Your Expert Witness No. 67

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CONTENTS IN THIS ISSUE 7

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Opening Statement

NEWS 9 Annual conference is biggest and best ever 10 EWI lecture tackles judges’ criticism of experts 10 Arbitration Bill seeks to keep UK “ahead of the curve” 11 New book is the expert’s guide to drink-drive prosecutions 11 Glasgow plea surgery hailed a success VIEWPOINT 13 When your expert costs you money!

FORENSIC ACCOUNTANCY 15 Chess-playing fraudster sentenced in absentia 15 Over £450,000 confiscated from global finance fraudsters 17 Law Society president comments on new economic crime law 17 Solicitor sentenced for ‘tipping off’ client about investigation 19 Which expert do you need, and when?

21 Solicitor suspended for failure to spot property fraud 21 Chartered accountants oppose government proposals on money laundering 22 Why should you employ a forensic accountant in legal proceedings?

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TREE CARE 23 The adventures of an expert witness: 21 years as a tree expert COMPUTER FORENSICS 25 Govt and tech firms unite to combat online harm 25 Forum promotes computer forensics LEGAL ISSUES IN CONSTRUCTION 27 What does your construction contract say about insolvency?

29 Landmark case protects firm’s new owners from previous H&S penalties 29 Stonemasons gain compensation for silica exposure FIRE INVESTIGATION 30 Fire chiefs publish response to consultations 31 New fire regulations now in force TRANSLATING & INTERPRETING 33 White paper calls for reform of public sector language services

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EXPERTS FOR MEDIA 34 Our new section for experts wishing to offer their expertise to the vast range of print and broadcast media

A to Z WEBSITE GUIDE 35 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

EXPERT CLASSIFIED 94 Expert Witness classified listings 99 Medico-legal classified listings

Your Expert Witness Suite 2, 61 Lower Hillgate, Stockport SK1 3AW Advertising: 0161 710 3880 Editorial: 0161 710 3881 Subscriptions: 0161 710 2240 E-mail: ian@dmmonline.co.uk Copyright Your Expert Witness. All rights reserved. No part of this publication may be copied, reproduced or transmitted in any form without prior permission of Your Expert Witness.

Views expressed in this magazine are not necessarily those of the publisher. Printed in the UK by The Magazine Printing Company Plc www.magprint.co.uk

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MEDICAL ISSUES

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39 Medical Notes NEWS 40 Doctors demand a pause in associate recruitment 40 Changes to medical reporting slated by PI lawyers 43 Surgeons’ body reacts to Surviving in Scrubs report 43 Law firms negligence team repeat awards success 45 NHS leaders call for doubling of capital spending on crumbling estate EMERGENCY MEDICINE 47 Emergency medicine report seeks to avoid repeats of ’24 hours in A&E’ 47 Podcast discusses negligence claims in A&E ANAESTHETICS 48 What are the complications and failures in airway management?

HEARING LOSS 51 Clinics aim to help prevent NIHL among musicians 51 Audiology services come under fire

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VASCULAR SURGERY 52 The enigma of limb ischaemia without blocked arteries: is there blame?

PLASTIC, RECONSTRUCTIVE & HAND SURGERY 55 People with facial scarring are more likely to suffer, study reveals 57 Number of cosmetic tourists needing treatment on return continues to soar NEUROSURGERY 59 Managing spinal cord injury pain: the voice of experience 61 Football failing in head injury management, charity claims 62 Continuous assessment is key to rehab TRICHOLOGY 63 To identify the hair damage in legal claims – turn to this trichology expert witness DENTISTRY & MAXILLOFACIAL SURGERY 65 Care homes urged to check residents for signs of mouth cancer 65 More people go abroad for dental treatment or attempt DIY dentistry 69 GDC consults on remote hearings 69 BDA calls for expansion of sugar tax after study shows success

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ORTHOPAEDICS 71 Meniscal tears: the jury is not completely out!

73 Hospital neglect contributed to death of student with hip dislocation 75 The meniscus repair versus meniscectomy debate – courtroom choices 77 Former gymnast’s hip replacement delayed following expert consultatio OBSTETRICS & GYNAECOLOGY 79 When is midwifery practice wrong? It’s more than just analysis of biology UROLOGY 80 The maleficent seven; or, why young men keep losing testicles in the 21st century PSYCHIATRIC & PSYCHOLOGICAL ISSUES 83 Rise in suicidal thoughts among nurses should be ‘frightening wake-up call’ 85 Unlocking the mind – webinars expand legal expertise 86 Psychologists: a myth-buster for the legal profession OPHTHALMOLOGY & OPTOMETRY 87 Follow your dream – but be alive to the practicalities 89 Thinktank report finds ophthalmology tops list of ‘hidden waitlist’ patients 91 Eye care professionals join charity to launch support pathway CARDIOLOGY 93 Blood test helps improve heart diagnosis www.yourexpertwitness.co.uk

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Opening Statement [

THE PRICE OF LIBERTY is eternal vigilance: while that famous adage, usually attributed to Thomas Jefferson, is normally seen to apply to political interference in the rule of law, it can equally apply to ensuring the probity of those whose job it is to apply the law and prosecute or defend those accused of breaking it.

So it was something of a shock to see two cases in recent months of solicitors being found guilty of impropriety – one of which resulted in a suspended jail sentence. In a further case a tax consultant was jailed for 10 years in absentia for appropriating the tax payments of his clients.

Solicitors and financial professionals are subject to more temptation than most of us because of their involvement in large transactions, but that is all the more reason why they must resist that temptation.

On the other hand, it is reassuring that there are mechanisms in place that will detect and punish such misdemeanours.

• When it comes to your more regular criminals, the Serious Fraud Office deals with eye-watering sums of money. One longrunning case involving half-a-billion dollars (yes, billion) is being brought to a conclusion by a number of Proceeds of Crime Orders, or POCA. The ability to retrieve ill-gotten gains is one of the pillars of making crime unprofitable, and criminals go to great lengths to hide their hauls in seemingly legitimate businesses. The government’s efforts to reform the overview of anti-money laundering has not impressed the Law Society, who prefer an upgrading of the present system.

Unravelling the complexities of financial affairs is where the forensic accountant comes in, as two of our contributors explain.

• Expert accountancy may also be needed in the case of a company insolvency, which involves no misdoing but can be complex nevertheless.

When the insolvency occurs during a construction project it can have major consequences. To avoid as much damage as possible, it pays to ensure the contract deals adequately with the issue. Three experts from law firm Womble Bond Dickinson explain how different contract forms approach insolvency, in the first of a two-part report.

• The construction industry is sometimes its own worst enemy, as the report of three stonemasons securing compensation for damage from inhaling silica dust demonstrates.

• Keeping disputes of all kinds out of the courts is the goal of most in the justice system. Arbitration is what the British are good at and London is seen as a major international centre, generating £2.5bn in revenue. The new Arbitration Bill aims to modernise the arbitration process and has generated a surprising amount of agreement from across the sector, including the Chartered Institute of Arbitrators. It’s good to see that the government can please some of the people some of the time.

• When expert testimony does get to court, the expert can sometimes draw criticism from the judge. The most common criticisms concern the expert veering from their expertise or presenting their report incorrectly. Mr Justice Williams urged experts not to be too thin skinned, in his address to the Expert Witness Institute.

• Experts were also out in force for the Bond Solon Expert Witness Conference. The day contained a full programme of addresses, as Meera Shah describes.

The Bond Solon Conference always heralds the fast-approaching festivities, coming as it does in the murk of November.

• Unfortunately, Christmas is also boom time for drink-driving. Otherwise sensible and law-abiding citizens suddenly take leave of those senses and drive their cars having consumed alcohol.

The process of prosecuting for driving over the prescribed limit is uniform across the UK and is explained in a new book by Joanne Caffrey.

So, to all readers, a Merry (and law-abiding) Christmas and a Happy New Year! q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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ANNUAL CONFERENCE IS BIGGEST AND BEST EVER And just like that, the biggest event in the Bond Solon calendar was over for another year!

The company’s Expert Witness Annual Conference 2023 took place on 3 November.

Here Bond Solon’s Meera Shah gives us a taste of what was on offer.

[I HAVE ATTENDED Bond

Solon conferences for many years.

This year’s conference was one of the best ever. Why? Because it had experienced practitioners well versed in their fields operating at the coal face in the legal system.

Such an approach has much more relevance than listening to academic theory: the real issues that can occur highlighted brilliantly in the case law updates.

Before we start winding down for the holidays, we thought we’d reflect on another successful conference and share some highlights for those of you who were unable to attend.

At 7am, fuelled by pastries and grande coffees, the Bond Solon team arrived at Church House to prepare for the conference. Those with the widest smiles manned the reception desk ready to greet experts on their arrival, while other members of the team set up the Bond Solon stands in the two exhibition rooms, greeted the speakers and assisted our virtual delegates on Swapcard.

At 9.45am Mark Solon opened the conference, followed by the renowned Isabel Hitching KC, who delivered a talk on Rules, Practice Directions and Court Guidance. In her capacity as member of the Civil Procedure Rules Committee, she offered insight into the intention behind the new 20-page expert report limit in the intermediate track of civil claims in England and Wales.

The morning session continued with a talk by the former President of the Law Society, Lubna Shuja, who spoke in detail about the working relationship between expert witnesses and solicitors.

After a brief break we resumed with the Annual Legal Update – a thorough analysis of the new cases and changes to the law and procedure over the past year, the principles of which experts are encouraged to apply to their practice. Kathryn Clague’s presentations are always well received and this year proved to be no exception.

This year we were delighted to hear from Karyn A Harty, the Global Co-Chair of Disputes and Head of Litigation at international law firm Dentons (Dublin), who delivered a fascinating presentation on how artificial intelligence can be used in the legal system.

After breaking for lunch the conference dispersed into the following parallel sessions: • Medico-legal with Dr Jock Mackenzie, partner at Anthony Gold and medical doctor, and Mark Burton, partner at Kennedys.

• Criminal with Natalie Wortley, Associate Professor at Northumbria University, and Carole McCartney, Professor at Leicester Law School.

• Commercial with Jonathan Carey and Olivia Dhein of RPC. • Family with Caroline Lynch, Barrister and Principal Legal Adviser of the Family Rights group.

The afternoon continued with a session by Peter Sommer, Professor of Digital Forensics at Birmingham City University, Visiting Professor at de Montfort University and course developer for the Open University. Peter explored how to work effectively in a digital legal system to produce court compliant evidence while working securely to avoid the loss of sensitive material.

The final session of the day was the much-anticipated debate between Amanda Savage KC and Helen Evans KC of 4 New Square – both leading barristers practising in professional negligence and disciplinary and insurance work. The motion was Should all experts be independently accredited?

Before the debate, 66% of those attending had answered ‘Yes’ and 34% ‘No’. But following a strong argument from Amanda, after the debate the percentages almost reversed to 36% answering ‘Yes’ and 64% answering ‘No’!

The Bond Solon team then joined the experts at Church House in toasting the conference with a drink’s reception (sponsored

by ALLDOQ) and a presentation for some of the new Cardiff University and Aberdeen University Expert Witness Certificate holders (above), before we all parted ways.

The conference working group is now looking ahead to next year’s Expert Witness Conference, taking place on Friday 8 November 2024 at Church House, Westminster and virtually on Swapcard. We have some exciting plans which we will share in due course. But in the meantime, if you would like to join the 80-plus experts who have already secured their place, do not hesitate to contact a member of the team on 020 7549 2549 or visit www.bondsolon.com. q www.yourexpertwitness.co.uk

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EWI LECTURE TACKLES JUDGES’ CRITICISM OF EXPERTS For this year’s Sir Michael Davies lecture, the Expert Witness Institute invited The Honourable Mr Justice Williams, High Court judge and chair of The Family Justice Council Subcommittee on Experts, to share his views on criticism of experts by members of the judiciary. Here, the EWI’s Emma Mitra sums up his advice.

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DISTINGUISHING BETWEEN constructive criticism, destructive criticism and disagreement, Mr Justice Williams made excellent suggestions around what to do if you find yourself being criticised as an expert, as well as how to avoid finding yourself in that situation in the first place.

Constructive vs destructive

Criticism isn’t all bad, Mr Justice Williams noted. Constructive feedback to an expert can help improve the way that other experts approach courts in the future – and that can only be a good thing.

All experts should remember, though, that disagreement from a judge is not necessarily criticism. “Don’t be too sensitive!” he reminded the audience.

A lack of preparation, failure to abide by court directions, going beyond remit or expertise and poor presentation on paper and on screen are all areas where experts commonly face criticism.

Efforts to change the way that criticism is managed have been made in the family law arena, with the establishment of a working group the Family Justice Council Sub-Committee on Experts.

The good, the bad and the ugly

Mr Justice Williams highlighted three areas likely to put an expert in a positive light in the eyes of a High Court judge: the ability to express complex concepts in accessible language, objectivity and staying within the bounds of your expertise and, of course, sticking to the facts.

At the opposite end of the spectrum, being unprepared, not abiding by court directions and

going beyond your remit or expertise are all traits that are likely to attract criticism from a judge.

As for the ugly – make sure that your presentation on paper and on screen is up to scratch!

How to avoid destructive criticism

To help avoid destructive criticism altogether, Mr Justice Williams’s top tips included: don’t take on too much, comply with timetables and communicate any difficulties.

Importantly, he said, remember the fundamentals of being an expert: comply with your subject matter expertise and with procedural codes.

Managing criticism

“If you’re being criticised in court, the best position to take is to remain as objective as possible and try to give considered answers,”

was Mr Justice Williams’s advice for managing criticism. “If you need it, ask for time to respond.

“Destructive criticism can also be valuable as a learning process in itself,” Mr Justice Williams reminds us. “It illustrates to the broader community that bad practice is a part of everyone learning.”

The happy judge

Judges are very busy people: that’s partly why the presentation of expert reports, with an executive summary of four pages, is so important.

“If you’re clear in your conclusion with clear and practical advice with a range of opinions, where relevant, the judge is going to be on your side to start with,” Mr Justice Williams said. “If you’ve got a happy judge, even if you’re robustly cross examined, having the judge on side is something to value.” q

ARBITRATION BILL SEEKS TO KEEP UK ‘AHEAD OF THE CURVE’ [A NEW ARBITRATION BILL, laid before Parliament on 21

November, aims to modernise the framework for arbitration in the UK for the first time in 26 years: making it quicker, cheaper and more efficient. It is also hoped it will cement the position of the high-value sector in the face of growing competition from other centres such as Singapore and Paris.

With arbitrations in England and Wales worth £2.5bn to the British economy each year in fees alone, the Bill will help the UK’s world-leading legal services sector to continue to flourish.

Justice Minister Lord Bellamy said: “These much-needed changes will modernise the role of arbitrators and further cement our position as a world leader in the field.

“The UK is a globally-respected hub for legal services, with English and Welsh law the bedrock for the majority of international disputes, and the Arbitration Bill will ensure businesses from around the world continue to come here to resolve their disagreements.”

In 2021 the government asked the Law Commission to review the Arbitration Act to ensure the UK remains ahead of the curve when it comes to dispute resolution. They consulted extensively before

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making recommendations to the government which were backed by the arbitration sector.

Accepting the Law Commission’s recommendations in full means arbitrations in this country will remain fair and efficient and will cement the UK’s status and economic benefit as a world leader, the MoJ said.

The changes include strengthening the courts’ powers to support emergency arbitration so time-sensitive decisions can be made more easily, such as the preservation of evidence to avoid bad actors destroying key materials. They will also protect arbitrators from unreasonable lawsuits.

Catherine Dixon, CEO of the Chartered Institute of Arbitrators, said: “We worked very closely with the UK Law Commission and other officials during its review of the Arbitration Act 1996. As the leading professional body for dispute resolvers, we are delighted that the majority of our recommendations were adopted in the Law Commission’s report and, subsequently, the Bill.

“We are pleased that the UK Government has included legislative reform of the Arbitration Act as a key priority in this Parliament, recognising the importance of arbitration to the UK and globally, as the Act forms the basis of legislation in many other jurisdictions.” q

NEW BOOK IS THE EXPERT’S GUIDE TO DRINK DRIVE PROSECUTIONS IN THE UK it is not unlawful to drink and drive. It is only unlawful to drive while above the prescribed limit of alcohol or be unfit to drive through the amount of alcohol consumed.

The prescribed limit also differs around the UK. Scotland, for example, has a stricter level than England, Wales and Northern Ireland.

Prosecutions of suspected drink drivers sometimes fail because the police fail to follow correct procedures.

As an ex-police custody sergeant, police trainer and now expert witness, Joanne Caffrey has conducted in excess of 1,000 evidential drink drive procedures, taught officers what they should be doing, and provided courts with reports for what the officers did or did not do.

Time and time again prosecutions fail because officers do not comply with basic fundamental principles and practices in law, or lack knowledge and confidence in which procedure they should be following.

Now, in this volume, Ms Caffrey outlines the real-life procedures for bringing a prosecution.

She explains: “Law books are available which discuss the legislation and case law, but what this book brings to the reader is the holistic safer custody process to safeguard the prosecution and safeguard the detainee, preserving life whilst not losing evidence. I use my experience

GLASGOW PLEA SURGERY HAILED A SUCCESS

[A NEW PLEA SURGERY at Glasgow Sheriff Court has led to the

early resolution of nearly 130 cases. The surgery was introduced by Sheriff Principal Aisha Anwar, with the support of the Procurator Fiscal, the Glasgow Bar Association and the Royal Faculty of Procurators, in a further initiative aimed at reducing the number of cases calling at a trial diet and as a measure to tackle the backlog.

The plea surgery deals with all sheriff summary and solemn business, as well as cases before the Justice of the Peace court. It is conducted each Monday on a drop-in basis, which allows defence agents to attend while at Glasgow Sheriff Court on other business.

Having taken instructions from their client, a defence agent can discuss the case with a procurator fiscal depute who is authorised to discuss and agree pleas if that is possible.

There have been plea discussions in 58 solemn cases and 79 summary cases. In addition, 30 Section 76 letters, indicating an intention to plead guilty, have been tendered. The solemn plea discussions alone represent approximately two weeks of all jury trial business in Glasgow Sheriff Court.

A recent study across Scotland found that, in a 12-month period, out of 36,000 not guilty pleas in summary cases, only 5,500 evidence-led trials took place.

Sheriff Principal Aisha Anwar, for the Sheriffdom of Glasgow and Strathkelvin, said: “Working together to secure early resolutions and to promote efficient disposal of court business helps to prevent witnesses and complainers being called to court unnecessarily and allows the accused to bring a conclusion to proceedings. It also assists with reducing waiting times for cases which do proceed to trial. In short, it helps to improve public confidence in the court process.

“I would like to thank the Crown and the defence for their enthusiastic participation in the plea surgery.”

John Bett, vice-dean of the Royal Faculty of Procurators in Glasgow, added: “Early indications are that the plea surgery is proving a resounding success, facilitating the early disposal of criminal proceedings where that can appropriately be achieved. Our members hope that the plea surgery will become a permanent fixture in Glasgow, promoting a closer working relationship between the Crown and defence agents and delivering prompt conclusions for complainers, accused persons and witnesses.” q

to draw upon real case examples of how prosecutions have failed against suspected drink drivers.”

The book is aimed at all police staff – from the point of scene attendance to arrest, transport and the custody unit ‘station procedures’. Defence and prosecution teams will also find it extremely useful to understand what should have occurred.

The book also reviews the working relationships between healthcare professionals, hospital staff and custody staff.

Ms Caffrey continued: “The principles apply to all UK police forces of England, Wales, Scotland and Northern Ireland, and those forces who have adopted the UK standards and expectations. Comparable practices and policies exist throughout the UK police services.

Domestic laws may differ, but the practice delivery is to meet the UK standards for those detained at the hands of the state.”

Drink Driving: Police Custody Procedures is a must-read for any person involved in drink drive prosecutions, either as part of the defence or prosecution teams. q • Amazon: Hardback £30, Paperback £25, Kindle £9.99; ISBN 979-8866034208

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WHEN YOUR EXPERT COSTS YOU MONEY!

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

[YOU, KIND READERS of this journal – or of the blog page on

my website – will have noticed that I go on and on (and on and on…) about incompetent or even dishonest expert witnesses. It is over 12 years now since the expert’s immunity from suit was removed – see Jones v Kaney [2011] UKSC 13 – and since then we have had: • A third party costs order against an expert – see Martine • Robinson v Liverpool University Hospital NHS Trust in Liverpool • County Court at reference F95Y511 – though that was quashed • on appeal.

• A medical expert threatened with jail in Liverpool Victoria • Insurance Company Ltd v Dr Asef Zafar [2019] EWCA Civ 392 • where the solicitor was jailed immediately.

• We have also had blatantly dishonest experts in a major • conspiracy to defeat justice in Accident Exchange Ltd v Nathan • John George-Broom and six others [2017] EWHC 1096 (Admin) • where seven experts were jailed for up to 13 months.

Preaching the obvious, the courts rely heavily on expert testimony and are becoming harsh on experts who get it wrong, particularly if they are dishonest.

But what about the lawyers? Do they get off scot free? Not any more!

There have been examples in judgments of the court insisting that instructing solicitors know CPR Part 35 as well as the experts they instruct. Arnold LJ, sitting as a judge down in the High Court because the case was so very technical, castigated instructing solicitors in Akebia Therapeutics Inc and Otsuka Pharmaceutical Co Ltd v Fibrogen Inc, stressing many times that it is the duty of the instructing solicitor, not just the expert, to know CPR 35 and the Practice Direction and to ensure for example that the expert attaches their CV to their report (basic!) and that there is nothing in the published literature by an expert which contradicts the opinions they express to the court.

But so far, although the reputation of these solicitors can hardly have been enhanced in their clients’ perception and although costs recovery may have been difficult, there was no example so far as I am aware of the management of experts being a direct cost to instructing solicitors.

However, now it’s different. In Jagger v AXA Insurance UK PLC [2023] 7 WLUK 293 the solicitor’s management of their expert was so bad that they rightly will have to meet the cost.

The case concerned a claim for allegedly defective cavity wall insulation installed by Heatwave Energy Solutions. Heatwave had gone into liquidation by the time the claim was issued in 2022, so their insurers became the defendant. The claim was for less than £10,000, although the solicitor said they hoped to be able to find an expert who would put it far higher. They had four months after issue to find such an expert.

In that time, the claim was amended from some £10,000 to a remarkably different £83,562 to £104,000! Perhaps the broad band of claim value was an indication that the lawyers didn’t know what the case was worth. The amended claim form was served almost at the end of the four months, but there was no appended Statement of Truth and the increased court fee was not paid within that four months.

Experts in this speciality were difficult to find. There was a Mr X who may have been able to help, but he had withdrawn from a number of similar cases when it emerged that he was to take a share of the damages – a very obvious challenge to the expert’s independence.

The claimant solicitors never did find a suitable expert. The defendants applied for striking out or summary judgment and the DJ granted this in part. He was scathing of the solicitor’s behaviour, saying this was an abuse of process. After all, they had amended the claim from about £10,000 to

about £100,000 and had not even paid the additional court fee!

The judge had costs orders in his armoury. He ordered that the claimants would pay the defendant’s costs of the application for striking out and they were debarred from claiming any costs incurred during the period of the abuse.

Who in the end will pay these costs? It is reasonable to suppose that the client will object to paying, so the costs will then fall on the solicitor.

