Your Expert Witness Issue No. 31

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contents IN THIS ISSUE 7

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Opening Statement

NEWS 9 Bond Solon holds 20th annual conference 9 Rioting sentences ‘excessive and arbitrary’, study claims BUILDING & PROPERTY 10 New RIBA contracts for small projects 11 Building surveyor or expert witness? How to stop disputes escalating FINANCE 12 Festive campaign against online fraud 12 Business valuations 13 Changing dynamics: the evolving landscape of family law in the UK TREES & FORESTRY 14 Establishing the next generation of trees – getting it right

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VETERINARY ISSUES 16 Veterinary care for companion animals TRANSLATION & INTERPRETING 18 Chartered Institute relaunches register 18 Linguists look to future-proof their profession 19 Prince honours language learners WILLS, LEGACIES AND CHARITABLE BEQUESTS 21 Legacies – a way of leaving the world a better place 23 Charity consortium promotes legacies to solicitors 25 Major beneficiary explains how to leave a legacy 29 Concerns raised over the intestate ‘timebomb’ 32 Cancer research forges ahead thanks to bequests 32 Professional body supports legacy managers 34 Chancellor’s standstill on inheritance tax good news for charities 37 Foundation giving on the rise as income falls

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A to Z WEBSITE GUIDE 38 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

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 41 Medical Notes

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OSTEOARTHRITIS 42 Treatment of early osteoarthritis REHABILITATION 45 Problems in store as cuts take toll of rehabilitation services 47 Psychology and brain injury rehabilitation 48 The lawyers that Think Rehab!

48 Sports injuries need careful rehabilitation PSYCHOLOGICAL ISSUES 49 New code of conduct proposals explained by experts 51 Traumatic brain injury and clinical neuropsychology CLINICAL NEGLIGENCE 52 Honesty is the policy in the NHS – at last!

53 New edition updates clinical expert’s companion volume

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PLASTIC SURGERY 55 Plastic surgeons call for better informed press reporting WHIPLASH 57 Insurers and claimants clash over whiplash 57 APIL joins MoJ in attacking pre-medical settlements 59 The biter bit ORAL & MAXILLOFACIAL ISSUES 60 Expert surgeons assess injuries to the face 60 Maxfax conference: call for abstracts 61 GDC consults on fitness-to-practice changes 61 BDA granted judicial review of retention fee 61 Patient recall welcomed by dentists’ body 63 Your dental expert witness – profiling Professor Paul Tipton

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INDUSTRIAL HEARING LOSS 65 Industrial hearing loss is still taking its toll GYNAECOLOGY & ISSUES IN PREGNANCY 66 Data collection project looks to reduce deaths and injuries 67 How to manage pregnancy – doctor’s advice, not doctor’s orders!

68 Royal Colleges team up to combat bullying

EXPERT CLASSIFIED 69 Expert Witness classified listings 71 Medico-legal classified listings www.yourexpertwitness.co.uk

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Opening Statement ‹ THERE HAS BEEN A certain amount of research published recently about how few people in this

country make a will. Less than half of us, apparently, get around to setting down in writing what we want to happen to our assets after we die. For some, it’s a case of not wanting to raise the issue with loved ones – and, being British, certainly not wanting to discuss it with a stranger!

If, however, someone wants to leave money or other assets to an organisation such as a charity, then making a will is absolutely essential.

Leaving bequests or legacies to charity has long been part and parcel of civic life – from kings endowing schools for the poor and industrialists setting up philanthropic foundations, to old ladies leaving their life savings to the cats’ home. In recent years, however, the practice has become more widespread and now around 6% of people leave a legacy to charity.

Campaigning organisation Remember A Charity is active in persuading solicitors to mention the possibility of leaving a legacy to charity – described by them as ‘the charitable prompt’ – and has set up a scheme to allow solicitors to access details of appropriate charities for their clients, as well as to be part of a register of solicitors who can help. The proportion offering such a prompt stands at 65%, according to new research.

From animal charities to medical research organisations, all are in need of funds and legacies are a useful source. Our special feature in this issue offers a glimpse of some of them and the varied and valuable work they do.

• Animal welfare has applications beyond the charitable sector, however. Companion animals throw up particular issues in terms of healthcare and medicine that may need the attention of an expert – for example when it comes to their value and fitness as breeding stock. Such experts may also be of value to government in formulating animal welfare legislation.

• One of the most stressful situations for any homeowner is ‘having the builders in’, as evidenced by numerous TV programmes. When the building project becomes a source of dispute the stress levels rocket.

Most homeowners have little or no knowledge of the building process, so are at a disadvantage if the dispute escalates. Employing the right expert is a must, as explained by chartered surveyor Michael Carr.

The Royal Institute of Bristish Architects has made life potentially a little easier with the publication of a new set of contracts for small projects.

• Many local neighbourhoods are enriched by the presence of trees adorning the open spaces and avenues, and for many the destruction of trees is a crime beyond any other prompting anger and even direct action.

In some cases, trees in a bad state of health can blight an area and cause infection of healthier specimens.

So it is important that developers and campaigners alike recognise when it is time to act to preserve the next generation. The help of experts like Mark Chester is invaluable.

• There has been a great deal of change and reform when it comes to expert witnesses in the family court.

Matrimonial disputes continue to be divisive, however, particularly when there is a substantial financial interest. Nick Andrews is a partner with accountancy firm Grant Thornton and explains some of the changing landscape. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Media failure – data disaster? ‚ HARD DISK FAILURE CAN be extremely frustrating, particularly

when it contains the only copy of your treasured photos or your favourite music collection. Just imagine the despair a client would feel if it was their hard disk which had failed and it contained evidence crucial to their defence. So, what can be done if critical digital media fails?

There are a number of options available depending on the media and the nature of the failure – if it contains crucial evidence or important data, arrange for the media to be inspected by a reputable data recovery company. Griffin Forensics prides itself on providing a friendly, cost effective and professional data recovery service and, where evidence is involved, a forensic data recovery service.

The company has vast experience dealing with all makes and models of hard disks as well as USB thumb drives, CDs, DVDs, memory cards, complex RAID configurations, tape media and server failures. They realise how important data is and will try every technique available in order to recover it.

Once they have achieved the forensic data recovery, they have an experienced digital investigation team who can undertake an examination of the data and provide you with expert evidence for court. q

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Bond Solon holds 20th annual conference ‹ ON 7 NOVEMBER the 20th annual Bond Solon expert witness

conference took place at the Church House Conference Centre in Westminster. The conference is the largest annual gathering of expert witnesses in the UK and a number of key issues affecting experts were put under the spotlight.

In its introduction to the conference programme, Bond Solon said: “While it is accepted that good expert evidence is fundamental to good justice, after reorganisations, budget cuts and time restrictions, experts are still expected to provide ethical, high quality, independent expertise.”

Lord Neuberger, President of the Supreme Court, gave the keynote address. In it he warned against taking what is accepted at the time as being correct as always being correct.

“Experts and their views are very much creatures of their time, even in a field which may seem to be as black and white as elementary physics. An expert’s view on what is, in principle, a timeless issue

Rioting sentences ‘excessive and arbitrary’, study claims ‹ A REVIEW OF sentencing following the 2011 riots in England

has shown that sentences were much harsher than realised at first.

The study was carried out by The University of Manchester and Liverpool John Moores University.

Dr Hannah Quirk, a senior lecturer in Criminal Law and Justice at The University of Manchester, was the co-author of the research, which was published in The British Journal of Criminology in October.

She said: “Whilst the offending may have been impulsive, sentencing should not be.”

The summer riots of 2011 were commonly described as the worst in living memory due to the speed with which they spread over such a wide geographical area. The disorder began after Mark Duggan was shot dead by the police in Tottenham, north London.

Over three thousand prosecutions were brought in connection with the unrest, which saw streets in parts of the country awash with violence, looting and arson. By 31 August 2012, of the 2,158 convicted all but 20 had been sentenced, with the vast majority of offending having taken place in London, followed by the West Midlands and Greater Manchester.

Dr Carly Lightowlers, a lecturer in Criminal Justice at Liverpool John Moores University, says the courts decided not to follow sentencing guidelines which led to excessive and arbitrary punishments.

She said: “It was not just the courts that over-reacted. An ‘uplift’ was applied at every stage from arrest, to charge, to remand, to which court dealt with the case.”

Much of the drive came from the Crown Prosecution Service.

Suspects were charged with burglary rather than theft, which carries a tougher sentence.

Dr Quirk said: “From arrest to sentence our research found that a tougher stance was adopted for sentencing riot-related offending and an air of prosecutorial zeal and judicial abandon was commonplace.

“All the agencies were working under great pressure to restore order and the courts made it clear that they saw their role as being to pass enhanced sentences to reinforce notions of punishment and deterrence.”

The study used Ministry of Justice statistics and data collected by the Manchester Evening News. q

may be perceived as being ‘right’, because it complies with the generally accepted contemporary view of the time, even though it will be thought to be completely wrong-headed later.”

In her blog for the Supreme Court website, Lauren Wood of Olswang LLP cites the example of the centuries-long debate over whether light is made up of particles or waves. She explained numerous historical examples of when generally accepted views later become disproved.

Later the conference heard from the barrister who took part in the controversial BBC programme claiming to show experts willing to fabricate reports. He said there was no pressing need for regulation, but there should be investigation of such practices when they were uncovered.

Those attending the conference were also asked to participate in the annual survey. One of the results, published two weeks later, was that 30% of expert witnesses said that in the past 12 months they were asked to, or felt pressurised to, change their report in a way that damaged their impartiality.

