Your Expert Witness No. 64

MEDICAL ISSUES

33 Medical Notes

NEWS

35 CQC prepares to implement new powers

37 Census shows health and disability improvements, but regional differences persist

39 Collaboration leads to fewer than expected COVID era claims

41 BMA attacks ‘limit sick notes’ policy

41 GMC welcomes consultation on associates regulation

VASCULAR SURGERY

42 Study reveals scale of vascular claims

42 Vascular surgery is now covered by quality framework

DIABETES

43 A Charcot joint may have severe consequences, but is difficult to diagnose

ORTHOPAEDICS

45 Remember: the judge and jury are not medical professionals – usually

45 Patient Safety Notice follows recall of knee implants

47 New ‘toolkit’ aims to improve hip fracture care

PLASTIC, RECONSTRUCTIVE & HAND SURGERY

49 Statement addresses concerns regarding non-NHS aesthetic plastic surgery

50 Research finds drug can limit the effects of hand arthritis

PODIATRY

51 Foot injuries can affect all walks of life

51 Royal college makes the case for MSK podiatry

DENTISTRY & MAXILLOFACIAL SURGERY

53 Dentist’s regulator modifies fitness to practise procedures

OPHTHALMOLOGY & OPTOMETRY

57 Ophthalmologists can reveal problems away from the visual

57 First annual NOD AMD audit report published

59 Intraocular lenses spark patient recall following cataract surgery

59 Guidance sets out emergency eye-care standards

CARDIOLOGY

61 BHF chief calls on PM to act on organ donation law

61 Study finds increased heart disease in women with problems in pregnancy

PSYCHIATRIC & PSYCHOLOGICAL ISSUES

63 Judge calls for inquiry into Alemi registration

63 Specialist team treats mental trauma caused by burns

PAIN

65 The medical and medicolegal implications of the undertreatment of pain

NEUROLOGY

66 Just how do you know which neurology expert you need?

67 Link is found between head injury and brain cancer

67 Valproate: new restrictions introduced

TRAUMATIC BRAIN INJURY

68 Therapy must show measurable benefit to support a case for its continuance

Opening Statement

[ THE AFTERMATH of the Grenfell Tower disaster is finally finding its way onto the statute books, after six years of investigations and reports. The Fire Safety Act is already being implemented, while the Building Safety Act is beginning to be brought into effect. The Building Safety Regulator, an employee of the HSE, is currently looking for experts from the industry to make up its Industry Competence Committee.

Meanwhile, the whole issue of building safety is being kyboshed by Brexit. The complex issue of standards in construction products, together with the current regime of health and safety at work, is built on the comprehensive network of rules and regulations adopted by the EU as a body. The government’s efforts to dismantle that network as it applies to the UK and replace it with a UK-based series of standards is being stalled for reasons most people would have foreseen. The deadline for CE marking has now been extended again, to June 2025.

• Where the HSE is looking more to the past is in a campaign to remind young people that asbestos is still with us as a threat to life. Because the substance has been banned since 1999, that does not mean it has ceased to exist. It makes sobering reading to learn that 5,000 people will die this year from asbestosrelated diseases. Anyone who has lost a close friend to mesothelioma will hope the younger generation take heed of the warning.

• If, as Shaw declared, Britain and the USA are two countries divided by a common language, in the case of England and Scotland we are united by a shared respect for what is, in some cases, a different legal system. And increasingly since the establishment of a Scottish Government an element of statute law has been added to the established system there. The legislature in Scotland is keen to work constructively with the legal system, as evidenced by the recent address to the Law Society of Scotland’s annual dinner.

• The UK and the US can work in tandem in some areas – and that has recently included co-operating in bringing to light the workings of a group of cyber criminals responsible, it has been established, for a plague of offences including ransomware attacks on health systems and local authorities, among other organisations. Seven Russians have been ‘sanctioned’ by both jurisdictions for nefarious activities aimed at blackmailing those organisations.

The joint actions by transatlantic authorities adds to the clutch of financial misdoings uncovered by expert Fiona Hotston Moore.

• Language divisions between the UK and USA – even between England and Scotland – pale into insignificance when compared to the multitude of languages used by the many nationalities seeking sanctuary in these isles. It goes a long way to explain why the two main organisations representing linguists have reacted with fury to a leaked report that the government is considering sending asylumseekers ‘questionnaires’ to support their claims.

One of the more bizarre aspects of the reported plan is the encouragement to use Google Translate to fill in their forms. As contributor Hayley Cowle points out, AI has a host of failings when it comes to accurate translation. Myself unquestionable you’ll correspond [I’m sure you’ll agree].

• One area where a recognised imbalance among experts is being addressed is that of the dearth of women experts. The ERE Pledge is making an effort to address that imbalance and we are proud to promote its efforts. Take the pledge at www.expertwitnesspledge.com/take-the-pledge q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

Pilot gives journalists greater access to Family Courts

[ A NUMBER OF TRIALS have begun to give journalists greater scope to report on matters in Family Courts for the first time. A 12-month pilot launched on 30 January in Leeds, Cardiff and Carlisle means accredited journalists and legal bloggers can report on proceedings, provided they protect the anonymity of the families involved.

Professor Engobo Emeseh, head of the Law School at the University of Bradford, believes it is a positive move which will lead to greater transparency in cases which were previously kept private.

She commented: “There have been calls for a change to allow for more transparency in this area for a while. Family courts are concerned with making fundamental decisions about the life of a

child and their future, so there needs to be some level of transparency and accountability, at the same time protecting other valid interests.

“Previously, there have been campaigns around decisions made concerning children which have been deemed to be unfair, but the public hasn't been given access to all the evidence as it couldn't be reported. So they couldn't come to a fair assessment of whether or not the right decision had been made.”

Nearly 250,000 cases go through the family justice system in England and Wales each year, including custody cases when parents have divorced, as well as the placement of children where welfare issues are concerned, such as abuse and neglect.

Should the trial prove successful it could be rolled out to every court in England and Wales. q

Nightingale Courts won’t achieve anything with no staff

IN RESPONSE TO the news that the UK will extend the use of Nightingale Courts for a further year, Michelle Heeley KC, leader of the Midlands Circuit and Barrister at No5 Barristers' Chambers, commented: “As the criminal court backlog in the UK grows more by the day, extending the use of Nightingale Courts provides some help to getting more cases through. However, this shortterm measure does not address the cumulative effect of a lack of recruitment to the Criminal Bar, the loss of barristers to other areas of law and court closures over the years.

“The impact we are seeing on both victims and the accused following these delays has been catastrophic. During the agonising waiting time to go to court, there is significant pressure on all parties. Victims are left without justice and witness memories

begin to fade, which can have serious repercussions when they are called to testify. My concern is that people will completely lose faith in our broken justice system, put off pursuing justice in highly traumatic and sensitive cases because it could take years to reach court.

“The solution is not a short-term one. We must recruit more barristers and judges to the Criminal Bar and recognise that working in this area of law is tough. For barristers and judges who are currently overworked and taking on cases, greater support is needed to avoid them leaving the Criminal Bar and worsening the crisis.

“We cannot afford a situation where the public lose faith in the judicial system and so we must address the long-term issues for us to be able to deliver justice for victims and the accused.” q

Minister addresses Scottish Law Society dinner

[THE SCOTTISH MINISTER for Community Safety, Elena Whitham MSP, praised Scotland’s legal profession and made a commitment to work constructively, in a speech at the Law Society of Scotland’s annual dinner on 3 March.

Law Society president Murray Etherington also addressed the more than 200 guests who attended the function, speaking about the importance of the rule of law and the profession standing together.

The minister highlighted the need for a diverse and inclusive legal profession and judiciary, and thanked Scotland’s legal profession for its adaptability, resilience and hard work serving the public.

“One of the many things I want to do in my time in this office is to have a positive, constructive and collaborative working

relationship with the legal profession, the legal professional bodies and the wider justice sector in Scotland,” she said.

Murray Etherington spoke in his speech on the importance of the rule of law and highlighted the recent anniversary of Russia’s illegal invasion of Ukraine.

He said: “Our profession does have a special duty to stand up for the rule of law here and elsewhere. I’m proud to say that over the past year we have stood up and been counted. Just this morning council passed a motion reaffirming our condemnation of the illegal invasion and expressing our profound sympathy with the people of Ukraine.”

Mr Etherington also spoke about his optimism for a thriving, high-quality profession in the future: “We are pleased with the government’s plans for new legislation to

reform and modernise the regulation of legal services. Our profession is well respected, with a high degree of public trust; but much of the legislation covering legal regulation is now older than I am. It is not fit for the modern legal sector and the international market we now compete in.”

Those attending raised £6,500 for the Lawscot Foundation charity to benefit law students from less-advantaged backgrounds. Diners heard from Lawscot Foundation trustee and former Lord Advocate James Wolffe KC, and Lawscot Foundation graduate Jordan Scott on the importance of the charity’s work.

Jordan Scott, who is now a trainee with Morton Fraser, explained how the charity’s mentoring and financial and other support had been of crucial importance to his studies and subsequent legal career. q

Pledge encourages equal representation among expert witnesses

[IN A PREVIOUS ISSUE of Your Expert Witness we reported on the move by the Expert Witness Institute to sign up to the ERE Pledge. The Equal Representation for Expert Witnesses (ERE) initiative was conceived in 2021. Its purpose is to bring and drive commitment to

improve the visibility and representation of women as expert witnesses.

The ERE Pledge has been created to be a sister pledge to the Equal Representation in Arbitration Pledge, which has been highly effective since its inception in 2015 in calling for – and seeing – an increased proportion of women appointed as arbitrators.

The Pledge aims to encourage action and advocacy to:

• Increase, on an equal opportunity basis, the number of women

• appearing as experts in order to achieve proportional representation

• and, eventually, full parity.

• Support hiring, mentoring and promoting women experts.

• Create a coalition of supporters and advocates in the world of

• dispute resolution.

• Encourage women to aspire to be expert witnesses in their

• chosen professions.

• Give women who are, or aspire to be, expert witnesses better

• opportunities to achieve their goals.

• Widen the pool of expert witnesses available and enhance the

• reputation of expert witnesses.

The ERE Pledge seeks to address the challenges faced by women who work, or aspire to work, as expert witnesses in all forms of dispute resolution globally. It was initiated by Kathryn Britten, a chartered accountant and managing director of global consulting firm AlixPartners, with American colleague Isabel Santos Kunsman.

In an interview with the Daily Telegraph she said: “We felt we had to do something about this, as the proportion of appointed expert witnesses [who] are women is really shocking,”

At the time of writing the Pledge had 972 signatories, both individual and corporate. To find out more and sign the Pledge, visit the website at www.expertwitnesspledge.com/take-the-pledge q

When experts pay for their failings – however…

By CHRIS MAKIN chartered accountant, accredited

mediator and accredited expert determiner

[ YOU MAY HAVE READ lots of articles and blogs from me about inadequate or incompetent experts – and having an expert who doesn’t know his job doesn’t help your case.

There are often costs consequences, a strident example being Patricia Andrews & Ors v Kronospan Ltd [2022] EWHC 479 which I discuss at length in my blog at www. chrismakin.co.uk/expertmeeting-leave-well-alone/

There, you may remember, an expert had charged £225,000 – an enormous sum, far higher than I have ever charged! – but was over two years late in delivering a Joint Statement of Experts. Then, when enquiries were made, it was revealed that the expert had been in very frequent contact with the instructing solicitor, who had played an active part in compiling the joint statement.

The outcome was that the judge decided the expert had no regard for their independent duty to the court. The instructing solicitor was permitted to appoint another expert to start the task again, so £225,000 was wasted and there was probably an order for costs lodged by the other side.

But what we don’t know in this and similar cases is who paid for the damage caused by the incompetent expert; we don’t even know if the experts were paid for their misguided efforts.

Now it’s different, because we do have a case where the expert was himself ordered to pay wasted costs.

Third party costs order

The case is against Dr Chris Mercier following Martine Robinson v Liverpool University Hospital NHS Trust in Liverpool County Court at reference F95Y511.

Dr Mercier was an expert witness in a dental negligence case. An indication of his performance may be gleaned from the very first paragraph ‘Background’ of the judgment in the costs order:

“This was a claim for dental negligence brought by Mrs Robinson, against the Defendant hospital trust, for treatment she received at Aintree Hospital. At the conclusion of her evidence, Mr Gray on behalf of the Claimant withdrew her claim [Mr Maddison for Defendant asked that a third party costs order be sought against Dr Mercier in view of the evidence he had given. I granted that application].

“Unfortunately, Dr Mercier had blanked his screen at this stage in the proceedings having left to pick his son up from school. It is not clear how much he heard. In the same vein, his screen was blanked throughout much of the first day of the proceedings. His second witness statement suggests that he was similarly not present for some of the hearing prior to giving evidence.”

Pausing there, it is not wise for anyone to ignore a judge when he has the power to make an order against one, and an expert can arguably not do their job effectively if they have not heard the preceding evidence. A judge rightly gets upset when a witness walks out of the courtroom at key stages, but it is just as offensive when a witness turns off Zoom during a remote hearing.

In the main trial, the matter in issue was confusion over the extraction of a molar. Mrs Robinson was a nervous patient, and had to have a molar extracted under general anaesthetic. References were made to UL7 and UL8. On the day of the operation, the oral surgeon had before him an early referral but not the record of a later referral, and it was admitted that this was a

civil

breach of duty. The surgeon did not extract UL7, believing it could be restored.

“Dr Mercier for the Claimant argued that no reasonable dental surgeon could have concluded that the UL7 was restorable as at that date… Mr Webster for the Defendant disagreed as to restorability… and it would have been negligent to remove it.”

So that was a clear conflict of expert evidence, as to whether the Defendant should have extracted UL7 as the Claimant contended. As the judge said:

“…the Claimant’s case in respect of breach of duty and causation rested solely on the expert evidence of Dr Mercier.”

The Defendant averred that Dr Mercier should not have been giving expert evidence at all, that he had an ongoing duty to assess whether he was an appropriate expert, and that he failed in that duty.

The law

In his review of the law, the judge made reference to Philips v Symes (No 2) [2004] EWHC 2330 (Ch) where Peter Smith J found that the court should not remove from itself the power to make a costs order against an expert who, by his own evidence ‘…causes significant expense to be incurred, and does so in flagrant reckless disregard of his duties to the court .’ (my emphasis)

There was a reminder that the court, when making such an order, should report the matter to the expert’s professional body. So this is another danger facing the incompetent expert, which could have serious adverse effects on their practice – and not just as experts.