No expert was maligned in this case, but it is a shameful example of a solicitor trying to use the presence – or absence – of an expert to strengthen their case, and finding that it just didn’t work. They should have known better. q

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

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

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

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CHESS-PLAYING FRAUDSTER SENTENCED IN ABSENTIA [A CROOKED TAX AGENT who stole more

than £750,000 in a tax and mortgage fraud has been jailed for 10 years.

Robin Moss (pictured), who is an internationallyranked chess player, lied about his income, made bogus claims in the names of unsuspecting clients and provided false documents that were used in fraudulent mortgage applications.

On 9 October the 58-year-old was convicted in his absence of tax fraud, money laundering, mortgage fraud and theft following a joint investigation between HM Revenue and Customs (HMRC) and Leicestershire Police.

Moss persuaded one client to pay their £53,000 tax bill through the crooked agent who paid it straight into his bank account rather than paying it to HMRC. Other clients had their HMRC

OVER £450,000 CONFISCATED FROM GLOBAL FINANCE FRAUDSTERS [ON 1 DECEMBER the Serious Fraud Office (SFO) secured over

£466,000 from former Balli Steel Plc executives who are currently in prison after a successful prosecution by the UK’s specialist antifraud agency.

In March, CEO Nasser Alaghband and senior executives Melis Erda and Louise Worsell were jailed for over 12 years for defrauding over 20 banks and securing loans for around half a billion dollars. SFO investigators exposed that the executives benefitted personally from the frauds they perpetrated by paying themselves large salaries and drawing additional funds from the company.

Those monies were used to pay for luxury lifestyles, including a £70,000 rental property near Cannes for the CEO’s personal use and his membership of an exclusive golf resort in the south of France.

Following action by the SFO proceeds of crime team, Southwark Crown Court ordered Mr Alaghband to pay over £100,000, while Ms Erda will pay over £350,000. The executives have up to six months to fulfil their confiscation orders and failure to pay could result in an additional prison sentence.

The SFO’s investigation into Louise Worsell is on-going. The case will return to court on 4 January.

Nick Ephgrave QPM, Director of the Serious Fraud Office said: “Following our successful prosecution, my team uncovered secret Swiss bank accounts and offshore trusts used to try to conceal the proceeds of this huge fraud.

“A prison sentence is hugely significant but not the end of our work.

We have the tools, the expertise and the determination to find and seize money made through fraud and hit criminals in their pockets.” q

details used by Moss to make false tax repayments which he had paid into his own bank accounts.

Moss splashed hundreds of thousands of pounds from the proceeds of his crimes on luxury items, including more than £115,000 on collectible Moorcroft pottery, £89,251 on gold coins and £18,930 on jewellery. His wife, 49-year-old Liliana, admitted a £115,000 money laundering charge on 9 June.

Robin Moss failed to attend sentencing at Nottingham Crown Court on 9 October. Liliana Moss attended via video link. Robin Moss was sentenced to 10 years in prison and Liliana Moss was sentenced to seven months in prison, suspended for 12 months.

Nick Stone, operational lead in HMRC’s Fraud Investigation Service, said: “Robin Moss abused his position of trust to steal from clients and the taxpayer. Tax fraud is never a victimless crime and the eye watering sums he spent on pottery and gold should have been funding the public services we all rely on.

“I hope this sentence serves as a warning to the minority of corrupt professionals who wrongly believe they can use their knowledge to commit fraud. We can and will work with our law enforcement partners to bring you to justice and we encourage anyone with information about any type of tax fraud to report it online.”

Former Leicestershire Police Detective Jason Helmn, who now works for the East Midlands Special Operations Unit, added: “It took the jury just 55 minutes to find Robin Moss guilty and I’m glad they saw how this so called ‘professional’ was taking advantage of his clients, who believed his work was genuine.

“He went to great lengths to hide his criminality, shown in a complex web of transactions which proved how he converted his criminally obtained funds into cash and high value items.

“This has been a lengthy investigation and one that has required a lot of hard work and tenacity across both police and HMRC.” A third person, Rajvir Sahota, admitted mortgage fraud using false documents supplied by Moss. He pleaded guilty in May 2021 and was sentenced to six months in prison, suspended for 12 months, on 9 October.

Action to recover the stolen money is underway. q

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SOLICITOR SENTENCED FOR LAW SOCIETY PRESIDENT COMMENTS ‘TIPPING OFF’ CLIENT ABOUT INVESTIGATION ON NEW ECONOMIC [ CRIME LAW [

THE Economic Crime and Corporate Transparency Act has passed through Parliament and become law, meaning solicitors can continue to support the fight against illicit finance. The new Act also includes reforms to Companies House, which will help to improve transparency of UK companies and strengthen the business environment.

The president of the Law Society of England and Wales, Nick Emmerson, commented: “The Law Society worked hard as the legislation made its way through Parliament to lobby for important changes on behalf of our members. We welcome the government’s focus on fighting economic crime and the recognition of the role solicitors play in this area.

“We appreciate the ambition behind adding a regulatory objective for legal services regulators to uphold the economic crime agenda. We were successful in pushing for a clarification of the scope of the new objective, which risked being so wide that it would divert focus away from the areas of real risk.

“At report stage the minister agreed with many of our points and made clear the regulatory objective will need to be implemented in a targeted and proportionate way. Regulatory activity should also be transparent, accountable, proportionate and consistent, as well as targeted only on cases where action is required.”

On the Solicitors Regulation Authority’s new fining powers, Nick said: “Under the act, the SRA can now issue unlimited fines in relation to economic crime offences.

“It is important for any solicitor who has committed serious misconduct to be dealt with swiftly. However, we strongly urged the government to carefully consider the proportionality of any further increases to the SRA’s fining powers, given that its fining powers increased from £2,000 to £25,000 as recently as July 2022. There is no evidence that the current fining powers are insufficient.

“Unlimited fines can already be imposed via the independent and ultimate arbiter, the Solicitors Disciplinary Tribunal (SDT), which was established to deal with the most serious cases of misconduct. The independent and transparent SDT process has the confidence of both the profession and the public.”

On Companies House reforms, he added: “We are pleased the Act gives Companies House the powers to be more active in preventing the creation, and shutting down, of fraudulent companies. These powers should help to give people more confidence that companies have put correct information onto the register.

“We look forward to working with Companies House to make sure that the powers are implemented in a way that is effective in minimising fraud, but at the same time does not put onerous burdens onto legitimate businesses.”

On the register of overseas entities, he said: “We worked hard behind the scenes to ensure that the reporting requirements for the new register of overseas entities were not unreasonable and burdensome on our members. Following close engagement with the government and peers, the update period remains 12 months after the entities’ initial entry onto the register.”

On strategic lawsuits against public participation (SLAPPs), Nick Emmerson concluded: “We understand why the government is implementing these measures. However, as only cases related to economic crime are covered, this means that some claimants may still use SLAPPs to stifle scrutiny. There are weaknesses in the current provisions that will need to be addressed in further legislation.” q

SOLICITOR WILLIAM OSMOND was sentenced to nine months in prison, suspended for 18 months, for tipping off his client about a Serious Fraud Office money laundering investigation and issuing investigators with a forged document. Osmond was also ordered to complete 100 hours of unpaid work and pay £5,000 costs.

Osmond, director and money laundering reporting officer for his law firm Osmond & Osmond Solicitors Ltd, was convicted on 14 November of informing his client James Redding Ramsay about the SFO’s investigation into Ramsay’s loan of £4m towards the purchase of a house in Mayfair and forging a Letter of Engagement about his role as solicitor around the purchase. He was sentenced at the Old Bailey on 30 November.

Osmond’s actions were revealed after SFO investigators searched his office in April 2019, revealing hand-written notes on his discussions with Ramsay and computer files that showed his forgery of the legal letter.

The SFO regularly issues notices requesting information for its criminal investigations and it is an offence not to comply without a reasonable excuse. It is the first time the SFO has ever prosecuted a solicitor for ‘tipping off’ another person about an investigation after receiving one of the notices.

Matthew Wagstaff, joint head of fraud, bribery and corruption at the SFO, commented: “This solicitor abused his trusted, professional status to knowingly break the law. No one is above the law, and we will pursue anyone who attempts to obstruct our investigations.” q

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WHICH EXPERT DO YOU NEED, AND WHEN? Forensic accountant and accredited expert witness Fiona Hotston Moore, of FRP Advisory, shares her top tips for instructing solicitors when considering engaging an accounting expert witness When to engage your expert

In my experience it can be helpful to engage your expert early in the dispute. Often I am engaged in the first instance to provide a preliminary view on a matter. The preliminary view is typically given in a brief written report, with financial analysis; but it is not in a courtcompliant form at that stage.

That report helps the solicitor and legal counsel to advise the client on the strengths and weaknesses of the case. It is typically prepared ahead of mediation and may be disclosed in mediation. A preliminary report can normally be provided quicker than the full court-compliant report and will then form the basis of the court report. It is often useful to have the expert attend part of the mediation to assist the parties and mediator.

In some instances the expert is approached by both parties, so clearly it is advisable to approach and engage your choice of expert as soon as possible. It may be tempting to instruct your expert late in the process to minimise costs; but bear in mind that experts will have existing case obligations and may not be willing to take an instruction at short notice.

How can your client assist us?

Typically, we will receive a helpful summary of the matter in dispute and some detail on the companies involved. As forensic accountants we usually have experience in a breadth of sectors. We will undertake our own research on the sector. That research will look at how the sector has fared historically and will include consideration of strengths, weaknesses, opportunities and threats. We will look at published data on companies in the sector, including any transactions.

However, your client will have a deep knowledge of the sector and could assist the expert at the start of the engagement in highlighting relevant sources of industry data, background information and identifying competitors.

Should I get a second expert opinion?

In matrimonial cases, and often in shareholder disputes, the expert is appointed as a single joint expert, instructed by all parties to give an independent opinion. In such instances a ‘shadow adviser’ may assist one party in framing the questions they wish to ask on the report of the single joint expert. Typically, there are 10 days to ask the questions, so it is important to line up your shadow adviser ahead of receipt of the report.

The shadow adviser can also give an opinion on the report to assist the party in deciding if they wish to ask the court to allow a party expert to be appointed if they do not accept the conclusions of the single joint expert report. Obviously, be aware of the court’s view on ‘shopping around’ for an expert witness.

Consider what areas of accounting experience your financial expert will need

Accounting is a wide subject area and accountants work in many different roles and sectors. You will need to identify an accountant who is not only experienced in acting as an expert witness, but who also has the relevant expertise. For example, if the case is a professional negligence claim against an auditor or tax adviser, you will need to identify a professional who has been in professional practice as an auditor or tax adviser. If the instruction requires an opinion on the valuation of a company, you will need an expert with experience in valuing businesses. q

How can I ensure costs are proportionate?

Consider whether you need a financial expert from a ‘top four’ firm of accountants, or whether an expert from an independent or regional firm might be suitable. Since the pandemic, instructing solicitors are far more willing to appoint an expert from another location and to use video conferencing to avoid the costs of physical meetings.

An expert working within a team will have assistants who can complete some of the financial analysis at an appropriate hourly rate. www.yourexpertwitness.co.uk

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SOLICITOR SUSPENDED FOR FAILURE TO SPOT PROPERTY FRAUD [A SOLICITOR who failed to spot warning

signs of fraud or exploitation of a client has been suspended for 12 months following a Solicitors Disciplinary Tribunal (SDT) hearing.

The solicitor, with over 30 years of experience, was initially referred to the Solicitors Regulation Authority for acting on behalf of both the buyer and seller of a property, risking a conflict of interests. The subsequent SDT heard that the solicitor acted in the transfer of a property from client X, a vulnerable individual, to a company owned by client Y, with whom the solicitor had a longstanding professional relationship.

Client X had a diagnosis of autism and an estimated mental age of 12.

Despite there being significant doubts about X’s capacity to manage their financial affairs

and enter into contracts, the solicitor allowed the transfer of the property to client Y without payment or any formal agreement allowing X to continue to reside in the property.

In the client care letter to X, the solicitor said they were simply giving effect to the transfer and not advising on whether it was sensible or reasonable.

The SDT heard that the solicitor failed to: • Make the necessary enquiries in relation • to the transaction • Meet the client on their own to advise • them of the risks • Determine whether the transfer was in the • interests of the client • Take steps to protect the client’s interests, • including any right they had to continue • residing in the property

Had the necessary checks been carried out on X’s behalf, the solicitor would have discovered Y had been convicted of several counts of fraud, one count of money laundering and sentenced to over five years’ imprisonment.

The SDT found the solicitor’s actions were ‘inept’ and ‘reckless’ and led to a vulnerable person being defrauded out of their property.

The SDT found further that there were no mitigating features, with the solicitor denying the allegations in their entirety up to the point of the hearing. q

CHARTERED ACCOUNTANTS OPPOSE GOVERNMENT PROPOSALS ON MONEY LAUNDERING [PROPOSALS TO CREATE a single anti-money laundering (AML)

regulator could create disruption that would harm the UK financial system, chartered accountancy body and AML supervisor ICAEW has warned.

In its response to HM Treasury’s AML supervisory consultation, submitted on 28 September, ICAEW explained its preferred option was for the proposed OPBAS+ model, which would enhance the powers of OPBAS – the Office for Professional Body Anti-Money Laundering Supervision – and increase the effectiveness of professional body supervision.

ICAEW said this would preserve and build on the significant investment already made in OPBAS, maintain the UK’s alignment with AML work in Europe and reduce the risk of uncertainty posed by the upheaval which would be caused by the other options proposed.

OPBAS+ was the option that could be implemented swiftly, building on the current system and requiring only minor changes to legislation.

The other proposals – consolidation of professional bodies, a single supervisor for professional services and a single regulator – would bring with them a number of risks which could allow criminals to operate and do damage to the economy.

ICAEW said that the other options would risk gaps in intelligence from the disruption in already-existing intelligence-sharing relationships.

There would also be a reduction in awareness and competency of AML risk as professional bodies would lose their incentive for creating educational material and running initiatives to boost knowledge, ICAEW said.

Additionally, ICAEW raised fears that a new regulator could be understaffed if employees at the existing bodies did not move across. In this case it would lack the expertise to operate effectively, which would weaken AML supervision.

Michelle Giddings, ICAEW’s head of AML and operations, said: “We take our role as an AML supervisor very seriously, but acknowledge there are areas where the system could benefit from reform.

“It’s vital that professional bodies like ICAEW continue to play a role in AML supervision. We gather a wealth of intelligence through our relationships with the firms we supervise, and removing professional bodies from AML supervision risks losing this valuable intelligence.

“In our view the OPBAS+ model will deliver the most feasible and effective way to improve supervision by building on what works. We

are concerned that the other options proposed would weaken AML regulation, and risk leaving the door open for criminals to do business in the UK and cause wider damage to the economy.” q

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WHY SHOULD YOU EMPLOY A FORENSIC ACCOUNTANT IN LEGAL PROCEEDINGS? [ENGAGING THE SERVICES of a forensic

accountant may prove to be a judicious course of action when confronted with the imperative to comprehend the intricacies of financial data entwined with litigation.

Such professionals play a pivotal role in appraising losses linked to claims, providing alternative perspectives, contesting opposing parties' assertions and, when requisite, offering expert testimony in a court of law.

Manchester and London-based Lennie Harris of HCA Consultancy (pictured) explained: “Drawing from my extensive experience, particularly in navigating the complexities of Proceeds of Crime (POCA) orders, I have encountered instances where court-ordered monetary demands appeared capricious, bearing no correlation to the actual illicit gains.

“My independent reports have been instrumental in assisting numerous incarcerated individuals grappling with such predicaments. This success is attributed to my acumen in scrutinising financial records and identifying critical nuances that mere invoice production cannot unveil. To maximise the advantages of employing a forensic accountant, early engagement is paramount – rather than seeking court permission to enlist their services during trial proceedings as expert witnesses.

“In the realm of POCA cases, legal firms frequently enlist my expertise to guide their clients through confiscation proceedings.

During the sentencing hearing a timeline is established, delineating various dates for the submission of statements by both the defence and the prosecution.”

The POCA timeline prescribes the deadline for a client's Section 18/16/17 Statements. The Section 18 Statement, prepared by the legal representative, details the client's available assets, encompassing properties, cash holdings, vehicles, jewellery and savings. It also enumerates assets that can be liquidated to satisfy the Confiscation Order.

Subsequently, the prosecution serves the Section 16(3) Statement, elucidating their case against the client, highlighting the financial gains resulting from the criminal activity and the assets available for restitution.

That statement is prepared by a financial investigator employed by the prosecution. He does not usually have the academic

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qualifications of a qualified accountant, or the benefit of discussing them with the client. He will go through bank accounts and other financial records, flagging items – the nature of which is unknown on the face of it – and marking them as stemming from criminal conduct, with a window extending back six years. Lennie Harris will work with the client to identify legitimate items with supporting documents.

He continued: “On reviewing the Section 16(3) Statement, you may find yourself astounded by the assessed benefit figure. Here is where the careful examination and deliberation of entries with a forensic accountant can significantly reduce the sum in question. Collaborating closely with you as an integral part of your legal team, my role is to provide the necessary evidence to challenge the prosecution's assertions. Subsequently, you will submit the Section 17 Statement, which demands meticulous preparation. You may contemplate disputing the prosecution's asset valuations, possibly by securing expert valuation reports.”

In some cases, family members may assert ownership rights or entitlements to certain assets, arguing that they are not proceeds of criminal activity. Such claims can serve as the basis for separate court applications.

Following the submission of statements, parties often engage in discussions to reach an equitable settlement without resorting to judicial intervention. Lennie Harris said: “My involvement in these negotiations, as a forensic accountant, can contribute significantly to achieving a reduced settlement.”

Upon conclusion of the case, a Confiscation Order will be issued, stipulating the final benefit figure and available assets. Those assets will be itemised and a payment deadline, typically three months, will be set. Extensions of an additional three months may be granted, but interest will accrue daily thereafter. Failure to remit the owed amount can result in an extended prison term. Given the stringent timeline, seeking professional guidance from an experienced forensic accountant as soon as dates are established is imperative.

Harris concluded: “I am frequently approached directly by defendants seeking recommendations for seasoned solicitors in this field, subject to court approval. I am available to serve as an expert witness during court proceedings.” q

THE ADVENTURES OF AN EXPERT WITNESS: 21 YEARS AS A TREE EXPERT Mark Chester of Cedarwood Tree Consultants describes some further cases he has been involved in.

[IT WAS BACK IN 2002 that I found myself, unexpectedly, the expert

in a court case being prosecuted by the local authority I worked for. I was part of a small team managing trees for the local authority and I had taken on the role of dealing with Tree Preservation Orders. That included taking enforcement action when someone had pruned or felled a tree without permission, or had not pruned properly.

My colleague – and manager – who had two decades of experience, had started the process but was now on long-term sick leave. The defendants were pleading not guilty and we were off to court. At the last minute there had been a change as the lead witness, who had witnessed the work, was no longer willing to attend. It was now up to me.

I had only been in post for two years, and did not consider myself an ‘expert’. Experts in my field had decades of experience. Suddenly, I was the expert, guiding the magistrate in decision making. Someone had heavily pruned a tree and damaged it. Their defence was that this had been agreed with my colleague. I knew that my colleague had not agreed to the work, but couldn’t prove this. The magistrate probably didn’t have any alternative but to dismiss the case. I was disappointed but the seeds of being an expert witness had been sown.

As I pursued vocational training, which would lead to become Chartered, my tutor shared with me his experience regarding the role of the trained expert witness. He was involved with a court case, and the process opened my eyes.

It was a decade later that I found myself back in court: again as the expert, again with an alleged breach of a Tree Preservation Order; but this time being employed by the defence. I was now aware of the Part 35 declaration. It was my first experience of the intense grilling of a crossexamination, as I was questioned for four hours. The defence barrister later explained to me that it had been because the prosecution barrister had begun to appreciate the limitations of his client’s case.

Sometimes, employing the services of a barrister is considered a luxury, and some clients feel it is one they cannot afford. I have been involved with numerous cases where a barrister has been employed, and while a poorly equipped barrister can cause a case to be lost in court, the involvement of a barrister, even just for opinion, has resulted in many of the civil litigation claims I have worked on being resolved, in my clients’ favour, without the need for a court hearing.

Expert witnesses know that our duty is to the court, and we need to remain independent. For me, it is important for my credibility. I recall one case where I was instructed to advise on damage to a boundary conifer hedge. Part of the hedge was dead, and we were exploring how that had happened. One view was that there had been a chemical leakage from farm machinery using the adjacent lane. The instructing solicitor liked that idea, and asked if I would write a court report supporting the view.

The evidence didn’t support it – only part of the hedge being dead and not being consistent with chemical damage. I declined to write the report as requested. If I was unwilling to do that, the solicitor informed me she would find an expert who would.

The claimant then spotted that the damaged hedge was where the lane was narrow: the damage had been caused by a hedge trimmer.

I was happy to write a report based on that. If I had agreed to the first theory, my credibility would have been affected.

I have written in the past about how a claimant can present the opinion of an expert who is not that expert in their field. I have had two recent experiences that contrast and indicate the importance, or otherwise, of the CPR Part 35 declaration. In the first case the defendant’s insurers employed the services of a specialist, in the expectation that this person would provide a defence against the claim.

The subsequent report was not as helpful as the insurers expected.

It concluded that the claimant had a case. It was certainly an expert report, but not the report of an expert witness. The author was then presented with some limited new evidence and invited to review the situation. It is unclear how much pressure they were placed under, but they produced an addendum which included a reversal of the original conclusions. On review, the claimant did not have a case.

I was instructed to review the situation at that stage. I was able to show that the reviewed evidence should not have led to the specialist reaching the updated conclusion. The absence of the expert witness declaration meant that the author was writing in an adversarial capacity and was no longer a reliable expert witness.

I have realised since then that the presence of the declaration does not, in itself, make a report the work of an independent expert witness.

In one case the specialist proceeded to summarise the situation (the executive summary) by quoting the thoughts of the claimant, who clearly felt she had been wronged.

Some trees had been felled to clear a power line and the claimant wished to have them replaced on a like-for-like basis. Not only was this not practical, it was also not the best way to manage that feature. Instead of guiding the claimant on the best way forward, which could have included other species of trees, the expert endorsed the claimant’s view. That detracted from their skills as both a professional and an expert witness.

As I reflect on 21 years since my first court appearance, and the diverse range of cases I have worked on, I value my training with Bond Solon and appreciate the challenges that each case brings. My role in each case is to be independent and impartial. However, I remember the case, from several years ago, wherein the claimant was injured when a tree split in two. One branch had landed on the busy road next to it, causing the claimant to swerve in their car and drive into a wall.

The evidence was that the company that managed the grounds of the property where the tree had stood were not fulfilling their duty of care. They settled within days of receiving my report. The claimant, who knew enough about trees to also recognise there was a problem at the site, thanked me for pursuing the evidence and recognising that the defendant’s expert was not an expert.

Not every client gets the outcome they seek; however, for each case, I work to find the evidence and ensure that the decision makers are informed. Each case is different, and I enjoy the challenge almost every time. q

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GOVT AND TECH FIRMS UNITE TO COMBAT ONLINE HARM [PEOPLE ACROSS THE UK will be better protected from online

scams, fake adverts and romance fraud as the world’s biggest tech companies pledge to take additional action to block and remove fraudulent content from their sites.

