wake of the pandemic.

[

THE RATES AND VARIETY of postoperative complications and the rate of mortality have been affected by the pandemic, even after routine procedures; and that increase in risk must be conveyed to the patient. The main implications of the COVID-19 pandemic on orthopaedic trauma fall into one of two categories: changes to the care offered and the risk of developing COVID while in hospital.

Owing to the pressure on resources, many aspects of urgent orthopaedic care are stretched, and surgeons will need to consider alternative forms of treatment. Thus, non-operative treatment options need to be considered more readily in order to minimise a patient’s exposure to the hospital setting. Furthermore, complications may be treated more slowly – and in different locations – than would previously have been the case.

For example, most fractures of the upper limb have a high rate of union and will heal well on their own after immobilisation, so an operation may not be necessary. However, patients need to be made aware that good union of the bone will not be achieved in every case and surgery for late reconstruction may be necessary.

Surgery for complex fractures should be planned to minimise the length of hospital stay; if surgery is staged, patients may be discharged and then readmitted. The use of splints or casts that can be removed by the patient at home will become more common. Patients also need to be aware that access to follow-up appointments and imaging, as well as to rehabilitation services, is likely to be very limited and will almost certainly be delivered remotely.

As well as changes to treatment plans, there is now an inherent possibility of contracting COVID-19 while attending hospital.

Emergency admissions for orthopaedic trauma can often involve older, frail individuals with co-existing morbidity – a group particularly at risk from COVID-19 infection. Thus, attendance for treatment is now much riskier than it was, particularly for patients in vulnerable groups, and the potential benefits of treatment in hospital may not outweigh the risks.

The British Orthopaedic Association suggests that factors such as increased age, chronic lung disease, diabetes mellitus, obesity, heart disease, cirrhosis and immunosuppression all contribute to a patient’s risk of contracting COVID-19. Clearly, pertinent risk factors will need to be assessed on a case-by-case basis.

At the start of the pandemic COVID-19 infections acquired in hospitals were relatively common, but more recent surveys indicate that the rate of infection in hospitals is similar to, or lower than, that seen in the community at large. Public Health England estimates that only around 20% of inpatient infections actually originate in hospital.

The risk is unlikely to be uniform across the country and may change quickly as infection ‘hotspots’ develop and are controlled. Therefore, communication between infectious disease specialists and surgical teams is vital to ensure that patients are provided with facts relevant to any decision about admission.

There is little available information on the consequences of surgery for patients who are already positive for COVID-19. The risk of transmission from surgical patients is unclear and little is known about the course of the virus in that patient group. Furthermore, a lack of data on surgical outcomes for that group means patients cannot be provided with accurate information. Worryingly, there have been reports of very high rates of both complications and mortality in COVID-19 patients undergoing surgery, although many of those patients were at high-risk.

With the advent of effective vaccines, the end of the COVID-19 pandemic appears to be in sight; however, we are still a long way away from herd immunity. While there has always been a need to balance optimum treatment against available resources and clinical safety, that has now become paramount.

Best practice dictates that patients should be made aware of all the risks of a procedure, however small. Given the increase in mortality now seen in orthopaedic patients, the procedures used to obtain informed consent need to be updated to reflect the recent changes and increased risks posed by this potentially fatal virus. q • Mr Aswinkumar Vasireddy BSc (Hons) MBBS FRCS is a full-time Fellowship-trained orthopaedic trauma surgeon based at King’s College Hospital. He specialises in the management of complex open and closed pelvic, acetabular, upper limb and lower limb fractures and amputations in both his clinical and expert witness work. He is also one of a small group of surgeons in the UK – and the only contemporary orthopaedic surgeon – who works as a HEMS air ambulance pre-hospital care doctor.

He qualified at Guy’s, King’s & St. Thomas’s Medical School and completed his orthopaedic training on the prestigious South East Thames Rotation. He completed specialist orthopaedic trauma Fellowship training in the UK and USA. His medico legal practice includes those who have sustained high-energy injuries. With his training, he is able to provide comprehensive reports and review all aspects of a patient’s treatment. To read his full biography and download his CV visit www.medicolegal-partners.com/vasireddy. www.yourexpertwitness.co.uk

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Patients awaiting joint ops suffer poor quality of life, study finds [

A PAPER PUBLISHED in the Bone and Joint Journal highlighting grave concerns about the very poor quality of life experienced by patients waiting for hip and knee surgery during the COVID-19 pandemic drew a joint response from the British Orthopaedic Association (BOA), the British Hip Society (BHS) and the British Association for Surgery of the Knee (BASK).

