Your Expert Witness Issue No. 48 by DMMonline

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contents IN THIS ISSUE 7

Opening Statement

NEWS 8

Court reform: HMCTS admits to slippage

Court system is letting down child witnesses, says charity

LSB urged to apply caution to rule changes

MoJ grant will help provide support for victims in court

BUILDING AND CONSTRUCTION 13

Grenfell campaigners form national action group

Minister attacked over ‘inactivity’

Edinburgh to host fire safety conference

17 MEDIATION 14

A century of mediations: the musings of a modest mediator

FINANCE AND ACCOUNTACY 16

HMRC set to begin crackdown on loan schemes

ROAD TRAFFIC ACCIDENT INVESTIGATION 17

Tyre expert’s evidence in multi-fatal accident supports change to tyre laws

ANIMAL WELFARE AND BEHAVIOUR 18

Dr WHO?

A to Z WEBSITE GUIDE 19 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

EXPERT CLASSIFIED 43 Expert Witness classified listings 46 Medico-legal classified listings

Your Expert Witness Suite 2, 61 Lower Hillgate, Stockport SK1 3AW Advertising: 0161 710 3880 Editorial: 0161 710 3881 Subscriptions: 0161 710 2240 E-mail: ian@dmmonline.co.uk Copyright Your Expert Witness. All rights reserved. No part of this publication may be copied, reproduced or transmitted in any form without prior permission of Your Expert Witness. Views expressed in this magazine are not necessarily those of the publisher. Printed in the UK by The Magazine Printing Company Plc www.magprint.co.uk

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MEDICAL ISSUES 21 Medical Notes

NEWS 23

Welsh inspectorate publishes report into Kris Wade affair

New indemnity schemes embraced by GPs

GMC consultation welcomed by doctors’ legal body

CQC urges people to ‘declare their care’

OPHTHALMOLOGY 27

Ophthalmology standard welcomed; but implementation is another matter

ORTHOPAEDICS AND ORTHOTICS 29

How long should a hip or knee replacement last? Now we know

Orthopaedics experts come in many forms

Physios in primary care can free up GPs’ time

Patient Safety Alert issued for fracture fixation plates

New centre of excellence to be sited at Salford

What the eye cannot see...

PELVIC MESH COMPLICATIONS 32

The medicolegal challenges associated with pelvic mesh complications

DENTISTRY & MAXILLOFACIAL SURGERY 34

Maxfax body calls for dermal filler regulation

Dentists should screen for head and neck cancer

CARDIOLOGY 35

UK heart attack survival improvement modest, research shows

CVD prevention a priority for NHS

PSYCHIATRIC & PSYCHOLOGICAL ISSUES 37

Reconsider mental capacity changes, Law Society says

Guardianship call echoed by RCPsych

Mental Health Act: CQC finds care improvements

How reliable are the results? Best practice effort testing in neuropsychology

PLASTIC, RECONSTRUCTIVE & HAND SURGERY 41

Cosmetic practitioners and CQC agree way forward

Surgeons asked to look out for stolen Botox

OBSTETRICS & GYNAECOLOGY 42

GPs vote for decriminalisation of abortion

Teachers get help in teaching about abortion www.yourexpertwitness.co.uk

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Opening Statement [

LATER THIS YEAR the ITV series Judge Rinder’s Crime Stories will be charting the campaign to introduce regulations regarding the age of tyres on buses, coaches and lorries. The campaign was begun by the mother of an 18-year-old man killed when the coach he was travelling in crashed after the tyre burst. Forensic examination showed the tyre to be nearly 20 years old and seriously degraded from within because of its age. After more than six years the campaign is finally reaping some reward, with the announcement that the government will be consulting on possible legislation. The expert witness at the inquest into the tragedy has also been campaigning for a change in the law. He explains the reasons and describes another, similar incident. • Nearly two years after the horrendous loss of life at Grenfell Tower, while action has been taken to remove the deadly cladding from public buildings and social housing, privately-owned blocks of leasehold homes remain at risk, principally because the ‘owners’ or freeholders have declined to pay for its removal. In some cases campaigning and threats to developers’ reputations have succeeded in shaming them into shelling out, but more often the residents – many first-time buyers – are threatened with being forced to pay for the work. What’s worse is that some freeholders have thumbed their noses at government threats. • It is to be hoped that the now-banned cladding won’t turn up on the new Courts and Tribunals Service Centres, part of HMCTS’s £1bn modernisation programme. Whether it will be that modern by the time the programme is finished is open to debate, however – the six-year programme has turned into a seven-year process already. The main thrust of the programme is to digitalise most of its work – work that has, to be honest, been carried out to date in a manner recognisable by Dickens. Trying to bring everything into the 21st century at one fell swoop is proving to have been an overambitious effort. • Whatever the level of computerisation of a court system, the need to hold physical trials remains, and witnesses in those trials need to have assurances they will be treated fairly – especially children. A recent report from the NSPCC says that is not happening – mainly because repeated delays to trial dates mean that detail and circumstances become forgotten in the interminable time lag. The lives and education of these children is being ruined by having trial dates repeatedly put back; what is worse is that in some cases perpetrators are going free and even evading trial altogether. • Expert witnesses, hopefully, do not have the worry of their evidence being compromised by lack of memory. Where there are potential problems, however, is when the wrong expert is appointed. In cases involving animals the danger is accentuated by the fact that there is a lack of easily-recognisable specialties in the veterinary world. Add to that the fact that anyone can call themselves an animal behaviourist and set up as an expert. As usual, a combination of relying on reputable professional bodies, picking colleagues’ brains and asking the right questions is the best way forward. Our contributor – an equine expert with over two decades of experience – is a good starting point. • Of course, it doesn’t always have to go to court. Alternative dispute resolution is becoming more common – though not as common as the authorities would like. Mediation, in particular, is an efficient way of resolving those disputes that are capable of being resolved. In the commercial world most are – it is in nobody’s interest for disputes to drag on and go to court. You could do worse than take advice from a mediator with a century under his belt. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Court reform: HMCTS admits to slippage [ H M COURTS & TRIBUNALS SERVICE has put the

completion date for its court modernisation programme back by a year. The government has announced that a revised proposed finish date of the £1bn project will now be 2023. Ministers said they had learnt from the services already reformed and feedback received from the Public Accounts Committee and National Audit Office. The plan is now to ‘reorder aspects of the programme’ to allow more time to develop some of the shared systems that will form the basis of the next set of online services. It is not clear from the announcement which services are being held back and delayed by the extra year. HMCTS added: “The reform programme is both essential and ambitious. It will transform the administration of justice by shaping it around the needs of its users, and we are determined to deliver it effectively in the interests of all. “Existing services, which are already providing quicker and easier access to justice for many – including divorcing couples, executors of wills and people appealing decisions about their benefits – continue to be available and will have more elements added to them in the coming years.” The programme has so far delivered a pilot of fully-video hearings in the tax tribunal, a new in-court system to record the result of cases digitally and instantly, a civil money claims service

for low-value cases and online divorce and probate services. As recently as last month, when HMCTS responded to the Public Accounts Committee’s plea for progress reports, the department was envisaging a finish date of May 2022. Last May, the National Audit Office warned of a ‘significant risk’ that HMCTS would not be able to achieve all it wants within the time available. The revised completion date, subject to crossgovernment approval, means the project is now due to take seven years in total. Responding to the HMCTS announcement, the chair of the Bar Council, Richard Atkins QC, said: “This extension, while sensible, reflects the fact that the programme is over-ambitious and is not delivering all projects to time and cost, as reflected by the National Audit Office and the Public Accounts Committee. “The Bar Council has had serious concerns about aspects of the programme since its inception. It has appeared to focus too much on what might be technically feasible and not enough on the quality of justice. As the investment of over £1bn was predicated on delivering very significant savings year after year from the completion of the programme (a 'spend to save' programme), this delay must be accompanied by a re-profiling of the expected saving. “Despite our concerns we continue to engage constructively with the CEO of HMCTS and her team.” q

Court system is letting down child witnesses, says charity [A 13-YEAR-OLD WITNESS struggled

to recall information in detail when crossexamined in court after waiting two years for a trial to begin: that is one of the findings of research commissioned by the NSPCC. The charity says child witnesses are being let down by the criminal justice system. Reducing delay between reporting and trial is crucial to ensuring that children can provide the ‘most complete and consistent testimony’ as possible, says the NSPCC. However, its Falling Short? report highlights the impact of delays on young witnesses. One intermediary told researchers: “I had a case recently where I had met the child when she was four for the ABE (achieving best evidence), but the trial was two years later. A date was set and I’d been asked to attend, before it was decided that too much time had elapsed and she wouldn’t remember.” Another intermediary recalled: “I was at a trial yesterday with a 13-year-old. It has taken two years to get the case to court and during cross-examination she had to reply ‘I can’t remember’ to several questions. Part way through, she turned to me and said ‘I can hardly remember any of it.’ It’s completely unacceptable that children should have to wait two years and then be expected to recall information in minute detail.”

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According to respondents – who included judges, barristers and solicitors – demand for access to the young witness’s social media, emails or phone records is cited as a major reason for pre-trial delays. Government policy states that cases involving a vulnerable or intimidated witness must have a fixed date for the start of the trial. However, several respondents said fixtures involving young witnesses were sometimes 'floated'. An independent sexual violence adviser recalled a 13-year-old whose first trial date was in May 2017, and which was adjourned to December that year. On the way to court the family was called to be told that the case was being adjourned to June 2018. “The child’s education is suffering and the family has been devastated,” the adviser said. While the report focuses heavily on child witnesses, it also highlights concerns that young defendants are treated differently. Some judges were concerned about the absence of a regulated intermediary scheme for vulnerable defendants. Some judges thought young defendants were dealt with less fairly than young witnesses for the prosecution, including a lack of automatic access to special measures and being routinely confined in the dock in adult courts.