With fraud being the most common crime in the UK, the government has joined forces with leading tech companies Amazon, eBay, Facebook, Google, Instagram, LinkedIn, Match Group, Microsoft, Snapchat, TikTok, X (Twitter) and YouTube to develop and commit to the Online Fraud Charter, the first agreement of its kind in the world.

The services have committed to bring in a raft of measures to help protect people from fraud and scam content when using their sites. Actions include verifying new advertisers and promptly removing any fraudulent content. There will also be increased levels of verification on peer-topeer marketplaces, and people using online dating services will have the opportunity to prove they are who they say they are.

The charter will be supported by tough action to crack down on illegal adverts and ads for age-restricted products, such as alcohol or gambling, being seen by children. An action plan, agreed by the Online Advertising Taskforce, has been published, setting out steps industry and government are taking to tackle harms and increase protections for children. This includes developing a base of evidence, improving information sharing and promoting industry best practice.

Home Secretary James Cleverly said: The Online Fraud Charter is a big step forward in our efforts to protect the public from sophisticated, adaptable and highly organised criminals. An agreement of this kind has never been done on this scale before and I am exceptionally pleased to

FORUM PROMOTES COMPUTER FORENSICS

see tech firms working with us to turn the tide against fraudsters.

“Our work does not end here – I will continue to ensure we collaborate across government, and with law enforcement and the private sector, to ensure everyone in the UK is better protected from fraud.”

The Home Secretary and Anti-Fraud Champion Anthony Browne MP met with senior representatives from the tech firms to sign the charter at Lancaster House on 30 November (pictured).

Martin Lewis, founder of MoneySavingExpert.com, commented: “I’ve long called for regulation and law changes to make these big tech firms step up to the plate and deny these scammers the oxygen of publicity. So I am pleased at the signing of this voluntary agreement, which is adopting many of the scam ad protection measures we’ve been calling for – such as 2-click reporting, and advertiser and site destination verification.

“We will be watching closely to check these companies work hard, and work together to make good on their promises.” q

[

THE BODY THAT PROVIDES a network for computer forensics practitioners is the First Forensic Forum (F3). The forum was founded in the 1990s and since its inception it has always had the same goal: “F3 exists to provide an open forum for all forensic computing practitioners, to enable them to share their collective knowledge through discussion and training.”

According to its website: “F3 membership is open to any person or organisation currently active in the field of digital forensics. Members are drawn from both the public and the private sectors, and those engaged mainly in the field of defence work are as welcome as those working for prosecution agencies. All members have equal access to all the information disseminated by the forum and to all lectures, workshops and training sessions organised by F3.”

F3 is run entirely by a committee of volunteers, who are themselves involved in the field of digital forensics. It is non-profit making, and all of the income received is used exclusively for the benefit of the membership. In most cases the speakers who present to F3 also give their time voluntarily.

In a typical year it will hold four or five one-day workshops in various locations throughout the country, and also one two-day annual conference.

The website continues: “Computer technology is a fast-moving area and in order to function effectively forensic computing analysts are constantly faced with the necessity of updating and expanding their knowledge. F3 aims to provide them with the opportunity to do so.” q www.yourexpertwitness.co.uk

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WHAT DOES YOUR CONSTRUCTION CONTRACT SAY ABOUT INSOLVENCY? In this two-part article, Fintan Wolohan, Frances Antoniak and Nicola Deedes of Womble Bond Dickinson discuss the importance of scrutinising a construction contract to understand the position regarding insolvency.

[ FOR THE PAST 10 YEARS the construction sector has been

susceptible to insolvencies at all levels, from tier one contractors down to specialist sub-contractors. In particular, the construction industry has been blindsided by a perfect storm of factors outside of its control, such as COVID-19, the war in Ukraine and Brexit, which has inevitably resulted in record numbers of contractors becoming insolvent.

Here, we’ve looked at the approach to insolvency in the standard building contracts most commonly used in the UK – namely the JCT, NEC and FIDIC – focusing on the JCT D&B 2016 (JCT), NEC4 ECC (NEC4) and FIDIC Yellow Book (FIDIC).

What do you mean by ‘insolvency’?

The first place to start is to see how your contract defines ‘insolvency’. The JCT defines a party as ‘Insolvent’ by referring to the legislation of England and Wales (clause 8.1). This is not necessarily straightforward to understand, or to ascertain, and so it is advisable to seek professional advice regarding the precise status of the potentially insolvent party and trigger event under the contract. For example, a company does not ‘enter administration within the meaning of Schedule B1 to the Insolvency Act 1986’ (8.1.1) until the administrators have been appointed, not at the point where a notice of intention to appoint administrators has been filed.

The unamended NEC4 is broader and includes insolvency events as reasons for termination (in R1-R10, 91.1) to include: a company having a winding up order made against it (R5); having an administration order made against it or having an administrator appointed over it (R8); and making an arrangement with its creditors (R10), making it broader than the JCT’s 8.1.

As for the FIDIC, that is similarly drafted to NEC4, but also includes a catch-all provision to include ‘any event which is analogous to or has a similar effect to any of these acts or events under applicable laws’ (15.2.1(g) in the case of the contractor and 16.2.1(h) for the employer).

So, when faced with a potentially insolvent party it is essential to understand whether the party in question has in fact met the definition of insolvent under the relevant contract. For example, a party in financial difficulty that chooses to enter into an arrangement with its creditors – a Company Voluntary Arrangement (CVA) is one such arrangement – when contracting under NEC4 or FIDIC would not be able to avoid the contractual ramifications of insolvency.

Steps to take on insolvency

If you do establish that the other party is insolvent under the terms of your contract with them, what next?

Under the JCT, if either party is ‘insolvent’, the contractor's employment may be terminated at any time by notice, provided it is given in accordance with the contract’s notice provisions. Such a termination shall take effect on receipt of the relevant notice.

Another important point to note is that, from the date the contractor becomes ‘insolvent’, regardless of whether the employer has given

a notice of termination, the contractor's obligation to carry out the works are suspended (8.5.3.2) and no further sums will fall due to the contractor (8.7.3), subject to a final account balancing.

The NEC4 also provides for termination, stating that either party may terminate if the other party has ‘done’ one of the insolvency events listed at clause 91.1, such as having a provisional liquidator appointed to it (R6). Once the project manager issues the termination certificate, the termination is effective immediately and the contractor does no further work necessary to provide the works (90.4).

The FIDIC provides that a Notice of Termination can be issued in the instance of the insolvent events defined in the previously-mentioned clauses 15.2.1(g) and 16.2.1(h), applying to either the contractor or the employer as appropriate. The contract is terminated immediately on the date the notice is received (15.2.2).

If you want to terminate, for all three of the contracts you’ll need to issue a notice or certificate. In doing so, check you have ‘crossed all the Is and dotted all the Ts’, because non-compliant notices have been held in court to be inadequate, which would then put you on the backfoot (needing to re-issue) and in breach of the contract. Similarly, trying to terminate but not using the right grounds under the contract can create further problems for you by limiting your rights to complete the works.

To add a further layer of complexity, the economic impact of COVID-19 resulted in a number of lasting changes to UK insolvency law under the Corporate Insolvency and Governance Act 2020 (CIGA).

In short, where you are supplying services to the insolvent party, the insolvency events set out in your contract that trigger your entitlement to terminate may also trigger the provisions of CIGA, which broadly speaking acts to prevent suppliers from terminating a contract and ceasing to supply for reasons of insolvency – known as the ‘ipso facto’ provisions.

While CIGA isn’t an absolute bar on termination and is unlikely to apply where an employer – ie the party being supplied with services – is looking to terminate its contract with an insolvent contractor, care needs to be taken before serving a notice. q • In the next issue the trio discuss how the employer can complete the works, what to do about monies due and other considerations. www.yourexpertwitness.co.uk

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LANDMARK CASE PROTECTS FIRM’S NEW OWNERS FROM PREVIOUS H&S PENALTIES [A LANDMARK LEGAL DECISION has

saved the new owners of a pop-up hotel firm from ruinous fines in a fatal health and safety case. The new managers rescued the business from insolvency after it had gone through a Company Voluntary Arrangement, keeping it alive as a going concern.

The firm was already under investigation for the on-site fatality and after the takeover the Health and Safety Executive brought a corporate manslaughter case against the company. With their business facing a potentially huge fine, the new owners called in property and construction legal specialists Cardium Law, who successfully argued that a fine could not be enforced as the HSE had not made a claim during the CVA process.

The fatal accident happened when the firm was adapting a barn to use as a dining room for guests, alongside shipping containers converted into temporary hotel rooms.

Discovering a sub-contractor on the roof of the leaking building without the proper safety equipment, site managers ordered him to get down, but he scaled the barn again on more than one occasion and died when he plunged through a skylight.

Being forced to abort the project created

a cashflow crisis for the firm's then owners.

Liquidators came in and recommended a CVA. Typically, under a CVA the insolvent company agrees a schedule of repayments to creditors; but in this case, the main creditor waived its right to repayment in return for ownership of the business, which it swiftly sold on to the current owners, now Cardium Law's clients.

The sale appeared to be a success for all concerned, but then came the HSE's corporate manslaughter case.

Cardium's team reckoned they had a reasonable argument in the criminal case that the worker who died had ignored safety instructions. But because the HSE case was filed against the company under the management of its new owners as well as against the former directors, it meant if a jury wanted to convict the former owners, they would need to convict the company as well, leading to fines it probably couldn't afford.

So the Cardium team looked for another way to protect the client company from another insolvency. They launched a parallel civil case to argue that any fines levied by the criminal court were unenforceable because the CVA process discharged all the company's liabilities. Crucially, the HSE had been

informed of the CVA process but did not make any claim as a creditor.

Cardium won the civil case, which meant that even if the company was found guilty of corporate manslaughter, it would not have to pay the resulting fines.

As things turned out in the Crown Court, Cardium and Mark Watson KC of Six Pump Court persuaded the prosecution to drop the corporate manslaughter charges based on ‘no case to answer’.

Instead, the trial focused on a technical infraction of failing to prevent the contractor climbing onto the barn roof on the first occasion. That incurred a £140,000 fine, nowhere near the millions that would be levied for a guilty corporate manslaughter verdict; but even that was not collectible because of the civil case ruling.

Cardium director Chris MacQueen explained: “If someone is looking at buying a business that has been through a CVA and discovers that the target acquisition is under investigation for HSE or other infractions, it means the company and its new owners are safeguarded from fines relating to events before the CVA where a prosecution isn't already underway.” q

STONEMASONS GAIN COMPENSATION FOR SILICA EXPOSURE

by Oliver Collett, partner for workplace illness at Irwin Mitchell

[THE Health and Safety Executive describes silica dust as ‘the single

biggest risk to construction workers after asbestos’ and, starting in May, HSE inspections have been specifically focused on dust control as part of a respiratory health intervention initiative. Inspectors have been checking that employers and workers know the risks of exposure, plan their work and are using the right controls.

The aim of the initiative is to prevent at-risk workers from dangerous levels of occupational exposure to silica dust and the potential consequences, namely the development of silicosis and other lung diseases such as lung cancer, COPD, tuberculosis and rheumatological disease.

The most common type of disease, however, is silicosis, which is a form of pulmonary fibrosis. The disease is caused by breathing in fine silica dust, a common mineral found in certain types of rock, stone, sand and clay.

The condition affects many workers exposed to silica dust in jobs such as construction, mining and stonemasonry.

Legal claims involving occupational exposure to silica dust and the resultant development of silicosis and other lung diseases are becoming far more commonplace. Notwithstanding the HSE’s provision of detailed guidance on the control of exposure to silica dust in the workplace, there are many individuals who have not been and are not being adequately protected by their employer.

Back in early 2020, our Newcastle team were contacted by three stonemasons, all of whom were employed by a large engineering and construction company in the 1980s, 1990s and 2000s. During the course of their employment all three claimants were negligently exposed to silica dust when using grinders, pneumatic breakers and other hand tools to work on stone materials. Their employer did not implement measures to

remove or reduce the dust levels produced, and particularly did not provide any adequate respiratory protection. All three men developed respiratory symptoms many years after working for the company.

All three had seen a significant decline in their overall levels of fitness as a result of the disease, which had significantly impacted upon their work and capacity to earn, as well as their social and family life. In addition to those challenges, the claimants were also now required to come to terms with the increased risk of them contracting potentially life-threatening conditions, such as tuberculosis and lung cancer.

Given their similarities, all three cases were managed together through the court proceedings process. Medical and engineering experts were instructed and all three claims were fully quantified. The claimants’ former employer initially denied liability and sought to contest the cases on medical causation grounds, as well as arguing that the claims were out of time.

It is quite common for people to receive a late diagnosis of silicosis, as initial medical investigations can often conclude that the fibrotic disease is naturally occurring. As a consequence, some claimants can find themselves facing arguments that they have not brought their claims to court within the required three-year time limit. That was the case in two out of three claims in this instance, as early diagnoses of sarcoidosis – a naturally occurring but very similar condition to silicosis – were made.

The three claims were listed to be heard together in the High Court in London, but shortly before the trial was due to start, the defendant settled all three claims. All three claimants were able to settle their cases on a provisional basis, meaning that they are free to return to court for additional compensation if their condition worsens or they develop any of the other conditions that they were at risk of developing as a consequence of their silica exposure. q www.yourexpertwitness.co.uk

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FIRE CHIEFS PUBLISH RESPONSE TO CONSULTATIONS [ THE NATIONAL FIRE CHIEFS COUNCIL (NFCC) has published

its responses to two government consultations which seek to modernise product safety legislation. The consultations have been undertaken by the Department for Business and Trade and look at the regulatory framework for product safety and for fire safety in domestic upholstered furniture.

Charlie Pugsley, the NFCC’s lead for electrical safety and fire investigation, said: “The consultations are an important step in improving product safety laws. NFCC and fire and rescue services have seen the impact of outdated laws on fire safety in the modern

environment. It is time for change to protect consumers no matter where or how they buy products in the UK.” The Smarter Regulation: UK Product Safety Review consultation looks at the UK’s product safety framework to protect consumers and help businesses bring new and innovative products to market. The NFCC’s response drew from learning from the Grenfell Tower fire and the expertise of fire and rescue services in construction product safety. In the response NFCC highlights recommendations made in two independent reviews: Dame Judith Hackitt’s 2018 Building a Safer Future and 2023’s An Independent Review of the Construction Products Testing Regime, which included the need for increased activity from regulatory bodies, improved traceability and the application of centralised systems to products more generally.

The current system for building regulations has already been described and accepted by the government as ‘not fit for purpose’. The NFCC has, therefore, recommended that caution be exercised with regard to ‘reducing business burdens’, with the potential to introduce even more unknown and untested products into places where people live, work and play.

Product development and innovation can outpace safety standards, and the full risk of new and innovative products may not be understood until much later. The NFCC supports the drive to encourage innovation and support decarbonisation ambitions, but it must not come at an increased safety risk. That is a real concern for fire and rescue services: London Fire Brigade, for example, has reported that in 2023 it has been called out to an e-bike fire approximately every two days.

The Smarter Regulation: Fire safety of domestic upholstered furniture consultation looks to update regulations to protect the public from injury and death arising from flammable furniture, taking into account modernday hazards and risks.

The NFCC agreed that a new approach is needed to ensure that domestic upholstered furniture continues to be fire-safe and to ensure high levels of consumer protection in the modern home.

NFCC supports the regulations which enable a reduction in the use of chemical flame retardants and new regulations around labelling which will benefit the consumer and enable better enforcement by improving traceability, coupled with the increased time available to take legal action in the case of non-compliance.

It has welcomed the proposal by the Office for Product Safety and Standards to play a central co-ordinating role in the regulatory regime, which it is hoped will mitigate some of the resourcing pressures faced

by Trading Standards.

However, it believes that the modern approach must be kept under review to ensure that fire safety is not compromised. q

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www.yourexpertwitness.co.uk

NEW FIRE REGULATIONS NOW IN FORCE [ FROM 1 OCTOBER new fire safety

guidelines have come into force for all buildings regulated by the Regulatory Reform (Fire Safety) Order 2005 (FSO).

The guidelines form part of Phase 3 of the Home Office’s fire safety reform programme and are a crucial step towards bolstering fire safety on all FSO-regulated premises.

Local fire and rescue authorities remain the primary enforcing body for the Fire Safety Order, including the additional requirements. The Housing Act 2004 lists enforcement by the local authority in nondomestic parts of multi-occupied residential buildings (for example communal corridors, stairways) as well.

The enforcing body will be the Health and Safety Executive in the case of non-occupied buildings on a construction site, the Defence Fire Safety Regulator for sites occupied for the purposes of the armed forces, and the Crown Premises Fire Safety Inspectorate in buildings occupied or owned by the government.

The new regulations aim to enhance collaboration and co-ordination between responsible persons (RPs), impose stricter requirements for recording and sharing of fire safety information, simplify the process for enforcement authorities to take action against non-compliance and provide residents with comprehensive information regarding fire safety in their buildings.

The level of fines for some offences have been increased, including intentionally deceptive impersonation of a [fire] inspector, failure to comply (without reasonable excuse) with specific requirements

imposed by a [fire] inspector (such as by not providing a copy of the fire risk assessment when requested) and failure to comply with requirements relating to the installation of luminous tube signs.

The authorities have recently published three new fire safety guides that are aimed at small non-domestic premises, small blocks of flats and small sleeping accommodations. The guides are intended to replace the old short guide to making premises safe from fire.

Moreover, an updated fire risk assessment checklist has also been published to help responsible individuals understand and meet the new requirements. That checklist will support them in ensuring that their premises are safe and secure from fire hazards.

The new regulations have been welcomed by the Fire Industry Association as a significant step towards enhancing fire safety standards nationwide. They have urged all responsible persons to thoroughly review the updated guidelines and take the necessary steps to ensure full compliance.

The Home Office is not at this stage commencing a requirement for responsible persons to ensure that anyone they appoint to do a fire risk assessment is competent. They are actively working with the sector to develop a robust roll-out plan to support implementation and will provide more information in due course. They published guidance in July 2023 that explains to RPs what they need to do as a result of the changes to the FSO. q

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WHITE PAPER CALLS FOR REFORM OF PUBLIC SECTOR LANGUAGE SERVICES [A NEW WHITE PAPER published on 21 November sets out urgent

recommendations for tackling immediate challenges around procurement and provision of language services for the UK’s public sector.

Produced by a joint Public Sector Working Group consisting of the Association of Translation Companies and a number of interpreting and translation associations under the umbrella Professional Interpreters for Justice (PI4J), the paper outlines challenges and proposes solutions for resolving pressing issues in a dynamic, continuously changing landscape, where public sector commissioning and buying organisations, language service companies and freelance interpreters and translators form an interdependent ecosystem where each stakeholder plays a crucial role in the sustainable development of the supply chain.

Changing patterns of demand, unmapped or unforeseen, rapid regional and national changes in the need for different languages and the requirements for rare languages pose challenges both for procurement and provision of services and ultimately equality, fairness and public safety.

The impact of a tightening economic situation is evident in stakeholder evidence gathered by the Working Group organisations. The evidence put forward in the White Paper highlights the impact of the growing resource allocation issues in attracting new entrants and retaining qualified and competent professionals, a decline in language learning, and the continued pressure on prices.

The foundations of sustainability across public sector procurement are laid by commissioning organisations at policy, framework and contract levels. The Working Group believes that implementing best practice and unambiguous requirements at Framework specification level will result in a more uniform service delivery across the supply chain, enable good governance and oversight practices and, importantly, create an equitable and sustainable working environment for freelance interpreters and translators.

Reporting on the publication of the document, PI4J member the Institute of Translation and Interpreting (ITI) says: “The paper provides evidence of growing resource allocation issues, and was published in response to a survey conducted by the BBC Radio 4 File on Four programme, which found that 10% of public service interpreters are unlikely to stay in the profession after the next 12 months due to poor remuneration, exacerbated by the cost-of-living crisis and challenging contractual terms and conditions.”

It quotes data from the National Register of Public Service Interpreters which show that, over the past 11 years, the number of interpreters registered has fallen by 33% – from 2,400 registrants in 2011 to 1,600 in 2023. Another key measure of the pipeline of interpreters, the NRCPD Register of Trainee Sign Language Interpreters, is currently showing a troubling 30% drop in the past five years. Those figures illustrate the long-term trend in the decline in the number of registered public service interpreters, the ITI says.

The paper proposes 10 key, urgent improvements for public sector commissioning and buying organisations to tackle the immediate challenges of the cost-of-living crisis, and to ensure the continued safe provision of multilingual services for the public sector. They are: • Collaboration between stakeholders in the ecosystem • Indexing cost of contracts and linking them to inflation • Fair and equitable fees for translators and interpreters • Increasing transparency on rates of pay • Reviewing practices and fees for travel time and compensation • Implementing minimum assignment durations and charges

• Ensuring fair and transparent cancellation policies • Promoting and prioritising the use of qualified professionals • Building pathways to support career progression • Supporting small businesses’ access to public sector work Raisa McNab, CEO of the Association of Translation Companies, said: “In our linguistically diverse society, translation and interpreting services underpin the fair and equitable treatment of speakers of more than 300 different languages. This vital work must be safeguarded; positive action is needed to create a pipeline for new entrants into the profession and to support the retention of qualified, competent professionals.

“This white paper signals the start of a new era of associations and stakeholders across the ecosystem joining forces in a joint effort to ensure that provision of translation, interpreting and other language services continues uninterrupted.”

Mike Orlov, on behalf of Professional Interpreters for Justice, said “The UK’s public sector interpreting and translation landscape is fragmented across the four UK nations, government departments and different public services. This complicates the way interpreters and translators are engaged and creates challenges and disparities around delivering and monitoring best practice at all levels.

“We believe that implementing these recommendations will result in a more uniform service delivery across the courts and tribunal service and create an equitable and sustainable working environment for freelance, self-employed interpreters and translators.” q

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EXPERTS FOR MEDIA The following experts offer their expertise to the media EXPERTS FOR MEDIA is a new section in Your Expert Witness for experts who wish to offer their views and the benefit of their experience to the vast range of print and broadcast media.

Ever wondered how news teams find the experts they consult to explain the ramifications of breaking news stories, seemingly at the drop of a hat? Or how the producers of TV drama series ensure their stories are accurate and reflect the realities of the professions they portray?

The fact is that researchers consult registers of experts and expert periodicals just as lawyers do. In fact, Your Expert Witness is receiving an increasing number of enquiries from media researchers and public relations agencies looking to locate appropriate experts to inform their clients.

Experts for Media is therefore an ideal space to attract their attention. For prices and to book your space, contact Ian on 0161 710 3880 or via ian@dmmonline.co.uk.

Professor Charles Davis MBBS FRCS Consultant Neurosurgeon

Professor Charles Davis acts as an expert witness with very extensive experience in cases relating to neurosurgery, including the preparation of medico-legal reports and appearing in court. Speedy reporting, free advice and screening.