Examples ranged from being asked to remove sections of reports which were seen as damaging to the client’s case to being asked to re-write in their favour. Other experts said some solicitors had even refused to pay them if they felt they had written an ‘unhelpful’ report. q

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New RIBA contracts for small projects ‹ The Royal Institute of British Architects

(RIBA) has launched two innovative building contracts designed to be used in conjunction with RIBA’s Architect’s Appointment Agreements for Small Projects. The new contracts are fully aligned with the RIBA Plan of Work 2013 and have been designed in response to feedback from RIBA members calling for improvement and innovation within the building contracts currently available.

The RIBA Domestic Building Contract provides a simple, comprehensive and legally appropriate contract solution for all types of non-commercial work, including renovations, extensions, maintenance and new buildings. The contract is endorsed by the HomeOwners Alliance.

The RIBA Concise Building Contract provides a complete contract solution to cover small scale commercial building projects of a standard and straightforward nature.

The new contracts were launched on 5 November and are available in both print and online formats. They form part of a move towards a suite of project contracts that can be prepared and stored digitally and are more relevant and focused around the needs of those undertaking smaller projects. The RIBA is also working on updating the suite of RIBA

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agreements, to be available as an online tool.

RIBA president Stephen Hodder MBE, commented: “The new RIBA building contracts are a major step forward for the RIBA, our members and more importantly our members’ clients. The contracts complement our existing suite of architect’s appointment agreements for small-scale residential and domestic building projects and have been written in straight forward language that can be completed with confidence, without the need for legal advice.”

Jane Duncan, director of Jane Duncan Architects and RIBA president-elect added: “The RIBA building contracts are fair and balanced, supporting and enabling the work of the contractor whilst protecting the rights and interests of clients. This offers appropriate provisions for the major risks that either parties may encounter, including the risk to the contractor of failure by the client to pay for the work done and the risk to the homeowner of defective or incomplete work.

“I am proud to have been instrumental in the development of these two new forms of building contracts and very much welcome their publication.”

Paula Higgins, chief executive of the

HomeOwners Alliance commented: “Most homeowners do not have experience in carrying out major building work, like an extension or loft conversion, and we therefore strongly support this new form of contract. It will help homeowners protect their home, help them have a better understanding of their and their builder’s obligations and ensure that the result is a dream come true.” q • For further details on the new contracts visit www.ribacontracts.com.

Building surveyor or expert witness?

How to stop domestic building disputes escalating Michael Carr, BSc FRICS FCIArb MEWI, has 35 years’ experience in private practice and co-founded Kempton Carr Croft, a firm of Chartered Surveyors for London and the South in 1986.

Michael has built up considerable experience as an advisor and Expert Witness relating to Valuation, Landlord & Tenant, Construction, Boundary and Party Wall disputes as well as dealing with reports on issues of professional negligence.

Here, he offers his expert opinion on managing the client and contractor relationship to prevent the escalation of domestic building disputes.

‹ CARRYING OUT DOMESTIC building or renovation work can be stressful enough for the homeowner without the added tension of a legal dispute with their building contractor resulting from unexpected bills or unfinished projects. For builders, these disputes are both frustrating and potentially disastrous, as clients refusing to pay can dramatically impact on the cash flow of the business and, therefore, their livelihood.

An incomplete building project or an unsettled bill is undesirable for all parties but, these disputes do occur and require the intervention of an Expert Witness to provide advice to the parties and ultimately to offer evidence to the court.

Appointed by parties to the dispute, usually through their solicitors, often following Directions from the court, I’ve seen a marked increase over the last few years in the amount of disputes I’m called to deal with as an Expert Witness. Many of these disputes could actually have been prevented if a Chartered Building Surveyor (CBS) had been called in at an earlier stage.

In one recent notable case I was involved in, the original quote for the building works was less than £11,000, then revised to £40,000, but the final bill came in at £125,000. I was able to provide an Expert Witness report and a settlement was made at £80,000 – but it is a dramatic example of how, without early intervention, costs can spiral out of control.

Most disagreements, I believe, are caused by poor communication between the home owner and the builder and these could be avoided by the involvement of a CBS earlier in the process. Home owners often need to be guided to specify and fully itemise exactly what they want from the work so that there is no confusion. For example, a discussion about ‘fitting some sockets’ probably isn’t going to be detailed enough. The discussion should include particulars such as what type of sockets, what material the socket covers will be made out of, whether they will be

double or single, how many, where they will be positioned, whether there will be aerial points added and so on.

These minute decisions may seem inconsequential – and may even seem premature to be making before a single brick has been laid – but the details need to be agreed at the drawing stage. It’s very easy to change a line on a piece of paper, but much harder to move a wall. Disputes often originate because these finer points aren’t agreed, in writing, before the contractors start work.

If a professional building surveyor is employed at the start of the project, they can ensure these details are agreed in advance.

Their experience in this field means that they are more aware of which areas need to be agreed at earlier stages than the average homeowner. They are also able to keep the project on track and make sure the work is completed to the homeowner’s satisfaction at each phase of the build instead of waiting until things escalate at the end of the project to the point where legal action is the only option.

A CBS acting as a Contract Administrator will ensure the homeowner isn’t pressured into paying upfront but makes sure the builder receives regular payments to cover work that has actually been done. Many homeowners feel pressured by their builder into paying too early in the project which then gives them very little power if things aren’t completed on time or to a high enough standard. If a builder is requesting money upfront, there needs to be a valid reason as to why he needs this and using a professional surveyor to handle the contracts gives homeowners the confidence to question whether payment upfront is appropriate.

Involvement of a surveyor before the start of a build is sometimes seen as an unnecessary expense but, in my experience, the costs of an Expert Witness being called in once the case is preparing to reach court

are increasing and this is a costly way to resolve what could have been a preventable problem. An Expert Witness is required to assess work which has already been done and try to understand how the dispute has come about before presenting their report but this is both time consuming and more complicated.

Disputes can become incredibly convoluted and it’s rare to come across a situation where there is a clear-cut right or wrong. By the time an Expert Witness is called in there are likely to have been a number of faults on each side and dissecting the situation to assist the court in finding in favour of one side or the other is complex.

Having seen the number of building projects that end in disagreement, I believe the decision not to involve a surveyor early on is a false economy. Tensions run high when building projects result in disputes – both for the builder who needs the issue resolved to free up cash flow for his next job and for the homeowner who has to live with the unwanted effects of the incomplete building work on a day to day basis. Taking a dispute to court is unpleasant for all concerned and can get very combative, so it is in everybody’s interest to prevent the disagreement from occurring in the first place Naturally, there will be instances where the involvement of an Expert Witness is unavoidable. It would be unrealistic to assume that all building projects can progress smoothly with no issues at all.

However, for the majority of cases which do reach the courts, the earlier involvement of a surveyor could have prevented misunderstandings, improved communication and made the process easier and less stressful for everyone. q • For more information on Building Contract Administration or Expert Witness Services visit the website at www.kemptoncarr.co.uk or call Michael on 01628 771221. www.yourexpertwitness.co.uk

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Festive campaign against online fraud ‹ DURING THE FESTIVE season the City of London Police, in partnership with a range of public

and private sector supporters, is running a campaign to protect millions of people across the country from falling victim to cyber-fraudsters. Involving 37 local forces, it will raise awareness of a dozen online frauds that could ruin the holiday fun.

The 12 online frauds of Christmas campaign kicked-off on ‘Black Friday’ – Nov 28 – by shining a light on the ‘do’s’ and ‘don’ts’ of online shopping, followed by a special ‘Cyber Monday’ focus on Christmas e-cards and the danger of opening unknown email attachments and links which could be carrying a malware. Every 24 hours for the following 10 working days another of the campaign’s 12 festive online threats, identified by the City of London Police’s National Fraud Intelligence Bureau, were revealed.

The 12 scams are: online shopping fraud; Christmas e-cards; auction fraud; holiday fraud; loan and investment scams; ticketing fraud; donating to charity; mobile malware/malicious apps; money transfers; social media scams; dating/romance scam; mobile payments.

Tony Neate is the CEO of Get Safe Online. He said: “Sadly, year-on-year we hear about people thinking they have got the perfect Christmas gift for someone but they end up disappointed because they didn’t recognise the most common scams out there. We are urging online shoppers to take a step back and think before they buy – always question if it is too good to be true, do your due diligence to check the authenticity of the site or product and make sure you use secure and protected methods of payment.” R

Business valuations

By DEREK WILLIAMSON, forensic accountant at Goddards Chartered Accountants

‹ BUSINESS VALUATION IS a

process and a set of procedures used to estimate the economic value of an owner’s interest in a business. All too often, shareholders, directors and/or partners in a business do not have any formal agreements and so, when they fall out, valuing the business becomes very difficult as there are no pre-agreed terms of reference.

If it is a limited company, should one remove the (very low) directors’ remuneration and replace it with a market value remuneration prior to calculating the buyout value?

What expenses have the parties agreed to put through the company that would not normally be treated as valid business expenses? Do they have spouses on the payroll that do not genuinely earn their salaries?

Should these be added back? Do they work from home and would this be necessary for the new owners?

Is their business repeat business or do they suffer from high marketing costs to enable them to find new clients? In the direct marketing business up to 30% of overheads can be marketing. Are they professionals and so liable to keep repeat business and reduce their overhead costs?

The type of business – professional or commercial – will affect the multiplier for the basis of valuation. In the case of accountants it is the repeat client value that is used to calculate the valuation from 1.00% to 1.25% of client value. Yet for many commercial enterprises it will be the amended net profit with a multiplier of between four and eight.

The most common requirement for a valuation is in a matrimonial dispute where the shareholding partner usually wishes to materially down value the business whilst their spouse is equally keen to over value it. In those circumstances, one would need to look at an open market valuation of the business.