Just for Kids Law, which represents and advises children, said it ‘too often’ finds that child defendants are not given the appropriate support they need. The charity’s legal director and founder, Aika Stephenson, said that is particularly concerning ‘given that a significant proportion of child defendants have learning difficulties, disabilities and mental health issues which can magnify the impact of court proceedings’. q

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LSB urged to apply caution to rule changes [ IT IS IN THE public interest that the Legal Services Board

(LSB) demands and scrutinises evidence before approving major rule changes, the Law Society of England and Wales said in response to the LSB’s Business Plan 2019/20. The consultation period for the draft plan closed on 28 February. The plan contains proposals for the LSB to achieve its three strategic objectives: • Promoting the public interest through ensuring independent, • effective and proportionate regulation • Making it easier for all consumers to access the services they • need and get redress

MoJ grant will help provide support for victims in court [ THE MINISTRY OF JUSTICE has announced the award of

a grant of just under £900,000 to two organisations who provide in-court support to vulnerable victims: the Personal Support Unit (PSU) and the Citizens Advice Witness Service. PSU has been supporting litigants in person in family courts since 2001 and Citizens Advice has been supporting witnesses in criminal court proceedings since 2015. They both have extensive front-line experience of helping victims and witnesses to navigate court processes and feel safe at court. Citizens Advice will be using the funding to extend their current Witness Service to selected family courts, to provide information and practical and emotional support to victims before, during and after the day of the hearing. PSU will be using the funding to invest in further training of their staff and volunteers and to share learning on best practice with a range of family justice stakeholders. The funding runs from January this year to 31 March next year. It will allow Citizens Advice to provide these services in up to 12 family courts across England and PSU in 24 courts across England and Wales. In a statement the Ministry of Justice said: “We are determined to improve the experience of victims of domestic abuse in the family courts, and this grant is part of a wider package of measures across the family justice system.” q

• Increasing innovation, growth and the diversity of services and • providers That includes working in partnership with the Law Society. Law Society president Christina Blacklaws said: “We support evidence-based regulation, making use of the available research, to enable a robust assessment of the costs, benefits, risks and opportunities of any given regulatory intervention." “Given the push for greater transparency in the legal sector, the LSB should insist on consistent use of evidence across regulators. Making such evidence publicly available will give increased public confidence in regulatory decision-making. “This should ensure regulatory changes are more incremental, more targeted, easier to implement, and more beneficial to the public and solicitors alike. “The oversight regulator should provide a stabilising influence for the market, ensuring that all the regulatory objectives are applied in a balanced way.” Another respondent to the consultation was the Association of Chartered and Certified Accountants, which commented: “We would expect the LSB to place less emphasis on issuing rules in accordance with the Legal Service Act 2007, conducting research and publishing reports. Although compliance with legal requirements is of course important, we feel there is too much focus on rules and structures and a lack of focus on achieving the right outcomes. “We are broadly supportive of the LSB’s proposed business plan for 2018/19. The key workstreams provide clarity on the activities that the LSB intends to complete in the first year of its three-year strategic planning period.” q

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Grenfell campaigners form national action group [

A CAMPAIGN GROUP of leaseholders in private blocks with Grenfell-style cladding has been formed. Called the UK Cladding Action Group, it comprises leaseholders in London, Leeds, Sheffield and Manchester. According to a report in The Guardian: “The launch of the national campaign reflects a sharp contrast in how private and social housing is being fixed. Similar cladding to that which helped spread the fire at Grenfell has been used on 433 highrise residential and public buildings in England.” The report notes that, while 79% of council or housing association blocks have been remediated or have work underway, only 11% (10 out of 173) of the privately-owned blocks have had work done. A major issue is the fact that many of the blocks have had the freehold passed on to third parties – many offshore companies – who have threatened to pass on the cost, often running into millions, to leaseholders. That is despite

government assurances that it will act to prevent that happening – assurances that have been described as ‘empty threats’ by one freehold owner. In a small number of cases the original developers have agreed to pay to have the work done – mainly to avoid ‘reputational damage’. One such case was resolved in March in Manchester, when residents of two blocks in the city’s Green Quarter won a battle against having to pay. A consortium including Lend Lease, the Australian giant which built the blocks, agreed to finance the work. Last year a housing tribunal ruled the residents would have to pay for the remedial work – as well as the walking fire watching. It also refused a Section 20c order, thus allowing the freeholder to recover its costs. The issue surrounding the Green Quarter flats sparked fury in January when it was announced that Lend Lease had been awarded the £330m contract to refurbish Manchester Town Hall. q

Minister attacked Edinburgh to over ‘inactivity’ host fire safety [ THE LATEST DEVELOPMENTS in Manchester followed

a blistering attack in the House of Commons in January on Housing Minister Kit Malthouse by his opposite number, John Healey. Referring to the government’s ‘inactivity’ over Grenfell-style cladding in private blocks of flats, Mr Healey asked: “If the government cannot deal with this, what is it in office for?” Mr Malthouse referred to commitments from the owners of 268 privately-owned buildings, 212 of which had either started works, completed them or have commitments in place to remediate. There remain, he said, 42 for which the owner’s plans are unclear. Mr Healey declared: “It should be a cause for national shame that, over 19 months after the Grenfell Tower fire, I am having to drag Ministers to the House because there are still buildings in this country cloaked in Grenfell-style cladding and residents who do not know whether their homes are safe.” Mr Malthouse even came under attack from Members on his own side. Robert Neill, Conservative MP for Bromley and Chislehurst, raised the issue of Northpoint in his constituency, where 57 leaseholders face bills of £4m to remove cladding. “Assertive measures are urgent for my constituents at Northpoint in Bromley, one of the 42 buildings where the owner – in this case Citistead, an offshoot of the Tchenguiz family trust – refuses to meet its obligations and insists that it will use a term in the lease to pass on the costs to the flat owners regardless. The Government need to introduce a legally foolproof mechanism to override those provisions and prevent my constituents and others from being forced to pick up the tab. Words are not enough.” q

conference

[ THE HILTON CARLTON HOTEL in Edinburgh will be the venue

on 21 May for the BSI conference on Fire Safety in Construction: The Future. Billed as a ‘must-attend’ event, it features the latest fire safety updates and an insight into standardisation within the fire safety sector. Speakers from all aspects of the fire safety community will provide cutting edge opinions and commentary on the major issues facing the industry today. Delegates will gain an in-depth understanding of the forthcoming changes to key fire-safety standards and hear about the impact they will have on their organisation and the fire safety industry. Conference topics include BS 7974 fire safety engineering, risk assessment, building regulations and fire suppression systems. In light of recent events there will also be sessions on fire evacuation techniques in tall buildings and facade testing, as well as Brexit's impact on standards. q www.yourexpertwitness.co.uk

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A century of mediations: the musings of a modest mediator

By CHRIS MAKIN Chartered Accountant, Civil Mediator and Expert Determiner

[ LAST YEAR I completed my 100th

mediation: it’s now 112 to date, at a settlement rate of 80%. Now a century may not be a huge number compared with those QCs who do nothing else, but it is a landmark: and it got me thinking about where I’ve come from, how I got where I am now, what I’ve learned, and how much good I may have been able to do for others along the way. And if what follows is of modest value to you, dear reader, then I’m content. I qualified as a mediator 21 years ago – how time flies! It seemed the natural thing to do, after I’d attended all the expert witness courses at The Academy of Experts. And as good luck would have it, that was when Lord Woolf was following his Access to Justice agenda – and just nicely before April 1999, when the Civil Procedure Rules (CPR) were introduced. Under Part 1 of CPR, judges now had a duty to encourage and facilitate ADR, so everyone in civil litigation would see a mediator instead of pursuing formal litigation and the courtrooms would be empty. What a time to be alive on this glorious dawn! Did it happen? Well, not really. In fact, my phone didn’t ring for the first few years; but that wasn’t too important because I was very busy as a forensic accountant and expert witness, which continues to be the case. So the first lesson I learned was that mediation is not a career – unless you are one of the 65 mediators in England who do 65% of the mediations each year – so don’t give up the day job! The challenge is to know how to get going, and I had expected that the first job might come from one of the mediation groups I had joined. It finally happened, but only when a solicitor I knew asked one of these groups to find them a mediator. The first two had conflicts; they then said could they have Chris Makin because they knew he was a mediator, and the group found that they had forgotten to put me on their list! So the second lesson is to check whether the groups you join have remembered you. Now I had a first mediation and I was away. It settled, so now I was a mediator with experience, and a 100% success rate: one out of one! The first few mediations were accountancy based: partnership, fees, shareholder disputes and the like. I was chosen because I was a mediator and an accountant; solicitors and their parties thought they would need someone with specialist knowledge. To an extent they were right. For instance, in a partnership dispute I normally set up a spreadsheet to answer the ‘what ifs’: what if I agree to my partner taking out the freehold property at £x; what if we agree to vary the profit share ratio from 50:50 to 45:55; and so on. My spreadsheet can quickly calculate the financial effect of agreeing (or not) certain matters. But while specialist knowledge helps to gain appointments, it is not too important in the mediation. A solicitor may want to

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appoint an accountant mediator for a partnership dispute, but most parties just want to get things off their chest – and after that it’s largely a matter of finding an accommodation which the parties can live with. So the third lesson is that parties don’t need a specialist mediator so much as a social worker; learning to listen and empathise is much more important than being able to understand all the technicalities of the case. If that were not so, then I would not have been able to mediate cases concerning defective premises, boundaries, rights of way, probate, planning permissions, construction projects, legal professional negligence – the list goes on. With a good range of subjects under your belt, you can be known as a mediator per se. The next challenge was how to develop a good flow of appointments, because it is not enough to rely on leads from directories or adverts. I write to solicitors as often as I can, usually with some update to show that I am keeping up with developments; and I talk mediation to whoever I meet. I also try as often as I can to get in front of groups of lawyers and give them a free talk on mediation. It’s surprising how many litigation lawyers have never done a mediation. Lesson four: never miss the chance to tell the world that you are a mediator. My website – www.chrismakin.co.uk – is a good marketing tool: that’s lesson five. It includes simple hints on what mediation is, how to arrange one, how to prepare for one, what happens on the day and so on. I even include videos. I always suggest that lawyers draw their clients’ attention to it, knowing that the lawyers who are unfamiliar with the process will have a peep for themselves. So what does happen on the day? Lesson six: you never know! Both (or all) sides will normally have submitted a position statement and supporting documents, and of course one has to read them carefully. But it is surprising how often things come out in the private meetings which were not mentioned at all in the papers. The mediator must be on their toes, listen carefully and use whatever becomes available. One example will suffice: I had a mediation between a mother and son, where the son accused his own mother of diverting £274,000 of cash takings to herself. The son attempted to prove it by compiling capital and income statements, as a tax inspector might when investigating a taxpayer. A son-in-law who came along for moral support happened to be a tax manager at a firm of accountants. I asked him to sit in a separate room and mark his brother-in-law’s ‘homework’. The errors found narrowed the gap between mother and son considerably, which led to a settlement. So use what you have, but listen carefully to pick up the clues. Lesson seven is to be kind to one’s fellow mediators. There still aren’t enough mediations around, so I always try to take along a co-mediator,

who will participate in the mediation for no fee – buy one, get one free! Mediators are always keen to accumulate ‘flying hours’. It is an act of generosity to give them that opportunity, but it pays dividends too. I have received several mediations and forensic assignments from lawyers who were happy to come along just for the experience. The next lesson I have learned is that parties are truly relieved when the case settles on the day. Litigation is like dancing with a gorilla: the dance stops only when the gorilla chooses to let go. But with mediation the parties are in charge, and mediation is probably the last chance they will have to stop the dance. When a case settles there is a huge sense of relief, sometimes followed by a puzzled look when parties start to wonder what to do with all their spare time now that the dance has stopped. Lesson nine is that parties really can reach an agreement which a judge could never order. In litigation, with minor exceptions the judge can only make a finding that A will pay £x to B by a certain date – with arguments over who will pay the costs, though the loser still normally has to pay. So there is a victor, and a lot of blood on the carpet for the loser. In mediation, virtually anything legal can be agreed between the parties. For example, in a defamation mediation an ex-employer had given a damning reference and regretted it. The ex-employee sued. I settled the mediation when the employer resiled from the reference and wrote a new one during the day, agreed paragraph by paragraph with the ex-employee. She was then able to reapply for the job she craved. A judge could never have ordered a new reference. In another case, a dispute over the purchase of a business was going nowhere. The purchaser wished to exercise an option to buy a freehold factory worth £600,000, on which the 4% stamp duty would have been £24,000; except that the option was in favour of the purchaser’s company, whereas he wanted his pension fund to buy the factory.