Contact: Marlene Scruton T: 01772 761150 F: 01772 761150 E: marlene.scruton@talktalk.net

Dr Emma Ferriman MBChB MRCOG FRCOG Consultant Obstetrician and Fetal Medicine Specialist Medical negligence cases involving: • multiple pregnancy and high • prenatal diagnosis • risk obstetrics including intra • obstetric ultrasound • partum complications and • first trimester screening • birth asphyxia T: 07812 353820 E: emmaferriman@doctors.org.uk W: www.emmaferriman.co.uk

Mr Robert Hensher

FRCS FDSRCS Consultant Oral and Maxillofacial Surgeon

Mr Luke Meleagros BSc MBBS MD FRCS Consultant Surgeon

Mr Meleagros completes around 6-10 expert reports per month, the majority in medical negligence cases and a smaller number of personal injury cases. He has reported extensively on cases involving abdominal laparoscopy surgery and hernia surgery.

T: 0208 527 0977 E: L.Meleagros@btinternet.com Sec: jawdobson@gmail.com

Professor Panayiotis Kyzas

FRCS(OMFS) PhD MBBS BDS FST GDL Consultant OMFS Head & Neck Surgeon Professor Panayiotis Kyzas is a Consultant OMFS Head and Neck Surgeon who specialises in major oncological head and neck cancer surgery. Professor Kyzas accepts cases relating to facial trauma, oral surgery, facial cosmetic surgery, TMJ disorder and facial skin cancer surgery. He can take instructions on behalf of either claimant or defendant or as a Single Joint Expert.

T: 07505 402640 E: kyzasp@icloud.com

Dr Ian C Perry

MBBS MFOM DAvMED(Lond) CFIOSH FCIM MAE Consultant in Occupational Medicine Clinical negligence and personal injury cases on behalf of claimant, defendant or as a Single Joint Expert. Specialist areas of expertise include work related accidents and injuries – most notably in the aviation industry – and those due to long term exposure to chemicals, noise and vibration.

T: 07836 664670 E: ian@ianperry.com W: www.ianperry.com

Mr Thomas Wood MSc MPhil CUBS

Data Science Consultant

Mr Hensher’s subspeciality interests include dental implantology, facial injury and temporomandibular joint replacement. He prepares over 50 reports yearly including negligence and criminal cases.

Mr Thomas Wood is a CUBS-accredited Expert Witness, certified for civil litigation. He also offers due diligence services for acquisitions of technology companies using AI. • Natural language processing (NLP) • Machine learning • Data science • Artificial intelligence (AI)

E: jackiesorrell0101@gmail.com M: 07947445414 E: roberthensher@gmail.com M: 07836540457

T: 020 3488 5740 E: thomas@fastdatascience.com W: fastdatascience.com

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www.yourexpertwitness.co.uk

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 D & HB Associates Ltd Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

Experts in Road Traffic Offences • Accident investigation and reconstruction • Tachograph analysis • Stolen vehicle examination and identification • Statement Taking

Andrew F Acquier BA FRICS

Dr Lars Davidsson MRCPsych MEWI

www.abc-translations.co.uk

Chartered Art & Antiques Surveyor Expert witness reports and representation at court for matters involving: • Divorce settlements • Insurance valuation disputes • Arts litigation • Contentious Probate

www.dandhb.com

Consultant Psychiatrist and Accredited Mediator Reports within most areas of general adult psychiatry.

Specialist in PTSD, anxiety disorders & mood disorders.

www.andrewacquier.co.uk

www.angloeuropeanclinic.co.uk

Salam Alaswad LLM PGDip BSc

Chris Dawson MS FRCS LLDip

• Financial derivatives • Contracts for Difference (CFD) • Forex fraud • 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

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 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

David Berry PhD FRC Path MFSSoc MRSC Independent Toxicology Consultant Specialist in Clinical and Forensic Toxicology with particular emphasis on drugs (both illicit and therapeutic) and alcohol.

Mr Mark Duxbury MA (Oxon) DM FRCSEd (Gen Surg)

www.toxicologyservices.co.uk

www.markduxbury.info/medicolegal

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 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.

Consultant Hepatobiliary, Pancreatic & General Surgeon • General & emergency surgery • Hernia surgery • Liver & pancreatic surgery • Gallbladder & biliary surgery • Laparoscopic surgery • Hepatobiliary surgery

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 • Industry • Pricing • Contractual • Valuations T: 07974 351704 E: roger@rogeremmottassociates.com

www.rogeremmottassociates.com Equip2Speak

Specialists in Brain and Spinal Injury. SLT & AT Consultants • CUBS Certified Experts since 2012/2013 • Accident, Negligence and Criminal Cases • Experienced in High Value Claims • Claimant/Defendant/Joint Instruction

www.urologyconsultant.co.uk

www.equip2speak.co.uk

Professor Paul J Ciclitira MB PhD FRCP MRCS FRCP AGAF

Face Restoration

Professor of Gastroenterology with particular interest in food allergy, including Coeliac disease, peptic ulcer, inflammatory bowel disorder and hepatology.

• Complications of cosmetic eyelid surgery • Brow lift surgery • Ptosis • Non-surgical aesthetics • Orbital diseases • Watery eyes • Thyroid eye disease

www.profpaulciclitira.co.uk

www.facerestoration.com

Clarke Gammon

Mr Faz Page Bsc(Hons) Dip Registered Osteopath

Chartered Surveyors with experience in All Aspects of Property • Residential property values • Asset valuations • Land values and more

Personal injury claims involving back, neck and joint pain as a result of road traffic accidents, work related injuries, occupational injuries and sports injuries.

www.clarkegammon.co.uk

www.pageosteo.co.uk www.yourexpertwitness.co.uk

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FHDI - Kathryn Thorndycraft-Pope

Mr Chris Makin

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

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

www.forensichandwriting.co.uk

www.chrismakin.co.uk

Forensic Collision Investigation & Reconstruction Ltd

Martyn Slyper Consultancy

Specialists in the analysis of road traffic collisions • Collision Reconstruction • Expert Witness • Vehicle Examinations

Expert Witness in Assistive Technology • Personal Injury • Clinical Negligence • Industrial Injury E: ms@martynslyperconsultancy.co.uk

www.FCIR.co.uk Formedecon Ltd

www.martynslyperconsultancy.co.uk

Forensic & Investigative Services to the Legal Profession • All Aspects of Forensic Work Undertaken • LAA and Privately Funded • Free Estimates

Mr Fredrik P Nath FRCS MBChB Consultant Neurosurgeon • Head injury • Spinal injury • Acoustic neuroma • Lumbar and cervical degenerative disease • Musculo-skeletal injury including whiplash

www.Formedecon.com

www.neurosurg.co.uk

Professor Parviz Habibi MB ChB PhD FRCP FRCPCH

Matrix Forensic Accounting & Investigations

Consultant in Paediatric Intensive Care & Respiratory Medicine.

Specialist in treating respiratory conditions and sleep disorders as well as paediatric intensive care.

Matrix Forensics are an independent niche practice of Chartered Certified Accountants providing expert witness and alternative dispute resolution services.

www.childrensrespiratorydoctor.co.uk

matrixforensic.co.uk

Fiona Hotston Moore (FRP Advisory)

Mr Abraham Odumala

Fiona is a partner of FRP’s Forensic Services practice specialising in share and business valuation cases, commercial and tax disputes and professional negligence.

Consultant Orthopaedic Surgeon – Upper Limb Specialist.

Expertise in all upper limb conditions and treatment.

Shoulder, elbow, wristand hand injuries.

www.frpadvisory.com/people/people-profiles/fiona-hotston-moore/

MBBS M.MedSci FWACS FRCS FRCS(Tr & Orth)

www.yorkshire-upperlimb.co.uk

Griffin Forensics eForensics and Data Recovery Experts • CCTV Recovery and Analysis • Computer Media Investigations • Mobile Phone Extraction and Analysis • Forensic Data Recoveries

Dr Shanthi Paramothayan

www.griffinforensics.com

www.paramothayan.com

Mr Kim Hakin FRCS FRCOphth

Dr Stuart Porter Chartered Physiotherapist

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

BSc PhD MBBS LLM MScMedEd FHEA FCCP FRCP

Consultant Respiratory Physician specialising in negligence cases relating to all aspects of respiratory medicine.

PhD MCSP HCPC BSc Hons Grad Dip Phys MLACP PgCAP Cert.MHS SFHEA

Specialist areas of expertise include: • Clinical negligence • Breach of duty • Allegations of inappropriate contact • Assessment of adults and children.

www.kimhakin.com

stuartbporter@aol.com

Haydn Jones MEng DipLaw FIET

Simon Quinton Smith BSc FRICS MI Hort

Data Technologist & Digital Regulation Expert • Injunctive relief • Money laundering • Digital currency theft • Counter funding of terrorism

Expert Witness to the Garden Centre & Horticultural Industry • Rent Reviews • Valuation • Compensation • Lease Renewals • Planning • Tax Issues

Atul Khanna FRCS (Plast)

Professor Christopher Raine MBE

Consultant Plastic, Reconstructive and Hand Surgeon • Hand surgery • Soft tissue injury • Burns management • Medical negligence in cosmetic surgery

Specialist in paediatric and adult otology • Medical negligence • Personal injury cases involving noise induced hearing loss.

E: Haydn.Jones@kroll.com

www.atulkhanna.co.uk/expert-witness/

www.quintonedwards.co.uk

www.profchrisraine.co.uk

Dr Raj Kumar – Dental Expert

Mr Sameer Singh MBBS BSc FRCS Orth

Causation and Liability and Condition and Prognosis Reports • General dentistry • Cosmetic dentistry • Patient consent • Dental implantology • Orthodontics • Facial aesthetics

Consultant Orthopaedic Surgeon • All aspects of trauma – soft tissue and bone injuries • Upper and lower limb disorders and injuries • Whiplash injuries • Expert Witness for defence and claimant

www.dentalexpert.me

Clinic locations – London, Milton Keynes and Bedford

www.orthopaedicexpertwitness.net

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 36 36

www.yourexpertwitness.co.uk

Andrew Smith FPC III CeMAP

Financial Conduct Authority Compliance & Risk Consultant Cases relating to FCA compliance in consumer credit and mortgage lending.

• Mediation • Arbitration • Adjudication • Expert Determination

www.paxen.co.uk

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. William E G Thomas Bsc, MBBS, FRCS, MS Consultant Surgeon specialising in general surgery, hernia surgery, gastrointestinal surgery, hepatobiliary-pancreatic surgery, laparoscopic surgery and endocrine surgery T: 0114 262 0852 E: wegthomas@btinternet.com W: www.wegthomas.com

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 Dr Ian Starke MSc MD FRCP

UK Ophthalmology Experts

Stroke Medicine and Medicine for the Elderly Reports and examinations for clinical negligence and fitness to practise cases in stroke medicine and geriatric medicine

UK Ophthalmology Experts are a team of leading, independent ophthalmology experts covering all aspects of ophthalmology.

www.expertwitnessinstrokes.co.uk

www.ukophthalmologyexperts.co.uk

Mr David Anthony Sykes (Tony Sykes)

Dr David Usher BSc DPhil FCIEHF

Specialist in IT and Telecommunications. Expert witness and consultancy services to lawyers, insurers and loss adjusters.

Experience in international arbitrations and the High Court TCC.

Identification of ergonomic and biomechanical issues underlying injuries. Assessment of tasks, equipment, forces and postures. Civil & Criminal cases undertaken.

Target Psychology Ltd

DR S V MEDICALS (Mr Sen Venkat)

BSc CEng CITP MBCS MIET FAE MEWI

www.rocksideconsultants.co.uk

• Public & Private Law Proceedings • Pre-Proceedings • Immigration Proceedings • Criminal Proceedings • Court of Protection Proceedings • Personal Injury and Clinical Negligence

www.interactionofbath.com MSc Ortho (London) FRCS Consultant Orthopaedic Surgeon

• Whiplash injuries • General trauma • Sports injuries • Clinical negligence work • Joint replacement surgery of hip and knee • Hand, shoulder, elbow and wrist injury

www.targetpsychology.co.uk

www.drsvmedicals.co.uk

Myles J O Taylor BA(Oxon) PhD FRCOG

WOODEXPERTS

www.mylestaylor.co.uk

www.woodexperts.com

Expert witness specialising in: • General obstetrics & gynaecology • Fetal Medicine • Multiple pregnancy – including twin to twin transfusion syndrome, intrapartum care and general gynaecology.

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

Specialist Timber Consultancy and Training since 1991 • Site visits & investigations • Structural surveys • Desktop analysis & review of documents • Specialist reports • Species identification

Ms Leyla Ziyal MPhil AFBPsS CPsychol HCPC Registered clinical Neuropsychologist • Neuropsychological assessment and rehabilitation • Depression • Occupational stress • PTSD • Anxiety

www.accentpsychology.co.uk

www.yourexpertwitness.co.uk

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MEDICAL NOTES [THE NUMEROUS BODIES representing surgeons, as well as the overarching Royal College of Surgeons, have been unanimous in their condemnation of the appalling picture that has emerged of sexual misconduct in the NHS. It seems inconceivable that such behaviour can exist among a workforce that is highly qualified and dedicated to the public good: that it goes on in the context of a healthcare establishment – even in the operating theatre – beggars belief. It is to be hoped that those exhibiting such behaviour and committing what are crimes can be rooted out.

• Being subjected to abuse and assault only adds to the stress and mental fatigue of those working at the ‘coal face’ of healthcare. It should come as no surprise, therefore, that the mental health of nurses is suffering.

It is particularly worrying that the number of nurses calling an advice line and revealing that they have had suicidal thoughts has nearly doubled. The RCN has called it a ‘frightening wake-up call’. The NHS must take its responsibility for the welfare of its employees seriously if we are to have any kind of healthcare system at all.

• The government’s response to the staffing crisis in the NHS has been to encourage engagement of more associates: people who are not trained to the same level as their qualified counterparts but who carry out some tasks within the healthcare setting.

That in itself is not problematical, but it doesn’t take a genius to predict that a cash-strapped management will soon see the attraction of substituting relatively low-paid workers for the real thing. Now, doctors have called for the recruitment of associates to be suspended pending a thorough review of their regulation and defining what their role is. GPs in particular are worried that people are being seen by associates and come away with the impression they have seen a GP. • Getting to see anyone these days is a cause for celebration. The press has been full of reports of long waiting times and the resulting harm – sometimes even resulting in patients dying while waiting for an operation that could have saved them.

But even the official waiting time figures do not tell the whole story. They only show the time elapsing from referral to first appointment with a specialist: what happens after that, when it comes to follow-up appointments, is another matter altogether. It has been dubbed the ‘hidden waitlist’ and paints an even more depressing story.

The speciality that is experiencing the worst effect of this hidden waitlist is ophthalmology. That is particularly unfortunate, as eye conditions are especially prone to deterioration if not caught early.

• If capital investment in the NHS is not ratcheted up, by the time some people get their appointment there will be no hospital to attend, or no equipment to carry out the investigation. A report from the NHS Confederation, which represents the many organisations providing NHS services, has warned that a doubling of capital investment is needed to bring the system back into full working order. The report puts into perspective the fiction of all those ‘new’ hospitals.

• With all the decay, dysfunction and underfunding in the NHS, it is a miracle anything is achieved in the healthcare field in this country. But we are constantly able to report on important breakthroughs across the board. This issue is no exception. In a number of cases, patients suffered heart attacks after damage to the heart muscle was missed following treatment for other heart conditions. An early blood test to detect the protein troponin can be used to detect the damage and prevent future, possibly-fatal events.

Those involved in all the groundbreaking research going on in the UK deserve all our plaudits. q

www.yourexpertwitness.co.uk

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DOCTORS DEMAND A PAUSE IN ASSOCIATE RECRUITMENT [

THE BMA has called for an immediate halt to the recruitment of medical associate professionals (MAPs) in the UK, including physician associates (PAs) and anaesthesia associates (AAs).

Doctors from across the UK who make up the BMA’s UK Council have passed a motion which calls for the moratorium on the grounds of patient safety. They want the pause to last until the government and NHS put guarantees in place to make sure that MAPs are properly regulated and supervised. The move follows a number of recent cases in which patients have not always known they were being treated by a physician associate and have come to harm.

Professor Phil Banfield, BMA chair of council, said: “Doctors across the UK are getting more and more worried about the relentless expansion of the medical associate professions, brought into sharp focus by terrible cases of patients suffering serious harm after getting the wrong care from MAPs. Now is the time for the government to listen before it is too late. We are clear: until there is clarity and material assurances about the role of MAPs, they should not be recruited in the NHS. “We have always been clear that MAPs can play an important part in NHS teams and doctors will continue to value, respect and support individual staff they work with. But MAPs’ roles and responsibilities are not clearly defined. We are seeing increased instances of MAPs encroaching on the role of doctors. They are not doctors, do not have a medical degree and do not have the extensive training and depth of knowledge that doctors do. As doctors, we are worried that patients and public do not understand what this could mean in respect of the level of experience and expertise in care they receive.

“The General Medical Council (GMC) is the exclusive regulator of doctors in the UK. Adding staff who are not doctors and do not have a medical degree to the GMC register brings into question the competence and qualification of the whole medical profession. The government may view this as a price worth paying for a shortcut to solving the workforce crisis they have presided over. We know

otherwise. GMC regulation of MAPs will only add to the confusion and uncertainty that patients face.”

The call followed a similar motion passed by the BMA’s General Practitioner Committee (GPC) expressing concerns over the increasing trend of physician associates doing the work of GPs. Dr Katie Bramall-Stainer, chair of GPC England at the BMA, said: "The BMA recognises the vital role that multidisciplinary teams play in the NHS. In general practice, patients have long benefited from having access to a wide variety of healthcare professionals that can input into their care, from physiotherapists to diabetes nurses.

“However, recently we have seen some examples in the media that suggest there is a potential blurring of the line between doctors and nonmedically qualified professionals, leading patients to think they’ve seen a GP or other medically-qualified team member – when they haven’t.

“GPs are expert medical generalists with the experience and medical knowledge to diagnose, treat and manage multiple and complex conditions. PAs are not doctors; they are not regulated and cannot prescribe. At best this is confusing – at worst it can threaten patient safety.

“This distinction must be protected: PAs cannot be used as a substitute for GPs, or in place of a GP when supervising GPs in training.” q

CHANGES TO MEDICAL REPORTING SLATED BY PI LAWYERS [PROPOSALS TO CHANGE the way medical reports are sourced

and disclosed in road traffic injury claims would be a ‘backwards step’ for the process, the Association of Personal Injury Lawyers says.

APIL has responded to a Ministry of Justice consultation Revisions to the Medical Reporting Process for Road Traffic Accident Claims.

The campaign group says proposals in the consultation would lead to delays to injured people getting the compensation they need.

The MoJ suggests that medical reports should be uploaded to the

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Official Injury Claim (OIC) portal as soon as they have been completed by the medical expert.

“Forcing premature disclosure of medical reports by getting experts to upload them to the OIC without due consideration and fact checking is a dangerous proposal which would ultimately erode injured people’s rights,” said APIL secretary Brett Dixon. “It also causes the risk of significant satellite litigation as it does not take account of the privileged nature of the report in this context.

“A claimant is entitled to take time to fact-check or even consider whether they want to rely on a report. They may also want to wait for a prognosis or finalise other evidence.”

APIL is also opposed to the proposal that claimants must wait for the at-fault compensator to confirm decisions on liability and causation before they can instruct a medical expert.

“Waiting for confirmation would lead to significant delays,” said Brett Dixon. “The key issue is not when the instruction occurs, but when the expert's report is actually obtained. It is counterproductive to aim to address delays in the OIC by proposing something that could further impede the process.

“The proposals fail to acknowledge that the vast majority of OIC users have legal representation. For the process to work it must reflect the needs of the majority.

“The majority of users in this system are represented and changing the process to reflect the minority unrepresented journey is not wise.

Changing this will be to the detriment of injured people who must be at the centre of any decisions.” q

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SURGEONS’ BODY REACTS TO SURVIVING IN SCRUBS REPORT [

PROFESSOR VIVIEN LEES, vice president of the Royal College of Surgeons of England, and Ms Tamzin Cuming, chair of its Women in Surgery Forum and co-author of the Working Party on Sexual Misconduct in Surgery report, have issued a joint response to the publication of Surviving Healthcare: Sexism and Sexual Violence in the Healthcare Workforce by campaigning group Surviving in Scrubs.

They said: “The findings and personal testimonies in this report are deeply disturbing and further strengthen the accounts given in the Working Party on Sexual Misconduct in Surgery’s recent report, Breaking the Silence: Addressing Sexual Misconduct in Healthcare.

The report by Surviving in Scrubs is an analysis of 150 survivor stories submitted to its website since its launch in 2022. It details findings on the incidents, factors and challenges unique to healthcare

LAW FIRMS NEGLIGENCE TEAM REPEAT AWARDS SUCCESS [FOR THE SECOND YEAR RUNNING Anthony Gold Solicitors

have scooped the prestigious Clinical Negligence Team of the Year award at the Personal Injury Awards 2023.

The awards, presented by Claims Media in association with Blume, provide a unique opportunity to highlight and celebrate the excellence of individuals and organisations working in the personal injury and medical claims sector. Their aim is to identify high standards of practice and inspire others by recognising the achievements of the sector’s finest.

This year’s awards took place on 23 November 2023 at the Hilton Deansgate in Manchester and were hosted by former doctor, now comedian and Chaser Paul Sinha.

The Clinical Negligence Team of the Year category is open to law firms and teams working on clinical negligence cases and is judged by an independent panel of experts.

The judges said they were impressed with the way the team at Anthony Gold Solicitors were able to demonstrate how their expertise in complex cases has consistently achieved high-value settlements for their clients.

Four of the firm’s partners have medical backgrounds: two are qualified doctors, one a former psychiatric nurse and one is a former nurse. The cases they handle often involve numerous complex medical specialties such as orthopaedics, cardiology, hepatology and endocrinology.

In the wider community they are active members of Action against Medical Accidents (AvMA) and the Association of Personal Injury Lawyers (APIL). One of the partners is an accredited member of the AvMA specialist legal panel and two are accredited specialists on the Law Society’s clinical negligence panel.

Mike Benner, chair of the judging panel and chief executive of APIL, commented: “The quality and number of submissions was very high and it was, for me, an inspiring and enlightening experience to read the entries.”

Jackie Spinks, head of Anthony Gold’s injury and medical claims team, said: “I’m delighted that the clinical negligence team have, once again, been recognised for their dedication and commitment to put the client at the heart of all they do.”

Last year, in addition to the Clinical Negligence Team of the Year category, partner Jenny Kennedy won Catastrophic Injury Lawyer of the Year. q

that permit sexism and sexual violence in the healthcare workforce.

The report contains recommendations to healthcare organisations to better support survivors and end those behaviours.

The report finds that there is systematic and institutional sexism and sexual violence within healthcare in the healthcare workforce, stating: “The stories describe the significant power imbalance between powerful senior male staff perpetrating sexual violence to junior female staff members in healthcare, in a normalised culture of sexism, entitlement, and the devaluing of women staff.”

Those subjected to the abuse are nurses, doctors, paramedics, psychologists, administrators, dentists, carers, optometrists, pharmacists, managers, healthcare assistants and healthcare students.

Professor Lees and Ms Cuming added: “There is absolutely no place in our NHS for these abhorrent behaviours. NHS trusts need to take a long, hard look at whether their policies and procedures for sexual misconduct are fit for purpose, as do regulating bodies.

It is essential that staff members feel empowered to report instances of misconduct without fear of reprisal or negative impact on their career progression.

“The Royal College of Surgeons of England is taking this issue seriously. We are supporting calls for a National Implementation Panel to oversee progress in tackling these problems by organisations.