Finally, the business may also have properties which would need to be separately valued and then consolidated into the overall business valuation. R

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Changing dynamics: the evolving landscape of family law in the UK

By NICK ANDREWS FCA, partner with Grant Thornton

‹ AT GRANT THORNTON we are just in the process of releasing our

annual matrimonial survey that looks at key issues facing family lawyers.

The survey has evolved over the last 10 years, as has the family law environment, to examine different variables impacting on the way in which family law in the UK operates. In 2014, one significant trend has been the rise of the litigant in person – driven by legal aid cuts for the most part. This has also been one factor leading to an increase in private arbitrations and mediations.

It is without doubt that 2014 has been a historic year for family law. The introduction of the single family court in 2014 was a significant moment and was described by Sir James Munby (president of the Family Court Division of the High Court) as ‘the largest reform of the family justice system any of us have seen, or will see, in our professional lifetimes’. There were high profile and high value divorce cases throughout the year such as Hohn v Hohn, disputes about jurisdiction in the case of Chai v Peng and issues of concealment in the cases of Scot and Michelle Young and Mr and Mrs Sharland – and further developments in Prest.

The role of the expert in family law cases must also evolve to reflect changes in society and the changing way in which family units operate, as well as the economic impact still felt from the financial crisis and the part that this has played in cases. The family law landscape can often be a complex one to navigate and having an experienced expert is critical.

An effective expert, whether a single joint expert or a party-appointed one, should be able to work collaboratively and proactively with family lawyers, understand their pressure points and provide an added-value approach to resolving disputes.

Typical areas of remit for accounting experts in matrimonial cases include the valuation of business assets/investments, assessment of liquidity and tax considerations and asset tracing.

Another development in 2014, has been the onward march of the status of pre-nuptial (and post-nuptial) agreements in English Law. The Law Commission, reporting in February 2014, recommended that legitimately executed ‘pre-nups’ should become legally binding: the Government is due to give its response by February 2015. In such a dynamic environment, it will be interesting to see the impact these developments will have on the role of the expert witness in the coming year. q • Nick Andrews is a partner in the Forensic, Investigations and Recovery Practice at Grant Thornton. Nick specialises in dispute work and has acted as an expert accounting witness in over 200 cases, including numerous matrimonial disputes. Nick has also undertaken a large number of business valuations in a dispute related context including shareholder, M&A, CPO and matrimonial cases. You can contact Nick on 020 7865 2174 or via email nick.d.andrews@uk.gt.com.

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Establishing the next generation of trees – getting it right

By MARK CHESTER of Cedarwood Tree Care

‹ TREE PLANTING IS OFTEN associated with ceremonial and

other landmark occasions. Trees are planted to commemorate births, anniversaries and civil events. The sight of a dignitary, spotless spade in hand, carefully pouring soil around a young tree, is guaranteed to get photographers busy – with those observing taking reassurance that a legacy for future generations is being birthed.

However, establishing the next generation of trees is far more than a photo opportunity. As we are faced with the challenges of climate change, urban heat islands and the rise in respiratory illnesses – and the need to increase canopy cover to counter them – so it is important that we are planting the right trees in the right places and equipping them for the future.

Increasingly, tree planting is a requirement for planning applications and the need to demonstrate feasibility is a key factor. In addition, the presence of young trees in decline can be an obstacle and the cost of replacing dying trees is often substantial, not just in terms of the actual tree but also of interuptions to infrastructure. It does not reflect well on developers when a scheme fails to mature and instead of an attractive green landscape, less attractive swathes of concrete are left.

Trees are really important to improving the health of our urban environments. Research by Professor Roland Ennos at Manchester University, using birch trees to measure the interception of air particulates linked to asthma, found that placing larger specimens outside properties fronting a busy road significantly reduced the air pollution. However, some 25% of all newly planted trees fail to reach maturity and canopy cover is being further reduced as larger, mature trees are felled and either not replaced or replaced with smaller and often shorter-lived specimens.

Several years ago, I was engaged as the arboricultural consultant for a scheme in a sensivite setting within a National Park. What might otherwise have been a relatively straight forward brown field regeneration project was being subject to a more intense level of scrutiny. There was a plethora of issues needing to be considered – from bats and ecology to landscape and architecture. I had been instructed to survey the trees on site and attended a meeting with the planning officials in this capacity.

Part of my role as an arboricultural consultant involves identifying trees and shrubs suitable for a landscape scheme. I consider the setting and the qualities that specific trees may bring and the anticipated timescale that a tree may have to mature and develop. There are situations where it is hard to justify the budget for larger trees, such as some residential settings where a larger number of smaller, less expensive trees can make a greater contribution. Other situations may call for impact, such as prestigious retail and technology parks where a smaller number of larger trees is the preference. There is also little purpose in planting a tree likely to take half a century to become established if the site may be re-developed within several decades.

One of the elements that I have appreciated is that the place within a site where a tree is planted can have a significant bearing on whether it provides a positive or negative contribution. For example, having a seedbearing tree near to a footpath where berries will be squashed under foot is not necessarily the best idea. However, the same tree situated among shrubs, away from pedestrians, can make a valued contribution.

The alder is popular on sites with contaminated soils. Growing fast, it thrives in the harsh settings of the urban environment and can help to improve otherwise poor soil. However, individual trees often reach heights exceeding 25 metres and the foliage can cause shading. It is a species to be used carefully in proximity to residential settings, especially those with a higher density of properties such as apartments.

In my meeting with planning officials, I saw detailed site plans including

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landscaping. These included a row of alders proposed to line the side of a road, fronting apartments. I saw a recipe for problems here and, as this was highlighted by the planners as a concern, I was able to reassure them that the plan was not the final document and that different species would be used.

Whilst some trees, such as London plane, respond well to being planted in the landscape and can be moved when they become larger, others, especially birch and beech, are more sensitive to this major change. With such trees it is preferable to plant them when smaller – providing informed insight can ensure that a good idea becomes a better one.

As an independent consultant, I seek to guide interested parties whether they are preparing an application or seeking advice on how to respond to a proposal. Some years ago, I was approached by a group of residents concerned about the potential impact of a major regeneration project proposed for nearby parkland. The site contained some 100 or so trees, including ornamental apple, beech, horse chestnut and willow, and many were being recommended for removal with a promise of new trees being planted.

The residents were concerned that the proposals may not have been appropriate. If the removals were justified, then the residents would accept it, however they wished to make an informed response and to focus their efforts where it was justified. As I walked the site, I recognised that, attractive though they were, the many ornamental apple trees were actually coming to the end of their natural life. Such trees tend to live for 50-60 years, compared to the several centuries of beech, London plane and oak. When trees are coming to the end of their natural life a recommendation to fell is understandable.

There is a serious pathogen attacking horse chestnut, called ‘bleeding canker’. It attacks the bark and, although research is identifying ways to equip some specimens to resist attacks, at the time of my visit it was generally regarded as untreatable. With this insight, I recognised that proposals to remove the horse chestnut trees had merit. Indeed, I suggested that several specimens showing the early signs of infection, but not identified for removal, should be considered for felling.

A row of willow trees had also been recommended for felling on the grounds that they were unsafe. No specific failure points were cited and I had concerns that this element of the proposal was unjustified. I provided the residents with my comments and queried the credentials of the author of the original report, commissioned by the local authority.

The response, that the author was an approved consultant, raised concerns for me as there is no national ‘approved consultant’ scheme.

The Arboricultural Association has a list of registered consultants and approved contractors, the latter being specialists in pruning and felling trees. Whilst they are often instructed to write tree reports, this is not their specialism, as is the case with tree consultants.

I advised the residents to focus their attentions on the willow trees and to seek to have quality new trees planted as part of the regeneration project. Today, the willows remain for another generation to enjoy and the landscaping, which included longer-lived lime trees, is maturing as an attractive feature. This highlights one of the key elements in increasing canopy cover – to retain current trees for as long as possible as they provide maturity, size and are already established.

Developers are aware of the importance of tree planting. There is a tendency either to plant big trees, demonstrating they are not operating on a ‘shoe-string’ budget, or to choose trees which will provide blossom and look attractive. Cherries and ornamental apples seem to be very popular. Whilst these trees can provide an attractive feature, especially when they are in blossom, they tend to be high maintenance – sensitive

to pruning and with invasive roots – which is often overlooked when they are planted near to expensive block paving or tarmac surfaces. They also tend to be comparatively short-lived.

There is nothing wrong per se in choosing trees supplied as ‘rootballed’, a common specification. These are trees grown in a field and lifted with many of the roots and some of the root ball intact. However, without an appreciation of production methods, one can easily order trees with poorly developed roots that struggle to become established once planted. As a tree is growing in the nursery, its roots need to be pruned every two to three years to ensure that they remain in good vigour and become well developed. One important factor is how much those doing the actual planting appreciate the importance of their role.

When a tree is prepared as a rootball, its roots are usually encased in wire netting for transportation. I have actually seen trees planted with the wire caging still in place (see below) when it should, of course, be removed prior to planting.

However, merely requesting trees be either container grown or rootballed is a bit like asking for a car that runs on petrol or diesel. Much more detail is required. One customer I am aware of, with a six-figure budget to purchase nursery trees, provided a document several hundred pages long inviting tenders. It contained a single page relating to the trees being ordered, with a specification relating solely to the size of tree and no reference to quality of stock. Issues such as pruning of roots to encourage vigorous growth and of branches to enable the crown to develop were absent. The remainder of the document covered issues not relating to trees at all.

Tree health has been a high profile issue in the past few years with attention focused on Chalara fraxinea which can be devastating for ash.