The purchaser would have had to have his company exercise the option – stamp duty £24,000 – and then the company would have had to convey the property to the pension fund – another £24,000. The case settled when the vendor agreed that the option clause could be amended, so that the factory could be bought directly by the pension fund. That saved £24,000, which was a big enough concession to enable the parties to settle all their differences – and it cost the vendor nothing. That leads me to lesson 10, the most important of all: look for the gold dust. In almost every case there is something which one side can afford to give up at minimal cost, but which the other party values highly. In the cases above it was the employer’s reference and the stamp duty saved. The mediator must be patient and listen to all the high emotion between the parties – let the bile spill out – but must also be alert to the clues which might lead to settlement. It is easy to encourage the habit of saying yes if one side is losing nothing and the other side is gaining a lot. There is just one more lesson to mention. Most mediations settle, and I tell the parties that they have made the right choice in agreeing to mediate – also that everything is in confidence, so it cannot be used in any later court hearings. But for the small minority of cases which fail to settle, there is still value because the parties will have learned a great deal about the other; and that knowledge so often results in a well-informed Part 36 offer, or a without-prejudice discussion which leads to settlement. So is mediation a satisfying experience? Absolutely! The satisfaction of bringing together warring parties, especially family members or business partners, is enormous. The more often I can bring the gorilla dance to an end, the happier I feel. So if you want a really keen, experienced and helpful mediator, bring it on! As Lord Justice May said in Egan-v-Motor Services (Bath) Ltd [2007] EWCA Civ 1002: “Try it more often.” q

About Chris Makin [ CHRIS MAKIN has practised as a forensic accountant and

expert witness for 30 years, most recently as head of litigation support at a national firm. He has been party expert, single joint expert, court-appointed expert and expert adviser in hundreds of cases, and given expert evidence around 100 times. He also frequently performs expert determinations. Chris is a fellow of the Institute of Chartered Accountants, where he serves on the Ethics Advisory Committee and as an ethical counsellor. He is a fellow of the Chartered Management Institute, a fellow of the Academy of Experts, where he serves on the investigations committee, and a qualified mediator and expert determiner. He now practises as a freelance mediator from his home in West Yorkshire and his office at 3 Gray’s Inn Square, London WC1R 5AH. Tel 020 7430 0333 / 07887 660072 or visit www.chrismakin.co.uk. He has mediated a vast range of cases, with a settlement rate to date of 80%. q

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HMRC set to begin crackdown on loan schemes [ UP TO 50,000 self-employed workers

in the UK are facing a huge tax bill as HMRC deploys a crackdown on loan schemes dating back 20 years. The schemes, in which they were enrolled as contractors, saw them paid them via loans from an offshore trust. The Association of Chartered Certified Accountants (ACCA) has urged those affected to seek advice from a qualified accountant. The new charge, to be levied from 5 April, stems from government legislation in 2016, which applied a tax charge on outstanding balances – where employees had benefited from the lower tax rates applied under loan advances, instead of being paid salaries. The schemes first arose in 1999, following a change in legislation on the way contractors were taxed. In 2010, HMRC issued a notice on such schemes advising they would fail, and three years later revealed it would conduct an investigation into the tax affairs of loan schemes users. Those yet to have paid on outstanding loans dating back to 1999 could be facing

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a hefty tax bill. On average, the tax at stake is £13,000 per person – a figure based on extremes. Examples of those using the practice were highly-paid contractors redirecting personal income through trusts based abroad. If the loan was repaid within the tax year, then it is ignored for tax purposes. It has also been widely reported HMRC is now issuing settlement offers in some cases, allowing users to avoid the loan charge. Chas Roy-Chowdhury, head of taxation at ACCA, said: “ACCA urges anybody who used a loan scheme, or even thinks they may have been enrolled on one, to seek advice from a chartered certified accountant. It is important to check if you are still enrolled, as HMRC will only offer you help if you are no longer using loan schemes. “HMRC has revealed that settlement do not necessarily need to be paid in one go. Payment arrangements are available. Those with a taxable income of less than £50,000 in the 2018/19 tax year won’t have to provide detailed supporting information about income and assets, and can spread

payments over five years. A seven year plan is available for those with an income of less than £30,000 a year.” He said the number and variety of taxpayers involved is quite considerable, and that over the last 20 years differences in each scheme have arisen. “It is impossible to generalise, and we are witnessing what is becoming an irreparable situation. Some employees were doubtlessly fully aware of the scheme, relying on the fact it was a loan which would never be repaid. Others rightly or wrongly relied on reassurances the scheme was legal and effective. “HMRC were very slow to publically condemn these schemes, and to pursue taxpayers, even those where enquiries were opened into their affairs. The schemes relied upon having terms which would have allowed the balance to be repaid, and maybe even on certain conditions being met. Whatever the intentions of the parties, the legal words said that the advance of the funds was a loan.” q

Tyre expert’s evidence in multi-fatal accident supports change to tyre laws [

A CAMPAIGN TO BAN the use of tyres more than 10 years old on public service and commercial vehicles has moved a step nearer to success, with the announcement by the Transport Secretary that there will be a consultation on the issue. The campaign – named Tyred – has attracted considerable attention in the North of England since its launch by Frances Molloy, whose son Michael was one of three people killed in 2012 when the minibus they were travelling in on the way home from a music festival veered off the road and crashed. The cause of the crash was established as being the failure of a tyre that was nearly 20 years old – older than Michael himself and even older than the coach! One of those who gave expert evidence to the Surrey Coroner was David Price of Forensic Accident Investigation Services. David testified that the tyre failed principally as a result of its age. In March David found himself giving evidence before a judge – in this case Judge Rinder, at the ITV Studios in Salford. An episode of Judge Rinder’s Crime Stories describing the accident and subsequent campaign will be aired in September. The timing was poignant for David, as it came just a week after he gave evidence to the Avon Coroner concerning yet another accident caused by tyre wear. In that case a lorry had gone out of control as a result of an old front tyre bursting, again principally as a result of its age. The lorry had crossed over the central barrier of the M5 motorway north of Bristol and collided with oncoming cars, in which five people died. David had been asked by Avon and Somerset Police to investigate the failure of the tyre following the crash in 2017. He found that both the front offside and the front nearside tyres were 18¼ years old. Said David: “The tread of the front offside tyre had been delaminating (separating) and ultimately the tread had started to peel off, exposing the underlying casing ply which then burst open. As always with lorries, buses and coaches, the vehicle veered sharply across to the side of the deflated tyre despite the efforts of the driver to resist the steering pull. “Once again, I found that the tyre failure was mostly attributable to ageing of the tyre. I also found that the front nearside tyre’s tread had partly torn away, but it had only done so during the accident. However, I considered the ease with which it tore away to be surprising. A further examination commissioned by DfT found that there had been significant deterioration of the rubber in the tread of both tyres (worse in the failed front offside one).”

David expressed himself pleased that the government is taking action on the issue, but thinks the proposals don’t go far enough. “In my view, legislation should apply not only to larger vehicles but to cars and vans, too. Additionally, it should apply to caravans, trailers and motor-homes, as they often have infrequent use and therefore can have treads with a pattern depth well in excess of the legal minimum, despite the tyres being very old.” q

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Dr WHO? Dr DEBBIE MARSDEN, a leading equestrian expert with over 20 years professional experience of expert witness work, offers some advice on selecting the right expert in cases involving animals

[

IN ANIMAL RELATED CASES, a veterinary surgeon is often the best expert, being generally regarded as an authority on animals and easily recognised by the word ‘veterinary’ – a protected title – and the letters MRCVS (Member of the Royal College of Veterinary Surgeons) after various degrees. As with all professions, when seeking an expert it is best to use a specialist; and vets are not allowed to describe themselves as a ‘specialist’ until they have taken considerable further study and been further examined in a particular area. The letter D or Dip, for Diploma, is the additional qualification to look for in a vet with particular expertise in any area, for instance DSAS – Diploma in Small Animal Surgery (Orthopaedics). But beware! All vets are entitled to use the title ‘Dr’ without having carried out research or undertaken any further study, such as that which will have been done by the academic with a PhD degree, who is also entitled to use ‘Dr’. Vets can also gain Certificate status in any particular discipline (for example Cert EP – Certificate in Equine Practice) when beginning their postgraduate interest, without necessarily having been further examined or undertaken a residency in any area. So do look for the ‘D for Diploma’ if wishing to instruct a veterinary expert with particular expertise in any specialism. The Royal College has a list of vets who are ‘recognised specialists’ in all the various areas, available on the website at www.rcvs.org. If the physical aspects of performance, welfare or movement patterns are important to your case, you may find a chartered veterinary physiotherapist particularly useful. Again, they are recognised by the protected title ‘veterinary’ and registered with a specialist organisation such as ACPAT (Association of Chartered Physiotherapists in Animal Therapy) – listed on www.acpat.org.uk. Many people assume that vets are also experts in animal behaviour; but they are primarily experts in the diagnosis and treatment of disease, and actually taught very little animal behaviour beyond that necessary to recognise a healthy animal, or various signs of illness or injury, and to give a basic welfare assessment. That assessment is mainly based

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on health – which is after all important, but not the only aspect of welfare to consider. In animal welfare-related cases you should consider also using an animal behaviour expert, ideally one who also has extensive experience in the day-to-day care of that species. After health, various freedoms – including ‘from fear’ and ‘to express most normal patterns of behavior’ – are embedded in how welfare is assessed in the UK. If the behaviour of an animal is key to your client’s position, then an animal behaviour expert will be more useful than a vet. That is also the case when the adequacy (or not) of any training, instructing, handling or management of the animal is in question. In particular, an animal behaviour expert can usually answer the question “Why did the animal…?” and that can often greatly assist with assessment of cause and effect in, for example, personal injury cases. There is a lot less regulation in the animal behaviour industry; anyone can set themselves up as an ‘animal behaviourist’ and ply a usually very lucrative trade among distressed pet owners. There are no protected titles and no professional penalties for ‘over-selling’ or marketing yourself as a specialist or as having particular expertise. There are also many experienced animal trainers who may be able to assist, but the safest option for expert witness work is to use a behaviour consultant, behaviourist or counsellor, who is a member of a recognised professional body, such as for small animals the Association of Pet Behaviour Counsellors. They are at least required to hold an appropriate degree and insurance, and their work is assessed by the organisation before joining and being listed on www.apbc.org.uk. For horses there is the Society of Equine Behaviour Consultants, a professional and regulatory body where entry to the professional register is by examination after a considerable amount of specific postgraduate-level training and submission of portfolio work. Consultants must also hold public liability and professional indemnity insurance, prioritise safety and welfare in their work, offer the highest standards of customer service and stay up-to-date with required CPD – see www.sebc.org.uk. So, if you reckon the Animals Act is complicated, animal ‘experts’ can be too; but hopefully this information will help to point you in the right direction and sort the sheep from the goats. q

Welcome to our A to Z guide of the websites of some of the Expert Witness field’s leading players. If you are one of our many online readers simply click on any of the web addresses listed below and you will be automatically directed to that particular website. To get your website listed on this page just give us a call on 0161 710 3880 or email ian@dmmonline.co.uk Mr. Michael Hodge Translations and Interpreting for the Legal Profession since 1997. Specialists in Personal Injury and Clinical Negligence.