Additionally, we would like to see reform of reporting and investigation processes of sexual misconduct in healthcare, to improve safety and confidence in raising concerns and to ensure investigations are external, independent and fit for purpose.” q

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NHS LEADERS CALL FOR DOUBLING OF CAPITAL SPENDING ON CRUMBLING ESTATE [

THE NHS won't be able to deliver faster and more productive patient care unless capital budgets are nearly doubled to at least £14.1bn, according to a new analysis published by the NHS Confederation on 28 November.

The NHS leaders say the next government must boost capital funding by an extra £6.4bn in all three years of the next Spending Review to help the NHS address its £10.2bn maintenance backlog, refurbish dilapidated buildings, upgrade equipment and turbocharge staff productivity. That would take annual NHS capital spending to £14.1bn per year, compared to the current level of £7.7bn.

The consequence otherwise will be long waiting lists and delayed care for patients.

Local NHS leaders have told the NHS Confederation that investment in capital spending is their priority for any additional spending on the NHS after the next general election, and that underinvestment has been the number one issue holding back their progress towards greater productivity.

New analysis from the NHS Confederation sets out the impact that low levels of capital investment have had over the last decade, including the effect on productivity, and makes the case for greater funding if the NHS is to meet stretching productivity targets of 2% by 2030.

Yet capital budgets continue to be raided, the confederation says, with the latest raid being used to plug the rising deficits in the day-to-day NHS budget caused by strike action and other cost pressures. That was outlined in NHS England’s letter to NHS chief executives on 8 November, following the outcome of negotiations between The Treasury and Department of Health and Social Care ahead of the Autumn Statement.

Matthew Taylor, chief executive of the NHS Confederation, said: “Some of our members have parts of their estate that are barely fit

Image – Jonathan Hutchins

for the 19th century, let alone the 21st, so any future Secretary of State for Health and Social Care must make the physical and digital condition of the NHS a priority if the health service is to reduce backlogs and get productivity levels to where the government wants them to be.

“Lack of capital across different care settings, covering digital and physical infrastructure and mental and physical health, is clearly not just leading to missed opportunities to improve productivity, but actively undermining it and causing patient safety issues. Health leaders across England have endless ideas about how capital funding could drive large productivity increases.

“Equipping staff with the right tools and allowing them to operate in safe, modern, optimised environments will improve efficiency – meaning that an increase to the capital budget will help limit the need for growth in revenue spend, relieve pressure on wider NHS finances and services and put the NHS on the path to longer-term financial sustainability.

“This will require a significant increase to

the NHS capital budget to make up for years of under-resourcing and repeated raids on capital that has left much of the estate broken.

Based on the assessment of health leaders, this will need to be an increase of £6.4bn to take the capital budget to £14.1bn for each year of the next Spending Review in order to fully address the repairs backlog and realise some of the innovative transformation projects which have previously fallen by the wayside.

The next government must grasp the nettle.”

The report, Investing to save: The capital requirement for a more sustainable NHS in England, looks at where the NHS is using capital investment to drive productivity and makes the case for greater funding if the NHS is to meet its stretching productivity target by 2030.

It also outlines examples of capital projects which have been transformational for patient care and productivity, along with numerous case studies of proposed cost-effective, forward-thinking developments which have been delayed, hindered or scrapped due to the lack of initial funding needed to get them off the ground. q

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EMERGENCY MEDICINE REPORT SEEKS TO AVOID REPEATS OF ’24 HOURS IN A&E’ [A JOINT REPORT compiled by the Royal College of Emergency

Medicine (RCEM) has highlighted the lessons that must be learned from the emergency care crisis last winter, concluding that ‘too many patients are in the wrong place for their needs’.

The report, Right Place, Right Care: Learning the Lessons from the UK Crisis in Urgent and Emergency Care in 2022, published on 21 November, provides cases studies and analysis of last year’s crisis in emergency care.

It includes contributions from 16 other leading healthcare organisations, including eight other Royal Medical Colleges, the British Geriatrics Society, the Society for Acute Medicine and the charity Diabetes UK. It makes a series of recommendations, including: • Developing and promoting strategies to improve the retention of • healthcare workers.

• Reducing the bed occupancy of acute and psychiatric hospitals to 85%.

• Increasing the number of staffed beds in appropriate specialties.

The recommendations are aimed at enabling the next government to work with the health service to improve care, with the principles of rebuilding public confidence, improving accountability, seeking innovation and moving away from short-term initiatives and funding streams.

RCEM president Dr Adrian Boyle commented: “Last year was a ‘ground zero’ moment for emergency care. Too many patients waited for too long in overcrowded A&Es up and down the country: 24 hours in A&E became everyday reality, and little has improved since.

“As a group of experts we were committed to learning the lessons from this incredibly challenging time, which is why we have written this report.

“It contains expert analysis as well as deeply moving patient testimonies and we at RCEM are deeply grateful to everyone from the organisations and specialties who have contributed their time and expertise to help make this such a comprehensive report.

“Compiling it has been a sobering experience and it brings into sharp focus many of the serious issues facing the health service. These problems are not insurmountable, but they require political will, decisive leadership and long-term planning and investment.

“We are heading into what will likely be another extremely challenging winter. Our recommendations are clear and should be actioned. It is time for meaningful change.”

Dr Camilla Kingdon, president of the Royal College of Paediatrics and Child Health, which also contributed to the report, said: “Child health is in a crisis, and we can see it first hand in our paediatric emergency care.

“Last winter was one of the toughest on record for paediatrics, and with little progress having been made this year it is easy to feel discouraged. But there are clear policy solutions to this problem.

“The joint recommendations within this report are both comprehensive and achievable. We urge politicians and policy makers to act now in order to safeguard our children and our NHS.” Professor Adam Gordon, president of the British Geriatrics Society, added: “We welcome this new report from RCEM and we are pleased to have had the opportunity to feed into it. The report is a stark reminder of the challenges facing the NHS and the impact that pressures on the system have on all patients, especially older people.

“We must take action now to ensure that older people presenting to emergency care services this winter have better experiences than last year.” q

PODCAST DISCUSSES NEGLIGENCE CLAIMS IN A&E [NHS RESOLUTION has launched a new podcast episode,

Learning from emergency department claims, bringing together guests working in emergency medicine to discuss clinical negligence claims related to the emergency department, and how insights from claims data can be used to help improve safety.

The total value of clinical claims associated with emergency medicine was nearly £700m in 2022/23, making them the second highest total value of claims by speciality.

The discussion looks at the key themes and recommendations from three reports released by NHS Resolution in 2022 on emergency department claims. Those reports aimed to provide clinical staff working in emergency departments with national learning from what NHS Resolution sees in claims across emergency medicine in England.

The group also speaks about how teams can use local claims data from NHS Resolution and operational performance data from GIRFT (Getting It Right First Time) to inform safer patient care. q www.yourexpertwitness.co.uk

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WHAT ARE THE COMPLICATIONS AND FAILURES IN AIRWAY MANAGEMENT?

By Dr Martin Stotz, consultant in intensive care and anaesthesia, and Airway Lead at St Mary's Hospital, London.

[WHILE COMPLICATIONS of airway management are surprisingly

common, most are minor in nature. Major complications are rare, and although they have the potential to be life-threatening they tend to result in morbidity rather than mortality. In the UK, airway management complications during anaesthesia occur at a rate of about 46 per million patients, or one in every 22,000 anaesthetics administered.

However, it is possible that airway events are under reported, and it has been estimated that the true rate could be up to four times higher than that figure. In addition, airway management away from the operating theatre carries a considerably higher risk, with the incidence of serious airway events – leading to death or brain damage – estimated to be approximately 30 times higher in the emergency department (ED) and 60 times higher in the intensive care unit (ICU) settings. These differences are due to many factors, including the case mix and working environment. In addition, the higher number of cases presenting out-of-hours in the ED and ICU means that staff with advanced airway skills may not always be available.

A number of risk factors contribute to airway management complications, many of which are well-documented. It is also likely that many could potentially be avoided. Perhaps the most important of them is the presence of a ‘difficult airway’. This term has traditionally been used to describe situations where anatomic characteristics make visualisation of the vocal cords, and thus placement of the tracheal tube, challenging. As difficult intubations are an independent predictor of increased mortality, it is therefore important that any possible issues are accounted for in the intubation plan.

Patient factors also influence the likelihood and severity of airway management complications. While it is known that some conditions, such as diabetes mellitus, can predispose patients to major complications, it is not fully understood why some patients develop long-term sequelae while others subjected to the same mechanism of injury do not. The influence of age and gender is controversial, with some studies reporting that older patients and women suffer higher rates of complications, and others finding no increase.

However, obesity does appear to be a major contributor to airway management complications and is likely to become more of an issue in the future as obesity rates in the general population continue to climb.

Obese patients are twice as likely to suffer a serious complication as patients who are not obese, and for those whose body mass index is above 40 the risk may be increased up to four-fold. That may be due to distortion of the oropharynx, limited neck extension and a higher incidence of comorbidities.

Additionally, obese patients have a lower tolerance for apnoea and tissue hypoxia, so if those events should occur, their consequences may be more severe. Despite that, airway assessment in overweight patients is often poor. Risk-reducing techniques, such as awake fibreoptic intubation, are rarely used, even in extreme cases, and the choice of anaesthetic technique is often inappropriate for that group of patients.

Aspiration of the gastric contents is a relatively common complication of airway management, and one that frequently leads to mortality: it is responsible for around 50% of the incidences of patient death and brain damage during anaesthesia, although the figure does appear to be falling. Aspiration occurs most often during induction or airway instrumentation and the majority of patients have identifiable

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risk factors. Poor planning, including a failure to properly assess the patient’s aspiration risk, is a factor in many cases.

Neglecting to use accepted precautions in patients deemed to be at higher risk, such as tracheal intubation or rapid sequence induction in patients with intestinal obstruction, is also a frequent contributing factor. Skilled insertion and the use of a supraglottic airway device are paramount in reducing the risk of aspiration.

Unlike aspiration, unrecognised oesophageal intubation is overall very rare and is sometimes considered a historical problem, although recent reports confirm that it is not the case. Oesophageal intubation can easily be missed, particularly when capnography – a procedure used to confirm ventilation of the lungs – is not used, and confirmation of the correct placement of the breathing tube is via another technique, such as auscultation. Unfortunately, that is often the case, particularly outside of the operating theatre, where the absence of capnography may be a contributory factor in around 80% of events leading to death or brain damage in the patient.

Often, the misplacement is not diagnosed until cardiovascular collapse has occurred. Even when capnography is used, incorrect interpretation can lead to misdiagnosis. Therefore, clinicians should always assume that a flat capnography trace is due to oesophageal intubation until that possibility has been actively excluded. It is no surprise that capnography is now a mandatory monitoring requirement for all anaesthetic and airway areas.

Airway management failure is important because it often precedes major complications. Furthermore, failures are often cumulative: when one procedure fails, the risk of difficulty or failure with subsequently used procedures is much higher. That is not entirely surprising, given the importance of patient factors in the risk of complications. However, it does mean that clinicians must be aware that any rescue techniques used when the primary technique fails are also more likely to fail and that must be taken account of when planning the procedure.

Tracheal intubation failure is heavily dependent on the clinical setting, with the incidence ranging from one case in every 2,000 in elective surgery up to one case in every 100 in the emergency department.

Risk factors include a previous history of failed or difficult intubation, but around half of all cases are unexpected. That is significant, because tracheal intubation is the most frequently used technique for patients who are already deemed high-risk and it is also the commonest rescue technique when another form of airway management has failed.

Furthermore, the consequences of failed intubation can be severe and include oxygen desaturation, hypertension, admission to ICU and hypoxia and its sequelae.

Airway trauma or injury following endotracheal intubation is relatively common, with an incidence of 0.5-7%. Problems may occur at the initiation of intubation or arise later, as a result of prolonged intubation, and some may occur in the absence of direct tissue trauma, as a result of tissue-endotracheal tube interactions. The larynx, which suffers some degree of trauma in up to 97% of intubations, is the most frequently injured anatomical site, followed by the pharynx and the oesophagus. Injury to the larynx and jaw is more often associated with non-difficult intubations, while oesophageal or tracheal trauma is more likely to arise during a difficult intubation.

Following extubation, patients complain of minor symptoms, such as sore throat, hoarseness and difficulty in swallowing. In the majority of

cases those symptoms resolve after 24 hours; but where they persist or progress, the presence of more serious conditions, such as traumatic lacerations and haematomas, should be investigated. Not only do those types of injuries take longer to heal, they can also be associated with poor outcomes and lead to prolonged problems with speech and swallowing if scarring occurs. Long-term consequences also often follow laryngo-tracheal stenosis and structural changes to the trachea (tracheomalacia), both of which are associated with prolonged intubation, and can include respiratory failure. In severe cases a tracheostomy may be required to provide adequate ventilation.

Dental damage during intubation is also common, occurring in about one in every 1,000 anaesthetics involving tracheal intubation, and may often lead to litigation. However, the outcome is unlikely to be severe and thus the majority of claims are of low value. Damage ranges from chipping of the teeth to loosening or even complete dislodgement. The upper incisors are the most commonly damaged, and around two-thirds of cases involve teeth which are already diseased or have previously been repaired.

In conclusion, airway management during anaesthesia is generally a very safe procedure. Complications are more likely in patients with difficult airways, but as that condition is relatively rare the majority of issues occur in normal airways. Many risk factors for airways complications are identifiable and avoidable. By carefully evaluating them, clinicians could potentially reduce the risks for complications still further, thus preventing adverse events and leading to better outcomes for patients. q • Dr Stotz is the Airway Lead at St Mary's Hospital, London – part of Imperial College NHS Trust – where he leads a multi-disciplinary team.

St Mary's is a major trauma centre and a tertiary vascular referral centre.

Dr Stotz is also an experienced expert witness providing expert opinion on most aspects of anaesthesia, the care and management of patients pre, during and post-operatively and the clinical management of critically ill patients.

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CLINICS AIM TO HELP PREVENT NIHL AMONG MUSICIANS [BELFAST WAS THE VENUE for the latest Musicians’ Hearing Health Scheme clinic in November.

The Musicians’ Hearing Health Scheme was launched in 2016 by Help Musicians, in partnership with the Musicians’ Union (MU). The scheme began when MU officials and Help Musicians saw the importance of hearing health and the need to make its provision accessible.

The national support scheme aims to make hearing protection an affordable and essential part of a musician’s toolkit.

In the past two years around 800 MU members from all over the UK have accessed the Musicians’ Hearing Health Scheme. The scheme has permanent clinics in London and Manchester and there is a rolling programme of regional clinics.

Musicians are affected by noise levels as workers in any industry are, and their hearing is crucial for the job they do.

That presents interesting challenges for musicians and the MU has sought to assist members in dealing with them.

According to the union: “Noise-induced hearing loss has distinguishing characteristic features that are detectable after a hearing test. There is a range of hearing that is described by doctors as ‘within normal limits’. The fact that you may have worked in noise does not necessarily mean that you have any hearing problems, or that those problems have been caused by work.

“Noise-induced hearing loss can be prevented if you take the appropriate measures. Through the Musicians’ Union, you can get very affordable access to specialist audiologists and bespoke hearing protection.” q

AUDIOLOGY SERVICES COME UNDER FIRE [

RECOMMENDATIONS TO IMPROVE audiology services in Scotland have been made to the Scottish Government, health boards and third sector partners. The Independent Review of Audiology Services in Scotland sets out 55 recommendations for improving governance and structure, education and leadership.

Professor Jacqueline Taylor MBE conducted the review for ministers following failures identified in audiology treatment for children.

Professor Taylor said: “The wide-ranging recommendations in this report provide the foundation for improvements which will ensure high-quality, joined-up, patient-centred services. Audiology staff are working incredibly hard, often in challenging circumstances and during the course of the review process we have seen many examples of good practice.

“We have also identified a range of issues which need to be resolved.

I am extremely grateful to the patients, parents, audiology staff and stakeholders who helped to shape this review. We have listened carefully, and I believe that by working together, we have a real opportunity to develop excellent services across Scotland.

Following the publication of the report, Mark Ballard, head of policy and influencing for Scotland at the National Deaf Children’s Society, said: “This report paints a deeply concerning picture of the state of audiology in Scotland. Parents who rely on audiology services for their children will be shocked to learn there has been an absence of national leadership, strategic planning and workforce planning at audiology departments across Scotland and that there has been no quality assurance of services in recent years.”

The most urgent recommendations in the review are around the quality of auditory brainstem response (ABR) testing, which is carried out to identify deafness in very young children.

Mr Ballard said: “It is alarming that issues were identified in the quality of ABR testing at every single health board across Scotland.”

The publication of the report follows a similarly damning report in June regarding NHS audiology services in England. The National Deaf Children’s Society warned then that ‘hundreds, if not thousands’ of children across England may have been left permanently damaged.

According to medical negligence specialist Maria Repanos of Hudgell Solicitors: “Failure to diagnose and treat hearing loss early can significantly affect a child’s speech and language development permanently.

“Audiology experts believe there is an on-going national failure, dating back to 2013, when a decision was made by the government to cease reviews of hospital performance.”

NHS England subsequently ordered all hospitals to carry out an urgent review of their services. q

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THE ENIGMA OF LIMB ISCHAEMIA WITHOUT BLOCKED ARTERIES: IS THERE BLAME?

By Philip Coleridge Smith DM MA BCh FRCS Consultant Vascular Surgeon, Medical Director of the British Vein Institute and Emeritus Reader in Surgery at UCL Medical School

[ I HAVE BEEN ASKED to advise in

cases where gangrene of the limb occurred despite normal function being present in the peripheral arteries. The explanation is that the circulation collapsed and the claimants were supported by modern ITU care, which permitted preservation of blood flow to the heart, lungs, liver and kidneys; but that was at the expense of blood flow to the limbs. The severity of the loss of peripheral blood flow was so severe that amputation of toes, fingers or limbs was required.

Septicaemia may cause limb ischaemia

Sepsis, or septicaemia, is a condition on which there has been considerable focus in recent years. In this condition severe illness results from infection which may arise in the lungs, kidney or bile ducts in the liver. Other sources include meningitis and intra-abdominal infection. The clinical presentation may be insidious malaise in a patient who looks sick.

The signs of infection have to be carefully sought in order to make the correct diagnosis.

Ischaemia of toes following an episode of sepsis There has been considerable emphasis on the subject reflected in training for medical and patency of peripheral arteries is essential to detect blocked major nursing staff. arteries. These can be reopened by standard vascular surgery The clinical features include a confusional state, low blood techniques. Anticoagulant treatment may be appropriate, depending pressure, high heart rate, high respiratory rate, increasing oxygen on the function of the platelets and clotting factors in the blood. The requirement and a rash or mottled look to the skin. Left untreated or skin of the peripheries should be carefully protected by off-loading neglected, this condition leads to considerable mortality. Appropriate devices to avoid pressure ulcers developing. treatments include oxygen administration, intravenous fluids and antibiotics. Delays in commencing appropriate treatment may lead to Peripheral ischaemia after major haemorrhage collapse, with a high mortality rate.

Peripheral ischaemia may develop after large volume Despite implementing appropriate treatment, some patients may haemorrhage following major injury, complex surgery or as the remain in a poor condition and require management in ITU. The result of obstetric disasters. Large volume blood loss is another cause of the problem is toxins released by the bacteria giving rise to circumstance in which the body’s response is to close down the infection. The circulation of the patient has to be supported by circulation to the limbs to maintain the blood flow to vital organs. the infusion of fluids and with ‘inotropic’ drugs. These increase the Urgent blood and fluid transfusion by medical staff is essential in blood pressure and ensure that blood continues to flow to the major order to maintain the blood flow; however, that may result in large organs at the expense of reducing blood flow to the extremities. volumes of blood being transfused. DIC may arise in that situation, Usually, the limb will tolerate the treatment for a limited period; but again leading to thrombosis in arteries and veins. The response after several days in severely ill patients, peripheral gangrene may of the body to low blood pressure involves reducing blood flow to be the result. the peripheries and to the intestines. The intestines contain many A further complexity in patients with sepsis is that the platelets bacteria which can cause sepsis. These release toxins as they travel and clotting system may become generally activated. That is called through the intestines. disseminated intravascular coagulopathy (DIC). The platelets The toxins inside the intestines do not normally get absorbed become stuck to the inside of blood vessels leading to deposition of with a healthy intestine. The lining of the bowel prevents the toxins thrombus on the wall of arteries and veins. Sometimes thrombosis crossing into the blood as it retrieves nutrients from the food. That blocks major arteries, leading to deterioration of limb ischaemia. mechanism may break down when the intestines are subjected The lack of platelets and clotting factors may lead to life-threatening to greatly reduced blood flow, allowing the toxins to enter the haemorrhage simultaneously with thrombotic occlusion of blood circulation, leading to a similar collapse to that seen in sepsis. vessels. Transfusion with platelets and plasma may be required to I have advised in cases where a range of complications arose treat the problem. from peripheral ischaemia in such cases. Residual problems have A vascular surgeon confronted with the evolution of ischaemic included amputation of limbs and digits. as well as persistent toes or fingers, or more extensive limb ischaemia, may be able to neuropathic pain. offer little other than advice in such a situation. Assessment of the

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Litigation arising from sepsis and haemorrhage cases

As a general statement, once the diagnosis of sepsis or major haemorrhage has been identified, the aftermath has been the management of the collapsed state of the patient by senior clinicians in a competent manner. ITU is usually managed by experienced clinicians who are familiar with the correct treatment for those conditions. The use of inotropic drugs is often the cause of worsening peripheral blood flow, but they are given with the aim of saving life in the full knowledge that peripheral ischaemia may arise. That is a known adverse effect of lifesaving treatment.

Delayed treatment of sepsis or haemorrhage leads to worse outcomes. For that reason much effort has been put into additional training of staff to ensure that deterioration in the condition of patients is detected at an early stage. I recommend careful review of the clinical records in those cases to identify evidence of delayed treatment. Where that is present a claimant may be able to assert that a better outcome would have been achieved with prompt diagnosis and treatment.

As I have already noted, the role of the vascular surgeon is limited in those cases and any treatment is delivered with careful consideration by experienced senior staff. I have not identified a single case where the outcome of peripheral ischaemia arising from sepsis or haemorrhage would have been improved by better vascular surgical care.

In conclusion, in cases where sepsis or major haemorrhage, gangrene of limbs or digits may occur despite normal function being present in the peripheral arteries, the explanation is that the circulation collapsed and the claimants were supported by modern ITU care which permitted preservation of blood flow to the heart, lungs, liver and kidneys but this was at the expense of blood flow to the limbs.

The severity of the loss of peripheral blood flow was so great that amputation of toes, fingers or limbs was required. Expedient treatment of sepsis and major blood loss is required to minimise the likelihood of such complications. Vascular surgeons have a very limited role. q

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PEOPLE WITH FACIAL SCARRING ARE MORE LIKELY TO SUFFER FROM ANXIETY AND DEPRESSION, STUDY REVEALS [

RESEARCHERS FROM SWANSEA UNIVERSITY used health records from over 170,000 people to measure how many people with scars on their face struggle with mental health problems – and what factors make anxiety and depression more or less likely.

The study, Assessing the burden oF Facial scarring and associated mEntal health Conditions to identify patients at greatesT risk – known as AFFECT – was funded by The Scar Free Foundation and Health and Care Research Wales.