The disease arrived in the UK on trees imported from the continent and has highlighted the issue of provenance. However, provenance – the origin of the seed from which a tree has been grown or of the parent plant if the tree is cultivated from a cutting – cannot be established simply by requesting stock be sourced from a local nursery. In the UK, many ash trees have been germinated from local seeds which have then been exported as seedlings to nurseries on the continent where production costs are lower. They have then been brought back to the UK and sold to customers here – sometimes with unexpected passengers!

Seeking local provenance is more than simply buying from a local supplier. A tree which has grown in the south of England and is then taken north to be planted can find the cooler conditions difficult and may take longer to establish. Whilst this is less of an issue when trees are grown in cooler climes and then move to a slightly warmer setting, if a tree has grown as a sapling in a climate with a later spring, for example in Scotland, it will come to leaf at this later time if planted in England where spring arrives earlier. This can be a problem, as trees coming in to leaf ahead of others within a population gain an advantage, shading the later budding specimens. English oak trees come in to leaf depending on temperature, benefitting from warm spring weather, whilst the common ash is influenced by day length which is a fairly regular annual feature.

With time, and warm springs, oak will shade out ash.

Work over the past decade has focused on creating subterranean

conditions to enable trees to be successfully established within settings where otherwise it would be impossible. Trees need access to well aerated growing media which can be maintained with sufficient moisture and kept free from compaction. The infrastructure used also needs to have sufficient strength to support activities above ground, such as delivery vehicles which can weigh many tonnes. This is now possible and there are examples of trees maturing within the car parks of retail centres, pedestrianised high streets and even in the central reservations of main roads. The work has been so successful that one experienced and highly reputable nurseryman I know considered the trees in one venue, planted ten years ago, to be as healthy now as they would be if still on the nursery. High acclaim indeed!

The process of establishing the next generation of trees is complex and breaks in the chain can easily occur. A single break in the chain can undermine the whole process. It is possible to choose appropriate trees, in suitable settings, yet find that they struggle to flourish. Some of the trees leaving our nurseries for landscaping schemes are already dead or in decline and, until now, it has not been possible to assess the physiological condition of a tree.

Work by Barcham Trees and the Bartlett Tree Research Centre in Reading, using equipment developed by Hansatech Instruments, has identified a method for assessing a plant’s health. Chlorophyll, the chemical which drives photosynthesis, is very sensitive to stress within a plant and its response can be accurately measured. It can detect stress, such as from drought, long before it becomes evident in the plant. It is now possible to assess the health of young and more established trees using the simple test that these three organisations have devised. One colleague did the test on some trees planted several years ago, which looked to be in good vigour, as a trial. The test indicated that the trees were being affected by a condition which, with time, was likely to prove terminal. He held his breath waiting for the results and, sure enough, within the month the trees began to die.

At a conference at Birmingham University in 2014 – Trees, People and the Built Environment II – Glenn Gorner, tree manager for Leeds City Council, discussed a project to enable a large London plane tree to be planted within a prominent retail setting in 2013, using some of the techniques I have described. Much planning went in to the project, but Glenn had underestimated the impact of a particularly hot and dry June on the irrigation arrangements he had put in place. Local retailers brought in extra supplies of water on a daily basis during those sultry days, ensuring that this important tree has been sustained.

However, a tree can be vulnerable, even years after planting, to unseasonally dry weather or extended drought. In the springs of 2007 and 2008, many trees came in to leaf in April to be faced with a hot and dry May. Cooler and wetter conditions in June were too late for some of the young trees I was managing at the time for a local authority. One of the current areas for research, aimed at equipping the next generation of trees to thrive, is to identify the factors that enable some species to become established even during drought conditions. If we can select trees naturally, unaffected by such challenges, another hurdle can be removed. q

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Veterinary care for companion animals

By PAUL ROGER of Veterinary Consultancy Services

‹ PROVIDING REPORTS ON companion

animals encompasses a wide variety of species. This grouping includes not only dogs and cats but all species kept as pets and can therefore include exotic and unusual species as well as animals normally kept for other purposes such as food production.

In previous articles, I have outlined veterinary involvement in production animals and considered the implications of changing societal expectations on how we use these animals and the duty of care that we owe them. This article will concentrate on the various avenues of veterinary involvement with companion groups.

Usually our first contact is to provide preor post- purchase checks aimed at verifying an animal’s health and offering an opinion as to its current status, together with a professional assessment of whether this check has revealed any potential deficiency which may later become a problem. For example, if the animal has a conformational defect that may lead to locomotor problems which would not occur without the presence of this defect.

These checks are systematic and thorough and may lead to the suggestion of further and deeper investigations into a particular aspect of the animal’s make up, such as its circulation, anatomy or

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behaviour. Examples could include the shape of a horse’s hoof or an assessment of the likelihood that a bony lump might impact on movement. In dogs, it could be a genetic make-up which may lead to problems in the animal being considered for breeding in the future. Indeed, the profession runs a number of schemes aimed at reducing genetically based problems in small animals through the British Veterinary Association.

Pre-purchase examination is an area that requires professional experience and knowledge if it is going to be effective and useful to the client. To assess these aspects in greater detail, it may be necessary to access specialist equipment or knowledge.

Specific disease control, through the use of vaccines or other medication, and strategic interventions for ecto-parasite (fleas, ticks and mites) and endo-parasite (worms) control, together with advice on the selection of animals for breeding and the need for such animals to have an acceptable quality of life, are issues regularly dealt with.

The world of veterinary specialisation is complex. With companion animals this has become more systems focussed within species whereas, in the field of production animals, specialisation remains more species focussed. For this reason, referral of an animal to recognised specialists

requires a knowledge of veterinary specialities – an area that is poorly understood outside the profession and which can be confounding to those without this insight.

General practitioners accrue a wealth of experience and expertise in those species which they deal with on a day to day basis and are therefore ideally placed to help source specialists in particular fields. These specialists have recognised qualifications and are subject to regular revalidation by the profession’s governing body, the Royal College of Veterinary Surgeons (RCVS), and by the European Board of Veterinary Specialities (EBVS) and so there is a quality assurance built in to the status granted to these surgeons.

This may be difficult to understand for those outside the veterinary profession, but the days of the omni-competent veterinary surgeon have passed as the knowledge base has grown and the expectation of the level of service provided to the general public has increased. There remains an important role for the experienced general practitioner, however there is a steady recognition and utilisation of referral to specialists where these added skills and knowledge are needed.

This is a well established practice for small animal species and in equine and

zoological disciplines but is less well accepted in production animals. Our young graduates now qualify realising that an omni-potential is only developed through experience and post-graduate training – whether this be formal or informal. The day one skills which these graduates possess are better recognised and their need to develop these into specialist competencies is part of the continuing role that the degree fits them for. It is just the start of a lifelong journey in the profession, developing and honing technical skills and knowledge in the health and care of the animals under their control and in ensuring animal and human health through responsible use of pharmaceuticals and management practices.

It is not surprising that this makes selection of veterinary specialists a difficult area and that the provision of expert opinion and reports has become a finely tuned and selective practice by those specialists within the profession.

Our expertise as a consultancy lies not only in covering a broad and active range of specialities with formal recognition of expertise but also in covering areas related to the delivery of just and equable outcomes based on evidence and a transparent application of science. The varied background of our consultants gives VCS Ltd a unique overview of the complex and intricate areas of veterinary specialisation and is a considerable strength in this rapidly changing area. VCS Ltd can access specialists in all areas of veterinary involvement.

Recent involvement includes providing expert reports for courts (in both civil and criminal cases), advice on regulatory affairs and input into government policy development, reports for pharmaceutical companies and suggestions for development of product application as well as co-ordination of research products and involvement in clinical research projects.

This is in addition to maintaining clinical expertise and actively promoting our various specialities through teaching, training programmes and published work. R

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YOUR EXPERT WITNESS SPECIAL FEATURE: TRANSLATING AND INTERPRETING

Chartered Institute relaunches register ‹ THE Chartered Institute of Linguists (CIOL)

has relaunched its chartered linguist scheme in a move that will make the register more accessible to professional linguists.

CIOL holds a register of chartered linguists in the public interest, to provide users of language services and employers with access to a comprehensive source of qualified, practising and experienced professional linguists. The register holds details of freelance translators and interpreters, educationalists and those working in business, the professions and government, as well as providers of specialist language services.

According to the new criteria, a chartered linguist must have been a full member or fellow of CIOL for at least two years, have been in regular professional practice as a linguist for three years and take part in relevant continuing professional development.

The relaunch was announced at the institute’s Members’ Day on 11 October by council member and chartered linguist Karen Stokes FCIL. She said: “Today is something of a milestone. We are really keen to encourage as many people to take up the scheme as possible.”

As an incentive to boost numbers on

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the register, CIOL waived the first annual registration fee for successful applications received in the first month of the pilot. In return, applicants were asked to give their feedback.

Among the comments made by current and former members of CIOL were: “For me, becoming a chartered linguist was the next stage in my career development and I believe it

will allow me to demonstrate my commitment to quality in my translation.

“Quality assurance is something we can never have enough of in our profession and a recognition of quality which is understood by those who work with interpreters, translators and linguists can only further enhance the credibility of our profession.” R

Linguists look to future-proof their profession ‹ AMONG THE MANY EVENTS at Language Show Live in October the CIOL continued the

collaborative Future-proofing the profession: Equipping the next generation of translators project with a well-attended seminar delivered to a mix of translation freelancers, students, academics and in-house professionals.

The seminar, chaired by Helen Campbell Hon FCIL, was a follow-up to the first event held in July at Europe House under the Translating Europe initiative of the European Commission’s translation service DGT and co-organised with the Institute of Translation and Interpreting and the EU. The report based on July’s event was presented for the first time by European Commission Language Officer Paul Kaye.