Maxillofacial and Oral Surgeon. • Personal Injury • Criminal Cases • Clinical Negligence

www.abc-translations.co.uk

www.consultantoralandmaxillofacialsurgeon.co.uk

Dr Thomas C M Carnwath

Laird Assessors

Consultant Psychiatrist and expert witness in medical negligence and personal injury cases.

The UK’s leading Independent Automotive Expert Witnesses. Comprehensive, clear reports backed by technical prowess

www.tomcarnwath.co.uk

www.laird.expert

Mr Jeremy P Crew MA MD BChir FRCS

Mr Chris Makin

Consultant Urological Surgeon Medical reports on all legal aspects of urology. Reports in some cases based on hospital notes only.

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

www.oxfordurology.co.uk

www.chrismakin.co.uk

Dr Lars Davidsson MRCPsych MEWI

Mr Marcus Ornstein

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

Hon Senior Lecturer and retired Consultant Surgeon with expertise in general surgery, breast disease, hernia and abdominal trauma. T: 07713 860000 E: markornstein@gmail.com

www.angloeuropeanclinic.co.uk

www.marcusornstein.co.uk

Drilling Expert Legal Services

Principis Ltd

Mr Steve Devereux CEng ACIArb • Well engineering • Onshore & offshore drilling • Drilling rigs & operations

Asbestos expert witness and opinion relating to the safe management of works, regulatory compliance, disputes and exposure.

www.drilling-expert.legal

www.expertasbestos.com

Emma Ferriman Ltd

Dr Gerry Robins MBBS FRCP MD PGCLTHE

Consultant Obstetrician and Fetal Medicine Specialist • Prenatal diagnosis • Obstetric ultrasound • First trimester screening • Multiple pregnancy and high risk obstetrics

Consultant Gastroenterologist Full medico legal service in all cases relating to gastroenterology

www.emmaferriman.co.uk

www.drgerryrobins.co.uk

Expert in Mind

Mr Bernard Speculand MDS FDS FFD FRACDS (OMS)

Providing high quality medico-legal reports within the field of mental health

Consultant Oral and Maxillofacial Surgeon. Personal injury and clinical negligence cases for claimant, defendant and as Single Joint Expert. Special interest is TMJ Surgery.

www.expertinmind.co.uk

www.birminghamtmj.co.uk

Professor Parviz Habibi MB ChB PhD FRCP FRCPCH

Target Psychology Ltd

Consultant in Paediatric Intensive Care & Respiratory Medicine. Specialist in treating respiratory conditions and sleep disorders as well as paediatric intensive care.

Adult and Child assessments within: • Public & Private Law Proceedings • Pre-Proceedings • Immigration Proceedings • Court of Protection Proceedings • Criminal Proceedings

www.childrensrespiratorydoctor.co.uk

www.targetpsychology.co.uk

Mr Kim Hakin FRCS FRCOphth

Mr Antony M. Visocchi

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

Independent Dental Expert Witness • Emergency care • Diagnosis and treatment planning • Issues of consent • All routine treatment

www.kimhakin.com

www.dentalexpertwitness.co.uk

The Hampden Consultancy

Dr Rowland James Whale MBBS MRCP(UK)

Consulting Engineers • Mechanical & Electrical Services We can be appointed as Expert Advisers, Party-appointed Experts or as Single Joint Experts

Consultant Physician and Geriatrician • Elderly claimants • Medical negligence • General medical issues • Personal injury

www.thehampdenconsultancy.com

www.drwhale.co.uk www.yourexpertwitness.co.uk

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MEDICAL NOTES [

FOLLOWING THE PUBLICATION of the NHS Long Term Plan the government and GPs agreed a new contract, which involves a number of substantial changes. One of the mainstays – designed to allow the plan to be realised – is the introduction of an army of medical professionals other than doctors to work within practices and act as first point of contact for patients needing their particular skills. That includes thousands of physiotherapists who will deal with patients presenting with musculoskeletal problems, which currently account for around one fifth of GP appointments. The idea is it will free up GPs to deal with problems requiring their generalist skills. It is also expected to substantially reduce the number of secondary referrals to physiotherapists by GPs. In a rare show of solidarity between the medical profession and government, the scheme was welcomed by GPs and the Chartered Society of Physiotherapists. • Another major development for GPs is the establishment of a state-backed indemnity scheme, such as enjoyed by their colleagues in hospitals. It has long been seen as an anomaly that, while the NHS picks up the tab for sometimes huge compensation pay-outs, GPs have been left to fend for themselves. The scheme as announced in the Long Term Plan covers only England. Wales is to have its own scheme, launching in April, and plans for Scotland and Northern Ireland have yet to be seen. • GPs have been in the news a lot recently. The Royal College of General Practitioners has also become the latest medical professional body to call for the decriminalisation of abortion. Currently, abortion is still subject to the criminal law and a woman can be imprisoned for having a termination without the consent of two doctors. Doctors, understandably, believe that in an age of internet prescribing, the regulation of abortion should be the remit of medical authorities, not the police. • Freedom of choice is a cherished liberty, not least the freedom to decide on whether we want to live in a care home or hospital. That freedom is set to be undermined with the passage through Parliament of major changes to the Mental Capacity Act, the Law Society says. According to the lawyers’ body, the changes will strip away protection for many more vulnerable people from being deprived of their liberty. The measures the Law Society takes issue with include excluding parents from involvement in the care of 16 and 17-year-olds, and passing on the job of assessing whether people should be detained in care homes to the managers of those very care homes: people without the clinical skills to make those decisions, and with a potential conflict of interest. • Stories about the activities of the Care Quality Commission in this publication are usually prefaced with news that a hospital or trust is being subject to investigation or sanction. So it’s nice to be able to report an optimistic view from the CQC, which reports finding improvements to the way care is planned for people subject to the Mental Health Act. The recent attention being paid to mental health has brought more scrutiny of mental health services and the service has responded. Sadly, the optimism regarding the standard of care planning is blended with concern about the state of the actual mental health wards themselves. Many, says the report, are of poor quality and some are unsafe. • Another good news story appeared in The Lancet. Researchers in Bristol found that around 80% of hip and knee replacements are still going strong after 25 years. Hitherto, there has not been any data available to draw a generalised conclusion from regarding longevity of replacements. The good news for lawyers? You now have a yardstick to measure how long they should last. q

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Welsh inspectorate publishes report into Kris Wade affair [

HEALTHCARE INSPECTORATE WALES (HIW) has made 24 recommendations for improvement in its special review of Abertawe Bro Morgannwg University Health Board’s (ABMUHB) handling of former employee Kris Wade – referred to as Mr W. Between 2011 and 2013, three people who received care from the learning disability service made allegations of sexual abuse against Mr W. Mr W was suspended from work in 2012 following the abuse allegations, but was still an employee of the health board in 2016 when he was arrested and convicted of murdering his neighbour Christine James. Last September HIW was asked by the Welsh Government to carry out an independent review of the health board’s actions. This review examined staff recruitment and employment, incident reporting, adult safeguarding, governance and culture, an assessment of ABMUHB’s desktop review, and commissioning arrangements between health boards. It did not look at the actions of the police or the Crown Prosecution Service as this is outside HIW’s statutory remit. Chief executive Dr Kate Chamberlain said: “There are areas of learning within this review which are relevant to the NHS as a whole and we expect all health boards to consider our findings and recommendations. “This case highlights the importance of safeguarding and governance processes which are essential in protecting adults at risk. “The robustness of these processes is intrinsic to the confidence that patients and their families have in the safeguarding system as a whole. “HIW hopes that the content and learning from this review will promote improvement in these areas, as well as highlighting the need for the new safeguarding guidance to be delivered in a timely way.” The BMA referred to the original investigation as being ‘bungled’. In a report on its website the association pointed out that: “Wade, whose father was the former clinical director of the health board’s learning disabilities

directorate, had originally worked in the IT department. He was moved to the learning disabilities directorate as a nursing assistant in 2004 after concerns that screen time was affecting his health. “No vacancy form was filled in and no police checks were ever carried out on him. HIW found that 142 of the 2,000 staff working in ABMU’s mental health and learning disabilities service delivery unit did not have DBS checks or renewed checks.” The chair of the BMA’s Welsh Council, Dr David Bailey, commented: “Despite concerns being raised by us for a number of years, it is disappointing that the report found that the reporting structure for quality and safety remains unclear. “The health board has had a significant amount of time to rectify this and has not done so. It is imperative that they now take urgent steps to put in a robust structure to ensure the safeguarding of patients. Dr David Bailey “It is deeply troubling that the report found that some executive board members were individually aware of the details of the allegations against Mr Wade throughout the investigation and that these were not formally reported to the board. This report highlights the dire need for an individual within health boards with whom staff can raise concerns. BMA Cymru Wales stands ready to work with the Welsh Government and health boards to implement these recommendations.” q