Dr Mercier’s oral evidence

The arguments focused on the limited experience of Dr Mercier, a general dental practitioner, compared with the defence expert Mr Keith Webster, an oral and maxillofacial surgeon. Dr Mercier’s failings are illustrated in this exchange:

Q. Can you speak to the standards attributable to an oral and Q. maxillofacial surgeon?

A. I believe so.

Q. You have never actually occupied that position having never Q. actually been an oral and maxillofacial surgeon, have you, no?

A. No, that’s correct.

Q. Since 2000 you have never had a patient on a table under general Q. anaesthetic?

A. Correct.

Q. Would you say you are as well placed as Mr Webster to speak to Q. the standards to be applied to the evidence of an oral and Q. maxillofacial surgeon?

A. No, Mr Webster is an oral and maxillofacial surgeon so he is going Q. to have more experience in a hospital setting that I have.

Q. My question was are you as well placed. Would you accept you

Q. are not as well placed to speak to...

A. Yes.

It is clear that Dr Mercier accepted he was outclassed when he didn’t even wait to hear the whole of the last question. He clearly was the wrong expert.

There was then discussion of the Bolam test, yet:

“That is the test that Dr Mercier is purporting to apply when he gives evidence before the court in relation to a claim of dental negligence.

It is right that at no point in any of his written or oral evidence did he himself refer to that test.”

You will recall that the Bolam test asks the expert to say what, in his opinion, the reasonably competent professional would have done in the circumstances. By failing to make reference to Bolam, one must question whether Dr Mercier knew what was the fundamental test he was expected to apply to the evidence.

The judge’s view of the expert

There are disparaging remarks by the judge, such as:

“The report itself reaches wholly unsustainable conclusions.”

“…what he does not do is address his mind in any way to the standards to be applied to an oral and maxillofacial surgeon.”

“Dr Mercier’s witness statement it seems to me entirely misses the point.”

“His opinion fluctuates to whatever he feels will win the case.”

“Dr Mercier’s evidence is simply absurd and his inability to recognise that is extremely concerning.”

There is more, but you get the picture. It’s all damning stuff.

The outcome

It was clear which way the judge was thinking. Two sentences say it all:

“The application before me is predicated on the specific assertion that it should have been obvious to Dr Mercier at the outset, and at various stages throughout the proceedings, that he was not the appropriate expert to opine on the management and treatment afforded to the claimant on 8 November 2016.”

and:

“I conclude that Dr Mercier has shown a flagrant reckless disregard for his duties to the court and that he did so from the outset in preparing a report on subject matter in which he has no expertise.”

And therefore:

“All costs claimed within the Defendant’s cost budget are therefore caused by Dr Mercier’s flagrant disregard for his duty to the court…”

The judge found that those costs of £50,543.85 must be paid by Dr Mercier.

The moral

It is very simple: as so often, the answer is in CPR. At Part 35.3(1) I emphasise the three key words: “It is the duty of experts to help the court on matters within their expertise .”

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

It should have been apparent to this witness, and of course to the lawyers who instructed him, that oral and maxillofacial surgery is not within the expertise of a general dental practitioner. Any expert, when offered an assignment, must think carefully whether they have appropriate expertise. The consequences of biting off more than one can chew can be grave.

However…

However, the story doesn’t end there.

It is obvious from the above narrative that Recorder Abigail Hudson had not been impressed with Dr Mercier’s performance as an expert. Indeed, when permission to appeal the TPCO was granted, Choudhury J said some of the language used was ‘regrettable’ and ‘unduly harsh’.

An appeal, supported by Dental Protection, was heard before Sweeting J and he quashed the order. He said there was ‘nothing illogical or partisan’ in Dr Mercier’s evidence or conclusions. Little was said about the matters to which Recorder Hudson had taken exception, but the nub of this case was whether the tooth in question was restorable, or should have been extracted.

This was within the expertise of a general practice dentist as much as that of a maxillofacial surgeon. Mrs Robinson was under anaesthetic only because of her phobia about dental treatment.

So the whole case did indeed stand or fall on expert evidence, and both experts were competent to give that evidence under CPR 35.3(1). Because Dr Mercier was now regarded as competent, he had not wasted the time of the lawyers or the court. So he was not required to pay for wasting the defence’s time.

But, as the Duke of Wellington said about the battle of Waterloo, it was a close run thing. And Dr Mercier’s reputation cannot have been enhanced by his performance before the Recorder. This case illustrates the important part played by experts in litigation, why we must get it right, and the likely consequences if we don’t. q

An expert witness’s reflections on 2022

Forensic accountant and accredited expert witness Fiona Hotston Moore, of FRP Advisory, looks back on some notable cases she contributed to last year.

[I ENJOY THE VARIETY OF CASES I work on as an expert witness and the challenge that every case inevitably presents. 2022 was a busy year and I was fortunate to be instructed as a forensic accountant on 38 new matters, including 19 engagements as a single joint expert.

Some matters are relatively discrete. They typically require preparation of a court-compliant report and my involvement is limited to a couple of months. Other matters, however, involve preparation of a number of reports over many months or even years and can involve meetings with other experts or legal counsel, attending mediation and –if the matter is not resolved – giving evidence in court.

I am fortunate to be supported by a specialist team of forensic accountants. That allows me to undertake a number of assignments concurrently and gives me access to different skill sets and the opportunity to take soundings from colleagues.

Notable matters on which I was instructed in 2022 included:

A financial investigation following a report by a whistle-blower

Following a report by a whistle-blower I was engaged to undertake a financial investigation into the financial reporting, corporate governance and internal controls of a fast-growing entrepreneurial business in the technology sector.

The assignment included a review of financial records, interviews of company staff and the investigation of electronic records. My review initially identified over 240,000 documents: the team was able to refine those to a subset of 15,000 potentially relevant items that were included in the investigation.

My engagement was concluded – and a full report including recommendations issued – within 10 weeks. The client and instructing lawyers were pleased with the efficiency and thoroughness of my team’s investigation. Following the issue of my report the investigation was concluded and the company was able to share the executive summary with relevant parties.

Appointment as party expert to value a chain of wine bars and hotels

The client, the owner of a chain of wine bars and hotels in London, was going through a divorce and had obtained an expert valuation of

the business as part of the settlement process. However, the client was unhappy with the valuation received and required a second opinion. I was initially instructed to give a high-level opinion as party adviser on the valuation report of the single joint expert.

In my view, the valuation had been significantly overstated and my opinion reflected the belief that the valuation methodology was not appropriate. In light of my opinion the client then obtained permission from the court to allow me to prepare a full court-compliant valuation report as party expert. That report included commentary on the single joint expert’s report, as well as my own assessment of the value of the business.

My valuation of the business was approximately £4m. That valuation was significantly lower than that of the original expert, who valued the business at approximately £9m. The Family Court considered both reports and decided to put a valuation on the business midway between the two. The client was pleased with the outcome, which in his view was a fairer position.

Valuation helps client to settle professional negligence claim

The client – a business providing services in the construction sector – was involved in a professional negligence claim against a firm of solicitors, arising from the advice given in relation to the corporate finance transaction regarding the disposal of the business. The company was claiming for a resulting loss, as the sale consideration was substantially less than was anticipated. I was engaged as party expert witness to give a valuation of the company at the time of the sale, which had taken place around 10 years earlier.

I prepared financial and market analysis, looking at the information available at the time of the sale. My valuation considered the relevance of alternative methodologies and explored the value that an alternative purchaser might have placed on the company. Following the valuation a joint report was prepared, comparing my findings with the findings from the other party’s expert, who provided an alternative view.

The matter was settled just prior to the court hearing, in favour of my client. The lawyers said the work undertaken by FRP had placed the client in a good position to negotiate the deal achieved.

Appointment as single joint expert on a probate valuation of a care home

The client, a company in the care and social services sector, sought a valuation when one of the joint shareholders passed away. I was jointly instructed by executors of the deceased’s estate and the remaining shareholder of the company to provide an independent assessment of the probate valuation of the shareholding in question. The tax implications of the valuation were also required in respect of inheritance tax payable by the beneficiaries of the estate and any capital gains tax that would arise on a subsequent sale of the shares. q

Serious Fraud Office gains convictions in steel fraud case

[ ON 2 FEBRUARY two executives of a British steel trading business, Balli Steel Plc, were convicted on six counts of fraud at Southwark Crown Court. The convictions were secured following investigations by the Serious Fraud Office (SFO).

SFO investigators exposed how two of the defendants, executives Melis Erda and Louise Worsell, conspired to deceive trade finance banks by providing misleading information, false shipping documents and forged signatures on fake sales contracts. A third defendant, Nasser Alaghband, CEO of Balli Steel, had pleaded guilty to one count of fraudulent trading, ahead of the 20-week trial.

Balli Steel Plc bought and sold steel around the world using short-term loans from trade finance banks to fund its deals. The company collapsed in 2013, having amassed debts of around $500m to over 20 creditor banks, triggering an investigation by the SFO. Over $100m was owed to the Development Bank of Singapore.

The SFO also uncovered that many of the falsified documents were produced under the name of an in-house shipping company, Trans Ocean Navigation (TON). It was concealed from Balli’s creditors that TON was not an independent shipper but controlled by Balli, was registered at an accommodation address in the Cayman Islands and was operated from Balli’s own London offices in Marylebone.

The investigation involved a record-breaking degree of international co-operation. Law enforcement partners in 36 countries, including Belgium and The Netherlands, provided evidence and information: more than any previous SFO investigation.

Lisa Osofsky, director of the Serious Fraud Office, said: “Today’s result demonstrates our commitment to battling serious economic crime. I am proud of the whole SFO team for successfully exposing such a complex case of international fraud, and for bringing the company’s top executives to justice.

“This group of individuals intentionally defrauded multiple international finance houses as they attempted to keep their fraudulent business afloat, using increasingly audacious methods as the scale of their debt spiralled.”

Sentencing will take place on 3-4 April. q

UK and USA sanction Russian cyber criminals

[SEVEN RUSSIAN cyber criminals who are linked to the group behind some of the most damaging ransomware attacks on the UK in recent years have been exposed and sanctioned by the UK and the US.

The sanctions, which have been announced by the Foreign Office alongside the US Department of the Treasury’s Office of Foreign Assets Control (OFAC), form part of a concerted campaign by the UK and the US to tackle international cyber crime. They follow a lengthy investigation by the UK’s National Crime Agency (NCA) into the crime group behind Trickbot malware, as well as the Conti and RYUK ransomware strains, among others.

The NCA assesses that the group was responsible for extorting at least £27m from 149 UK victims, including hospitals, schools, businesses and local authorities – although their true impact is likely to be much higher.

The director general of the National Crime Agency, Graeme Biggar, said: “This is a hugely significant moment for the UK and our collaborative efforts with OFAC to disrupt international cyber criminals.

“The sanctions are the first of their kind for the UK and signal the continuing campaign targeting those responsible for some of the most sophisticated and damaging ransomware that has impacted the UK and our allies. They show that these criminals and those that support them are not immune to UK action, and this is just one tool we will use to crack down on this threat and protect the public.”

Ransomware is designated as a ‘tier one’ national security threat, with attacks continuing to increase in scale and complexity. The criminals behind the attacks specifically target the systems of organisations they judge will pay them the most money and time their attacks to cause maximum damage, including targeting hospitals in the middle of the pandemic.

Although the Conti group disbanded last year, reporting suggests that its members, including those sanctioned, continue to be involved in some of the most notorious new ransomware strains that dominate and threaten UK security.

The seven cyber criminals are now subject to travel bans and asset freezes, and are severely restricted in their use of the global financial system. At the same time an indictment was unsealed in the US District Court for the District of New Jersey charging one of the individuals, Vitaliy Kovalev, with conspiracy to commit bank fraud and eight counts of bank fraud in connection with a series of intrusions into victim bank accounts held at various US-based financial institutions that occurred in 2009 and 2010. That alleged offending predates that of the Conti group.

According to research from Chainalysis, the group extorted $180m from global ransomware victims in 2021 alone. Recent victims in the UK include the Scottish Environment Protection Agency, Redcar and Cleveland Council and forensic laboratory Eurofins. Internationally the Irish Health Service Executive, Costa Rican Government and American healthcare providers were targeted.

NCSC CEO Lindy Cameron explained: “Ransomware is the most acute cyber threat facing the UK, and attacks by criminal groups show just how devastating its impact can be. The NCSC is working with partners to bear down on ransomware attacks and those responsible, helping to prevent incidents and improve our collective resilience.

“It is vital organisations take immediate steps to limit their risk by following the NCSC’s advice on how to put robust defences in place to protect their networks.” q

New regulator hails ‘landmark moment for building safety’

[THOSE RESPONSIBLE for the safety of high-rise residential buildings in England have six months from April to register with the new Building Safety Regulator. The Building Safety Regulator is an independent body established by the Building Safety Act 2022 in response to the Grenfell Tower fire. It forms part of the Health and Safety Executive and is led by Chief Inspector of Buildings Peter Baker.

Under the Building Safety Act high-rise residential buildings which are 18 metres tall or higher, or at least seven storeys, with two or more residential units, are defined as ‘higher risk’. Across England there are approximately 12,500 such buildings and the new regulator will require all of them to be registered from April 2023, with a named person responsible for maintaining their safety.

A new campaign aimed at owners and managers of high-rise residential buildings will highlight their new legal duties. It will call on those responsible for the safety management of higher-risk buildings to prepare for a new wave of regulatory change to ensure that they are ready to step up and comply.

The registration process is a crucial stage in setting up the new building safety regime. Registering buildings in scope will be a legal requirement and owners and managers who fail to comply by October 2023 will be investigated and may face prosecution.

HSE chief executive Sarah Albon commented: “This registration process is an important step towards building a safer future for residents of highrise buildings. We want it to be clear where responsibility for safety in these buildings lies.

“As the Building Safety Regulator, we will draw from our experience to provide guidance and oversight for the industry and lay the foundation for a

world-leading building safety regime, which is a part of our mission to protect people and places.”

Chief Inspector of Buildings Peter Baker added: “Our message is clear – industry must raise its standards and residents of high-rise buildings in England must be kept safe.

“This is a landmark moment for building safety; the information provided through registration will be an invaluable part of our crackdown on unsafe building practices. Those who are responsible for high-rise residential buildings must register; failure to do so will be against the law.”