Since the July event the CIOL undertook a survey of opinion among translators and other translation professionals on some of the themes discussed. The key findings were presented to the public for the first time by Jack Sellen, CIOL’s professional development and membership services officer. R

YOUR EXPERT WITNESS SPECIAL FEATURE: TRANSLATING AND INTERPRETING

Prince honours language learners ‹ ON 6 NOVEMBER the Royal Patron of the Chartered Institute of

Linguists, HRH Prince Michael of Kent GCVO, presented its Awards for Excellence in Language Learning, at the Barbican in London.

A new award, donated by the National Register of Public Service Interpreters (NRPSI), was presented for the Diploma in Police Interpreting, a new qualification taken for the first time in 2014.

Ted Sangster, chairman of NRPSI, said: “As the independent voluntary regulator for public service interpreters, qualification standards are central to our registration criteria and the police are major users of the National Register. We are therefore delighted to provide the annual NRPSI Award for Excellence in the Diploma in Police Interpreting to the best examination candidate.”

The Threlford Memorial Cup – the highest award offered and presented annually since 1935 in memory of the institute’s founder for ‘fostering the study of languages’ – was won by GCHQ for their Language Outreach Programme. Members of the Threlford Memorial Committee praised the GCHQ team’s creative approach over the past eight years towards promoting an interest in languages by visiting secondary schools across the UK and highlighting the career opportunities available to those with a knowledge of languages.

Chair of the Threlford Committee, Chris Pountain, said: “Amongst the impressive nominations for the Threlford Memorial Cup this year, the GCHQ schools outreach programme and its new initiative – the Schools Language Challenge – stood out, not only for stimulating interest in languages not normally studied in UK schools, but also in raising awareness of the importance of languages for our national life.”

A second award in this category received a Special Commendation and was awarded to the Shpresa Programme, a language-learning initiative led by Luljeta Nuzi for her work with the Albanian-speaking community in London. The David Crystal Trophy, donated by the eminent linguist, was presented for that award.

Other candidates were presented with awards for their success in the Diploma in Translation, Diploma in Public Service Interpreting and Certificate in Bilingual Skills.

Ann Carlisle, executive director of IoL Educational Trust, said: “It's always a great pleasure to present these Awards to individuals and organisations leading on language study and learning – all the more so given the critical need to spread awareness of the value that languages add to the UK and other world economies and to the promotion of cross-cultural understanding.” R

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Legacies

a way of leaving the world a better place Leaving a bequest in a will to a favoured charity – maybe an organisation that has provided relief or comfort to one’s family – is a noble way of leaving a mark on the world.

On a grander scale, family foundations using the fortunes left by wealthy philanthropists have been helping the less privileged for centuries. In the following pages we will be examining trends in legacy giving.

‹ In the 21st century there are thousands of charities – at local, national

and even international level – that derive part of their income from legacies left in people’s wills. That proportion varies by sector and research by the Civic Society shows that some charitable sectors rely more on legacies than others.

Legacies enable medical research charities to plan better for the future, while the story of elderly pet-lovers leaving their savings to the local cats’ or dogs’ home is no myth. Indeed the RSPCA says that more than half its work is funded that way, while animal welfare organisations generally received 31% from legacies.

The great bulk of the funds left to charity go to a small number of very large charities, but in recent years that trend has been changing, with smaller, local charities increasing their legacy income at a faster rate than the major national ‘brands’. The same research from the Civic Society showed that between 2005/6 and 2009/10 local charities experienced growth of 5.4% per annum compared to 2.5% for the large organisations.

Charities are also becoming more aware of the role legal advisors can play in helping people to make provision in their wills. All the major charities offer provision for leaving legacies and there is a professional body representing legacy managers. Smaller charities have clubbed together to form an organisation promoting legacy giving which has a scheme specifically aimed at solicitors.

One of the major limiting factors on legacy provision is the fact that most people do not make a will, as can be seen from recent research. The most common reason given is that people don’t think they have anything worth leaving.

Recent leaps in house prices, coupled with the static threshold for inheritance tax, give the lie to that argument.

Ironically, though, there is an argument that raising the threshold of inheritance tax would result in fewer people leaving bequests to charity as it would remove the tax incentive.

The major foundations can also act as a barometer on society. Research into foundation giving has shown that, as their income has fallen, the level of grant giving has increased. What is seen as easing the debt burden results in a squeeze on returns. q www.yourexpertwitness.co.uk

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Charity consortium promotes legacies to solicitors ‹ ALTHOUGH 75% OF THE British public supports a charity

during their lifetime, only 6% think to include their favourite causes in their will. According to Remember A Charity, the organisation that promotes legacy giving, research shows that more than a third of adults would be willing to include a charity in their will, after they’ve made provision for family and friends.

The organisation has set up a scheme to encourage solicitors and other accredited will-writers to offer clients the information that leaving a legacy to charity is an option. The Campaign Supporters scheme is free to join and, by doing so, solicitors can support the aims and objectives of Remember A Charity while looking after the best interests of their clients. They will also be listed on the ‘Find a Professional Advisor’ section of the organisation’s website at www.rememberacharity.org.uk.

The scheme focuses on four key areas: • Raising awareness and relevance among the will-writing public • Making charitable prompting the standard practice among • solicitors and will-writers • Influencing a climate for successful charitable will-giving by • working in partnership with individuals, government and private • sector organisations • Helping the charity sector to become more effective at • promoting gifts in wills.

Remember A Charity is a consortium of over 140 charities that seeks to ‘change the perceptions and perspectives of the nation towards charitable legacies, so that, over time such legacy giving becomes the norm for the many, rather than just the few’.

In December the organisation published figures showing that the proportion of solicitors and will-writers informing their clients about the option of leaving a gift to charity is at its highest for more than a decade. The report, by SPA Future Thinking, showed that 65% of solicitors and will-writers are ‘always or sometimes’ making the charitable ‘prompt’ – the highest level since Remember A Charity started monitoring prompting levels in 2002.

The research also shows that those advisors who prompt about charitable legacies have up to three times as many of their clients leaving charitable bequests in their wills.

Remember A Charity’s director Rob Cope said: “There has been a large disconnect between the 35% of adults who say they’d be happy to leave a gift in their will and the 7.3% who went on to do it. Solicitors and will-writers play a crucial role in informing their clients about this form of giving. This report shows that our campaign is helping to shift charitable prompting to become a social norm, potentially generating millions for good causes every year.” q

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Major beneficiary explains how to leave a legacy ‹ ONE OF THE charities that benefits

most from legacies in people’s wills is the RSPCA. It is also active in promoting the idea to prospective donors and making information available. In November last year the charity teamed up with The Telegraph in a project known as Inspiring Animals to promote its work. As part of that project a number of in-depth articles were published detailing how to make a legacy and the tax advantages.

According to the RSPCA, more than half of its work is funded by legacies. The Telegraph article explained: “In 2013, this funding helped the charity to rescue and collect nearly 245,590 animals, provide over 180,000 treatments in hospitals and investigate more than 153,000 cruelty complaints.

“The legacy gifts that the RSPCA receives ensure that there is help for vulnerable animals every single day,” it added. There is also a substantial and informative section on the RSPCA’s website.

Of course, the first and most important piece of information to pass on is to contact a

solicitor to ensure the legacy is properly made and carried out.

On the Your Questions Answered page of the legacy section the RSPCA says: “Whether you are making a new will or updating an existing one, we recommend you speak to a

specialist legal advisor. They have the legal expertise to clearly express and carry out your wishes.”

The section also details the three types of legacy that can be left: A pecuniary gift: This is the gift of a specified sum of money. The RSPCA’s advice is to bear in mind that with inflation the value of this gift can be affected over time.

A residuary gift: This is where you set aside a portion or all of your remaining estate, known as the residue (what is left over after the payment of debts, funeral expenses, administration costs and all the specific and other gifts have been paid) to be divided between named beneficiaries.

A specific gift: This is where you leave a specific named item to a named beneficiary, such as a car, property or an item of jewellery.”

As well as answering frequently asked questions the section has downloadable files explaining Inheritance Tax and legal terms.

There is also a form to inform the charity of the legacy, allowing it to thank the donor. q

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Concerns raised over the intestate ‘timebomb’ ‹ RESEARCH CARRIED OUT for the Law

Society in October has shown that the majority of Britons have not even written a will at all.

The representative body for solicitors has warned that the consequences of dying without a valid will can be dire for those left behind.

The research, carried out by Opinion Matters, revealed that 73% of 16-54 year olds don’t have a will, while 64% of people over the age of 55 have made their final wishes clear in a will. The research also found that men are more likely to have a will and keep it updated than women.

Last year, £8m went to the government because people died intestate, while 23% of respondents wrongly believed that, without a will, their possessions would automatically go to their family.

According to the Law Society, it is estimated that by 2018 the government will receive nearly £6bn from inheritance tax. But by careful planning, such as leaving money to charity, those with a will can substantially reduce the amount of tax that becomes liable

or even alleviate it altogether. Inheritance tax can be a lot higher without a will.

Law Society president Andrew Caplen said the figures are extremely concerning: “Thousands of people die every year without making a will or without a properly drafted will. These figures show just how bad the problem is. Dying intestate not only means your final wishes will probably go unheeded, but the financial and emotional mess is left for your loved ones to sort out. This need not be your final legacy.

“Making a will is usually a very simple process but we urge people to use a qualified, insured

solicitor because he or she will be able to spot the nuances that could lead to trouble later on if not properly addressed.”

The findings echoed a survey of 2,000 over50s commissioned to mark the launch of the 2014 Remember A Charity Week in September.

That survey found that nearly 40% of those aged 50-plus have not made a will.

One in five of those polled (22%) say that they haven’t discussed their wishes with family or friends, with men finding the subject harder to raise than women. A quarter of men (26%) had not conveyed their wishes compared with just under one in five (19%) of women.