New indemnity schemes embraced by GPs [

GP LEADERS HAVE welcomed the establishment of an indemnity scheme in England as part of the new GP contract. Professor Helen Stokes-Lampard, chair of the Royal College of GPs, commented: “We are particularly pleased at the news that a statebacked indemnity scheme will be introduced from April this year, providing all GPs in England with full insurance cover that is on a par with the arrangements already in place for our hospital colleagues. “Escalating indemnity costs have become a huge burden for GPs at all stages of their careers, and some GPs have even cited this as their reason for leaving the profession. The college has been campaigning for a state-backed scheme for a long time, and we are extremely pleased that the government has kept the promise first made by former Health Secretary Jeremy Hunt at our annual conference in 2017.” A similar scheme has been announced for GP practices in Wales. The Future Liability Scheme (FLS) will also come into effect from April this year and will be run by NHS Wales Shared Services Partnership, which already indemnifies GPs working out of hours. The scheme will cover GP practice staff and other medical professionals such as salaried GPs, locum GPs, practice pharmacists, practice nurses and healthcare assistants. The Welsh Government has said the FLS will be aligned to England’s indemnity scheme so that Welsh GPs are not at a relative disadvantage, and to ensure there are no problems with cross-border working. Health Minister Vaughan Gething said: “This new scheme will provide greater stability and certainty for GPs in Wales. It will support

GP practices and primary care clusters in their delivery of sustainable and accessible health care.” BMA Welsh GPs committee chair Charlotte Jones said: “GPC Wales supports the Welsh Government’s decision for Legal and Risk Services to operate the future liability scheme from 1 April. The proposed scheme will address one of the biggest financial pressures on GPs, and will enable all GPs, practice teams and wider cluster healthcare professionals to work more closely together taking forward the transformation of Welsh primary care.” q

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GMC consultation welcomed by doctors’ legal body [

DOCTORS’ DEFENCE ORGANISATION Medical Protection has welcomed proposals by the GMC to update its guidance on decision making and consent. In a statement, Medical Protection said: “Consent is one of the cornerstones of the doctor-patient relationship – doctors should feel empowered to have the flexibility to provide patients with the information that they need to make decisions about their healthcare in a way which they will understand. “Obtaining informed consent is also one of the biggest challenges doctors face as healthcare delivery constantly evolves. It is also an area that has been subject to recent legal scrutiny. The case of Montgomery v Lanarkshire Health Board in 2015 changed the law on informed consent following a Supreme Court judgement. Since this landmark ruling, doctors must ensure that patients are aware of any material risks involved in a proposed treatment, and of reasonable alternatives.”

Commenting on the consultation response, its head of policy and technical Dr Richard Stacey said: “Medical Protection welcomes the GMC’s efforts in updating the consent guidance to help doctors practise ethically and in line with the evolving healthcare environment. “In its draft guidance the GMC proposes to move reference to jurisdiction from the main guidance to a legal annex: Medical Protection believes this is a pragmatic and sensible approach. A mechanism would have to be put in place to ensure that the legal annex could be updated promptly as case law evolves. “We believe that the new guidance will be much more meaningful for doctors in today’s practice, taking full account of new case law. “We look forward to the publication of the final guidance following the outcome of the consultation. We expect it to be published in the autumn.” q

CQC urges people to ‘declare their care’ [NEW RESEARCH has shown that almost seven million people in

England who have accessed health or social care services in the past five years have had concerns about their care, but never raised them. Of those, over half (58%) expressed regret about not doing so. The most common reasons for not raising a concern were not knowing how or who to raise it with, not wanting to be seen as a ‘troublemaker’ and worries about not being taken seriously. Over a third of people felt that nothing would change as a result. However, when people did raise a concern or complaint, two thirds found their issue was resolved quickly, it helped the service to improve and they were happy with the outcome. The research was published by CQC on 19 February to mark the launch of its Declare Your Care campaign. The campaign is encouraging people to share their experiences of care with CQC, to support its work to improve standards of care in England. The majority of people who did raise a concern or complaint were motivated by a desire to make sure that care improved for others. This included wanting to improve the care they, or a loved one, had received and improve care for everyone using the service, with a smaller number also hoping for an apology or explanation. The main reasons given for raising or wanting to raise a concern were delays to a service or appointment, lack of information and poor patient care. Additionally, over a fifth indicated that they have raised or wanted to raise concerns about the lack of communication between health and care services. CQC chief executive Ian Trenholm commented: “We know that when people raise a concern they have a genuine desire to improve the service for themselves and others. We also know that the majority of services really appreciate this feedback and make positive changes, as this new research shows. “Hearing from people about their experiences of care is an important part of our inspection work and contributes to driving improvements in standards of care. Everyone can play a part in improving care by directly giving feedback to services, or by sharing information and experiences with us so that we can take action when we find poor care. Sharing your experience also enables us to highlight the many great examples of care we see.” Minister of State for Care, Caroline Dinenage, said: “We want the NHS and social care system to provide the safest, most compassionate care in the world. This means encouraging patients to speak up with concerns, ensuring we act on them and learning from what happened so we can do better in future.

“That’s why I encourage anyone who has concerns over their care, or the care of loved ones, to share their experiences with the Care Quality Commission - so they can continue their vital work of protecting patients and improving the excellent care we see across the health service.” q

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Ophthalmology standard welcomed; but implementation is another matter [

THE National Institute for Health and Care Excellence (NICE) has published its first quality standard looking at serious eye disorders. The standard covers the diagnosis and management of cataracts, glaucoma and age-related macular degeneration (AMD), and the prevention of sight loss. The standard has met with a guarded welcome by the Royal College of Ophthalmologists, which believes that the implementation of the standard – which it supports – will be challenging for the overwhelmed hospital eye service. “At a time when the hospital eye service is overwhelmed by increasing demand,” says the RCOphth, “measurable quality standards are crucial to identify areas of poor performance or reduced patient safety. This helps to inform policy makers, commissioners and providers of the need for more resources and staff. The RCOphth 2018 Workforce Census demonstrates a severe workforce shortage in ophthalmology services which contributes to ongoing patient safety issues.” The college points to its own database as a benchmark in collating information. “The RCOphth National Ophthalmology Database (NOD) is a prime example of how ophthalmology has been able to lead the way in demonstrating how to collect meaningful metrics which are driving improvements in patient outcomes.

“Over the past nine years the NOD has documented a 30% reduction in posterior capsular rupture or vitreous loss complications, a significant improvement in patient outcomes and a cost saving to the NHS.” The new standard consists of a prioritised set of specific, concise and measurable statements, based on recommendations in previous key NICE guidance for ophthalmology. The standard has been widely consulted, including with members of the RCOphth. RCOphth points out that NICE itself recognises that levels of achievement for the standard will vary nationally and recommends that desired levels of achievement should be defined locally, taking account of safety, shared decisionmaking, choice and professional judgement. The college highlights several of the statements making up the standard that it says will be challenging to achieve. They relate to referrals for cataract surgery, treatment and monitoring of wet-active AMD and monitoring of adults with glaucoma, as well as the issuing of vision impairment certificates. Nevertheless, following the publication of the standard the RCOphth recommends that all members familiarise themselves with it and work with their commissioning body, clinical leads and medical directors to implement it where possible. q

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How long should a hip or knee replacement last? Now we know [

RESEARCHERS FROM the Musculoskeletal Research Unit at the University of Bristol have found that eight out of 10 total knee replacements and six out of 10 total hip replacements will still be in place after 25 years. The research, funded by the National Joint Registry and the National Institute for Health Research was published in The Lancet in February. After reviewing thousands of case studies going back 25 years across six countries, generalisable survival data is now available for the first time to estimate how long hip and knee replacements are likely to last. “Over two million hip and knee replacements have been performed in the UK since 2003, and patients often ask clinicians how long their hip or knee replacement will last; but until now we have not had a generalisable answer,” said lead author Dr Jonathan Evans, National Joint Registry Research Fellow and Clinical Research Fellow at the Bristol Medical School’s Translational Health Sciences department. “Previous studies have been based on much smaller samples. At best, the NHS has

Images – Musculoskeletal Research Unit, University of Bristol

only been able to say how long replacements are designed to last, rather than referring to actual evidence from multiple patients’ experiences of joint replacement surgery. Given the improvement in technology and techniques in the past 25 years, we expect that hip or knee replacements put in today may last even longer.” Hip and knee replacements are two of the most common and effective forms of surgery. Yet, even in the best-case scenarios, they will ultimately fail due to processes such as infection, fracture, normal wear and tear or

Orthopaedics experts come in many forms [ONE OF THE AREAS of medicine that has attracted debate

regarding the appropriate expert to appoint for a particular case is orthopaedics. That is partly due to the fact that many orthopaedicsbased claims are for injuries following accidents – particularly road traffic accidents. In those cases the parties may have different approaches to the kind of expert needed. It may seem axiomatic, but law firm TruthLegal put in a nutshell the basis of appointing any expert. “The type of expert that an injured person needs to be examined by,” the firm says, “is usually the same type of doctor who has been providing their care. So if an injured client has been treated by a consultant hand surgeon, then a report from an independent consultant hand surgeon is required. In injuries involving fractures, the client is usually examined by a consultant orthopaedic surgeon.” In the case of injuries such as whiplash, however, a report from a GP may be the most appropriate. In more serious personal injury cases the determination of damages and assessment of the way forward may be crucial. It is generally agreed that rehabilitation is a prime aim, and experts such as physiotherapists or orthotists may be of value. In the last issue of this publication we reported on the case of HJ v Burton Hospitals NHS Foundation Trust, in which the evidence of the occupational therapist was preferred when assessing damages. It may be, of course, that a team of experts reporting on different aspects of a case may be the best route. q

reaction to wear particles. In many of those cases, patients require revision surgery, which is more prone to failure, associated with poorer function and more expensive than primary surgery. Knowing how long a hip or knee replacement is likely to last is therefore key for patients, orthopaedic surgeons and commissioners when deciding whether surgery should be done and when. That will become increasingly relevant to more people given the longer life expectancy of a growing population. q

Physios in primary care can free up GPs’ time

[THOUSANDS OF PHYSIOTHERAPISTS could be recruited to

work in GP practices over the next five years, as part of the new fiveyear GP contract. The plan follows a number of pilot schemes. Musculoskeletal health issues account for around a fifth of all GP appointments and so-called first-contact physios will be able to provide patients with musculoskeletal checks. That will help to free up time for GPs and reduce their workload. An increase in first-contact physiotherapy will also reduce secondary referrals, help older people avoid falls and stay independent for longer – ultimately saving the NHS money. The chief executive of the Chartered Society of Physiotherapists, Karen Middleton, commented: “This is excellent news for patients seeking help for a muscle, bone and joint problem in primary care. It’s a model that is already working across the country to ensure patients see the right professional at the right time, while easing the pressure our GP colleagues are under. “It’s about expanding the team to make full use of the expertise available to the NHS, and it is shown to improve patient outcomes and save money by cutting the number of unnecessary tests and referrals.” GPs have offered a guarded welcome to the plan, acknowledging that expanding the practice team to include clinical colleagues like physiotherapists can free up GPs’ time for patients who need expert generalist skills. However, the Royal College of General Practitioners has warned that they must not be seen as a substitute for GPs. q www.yourexpertwitness.co.uk