COVID-19 has meant that the maintenance of normal levels of elective surgery has not been possible within the NHS, the response noted, with orthopaedics disproportionately affected.

“We now have a large number of patients who have been waiting for many months for their surgery, and we need to emphasise the importance of resuming surgery on this group as rapidly as possible. We are working very actively with the NHS and other relevant stakeholders to address this as the UK emerges from the winter COVID-19 lockdown.”

The patients involved in the study were asked to respond to a standard set of questions about their quality of life and a concerning proportion reported very poor quality of life as a result of the pain, immobility and loss of function that end-stage arthritis typically causes. Where a patient completing

this survey scores less than zero in their responses, it may be equated to a position that is ‘worse than death’.

In the study, over one-third of patients waiting for total hip replacement and nearly one-quarter waiting for a knee replacement scored less than zero. Those levels are almost double what they were prior to the pandemic. Increasing length of time on the waiting list was associated with decreasing quality of life.

Bob Handley, president of the BOA, commented: “We are well aware of the misery and despair caused by the pain and immobility of end-stage arthritis, and that this

has sadly only grown during the course of the pandemic. We urge those with oversight responsibilities to restore full services to prioritise and treat these orthopaedic patients as soon as possible. This is no time for nodding in agreement with no positive action.

“All who read and understand a paper such as this should recognise the great need of these patients and play what part they can to address the problem. If orthopaedic patients continue to be last in the queue when services resume, this will lead to a tsunami of further health and societal problems, affecting physical and mental health of these people as well as their ability to live independently and contribute to society.”

The three organisations which issued the response represent orthopaedic surgeons who are doing all they can to support an effective restart of services as and when the COVID-19 pressures have eased sufficiently.

The joint response reads: “We will work with NHS and other bodies to identify sustainable solutions to address the backlog of patients.

We note that orthopaedics was specifically mentioned as a priority area in NHS England’s plans in December and we urge all those involved in planning and implementing strategy for tackling the waiting lists to ensure that orthopaedic care is prioritised.” q

Minister’s attendance at APPG highlights ‘significant issues’ [

THE ATTENDANCE OF Minister for Social Care Helen Whately at the All Party Parliamentary Group on Spinal Cord Injury (SCI) in March highlighted the significant issues facing spinal cord injured people nationwide.

The minister (pictured) made a formal commitment that the specialist spinal centre beds that have been repurposed for general medical use during the COVID pandemic will revert back to spinal centre use after the crisis has subsided. She also agreed to a meeting with APPG chair Owen Patterson MP and the Spinal Injuries Association – which holds the APPG Secretariat – to thrash out ways of working together to improve the lives of the SCI community.

The commitment to return specialist spinal centre beds is hugely significant, the association says, because historically, when beds have been repurposed to deal with ‘winter beds pressures’ in the NHS, they haven’t always reverted to spinal centre use afterwards. That has eroded the national capacity of the spinal centre network and so

reduced the availability of beds to newly-injured people, leaving them isolated in more expensive major trauma centre beds without the specialist input and support to help them start to come to terms with their spinal chord injury, and learn the skills needed to manage their condition going forward. q

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Pelvic fractures: an increasingly common feature of medico-legal cases Pelvic fractures commonly figure in serious personal injury cases in terms of determining the condition and long-term prognosis of the injuries – and sometimes in clinical negligence matters relating to breach of duty in diagnosis or treatment. In this simplified ‘primer’, consultant trauma and orthopaedic surgeon MR NIKHIL SHAH tries to cover the salient features of that kind of injury.

[

FRACTURES OF THE PELVIS can be serious injuries. They are usually associated with high-energy mechanisms such as major road traffic collisions, motorcycle accidents, falls from height or pedestrian versus vehicle accidents. Such injuries can be associated with life-threatening bleeding and require prompt diagnosis and timely resuscitation for optimal management.

In recent years there has been an exponential rise in pelvic fractures in elderly patients with osteoporosis, from low-energy trauma such as falls from a standing height. Those patients now form a significant number of referrals to pelvic fracture services.