Rob Cope, director of Remember A Charity, said: “With gifts left in wills worth more than £2bn to UK charities – the equivalent of almost 20 Comic Relief appeals – the intestate ticking timebomb puts their future at risk too. The hard truth is that many of our favourite charities simply wouldn’t exist if it weren’t for legacy donations.

By writing a will and leaving to charity within, no matter how big or small, you can ensure that good causes live on.” q

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Lives saved by Medical Detection Dogs ‹

MEDICAL DETECTION DOGS is a charity based in Buckinghamshire which works in partnership with researchers, NHS Trusts and universities.

Its aim is to train specialist dogs to detect the odour of human disease.

Medical Detection Dogs does not receive government funding and relies totally on legacies and public donations to fund its work.

There are two divisions to the charity: • Medical Alert Assistance Dogs • Cancer Detection Dogs Medical Alert Assistance Dogs are trained to assist individuals who manage complex medical conditions on a day to day basis. The dogs are taught to identify the odour changes that are associated with certain medical events. For example, for someone living with brittle type 1 diabetes, avoiding hypoglycaemia (low blood sugar) can be a daily problem.

Cancer Detection Dogs are trained to detect the odour of volatile compounds present in the urine or breath of individuals with cancer. The charity has completed trials on bladder cancer and is currently embarking on a study into the detection of breast and prostate cancer.

Medical Detection Dogs is already saving lives, but if the charity had the resources to roll out detection units nationwide, it would have the potential to save thousands more. q • For more information visit www.medicaldetectiondogs.org.uk.

The charity that takes aid, not sides! ‹ HOPE AND AID DIRECT is a registered charity that delivers

humanitarian aid worldwide. Twice a year unpaid, self-motivated volunteers from all UK backgrounds, with no paid staff, drive lorries of humanitarian aid to the Balkans, with life-saving basic essentials of food, blankets and other items.

The main focus is currently Kosovo, where over 340,000 people are still surviving on less than the cost of a bag of crisps every day. Vulnerable individuals and families, young and old, are identified by in-country NGOs and charities who facilitate delivery by the UK volunteers directly into the hands of the neediest.

If practicable, as was the case in January 2014 when they sent six shipping containers with 120 tons of vital aid to the Philippines – including 60 generators, a full container of bottled drinking water and another full of food – the volunteers will respond to other world emergencies.

In addition to twice-yearly aid convoys, other projects are undertaken including initiatives such as house repairs, provision of beehives, stationery for schools, vitally important winter firewood and medical support. A specially made computer for a young boy with no arms, ambulances, a nearly new fire engine and a portakabin toilet block have all been taken and donated.

Another major undertaking was the complete replacement of commercial washing and drying machines in an in-house laundry at a mental and physical disabilities institute. The volunteers love a challenge!

Hope and Aid Direct has no government or institutional support and relies totally on public fundraising, which is why legacy donations are so important. q • For further information visit the website at www.hopeandaiddirect.org.uk.

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Take a moment... ‹ MOMENTUM CHILDREN’S CHARITY asks solicitors to prompt

their clients to consider charitable giving in their wills. With 13% of all charitable donations coming from legacies, any increase in this area will have a significant impact on all charities, particularly the smaller ones.

Small and medium sized charities are sometimes overlooked but their impacts can be enormous within the local communities they support.

One such charity is Momentum. Now in its tenth year, Momentum is a UK registered, regional charity based in Kingston, Surrey that supports children with cancer. Its impact on improving the lives of children with cancer and their families has been proven with the full support of all the CEOs of the local hospitals it supports.

The charity has two key objectives. Firstly, to help children with cancer through their difficult journey from initial diagnosis throughout treatment and beyond. Secondly, Momentum enhances the healing environment within local hospitals, making the children’s lengthy periods in hospital more bearable. This is not currently possible within the current NHS financial limitations.

Momentum is a charity that is well established with a proven track record and is here to stay. With multiple projects, clients can choose where they would like to leave their money – helping with family support or specific hospital enhancing projects.

With wills and legacies, the role of solicitors is imperative – they can bring lasting changes to children’s lives by making their clients aware of charities such as Momentum and the vital work they undertake.

Small legacy donations can bring about big changes for a charity like Momentum. q • For more information you can visit Momentum’s website at www.moment-um.org or contact the team on 020 8974 5931.

Sanctuary provides a safe haven ‹ WALES APE AND MONKEY SANCTUARY, located on the edge of

the Brecon Beacons in South Wales, provides a permanent safe home for apes, monkeys and other mammals whose backgrounds include closed zoos, laboratories, the pet trade and circuses. Even two stowaways on container ships – a monkey from Malaysia and a Raccoon from the United States of America – have found refuge there!

“We were motivated to establish the sanctuary when the local zoo closed and left seven adult chimpanzees stranded with no offers of homes anywhere in the UK," said trustee Jan Garen. “The bulldozers were poised to move in and the zoo owner informed us that the only option was to shoot the chimpanzees.”

Fifteen years later the sanctuary is a safe haven for approaching a hundred apes and monkeys as well as numerous other species including horses rescued before the advent of the primates. “There is space for much expansion,” Jan added. “However funding for animals is very limited and our Board of Trustees is united in the decision not to jeopardise the residents’ welfare by over extending. As they are not equipped for living in the wild we must make their lives as enjoyable and stress-free as we can. We operate a non-breeding policy and never take animals from their indigenous countries whenever release back to the wild may be possible.”

The sanctuary’s rescue work has taken them all over Europe and some of these journeys have featured in various BBC television programmes such as Animals 24/7 and Rhys to the Rescue. They have also worked with other organisations in Lebanon, Kuwait, Bahrain and Qatar where the pet trade in monkeys at street markets is rife. Patrons of the sanctuary include Graham Norton, James Corden, Sheridan Smith and Dr Rhys Jones. q www.yourexpertwitness.co.uk

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Cancer research forges ahead thanks to bequests ‹ ONE OF THE most successful uses

to which legacy gifts have been put over the years has been cancer research. Now, 50% of people diagnosed with cancer will survive their disease for at least 10 years,

according to figures published by Cancer Research UK. Each day more than 450 people can now expect to reach their 10 year milestone of surviving cancer. In the early 1970s just a quarter of people

Professional body supports legacy managers ‹ THE PROFESSIONAL BODY for those who manage legacy income is the Institute

of Legacy Management (ILM). ILM represents approximately 300 charities and over 500 individuals. A proportion of the membership of the ILM comprises full-time legacy professionals, however that is not true of all of them.

ILM’s Certificate in Charity Legacy Administration, known as CiCLA, was developed by ILM in partnership with the College of Law. It is the only nationally accredited legacy qualification in the UK. Its educational and informative role is furthered by its annual conference. This year the keynote speech was delivered by veteran campaigner for children and older people, Esther Rantzen.

She spoke on Isolation and loneliness amongst older people and the work of The Silver Line – one of a number of subjects to be addressed. Others included Contesting Wills, Capacity, Lack of Approval and Knowledge and Undue Influence, Managing Legacy Income and The Law Society WIQS Scheme. The conference was followed by the ILM Awards Ceremony.

Another subject under discussion was a proposed merger between the ILM and the Institute of Fundraising. q

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diagnosed with cancer survived 10 years.

Since the 1980s over half a million lives have been saved thanks to research, much of which is funded by legacies.

In fact, nearly a third of the total income of Cancer Research UK comes from legacies. And while it is the only charity that supports research across the full spectrum of cancers, there are a myriad of smaller organisations funding research into specific disease types – leukaemia, bowel cancer, breast cancer, mouth cancer, to name just a few.

There are also specialist charities funding research into cancers for children, cancers in particular ethnic groups and secondary cancers. All derive income from legacies that allow this research to continue.

Legacies also provide certainty and on-going funding for organisations that support people suffering from cancer. In addition to the national charities, local support groups – in particular hospices – are increasingly benefiting from legacies.

According to the Civic Society Almanac for 2012 the hospice movement is one of the local charity sectors that are seeing a faster growth in their legacy income than national brands. q

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Chancellor’s standstill on inheritance tax good news for charities ‹ CHANCELLOR George Osborne’s

Autumn Statement did not, as many expected, include a rise in the threshold for Inheritance Tax (IHT) from £325,000 to £1m.

Although many will be disappointed, the charitable sector can breathe a sigh of relief, according to specialist wills and tax law firm Moore Blatch.

Experts at the firm had warned that if the Government raised the IHT nil-rate band to £1m, many people would be put off from leaving money to charity in their will.

If an estate is worth over £325,000 when the person dies, Inheritance Tax may be due. However, any gifts made to a qualifying charity either during an individual’s lifetime or in their will are exempt from the tax.

Additionally, if 10% or more of an estate is left to a qualifying charity, any IHT due from the estate may be paid at a reduced rate of 36% instead of 40%. This means that a gift to a charity often costs nothing to the beneficiaries.

Moore Blatch had warned that the charities most likely to be affected are those

that receive significant annual legacies.

They include two major cancer charities, Cancer Research UK and Macmillan Cancer Support, as well as leading animal charities the RSPCA, the People’s Dispensary for Sick Animals (PDSA) and the Royal Society for the Protection of Birds (RSPB).

The two major supporters of blind people – the Royal National Institute of Blind People (RNIB) and Guide Dogs – are also among the major beneficiaries from legacies, as are the National Trust and the Salvation Army. A whole range of local charities that rely on legacies would also potentially by affected.

Commenting prior to the Autumn Statement, Carla Brown, partner and head of wills, tax and trusts at Moore Blatch, said: “It is not just the major UK charities such as Cancer Research UK or the RNIB that rely heavily on legacy donations. Smaller, local charities also benefit greatly from money left to them in the will of kind benefactors.