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Patient Safety Alert issued for fracture fixation plates [NHS IMPROVEMENT has issued a

Patient Safety Alert on fracture fixation plates. The alert, issued on 12 February, asks all hospitals in England to review the X-rays of patients who have had metal plates fitted for fractures, to ensure that the correct plates were used. A variety of fracture fixation plates are used in orthopaedic surgery, including dynamic compression plates and reconstruction plates. The plates have different properties – importantly, their rigidity and strength – and the two types are not interchangeable. Recent changes in the design of some reconstruction plates have made it easier to confuse types of plates that were once visually distinct. According to NHS Improvement: “Some organisations use an instrument tray system, where multiple plates and screws are contained on the same tray which is replenished and resterilised after each operation. This creates a risk of confusing the types of plates used both at the point the tray is replenished and at the point a plate is selected for use. Where individual, sterilised

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packs for each different type of plate are used, the risk of wrong selection is likely to be lower but still exists, especially if both types of plates have been made ready for use.” To provide a stronger barrier to inadvertent wrong selection, the alert asks providers to put an action plan in place to purchase reconstruction plates as individually sterilised packs, to ensure the packs are stored separately and to ensure they are

only fetched and taken out of their sterile packaging when specifically required. Providers are also asked to identify all patients who have had a plate fitted since 1 February last year for the treatment of shaft fractures, and undertake a retrospective review of patient X-rays to ensure the correct plate was used. The safety alert was issued jointly with the British Orthopaedic Association (BOA). In a media statement, the BOA said: “NHS Improvement approached the BOA for advice on the use of certain metal plates for limb fractures following the identification of an issue at one trust. We agree with the need to act swiftly in the interest of patient safety but our view is that very few patients will be affected and the risk of harm is extremely low. “We would recommend that trusts review the X-rays as per the NHSI guidance issued today and would emphasise to patients that they should not be alarmed. Any patient affected will be contacted by the local hospital where they have been treated.” q

New centre of excellence to be sited at Salford

What the eye cannot see...

By STEPHEN SECCOMBE Consultant Orthotist

[CLAIMANTS WILL OFTEN present with discomfort and pain as a

[MORE HIGHLY-SKILLED ENGINEERS in prosthetics and

orthotics are to be trained at a new global centre of excellence based at the University of Salford. The centre is to train up to 60 individuals to doctoral level over the next eight years to address the skills gap at home and abroad. Salford’s key collaborators are the UK’s principal prosthetics and orthotics research centres at Imperial College London, the University of Strathclyde and the University of Southampton. The £11m project, with £5.3m coming from the Engineering and Physical Sciences Research Council, partners the centre with 27 industry and clinical collaborators, including two of the largest manufacturers of prosthetic and orthotic devices – Blatchford and Össur – together with the global leader in research in the field, Northwestern University in the US. The unique four-year research training programme will be complemented by a new Master’s programme operating across all four partner universities. Centre director Malcolm Granat, Professor of Health and Rehabilitation Sciences at the University of Salford, explained: “Globally, 100 million people need prosthetic and orthotic devices – and this is rising rapidly. With most users now being of working age, there is an ever-increasing need to develop more sophisticated devices suited to a range of diverse needs. “There is a woeful shortage of research engineers who have a deep understanding of these challenges. Our expectation is that this new centre will create a talented workforce, who will be equipped to produce local and global solutions to transform lives.” q

result of their injuries. In many cases the location of the symptom is not where the cause is. A clinician’s experience will help identify that, but there are scenarios that are different or ‘hidden’. For instance, they may only occur when active, and in those cases it can be difficult even for the trained eye to spot the underlying cause. Gait analysis is a tool used to gain insight into movement patterns specific to activity, and helps quantify any potential deficit or change. The benefit of gait analysis is that it can be very helpful in identifying overactive or underactive muscles, potential dysfunctions and inefficiencies. I perform both visual and computerised pressure gait analysis, such as standing balance, walking/running pressure distribution, velocity of movement through individual joints and the pressure time integrals of each stance phase. With visual analysis, large and most small movement problems are picked up. A computer analysis is more specific and is used to identify even smaller dysfunctions, such as a movement problem. The software allows the data to be viewed in real time and then played back much slower to view the gait frame by frame, which helps satisfy any interested patients!. Once the cause is determined, the recommendations and potential effect on the current clinical presentation are easier to quantify in terms of both treatment and value. The end result of treatment is often reduced pain and/or improved performance. The analysed information can be used to direct a personalised treatment plan and progression for future treatment by the treating clinician. q

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The medicolegal challenges associated with pelvic mesh complications Research published in October 2018 showed that 3.3% of mesh implants used for urinary incontinence cause complications requiring reversal operations. In this article, DR IVAN RAMOS-GALVEZ LMS FRCA FFPMRCA, consultant in pain medicine and expert witness, discusses the history of the introduction of pelvic mesh treatment for urinary incontinence. He explores the reasons why complications occur and the pain conditions associated with them.

[

URINARY STRESS INCONTINENCE is a common problem that affects women of all ages, more commonly after childbirth. The cardinal symptom is leakage of urine when the bladder is submitted to any pressure. This may involve anything from a few drops of urine when running to catch the bus, to leakage on coughing, sneezing or laughing. Traditionally the management was conservative, involving physiotherapy to reinforce the pelvic floor muscles and life-style changes to reduce exposure to the triggers. Unfortunately, these treatments are not always effective and the symptoms can be embarrassing and have a significant and negative impact on daily life; as a result, surgical techniques were developed. The surgical techniques to resolve the problem were safe, well tried and tested over time, and offered reasonably good outcomes. However, they were not always without complications, the most common being recurrent incontinence, as well as more general complications relating to potential tissue trauma and infection – as can be associated with any surgical procedure. In the mid 1990s a new technique for the surgical treatment of urinary incontinence was developed. It involved a monofilament of polypropylene made into a mesh that could be inserted percutaneously under local anaesthetic. The concept was based on the theory that lifting the mid urethra up could offer the resistance required to stop passive leakage of urine. The technique had many perceived advantages: • The mesh was inserted under local anaesthesia and therefore • allowed an intra-procedure cough test to ensure that the • incontinence had been successfully treated. • It avoided the risks of a general anaesthetic. • It was a quick procedure which could be carried out within a day • (20 minutes operative time) because it was percutaneously • inserted, with fast recovery to normal life afterwards. These benefits expedited the regulatory process and the ‘kits’ became widely distributed. Further kits became available and their sale was authorised based on their similarity to the original product, rather than pure efficacy and safety. Guidelines for the management of stress incontinence evolved to incorporate the new mesh treatment and older surgical methods became obsolete. Technical skills relating to the previous, more invasive surgery were lost and a new generation of ‘mesh surgeons’ trained. The results were promising, offering curative rates of 85% – based on cough tests, change in weight of a sanitary pad over 24 hours, urodynamics and a Visual Analogue Score of urinary symptoms – from 0 (zero) to 100 (unbearable). Overall, studies that now run to a 15-year history still report the same results, suggesting a low risk of complications.

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However, the technique involves a blind percutaneous transvaginal insertion of a trochar (a surgical instrument) directing it towards the iliac fossa on one side, ensuring it is positioned at the level of the mid urethra and then towards the iliac fossa on the other side. A modification involves a change in direction towards the obturador foramen in a more horizontal trajectory. The pitfalls are that the insertion involves passage of a large trochar incorporating a foreign material through a non-sterile cavity into the deep tissues of the pelvic floor. Structures on the way include bladder, muscles, nerves and bowel. Bladder perforations are relatively common and cystoscopy is routinely carried out to ensure the placement of the mesh avoids the bladder. Overall, in the short term there is a risk of infection of an implanted foreign material, bladder/ bowel perforation and nerve trauma/damage. The initial studies reviewing the outcomes never considered or reported the incidence of pain. They concentrated on the outcomes in urological symptoms and satisfaction with regards to incontinence. Unfortunately, some women develop pain which can be very intrusive to their lives; often more so than the incontinence they were trying to treat. On reporting the pain to the surgeon, many women have felt dismissed – initially being advised that it is as a result of the recent surgery, and later by underplaying it in comparison to curing the incontinence. Time has shown that meshes have been found to be coated in bacteria and when loaded with the weight of the abdominal organs transform into a cutting thread, akin to the handle of a heavily loaded plastic bag. Furthermore, the polypropylene material the mesh is constructed from has physical and chemical properties that change with time and temperature, akin to plastic containers used to reheat meals in a microwave. These changes include twisting, curling, contraction and even rupture of the mesh itself. In the short term, bladder infections that require prolonged courses of antibiotics, nerve damage and muscle dysfunction are seen. In the long term, antibiotic resistance, fistulae, chronic pain, mesh cutting into the vagina and bladder, dysfunction of the pelvic muscles, loss of sexual function, bladder incontinence, bowel incontinence, constipation, depression, anxiety, social withdrawal and isolation, and a loss of confidence are all reported symptoms. These late complications have been reported after years of successful results with no prior problems. It is a complex problem that has a complex solution. The obvious one is removal of the mesh without any further harm being caused. Mesh removal is challenging, laborious and very skilled. Patient

selection is key. Not all patients who experience complications from mesh insertion are suitable to have the mesh removed. When meshes have been removed, 100% of these meshes have shown histopathology in keeping with a â&#x20AC;&#x2DC;graft versus hostâ&#x20AC;&#x2122; reaction that suggests activation of the immune system as mediator of a systemic inflammatory reaction. This may account for the patients who report symptoms associated with the onset of autoimmune diseases, widespread arthritis and even fibromyalgia following mesh surgery. The treatment for women facing this worrying and painful situation is a multidisciplinary approach comprising of self-help techniques, psychological help and above all feeling listened to and supported. Monofilament of polypropylene is used in a mesh format for other procedures such as in the repair of prolapses and although not in the same numbers have, over time, given similar types of complication. The final and most common use of mesh is a mesh hernia repair. Neuropathic pain is a common complication in hernia surgery and it can develop at any time from immediately post-operatively to years later. The nerve pain these patients feel is often in the groin and low abdomen and testicles. Although severe, the overall symptoms are of a lesser level of impairment to the overall quality of life compared to the incontinence mesh. Class Action suits against the manufacturers of the mesh kits in the US have seen significant claims for compensation, and an increasing number of claims being brought by women individually. A consultant in pain medicine is well placed to assist with a medicolegal claim of this type which often involves complex chronic pain and associated conditions such as fibromyalgia. q â&#x20AC;˘ Dr Ivan Ramos-Galvez has provided expert opinion on such cases. He is a well-established pain expert, specialising in the diagnosis and treatment of complex pain conditions. He is well regarded as an expert witness in cases involving Complex Regional Pain Syndrome and other pain conditions. Please call 020 7118 0650 or email info@medicolegal-partners.com for further information.