The team, led by Professor Iain Whitaker, used an anonymised databank called SAIL as the basis for their analysis. Using health data from Wales, they found 179,079 people with facial scars. Those records were matched by socio-economic status, age of facial scarring and sex to the same number of people without scars.

The GP records of these matched pairs were compared to figure out how many people with facial scars and without facial scars were treated for anxiety and depression. They found that people with facial scars are more likely to suffer from anxiety and depression compared to the wider population.

The research showed that there are some key factors that influence how often people with facial scars experience these common mental health issues: • Anxiety and depression are most prevalent among people whose scars • came from self-harm, assault or traumatic injuries like burns.

• People whose scars came from congenital conditions are the least • likely to be treated for anxiety and depression.

• Women, people with a history of poor mental health and people • experiencing deprivation are also at a higher risk.

Millions of people in the UK live with scars, the Scar Free Foundation points out, but the impact of scarring on our mental health is understudied and often dismissed. The study is one step towards getting people living with facial scarring the support they need to feel happy, healthy and confident, the charity added.

Professor Iain Whitaker said: “I’ve been a plastic surgeon for 20 years and I see a huge number of patients that need to have cancers on their face removed, or who have facial injuries. Every surgery leaves a scar, but currently there is an absence of psychological support for patients.

“It’s important to me as a doctor that I know the repercussions of treatment on my patients beyond the immediate physical effects.

I want to give my patients better information and a better patient experience. I hope this research leads to a more robust system of mental health support for patients with facial scars.”

Dr Jaco Nel, Scar Free ambassador and sepsis survivor, commented: “From my own experience as both a psychiatrist and someone living with scars, I know there's very little psychological support built in to help people with scarring, especially in the early days. I survived sepsis, but the consequences of my illness were lifechanging. I lost both of my legs and several fingers and had extensive scarring to my face.

“Although it was a challenge to adapt to my physical disabilities, I found the psychological scars had, and still have, an enduring effect. I suffered from depression and PTSD. “I felt self-conscious about my facial disfigurement. Your face is what people recognise; it tells how you feel, what you are thinking, who you are as a person. Mine was suddenly foreign, unrecognisable, even ugly. I was aware of staring eyes. Someone once said to me in a restaurant how brave I was to be out and about.

“This study shows how important it is for patients to be offered good psychological support throughout their journey. The illness or event that leads to a facial scar is often fleeting, but our scars will be with us forever.

“I am no longer ashamed of my scars. I use them to tell my story, hoping to help others overcome their struggles with physical and

mental health. But it’s been a long and difficult journey to get to that point. I hope studies like this spur change so that in the future, people living with facial scars can live their lives without shame or anxiety.”

The AFFECT study is just one of the projects funded by The Scar Free Foundation at Swansea University. q

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NUMBER OF COSMETIC TOURISTS NEEDING TREATMENT ON RETURN CONTINUES TO SOAR [ NEW DATA COMPILED by the British

Association of Aesthetic Plastic Surgeons (BAAPS) reveals a growing number of people are returning to the UK after getting cosmetic surgery abroad with complications ranging from wound healing problems to life-threatening sepsis.

The number of people needing hospital treatment increased by 94% in three years, with procedures carried out in Turkey accounting for more than three quarters of those in the past six months alone. In some cases patients have needed intensive care treatment and several emergency operations – mostly on the NHS. BAAPS, which represents aesthetic plastic surgeons in the UK, has collated the UK's first ever database of the number of corrective procedures carried out in the UK after surgery abroad has gone wrong.

Along with the Royal College of Surgeons, BAAPS has also published guidelines for its members to adhere to when advising patients undergoing surgery in a different country from their residence.

Previously, the association has estimated the cost to the NHS for each person is around £15,000 – but it stresses that it varies significantly depending on the type and the extent of treatment needed.

BAAPS president Marc Pacifico said: “We are only scratching the surface of the true number needing treatment on an already-stretched health service with a record-high waiting list.

“BAAPS is in discussions with government departments in the UK and abroad to see if we can develop pathways through which patients can be treated to relieve the burden on the NHS. One of the other worrying things is that some people are returning with muti-resistant bacteria that are hard to treat and may infect other people.”

BAAPS is also in discussion with the Advertising Standards Authority to address the misleading adverts suggesting that having cosmetic surgery in Turkey is no different from a holiday in the sun.

“Nothing could be further from the truth,” said Marc Pacifico. “Medical advice and support for people looking to go abroad

is drowned and dwarfed by the number of paid promotions and glossy advertisements for the cosmetic tourism market itself.”

Several sites also offer prospective patients luxury accommodation before and after cosmetic surgery abroad, while several sell procedures as 'package deals' so customers can undergo more than one operation per visit.

Recently BAAPS and TSPRAS, the Turkish Society of Plastic Reconstructive and Aesthetic Surgeons, came together to draw up some advice and guidance for patients seeking surgery in Turkey. BAAPS has also drawn up guidelines for its own members because it recognises that there will always be patients from different countries who will seek aesthetic medical and surgical treatments abroad – both patients coming to the UK and those from the UK travelling for surgery elsewhere.

The aim of the guidance is to help to protect patients from harm and ensure that they are aware of standards of care both before and after surgery, that they should expect as a minimum. q

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MANAGING SPINAL CORD INJURY PAIN: THE VOICE OF EXPERIENCE Jamie Rhind, client support manager at JMW Solicitors, has lived with a spinal cord injury for more than 25 years. Here he explains what it feels like from his own perspective and that of a client.

[SPINAL CORD INJURY covers a wide spectrum of disability – from

and being open to trying 'alternative' techniques to manage pain are all helpful tips. Keeping your mind distracted seems to be the most complete paralysis and being dependent on a ventilator to breathe at one commonly held belief to combat pain, but that's easier said than done end, to having reduced sensation or slight impact on gait at the other. In when the pain feels inescapable. my experience, there's often an assumption that the higher the level of I do know the feeling of chronic neuropathic pain. For me it's more of injury – ie the more severe the paralysis – the greater the impairment on an uncomfortable, nagging pain than a debilitating one. I don't take any quality of life. It's the obvious impact of spinal cord injury that leads us medication to manage it and find that it's at its worst when my mind's to that conclusion: if someone looks more disabled then it means they inactive and less apparent when I'm busy and focused on other things. I probably are. However, that assumption fails to take into consideration the genuinely feel quite fortunate that this hidden impact of spinal cord injury hidden aspects of living with a spinal cord injury. doesn't inhibit me and my ability to get I met with a client recently who has an on with life in the same way it does for incomplete thoracic spinal cord injury. As others: and I've seen first-hand how well as full upper body movement, the debilitating it can be. incomplete nature of their injury means they During my conversation with our still have movement in their legs and can client, we talked about interests and stand and walk with aids for short distances. discovered a shared love of football and Assessing that person on their level of live music. I asked them how their pain injury, it would be easy to conclude that the felt when they were at a gig or cheering impairment was less than, for example, a on their team from the stands. “Not as C5/6 complete tetraplegic like mine might bad when I'm there,” they replied, “but I be. After all, they have more movement and normally pay for it when I get home.” therefore a greater ability to do physical There is no hard and fast way to day-to-day tasks. deal with chronic pain, and it's unlikely Yet I came away from our meeting with sufferers will ever be free from it. the sense that, despite a higher level of Effective management is possible, paralysis, I was in fact more fortunate requiring a person-centred, holistic to have the injury I have. I came to that a nursing definition of pain approach that includes engagement conclusion following the first-hand account and willingness from the person of the debilitating impact of pain on that experiencing it. person's quality of life.

As a law firm, our future goals in It's widely reported that up to 80% of supporting our clients expand beyond people sustaining a spinal cord injury excellent legal expertise. In being more will experience pain in some form, with aware of the hidden aspects of living with around 50% experiencing neuropathic catastrophic injury that have the greatest pain, caused by damage to the nerves in impact on quality of life, we can be better the spinal cord. Treating that kind of pain equipped to offer helpful insight and is extremely challenging and research on guidance for how to manage them. q the effectiveness of treatments is largely inconclusive.

The first port of call when it comes to treatment of severe neuropathic pain appears to be a combination of drugs, which often come with not insignificant side effects. Other, non-pharmacological techniques for managing chronic pain – such as mindfulness, acupuncture, massage and even having a warm bath – have reported benefits, but the key word in that sentence is 'managing', not 'curing'. If you live with chronic neuropathic pain it's unlikely you'll ever be free from it, so developing a way to manage is key to minimising the impact on quality of life.

When pain isn't managed well, the impact can be devastating.

Alongside the physical effects, mental health often suffers hugely as a result. Pain is debilitating; it wears you out; it prevents you from sleeping and drains away your ability and desire to engage in work or social activities. Without the distractions of work, hobbies or a social life the pain gets worse and becomes the factor that life revolves around.

Identifying the severity, frequency and triggers relating to pain through a pain diary, consulting with a pain specialist to assess treatment options

‘Pain is whatever the experiencing person says it is, existing whenever he/she says it does’

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FOOTBALL FAILING IN HEAD INJURY MANAGEMENT, CHARITY CLAIMS [BRAIN INJURY CHARITY Headway has warned that progress made over the course of the past

10 years to improve the short and long-term health of footballers is at risk of being wasted by the sport’s continued inability to consistently manage in-game head injuries.

The warning came in November after commentators and fans watching Manchester United’s game against Fulham expressed shock and concern that Harry Maguire was kept on the pitch despite showing clear signs of discomfort that seemingly required the intervention of the referee.

“We have come such a long way since Hugo Lloris was labelled a ‘hero’ for overruling club medics to return to the pitch after a clear concussion while playing for Spurs against Everton in 2013,” said Luke Griggs, chief executive of Headway. “That shocking incident was a wake-up call for football. We called it ‘dangerous and irresponsible’ at the time, demanding it be used as a catalyst for change.

“That change has been a slow process, but attitudes have changed. Promises were made, such as the concept of players being immediately removed from play if there is any suspicion of concussion.

An ‘if in doubt, sit it out’ approach was enshrined in a series of concussion protocols, eventually adopted by various footballing bodies.

“But this progress is eroded with every high-profile incident in which the safety first principle is set aside and players are allowed to continue despite showing signs that a concussion could have occurred.

“The incident with Harry Maguire is concerning for a number of reasons.

An opponent’s shoulder strikes the side of his head. Minutes later he goes down on his haunches, showing clear signs of discomfort. After a brief on-pitch assessment – again highlighting the nonsensical lack of temporary concussion substitutes in football – he was allowed to continue.

“The sight of the referee then having to intervene in the second half when the player continued to look in difficulty was deeply concerning. But again, after another brief assessment with medics, he was again allowed to play on.

“We are not privy to the discussions with his medical team, nor should their professionalism be questioned. This is an issue with the very culture of football and its stubborn refusal to put players’ health above all else – including the result of a game.

“Every time the ‘if in doubt, sit it out’ principle is seen to be ignored in elite-level football, our chances of educating younger players and better protecting future generations from short and longterm brain injury is diminished. Temporary concussion substitutions would immediately help return some credibility to the process, but an evolution of attitude is urgently needed.” q

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CONTINUOUS ASSESSMENT IS KEY TO REHAB

By Lisa Humberstone of Equip2Speak

[

ALL CLINICIANS KNOW that assessment is an essential element of the intervention process in rehabilitation. Just how important it is to the litigation process is probably less well appreciated. From day one of my time on a private brain injury rehab unit, it was made very clear that if I was not able to show progress then the unit would lose the funding.

Naturally, that focused the mind; but then, achieving the most for the client is what rehab is about in the first place. But progress also needs to be achieved in a timely manner, allowing the client to regain skills as quickly as they are able. There is a clear consequence to the provision, in that faster progress will see an earlier decline in the therapy requirement needed, putting an end to the profitable period of the case for the treating clinician.

That can create a clear conflict for the clinician, as their reward for doing it right is a loss of earnings. With there being more therapists in private practice, hence fewer cases to go round, alternative work might not be available. Ethically the treating clinician has a duty to the client not to delay their recovery and to take whatever measures are available to accelerate it; but in recent years I have had to question why a therapist is still delivering impairment intervention when the client had clearly plateaued a long time ago.

One clear area is the early involvement of those working and living with the client to underpin the work being completed by the therapist. At Equip2Speak we are strong believers that support worker training should be on-going and not left as a handover exercise when a client’s skills have plateaued.

Assessment is key to identifying the nature of a person’s problems and points to areas of priority and, vitally for the litigation process, is the tool that demonstrates progress. A standardised assessment, repeated at appropriate intervals, provides solid evidence that therapy is being successful and justified. An initial standardised test quantifies difficulties; follow up assessment reveals the success or not of the intervention.

Progress needs to be material, in that it has added benefit to the client in their real lives, improving the interactions with the people around them. If the client is impervious to the problem, then practise will not extend beyond the therapy sessions. It follows that those skills will be quickly lost when the therapy ends. q

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TO IDENTIFY THE HAIR DAMAGE IN LEGAL CLAIMS – TURN TO THIS TRICHOLOGY EXPERT WITNESS [IN THE REALM of personal injury

and negligence claims, hair damage emerges as a niche yet impactful category. Solicitors are often presented with cases where the plaintiffs cite damage ranging from chemical burns due to hair treatments to physical trauma from road traffic accidents and industrial injuries leading to hair loss, as well as complications from poorly administered medical procedures.

The key to a strong litigation strategy in such claims lies in understanding the nuances of the reported damage and having the expertise to discern legitimate claims from the questionable ones.

Types of hair damage or loss solicitors should look out for • Chemical burns: often caused by treatments like bleaching, perms • or hair straightening. They can result in immediate hair loss or • weakened hair structure leading to eventual breakage.

• Physical trauma: accidents can lead to hair loss, especially in cases • involving head injuries or traumatic hair-pulling episodes.

• Improper hair procedures: incorrectly administered treatments can • lead to various complications, ranging from uneven hair colouring to • more severe scalp injuries.

• Medical procedures that caused the unwanted side-effect of • hair loss.

As these issues manifest in complex ways, determining liability and navigating the intricacies of the claim requires specialised knowledge.

Iain Sallis is a highly-respected trichologist and expert witness, who stands in that exact space. Having co-authored the Hairdressing Injury Advice and Information website (www.HISAI.org), Iain is wellversed in the myriad ways hairdressing and other procedures can lead to injury or damage. His memberships of elite organisations, including the Expert Witness Institute, the Society of Cosmetic Scientists and Institute of Trichologists, further bolster his authority in the field.

When faced with hair damage claims, turning to an expert like Iain ensures a comprehensive understanding of the issue at hand.

He offers a dual advantage: an in-depth grasp of hair and scalp pathologies combined with an acute understanding of the legal implications of hair damage claims. His expertise ensures that the factual and scientific aspects of the claim align seamlessly with the legal strategy, offering solicitors the best chance of a successful litigation outcome.

For solicitors navigating the complexities of hair damage claims, the importance of an informed, scientific perspective cannot be understated. Iain Sallis brings that perspective to the table, ensuring clarity, precision and credibility. q

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CARE HOMES URGED TO CHECK RESIDENTS FOR SIGNS OF MOUTH CANCER [EVERY NOVEMBER the Mouth Cancer

Foundation runs its Mouth Cancer Action Month event. Detecting mouth cancer early is crucial, as it increases victims’ chances of survival; however, statistics show that more than half (53%) of all mouth cancers are being diagnosed in the most advanced stage.

This year the campaign particularly targeted the care home sector, which often feels forgotten when it comes to examinations of oral health. The Mouth Cancer Foundation has produced a new video to illustrate how best to examine care home residents and is appealing for dental practices to work alongside residential homes in their area to make sure residents receive dental checks.

Oral hygiene is important at every age, the charity says, but as 78% of mouth cancer cases occur in the over-55 age group, it is imperative that care home residents look after their mouth and carers check their oral cavity on a regular basis looking for signs and symptoms of mouth cancer.

As 57.9% of patients in residential homes and 42% in care homes are living with dementia, extra care will need to be taken when carrying out examinations. It is important to observe a resident and notice any behavioural changes and listen to what they may be saying, as even the smallest detail can be an important sign.

Thorough and regular assessments can help prevent pain, disturbed sleep and health problems that poor oral health can cause.

Care staff need to know how and when to assess the oral health of a resident and when to report changes.

All residents should have an oral health assessment when they move into a care home with the result recorded in their care plan, the Mouth Cancer Foundation says. That includes discussions with family or friends involved in on-going care.

The discussion should include: • How the resident usually manages their • daily mouth care – for example, • toothbrushing and type of toothbrush, • removing and caring for dentures including • partial dentures. Check whether they • need support.

• If they have dentures, including partial

• dentures, whether they are marked or • unmarked. If unmarked, ask whether they • would like to arrange for marking and offer • to help.

• The name and address of their dentist • or any dental service they have had • contact with, and where and how long • ago they saw a dentist or received dental • treatment. Record if there has been no • contact or they do not have a dentist, and • help them find one.

Staff also need to understand how dental pain or a mouth infection can affect residents’ general health, wellbeing and behaviour.

Make sure staff know who to ask for advice, how and when to report any concerns about a resident’s oral health, and how changes in a person’s condition might affect their ability to manage their mouth care.

It is important to ensure the care home has a documented referral pathway so carers can report any concerns and refer to the dental and hospital consultants as soon as possible.

Mouth Cancer Foundation ambassador and patron of the Society of British Dental Nurses Emma Riley explained: “By looking, listening and observing for mouth cancers in our elderly population we may spot these cancers sooner which may increase the chances of a better outcome and maybe save a life. Our hope is that dental practices across the UK will work alongside the residential homes in their local area.” q

MORE PEOPLE GO ABROAD FOR DENTAL TREATMENT OR ATTEMPT DIY DENTISTRY [

NEW FIGURES from an annual Oral Healthcare Report by dental plan provider Denplan have revealed that at least 40% of Britons under 55 have cancelled a dental appointment because they could not afford it.

Catherine Rutland, clinical director of Denplan and parent company Simplyhealth, commented: “The UK dental sector crisis has left many patients struggling to have their basic needs met, with some groups in society far worse off than others. Cost of living pressures have understandably led to prevention slipping down people’s list of priorities. Sadly, many people cancelled appointments because they couldn’t afford them, then later paid for emergency treatment when problems had worsened.”

The report also revealed that 41% of respondents had travelled abroad for dental care, attempted some form of DIY dentistry by ordering at-home kits, or searched Google for dental advice.

Respondents who travelled abroad for treatment only saw a success rate of 50%.

Dr Nigel Carter, chief executive of the Oral Health Foundation, said: “Denplan’s report has uncovered some extremely troubling consumer

habits when it comes to having dental treatment. The findings support the reasoning behind one of our awareness campaigns, Safe Smiles, which provides people with advice about the best ways to receive safe and effective dental work.

“There are significant risks with going abroad for dental treatment and DIY treatments at home. It is buyer beware. If you are thinking about having any dental treatment, please speak to your dentist in the UK first.”

The report also shows people are visiting the dentist less frequently than a year ago, with 23% visiting less than every two years, only when they’re in pain, or not at all (compared with 20% in 2022).

Catherine Rutland added: “To keep communities healthy, there needs to be a joined-up approach to the way that dentistry is viewed within healthcare and government.

“When considering how best to improve access to dentistry, we must not consider the reform of the NHS contract in isolation.

We must also recognise the role of mixed and private practices in communities and wider initiatives such as making better use of the wider dental team to carry out a range of services.” q www.yourexpertwitness.co.uk

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GDC CONSULTS ON REMOTE HEARINGS [THE GENERAL DENTAL COUNCIL is carrying out a

consultation on the format of its hearings. The consultation is inviting views on proposals for all practice committee and registration appeal committee hearings to be held remotely by default, while providing for requests for hearings to be held inperson to be considered and decided fairly.

The process for deciding whether a hearing is held in-person or remotely – or both, referred to as a hybrid – is currently set out in guidance for directions made at preliminary meetings.

The GDC consulted on the process in 2021 as the country emerged from the pandemic, but committed to consulting with stakeholders again if they wanted to make a permanent change to their approach.

Around 90% of hearings are currently held remotely. Since 2022 there have been 42 applications for a hearing to be held either inperson or hybrid, with only five of those applications not accepted.

Where parties do not agree on the format of a hearing, directions

have been provided by a panel chair or panel members at a preliminary meeting.

The GDC’s executive manager for dental professionals hearings service, John Cullinane, said: “We think there are considerable benefits to holding hearings remotely, not least savings in travel and accommodation costs, but also reductions in lost hearing days due to travel disruptions and increased participation from those who find it difficult to be away from home.

“Since we started holding most of our hearings remotely, we have introduced additional support for all hearing participants by providing specific guidance on attending a remote hearing and introducing a participant support officer to address the challenges that these types of proceedings may present.

“Our view is that the process for deciding the format of hearings has been working well, and that we can now realise the benefits for all parties by making the process permanent.”

The consultation lasts 12 weeks and closes on 15 February 2024. q

BDA CALLS FOR EXPANSION OF SUGAR TAX AFTER STUDY SHOWS SUCCESS [THE SUGAR LEVY has secured huge gains in the fight against

tooth decay – and shows that ministers must remain willing to force the hand of the food industry on reformulation. That is the claim made by the British Dental Association (BDA) in response to new research using

data on hospital admissions for tooth extractions caused by decay.

The research, published in BMJ Nutrition, Prevention & Health, suggests that, 22 months after it was implemented, the Soft Drinks Industry Levy was associated with a 12% reduction in admissions amongst children aged 0 to 18 years.

The levy resulted in 47,000 tonnes of sugar being taken out of soft drinks in its first four years as it encouraged drinks manufacturers to reduce sugar levels to avoid the tax. That effectiveness is in sharp contrast to voluntary appeals to the food industry from the government.

In a statement the BDA said: “We’re clear expansion of the levy into other product ranges – including milk-based drinks, biscuits, cakes, sweets, yoghurts and cereals – would drive widespread reformulation of high-sugar foods and need not raise costs for consumers.”

Its chair Eddie Crouch declared: “The sugar levy is delivering the goods in the fight against decay, so it’s time to double down.

“This isn’t about adding to the cost of living. When voluntary action has clearly failed, this shows government must force industry’s hand on cutting sugar.”

The BDA statement continued: “Tooth decay is the number one reason for hospital admissions among young children. It’s a national scandal, and we will keep leading the argument for change.” q www.yourexpertwitness.co.uk

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MENISCAL TEARS: THE JURY IS NOT COMPLETELY OUT!

By Mr Turab Syed, consultant trauma and orthopaedic surgeon.

[SO FAR, opinion has been divided among

experts for meniscal tears, and experts are no longer supposed to be the hired guns of any side: the plaintiff/claimant or defendants.

There is new evidence in the medical literature on whether physical therapy – or physio – alone works, or whether one requires arthroscopic knee surgery either immediately or as a delayed option. That follows the publication of the STARR (Study of Traumatic tears: Arthroscopic Resection vs Rehabilitation) trial in 2022.

The cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears was reported on in a recent study from Rotterdam by Van Graff. The study was carried out from the original data of STARR. In that multi-centred, open randomised trial, patients aged 18-45 years, with recent onset traumatic, MRI-scan verified, isolated meniscal tear without knee osteoarthritis were studied.

Patients were randomised to arthroscopic partial meniscectomy or standardised physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. The analysis compared both treatments over a 24-month follow-up period. The trial consisted of a total of 100 patients, wherein 49 were randomised to arthroscopic partial meniscectomy and 51 to physical therapy.