Building registration is part of a package of measures to ensure highrise residential buildings are safe for residents and users. It follows the introduction of Planning Gateway One in August 2021 and will be followed by more robust building control of high-rise developments, and the certification of occupied high-rise buildings by the new regulator.

A campaign is being run throughout March to help owners and managers of high-rise residential buildings prepare for their legal responsibilities. For more information visit buildingsafety.campaign.gov.uk q

[AS PART OF THE Technology and Construction Court’s 150th anniversary celebrations, Sir Peter Coulson – the president of the Society of Construction Law – and renowned construction barrister David Sawtell have edited a collection of original essays and studies by current and retired senior judges, renowned academics and leading construction and technology lawyers on the past, present and future of the court. The History of the Technology and Construction Court on its 150th Anniversary –Rewriting the Rules will be published by Hart in April.

Its contributors include Lord Dyson, who was instrumental in the transformation of the Official Referees’ business into the modern TCC; Sir Rupert Jackson, who presided over the TCC in the early years of the Housing Grants, Construction and Regeneration Act 1996; Sir Peter Coulson, who writes about Sir Brett Cloutman – a Senior Official Referee who was awarded the last Victoria Cross in the First World War; Dame Finola O’Farrell, who describes the practice of the TCC today; and Professor Renato Nazzini, director of the Centre of Construction Law and Dispute Resolution at King’s College, London, who describes the contribution of the TCC to arbitration and ADR.

The book gathers together a range of perspectives and professional and academic backgrounds, looking at the court, the Official Referees and its judges through a range of different tones and methods – from close doctrinal analysis and archival research to individual personal recollection. The collection offers a unique insight from the judiciary, practising lawyers and academics into the birth, significance and development of the court.

To find out more about the book visit www.bloomsbury.com q

CE Marking deadline extended again

[ON 9 DECEMBER the government announced that CE marking will continue to be recognised until 30 June 2025, which includes marking for construction products. The previous deadline of 1 January already reflected an extension.

According to the guidance issued on 9 December: “Until 30 June 2025, products can continue to be supplied to the GB market without any need for reassessment or re-marking if EU requirements are met (including CE marking). To affix a CE mark, any third-party conformity assessment must continue to be carried out by an EU recognised notified body during this time. In addition, products that meet NI rules (including CE marking or CE UK(NI) marking) can be supplied to the GB market. Businesses should prepare for these provisions to end on 30 June 2025.

“Products that bear the UK mark must meet UK requirements, including that third-party assessments have been carried out by a UK-approved body.”

A further update clarified the position with regard to the government’s intention, announced in June last year, to allow manufacturers of construction products under AVCP system 3, whose products are tested by an EU notified body before 1 January 2023, to obtain a UKCA mark without having to retest through a UK-approved body. That measure will no longer be introduced.

The update states: “In recognition that legislation has not been introduced to cover this issue, and until further notice, the Office for Product Safety and Standards will not take enforcement action against any economic actor solely where the UKCA mark has been used on construction products tested by an EU recognised notified body for the purpose of CE marking, where this testing was done before 31 December 2022.” q

Book celebrates the history of the TCC at 150 Asbestos campaign targets younger workers

MILLENNIALS, gen Z workers and other younger people who work as plumbers, electricians and in other trades in the construction industry need to take the risk of asbestos much more seriously, according to the HSE.

The regulator has launched a new campaign to raise awareness of the risks associated with the substance. The campaign, Asbestos and You, will focus on construction workers who started their careers after the use of asbestos was banned in 1999.

HSE is concerned that the length of time it takes for symptoms to develop after asbestos exposure could lead to a perception among today’s younger workers that it is something that only impacts older people who were working before the ban. However, 5,000 people a year still die from asbestos-related illnesses and asbestos can still be found in buildings built or refurbished before the year 2000. Asbestos containing materials were used extensively in the construction and maintenance of buildings in Great Britain from the 1950s until the ban. That means construction workers of all ages could still be exposed to asbestos fibres today.

HSE’s chief executive Sarah Albon said: “Asbestos exposure in Great Britain is still the single greatest cause of work-related deaths. We are committed to protecting people in the workplace and reducing future work-related ill health.

“Everyone working in construction today, of any age, must take the risk from asbestos seriously.

“Asbestos is dangerous when not maintained in a safe condition, or if physically disturbed without the right measures in place to avoid fibres being released into the air.”

If asbestos fibres are inhaled, they can cause serious diseases such

as mesothelioma, asbestos-related lung cancer, asbestosis and pleural thickening. Construction tradespeople of any age are at significant risk if they disturb materials containing asbestos during repairs and refurbishment.

HSE’s head of health and work policy

Mike Calcutt added: “These diseases often take a long time to develop and it can take 20 to 30 years for symptoms to appear.

“It is crucial that all workers know how to recognise the dangers and take the right actions to protect themselves and those around them from being exposed to asbestos fibres.” q

Defects and failures of building systems: an expert’s view

By Rose Campbell, forensic and expert services manager at CEERISK Consulting Ltd.

[BUILDING SERVICES such as mechanical, electrical and public health systems bring a structure to life. Lighting, telecommunications, heating and ventilation, smoke management, fire alarm and firefighting, energy and building management systems all make up building services.

From the early design, through construction, testing and commissioning to operation and maintenance, building services engineers work alongside owners, developers, architects, contractors, occupants and fire and building inspectors throughout the development and occupancy of the building to ensure safe, secure and comfortable living for the public.

In addition to the contractual legal issues involved in defect claims, complex engineering issues are also involved and must be addressed. Because of their familiarity with the engineering principles in building services and the way they operate, building services engineers are best suited to review, analyse and provide opinions on defect claims involving building systems.

Simon Barrows, a chartered electrical building services engineer and one of CEERISK’s experts, has observed that: “The problem with litigation is that it centres around contract, programme and cost, whereas the root cause is usually something technical.”

Problems involving building services can be technically complex and stem from actions or omissions over a period spanning design, construction and operation. Therefore, instructing the right expert early can quickly identify

issues, highlight disagreements and assist in the resolution of problems – thus saving time and money for everyone involved.

The variety of failure scenarios involving electrical building services can also be broad and involve many types of building system that are typically interconnected to provide the desired functionality. Investigating failures in building systems may require a team approach, where input from different subject experts is required to sort through liability and assign responsibility.

A fire in a building, for example, may require input from a chemist, fire investigator, electrical engineer and a mechanical engineering expert to sort through the responsibility matrix. A building services engineer can provide the right mix of basic expertise and create the proper framework to deal with the engineering issues. q

• Rose Campbell is the forensic and expert services manager at CEERISK Consulting, a global engineering consultancy that specialises in providing clients in the insurance and legal fields with engineering expertise in different disciplines. Rose oversees the delivery of expert services to insurance and legal clients by identifying and managing the team of experts with the necessary expertise required to assist clients with legal disputes.

Refurbished lab adds to expert capability

[LAST SUMMER BM TRADA, the specialists in testing, inspection and certification services, unveiled its modernised timber laboratory following an extensive refurbishment and investment.

Part of Element Materials Technology, BM TRADA’s three-month long revamp at its High Wycombe facility included a complete overhaul of the laboratory’s layout. The space is now divided into two dedicated areas, with one room designated for timber inspection and timber species analysis and the other for woodworking and timber testing.

Alongside the new layout, the laboratory was stripped down and a host of new equipment installed. That includes new storage, dust extraction units, boil tanks and water baths for woodwork testing; and microscope testing kits to analyse timber specimens.

The organisation also fitted new tools and rigs for fastener and fixing testing for structural timber connections, which is operated under Element Material Technology’s Warringtonfire brand, as well as a cast-iron engineering table for measuring the straightness of wood samples and inspecting for timber distortion.

Ben Sharples, commercial lead at BM TRADA, said: “We decided to refurbish our timber laboratory following an increase in demand for timber testing and certification requirements.

“As well as timber construction, we’ve witnessed more demand for timber species verification from a wide variety of markets. We house one of the largest libraries of timber specimens – known as a xylarium – in the country at High Wycombe. With our new laboratory and equipment, we can continue improving on this service and providing even more accurate advice and knowledge on different types of wood.”

The timber testing and accreditation facility is complemented by BM TRADA’s expert witness service for all disputes involving timber and wood-based products.

The work is carried out by highly-experienced technical consultants who provide an independent expert witness report which complies with Part 35 of the Civil Procedure Rules. Reports may be used for litigation, although they more frequently assist clients in achieving settlement without the need to proceed to court. q

Members sought for building industry committee

[THE BUILDING SAFETY ACT 2022 has enabled the Building Safety Regulator (BSR) to establish an Industry Competence Committee (ICC) with a number of functions, including monitoring industry competence, advising the BSR and industry, helping industry to improve competence and producing guidance to the public about assessing the competence of people in the built environment industry.

The BSR is now looking for a chair and members to join the ICC. Members will be required to:

• Attend and actively contribute to six main committee meetings a year – combining in-person and virtual – of approximately two to three hours duration. One to two hours should also be set aside to read papers.

• Participate in committee work that extends beyond main committee meetings, including workshops and the work of technical working groups: approximately eight hours per month. Technical working groups will include additional members in specialist fields who will share the workload.

• Use personal industry experience and up-to-date knowledge to improve competence in the built environment.

• Provide advice and assistance to the ICC on the basis of the wider public interest without personal, business or sectoral gain.

• Follow the standards of behaviour in public life: the ‘Nolan Principles’.

The deadline for applications is 28 April. q

Is your expert really ‘the expert’? And why it matters

Mark Chester of Cedarwood Tree Care shares some cautionary tales

[ THE MATTER OF EXPERTS and their counsel has been in the headlines recently – including during the Brexit debate, as some questioned the calibre of opinions offered. My own profession, arboriculture, is largely unregulated, so when considering the ‘expert’ opinions of others, I need to consider the calibre of the expertise. When a party uses expert opinion that is limited there can be consequences, such as increased costs of resolving claims, as cases take longer to conclude.

Some time ago I was asked to assist in a case where a tree failure had caused a personal injury. The owner’s agent defended the situation: they had employed a specialist, the failure was not foreseeable and the tree had failed in a storm. When I looked more closely, the ‘specialist’ was a local contractor with no specialist skills, there hadn’t been a survey and there was no storm. Meanwhile, the costs of settling had increased.

Experts often cite their credentials, including degrees. That can seem impressive, and I recall reading the report of one expert on a case I was involved in. Their credentials were similar to mine, with a degree and professional memberships. However, as I dug a little deeper I realised that their degree was unrelated to the subject; and away from that their credentials were less substantial. In that case the claimant had been assured of the merits of their claim, which incurred costs and proved unsuccessful.

While the evidence of the expert witness is valued, sometimes others with expertise in a field, but perhaps lacking formal accreditation, can be as valuable. In another case, where a beech tree suffered root plate decay and blew over in a storm, the matter of foreseeability was raised. A boundary wall was damaged in the process and a loss adjustor, qualified as a chartered surveyor, was sent to visit the site.

The loss adjustor, familiar with the difficulties of using decay detecting equipment to assess root decay, but not trained in arboriculture, concluded that the failure was not foreseeable. A little knowledge, however, can be dangerous. An acquaintance of the claimant, an experienced ecologist with an understanding of decay strategies in trees and able to identify different fungi, observed a fungus on the tree which causes root plate decay.

A detailed decay assessment wasn’t needed: the presence of the

fungus made failure foreseeable. For the owner of the tree, or their insurers, the claim process had become avoidably protracted and costs had increased.

As an expert, it is important that I keep to my specialist area. I can comment on matters outside of that, such as weather, and I can also offer opinion on aspects that are common sense. For example, I may be asked to comment on whether a tree has caused a wall to collapse. I don’t need to be a structural surveyor to observe the pile of bricks left! With every job I ask myself why I am instructed, to ensure that the issues are within my specialist area. It is important that experts truly have expertise in their area. If I am asked to review a case, it is one of the first elements I consider.

Sometimes, the absence of expertise is actually the issue. Following the storms of February 2022 I was asked to assess whether the failure of one tree, which had demolished a property, was foreseeable. Fungi were on the remains and had been present for several years, indicating the inevitable. However, the insurance company had not requested a tree report before issuing cover and the position of the fungi was not obvious to the lay person. q

Revised fire safety regulations now in force

By Anthony Murray, Fire Investigation Specialist at Strange Strange & Gardner

[ THE Fire Safety (England) Regulations 2022 came into force on 23 January 2023 and apply to existing properties in England.

In response to the Grenfell Tower Inquiry, the regulations were revised to require those in control of high-rise residential buildings, occupancies that are defined as being those over 18 metres in height or having at least seven storeys, to act as a ‘responsible person’ and to provide fire and rescue services with additional information about their buildings. The information must be provided both in writing and electronically.

It is also a requirement that the responsible person provides information to the fire and rescue services to assist them in planning and implementing an effective response to an emergency. It includes ensuring that a secure information box is fitted in the vicinity of the main entrance to the property. The box must contain a hard copy of the floor plans of the property together with a single page document setting out the key firefighting equipment that is available on site. The contact information for the responsible person should also be stated in the box.

For residential buildings with a height exceeding 11m, the responsible person is required to conduct an annual fire door inspection and a quarterly fire door inspection in common areas. They must provide fire safety instructions and fire door information at all multi-occupancy residential buildings.

Strange Strange & Gardner offer advice, investigations and assistance as well as ongoing support and guidance for the future. For further information call us on 0161 848 0612. q

Man versus machine

by Hayley Cowle of Translate Hive

[ HUMAN TRANSLATION AND INTERPRETATION of foreign languages has been a vital tool for communication and understanding for centuries. While recent advancements in artificial intelligence have led to the development of AI translators, they still fall short when compared to the abilities of human translators.

One of the key advantages of human translation is the ability to understand and convey cultural context and nuances. Human translators have a deep understanding of the culture and society of the languages they work with, allowing them to accurately convey idiomatic expressions, colloquialisms and cultural references. They can also understand the intended tone and purpose of a text, and adjust their translation accordingly. AI translators, on the other hand, rely solely on algorithms and pre-programmed data, and lack the ability to understand cultural context or adjust their translations for tone and purpose. Another advantage of human translation is the ability to handle complex and technical subject matter. Human translators are able to understand and accurately translate specialised fields such as legal, medical and technical documents. They have the expertise and experience necessary to navigate the specific terminology and concepts of these fields, while AI translators may struggle with the complexity and lack of data in these areas.