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Maxfax body calls for dermal filler regulation [ THE British Association of Oral and Maxillofacial Surgeons

(BAOMS) has called for regulation in the UK of therapists who inject dermal fillers, in line with European Union (EU) rules. Caroline Mills, the BAOMS lead on aesthetic/cosmetic surgery and consultant maxillofacial surgeon at Great Ormond Street Hospital, said: “In the EU you have to have a medical licence to inject fillers, but no one in the UK government is saying we need similar regulation.” While BAOMS agrees with the recent call from MPs for the introduction of guidelines, on the grounds that dermal fillers should be considered medicines, it also goes further and wants to see regulation of the industry. BAOMS has concerns about the scope of training, health and hygiene issues such as infection control in the high street beauty salon industry. Unfortunately, serious medical complications can result from these procedures, such as vascular occlusion – possibly leading to blindness – or severe allergic reactions, both of which require emergency medical treatment. It’s recognising and managing those problems that is so important and where patient safety maybe compromised, the association says. There is an increasing cost impact to the NHS to treat high street procedures that go wrong, but the scale of emergency treatment and corrective surgery is as yet unknown because there is no NHS coding for non-surgical treatment problems where the client has to go to A&E. Caroline Mills pointed to a recent case of a patient who had taken up the offer of inexpensive dermal fillers that were being promoted at her gym: “The treatment went badly wrong and the patient has now had over 30 facial operations and has been forced to leave her job.”

She said that, despite the introduction of the voluntary register for non-surgical treatment practitioners last year, patients should be aware that the regulations allow non-medical staff to give nonsurgical injectables. “This is disappointing. We need regulation in the UK to protect patients properly,” she concluded. q

Dentists should screen for head and neck cancer

[THE MOUTH CANCER FOUNDATION has recommended that all dental practices carry out a thorough head and neck cancer screen on all their patients at least once a year at routine appointments. Early diagnosis is the key to ensuring patients have the best possible outcome. A simple Mouth Cancer Screening Protocol has been developed by the foundation to ensure that dentists have a screening tool that standardises the process and can be used with every patient over the age of 16. The examination can be carried out in the dental chair using gloved hands, a mirror and good lighting. Before the examination, dentists should communicate to the patient what they are doing and looking for. The time after the examination is ideal for giving appropriate advice to those at risk. It takes just two minutes to carry out a full head and neck cancer screening. q

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UK heart attack survival improvement modest, research shows [SURVIVAL AFTER A DIAGNOSIS of heart failure in the UK

has shown only modest improvement in the 21st century. That was the conclusion of a study published in the British Medical Journal in

CVD prevention a priority for NHS [

TACKLING RISK FACTORS and conditions that put people at the greatest risk of a heart attack or stroke are the key to preventing cardiovascular disease (CVD), health leaders have said. Atrial fibrillation (AF), blood pressure and cholesterol – known as ‘ABC’ conditions – were named as the focus for prevention efforts at a Public Health England (PHE) conference, Cardiovascular disease prevention: Saving hearts and minds, held in Manchester in February. Duncan Selbie, chief executive of PHE, said: “We have made great progress on the risk factors: sugar tax, reformulating food and tobacco control. Now we need to focus on physiological factors like AF, blood pressure and cholesterol.” Better detection and management of these factors could help to meet the NHS England ambition of preventing 150,000 heart attacks and strokes over the next 10 years, he said. Dr Matt Kearney, national clinical director for CVD Prevention at NHS England, said: “The NHS has realised the enormous scope for improvement. Treating these high risk conditions works – modifying physiological risks has a huge impact.” The National CVD Prevention System Leadership Forum (CVDSLF) has agreed specific ambitions for the detection and management of the ABCs. In the next 10 years, those ambitions are to see an increase in the detection rate of AF from 79% to 85%, as well as an increase in the proportion of people with AF whose condition is managed with anticoagulants from 84% to 90%. It also wants to see the detection rate of hypertension rise from 57% to 80%. At the same time it wants to see the proportion of people aged 4074 receiving a formal validated CVD risk assessment and having a cholesterol measurement recorded on a primary care data system rise from 49% to 75% and those in that age group who have a 20% or greater 10-year risk of developing CVD being treated with statins up from 35% to 45%. q

February. The findings also show that survival is worse for people requiring admission to hospital around the time of diagnosis – and for those in the most deprived groups. Using primary care data from 2000 to 2017, linked to hospital and mortality records, researchers at the Nuffield Department of Primary Care Health Sciences in Oxford compared survival rates for 55,959 patients aged 45 and over with a new diagnosis of heart failure with 278,679 matched controls. One, five, and 10-year survival rates increased by 6.6%, 7.2% and 6.4% respectively. Improvement in survival was on average 2.4 years greater for patients not requiring admission to hospital around the time of diagnosis. The researchers also found an average 2.4 year difference in survival for people who were least deprived compared with the most deprived group. Jeremy Pearson, associate medical director at the British Heart Foundation (BHF), said: “Heart failure is a cruel and debilitating illness affecting hundreds of thousands of people in the UK. Research funded by the BHF has shown a worrying increase in people being diagnosed with heart failure in hospital, rather than it being spotted by their GP. The later you’re diagnosed, the worse your outlook becomes. “This study adds to this concerning picture of heart failure care in the UK, but identifying the shortfalls is the first step towards addressing them. We need the communication between hospitals and primary care providers to make sure patients with heart failure are diagnosed and treated earlier, to prevent the need for hospital admissions – while those who are admitted receive that all-important follow-up care after they leave hospital.” q

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Reconsider mental capacity changes, Law Society says [ UP TO 300,000 people a year with conditions such as Alzheimer’s,

autism or learning disabilities will see their rights – specifically their right to liberty – stripped back by imminent changes to the Mental Capacity Act, the Law Society of England and Wales has said. According to the society, fewer cared-for people will qualify for the protection of important safeguards under the new scheme, and their access to advocacy and independent professional support will be more limited. People who are deprived of their liberty may face detention without any review for periods of up to three years. “The government must reassess this misguided legislation and recommit to empowering and protecting people who may not be in a strong position to protect and advocate for themselves,” Law Society president Christina Blacklaws said. “These people may be subject to highly restrictive measures in care homes, supportive living arrangements and hospitals.

Guardianship call echoed by RCPsych

“We are particularly disturbed that 16 and 17-year-olds would have gravely weakened safeguards and their parents’ rights would be undermined.” Care home managers would be given considerable influence over decisions about whether someone should be detained in a residential or nursing home under the government’s plans – a move opposed by the Law Society. “Care homes that profit from decisions to detain people in their care are given too great a role under the new regime, creating a dangerous conflict of interest,” said Ms Blacklaws. “The new legislation would task care home managers with the job of establishing whether or not a person deprived of their liberty in their care is happy with the arrangement or wishes to leave. This is a deeply flawed approach. “Care homes are unlikely to have the expertise necessary to oversee deprivation of liberty decisions, and many – stripped to the bare bones by austerity – will not have the financial resources to cover the subsequent cost. “The Law Society – and the vast majority of stakeholders – agree that a change in the law is needed. The current system is not working. There are huge delays and a backlog of over 125,000 people who are currently unlawfully deprived of their liberty. “But the Mental Capacity (Amendment) Bill needs urgent and extensive revision if cared-for people are to have meaningful access to justice.” q

[

THE PRESIDENT of the Royal College of Psychiatrists has welcomed a recommendation to appoint a senior member of staff as Wellbeing Guardian in every NHS trust: a key recommendation of the NHS Staff & Learners' Mental Wellbeing Commission Report. Professor Wendy Burn said: “We know from speaking to our members that staff are often put under unnecessary pressure due to processes that could be amended under the leadership of a Wellbeing Guardian. For example, we hear from our trainees of rota problems that include being put on call when a family holiday or even a wedding has been planned months in advance and notice given to the rota organiser. This sort of incident affects morale and makes clinicians’ lives harder. “A Wellbeing Guardian would have oversight of problems like this and encourage staff to truly flourish at their jobs which would ultimately benefit patients.” q

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Mental Health Act: CQC finds care improvements [THE CARE QUALITY COMMISSION (CQC) has seen some

improvement in the quality of care planning for patients who are subject to the Mental Health Act, but continues to be concerned about the quality and safety of mental health wards, according to a report issued on 26 February. As part of its work to monitor the Act, CQC carried out 1,165 visits to mental health wards in 2017 and 2018 and spoke to thousands of patients and their representatives to discuss how the Mental Health Act and its Code of Practice were being applied to them. The findings informed its annual report to Parliament on how health services in England are applying the Mental Health Act. In its State of Care report Monitoring the Mental Health Act in 2017/18 the commission concluded that there has been an overall improvement in some aspects of care over the two-year period compared with findings for the previous two years. They found: • Some improvement in the quality of care planning and patient involvement. A higher proportion of care plans are detailed, comprehensive and developed in collaboration with patients and carers. However, there is still considerable room for further improvement. • The provision of information about legal rights to patients and relatives is still the most frequently raised issue from visits. In many cases, patients may struggle to understand information given to them on admission because they are most ill at that point. • The greatest concern from Mental Health Act monitoring visits is about the quality and safety of mental health wards, in particular acute wards for adults of working age.