The bony pelvis is shaped like a ring. It has two innominate bones joined at the back to the sacrum and in the front to each other at the symphysis. On their own the bones would have no stability; however, the ring becomes a very stable structure because of strong ligaments that join the bony components to each other and to the spine.

of the lumbosacral plexus are at risk in pelvic fractures. The force causing the pelvic fracture also invariably damages those vital structures, leading to life-threatening bleeding or internal organ damage.

For the sake of description and planning of treatment, orthopaedic surgeons tend to think of pelvic injuries as either stable or unstable.

Another classification system categorises the injuries based on whether the direction of the force comes from the front, such as a motorcycle rider crashing against an obstruction, from the side, such as a pedestrian or passenger being hit from the side, or in a vertical direction – for example a fall from height. Those forces influence the pattern of the fracture and the degree of displacement, which in turn determine the treatment.

Different types of fracture are caused according to the direction of force

The bony pelvis is a ring with two bones joined at the front and the back made stable by strong ligaments Inside the bony pelvis are vital soft tissue structures such as major blood vessels, important nerves and the organs which form the end of the bowel (colorectal), the urological structures (urinary bladder and urethra) and the sexual organs. Important neurological structures

Timely diagnosis and treatment are extremely important to save lives. Initial treatment consists of the application of a pelvic binder, which closes the unstable ring to help stop bleeding while the patient is transported to hospital. That is combined with management of haemorrhagic shock by the administration of blood and blood products. Other methods of life saving treatment in an emergency setting consist of techniques such as pelvic packing or using angiographic embolisation to stop bleeding.

Definitive treatment of unstable fractures is usually by surgical stabilisation of the pelvic ring using a variety of techniques, such as external or

internal fixation using a combination of plates and screws that are applied to the pelvis by open or percutaneous techniques (pictured below).

Open pelvic fractures form a subset of highly serious injuries where the fracture communicates with the external or internal environment, resulting in an increased risk of infection. Those injuries have a high risk of mortality without appropriate expert management. Another subset consists of pelvic fractures associated with damage to the junction between the pelvis and the bottom of the lumbar spine – the so called spino-pelvic instability.

Such complex injuries require careful multidisciplinary management by a team of dedicated pelvic fracture surgeons, spinal surgeons, plastic surgeons, general and urological surgeons, anaesthetists, intensivists and rehabilitation specialists, among others.

The long-term outcomes after pelvic fractures are more often determined by the associated injuries, such as skin and soft tissue, urological or neurological injuries.

The advent of major trauma centres in the UK, and national guidelines for treatment, have led to a significant improvement and standardisation of care provided for injured patients. That has led to an overall improvement of outcomes nationally. q www.yourexpertwitness.co.uk

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Children worst affected by COVID-driven mental health crisis [A NEW STUDY by the Institute

of Psychiatry, Psychology and Neuroscience (IoPPN) at King’s College London, in collaboration with the universities of Liverpool and Reading and published in the journal JCPP Advances, shows that the COVID-19 pandemic led to a sharp increase in symptoms of depression and PTSD reported by children aged 11-12. The researchers are now calling for mental health providers to be given the necessary resources to cope with the increasing demand and complexity of children experiencing mental health problems if they are to keep pace.

The study looked at the mental health of adolescent children, from a sample representative of the general population, and compared levels of emotional and behavioural problems immediately prior to, and during, the pandemic. There has been widespread concern regarding the impact of COVID-19 and the associated lockdown and social distancing measures on the mental health of children and adolescents.

Children aged 11-12 years and their mothers participating in the Wirral Child Health and Development Study provided mental health data between December 2019 and March 2020 and again three months later. Of 202 participants, 89% were assessed both before and after the initial lockdown period. Of those, 44% reported an increase in symptoms of depression, while 26% said the same about PTSD. The group that experienced the biggest increase in behavioural problems were those without any prior experience, suggesting that the onset was associated with the pandemic.

Prior to the pandemic, rates of maternal and child depression were greater in families experiencing higher deprivation, but during the pandemic the results showed that they changed only in less deprived families, raising their rates to become comparable with those of the higher deprivation group.

Dr Nicola Wright of the Department of Biostatistics and Health Informatics at King’s, said: “Our findings indicate that referrals for depression and disruptive behaviour problems during the pandemic are likely to be made up of two kinds of young people: those with the onset of new mental health problems for which COVID-19 related issues may be the most relevant, and others where COVID-19 has added to pre-existing vulnerability with a need for attention to both.

“What’s not yet clear is whether COVID-19 exposure has simply ‘brought forward’ the first episode of depression in children who would have become depressed later in its absence. Meanwhile the findings underline the need for a better understanding of risk and protective factors for COVID-19 related mental health problems as a basis for new treatments.”