In addition, human translators are able to provide creative and artistic translations, such as poetry and literature. The ability to convey the beauty and emotion of a text is something that AI translators cannot replicate. Human translators also have the ability to make adjustments to the original text to make it more readable in the target language, if needed.

Interpretation, the process of interpreting spoken language, is another area where human interpreters excel. Human interpreters have the ability to listen and understand the nuances of spoken language, and can provide real-time translations in a wide range of settings – including business meetings, court proceedings and medical consultations. They are also able to adjust their interpretation based on the context and the speaker's intent. AI-powered interpretation devices still have a long way to go to reach the level of fluency and flexibility of a human interpreter. Another important aspect is the human touch and empathy. Human translators and interpreters are able to understand the emotions and feelings behind the words, and can convey them in a way that is both accurate and sensitive. They can also provide advice and guidance on how to navigate cultural differences and communication barriers. In contrast, AI translators are unable to provide this level of personal attention and understanding.

In conclusion, while AI translators have come a long way in recent years, they still fall short when compared to the abilities of human translators and interpreters. Human translators and interpreters have the ability to understand and convey cultural context, handle complex and technical subject matter, provide creative and artistic translations, and offer a personal touch and empathy. While AI translators will continue to improve, they will never be able to fully replicate the abilities and expertise of human translators and interpreters. q

Linguist bodies react to asylum questionnaire report

[THE CHIEF EXECUTIVES of the Institute of Translation & Interpreting and the Chartered Institute of Linguists – Paul Wilson and John Worne – have sent a joint letter to the Minister of State for Immigration Robert Jenrick MP, following reports in The Guardian that the government is considering ‘sending questionnaires to refugees instead of conducting official interviews’ with a demand that claimants ‘reply in English within 20 working days or risk refusal’.

The two bodies point to three particular concerns:

“Important information would be incorrectly translated: Notwithstanding advances in AI and machine translation, even in English and major European languages the frequency and severity of errors in machine translated texts is such that no public authority should contemplate its routine use, without human oversight. In world languages where there is less ‘training data’ the frequency and severity of errors can be so high

that professional translators would not waste time using the tools.

“Appeals: Given the risks above it seems inevitable that machine translated text would be a common cause of errors and appeals, likely cancelling out any perceived or imagined savings from the move.

“Identifiable personal data leaving the UK: The UK government encouraging people to use Google Translate or other online translation tools means you are encouraging them to input and send their most personal and identifiable data on a trip around the world –to servers and data processors in the USA, and other countries, with very different data protection laws and potential interest in them as individuals than the UK’s.”

They accept that The Guardian piece is based on a leak and is speculation and express the hope that the government has ‘no intention of moving in the direction the article suggests’. 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

Chris Dawson MS FRCS LLDip

Translations and Interpreting for the Legal Profession since 1997. Specialists in Personal Injury and Clinical Negligence. www.abc-translations.co.uk

Salam Alaswad LLM PGDip BSc

• Financial derivatives

• Forex fraud

• Contracts for Difference (CFD)

• Financial crimes

• Pre-action assessment

• Charts and diagrams for complex cases www.fxandcfd.com/expert-witness

Dr Paul Baskerville MA DM FRCS

Expert witness instructions in cases relating to all aspects of vascular disease. Can act on behalf of claimant, defendant or as Single Joint Expert. www.baskervilleclinic.com

Mr Timothy Burge MBChB FRCS FRCS(Plast) DMCC MSc

Consultant Burns & Plastic Surgeon

• Cosmetic and aesthetic surgery of the breast and trunk

• Burns • Trauma • Scars www.clifton-plastic-surgery.co.uk

CEERISK Consulting Ltd

Expert witness services in engineering

• infrastructure

• construction

• oil & gas

• petrochemicals

Consultant Urologist with over 19 years experience of medico legal report writing and expert witness work in personal injury and clinical negligence cases. www.chrisdawson.org.uk

DentoLegal Ltd – Gary M Simon

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

DRC Forensics Limited

DRC Forensics Limited offers the complete range of forensic accounting & litigation support: • Fraud • Money laundering

• Partnership disputes • Loss of profit • Professional negligence www.drcforensics.co.uk

Mr Roger Emmott CEng BSc(Hons) MSc/MBA MA FCMI FIC Steel and iron ore expert with international arbitration and cross-examination experience in complex disputes

• Pricing • Contractual matters • Valuations

T: 07974 351704 E: roger@rogeremmottassociates.com www.rogeremmottassociates.com

FHDI - Kathryn Thorndycraft-Pope

Examining documents & handwriting • to determine authenticity

• power & energy

• mining

• insurance

• technology

• telecomms www.ceerisk.com

Professor Frank Chinegwundoh MBE

Consultant Urological Surgeon specialising in Personal Injury and Medical Negligence cases on behalf of either claimant or defendant or as a Single Joint Expert. www.urologyconsultant.co.uk

Clarke Gammon

Chartered Surveyors with experience in All Aspects of Property

• Residential property values

• to expose forgery • to reveal aspects of origin. Electro Static Detection Apparatus and Mi-Scope used. www.forensichandwriting.co.uk

Forensic Collision Investigation & Reconstruction Ltd Specialists in the analysis of road traffic collisions

• Collision Reconstruction • Expert Witness

• Vehicle Examinations

www.FCIR.co.uk

Fiona Hotston Moore (FRP Advisory)

• Asset valuations

• Land values and more www.clarkegammon.co.uk

D & HB Associates Ltd

Experts in Road Traffic Offences

• Accident investigation and reconstruction

• Tachograph analysis

Fiona is a partner of FRP’s Forensic Services practice specialising in share and business valuation cases, commercial and tax disputes and professional negligence. www.frpadvisory.com/people/people-profiles/fiona-hotston-moore/

Mr Kim Hakin FRCS FRCOphth

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

• Stolen vehicle examination and identification

• Statement Taking www.dandhb.com

Dr Lars Davidsson MRCPsych MEWI

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

www.kimhakin.com

Haydn Jones MEng DipLaw FIET Data Technologist & Digital Regulation Expert

• Injunctive relief • Money laundering • Digital currency theft • Counter funding of terrorism haydn@blockchainhub.com

Dr Raj Kumar – Dental Expert

Causation and Liability and Condition and Prognosis Reports

• General dentistry

• Cosmetic dentistry

• Patient consent

• Dental implantology • Orthodontics • Facial aesthetics

www.dentalexpert.me

Laird Assessors

The UK’s leading independent automotive expert witness firm supporting claimant, defendant and criminal solicitors. From instruction to court. www.laird-assessors.com

Kulvinder Lall Consultant Cardiothoracic Surgeon

Instructions taken in cases relating to cardiac and thoracic surgery, including aspects relating to surgical care and those following trauma to the structures of the chest.

www.kulvinderlall.com

Mr Chris Makin

• Chartered Accountant • Accredited Civil Mediator

• Accredited Expert Determiner

www.chrismakin.co.uk

Martyn Slyper Consultancy

Expert Witness in Assistive Technology

• Personal Injury

• Clinical Negligence

E: ms@martynslyperconsultancy.co.uk

Mr Sameer Singh MBBS BSc FRCS Orth

Consultant Orthopaedic Surgeon • All aspects of trauma – soft tissue and bone injuries • Upper and lower limb disorders and injuries

• Whiplash injuries • Performs claimant and defence cases Clinic locations – London, Milton Keynes and Bedford

www.orthopaedicexpertwitness.net

Dr Elizabeth J. Soilleux MA MB BChir PhD FRCPath PGDipMedEd

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

www.expertwitnesspathologist.co.uk

Mr Bernard Speculand MDS FDS FFD FRACDS (OMS) Consultant Oral and Maxillofacial Surgeon. Personal injury and clinical negligence cases for claimant, defendant and as Single Joint Expert. Special interest is TMJ Surgery.

Yvette Young (Secretary) T: 0121 605 1884

E: info@medsecadmin.co.uk www.birminghamtmj.co.uk

Target Psychology Ltd

• Public & Private Law Proceedings • Pre-Proceedings

• Immigration Proceedings • Criminal Proceedings

• Court of Protection Proceedings

• Personal Injury and Clinical Negligence

www.targetpsychology.co.uk

Myles J O Taylor BA(Oxon) PhD FRCOG

Expert witness specialising in: • General obstetrics & gynaecology • Fetal Medicine • Multiple pregnancy

• Industrial Injury

www.martynslyperconsultancy.co.uk

Professor Christopher Raine MBE

Specialist in paediatric and adult otology

• Medical negligence • Personal injury cases involving noise induced hearing loss.

www.profchrisraine.co.uk

– including twin to twin transfusion syndrome, intrapartum care and general gynaecology. www.mylestaylor.co.uk

Vincent Theobald-Vega

Health and Safety expert • Asbestos management & removal

• Construction design and management • Laboratories

• Biological & chemical safety and much more.

www.safety4hed.co.uk

MEDICAL NOTES

[ WHEN I CAME ROUND from anaesthetic after serious vascular surgery some years ago, a nurse asked me to rate my pain on a scale of one to ten. My answer was a strangled “twenty seven!” – an answer that obviously hit a nerve with the staff as I heard the words ‘twenty seven’ being repeated around the hospital as I was wheeled to a ward.

I had been adjured by my wife before I went under to “don’t be brave; take whatever they offer”: her 40-odd years as a nurse, ward sister and eventual matron had led her to the conviction that pain should not and need not be endured.

Taking pain seriously is happily becoming more accepted in the medical profession; and not just among pain specialists. Our regular contributor Dr Chris Jenner reflects on how pain medicine has developed over the years; but pain is still in many instances undertreated.

• Vascular surgery is coincidentally a specialism that attracts a disproportionate number of claims, according to research carried out by surgeons at two Lancashire hospitals – in one of which the aforesaid operation took place. Delay in treatment was the most common cause for complaint, a failing that plagues many areas of medicine concerned with the cardiovascular system – almost always a result of the widely-recognised ‘gridlock’ in NHS services.

• Delayed treatment can be catastrophic in the case of Charcot’s neuroarthropathy, as described by another regular contributor, Dr Bobby Huda. In some cases a delay of up to three months can result in loss of a limb. It is a condition that many GPs only see once or twice in their entire careers, and is often mistaken for gout.

• Some problems, however, do not become apparent for a number of years. Brain injury that develops as a result of consistent head impacts, such as those experienced by football and rugby players, may not develop for many years. High-profile examples are now finding their way to court and we await developments.

• In neurological cases the line between the physical and the psychological can become blurred. Head injury can be seen to be a causal factor in the development of brain tumours and brain injury can result in cognitive issues that can be treated by a speech and language therapist. Similarly, physical injury can result in psychological trauma, such as that experienced by burns victims. It can be counterproductive, however, to predicate the psychological effect on the size or the extent of the burn. A team of experts at a leading hospital have produced a myth busting website page to explain some of the pitfalls.

• It is easy to be bogged down in the seemingly interminable succession of bad news regarding our health system and the problems it seems incapable of addressing. The 2021 Census showed that, in general, we are not as ill as we were 10 years ago. Figures published by the ONS, which carries out the Census on behalf of Parliament, showed a marginal reduction in the number of us who see ourselves as ill or disabled.

• The picture only shows a half-full glass: despite overall national improvements in selfreporting of health, disability and levels of caring, there is still a regional disparity. You guessed it: the North and the devolved nations fare less well than the South. Levelling up needed? q

CQC prepares to implement new powers

[THE HEALTH AND CARE ACT 2022 gives the Care Quality Commission (CQC) new powers that allow it to provide independent assessment of care at a local authority and integrated care system level.

It is expected that the new powers will commence in April. They will enable CQC to start to understand the quality of care in a local area or system and provide independent assurance to the public of the quality of care in their area.

CQC has published interim guidance for its assessment of local authorities. The assessments have been designed in partnership with the Department of Health and Social Care (DHSC), people who use health and social care services and their families, the Local Government Association, the Association of Directors of Adult Social Services, NHS England and other provider representatives and strategic partners.

Explaining the new powers, CQC said: “Unlike the legislation underpinning our regulatory approach to providers of health and social care, the Health and Care Act

2022 states that our approach to assessing local authorities and integrated care systems is subject to the approval of the Secretary of State for Health and Social Care.

“When assessing local authorities and integrated care systems, we will use our new single assessment framework. Although we’ll use this in the same way as when assessing providers, the approach will be tailored carefully to their specific context.”

The single assessment framework uses quality statements, developed with people who use services, and are based on people’s experiences and the standards of care they expect. The quality statements show what is needed to deliver high-quality, person-centred care and are commitments that providers, commissioners and system leaders should live up to.

The CQC said in a statement: “We want to start to assess integrated care systems as soon as it’s practical and meaningful to do so. We’re currently working closely with and seeking approval from the DHSC on our approach to implementing these

assessments and will provide more details on this as soon as possible. We are also engaging with the Hewitt Review to contribute our learning and to understand any potential considerations for our approach.

“Once we have agreement from DHSC on our approach we will be able to finalise guidance on how we will assess integrated care systems using our single assessment framework. We will publish this as soon as possible and will provide an update when it is available.”

The implementation of the new powers will take place from this April up to the spring of 2024. q

Census shows improvements in health and disability, but regional differences persist

[THE Office of National Statistics (ONS) has published findings from Census 2021 that show the proportion of people who reported to be in very good health in England and Wales increased over the previous decade.

After adjusting for differences in age profiles of the population between 2011 and 2021, census data on general health show an increase in the proportion of people across England and Wales reporting their health as very good to 47.5% (28.8 million) in 2021, up from 45.0% (26.4 million) in 2011.

The releases also show a smaller proportion of people were identified as disabled, while the proportion of unpaid carers aged five years and over has also decreased since Census 2011.

“Census 2021 data show we reported our overall health has improved over the decade, coinciding with a decline in the proportion of disabled people,” said Census 2021 director Jon Wroth-Smith. “The census is a point in time estimate and was taken during a pandemic and a time of lockdown. The unique circumstances of the pandemic may have influenced the results.

“For instance, we are also seeing fewer unpaid carers. Potential explanations for this

large change in the provision of unpaid care could be a result of lockdown measures, with people who previously shared caring responsibilities with a sibling, for instance, taking on that role alone due to a reduction in household mixing. This could be why, while the number of unpaid carers has declined, we have seen an increase in the proportion of people providing more hours of care as individuals took on more responsibility.