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The Mental Health Act 1983 is the legal framework that authorises hospitals to detain and treat people who have serious mental health needs and who are putting their own health or safety, or that of other people, at risk of harm. CQC has a duty to monitor and report on how services do this. Dr Paul Lelliott, deputy chief inspector of hospitals and the lead for mental health at the Care Quality Commission, said: “We are pleased to see an overall trend of improvement in the quality of care plans for people detained under the Mental Health Act. This is an achievement at a time of increased pressure on services and is in large part due to the dedication of frontline staff. “However, it is important that this does not mask the fact that many of the wards in which people are detained under the Mental Health Act are unsafe and provide poor quality care. We flagged this up in our State of Care report as our greatest concern and this continues to be the case. “Based on previous evidence from CQC, the independent review of the Mental Health Act recommends that we revise the criteria used to assess the physical and social environments of mental health wards. We welcome this recommendation and will be looking at how we can work with partners to take this forward to ensure that mental health inpatient services are providing a fit environment for safe and dignified care. This will include our work with others in the sector to deliver the improvements for mental health inpatient services outlined in the NHS Long Term Plan.” During the same period CQC received 2,319 complaints and enquiries about the way the Mental Health Act was applied to patients and its Mental Health Act assessors requested 6,049 actions required from providers to change the way care was being delivered to patients. In addition, CQC’s Second Opinion Appointed Doctor service carried out 14,503 visits to review patient treatment plans and changed treatment plans in 27% of their visits. The report used data collated over a two-year period to reflect CQC’s Mental Health Act review visiting patterns, whereby all wards in psychiatric units that detain patients under the Act are visited at no more than two-yearly intervals. q

How reliable are the results? The importance of best practice effort testing in neuropsychology By SIMON KIRWILLIAM, Principal Clinical Neuropsychologist at Expert in Mind

[NEVER TRUST A neuropsychologist who gauges the effort of an

individual’s performance at neuropsychological assessment purely on the basis of ‘clinical intuition’. The evidence is very clear – clinical observations, irrespective of astuteness, are no match for objective measures of effort. Without comprehensive assessment of effort, the overall reliability of findings from neuropsychological testing is open to serious scrutiny. Simply put, effort testing is the source of reliability. The current brief highlights two important questions that can help guide solicitors to better understand and assess the quality of effort testing of the neuropsychologists they instruct. How is the neuropsychologist measuring effort? Stand-alone and embedded measures of effort exist. While embedded measures may seem more sophisticated they actually derive poorer reliability than stand-alone measures, and only supplement the latter approach. There are numerous stand-alone measures available, however only a few are considered ‘gold standard’ with significant empirical support. It is essential that neuropsychologists protect the names of the effort measures they employ at assessment from common reading and, unfortunately, it is not appropriate to name them here. A question to ask the neuropsychologist you regularly instruct would be whether they are using

stand-alone measures of effort that are considered ‘gold standard’ by the neuropsychology community. Does the neuropsychologist clearly understand the concept of effort and communicate this? Research shows that the level of effort an individual is able to apply during neuropsychological examination has a significant impact on the test results. It is likely that effort accounts for large proportions of the variance in test performance. However, there are lots of extraneous influences that can compromise performance on a task. Failing an effort test simply indicates that these influences are likely to be mediating the individual’s attention during performance and that the findings are unlikely to be a valid representation of the individual’s optimal cognitive functioning. Failing an effort test, therefore, does not prove that the individual is malingering. Examples of extraneous influences that may compromise effort include severe mental health problems, alcohol or drug toxicity, severe sleep deprivation, and specific neuropsychological deficits that may relate to the injury sustained. The latter factor is perhaps most challenging to formulate and requires significant skill and knowledge of neurology and neuropsychology to interpret and communicate. q

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Cosmetic practitioners and CQC agree way forward [

THE Joint Council for Cosmetic Practitioners (JCCP) and the Care Quality Commission (CQC) have jointly hosted a meeting of representatives from a range of organisations to explore what is currently happening in the area of lifestyle choices and cosmetic interventions. The meeting, held on 15 February, also shared ‘concerns on the ground’ relating to public protection and the current regulatory framework that exists for that purpose. Organisations represented at the event ranged from professional institutions in the medical and nursing professions to the Advertising Standards Authority. The key aims of the event were: “To consider whether the current regulatory framework for cosmetic special treatments (including hair restoration surgery) and lifestyle therapies provides sufficient protection to safeguard the public from undue harm or consequence and to identify existing gaps in regulatory practice and legislation.” Representatives affirmed that a number of more invasive cosmetic interventions and so-called lifestyle therapies raise significant challenges for regulation, especially in terms of current definitions of ‘treatment and disorder’. Delegates agreed that there is the potential for significant risk to the health and wellbeing of the public and that there is a need for regulation. Significantly, the meeting agreed that the sector should work closely with the Advertising Standards Authority to identify potentially misleading or inaccurate advertising claims relating to the provision of cosmetic or lifestyle treatments or interventions, the inappropriate use of products and the advertising of those practitioner training programmes that falsely claim to meet a nationally agreed standard to affirm practice proficiency. The executive chair of the JCCP, Professor David Sines, said: “I am most grateful to the CQC for facilitating this important roundtable event with the JCCP, to bring together so many of the key regulators to discuss the critical issue of regulation in the cosmetic and hair restoration sector. These issues have been the subject of discussion for a number of years and its importance has recently been elevated by direct questions raised with the Prime Minister and by parliamentary debate. “By hosting this conversation between so many parties the JCCP and the CQC believe that a more coordinated approach can be developed in the interests of public protection and patient safety. I look forward

to engaging in further meetings with key interested parties and the announcement of further actions moving forward.” The meeting followed a parliamentary debate instituted by MP Alberto Costa, who called for regulation in the beauty industry covering treatments such as dermal fillers and Botox injections. During the debate, almost all participants recognised and advocated the need for greater regulation in the field of non-surgical cosmetic procedures. In particular, Mr Costa called for all professionals in the industry to be regulated, trained, qualified and licensed, and to have professional indemnity insurance. He argued that all practitioners should be registered with the JCCP. According to the British Association of Plastic Reconstructive and Aesthetic Surgeons there has been a worryingly increasing trend in botched cosmetic procedures being corrected by plastic surgeons, with 616 complaints reported in 2018 compared with 249 in 2016. Jackie Doyle-Price, Parliamentary Under Secretary of State for Mental Health, Inequalities and Suicide Prevention,

concluded the debate with a focus on the need for greater public education and empowering of the consumer to make an informed decision about the procedures. There was a general consensus among MPs that TV and social media advertising of cosmetic procedures was irresponsible. q

Surgeons asked to look out for stolen Botox [ESSEX POLICE are investigating the theft of a ‘large quantity’ of botulinum toxin

(Botox and Azzalure) – worth a six figure sum – from a supplier in Witham in February. The British Association of Aesthetic and Plastic Surgeons has urged its members to be aware of the incident. Detective Chief Inspector Martin Pasmore said: “We believe these items are most likely to have been stolen to be sold on, and so we want to make clinicians aware in case they are offered them for sale. “The boxes are labelled with the brand names Azzalure and Botox and, as with any drugs used in medical procedures, they must only be administered by people who are appropriately trained. “They also have to be stored appropriately in order to be at their most effective and safe. If patients use a qualified clinician it is highly unlikely that these stolen products will be encountered. “If not stored correctly, or used inappropriately, possible side effects could be allergic reactions including numbness or infections. Such side effects would require early medical advice.” Less likely other side effects could be serious infection, extended numbness, slurred speech or breathlessness. Reactions like this would require urgent medical attention. He urged anyone who has been offered, or seen, the items for sale recently and is suspicious of where they came from to contact Braintree CID. Police are also keen to speak to anyone who has any information about the burglary. The burglars are believed to have been using a white Ford Transit van, which had roof bars. There were at least four men, all wearing dark clothing. q

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GPs vote for decriminalisation of abortion [ THE UK council of the Royal College of General Practitioners

(RCGP) has passed a motion to support the decriminalisation of abortion, saying that the procedure should be governed by medical regulatory frameworks and not the criminal justice system. The decision was based on a poll of members and consultation with local faculties. They were asked whether the RCGP should have a position on the decriminalisation of abortion and what position they thought the college should take. Of members who responded, 62% said that the RCGP should support the decriminalisation of abortion, while 19% said it should oppose decriminalisation; 15% said that the RCGP should have a neutral position and 4% abstained. Of the 21 college faculties that responded to the consultation, none said that the RCGP should oppose the decriminalisation of abortion; 11 supported the motion, two said that the college should be neutral on the issue and eight abstained. The college did not ask members about the term limits on, or the morality of, abortion. RCGP chair Professor Helen Stokes-Lampard said: "This is an incredibly sensitive topic, but it's essential that we engage in debate and hear what our members have to say on all issues facing modern healthcare. "It speaks to the strength of feeling of our members that we had such a good response rate to our consultation. The quality of the feedback has been hugely valuable in helping us form an official position on the decriminalisation of abortion. "Ultimately, this is about providing non-judgemental care to our patients, so that women who face the difficult decision to proceed with an abortion are not disadvantaged by the legal system." The move was welcomed by the president of the Royal College

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of Obstetricians and Gynaecologists (RCOG). Professor Lesley Regan commented: “We very much welcome this important vote by the Royal College of General Practitioners. It places the rights of women and girls front and centre on the issue of abortion care in the UK. Removing the criminal sanctions associated with abortion care would be a crucial step in improving access to this essential area of women’s healthcare. “The RCOG continues to call on the UK government to decriminalise abortion across all UK nations as a matter of urgency.” q

Teachers get help in teaching about abortion [THE Faculty of Sexual and Reproductive Healthcare (FSRH)

and the Royal College of Obstetricians and Gynaecologists (RCOG) have published a free educational resource on abortion care to support teachers with relationships and sex education lessons in secondary schools in the UK. The joint FSRH-RCOG leaflet, launched on 31 January, aims to ensure that professionals involved in educating young people have a factually accurate, unbiased and evidence-based source of information about abortion care in the UK. It counters myths such as that abortion causes infertility, breast cancer and mental illness. The leaflet is officially endorsed by Public Health England, PSHE Association and Sex Education Forum. Dr Asha Kasliwal, president of the Faculty of Sexual and Reproductive Healthcare, explained: “Despite being a common medical procedure, myths about abortion are widespread. A 2012 Ofsted evaluation found that teachers needed more support and training to teach sexual and reproductive health themes. “FSRH believes that young people have the right to access factually accurate, unbiased information about sexual and reproductive health to help avoid unplanned pregnancies. They also need age-appropriate relationships and sex education in secondary schools so they are aware of the facts about abortion care. This makes resources such as the FSRH-RCOG leaflet important and relevant.” q

AGRICULTURAL CONSULTANTS

ANIMAL BEHAVIOUR

BUILDING, PROPERTY & CONSTRUCTION

COMPLIANCE CONSULTANTS

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COMPUTER & MOBILE FORENSICS

ERGONOMICS

FORENSIC ENGINEERS

CUSTODY & CHALLENGING BEHAVIOUR

FORENSIC SERVICES DRILLING CONSULTANTS

EMPLOYMENT CONSULTANTS

ENERGY CONSULTANTS

ENVIRONMENTAL HYGIENE

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GEOTECHNICAL CONSULTANTS

MECHANICAL & PROCESS ENGINEERING

WOOD & TIMBER

HEALTH & SAFETY

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MEDICO-LEGAL EXPERTS ACCIDENT & EMERGENCY MEDICINE

CARDIOTHORACIC SURGEONS

DENTAL & ORTHODONTIC EXPERTS ANAESTHESIA

CARDIOLOGISTS

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ENT CONSULTANTS HAEMATOLOGY

HAND SURGEONS

GASTROINTESTINAL & COLORECTAL SURGEONS

LIVER SURGEONS

NEUROSURGEONS

GENERAL SURGEONS

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NURSING & REHABILITATION CONSULTANTS

ORAL & MAXILLOFACIAL SURGEONS OBSTETRICS & GYNAECOLOGY

OCCUPATIONAL THERAPY

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OPHTHALMIC SURGEONS

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PLASTIC SURGEONS

PAEDIATRIC SURGEONS

PATHOLOGY

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SPEECH & LANGUAGE THERAPY

TRICHOLOGY

TOXICOLOGY

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