“Although an IHT nil-rate band increase to £1m seems unlikely in view of the continued deficit in the country’s finances,

any increase would almost certainly have an impact on people’s propensity to leave money to charity. We would urge anyone who wants to give money to a charity to make the appropriate provision in their will.” q Image: M. Holland

Global MapAid hunts for today’s Charles Booths – individuals or organisations to help fight unemployment poverty! ‹ DURING THE 1890s, a great proportion of Londoners lived in terrible

poverty. Victorian cities were overcrowded, filthy and bleak. Booth believed that social reformers had significantly exaggerated London’s poverty levels as studies estimated that 25% of the population lived in unacceptable conditions.

So he decided to challenge the matter once and for all. In the event, his survey and subsequent London Poverty Map 1889 showed that about 33% of Londoners lived in abject poverty. He very graciously paid for the privilege of proving himself wrong.

Within 20 years of his 1889 map, the British government set up a state old age pension. In addition, his efforts significantly speeded up slum clearances and the introduction of universal state education all over the UK.

Today’s Charles Booths Global MapAid wants to make maps that show not just unemployment poverty but the solutions to it – such as vocational education, business mentoring and credit – here in the UK as well as in Africa. We want to share these maps with key stakeholders or decision makers and the public – so that everyone is clear how to help inspire sustainable job creation!

We are looking for new Charles Booths, ladies and gentlemen, to partner with us and build an enduring legacy. q

From LSE Library’s Collections

Patron: Archbishop Desmond Tutu • W: www.globalmapaid.org • T: 07951 958758 • E: info@globalmapaid.org 34 34

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Foundation giving on the rise as income falls ‹ IN MAY THE Association of Charitable Foundations (ACF)

published its first annual research report on Foundation Giving Trends, led by Professor Cathy Pharoah of the Centre for Giving and Philanthropy at the Cass Business School, and substantially supported by the Pears Foundation.

The report reveals that giving to charitable causes by family foundations grew by £271m (10%) over the 18 months to March 2013, while their income fell by the same amount. This ‘unprecedented finding’ highlights the importance of foundation assets, which have enabled several larger foundations to fund ‘counter-cyclically’ through a time of elevated need and reduced government expenditure.

However, such spending decisions have been made at a time of low investment returns, intensifying the pressure on trustees to balance today’s pressing issues with maintaining their spending power for future generations.

As well as ranking the top 300 foundations by the value of their grant-making, the report also provides fresh insight into the size, shape and nature of foundations’ contribution to UK civil society. The picture that

emerges is of a deeply diverse sector, using its independence in order to respond flexibly to need, make bold interventions in line with its charitable purposes, and support advocacy.

Commenting on the value of the report, which also draws on findings from a new ACF member survey and features a range of guest commentators, ACF policy advisor Richard Jenkins, said: “Over the coming years this programme of research will track key indicators of the health of the foundation sector: its giving, its income and the value of its assets. This vital research will help us see the patterns of change in order for philanthropists, practitioners and policymakers to make better decisions based on an understanding of the factors that drive the sector.”

Professor Cathy Pharoah said: “Better data on philanthropy is increasingly vital. It helps provide a realistic context for assessing the feasibility of political aspirations for the role of private philanthropy in public welfare provision. We also need to know whether philanthropy is growing at a time of increasing private wealth, but continuing social inequality.” R

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

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

To get your website listed on this page just give us a call on 0161 710 3880 or email ian@dmmonline.co.uk AAA Medicolegal Reporting Ltd.

David Bunker Arbitrator & Mediator

The Medicolegal Practice of Donald Campbell Consultant Neurosurgeon.

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

www.aaamedicolegalreporting.co.uk

www.david-bunker.com David W Dyson

Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

Firearms related Civil and Criminal cases • Negligence and liability • Technical Interpretation

www.abc-translations.co.uk

www.firearmsexpert.co.uk

Dr Aman Ranu

Elizabeth J. Soilleux

Expert Witness in Clinical Forensic Medicine.

Injury interpretation • Drink/drug driving cases

Expert Witness Pathologist with a particular interest in haematopathology.

www.expertphysician.info

www.expertwitnesspathologist.co.uk

A J M Birnie F.R.C.S.

Expert Forensics

Consultant Orthopaedic Surgeon. Specialist in backache, neckache and whiplash injuries

Independent forensic consultancy service run by experienced forensic practitioners.

www.whiplashconsultant.co.uk

www.expertforensicsltd.co.uk

A M Associates

Fingerprint Analysis

Chartered Building Surveyors & Project Managers. Expert Witness and Dispute Resolution Services.

Experts in fingerprint legislation, standards of fingerprint evidence and fingerprint development techniques.

www.am-associates.co.uk

www.fingerprint-analysis.co.uk

Building Design Workshop

Forensic Mobile Services

• Architects • Expert Witnesses • Project Managers • Energy Consultants

Specialists in Digital Forensics & Cell Site Analysis

www.expertsbdw.com

www.fmsgroup.co.uk

Central Investigation Bureau

Griffin Forensics

• Surveillance • Process Serving • Tracing • Insurance Investigation • Status & Financial Reports

Cost effective and jargon free Digital Investigation and Data Recovery service. Contact Chris Watts:

www.c-i-b.co.uk

T: 07789 986459 www.griffinforensics.com

Mr Chris Makin

Inclusion.me Ltd

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

Medico-Legal & Second Opinion Occupational Therapy Services.

www.chrismakin.co.uk

www.inclusion.me.uk

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Dr Joshua Adedokun

Mr. Michael Hodge

Chronic pain expert following personal and occupational injuries. Wide experience in medical negligence claims.

Maxillofacial and Oral Surgeon.

• Personal Injury • Criminal Cases • Clinical Negligence

www.expertpainreports.co.uk

www.consultantoralandmaxillofacialsurgeon.co.uk

Lakes Medico Legal

Mr Michael Thompson

Our specialism is musculo-skeletal trauma and we provide a full range of medico legal services in this field.

Specialist in bowel cancer and the effects of delay in diagnosis on survival.

www.lakes-medicolegal.co.uk

www.expertcolorectalsurgeon.co.uk

Dr Laurie Durand (Medlegal Consulting)

Optimum MedicoLegal

Expert witness services for court appearances countrywide in Forensic Psychiatric and Child Protection proceedings.

A Premium Service for Psychiatric.

Medico Legal Reports.

www.medlegal.co.uk

www.optimummedicolegal.com

Mr Marcus Ornstein

Mrs Robyn Webber

Recently (this year) retired general surgeon with expertise in general surgery, breast disease, hernia and abdominal trauma.

Private Consultant Urological Surgeon. Medicolegal reports for both medical negligence and personal injury cases.

www.marcusornstein.co.uk

www.robynwebber.com

Marsh & Parsons

Professor Roger James

Valuation expertise in rental and capital matters in respect of both residential and commercial property.

Independent Health Consultant and Expert Witness in the field of cancer services.

www.marshandparsons.co.uk

www.independenthealthconsultant.co.uk

Dr. Martin Barrett

Mr Simon Bramhall

Forensic physician and expert witness in cases concerning interpretation of injuries and custody medicine.

Consultant HPB & Liver Transplant Surgeon. Significant medico legal work undertaken in his area of expertise.

www.forensic-medical.co.uk

www.simonbramhallhpbsurgeon.co.uk

Maurice W McLain

Dr Thomas C M Carnwath

Consultant in Accident & Orthopaedic Surgery.

Specialist in whiplash and sports injuries.

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

mauricemclain@btconnect.com

www.psycholegal.org

MD5 Ltd

WeatherNet Ltd: Dr Richard Wild

Expert analysis of digital evidence stored on computers, phones and other digital devices

Legal (CPR/non CPR) Weather Reports or Certified Statements for civil and criminal cases (e.g. RTA/PI claims)

www.md5.uk.com

www.weathernet.co.uk

Medical Illustration UK Ltd

Mr William Stuart Hislop

High quality photography for personal injury claims and other medico-legal requirements

Consultant Oral and Maxillofacial / Head and Neck Surgeon.

Specialist in ablative and reconstructive surgery.

www.migroup.co.uk

www.wshislop.co.uk

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MEDICAL NOTES ‹ MUCH HAS BEEN MADE in recent years of the so-called compensation culture and the rush to litigation

to obtain what some regard as unmerited pay-outs. What often gets lost in the rhetoric is the fact that in most instances a claim is being brought because someone has been injured and needs some kind of help to get back on their feet, so to speak, and to replace what they have lost.

Where the injury has been severe, a comprehensive programme of rehabilitation is often needed. Not only can that be complicated, it can be costly. Furthermore, the process may be urgent. That is why the Association of Personal Injury Lawyers (APIL) has launched a campaign to persuade claimant lawyers to claim help for rehabilitation at an early point in a case. The logic is that mitigating the extent of an injury and its long-term effects is better than bickering about compensation afterwards.

That rehabilitation process may involve a multi-disciplinary team of clinicians and care workers. When it involves brain injury, the team is best led by a neuropsychologist or, more precisely, a clinical psychologist (the protected title) with expertise in neuropsychology, according to Dr Neil Parrett of Re:Cognition Health.

He argues for an earlier introduction of such expertise.

• There are, of course, instances where the injury is not as severe as the claimant makes out – or where it hasn’t happened at all. In some instances where the fraud has been unmasked there can be severe consequences, including a jail sentence for contempt. In most cases of ‘over-egging’, however, the expert’s evidence is enough for the false claimant to accept the inevitable and withdraw the claim.

As rheumatologist Dr Anthony Clarke points out, such fraudsters must be weeded out in order to make sure genuine claimants get proper redress.