“However, this is just one possible explanation. Another could be the high numbers of deaths due to COVID-19 in 2020 and early 2021. Sadly, this could have led to a reduction in the need for unpaid

care, while changes in the question wording between 2011 and 2021, for both the unpaid care and disability questions, may have had an impact on results too.

“There will be further insights from the census to follow as we look at health, disability and unpaid care by topics such as deprivation and other protected characteristics, which will give us an even clearer picture across England and Wales.”

The optimistic outlook was tempered, however, by a second release which showed that the difference traditionally seen in the regions in those reporting good health and disabled, as well as those acting as carers, continued to show. Despite improvements, parts of the North of England and areas of Wales had some of the highest proportions of people who reported being in bad or very bad health, were disabled and limited a lot in their day-to-day activities, or spent 20 hours or more per week providing unpaid care.

An infographic from the ONS shows what proportions of people in different areas are adversely affected by their circumstances in each of the three categories of health, disability and unpaid care. q

Collaboration leads to fewer than expected COVID era claims

[THE COLLABORATIVE APPROACH taken by NHS Resolution, Action against Medical Accidents (AvMA) and the Society of Clinical Injury Lawyers (SCIL) in designing and operating the COVID-19 Clinical Negligence Protocol has significantly reduced the volume of clinical negligence claims that have become litigated and created savings benefiting the NHS and patients.

Since the implementation of the protocol there has been a 6% reduction in the number of settled cases that have been litigated between financial years 2019/2021 and 2021/2022. That equates to a difference of 572 cases comparing the two years.

It is accepted that the longer cases run for, the higher the costs associated with the claim. It is another flag for cases to be properly investigated and settled fairly at the earliest opportunity: preferably pre issue. In the same period, the average difference in costs paid to claimant solicitors on litigated versus non-litigated closed cases amounted to around £57,000 per claim.

Those estimates are encouraging, says NHS Resolution, but there are areas of uncertainty, including around COVID-19-related effects on the numbers of claims received. Further data on claims trends before, during and after COVID should help isolate those effects and provide greater certainty on the effectiveness of the protocol itself and the savings achieved. Claims numbers and costs have also been affected by NHS

Resolution assuming more responsibility for historic GP claims during that time period. Those claims will also have to be extracted for the true costs savings to be identified.

If the protocol is shown in due course to have permanently reduced the overall volume of litigation, then that work is likely to have saved significant costs for all parties – and most importantly the NHS.

Simon Hammond, director of claims management at NHS Resolution, said: “The Clinical Negligence Protocol has proven how collaboration can be of benefit to all parties. We look forward to working with SCIL and AvMA on the possibility of developing how the protocol could apply in a postCOVID environment.”

Lisa O’Dwyer, director of medico-legal services at AvMA, the UK charity for patient safety and justice, added: “The impressive likely cost savings are testament to what can be achieved when key specialist clinical negligence stakeholders come together and collaborate. More generally, it is very positive to note that both claimant and defendant practitioners have derived considerable benefit from the Clinical Negligence Protocol.”

Paul Rumley, chairman of SCIL, concluded: “These figures are very encouraging and we are pleased to be part of this effective, practical and now cost-saving work, alongside AvMA and NHS Resolution. It goes to show how specialist claimant lawyers and indemnifiers can work in collaboration to find practical solutions to the challenges faced.” q

BMA attacks ‘limit sick notes’ policy

[DOCTORS HAVE REACTED with fury to a suggestion attributed to an ‘insider’ in the DWP in a leak to the Daily Telegraph that GPs should limit sick notes to help boost the nation’s workforce and economy.

Dr Kieran Sharrock, acting chair of GPC England at the BMA, said: “The BMA has been clear for many years that it may not always be necessary or appropriate for a GP to issue a sick note, but rather another member of the practice team, such as a nurse or physiotherapist – especially where a patient has already seen them for their condition.

“However, it is not the responsibility of anyone in general practice to implement government economic policy; our responsibility is to look after our patients. GPs and their teams undertake a thorough assessment of a patient before deciding if a fit note is required, and if one is issued, will then arrange a follow-up appointment.

“Any suggestion that GPs and their teams should limit fit notes undermines their expertise as doctors and puts patients and the wider community at risk. People will be left with no option but to go to work when they are unwell – potentially worsening their own health and putting those around them at risk of infection.

“The government should look closer to home for the root cause of the increase in long-term sickness and the need for more fit notes. The cost of living crisis is heaping mental and physical misery on millions as well as the ever-growing waiting lists for treatment and surgery. Prevention is better than cure; so instead of masking the symptoms through writing fewer fit notes, the government should seek to address why many of these notes are needed in the first place and how its own failings have contributed to this situation.” q

GMC welcomes consultation on associates regulation

[ ON 17 FEBRUARY the Department of Health and Social Care launched a public consultation on draft new legislation that will allow the GMC to regulate anaesthesia associates (AAs) and physician associates (PAs).

Welcoming what it described as ‘this important step’, the GMC said: “Not only will it maximise PAs’ and AAs’ contribution to the workforce, it will also serve as the blueprint for the future regulation of doctors and other health professionals.”

Charlie Massey, chief executive of the GMC, said: “We welcome the publication of the Anaesthesia Associate and Physician Associates Order consultation, which is an important step towards bringing anaesthesia associates and physician associates into regulation. AAs and PAs are a vital part of the health workforce and we appreciate the value they add to the UK’s health services. Regulation will improve the quality and consistency of AA/PA education, enhance professionalism and strengthen public protection.

“The new legislation will serve as a template for the future reform of regulatory framework for other healthcare professionals, including doctors, and will enable us to be a more effective, relevant and compassionate regulator in the years ahead.

“It’s been nearly 40 years since the legislation which underpins how we operate was introduced, and reform is long overdue. Our current legislation is complex, overly prescriptive and slow to adapt to change.

“We are currently developing our response to the consultation and would encourage stakeholders to take part and share their views.” q

Study reveals scale of vascular claims

[RESEARCH CARRIED OUT in 2020 by three surgeons at two Lancashire hospitals and published in the Annals of Vascular Surgery revealed that vascular surgery is a specialty with a disproportionately high number of claims for clinical negligence. The researchers – Vivak Hansrani, Tamer Ghatwary Tantawy and Haytham Al-Khaffaf –analysed clinical negligence claims in vascular surgery between the financial years 2005/2006 and 2018/2019.

According to the introduction to the paper, over the 13-year period 1,189 claims in vascular surgery were identified, with an annual mean of 91 within a range of 20-134 claims per year.

“Of the 1,189 claims, 875 (74%) are closed with payments made to the claimants. The mean annual total payment was £10,015,373. Delay in treatment was the most common cause for litigation claims in vascular surgery with 157 closed claims costing £33,255,248 over the 13-year period. Lower limb amputation was the most common primary injury claim with 140 closed cases but had a larger financial cost at £64,155,969.”

The analysis also found that clinical negligence claims in vascular surgery in the UK have been increasing steadily over that period and ‘with a changing claims culture’ is expected to continue.

“Improved consent, better communication with patients and a higher surgical skill level could significantly reduce the number of future claims.” q

Vascular surgery is now covered by quality framework

[IN MARCH LAST YEAR the Commissioning for Quality and Innovation (CQUIN) indicators for 2022/23 were published by NHS England, and for the first time included a vascular indicator. The Achievement of revascularisation standards for lower limb ischaemia are expected to drive quality improvement for patients with chronic limb-threatening ischaemia (CLTI).

The Prescribed Specialised Services CQUIN framework is a pay-forperformance scheme for English NHS Trusts. It supports improvements in quality of care by linking a proportion of the healthcare providers’ income to the achievement of quality improvement goals in clinical priority areas. The framework was launched in the NHS in England in 2013 but was suspended during the pandemic.

The Achievement of revascularisation standards for lower limb ischaemia CQUIN indicator is based on the Vascular Society of Great Britain and Ireland Peripheral Arterial Disease Quality Improvement Framework (PADQIF), published in March 2019, which recommends a timeframe of five days from referral to the vascular team to revascularisation for patients admitted urgently with CLTI.

NHS organisations will receive the full CQUIN value if 60% or more of CLTI patients who are deemed suitable for revascularisation are revascularised within five days from admission and no payment will be earned if this proportion is below 40%. Deductions will be graduated if performance falls between the two thresholds.

Vascular units may need to reconfigure their pathways to prioritise patients with CLTI and expedite patient review, imaging and treatment in order to achieve the target. In that effort, they may benefit from the experience of the early adopters participating in the PAD-QIF, who have introduced a number of innovative solutions that can serve as examples for other units. q

A Charcot joint may have severe consequences, but is difficult to diagnose

In his previous article on diabetic foot ulcers, Dr Bobby Huda – consultant in diabetes and metabolism at St Bartholomew’s and Royal London Hospitals –discussed the aetiology of diabetes foot ulcers and possible consequences. In this follow-up article he looks at issues surrounding Charcot foot: a specific clinical scenario that requires further discussion.

JEAN-MARTIN CHARCOT was a French neurologist and a professor of anatomical pathology in the mid part of the 19th century. He described a number of conditions, among which was the Charcot joint or Charcot arthropathy (or neuroarthropathy). This is the progressive degeneration of a weight-bearing joint seen in individuals with significant peripheral neuropathy. It can be seen in people with any cause of peripheral neuropathy.

In the 19th century, leprosy and syphilis were common underlying causes; however, with the decline of those conditions it is now most commonly seen in people with diabetes.

Epidemiology and pathophysiology

The incidence varies between 0.1 to 0.4% in people with diabetes, but the prevalence can be up to 35% of people with peripheral neuropathy. People with Charcot’s neuroarthropathy (CN) are usually in their fifth or sixth decade, and have had diabetes for 10 years or more.

It is more commonly unilateral, but can be bilateral in later stages. The underlying pathophysiology is not fully understood, but it is likely to involve alterations to blood flow to the foot caused by nerve damage, repeated minor trauma in the presence of neuropathy and an inflammatory bone response. The consequence of those different pathways are small microfractures within the foot bones, an inflammatory response and eventually destruction of bone and joint architecture.

Clinical presentation

CN usually affects the foot and ankle joints but can be in other areas, such as the knee. The foot is warm, reddened and swollen. That, however, is also common in other pathologies such as cellulitis (infection in the soft tissue), ankle sprain, deep venous thrombosis and inflammatory arthritis. The patient may or may not have pain associated with it. The increase in foot temperature can be measured by podiatrists and can be useful in monitoring response to therapy. That is the acute presentation of CN, but it can settle into a more chronic phase, where the destructive process can continue at a slower rate or stay relatively stable.

Investigations

CN is primarily a clinical diagnosis and hence it can be difficult to diagnose. The erythrocyte sedimentation rate (ESR) or C-reactive protein may be raised. X-rays may be normal in the first few weeks, but over time they can show inflammation, soft tissue oedema and evidence of fractures and bone destruction.

Magnetic resonance imaging (MRI) is the most sensitive imaging modality for detection of early CN, and soft tissue/bone oedema are often seen. Nuclear medicine uptake, white cell uptake and PET scans are used in specialist centres occasionally, particularly where they are needed to differentiate from osteomyelitis.

Treatment

The mainstay of treatment for CN is offloading the foot, so as to minimise further trauma. This can be done with an aircast boot, which is advantageous in that they can be easily applied, are commonly available and easy to remove for comfort, or to monitor progress or an accompanying ulcer. The disadvantage is that they are not bespoke for the patient – so may not be an ideal fit – and most importantly the patient can remove it, so subsequently may be without the treatment for several hours in the day. The gold standard of treatment is a total contact cast (TCC), which is bespoke for the patient’s foot architecture and is not removable. However, TCC needs skilled specialist staff, close monitoring – to avoid ulceration if poorly fitting – and is not available in all centres. Although there have been clinical trials of the use of medical treatment such as bisphosphonates, there has been limited evidence of benefit. Glucose control should be optimised and accompanying infection/ ulceration treated. Surgery can be used in chronic CN to reduce bone deformity and stabilise the foot, but is done only in specialist centres and is not commonly used.

Prognosis

Without prompt detection and treatment, people with CN will go on to develop bone deformity, ulceration and eventually the bone architecture of the foot can collapse, leading to a below knee amputation. In world-class

specialist centres, with prompt referral and treatment, prognosis can be good, with 94% of patients walking independently.

Pitfalls

However, CN is misdiagnosed in 95% of cases and in a survey of non-foot specialist providers 70% had a self-described poor or complete lack of knowledge of the condition. The consequence of delayed diagnosis can be catastrophic, with one study showing a 9.1% chance of a complication (fracture/severe deformity) after a one month delay in referral, and a 92.3% chance of a complication with a three month delay. Unfortunately, real world data shows that the average time between symptoms and treatment is 21 weeks.

The condition, however, is relatively rare, with most general practitioners in the UK usually only seeing 1-2 cases in their career. It is commonly misdiagnosed as cellulitis or a deep vein thrombosis. That leads to several weeks without offloading and progression of the destructive process. Ideally, patients with CN would be detected early and promptly referred to a specialist diabetes foot clinic. National Institute of Clinical Excellence NG19 guidelines recommend that people with suspected CN are referred to a diabetes foot multi-disciplinary team within one working day, but the National Diabetes Foot Audit shows that only 13% of patients are seen within two days of referral.

Medico-legal aspects

Most claims will centre on a delay in diagnosis and referral to a specialist centre. Cases for claimants will highlight the consequences of delayed diagnosis and treatment, which as above can be seen as causative for many complications. The defendant’s case can centre on the relatively rare nature of the condition and that many peers would also have poor knowledge of the condition. q

• To contact Dr Huda call 020 3594 6058 / 07919 924925, email bobby.huda1@nhs.net alternatively visit londondiabetes.com or clevelandcliniclondon.uk

Remember: the judge and jury are not medical professionals – usually

By Mr Turab Syed, consultant trauma and orthopaedic surgeon and expert witness.

I’VE BEEN READING ‘the aggressive expert’ article by Chris Makin in Issue 63 of Your Expert Witness over the Christmas holidays. He recalled the case of Siegel v Pummell (2015] EWHC 195 (QB).

The facts were simple and straightforward and show what an expert – especially, as I am a surgeon, what a medical expert – should not do. In fact, I would go further than Chris Makin to say that it should be a ‘never event’ and that the report of an expert should be pitched at the ‘informed layman’, or a GCSE-level student, avoiding any medical or complex terminology.