In the physical therapy group, 21 patients (41%) received delayed arthroscopic partial meniscectomy during follow-up. Over 24 months, patients in that group had a mean of 0.005 QALYs (quality-of-life lower scores) with a 95% confidence interval -0.13 to 0.14. The cost-utility ratio was €-160,000 per QALY from the healthcare perspective and €-223,372 per QALY from the societal perspective: indicating that arthroscopic partial meniscectomy incurs additional costs without any added health benefit.

Studying the relationship between quality-of-life score – where 1 means best score and 0 is very poor, comparable to being dead – the arthroscopic surgery group had a slightly better score compared to physical therapy, which narrowed and became equal at nine months.

From that point onward the physical therapy group had marginally better scores until 24 months. However, that was not clinically or statistically significant.

However, the bottom line from a medicolegal point of view is that of a 40% chance of still requiring arthroscopic meniscectomy and only a 60% chance of physio settling the symptoms. The follow-up is not long enough to opine upon if the percentage for arthroscopic meniscectomy – a need for future surgery beyond 24 months or progression of tear with the passage of time – would increase as time marches on. Another opinion which can be derived is that, if the symptoms are continuing after physio beyond 24 months, then they would require surgery. Hence the provisional opinion can be provided for a prognosis of 24 months or earlier settlement of symptoms with physio, but cannot be confirmed until 24 months. Thus, all traumatic meniscal tears need re-examination at 24 months.

It must be stressed that the majority of subjects were male (over 75%) in both groups and had a mean BMI of around 25, that is not obese or overweight.

Effects of meniscal tears

Traumatic meniscal tears limit patients in their activities during daily life and sports, which can lead to a loss of quality of life. Having a meniscal tear results in a six-fold increased risk of developing osteoarthritis of the knee joint, resulting in increased healthcare consumption.

Like any surgical procedure, arthroscopic meniscal surgical treatment carries risks, such as septic arthritis – infection of the native joint, which can have life-changing consequences and the need for a total knee replacement due to cartilage melting from infection if not treated promptly, and future increased risk of infection when a knee replacement is required of 0.135% to 0.211%; deep venous thromboembolism – clots in the legs which may require taking blood thinners for at least six months, with increased risk of bleeding from minor trauma of -0.413% to 0.568%; and pulmonary embolism – clots in the lungs which can potentially kill people and need potentially lifelong treatment on blood thinners at a risk of 0.078% to 0.145%.

On this evidence, one should have at least three months of physical therapy before considering surgery in the case of persistent knee complaints, and in consultation with the treating orthopaedic surgeon. I must stress that the ‘arthroscopic partial meniscectomy’ was performed in the study within six weeks of inclusion; that is, very early after diagnosis.

Based on the results of the Van Graff study, from a clinical and health economics perspective, physical therapy can be considered a reasonable alternative to early arthroscopic partial meniscectomy as a first-line treatment in young patients with a traumatic meniscal tear.

That opinion is not valid for those with a locked knee (when the patient was unable to fully extend or flex the injured knee, confirmed by clinical exam), a meniscal tear that was suitable for suture repair based on MRI findings, a concurrent rupture of the anterior or posterior cruciate ligament, radiological signs of osteoarthritis in the index knee (Kellgren-Lawrence grade 2 or higher) or a disabling comorbidity, as those conditions were excluded from the study groups. Thus, those claimants with these profiles would require an expert’s opinion.

Key messages

• Initial treatment with physio should be for at least three months • before considering surgery • 60 % of patients improve with physio alone and 40% require surgery • despite having physiotherapy • Surgery has initially marginally improved QALY scores, which meet • with those undergoing physio at nine months; but they are neither • clinically nor statistically significant. 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). www.yourexpertwitness.co.uk

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HOSPITAL NEGLECT CONTRIBUTED TO DEATH OF STUDENT WITH HIP DISLOCATION [THE INQUEST into the death of a

student rugby player has ruled that hospital neglect contributed to her death.

Maddy Lawrence, 20, died from an infection at Southmead Hospital, Bristol, in March 2022, a fortnight after she dislocated her hip during a match. A coroner found her deterioration was ‘not recognised’ and life-saving treatment was ‘not commenced promptly’.

Maddy developed an infection – which is likely to have led to sepsis or toxic shock syndrome and destruction of body tissue – and died in intensive care.

The University of the West of England (UWE) student could have survived if she had been given antibiotics earlier, one expert said.

A system was in place called NEWS – the national early warning score – that should have indicated any deterioration or, for instance, sepsis, the inquest heard. At one point, hospital staff did not even record observations about Maddy Lawrence’s condition for 16 hours.

Recording a narrative verdict, Avon

coroner Dr Peter Harrowing said there were ‘serious failings’ in Maddy Lawrence’s care.

He said: “There was a gross failure to provide adequate care. There were a number of opportunities to render the care to save Maddy's life. The investigation gives rise to concern of future deaths. There was a failure to recognise how seriously ill she was.”

North Bristol NHS Trust chief medical officer, Tim Whittlestone, said: “As a parent I can think of nothing worse than knowing there were missed opportunities which could have affected Maddy's outcome.

Despite the rarity of Maddy's condition and the heroic efforts of many of our clinical teams, we acknowledge, and apologise for, the omissions in her care.

“Beyond our apology we will reflect carefully on the findings of the coroner.

The coroner noted the actions that we have already taken, and we recognise the improvements we still need to make.

“The recognition of, and our response to, deteriorating patients is the main safety improvement priority for our hospital. This includes enhancing training and the planned

introduction of additional critical rapid response teams.”

Staff will have mandatory training on a scoring system that indicates signs of sepsis and other serious infections, a senior trust employee told the inquest.

The coroner also heard how Maddy Lawrence had to wait more than five hours for an ambulance to arrive after she was injured during the match. But Dr Harrowing said he did not find evidence for neglect by the South Western Ambulance Service NHS Foundation Trust.

The trust’s executive medical director, Dr Matt Thomas, said: “We are truly sorry that we were unable to provide the timely response that Maddy deserved.

As documented during our evidence at the inquest, the service was under enormous pressure during this period, partly due to handover delays at emergency departments.

“We continue to work hard with our partners in the NHS and social care to do all we can to improve the service that patients receive.” q

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THE MENISCUS REPAIR VERSUS MENISCECTOMY DEBATE: NAVIGATING CHOICES IN THE COURTROOM Orthopaedic consultant and expert witness Professor Paul Lee describes the factors that need to be addressed by both patient and surgeon

[THE KNEE’S MENISCUS plays a crucial role in joint health,

and when it’s injured patients face a decision that can affect the rest of their lives. The debate between meniscus repair versus meniscectomy is not just a medical or surgical pathway; it’s a choice that must be made by the patient, guided by the surgeon’s expertise.

The decision has significant implications, not only for their immediate recovery but also for the long-term functionality and health of the knee. Meniscectomy could be the beginning of the end in terms of knee osteoarthritis.

Patient-centred decision making

The surgical decision should be a shared process. The surgeon’s role is to inform the patient of all possible options, including the option of conservative, non-surgical management. That discussion should encompass the immediate impacts, rehabilitation journey and long-term outcomes associated with each choice.

Meniscus repair may offer the benefit of preserving the knee’s natural cushion, potentially avoiding or delaying arthritis. However, it comes with a more intensive rehabilitation period and success rate varies.

Meniscectomy provides quicker relief and a faster return to daily activities, but carries a higher risk of osteoarthritis down the line.

Once it is removed it is going to be that much harder to put back.

The choice is not always straightforward, and the surgeon must tailor the discussion to the individual’s lifestyle, occupational needs, and personal health goals.

Understanding degenerative tears

patient's symptoms and functional limitations. Age should not be the sole factor: the pattern of the tear, the presence of concomitant osteoarthritis and the overall health of the knee must all be considered.

Legal implications and expert witness contribution

When a meniscus injury leads to litigation, the plaintiff’s attorney must understand these nuances. The medical expert witness plays a vital role in explaining the nature of the tear and why a particular surgical option was chosen, based on the patient’s informed decision.

The expert witness should clarify that the surgeon’s responsibility extends beyond suggesting the most technically suitable procedure: it includes a comprehensive dialogue with the patient about the potential for degenerative changes and the impact of each surgical choice on their future quality of life.

In conclusion, the meniscus repair versus meniscectomy decision is a multifaceted one, with the patient’s informed choice at its heart. The dialogue between surgeon and patient should be nuanced, transparent and personalised, addressing the short and long-term consequences of each option.

In the courtroom, the strength of an expert witness’s testimony hinges on their ability to convey the depth of the decision-making process and the rationale behind the chosen path. It’s about painting a clear picture of the injury’s nature and its treatment options, ensuring the patient’s voice and long-term wellbeing remain at the forefront of the judicial outcome. q

The term ‘degenerative meniscus tear’ is pivotal in this discussion. A degenerative tear is often a chronic condition, typically seen in older patients, and is characterised by gradual wear and tear of the meniscus tissue. Unlike acute tears – often caused by trauma and seen in younger, more active individuals – degenerative tears may not always benefit from surgical intervention.

Determining whether a tear is truly degenerative involves a thorough assessment, including a physical examination and imaging, such as an MRI. It also requires a careful review of the

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FORMER GYMNAST’S HIP REPLACEMENT DELAYED FOLLOWING EXPERT CONSULTATION [HCA HEALTHCARE have shared a story of a hip

replacement patient who was able to delay the operation until it was absolutely necessary.

Yvette (54), a journalist from Kent (right), started experiencing pain in her hip in 2015. An ex-national gymnast who had been incredibly active and flexible her whole life, enjoying everything from fly fishing to pole dancing in her spare time, Yvette felt concerned about the growing discomfort impacting her quality of life; and so sought help from her GP. Yvette’s GP referred her to a consultant who believed the pain stemmed from her back – and so gave her a local injection for the pain. Scans then revealed issues with both her back and hips, and Yvette was told she would definitely need hip replacement surgery in the coming years.

“To hear that was quite a shock – I’d always been flexible and active, I didn’t anticipate needing hip replacement surgery, especially in my forties. I thought it could be related to the hip dysplasia I was born with – which meant that I walked with a splint for a time as a child.”

Concerned by this news, Yvette sought a second opinion; and in doing her own research came across orthopaedic surgeon Mr Hugh Apthorp, who was not only a leading hip replacement surgeon but also an expert in hip dysplasia. Yvette booked a consultation with Mr Apthorp in which he told Yvette: “You don’t need a hip replacement yet, but you’ll know when you do.”

Mr Apthorp said: "Yvette still was managing to continue enjoying her various sports at that time, but it was obvious she was heading towards needing intervention. When to operate is a very personal choice and I usually find patients will manage for a while with physio and analgesics.

However, one day most patients will wake up and feel that they have had enough – that is the right time to operate.”

On Yvette’s case, Mr Apthorp commented: “Yvette was born with hip dysplasia, a condition that affects one to two of every 1,000 babies where they are born with slightly abnormally shaped hips. Abnormally shaped hips are much more likely to wear out earlier than normal shaped hips and therefore patients with hip dysplasia tend to come to surgery earlier. Quite frequently they will have had treatment as a child which can make surgery more complicated because of deformity and scarring – and therefore the treatment of the hip dysplasia is quite a specialist area of hip replacement surgery.”

By May 2021 Yvette was in considerable pain and struggling to do anything active and she knew it was time to visit Mr Apthorp again, now based at London Bridge Hospital – part of HCA Healthcare UK – which is widely considered a centre of excellence for orthopaedic surgery. Mr

Apthorp informed Yvette that it was now indeed time to undergo a hip replacement. Yvette’s surgery was a success, and Mr Apthorp was very pleased with the outcome.

Mr Apthorp commented: “Seeing Yvette’s recovery was inspirational.

She shows what is possible with modern hip replacement techniques.

Her positive proactive positive approach made such a difference to her recovery. It’s been wonderful to help her achieve her goals.” q

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WHEN IS MIDWIFERY PRACTICE WRONG? IT’S MORE THAN JUST ANALYSIS OF BIOLOGY By midwifery expert witness Jayne Marie

[WHILE THE PREGNANT WOMAN is at the centre of

her maternity care, midwives are the professionals that are autonomously responsible for identifying the woman’s risk status and planning the care consistent with the woman’s specific needs.

The Nursing and Midwifery Council regulates the profession of midwifery and sets the expected standards for practice which centre around the well-known concept of duty of care.

Unambiguously entrenched in the professional duty of care owed by the midwife to the woman is the requirement to provide evidence-based care according to the individual risks that each woman presents with. Sometimes, despite the provision of the best midwifery care, things go wrong; babies die or are born damaged.

Poor outcomes do not always mean the provision of poor care. Few midwives, if any, go to work to do harm, with most striving – often in difficult circumstances – to go ‘above and beyond’ and do their absolute best despite the circumstances.

How does the midwifery expert witness decide what constitutes care that does or does not meet the required standards, if poor outcomes can occur despite the provision of excellent care in difficult circumstances or inefficient and ineffective maternity services?

Being a midwife is difficult, emotionally challenging and not always made easy by the system in which maternity care is delivered. Midwives can report feeling their decisions are limited and constrained due to the environment, the team or the demographics of the population they are working with.

The way in which the maternity service is organised can hinder the care being delivered in the way the individual midwife may believe is best for that specific individual woman. That means midwives need to understand the impact the structure of the service poses to the care they deliver, making it vital that the expert witness understands the constraints service structure provides.

Maternal, foetal and neonatal mortality and morbidity has been continually monitored, reported on and scrutinised over decades.

There is a trail of reports of failing maternity services listing faults within NHS trusts, their management and individual professions.

In response to those reports there is an abundance of guidelines, policies and procedures in place. Midwives are highly trained and drilled to respond to emergencies over and over again to reduce the risk of harm, yet harm still occurs.

Numerous reports identify trends and themes, all with the intention of reducing harm. But despite those efforts, harm still occurs.

Having a baby is potentially the riskiest time of a woman’s life in terms of health and wellbeing. Labour can be described as a short, yet high-risk journey for the foetus from the uterus to the world. The risks faced by mothers and their babies exist because, while pregnancy and birth is a physiologically normal event, they

involve every body system working to its most extreme capabilities – almost in overdrive. Trying to develop and sustain life, then expel that life in a complex process that requires everything to work perfectly means things go wrong. Trying to decipher whether the cause of the particular harm is due to a physiological malfunction or a failure in a duty of care requires an experienced midwife with the ability to understand, not only the biology, but the intricacies of care, with a healthy dose of risk analysis thrown in.

Clinical knowledge and understanding, gained and developed through being a midwife for 25 years in my case, is vital when it comes to being an expert witness. But, in the 40-plus reports written to date, I have drawn on my experience in risk management and governance within maternity care, arguably more than mere clinical knowledge alone. That is because of the fundamental need to not only explain the clinical basis for an adverse outcome, but more so the holistic rationale for why the adverse outcome occurred – combining physiology, risk analysis, understanding of service structure and human factors.

It is only with this comprehensive and rounded analysis that a midwifery expert witness can truthfully identify to a court whether the adverse outcome was a truly biological malfunction, unable to be identified and therefore proactively managed, or a risk that failed to be reasonably foreseen and thereby constituted care that fell below the standards of a reasonable and responsible body of midwives.

Midwifery is not a binary art of understanding as simple as right or wrong. The context is the key to viewing all clinical midwifery care. For example, a woman may lose her baby during late pregnancy in an apparently unexplained physiological event, while another woman may suffer the same unexplained event with exactly the same physiological causation, yet be able to pursue litigation because there is no evidence of the woman being advised of what normal foetal movements consist of, and how to escalate a concern in a timely manner because the IT system didn’t prompt the midwife to recite that information or to evidence that she told the woman what to do and when – and so she presented to the hospital too late.

The biology caused the poor outcome and the system to document the advice given prevented the midwife from evidencing her care. So is it fair for me, as an expert witness, to criticise that care? My answer to this is, yes; it is vital that midwifery experts identify the errors in such cases, even where the actual clinical issue was not preventable. Without shining a light on such cases care will never improve.

As we’ve seen from history, a report on trends and themes does not generate change; only exposure will stimulate the NHS to truly look at how to design maternity services that can safely care for women and babies in the contemporary maternity services. q • Jayne Marie is a midwife and lecturer in midwifery who can be contacted on 07771 700814 or via email jaynemarie2023@icloud.com.

Jayne can provide expert opinion on a wide range of midwifery cases throughout the antenatal, intrapartum and postpartum periods, and specifically complex cases for both claimant and defendant. With a sound portfolio of past cases, Jayne has undertaken expert work throughout the whole of the UK and the Republic of Ireland. www.yourexpertwitness.co.uk

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THE MALEFICENT SEVEN; OR, WHY YOUNG MEN KEEP LOSING TESTICLES IN THE 21ST CENTURY

By Mr Gordon Muir, consultant urologist and andrologist surgeon

[TESTICULAR TORSION is a surgical emergency wherein a twist in

the blood supply of the testicle causes it to be strangled and die due to a lack of oxygen. There are probably around 3,000 cases in the UK each year – meaning the average Accident and Emergency unit will see 10-20 cases per year.

Although it should never happen nowadays, young men lose salvageable testicles on most weeks in the NHS. Broadly, if a man is taken to surgery within six hours of the torsion occurring, the great majority of testicles will survive. A delay of 6-12 hours usually, but not always, leads to a salvageable testis. A delay of over 12 hours is often fatal to the testicle, and very few survive over 24 hours of torsion.

Presentation is normally of sudden severe testicle pain without any general symptoms. In boys, the presentation may be of abdominal pain.

Rarely, trauma or exercise may precipitate the torsion.

If a testis is alive then it will be replaced and fixed in place using one of a number of techniques to avoid recurrence. The other testicle should also be fixed, although that may on occasion be deferred several weeks. It is the patient’s choice as to whether or not a testicular prosthesis is placed, but it should always be offered to the patient.

In years of treating and reporting on torted testicles, I have observed seven preventable reasons for young men with torsion losing a testis unnecessarily. This informal review uses vignettes of real cases to demonstrate the problems.

Embarrassment

A 13-year-old boy developed left testicular pain in the morning. He had masturbated just prior to the pain starting and was worried the two were linked. Due to this, he did not mention the pain to his parents until he was unable to sleep. He arrived at hospital 20 hours after the onset of pain and at surgery two hours later a dead testis was found and removed. The other side was fixed, but no prosthesis was placed.

Young men with testicular pain may be embarrassed to speak to anyone about the pain. That can lead to a period of many hours before presentation to hospital. Anecdotally, this happens more often in boys or men with learning or communication difficulties. Short of education, it is hard to see how pre-hospital delays can be improved.

Misdiagnosis

An 18-year-old man awoke at 05.00 one morning with severe left testicular pain. He was seen at his local hospital at 08.00 and a presumptive diagnosis of testicular torsion was made. A urology staff-grade doctor saw the patient at 09.17 am. The history was that the patient had just returned from a music festival, where he had had penetrative intercourse with two separate female partners. A diagnosis was made of inflammation of the epididymis – infection of the collecting tubules behind the testicle – and he was sent home with analgesia and antibiotics. No urine tests or blood tests were ordered.

The patient returned the following afternoon with worsening pain and swelling. He was taken to theatre, where a gangrenous torted testis was removed. Fixation of the other side and a prosthesis were deferred for six weeks. On review the patient emphasised that he had never had unprotected sex, so a diagnosis of epididymitis was very unlikely. Here, the presumption of unsafe sex from the assessing surgeon led to an indefensible wrong diagnosis.

Pointless Investigations

A 19-year-old man presented with testicular pain of two hours duration at 7.00 pm. He was seen by the emergency team and the presumptive diagnosis was of infection, but torsion was a possibility. As there was no out-of-hours ultrasound he was admitted to the emergency ward to have an ultrasound the following morning. The ultrasonographer carrying out the exam found that the testis had blood flow but thought it may be reduced.

A second ultrasound three hours later suggested a dead testis, which at surgery was clearly unsalvageable: the testis was removed.

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While a clinical trial of point-of-care ultrasound is being considered in the UK at present, ultrasound and other imaging exams have no part to play in torsion patients except, in experienced hands, to confirm another diagnosis. However, if ultrasound will cause more than a short delay, then surgical exploration should go ahead.

Disorganisation

A 14-year-old boy went to his local A&E with a one-hour history of testis pain. The diagnosis of torsion was made, but as the hospital had no on-site urology and the general surgical team refused to see the patient, an ambulance transfer to the nearest teaching hospital was arranged. Due to a lack of availability, and the ambulance despatcher’s perception of this being a low priority case, no ambulance was available after six hours.

The patient’s family had asked a number of times if they could take their son but were advised to wait. Eventually the father, having been made to sign a self-discharge form, drove to the other hospital; but by the time the patient reached theatre the testis was dead, 10 hours from the pain starting.

The family contended that the A&E department should have diverted them immediately on arrival as the hospital did not have the capability to treat their son, and that delaying them while awaiting the ambulance was nonsensical.

Poor assessment

A 12-year-old boy presented around 6.00 pm with right lower abdominal pain. He was diagnosed with probable appendicitis and admitted to the surgical ward for analgesia and antibiotics. The following morning his genitals were examined for the first time and a clear torsion was found. At surgery one hour later the testis was dead and was removed.

Torsion in boys may present with abdominal rather than testis pain. It is mandatory that the testes are inspected in all cases of abdominal pain.

Age

Torsion is commonly presumed to arise only boys and in young men.

A 43-year-old lorry driver attended the A&E department at a hospital in Kent with right-sided scrotal pain. He was seen by a casualty doctor, who

diagnosed him with an infection and prescribed antibiotics. Four days later, on his return home to Yorkshire, he represented to his local hospital and was immediately taken to theatre, where a gangrenous testicle was removed.

On discussion, he gave a history of short-acting intermittent testis pain since his teenage years. The healthy testis had a fixation procedure six weeks later. This was a case of intermittent torsion which had been misdiagnosed a number of times over the years before the final error led to a dead testicle.

Previous torsion

A 16-year-old with learning difficulties presented with right testicular pain, having lost his other testis to torsion six months before. He was asked if the other side had been fixed and he said it had. Treatment was with antibiotics, but he returned the following day when a dead testis was removed.

He now faces a life on testosterone injections and sterility. Had the notes from his previous admission been looked at, then it would have been apparent that the right testicle had not been fixed: the plan had been to do an interval orchidopexy, but no follow-up happened.

While it is unlikely that a previously fixed testis can tort, it is possible.

Equally, in such a case there must be proof positive that a testis has been fixed before excluding torsion. Losing a solitary testis is, quite simply, a disaster.

Conclusion

There is no diagnostic test to exclude testicular torsion. In departments with very experienced ultrasound doctors, a number of conditions may be diagnosed which can mimic torsion. However, even in that situation there should be no delay to surgery if an absolute diagnosis cannot be made – the ultrasound should be done on the way to the operating theatre. If there remains any doubt, emergency surgical exploration should be carried out.

Adhering to this very simple guidance would keep many men with both testes, and save the NHS a large sum of money in medicolegal defence and compensation fees. q

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RISE IN SUICIDAL THOUGHTS AMONG NURSES SHOULD BE ‘FRIGHTENING WAKE-UP CALL’ [

THE ROYAL COLLEGE OF NURSING (RCN) has warned of a growing mental health crisis among nursing staff, as its membership support line data shows a substantial increase in the number of nursing staff seeking help for having suicidal thoughts.