The findings echo those reported by the Royal College of Psychiatrists in April, which found that children and young people are bearing the brunt of the mental health crisis caused by the pandemic.

The analysis of NHS Digital data found that: • 372,438 children and young people were referred to mental health services between April and December last year: 80,226 more than in 2019 – an increase of 28%.

• 600,628 more treatment sessions were given to children and young people: at 3.58 million the number was up by a fifth on 2019.

• 18,269 children and young people needed urgent or emergency

crisis care, including assessments to see if someone needs to be sectioned because they or others are at harm: an increase of 18% on 2019.

The RCPsych called for the additional £500m in the government’s mental health recovery plan to reach the frontline urgently, so that people can get the support they need.

That funding is on top of the existing planned investment in mental health services set out in the NHS Long Term Plan.

Dr Bernadka Dubicka, chair of the child and adolescent faculty at the Royal College of Psychiatrists, commented: “Our children and young people are bearing the brunt of the mental health crisis caused by the pandemic and are at risk of lifelong mental illness.

“As a frontline psychiatrist I’ve seen the devastating effect that school closures, disrupted friendships and the uncertainty caused by the pandemic have had on the mental health of our children and young people. Services were already struggling to cope with the number of children needing help before the pandemic hit, and they risk being overrun unless government ensures the promised money reaches the frontline quickly.” q

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Mental health community welcome moves to ban conversion therapy [THE British Psychological Society (BPS)

has welcomed the announcement in The Queen’s Speech that the government will take legislative steps to ban conversion therapy.

The BPS has urged the government to act with speed to outlaw the practice, which is unethical, potentially harmful and not supported by evidence.

Dr Adam Jowett, chair of the British Psychological Society’s Sexualities Section, said: “This news is a step in the right direction and we are encouraged that the government will move to bring forward measures to ban conversion therapy. It is vitally important that a ban is implemented as soon as possible.

“Diversity in sexual orientation and gender identity represent normal human variation and the BPS believes that gender and sexual minorities should be protected from discrimination. This includes protection from unethical therapies that purport to change or ‘convert’ sexual orientation or gender identity.

“We will continue to work closely with partners and hold the government to account on this issue to ensure this harmful and abusive practice is banned.”

Following the BPS’s welcoming of the move, the Memorandum of Understanding (MoU) coalition on conversion therapy reacted favourably to news that the government will lead a short consultation to ensure the ban is watertight for both mental health professionals and LGBT+ people who use mental health services.

Chair of the MoU, Igi Moon, commented: “The news that the government is bringing forward measures to ban conversion therapy is welcome. The wording of a national ban has to be considered extremely carefully to ensure it is truly effective.

“The United Kingdom has a long history of championing and developing LGTB+ equality and this ban could lead the way on a global platform. Conversion therapy appears in many guises and simply by using different

terminology LGBT+ people are still potentially at threat of entering into psychologically damaging spaces, which is why it is crucial the ban is watertight.

“We look forward to contributing to the consultation to ensure this ban works.”

The MoU also welcomed the announcement of the fund to help LGBT+ people impacted by conversion therapy, due to launch this summer.

Its deputy chair, Jeremy Clarke, explained: “The needs of survivors and victims are of the utmost importance and ensuring people get the support they need is vital. The MoU hopes to work closely with government and with devolved administrations to help set up these services urgently, so they are equally available

to LGBT+ people across the four nations.”

Carolyn Mercer, a 73-year-old former headteacher who underwent conversion therapy, said that she is pleased the government is taking action.

“I can never be repaid for the hurt and the sadness that has taken place since that time,” she said, “but it’s good that at last, the government is doing something to help people now.” q

Report analyses suicide in middle-aged men

[THE National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) has

published a report into suicide by middle-aged men. It reports on findings from a national study combining multiple sources of information that provide a detailed account from families, friends and professionals on the stresses men in their mid-life face before they take their lives.

The study provides rich data on the adversities middle-aged men were facing prior to their death, which it is hoped will help inform policy, public health strategies, and safer practice in all front-line agencies, including the identification of barriers to accessing services, and ultimately reduce suicide rates.