Coming back to the case, Mr Siegel was injured in a motor accident where Mr Pummell had admitted liability. The trial was on quantum and Mr Siegel succeeded in claiming a reasonable amount; but he claimed his costs on the indemnity basis for the following reasons:

• The defendant’s expert neuropsychiatrist had made personal and

• combative attacks on the claimant’s expert psychologist

• The defendant's expert had not co-operated in the joint statement

• process

• The defendant’s expert gave his written evidence, plus his oral

• evidence at trial, in a manner which the judge found too confusing

Patient Safety Notice follows recall of knee implants

[ON 15 FEBRUARY the Medicines & Healthcare products Regulatory Agency (MHRA) issued a Patient Alert notice regarding some of the NexGen knee replacement products.

The alert was issued after the National Joint Registry (NJR) identified that both of the NexGen Stemmed Option Tibial Components, when paired with either the Legacy Posterior Stabilized (LPS) Flex Option Femoral or the LPS Flex Gender Solutions Femoral (GSF) Option Femoral, had a higher overall revision rate and a higher revision rate for aseptic tibial loosening compared to the average revision rate of all other total knee replacements in the UK NJR.

The alert followed a voluntary product recall issued by supplier Zimmer Biomet, as reported in the last issue of Your Expert Witness

The MRHA said in its statement: “For patients implanted with the affected device combination there is an increased risk of needing an operation to replace their original implanted knee replacement. The UK NJR data suggests that tibial loosening is a key cause of the increased total knee replacement revisions for these specific combinations. Tibial loosening could typically present as new pain in the knee joint or limping. In rare cases tibial loosening may be asymptomatic.”

The NJR has provided all hospitals with a list of affected patients recorded in the registry with the affected combination. For Scotland this will be co-ordinated by health boards. q

• and the judge asked him to summarise it in a written document, in • plain English.

If a judge has to tell an expert to write his evidence in plain English, the expert has failed to help the court, which should be his overriding duty.

CPR says, at 35.3(1), that: ‘it is the duty of the expert to help the court on matters within their expertise’.

We doctors are good at writing letters to colleagues – doctors, members of multidisciplinary teams – who have some form of medical or allied training. So it is important that one attends courses and receives training to become an expert for the court, which is entirely different from being an expert in one’s field. Both are not synonymous and – as said by Barrister G. Eyres of Gough Chambers, London –‘requires one to develop a medicolegal mind’.

As I have previously said – and for fear of repeating myself – it is quintessential as an expert for the court to address one’s evidence and opinions at the level of an ‘informed layman’, whether judge or jury. Where it is essential to use medical terminology, make it bold and explain it in brackets in layman’s term, and reference in an appendix at end of report for cross referencing.

For example, an MRI scan report states: ‘Moderate degeneration of Tibio-Talar/Talo-Crural Joint and chondromalacia of SubTalar Joint’. Writing that in a letter to GP or medical records would be entirely reasonable, but it would be an alien language to judge and jury.

I would recommend that it should be written as below, so that the Judge and/or jury – normally in civil cases a jury is not involved – can understand easily.

‘Moderate degeneration [arthritis] of Tibio-Talar/Talo-Crural Joint [ankle joint] and chondromalacia [softening of cartilage – a sign of very early arthritis] of SubTalar Joint [the joint below the ankle joint which controls side to side movement and helps walking in rough or uneven surfaces]’.

One can use any format but I state in my expert reports that things in square brackets are my expert’s interpretation. q

• Mr Turab Syed MBBS MRCS DipSICOT DipSEM MFSEM FRCS (Tr & Orth) MSc (Sports Medicine) MFST (Ed) is consultant trauma and orthopaedics surgeon at Forth Valley Royal Hospital, Larbert, Stirlingshire, academic e-tutor in ChM Trauma & Orthopaedics at the University of Edinburgh, expert witness and treasurer of the Scottish MedicoLegal Society (SMLS).

New ‘toolkit’ aims to improve hip fracture care

A NEW ‘TOOLKIT’ for senior doctors and hospital managers, that will help make changes to their organisational arrangements and improve the quality of hip fracture care across the UK, has been launched by The Royal Osteoporosis Society (ROS) in collaboration with researchers from the University of Bristol.

The guidance was developed after the REDUCE study last year – carried out by the University of Bristol – found an enormous variation in how well patients recover after a hip fracture between NHS hospitals in England and Wales.

Significant findings from the study show that the way hospitals deliver patient care is linked to longer-term patient recovery. The researchers identified that patients had a lower risk of dying in hospitals where hip fracture staff met regularly to discuss feedback from patients as a team. In addition, in hospitals where staff were able to get at least 90% of hip fracture patients out of bed the day after surgery, patients stayed in hospital on average two days less.

Described by one early adopter as ‘a seriously comprehensive masterpiece’, the toolkit addresses different aspects of the care pathway, providing guidance on training,

clinical team planning, service specifications, quality improvement and patient discharge, making it easier for hospitals to improve the service they provide.

Jill Griffin, head of clinical engagement at the ROS, was core investigator on the project.

She commented: “The research findings have given us valuable information and shown us how we can work with healthcare providers and hospitals to improve patient recovery after a hip fracture.

“The study data has enabled us to make recommendations that we have used to build this toolkit for healthcare professionals and our aim is that it will dramatically improve the quality of care for everyone who suffers a hip fracture.”

Jill worked with Celia Gregson, Professor of Clinical Epidemiology and orthogeriatrician in the Musculoskeletal Research Unit at the University of Bristol, and chief investigator of the study, to develop the guidance which will now be hosted on the ROS website.

Professor Gregson added: “Our research has identified substantial variation in how hip fractures services are delivered across England and Wales. Such variation is not justified on clinical grounds, and this variation in clinical

practice translates to differences in important patient outcomes, like time spent in hospital, risk of death and recovery of mobility, as well as how much hip fracture care costs the NHS.

“As a team we wanted to try and tackle this, by making it easier for often very busy and overstretched services to implement changes locally, to make hip fracture care more equitable across the country. Hence, we developed this toolkit. It provides practical, evidence-based guidance on different aspects of the complex care pathway for hip fracture patients, from the emergency department to hospital discharge.

“We hope that this new library of tools provides a useful resource for the hip fracture community and we are interested to hear from services who use it to successfully improve their hip fracture care pathway.” q

Statement addresses concerns regarding non-NHS aesthetic plastic surgery

[ ON 16 JANUARY the two main professional bodies representing aesthetic and plastic surgeons, BAAPS and BAPRAS, issued a joint statement on plastic surgeons performing aesthetic surgery.

The statement reads: “The public in the UK rightly expect and deserve the highest possible standards and safety when considering aesthetic plastic surgery. Their surgeons should be well trained, competent and demonstrate involvement in continuing professional development in aesthetic surgery. Plastic surgeons are unique amongst UK surgical specialists with respect to aesthetic surgery, as plastic surgery includes training in aesthetic surgery across all anatomical areas of the body.

“The plastic surgery curriculum incorporates the psychological aspects of dealing with patients impacted by disfigurement, body image concerns and loss of form and function. Aesthetic surgery thus forms part of the plastic surgery syllabus and all trainees are formally examined in aesthetic practice as part of the FRCS(Plast) exit (consultant level) exams. No other surgical specialty in the UK incorporates aesthetic surgery in the same manner in its curriculum or training.

“The depth of history behind plastic surgery, including the speciality being at the forefront of developing aesthetic surgery, means that for the majority of people, when aesthetic surgery is being considered, one thinks of a plastic surgeon and plastic surgery.

“At a consultant level, plastic surgeons undertaking aesthetic plastic surgery include this aspect of their practice in their annual appraisals and five-yearly revalidation with the GMC, ensuring the maintenance of a high level of care and of continuing professional development (CPD) in this area of their practice.

“Due to restrictions in service provision over the last 20 years, many aesthetic procedures are not provided routinely in the NHS. However, plastic surgeons are still trained in all aspects of aesthetic plastic surgery. Unlike many other surgical specialties, the range of surgical procedures a plastic surgeon performs privately will therefore not exactly mirror their NHS practice.

“The concept of a surgeon’s scope of practice in the private sector reflecting their NHS practice has therefore not existed for many years.

“BAAPS and BAPRAS, the two UK official professional plastic surgery associations, fully support their members undertaking aesthetic plastic surgery, which they have been trained and examined in and can demonstrate their ongoing CPD in their annual appraisals. Should any advice or guidance be required regarding the governance of aesthetic plastic surgery, senior leadership team members from BAAPS and BAPRAS will be available on request.”

The statement was signed jointly by Marc Pacifico MD FRCS(Plast), consultant plastic surgeon and president of BAAPS, and Mani Ragbir FRCS(Plast), consultant plastic surgeon and president of BAPRAS. q

Research finds drug can limit the effects of hand arthritis

[ NEW RESEARCH HAS FOUND that retinoic acid could play a key anti-inflammatory role in hand osteoarthritis. Around 8.5 million people in the UK live with osteoarthritis – a condition that causes pain and stiffness in joints, as well as fatigue. It can affect any joint in the body, but it’s common for the joints in hands to be affected.

According to arthritis charity versusarthritis it’s easy to underestimate just how often we use our hands. But when they are painful, stiff, or have poor grip strength due to osteoarthritis, everyday tasks – such as opening a jar, holding a pen or doing up buttons – can become incredibly challenging.

Although there are ways to manage the symptoms of osteoarthritis, there are still no disease-modifying drugs that treat the condition. Disease-modifying drugs are drugs that change the way a condition progresses.

The latest study looked at the importance of a molecule called all-trans retinoic acid (at-RA), which is made from vitamin A. It confirmed previous research, which found that that people who have severe hand osteoarthritis are more likely to have genetic changes

which affect how the body controls levels of all-trans retinoic acid.

When examining the cartilage from individuals with hand osteoarthritis researchers found that the genetic change led to low levels of at-RA, which was linked to increased inflammation in the cartilage. Inflammation in the cartilage leads to the loss of its smooth surface, thus removing its ability to protect the joint during activity.

They discovered that boosting the levels of all-trans retinoic acid was anti-inflammatory in the cartilage.

When a drug which keeps levels of at-RA higher was given to experimental models of osteoarthritis, the development of the condition was slowed down.

The research is still in its early stages, but it is promising because it gives us a deeper understanding of the causes of hand osteoarthritis and the drugs

tested have been used for other conditions with a good safety record.

A small proof-of-concept study is now underway, where the team will test whether the drug reduces cartilage inflammation in patients who are awaiting routine NHS surgery for hand osteoarthritis. If successful, a clinical trial could follow. q

Foot injuries can affect all walks of life

PODIATRY IS ONE of the disciplines that is called upon to treat sports injuries – and the stakes can be high. Runners in particular can suffer career-threatening foot injuries and in some cases the problem can be traced back to the beginning of their lives.

Indeed, the client list of one clinic – the Gait and Posture Centre in Harley Street – boasts a winning team of its own, including a former world record-holder.

The Institute of Sport, Exercise and Health describes sports podiatry as ‘a discipline that assesses and treats foot, ankle and lower limb disorders. A biomechanical assessment will address whether there is a mechanical cause for the pain. Treatment may involve prescription of exercises; change in training program; advice and modification of footwear and/or corrective foot orthoses. A sports podiatrist could be of benefit if you have repetitive injuries; and seeking another approach to enhance your performance’.

The compensation levels for foot injury reflect the effect they have on mobility and everyday life, even for ordinary mortals.

According to the Association of Personal Injury Lawyers: “Injuries caused to, or by, either participants or spectators in the course of

sporting and recreational activities can, if they are caused by negligence, give rise to a claim for damages. From football and rugby to boxing and extreme sports such as kite-surfing, for example, negligent actions may lead to injury.” q

Royal college makes the case for MSK podiatry

[IN NOVEMBER the Royal College of Podiatry (RCPod) published an evidence ‘toolkit’ showing the effectiveness of musculoskeletal (MSK) podiatry services across the four nations of the UK – detailing the changes MSK services can make to patients’ health, function and quality of life.

The toolkit identifies the ideal referral and patient journey, reviews the impact of MSK podiatry treatment on patients and provides case studies to show examples of best practice. It uses the evidence to outline the costs of running an MSK podiatry service and provides evidence on the most effective treatments for many MSK conditions.

The evidence will eventually be used to develop a full MSK toolkit that will offer a unified approach that NHS and independent practice MSK podiatry services can use. It will solidify the scope of MSK podiatrists’ practice and show commissioners, trusts and health boards that MSK podiatry services are clinically effective and cost effective.

It is hoped that the adoption of the toolkit will encourage a more uniform approach to MSK services across the four nations. Independent practitioners can use it to develop their own MSK service for their patients.

Dr Helen Branthwaite, RCPod MSK lead, commented: “MSK podiatry services can make a huge difference to patient care and foot and lowerlimb health outcomes and the evidence we present here shows that. We hope that this toolkit will provide a compelling argument to healthcare commissioners in all four nations to consider increased investment in MSK podiatry.

“We set out the MSK podiatry service models that work in the NHS, which will arm our NHS and independent practitioner members with the evidence they need when considering how to build or improve an MSK service in their practice. We look forward to developing a full MSK toolkit in the future.”

Dentist’s regulator modifies fitness to practise procedures

[THE GENERAL DENTAL COUNCIL (GDC) has introduced some ‘small but important’ changes to its fitness to practise processes. The changes aim to reduce the impact on those subject to investigations, improve case progression and make best use of limited resources in the absence of regulatory reform.

The GDC had previously expressed its disappointment at the pace of regulatory reform, stating: “It is now clear that full regulatory reform for the GDC is several years away following [February’s] announcement by the Department of Health and Social Care.

“Fitness to practise can be a long and stressful experience for those involved. The latest improvements we are making will reduce the impacts that long-standing or multiple investigations can have on those who are the subject to an investigation, and lead to improved performance.”

The following changes have been made:

• The GMC will close cases that mirror an investigation being carried out by another authority, for example the NHS or Medicines and Healthcare products Regulatory Agency at the Registrar’s direction. Cases involving

an on-going police inquiry, interim order or where there are other open fitness to practise investigations will not be closed.

• The GDC will not automatically open cases for matters referred to it from the NHS, where the NHS is either investigating or managing the issues locally.

“Where there is a serious and immediate risk to public safety or confidence,” the GDC stated, “we will open an investigation – if, for example, the dental professional also practises privately – and, if appropriate, refer the matter to the Interim Orders Committee.

The council also announced it was

reviewing and closing some older cases, those where there is no realistic prospect of establishing that a dental professional’s fitness to practise is impaired, following review and approval of the Registrar.