The RCN reported a 98% increase in nursing staff telling its Advice Line during an initial call that they’re having suicidal thoughts. That was in the first 10 months of 2023 compared to the same timeframe last year.

In October there was the equivalent of one person every working day reporting suffering from suicidal ideation during their initial call, compared to just one person a week in October 2021. In response to the latest findings the RCN has commissioned research looking into the reasons why nursing staff are having suicidal thoughts and whether there’s a disproportionate impact on those from marginalised groups.

The RCN is reiterating its call on the government to urgently provide funding for dedicated mental health support for nursing staff and, more broadly, to tackle chronic nursing workforce shortages which add unprecedented pressure on staff. There are currently more than 40,000 nursing vacancies in the NHS in England alone, with a record number of patients on an NHS waiting list.

RCN interim head of nursing practice Stephen Jones said: “The rise in nursing staff having suicidal thoughts should be a frightening wake-up call.

Nursing staff contribute so much to our society, but working in an inherently stressful job can come at an enormous personal cost. Yet we see support services cut when we should be seeing greater investment in looking after those who care for us.

“The increasing burden on nursing staff, as they try to help clear the excessive backlog in care, has created intolerable working conditions on

every shift. Coupled with nursing pay not keeping up with the cost-of-living, we’re alarmed by this growing mental health crisis among nursing staff.

“The UK government must understand that cuts to mental health support for nursing staff can’t continue – when you invest in the health of nursing staff you also invest in the health of patients.”

Responding to the report, Dr Roman Raczka, president-elect of the British Psychological Society, commented: “Staff are the lifeblood of the NHS, and these deeply concerning figures from the RCN highlight exactly why the British Psychological Society is continuing to campaign for dedicated mental health support services for nurses and all health and care staff.

“It’s vital any member of the health and social care workforce having suicidal thoughts has rapid access to support from experienced clinicians to give them the help they desperately need.

“The workforce is on its knees, with NHS figures showing mental healthrelated sickness absence rose from 23.3% in January to 27.4% in June 2023, accounting for nearly three million full-time equivalent working days lost in the first six months of this year alone.

“With staff suffering under unprecedented pressure, we're calling on the government to provide long-term ring-fenced funding for staff mental health and wellbeing services to make sure people have rapid access to the psychological help they need.” q

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UNLOCKING THE MIND WEBINARS EXPAND LEGAL EXPERTISE [THIS YEAR has seen the launch of a new venture by Expert

in Mind, a company that manages a panel of esteemed expert psychiatrists and psychologists. The firm has hosted a series of CPD-accredited webinars enabling participants to delve into a diverse array of captivating subjects. They have been exceptionally well received within the legal profession as well as among mental health professionals.

In today’s ever-evolving word, knowledge dissemination has become more accessible than ever before. Expert in Mind has seized the opportunity to enable its mental health experts to share their knowledge and insights and give legal professionals a unique opportunity to deepen their understanding of topics frequently encountered within their caseload.

By gaining a mental health perspective through the webinars, legal professionals can enhance their ability to empathise with clients, grasp their needs better and, ultimately, navigate their cases with heightened insight and expertise.

The project was launched in September with the first host being Professor Walter Busuttil (right), a consultant psychiatrist and one of the leading experts, both nationally and internationally, on PTSD and trauma. Professor Busuttil is a Visiting Professor at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London and the King’s Centre for Military Health Research. He is Director of Research and Training for Combat Stress, the national charity for combat veterans and ex-service personnel, and was their Medical Director from 2007 to 2020.

Professor Busuttil’s inaugural webinar was a captivating exploration of post-traumatic stress disorder (PTSD) and trauma, the similarities between PTSD and other conditions such as psychosis and borderline personality disorder (BPD), unravelling the complex tapestry of these interconnected symptoms.

It was a tough act to follow; however, Expert in Mind was privileged to have the next webinar hosted by the acclaimed, awardwinning TV and radio journalist Nick Wallis (left), entitled The Great Post Office Scandal – The Human Cost.

Nick is perhaps best known for his work on The Post Office Scandal, a story he has been pursuing since 2010. Nick has Photo by Jenny Smith been instrumental in bringing the scandal into the public eye, broadcasting his first investigation for the BBC in 2011. He has subsequently made two Panoramas, a Radio 4 series and published a book in 2021 entitled The Great Post Office Scandal (top right).

Nick’s webinar delved into the heartbreaking narrative of the horrifying story of institutional injustice, described as one of the most widespread and significant miscarriages of justice in UK legal history.

The scandal, spanning from 1999 to 2015, had grave consequences.

Over 20 years incalculable harm has been done to over 3,000 innocent sub-postmasters and counter staff across the country, due to faulty information from a computer system called Horizon.

Although sub-postmasters continually complained about bugs in the system showing shortfalls in accounting, 736 branch managers received criminal convictions – averaging one a week – with many serving jail time for fraud, theft and false accounting.

Many of those upstanding citizens were financially ruined, left homeless and shunned by their communities.

In 2019 a High Court ruling found that the Horizon system, created by Fujitsu, was indeed flawed. In April 2021, the Court of Appeal quashed the convictions of 39 former sub-postmasters and ruled their prosecutions were an affront to the public conscience. Since then a further 500 convictions have been quashed.

Covering another diverse and fascinating topic, clinical psychologist Dr Laura PiponYoung (right) will host the forthcoming webinar, Breaking Point: Why Mothers Hurt Their Babies. With the case of Lucy Letby so prevalent in the news recently, Dr Pipon-Young promises a deep understanding of the psychological dynamics behind mothers who deliberately harm their babies.

Research suggests that 20-50% of parents will have thoughts of harming their baby at some stage, especially within the first few weeks of life. For the vast majority that will remain just a thought, most likely an intrusive, unwanted one at that. However, some will find themselves hurting their child deliberately, perhaps causing serious harm and even death. The question is why?

This webinar will explore maternal mental health, post-partum psychosis, personality factors, sleep deprivation, physical health, relationship issues and attachment. Dr Pipon-Young will provide a greater understanding of the role of denial and non-acceptance by perpetrators, as well identifying and managing risk.

Excitingly, Expert in Mind has plans for an array of webinars in the upcoming year, covering a wide range of engaging and educational topics and promising to be informative and captivating for a diverse audience. q • For more information and to register for upcoming webinars or access past sessions email enquiries@expertinmind.co.uk. www.yourexpertwitness.co.uk

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PSYCHOLOGISTS: A MYTH-BUSTER FOR THE LEGAL PROFESSION Lisa Crowther, Quality Assurance Manager at Carter Brown, explains the role of different experts in the field

[NESTLED JUST A WHISKER AWAY from Sherwood Forest, while

our administrative base is in Mansfield, Carter Brown’s experts have been providing a nationwide service for the past 20 years. We work with a network of over 200 psychologists nationwide.

The regulatory body for psychologists, the Health and Care Professions Council, registers them under nine ‘protected titles’. Of them, our experts work predominantly within the fields of clinical, forensic, educational and counselling psychology. This psychology myth-buster is intended to help you to establish the type of expert that may be most suitable to assess the needs of your client.

Clinical psychologists

Clinical psychologists deal with a wide range of mental and physical health problems, including addiction, anxiety, depression, learning difficulties and relationship issues. Depending on their experience, they can work with adults or children or sometimes both. Their assessments use a variety of tools, including interviews, psychometric testing and observation Clinical psychologists can assist in offering a better understanding of an individual’s presentation and behaviour and the impact that may have on their day-to-day functioning, including parenting, as well as in setting out the support that an individual may require and the timescales and intensity of that support.

Forensic psychologists

A forensic psychologist uses psychological theory to help understand the psychological problems associated with criminal behaviour, and the treatment of those who have committed offences. They are skilled in the assessment of risk and seek to explore and understand an individual’s offending behaviour and any vulnerabilities connected with it – for example past trauma or substance use. They can offer signposts to appropriate treatment pathways, which provide opportunities for recovery and rehabilitation.

Instructing a forensic psychologist can assist in fully understanding an

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individual’s behaviour, with a specific focus on the risk they may pose to others – including their children and intimate partners – and themselves, thereby informing safety planning.

Educational psychologists

Educational psychologists work with children and young people across educational settings. They tackle challenges such as learning difficulties, social and emotional problems and issues around disability, as well as more complex developmental disorders. Their assessments include observations, interviews and the use of a variety of tools. They are skilled in working alongside, consulting with, advising and supporting teachers, parents and the wider community, as well as the young people concerned.

They are well-versed in working with systems, including families, schools, local authorities and legal frameworks. That makes them well placed to deliver child-focused assessments, drawing in all significant individuals to that child. An educational psychologist can offer valuable insight into the world of a child and the impact of their experiences. They can assist in offering an understanding of a child’s individual needs and the ways in which parents, carers and professionals can work together to meet those needs.

Counselling psychologists

Counselling psychologists work with individuals in the context of therapy but can apply their skills – honed in their work with individuals experiencing a wide variety of mental health difficulties or facing life challenges – to an assessment context. They assist in providing an understanding of the drivers behind an individual’s behaviour and appropriate, tailored recommendations for intervention.

Each of our psychologists has a minimum of five years of post-qualification experience and is in good standing with their regulatory and professional body. We pride ourselves on our ability to help clients to find the right one to meet their assessment needs. If you’d like to understand how a psychological assessment could help to progress your client’s situation, get in touch to discuss your assessment needs.

We also offer paediatricians, psychiatrists and independent social workers, who can offer assessments of children, families and individuals within family, criminal and civil proceedings. If you’re not sure what sort of expert you need, we have spent the past 23 years building knowledge in this arena and can offer specialist advice to help you identify the right person. q

FOLLOW YOUR DREAM

BUT BE ALIVE TO THE PRACTICALITIES Consultant eye surgeon Mr Shahram Kashani offers some advice for surgeons considering working abroad for a charity.

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I HAVE NEVER FORGOTTEN a conversation I had with my supervising consultant back when I was a junior doctor in ophthalmology. He was doing some admin work when he just looked at me and said: “Around 8 to 10 years into your consultant career, you will hit this wall of routine work and boredom and you will need to find ways of getting through it.”

At that time I took little notice of that advice as my jobs rotated across various hospitals but after 12 years of being a consultant, I hit that wall a year ago. I had taken on many roles during my consultant career such as educational supervisor, governance lead, clinical lead and currently royal college examiner, but I needed something more.

The idea of working for a charity abroad had been very appealing to me, but I knew very little about the logistics of performing surgery abroad and where to start. In this article I would like to outline my journey, but would emphasise that doctors considering taking up charity work abroad need to perform their own due diligence for the process.

As a junior consultant I had seen a few of my colleagues taking one or two weeks off from their usual work to offer surgery through various charity organisations abroad. Usually, charities already have a group of surgeons on their books, so the first challenge was to find a charity looking for new volunteers. The COVID pandemic hindered that process for many but, thankfully, travellng to various remote destinations in the world is now back to normal. If the charity work is for a short period of time, then considerations such as taking time out of employment and it’s effects on the NHS pension are not a factor.

Immigration and work visa

These requirements are one of the first considerations that need to be addressed. In my case, the charity took care of obtaining the relevant invitations, permits and work visas on our behalf. In some places you may have to register with the local medical register before starting voluntary work. If you are responsible for obtaining work visas and other permits, allow plenty of time to acquire those documents.

Location, location, location

Many places offering charity work may not be your choice for a family vacation. It is worth checking with the Foreign and Commonwealth Office website about latest travel advice and alerts for your destination.

My charity trip was in Cucuta in Colombia, which is a town near the Venezuelan border, so we had to take advice from our contacts there locally on how to get around safely.

Duration and experience

It is important that you have a realistic goal of what you want to achieve and that you can deliver that goal within the resources that are available to you. It was very important to us, for example, that we were able to offer the whole ophthalmic pathway for managing the patient – especially if there was a complication after surgery.

One of our surgeons was a specialist in managing complications of cataract surgery, so in the event of any complication we were able to fix the issues ourselves and did not have to rely on local surgeons. In retrospect, I was glad to have gone on that trip as a senior surgeon as the case mix was extremely challenging.

Medico-legal considerations

Doctors working in the UK are protected in the UK by NHS indemnity and some choose to have additional protection by joining various medical insurance companies. When you volunteer to work abroad the usual NHS indemnity will not apply, and therefore you will need to explore your options for additional cover.

You should initially seek confirmation from the hospital, facility or health board that engages you as to whether they will indemnify you against any claims arising from work that you will undertake. Your charity agency can ask on your behalf; however, it is definitely worth discussing further cover for situations such as clinical negligence, complaints, coroner's inquests, criminal, disciplinary and regulatory matters with your current insurance provider.

Some charity agencies may have a preferred insurance company in mind, but it is worth engaging with your current insurance provider early for advice to clarify your options.

As a general guide, it is expected that you will work within your usual scope of practice as you do in the UK and that you will comply with the legal, regulatory, indemnity and data protection requirements in the jurisdiction where you are working.

Your insurance may be invalidated if there has been a failure to comply with those requirements.

It is advisable, therefore, that you familiarise yourself with the setting, staffing level and equipment you will be working with, before you commit yourself. In our case a senior surgeon visited the hospital, inspected the equipment and identified what additional equipment was required, and a clear plan was made in advance of our attendance.

It is important that you realise that the benefits of your insurance are only likely to apply to matters brought in the UK under UK law. Those benefits may not extend to any matters brought in a different jurisdiction – or in the UK under the law of any other jurisdiction, with the exception of The Good Samaritan Act. Volunteering abroad and charity work is immensely satisfying and we will all have our own reasons for pursuing such a feat. However, you need to do your due diligence to ensure that all the processes are followed and you have enough insurance cover for following your desires and working for charity. q • Mr Shahram Kashani Bsc MBBS MRCP FRCOphth MSc is a consultant eye surgeon specialising in cataract surgery, retinal disorders and uveitis. He is the Lead for Retina Service at East Sussex NHS Trust and the Lead Clinician for South East Eye Surgeons (SEES). www.yourexpertwitness.co.uk

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THINKTANK REPORT FINDS OPHTHALMOLOGY TOPS LIST OF ‘HIDDEN WAITLIST’ PATIENTS [

A NEW REPORT from public sector policy think tank Reform has revealed what it calls a ‘hidden waitlist’ of people waiting for follow-up appointments in hospital.

According to the Reform report, there are an estimated 11 million people on the list – estimated because many trusts were unable to provide data on the subject in response to a Freedom of Information request.

Most public discussion refers to the much-vaunted referral-to-treatment data – the elective waitlist – which only accounts for patients who are waiting for their ‘first definitive treatment’ following a referral to specialist care, usually by a GP. The report states: “However, many patients require on-going care – followup appointments after a treatment or operation, guidance on medication or support to manage a chronic condition – without which their recovery may stall and their health decline.”

The report points to ophthalmology as being the treatment area with the highest number of people on the hidden waitlist: nearly half-a-million this year, at an average of 10,000 per trust.

The report says: “In 2017, 22 patients per month were at risk of losing their vision due to delays in treatment and permanent harm from avoidable visual loss is nine times more likely in follow-up patients than in new patients.

“There are now about 30% more patients on ophthalmology waitlists as pre-pandemic, meaning the number of people at risk of sight loss may have increased. Patients with chronic ophthalmological conditions such as glaucoma, age-related macular degeneration and diabetic retinopathy are most likely to be associated with loss of vision as they require long-term routine follow-ups and are particularly vulnerable.

This is likely to worsen as the population continues to age.”

Commenting on the report, Jordan Marshall, policy manager of the Royal College of Ophthalmologists (RCOphth), said: “Reform particularly stress the risks associated with delays to follow-up appointments in ophthalmology, drawing on RCOphth research when noting that ‘permanent harm from avoidable visual loss is nine times more likely in follow-up patients than in new patients’.

“Over the last two years we have argued that we need a much stronger focus on follow-up waiting lists. In our November 2022 submission to a Public Accounts Committee Inquiry on managing backlogs, we pointed to ‘a huge hidden backlog…not accounted for in NHS England statistics’.

We emphasised the need to ‘focus recovery efforts on diagnostic and follow-up delays, not just surgical backlogs’ and for NHS England to publish ‘more granular data on outpatient waiting lists including risk stratification and follow-up delays – as Wales does’.

“Ophthalmology is particularly dependent on follow-up appointments as the best way to manage chronic eye diseases which can lead to irreversible loss of sight, such as glaucoma and age-related macular degeneration. Ophthalmology has a ratio of 3.3 follow-up attendances for each first attendance. This is notably higher than the 2.3 rate across all specialties, and significantly higher than most other large outpatient specialties. This is appropriate as regular assessment and treatment is needed to prevent permanent sight loss.

“As our population ages over the next 20 years and patient need for timely eye care increases, it will be more important than ever for NHS ophthalmology units to be well resourced – in terms of having both the

requisite clinic space and consultant ophthalmologists – to deliver and co-ordinate the management of care to prevent avoidable sight loss.”

He pointed to RCOphth’s guidance from February 2022, which highlighted other steps that ophthalmology departments, trusts and policymakers can take to tackle outpatient follow-ups. They included: • Delivering diagnostic services outside of the hospital, either through • virtual clinics, which can be delivered as part of community diagnostic • centres, or in community settings such as optometry practices.

• Offering patient-initiated follow-up (PIFU) appointments where • clinically appropriate. Eye disease can be non-symptomatic until • it is at an irreversible stage, so PIFU will not be appropriate in such • circumstances.

• More robust discharge guidelines and referral refinement criteria, • working closely with primary care to enable patients to be treated in • primary eye care where clinically appropriate.

He continued: “We will continue to work with all stakeholders to ensure that the issue of follow-up backlogs in ophthalmology is properly monitored and acted on. While we encourage NHS England to undertake regular monitoring and publishing of this data, our British Ophthalmological Surveillance Unit is launching a study into patient harms caused by delays in review or treatment.” q

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EYE CARE PROFESSIONALS JOIN CHARITY TO LAUNCH SUPPORT PATHWAY [ ON 16 NOVEMBER the College of Optometrists joined senior

leaders from the NHS and the social care and charity sectors to unveil a new UK-wide Eye Care Support Pathway.

The launch event, led by the Royal National Institute of Blind People (RNIB), took place at The View, the home of the Royal College of Surgeons in London.

The Eye Care Support Pathway is a framework to ensure patients with eye care needs and sight loss have timely access to information, as well as practical and emotional advice and support throughout their eye care journey.

Its overarching ambition is to provide patients with the information and support they need, from the moment they realise that ‘something isn’t quite right’ with their sight, through to diagnosis and onto being able to live confidently – and independently – with their condition.

There were more than eight million out-patient eye care appointments in the UK in 2021/22, the highest footfall for any speciality, and according to RNIB research people often report finding it difficult to access eye health and sight loss information, services and support.

With such a level of demand on NHS practitioners and eye care departments, there is a real need for change, the college said.

Speaking about the college’s involvement in the pathway, the college’s president, Professor Leon Davies FCOptom, said: “The College of Optometrists is proud to have collaborated on this RNIBled programme of work. With the support of the NHS, the Eye Care Support Pathway will, without doubt, result in improved care experiences for patients and their families, and improved outcomes.

“A cohesive, joined-up approach right from the beginning, and

throughout every patient’s journey, will transform eye care at a time when our services have never been needed more.”

RNIB’s chief executive officer Matt Stringer added: “We know that the experience of people with eye care needs and sight loss varies greatly across the UK. It’s not acceptable that anyone, regardless of their condition or where they live, does not get the right help and support at the right time.

“Today is an important milestone, but only the beginning of the work we need to achieve together, bringing everyone together and moving forward to better support people across their eye care journey.”

The previous day, 15 November, the pathway was presented to the All-Party Parliamentary Group for Eye Health and Visual Impairment at the Houses of Parliament.

The event was chaired by Kate Osamor MP and attended by the president of the Royal College of Ophthalmologists Ben Burton.

The ensuing discussion centred on action to improve patient support across their entire eye care journey, from an ophthalmology, optometry, rehabilitation and patient perspective.

Ben Burton spoke to the audience of cross-party MPs about the need to improve patients’ experience after diagnosis of eye diseases.

He also stressed the importance of integrated digital systems, including electronic patient record systems and electronic eye care referral systems, interoperable between primary, community and secondary eye care, to ensure a smooth patient journey.

There was also a presentation from Professor Davies on how the College of Optometrists is working to ensure optometrists provide the best possible care now and in the future.

Other speakers at the event included Simon Labbett of the Professional Rehabilitation Network. q

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BLOOD TEST HELPS IMPROVE HEART DIAGNOSIS [A FIRST-OF-ITS-KIND TRIAL has

found that a high sensitivity blood test in A&E can improve diagnosis for one in five patients who have a heart muscle injury. The trial, funded by the British Heart Foundation (BHF) and published in the BMJ in November, found that the test helped doctors to better diagnose and treat those patients, reducing death and future heart attacks in the group by almost 10% after five years.

Led by Professor Nicholas Mills at the University of Edinburgh, the trial showed that the new test – an update of one which detects levels of a protein in the blood called troponin – could spot more patients with injury to their heart muscle.

The better care they received as a result produced a lower rate of future heart attacks and deaths.

Troponin is released into the blood during a heart attack or when the heart is injured due to other heart conditions. Different troponin blood tests have been used for years by doctors to help diagnose those conditions in people with chest pains and related symptoms.

While the new test led to improvements for heart attack patients, those who benefited most were patients with a heart muscle injury caused by other heart conditions, such as heart failure, heart valve conditions and heart arrhythmias. The researchers found that those patients saw a nearly 10% drop in future hospital admissions and deaths in the five years after getting the new test, compared to those who had the older, less sensitive test.

To assess whether introducing the new test brought any improvement, the researchers studied the results for nearly 50,000 people who arrived at 10 A&E departments across Scotland with a suspected heart attack between 2013 and 2016. They used routinely collected health record data and a pioneering data service, DataLoch, to follow up all participants for five years.

The new test showed that over 10,000 patients had high troponin levels, indicating heart injury. With the high sensitivity test picking up more subtle warning signs, around one in five of these patients were only spotted by the new test.

By identifying heart injury in patients who may otherwise have gone unnoticed and untreated, the researchers hope that more people could receive the specialist heart care they need to avoid more serious events in the future.

Dr Ken Lee, clinical lecturer in cardiology at the University of Edinburgh, and the lead author of the study, said: “In the past, clinicians

could have been falsely reassured by the results of the less sensitive troponin test, discharging patients that appeared to not have heart disease.

“This new high-sensitivity test is the tool they needed, prompting them to look deeper and helping them to identify and treat both heart attacks and less obvious heart problems. In our trial, introducing this test led to an impressive reduction in the number of future heart attacks and deaths seen in this at-risk group.”

The improvements are now not limited to the 10 Scottish hospitals involved in the study and are likely being seen across the UK. Having already rolled out the new test widely to A&E departments across the country, the UK is now ahead of the curve when it comes to heart attack and heart injury detection.

Professor Sir Nilesh Samani, medical director of the BHF, commented: “Medical professionals in emergency departments need the most efficient and accurate tools to look after people. This particularly applies to those who arrive with a suspected heart attack. Such a time-sensitive and life-threatening condition requires the very best diagnostic tests.

“It is very encouraging to see that the new test trialled here is better at predicting long-term outcomes for these patients, whether they had a heart attack or a different kind of heart injury. This can lead to improved care for such patients.” q

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