In its summary the report states: “Since 2013, men aged 40-54 have had the highest suicide rate in the UK; accounting for a quarter of all suicide deaths in 2019. The suicide rate in middleaged men in the UK is three times higher than women of the same age and 1.5 times greater than men in other age groups. This is of concern because middle-aged men are often thought not to be in contact with health or other support services, and are more likely to be affected by economic adversity.”

The findings described in the study do not cover deaths that occurred during the COVID-19 pandemic.

• The NCISH is a research project carried out by the University of Manchester. It has been commissioned by the Healthcare Quality Improvement Partnership, a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices.

To download the NCISH’s reports and find out more about its work visit the website at www.manchester.ac.uk/ncish. q

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COVID infection increases risks for women giving birth, but overall numbers are low

[THE Royal College of Obstetricians and

Gynaecologists has welcomed a new study which sheds light on the association between COVID-19 and pregnancy outcomes. The study, by the National Maternity and Perinatal Audit, found that pregnant women who tested positive for COVID-19 in England at the time of giving birth had higher rates of stillbirth or a preterm birth – however, the actual increase was low.

The study, published in the American Journal of Obstetrics and Gynecology, analysed data from more than 340,000 births in England between May 2020 and January 2021. Around 3,500 women had tested positive for COVID-19 around the time of giving birth.

The study found that women who tested positive for COVID-19 around the time of giving birth were twice as likely to have a stillbirth: 8.5 in every 1,000 births, compared with 3.4 in every 1,000 births. The rate of premature birth was also twice as high when the mother had COVID-19 at the time of giving birth and women who tested positive for COVID-19 were more likely to have an emergency caesarean birth compared with those who didn’t have COVID-19.

However, it was more common for women who had COVID-19 at the time of birth to be younger and from a black, Asian or minority ethnic background.

Prof Asma Khalil, Professor of Obstetrics and Maternal Foetal Medicine at St George’s Hospital, University of London and obstetric lead of the National Maternity and Perinatal Audit was co-lead author of the paper.

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She explained: “This study is the largest yet in England to describe the pregnancy outcomes in pregnant women who had tested positive for COVID-19 around the time of birth. While it is reassuring that the overall increases in the rate of stillbirth and preterm birth remain low, this study does show that the risk of stillbirth or premature birth may be increased in women who have the infection around the time of birth.

“This highlights the importance of COVID-19 vaccination for pregnant women; it reduces the risk not just to themselves, but also to their babies.”

Dr Pat O’Brien, consultant obstetrician and vice president at the Royal College of Obstetricians and Gynaecologists, stressed the importance of the findings.

“While they do show that the rates of stillbirth and preterm birth were higher for mothers testing positive for COVID-19 at the time of birth compared with those who didn’t have the virus,” he said, “we want to reassure women that the numbers are still very low.

“However, every stillbirth is a tragedy and prematurity can have serious consequences for some babies, so this study highlights the importance of protecting pregnant women from this virus, as it also helps to protect their babies.

“This study shows the importance of women being offered protection from the virus. We would encourage pregnant women to use the RCOG’s decision aid to discuss the benefits and risks of vaccination with a healthcare professional so they can make an informed choice.” q

Developments influence updated guidance on third molars [

AN EXPERT working group has updated the 20-year-old NICE guidelines for lower third molar surgery to give them a fresh approach to patient care, explaining that retaining third molars can often have a detrimental impact on patients. The Royal College of Surgeons of England Faculty of Dental Surgery Working Group updated the guidelines for lower third molar surgery, which were originally published in 1999.

The British Association of Oral and Maxillofacial Surgeons was represented on the group by North West-based oral and maxillofacial surgeon Geoff Chiu, who explained: “Over these 20 years we have been able to see the effects that NICE guidelines have had on the oral health of patients in the UK. The new guidelines take into account all the developments since the NICE guidelines were published. This includes management of ‘high risk’ third molars, the current status of patient’s social wellbeing and their involvement in the decision-making.”

Since 1999 there have been developments, advancements and research in technology (cone beam CT scans), pharmacology (steroids and local anaesthetics) and outcomes in supreme court judgements (Lanarkshire vs Montgomery) – all of which have changed the management of third molars.

Geoff Chiu said that retaining third molars in some patients has had a detrimental impact. “This has led to patients developing latent caries or periodontal disease, which can often result in the loss of both the third and second molars,” he said.

He also voiced a concern that many studies have shown the removal of third molars in older age can cause surgical morbidity that increases with age. “The updated guidelines provide a fresh approach to the comprehensive management of third molars,” he concluded. q

Guidelines on dental aligners do not go far enough, say dentists [

THE British Dental Association has warned that newly-published guidance for patients on the risks of direct-to-patient orthodontics is no substitute for meaningful regulation.