The GDC’s executive director of fitness to practise John Cullinane commented: “We are looking to reduce uncertainty where we can for those who are subject to a fitness to practise investigation, because we know it can be a long and stressful position to be in. We are constrained by our legislation, but there are small changes we can make that, together with other changes we’ve made, will progress improvements in our performance and reduce the impact on those involved.”

The council says it will be tracking the impact of the changes, and other improvements it has made, through an updated set of key performance indicators and timeliness measures that provide a more detailed picture of case progression at each stage of the fitness to practise process.

To find out more about the changes to the fitness to practise processes, see John Cullinane’s blog at www.gdc-uk.org/newsblogs/blog q

Ophthalmologists can reveal problems away from the visual

By Mr Peter Gray MA LLM FRCS FRCOPHTH MFFLM, ophthalmologist and director of Eye-Law Chambers

Leonardo da Vinci: Notebooks

[ALTHOUGH THE CLINICAL PRACTICE of modern ophthalmology was unknown to Leonardo, his comment is very relevant today, when ophthalmologists can detect signs in the eyes which reflect pathologies elsewhere in the body. The following cases are illustrative:

A patient with a traumatic brain injury has difficulty in mobilising and performing the activities of daily living

In this case the eye can be likened to a camera which detects the image of the surroundings, generating nervous impulses which are conveyed via many individual nerve fibres in the optic nerve from the eye to the primary visual cortex of the brain located at the back of the head. Here the brain processes the nervous impulse to generate the perceived image. The nerve fibre pathway from the eye to the brain may be damaged anywhere in

its path – leading to the development of a visual field defect, such as not being able to see the same half of the visual world in each eye.

There are other parts of the brain which process higher visual function, such as the perception of colour, stereopsis (depth perception) and the ability to recognise faces. Damage involving those parts of the brain results in the loss of the relevant function. The ophthalmologist can plot the visual fields – and some defects are a bar to holding a driving licence – and assess colour and stereoscopic vision.

The patient with double vision (diplopia)

The ophthalmologist can assess the diplopia and determine the cause, which may relate to the extraocular muscles which move the eye, their nerve supply or entrapment in orbital fractures – as well as any associated injuries to the eye and the eyelids.

The patient with numerous fractures who develops blurry vision

The ophthalmologist can examine the retina (sensory membrane of the eye) for the presence of fat emboli in the retinal blood vessels.

The assessment of suspected child abuse

The ophthalmologist can examine the retina with regard to the presence of retinal haemorrhages which are suggestive of ‘shaken baby syndrome’.

The ophthalmologist can thus contribute to the holistic assessment of an individual with polytrauma, as well as reporting on specific ocular pathologies. At Eye Law Chambers we are a group of ophthalmologists with medico-legal expertise who all have a wide experience in general ophthalmology as well as specialist interests. q

• For further information visit the website at www.eyelawchambers.com

First annual NOD AMD audit report published

[

THE National Ophthalmology Database (NOD) age-related macular degeneration (AMD) audit report is a significant milestone in benchmarking the delivery of AMD treatment in the UK, using data recorded as part of routine clinical care.

It reflects the desire and willingness of ophthalmologists throughout the UK to quality assure the care they provide for many thousands of patients who have the rapidly progressive ‘wet’ form of AMD. The audit provides understanding of the quality of care and outcomes of treatment for AMD patients, recommendations and next steps for the audit.

AMD is the biggest cause of sight loss in the UK, affecting more than 700,000 people with 39,800 patients developing ‘wet’ AMD each year. At age 60 around one in every 200 people has AMD; however, by the age of 90 it affects one person in five. The number of people with AMD is expected to rise by an alarming 60% by 2035.

As AMD is such a significant public health concern it is essential that the NHS has a thorough understanding of the quality of the care it is providing and how to improve outcomes to maintain patients’ quality of life needs.

The audit found that more than 90% of eyes retained stable vision at the end of the first year of treatment and avoided a ‘significant’ further decrease in vision, while almost 20% of eyes experienced a ‘significant’

improvement in vision and more than 40% had ‘good’ vision – close to driving standard – after the first year of treatment.

‘Good’ visual acuity was retained in most eyes with that level of vision at the start of treatment, but eyes with ‘poor’ vision at the start of treatment rarely achieved ‘good’ vision. That highlights the importance of prompt referral, initial assessment diagnosis and treatment.

Treatment appeared to be safe, with a low number of serious sideeffects: for example, the risk of serious infection after an injection was around one in 6,500.

Mr Martin McKibbin, clinical lead for the NOD AMD Audit, commented: “I am delighted that the first report of the NOD AMD Audit has been published. Clinical staff at all the participating sites want to provide good clinical care and the best outcomes for their patients. The data in the audit will provide the first opportunity to benchmark care processes and acuity outcomes with peers and identify if any improvements are needed.”

The report confirms that regular injections help to stabilise vision in most eyes and early diagnosis and treatment are vital to maintaining good vision after treatment. By identifying best practice and allowing organisations to compare their performance with others, the audit aims to improve the outcomes for all patients having treatment for ‘wet’ AMD. q

“The eye, the window of the body, is the chief means whereby the understanding can most fully and abundantly appreciate the infinite works of Nature.”

Intraocular lenses spark patient recall following cataract surgery

[ON 26 JANUARY the Medicines and Healthcare products Regulatory Authority (MHRA) issued Device Safety Information regarding EyeCee One preloaded and EyeCee One Crystal preloaded intraocular lenses (IOLs). The MHRA had been made aware of cases of increased intraocular pressure (IOP) in patients recently implanted with the lenses.

That was followed on 1 February by a national Patient Safety Alert. The alert was issued following consultation with the Royal College of Ophthalmologists (RCOphth), the College of Optometrists and the National Clinical Director for Eye Care.

Initial reports suggest that 2-4% of people fitted with the lenses since October last year experience increased IOP. The MHRA has consequently written to cataract clinics and instructed them to contact – preferably by phone – every person who has been implanted with those lenses since that date. Each clinic will make local arrangements for IOP to be assessed in every patient.

According to a statement from the College of Optometrists, IOLs implanted prior to October are not thought to be affected, and

historically the lens has an established and well-published safety record. The cause and mechanism for the increase in IOP has not been identified and further investigations are on-going. Optometrists should ensure that they follow clinical updates.

The RCOphth has been in discussion with clinical leads from some of the centres impacted by the alert and together they have devised a number of consensus points for prioritising, screening and treating patients affected.

In a statement the RCOphth said: “These incidents will place a significant burden upon the affected departments and the college will continue to work with the MHRA, NHS Patient Safety teams and our members to provide advice and guidance on managing the situation.

“The college will facilitate the sharing of information between affected departments with regards to patient contact, screening strategies and the management of affected patients.”

Patients who are concerned are advised to contact the eye unit that carried out their recent cataract surgery. q

Guidance sets out emergency eye-care standards

[WHILE MOST ophthalmology services are delivered in a planned way, eye casualty attendances are estimated to be 20-30 per 1,000 population each year. Accident and emergency departments will be able to triage and manage some conditions, but many complex sight-threatening emergencies will need to be managed by ophthalmologists with the wider multidisciplinary eye care team.

With many eye units facing workforce shortages and other capacity constraints, it is more important than ever to ensure the right processes are in place to provide an appropriate urgent and emergency care service. Concerns that good practice was not being followed were raised by RCOphth Council members and the college has reminded its members of the available guidance for implementing the essential service, which can be used in collaboration with trust administrations.

The RCOphth guidance on good practice for urgent and emergency secondary ophthalmic care includes processes and principles for ensuring reliable administrative and clinical arrangements with the receiving unit(s) so that referral/transfer is efficient, timely and

maintains high standards of patient care.

The guidance states that there should be access to protocols and guidelines for key high-risk emergency care – such as acute glaucoma, endophthalmitis, orbital haemorrhage and acute central retinal artery occlusion. It provides triage guidelines for staff taking calls or initially assessing patients.

Every eye unit and ophthalmic surgical provider must have a plan for emergencies and urgent care 24/7, and there must be a formal agreement in place with the receiving provider to accept cases if sent off site.

The plan must cover urgent and emergency advice and care for patients who have received care from the unit, patients who come to or contact the hospital or the eye unit with an urgent problem, and the urgent and emergency care of patients who are already in the hospital or unit for some other reason who then develop an eye problem, as well as acutely unwell patients in eye settings.

When a unit usually or routinely directs emergency patients elsewhere, it must have agreed reliable administrative and clinical arrangements with the receiving unit or units, so that referral or transfer is efficient and timely.

It is also important that reliable arrangements for on-going follow up and information sharing are made between the units so that, after an urgent problem, patients can, where suitable, be rapidly repatriated to their original or nearest unit, rather than having to travel back to where they went for emergency treatment.

There must be supervision and availability of a consultant ophthalmologist or equivalent senior specialty doctor (SSD), such as a highlyexperienced and independently practising associate specialist, who will carry ultimate clinical responsibility for emergency patients. A consultant or SSD must be available to provide advice at all times, including being available by telephone for advice out of normal working hours and being available to come into the hospital to see patients as required.

The full guidance document contains further detail on important aspects of planning emergency eye care in hospital eye units and other secondary care settings. That includes information on equipment and access to investigations, guidelines for nurse practitioners, optometrists and allied health professionals, operating on ophthalmic emergencies, audit and governance, and patient communication. q

BHF chief calls on PM to act on organ donation law

Study finds increased heart disease in women with problems in pregnancy

[A NEW STUDY published in the British Medical Journal has found that women who experience complications during pregnancy, such as pre-eclampsia or gestational diabetes, have a higher risk of developing heart disease later in life. The study, conducted by researchers at the University of Cambridge, analysed data from over one million women in the UK who had given birth between 1997 and 2018.

The study followed the women for an average of 11 years after their last pregnancy, during which time over 14,000 cases of cardiovascular disease were recorded. The researchers found that women who had experienced pregnancy complications had a 70% higher risk of developing heart disease compared to those who had not. Risk was higher for women who had multiple pregnancy complications or who gave birth to a low birth-weight baby.

[THE CHIEF EXECUTIVE of the British Heart Foundation (BHF), Dr Charmaine Griffiths, has written to Prime Minister Rishi Sunak to call for the full implementation of ‘Dáithí’s Law’ on organ donation in Northern Ireland. The legislation, named after six-year-old BHF Heart Hero winner Dáithí Mac Gabhann – who is on a waiting list for a heart transplant – has been delayed because of the absence of a Northern Ireland Executive.

The law, which was passed by the Northern Ireland Assembly last year, would mean everyone would be considered a potential organ donor unless they opt out or are in an exempted group. It was due to come into effect this spring but has been stalled as secondary legislation is required to see its full implementation, which cannot now happen without an Executive in place. The legislation could be passed at Westminster, which would see Dáithí’s Law implemented as planned and the Mac Gabhann family have called on the Secretary of State for Northern Ireland to act.

In a letter to Prime Minister Sunak, Dr Griffiths – pictured with Dáithí, his parents Seph and Máirtín and head of BHFNI Fearghal McKinney –says: “The British Heart Foundation have campaigned for this change in organ donation law for many years across the UK and most recently in Northern Ireland.

“We have been proud to stand alongside Dáithí and the organ donation and transplant community as we have worked together to see Dáithí’s Law passed. We are very close to the soft opt-out system for organ donation being operational across the entire UK, which could increase the number of organ transplants and help to save lives.

“We are asking for your support to help this positive and uniting campaign reach its ultimate conclusion. We trust that your government, the Rt Hon Chris Heaton Harris MP, Secretary of State for Northern Ireland, and the Department of Health in Northern Ireland can work together to pass the necessary secondary legislation and make Dáithí’s Law a reality in spring 2023.” q

Women who had pre-eclampsia had the highest risk, with a threefold increase in their risk of heart disease compared to women who had not experienced the condition.

The study’s findings underscore the importance of healthcare providers ensuring appropriate follow up for this population, according to the British Cardiovascular Society. Women who have experienced pregnancy complications should be considered a highrisk group for heart disease, and cardiovascular risk factors should be monitored and managed accordingly. Clinicians should consider the importance of a detailed obstetric history when considering an individual’s overall cardiovascular risk. q

Judge calls for inquiry into Alemi registration

[THE JUDGE in the case of bogus psychiatrist Zholia Alemi has called for an inquiry into how she could have been registered as a doctor by the GMC. According to Judge Hilary Manley the documents she submitted in 1995 were ‘clearly false’.

Over a 20-year period Alemi worked as a NHS psychiatrist in hospitals in England, Wales and Scotland, earning income and benefits over £1m. She never held the medical qualifications necessary to undertake these roles. She claimed to have qualified at the University of Auckland in New Zealand, despite having dropped out of the course.

On 28 February she was sentenced to seven years in prison at Manchester Crown Court, having previously been found guilty of 13 counts of fraud, two counts of forgery, three counts of deception and two counts of using material to falsify medical qualifications.

Alemi joined the medical register in the UK under a section of the Medical Act which has not been used since 2003. The section allowed graduates of medical schools in certain Commonwealth countries, including New Zealand, to obtain registration based on a qualification in their originating country. As a result, Alemi did not have to sit and pass the Professional and Linguistic Assessment

Board exam, an assessment of skills which is usually required of doctors who qualified abroad.

Janice Wild of the CPS explained: “Alemi used forged New Zealand medical qualifications to obtain employment as a UK NHS psychiatrist for 20 years. In doing so, she must have treated hundreds of patients when she was unqualified to do so, potentially putting them at risk. Her fraudulent actions also enabled her to dishonestly earn income and benefits in excess of £1m, to which she was not entitled.

“We will now pursue confiscation proceedings against her, aiming to recover the criminal property from which she has benefitted.”

Una Lane, director of registration and revalidation at the GMC, said: “We are very sorry that Zholia Alemi was able to join our medical register in the 1990s, based on fraudulent documentation, and for any risk arising to patients as a result. Our processes are far stronger now, with rigorous testing in place to make sure those joining the register are fit to work in the UK.

“It is clear that in this case the steps taken almost three decades ago were inadequate. We are confident that, 27 years on, our systems are robust.” q

Specialist team treats mental trauma caused by burns

[THE PREVALENCE of psychological problems associated with burns injuries is becoming increasingly recognised among clinicians. The National Burn Care Standards 2018 outline that all patients who are admitted to a burns service for 24 hours or more are offered a psychosocial screen. It is significant that the size, cause or location of the burn are not helpful predictors of coping.

One major hospital with a burns psychology service is the Chelsea and Westminster. Its burns psychology team provides psychological support to current and historical Chelsea and Westminster Hospital patients, their families – especially the parents of burn-injured children – and the social networks who have been, or will be, supporting patients to manage having experienced a burn.

The hospital’s website also contains a Burn injuries myth busters section: for example, the myth that the size of the burn matters – the bigger, the more distressing it feels.

“There is no direct relationship between the size of the burn and distress,” the article says. “Some of the most upset people we see have very small burns and yet other people with large burns do not seem that bothered. To know, we have to ask.”

The good news, the hospital points out, is that most adults and children who experience a burn injury will recover psychologically without the need for professional support. Indeed, not everyone will want or need professional support for managing burns.

Adult Burns Support UK – adultburnsupportuk.org – is a support site offering information and support to burns victims. It is funded by Dan’s Fund for Burns – dansfundforburns.org q

The medical and medicolegal implications of the undertreatment of pain

By DR CHRIS JENNER MBBS FRCA FFPMRCA, consultant in pain medicine and experienced expert witness.

PAIN IS THE MOST COMMON reason for a patient to visit their doctor, with around 25% of adults suffering from chronic pain at any one time – a figure that rises to around 50% in the over-65s.

Advances in our understanding of pain have allowed the diagnosis and treatment of conditions that were previously ignored, such as fibromyalgia. However, inadequate pain management can still be found in many different clinical settings, including terminal illness, cancer, emergency care, post-operatively and in connection with chronic pain conditions. This lack of treatment occurs for many reasons but the consequences for the patient can be far reaching.

Many doctors place great faith in objective tests and measurements. Pain is a very subjective experience, which varies from patient to patient, and this does not fit in well with the traditional scientific approach to health and disease.

Therefore, pain is often viewed as a less important issue than a physical symptom, such as an abnormal scan or a high temperature. This often leads to pain management being given less importance in treatment plans than other concerns, such as prolonging life and restoring good health. Furthermore, some pain conditions have no obvious cause, so some healthcare providers have a tendency to dismiss such conditions as the result of psychological distress or deliberate deceit.

However, a causal basis should not be a requirement for acceptance of the reality of a condition: for many years, the causes of epilepsy were not understood but the condition was still recognised.

For many cases of moderate to severe pain, opioid drugs are the firstline treatment. However, worries about abuse and addiction often shape policies on their prescription. These have increased since instances of OxyContin misuse became common in the USA. Many doctors are also concerned about the development of tolerance to opioids, which they fear may lead to dose escalation and dependence. Side effects, such as constipation, may also be a concern.

Well publicised prosecutions of doctors for inappropriate opioid prescription have resulted in the misconception that such cases are common, when this is not actually true. It has also led healthcare professionals to face legal and regulatory pressures to restrict the use of some drugs, particularly opioids, in the treatment of pain. This has resulted in inconsistencies between educational efforts to encourage the appropriate prescribing of pain medications and the threat of prosecution for those who do so.

Patient factors also have an important role to play in the undertreatment of pain. Concerns about the probable or possible side effects of medication can decrease adherence to treatment plans. Some patients may also be reluctant to admit that their pain is getting worse, as they fear a lifechanging diagnosis or deterioration in their condition.

Undertreatment of pain, especially in chronic conditions, can lead to patient suffering. Inadequately treated pain after surgery increases

the heart rate and systemic vascular resistance and increases the patient’s risk of myocardial ischemia, stroke, bleeding and other complications. Untreated acute pain may lead to neuronal alterations, such as central sensitisation, with the pain eventually becoming chronic.

Chronic pain is associated with numerous negative effects. It can interfere with daily activities, impair sleep, limit the patient’s ability to work and enjoy social relationships, and lead to psychological symptoms, such as anxiety, depression or anger. Chronic pain also places a great burden, which is often hidden, onto caregivers, and this can be both economic and emotional. Untreated pain may also infringe the autonomy of patients in determining their own care.

Therefore, inadequate treatment of pain may actually constitute negligence on the part of the doctor. Failure to document a patient’s history of pain, to consider all treatment options, or to consult a pain expert for intractable cases may leave a practitioner open to accusations of not taking reasonable care and could lead to litigation. An increasing number of statutory bodies agree with this view, although where the boundaries of reasonable behaviour currently lie is not always obvious. As cases are decided, the picture should become clearer.

The development of tools to assess pain objectively would improve its management, although it will always remain a subjective experience. Adopting a multi-disciplinary approach to pain treatment is more likely to result in a successful outcome, but this may require considerable education and patient compliance, which may be difficult to achieve.

Statutory regulations that protect doctors from liability after administering pain relief, provided that treatment is given with the consent of the patient and with the intention of relieving pain and not shortening the patient’s life, would also help to remove barriers to effective pain management.

As medical developments have provided better methods of controlling pain, so attitudes to it have changed, to the extent that some organisations now regard pain as the ‘fifth vital sign’. Undertreatment of pain is now viewed as unethical and patients are less prepared to accept untreated pain. Often, if a condition cannot be cured, pain may be the only aspect of it that can be effectively managed. However, better treatment of pain will require changes to medical philosophy and education, as well as new legislation. q

• Dr Chris Jenner is well known as an experienced and skilled expert witness in a wide range of medicolegal cases involving pain. He has been an expert witness for 15 years and his instructions are broadly divided as claimant (55%), defendant (40%), single joint expert (5%). He provides reports for both medical negligence and personal injury claims and hosts clinics in London, Birmingham, Manchester and Bristol.

Read Dr Jenner's biography at www.medicolegal-partners.com/jenner and check availability at upcoming clinics on the website at www.medicolegal-partners.com/book-an-expert

Just how do you know which neurology expert you need?

[IT IS FREQUENTLY EASY to identify the specialism from which an expert should be drawn. In the case of a neurological injury, however, it may not be that simple.

It may not be obvious whether a physician’s or a surgeon’s opinion is required: whether a neuropsychiatrist, neuropsychologist or neurosurgeon, for example, is required; and in today's increasingly cost-conscious justice system, choosing the correct expert in the first place has become even more important.

The are a number of types of case where neurological expertise is sought. In civil cases there may be a claim for clinical negligence or for personal injury – which in turn may result from an accident at work, a road traffic accident or other accident.

Criminal cases may involve an assault or the need to determine state of mind at the time of an offence, while the Court of Protection may be called upon to determine capacity either to grant power of attorney or rule on the validity of a will.

The range of specialisms encompassed within the sphere of neurology is

reflected in the membership of the British Neurological Society.

A facet of neurological injury that has come into the public eye recently has been in the realm of sports injury – particularly football and rugby. Anyone watching international rugby matches has become used to the sight of the head injury assessment – the three-stage assessment for concussion after an impact.

Over the past year a number of lawsuits have been initiated by both amateur players and household names in both rugby union and league.

In football head injuries have become a cause for concern in recent years. Heading the ball is now banned among children under 12 in Scotland and in England as a trial.

The Advanced Brain Health Clinic at the Institute of Sport, Exercise and Health (ISEH) is a unique neurological service for retired elite rugby and football players who have concerns about their brain health and its team are embarking on a study into the long-term brain health of retired elite athletes.

The kind of neurological and psychiatric problems that football and rugby players are at risk of developing includes post-traumatic dementias, such as chronic traumatic encephalopathy (CTE).

The prevalence of brain health issues is unclear, the ISEH says, so it is crucial to understand it further.

The future development of the cases brought by those sportspeople may shed further light on the broad range of specialisms to be found among neurological expert witnesses. q

Link is found between head injury and brain cancer

[RESEARCHERS AT University College London’s Cancer Institute believe they may have identified the mechanism that shows a link between head injuries and the risk of developing a glioma.

Gliomas are tumours of the non-neuronal support cells of the central nervous system (CNS), known as glial cells. Glial cells are made up of a variety of cell types, such as astrocytes, oligodendrocytes and ependymal cells, which have many essential roles in the maintenance and function of the CNS.

Matured glial cells are less likely to give rise to tumours because, under normal conditions, they do not divide and, as such, do not cause a buildup of cells – a tumour. However, recent findings have demonstrated that a brain injury can cause astrocytes to behave like stem cells – the body’s raw materials – again giving rise to dividing abilities.

Professor Parrinello and her research team at UCL used mice to model a scenario where they had a gene mutation known to increase

brain tumour risk, simulating mutations that could accumulate through aging, as well as an early-life brain injury. They found the two worked together to further increase the brain tumour risk later in life.

Professor Parrinello said: “We know that normal tissues carry many mutations which seem to just sit there and not have any major effects. Our findings suggest that if on top of those mutations, an injury occurs, it creates a synergistic effect.”

As part of their research, published in Current Biology, the scientists looked at the medical records of more than 20,000 people diagnosed with head injuries, comparing the rate of brain cancer with a control group with no identified head injuries. They found patients who experience head injury were up to four times more likely to develop a brain cancer later in life. However, it is important to note that, even after an injury, the risk of developing a brain cancer remains modest. q

Valproate: new restrictions introduced

[THE Medicines and Healthcare products Regulatory Authority (MHRA) has introduced further restrictions on the prescribing of valproate, to be phased in from this spring.

Valproate is approved in the UK to treat epilepsy and bipolar disorder. Because of the known risk of birth defects and neurodevelopmental disorders following use of valproate in pregnancy, valproate should only

be used in women of child-bearing potential if a Pregnancy Prevention Programme is in place, which includes a requirement to use effective contraception. Valproate should not be used in female children and women of childbearing potential unless other treatments are ineffective or not tolerated.

The latest data on the use of valproate in England shows that in the six months to March last year the number of pregnant women prescribed had fallen to 17 compared to 68 women in the period from April to September 2018. Research found that the babies of those patients had an 11% risk of birth defects and a 30-40% risk of neurodevelopmental disabilities which can be permanent.

In light of concerns that the current regulatory requirements for safe use are not being consistently followed, the MHRA conducted a review of the available data and asked for advice from the independent Commission on Human Medicines (CHM), which has listened to the views of patients and healthcare professionals.

The CHM has advised that no one under the age of 55 should be initiated on valproate unless two specialists independently consider and document that there is no other effective or tolerated treatment. Where possible, existing patients should be switched to another treatment unless two specialists independently consider and document that there is no other effective or tolerated treatment or the risks do not apply.

The guidance stresses that no one should stop taking valproate without advice from their healthcare professional. q

Therapy must show measurable benefit to support a case for its continuance

[ MY THERAPY RECOMMENDATIONS are based on a long career in traumatic brain injury (TBI) developed around an accepted approach for this client group. Unfortunately, I am seeing more and more cases where the approach employed by the treating clinician does not follow the proven model.

That model is not cast in stone, and it is justifiable for the treating therapist to steer the intervention in any direction they feel will achieve results; but it is essential that, if the treating therapist breaks from the model, they can still achieve with the claimant an appropriate and measurable level of progress for the amount of time invested. The intervention must deliver value for money.

It is understood that therapy does not come with a guarantee. If the accepted model is followed and a reassessment then shows that the anticipated results haven’t been achieved – in the absence of some other attributable cause – then it is acceptable to reach the conclusion that the claimant has plateaued sooner than expected. The problem arises when the therapist appears not to have targeted the fundamental areas examined in formal assessment and no quantifiable gains appear to have been made. That situation is gold for the defence expert, but a nightmare for the claimant’s expert.

It is essential that SMART (Specific, Measurable, Achievable, Relevant and Time-Bound) goals are used and delivered upon, for the expert to be able to make a case for continued impairmentbased therapy and not be left trying to justify a continuance with no solid evidence.

Assuming joint discussions are not imminent, the claimant’s expert might continue to support the therapy rather than advocating a move to maintenance levels. If this doesn’t then produce a measurable improvement the claimant’s expert will enter the joint discussion at a serious disadvantage, potentially forced to defend why intervention hadn’t already moved to maintenance and undermine any argument for further therapy.

Sadly, the claimant may still have been capable of making measurable progress had the therapist targeted the right areas and employed an approach that is acknowledged as capable of getting results. That leaves the claimant at serious risk of losing out on the therapy they deserve.

The treating therapist has a duty to the claimant to work with the expert to gather the evidence to justify the provision. Moreover, the treating therapist can make or dismantle the case for future intervention. q

Lisa Humberstone of Equip2Speak warns of the possible consequences when therapy is not targeted

AGRICULTURAL & HORTICULTURAL CONSULTANTS

ARTS & ANTIQUES SURVEYORS

BETTING & GAMING

COLLISION INVESTIGATION & RECONSTRUCTION

COMPLIANCE CONSULTANTS

DIGITAL TECHNOLOGY

COMPUTER & MOBILE FORENSICS

CRIMINOLOGY

ENERGY CONSULTANTS

DIAMOND & JEWELLERY VALUERS

ERGONOMICS

FINANCIAL SERVICES

FORENSIC SERVICES

GEOTECHNICAL CONSULTANTS

MECHANICAL & PROCESS ENGINEERING

INSURANCE

POLICE CUSTODY

TRANSLATING & INTERPRETING

WOOD & TIMBER

TREE CONSULTANTS

STEEL & IRON ORE

MEDICO-LEGAL EXPERTS

ACCIDENT & EMERGENCY MEDICINE

CARDIOLOGISTS & CARDIOTHORACIC SURGEONS

ANAESTHESIA

DENTAL & ORTHODONTIC EXPERTS

ENDOCRINOLOGY

GASTROINTESTINAL & COLORECTAL SURGEONS

ENT CONSULTANTS

GENERAL SURGEONS

INTENSIVE CARE MEDICINE

LIVER SURGEONS & HEPATOLOGISTS

GERIATRICIANS

MEDICAL NEGLIGENCE

HAEMATOLOGY

MICROPIGMENTATION

NEUROPSYCHOLOGISTS

NURSING & REHABILITATION CONSULTANTS

NEUROSURGEONS

OCCUPATIONAL MEDICINE & THERAPY

ONCOLOGISTS

OPHTHALMIC SURGEONS

ORAL & MAXILLOFACIAL SURGEONS

ORTHOPAEDIC SURGEONS

OSTEOPATHS

PAIN MEDICINE

PATHOLOGY

PHARMACOLOGY

PHYSICIANS

PLASTIC & HAND SURGEONS

PSYCHIATRISTS

PSYCHOLOGISTS

SPEECH & LANGUAGE THERAPY

REHABILITATION

TOXICOLOGY

UROLOGICAL SURGEONS

VASCULAR SURGEONS