Remote provision – offering patients plastic aligners based on a 3D scan of their mouths or via an impression taken from at-home moulding kits – are growing in popularity, but can lead to fundamental changes to a patient’s mouth that may be irreversible. The BDA has been voicing concerns directly with the Care Quality Commission and General Dental Council about the practice since 2019.

The new patient guidelines from the GDC acknowledge vital principles that orthodontic patients need to be fully assessed by a dentist, that direct dentist-to-patient interaction – the basis for informed consent – is essential, and that patients must know the name and registration number of the dentist responsible for their care. However, the guidance does not offer any clarity on what sanctions the GDC might utilise and how the regulator backs up its assumption that such models of care are ‘safe for many people’.

The BDA has seen cases of patients with advanced gum disease that have been provided with these retainers, potentially leading to tooth loss. Last year an investigation into a leading provider by US network NBC revealed a wide range of complaints on treatment outcomes, including migraines and nerve damage.

The BDA says that, as these remote procedures have now been rightly defined as the ‘practice of dentistry’ by the GDC, at the bare minimum their premises need to be registered and inspected by the CQC in the same manner as other healthcare providers, simply to ensure patient safety. q

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Excess cardiac deaths are a harbinger of things to come, says BHF [

THE DEVASTATING DISRUPTION to the care of heart disease caused by the pandemic could put lives at risk for years to come, according to a briefing from the British Heart Foundation (BHF). The charity has predicted that the official figures due this autumn will show a rise in the UK’s heart and circulatory disease death rate for last year, sparking fears that decades of progress could be reversed in the coming years. That predicted rise is due to 5,800 excess deaths from conditions including heart attack and stroke in England during the first year of the pandemic.

That spike in deaths is, however, just the tip of the iceberg, according to the BHF. Missed opportunities to prevent and diagnose heart and circulatory diseases, an unprecedented backlog of people waiting for care and a cliff-edge fall in research funding could amount to a loss of progress for a generation and lead to many lives being cut short by treatable heart conditions.

In fact the charity called its briefing The Tip of the Iceberg. It revealed that the pandemic has caused disruption to every aspect of cardiac care, including: • Around 131,000 (28%) fewer heart procedures and operations were performed in England during the first year of the pandemic and there has been a 180-fold increase in the number of people waiting more than a year for heart procedures, including surgery.

• GP referrals to specialist heart doctors in England fell by nearly a third (29%) in 2020.

• There were 29% fewer ultrasound heart scans (echocardiograms) to diagnose or monitor people’s conditions.

At the same time, the fall in research funding is likely to delay life saving treatments reaching patients.

The BHF funds more than half of UK non-commercial cardiovascular research, but has had to cut its annual budget for new research from over £100m to £50m in the past year.

The BHF says that, with COVID-19 cases declining, the government must act to meet the Prime Minister’s promise to ‘beat the backlog’ and ‘build back better’, including substantial and on-going funding to support the exhausted NHS and help it tackle the vast backlog of people awaiting care.

Alongside that must come investment in the medical research charity sector to ensure the pace of breakthroughs for patients doesn’t stall, and a financial boost for public health services to help prevent people developing heart and circulatory conditions.

BHF’s associate medical director, consultant cardiologist Dr Sonya Babu-Narayan (pictured), said: “Despite the tireless efforts of NHS

staff the pandemic has caused untold heartbreak, with thousands of extra heart disease and stroke deaths and significant delays to cardiovascular care. However, what we have seen so far is only the tip of the iceberg.

“No part of the system providing care for people with heart and circulatory diseases has been left undamaged – from life saving prevention, detection, treatment, and recovery, to crucial research that could unlock future breakthroughs and cures.

“We face a cardiovascular ticking timebomb for the future that could start to reverse six decades of progress in reducing death rates from heart disease and stroke. Averting this disaster will require clear plans that help the NHS to recover, bolster public health and revive the hard-hit medical research charity sector.

Getting this right could protect thousands of lives from heart and circulatory diseases for years to come.”

The briefing also points to widening health inequalities, an overstretched NHS and heightened levels of anxiety among people with heart disease. For example, in the past year the BHF has seen a 38% rise in calls and emails to its Heart Helpline, with a significant proportion from people struggling to access care. q

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