The area where the clamour against injury claims is at its most strident is, of course, that of whiplash. The annual conference of the Motor Accident Solicitors’ Society provided a fitting backdrop for the latest spat. In particular, the Association of British Insurers’ proposals for the allocation of experts to provide a report were attacked. In a twist of irony, the insurance industry itself was accused of encouraging frivolous claims by settling without a medical report – by both the MoJ and APIL! • An area of industrial injury claims which some insurers have dubbed ‘the new whiplash’ is noise-induced deafness. Despite stringent regulation on noise at work there has been a steep increase in the number of claims, many of which are resisted by the insurance companies. Where such damage has occurred, however, the results can be debilitating, as described by ENT expert Dr Jack Lancer.

• Clinical negligence claims are also on a seemingly-inexorable rise. With events at Mid Staffs still fresh in the mind, the recommendation of the Francis Inquiry for a ‘Duty of Candour’ has been implemented, to the delight of AvMA. The move should make it easier for staff to report issues of concern, including bullying – which is the target of a joint campaign by midwives and obstetricians/gynaecologists.

The volume used for many years by medical expert witnesses as a guide to the practicalities of clinical negligence cases has been updated. The Effective and Efficient Clinical Negligence Expert Witness by Dr Michael Young is available both as a paper tome or an e-book, with added audio interviews.

• A group of clinicians that have accused their own regulator of overbearing behaviour is the dentists. The BDA is now taking the GDC to court for a judicial review of the way it arrived at its fee levels.

• The code of conduct for psychologist expert witnesses in family court cases is also being updated. Experts give their take on the new rules. q

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Treatment of early osteoarthritis:

what can we do before total knee replacement?

By IAN W FORSTER Consultant Orthopaedic Surgeon

‹ OSTEOARTHRITIS (OA), also known as dengenerative arthritis

or wear and tear arthritis, is extremely common. With increased activity and therefore trauma it is becoming much more common at a younger age. This raises considerations which affect possible treatment at these earlier ages.

Total knee replacement (TKR), and indeed any other joint replacement, is a good option but not perfect – some 10% of patients still complain of pain after the operation. As the life of a replacement is 10-15 years, and this is the same for any subsequent revision, if you start out with a replacement at 30 then you rapidly run out of options.

By 70 you would have had three revisions and any further operations would be ineffective.

This, coupled with the fact that the pain felt by patients may not correlate at all with any Xray changes, means avoiding major surgery early on would seem to be a good plan. The decision to go for major surgery is one for the patient, the surgeon’s job is to dissuade him from that decision in the early stages.

Symptoms of OA can be minimal, without causing too much distress, and a sudden activity such as playing a very hilly golf course or running a marathon can make the symptoms so much worse – I actually arranged an MRI scan for myself after a particularly painful round! In that particular instance a short course of anti-inflammatory drugs would be wise and helpful.

However, such drugs taken long term should be avoided because of side effects such as bleeding.

I know golfers who always take anti-inflammatories before their round but this is not advisable.

Early arthritis is defined as pain with little to show for it. The status of the meniscus and the surface of the joint and the arthroscopic areas of deranged surface cartilage need to be considered but are likely to be minor.

No reasonable surgeon would perform a TKR in this situation.

A number of conservative treatments have been suggested, although interestingly, they all have a 50% success rate.

• Quads exercises were shown in a paper from Nottingham to be highly effective.They were taught in groups of patients and so the treatment is also cost-effective.

• Glucosamine and chondroitin sulphate tablets had a wide following.Although easy to take and with few side effects it takes three months to know whether they have worked.

There is little science behind these drugs.

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• Paracetamol is effective in treating the pain but has no effect on its progression. Subsequent treatment gets more invasive and results in injections.

• Steroid injections are very commonly used around the joints.

Repeat injections are frequently needed but more than three in six months is thought to be unwise. There is a risk of infection and a risk of fat necrosis at the site of injection. Again the success rate is only 50%.

• Hylan injections (eg Synvisc) can be helpful. It is important to inject into the joint and not outside which would produce severe pain.

This drug is certainly licensed for the knee but, so far as I am aware, not for other joints such as the hip, although I have heard of it being used in the hip with success.

• Knee braces have become fashionable. They off load the painful arthritic area by loading the knee onto the normal cartilage and jacking open (slightly) the arthritic part of the joint. Such a brace can be helpful and works in approximately 50% of patients.

The leg should always be considered as a whole. Deformity is common and correction can be helpful. If a wedge is placed under the heel this can correct foot deformity which will alter the knee biomechanics and improve symptoms.

If symptoms continue after simple treatments, investigations are useful in differentiating from other types of arthritis which are inflammatory or autoimmune such as rheumatoid or psoriatic arthritis.The first test would be blood counts and particularly C-Reactive Protein (CRP) which is high in inflammatory disease and low otherwise. Treatment of inflammatory arthritis is very different compared to treatment of OA and inflammatory arthritis is much rarer.

Other tests include Xrays, preferably under load on standing. In early OA these signs would likely be very subtle and an MRI would be ordered. Again the signs would be subtle.There would be articular cartilage damage and possibly meniscal damage in the knee. There would also be similar changes in other joints but I am concentrating on the knee in this article.

The next stage is to consider is surgery. In the knee this would be an arthroscopy. This operation is widely performed but the results are variable. There is a detailed paper in the New England Journal of Medicine which says that athroscopy doesn’t work. They compared arthroscopy with a sham

operation – imagine that in the USA! This study has been repeated, however unfortunately they excluded all patients with mechanical symptoms which most surgeons would expect to find prior to the operation. Such symptoms would be locking and catching rather than simply pain and would be investigated by MRI. However, tears of meniscus are very common in early OA and recent papers have shown that removing a small tear is not effective. Apart from all the normal complications to discuss, it is important to advise the patient that pain may continue or even be worse after arthroscopy. The quoted success rate of an arthroscopy where there are no mechanical symptoms is only 50%. Making the joint worse is unusual but is devastating to both patient and surgeon.

When this happens there is a drive to move on to TKR, although this should be avoided particularly as the joint may improve spontaneously and one should wait at least six months before any further surgery is contemplated. Rapidly repeated surgery usually makes matters worse and can be the source of complaint.

Sometimes surgeons advise the patient to have an arthroscopy immediately prior to TKR to see if the TKR is necessary. This should be avoided, as if you can’t tell whether a TKR is the best option on the symptoms and Xrays, then you shouldn’t be operating! There are few instances when such actions would be right. There is another point – arthroscopy is a clean and sterile operation but TKR is a superclean operation and infection in a TKR is a disaster and difficult to cure. I have never taken such a course of action.

So, what can be done with a damaged knee with early degenerative arthritis? Is it possible to delay the progression of disease?

The first stage would be an arthroscopy to define the damage.

Simple trimming of meniscus and loose articular cartilage will help with the immediate symptoms, but not in the long term. The meniscus takes a lot of the load in the joint and removal has been shown over many years to be one of the main causes of arthritis.

This is particularly true if the majority of the meniscus has been removed. It is often possible, in regional centres, to implant a donated meniscus together with other procedures. This is in an early stage and is experimental. However, where the rest of the knee is in good condition, or can be made so, then the results can be worthwhile.

More commonly, with the articular cartilage, the defect is small and the underlying bone can be drilled.This is called microfacture and the aim is that tissue resembling articular cartilage will grow from the bone. Where the defect is small, this will usually relieve symptoms and possibly delay progression.

Bigger defects, of up to two cm, can be filled in various ways.

Normal cartilage pegs can be taken from healthy parts of the knee and implanted in the defects. This means that areas of the normal parts are denuded of cartilage and these areas need to be chosen for the least effect this will have. Thus the defects treated need to be small and few, less than three. To avoid autotransplantion it is possible to implant an artificial piece of cartilage. This gives a smooth surface and can relieve symptoms but the long term outcome is currently unknown.

Larger areas can be grafted by making a sheet of cells and placing them in the defect. This is called Autologolous Cartilage Implantation and the technique is only approved in certain regional centres. It has advanced to a point where an artificial sheet of tissue is placed across the defect and stem cells are injected under the sheet.

Tissue grows across the joint, not entirely the same as cartilage tissue but close to the original. This is a better outcome and may well delay progression of the disease. However, it can take two years to incorporate the graft, so recovery is slow and the patient may have to remain non-weightbearing for all this time.

Any cartilage surgery may require non-weightbearing for six weeks. Interestingly, in all such procedures it is important to move the knee as much as possible as this increases the quality of the cartilage which forms. Rehab is long but very necessary.

The final way to replace large areas of articular cartilage is to replace the whole condyle (one of the large bulbous ends of the femur) with a donated condyle. This is very unusual and usually reserved for patients with malignant tumours.

Deformity of the limb is a common precursor of arthritis. This can be inborn, usually bowlegs or knockknees, or can develop following progressive arthritic change in a single part of the joint, usually on the inside of the knee. This means that a greater load is placed in that area and arthritis is rapidly progressive. By correcting the deformity, the load can be spread over the whole knee and both symptoms and arthritis can be reduced. This correction can only be achieved by operation. Consent is vital and although the operation may have been performed perfectly, the success rate is only around 70%. Correction also means that the leg will be at least straight or, theorectically, slightly overcorrected. This is necessary to spread the load over the whole knee rather than have point loading.

The appearance of deformity can be very upsetting for the patient, particularly if the deformity is bilateral and the arthritis is only in one leg! Skirts and shorts can be a problem and the resulting shape needs detailed explanation pre-surgery. This operation can be carried out in a number of ways and the correction held by all the usual orthopaedic techniques. Healing can take six months.

Nerve and arterial damage is uncommon but more likely with this type of operation than others. Patients can be disappointed with the result and one of my patients demanded a TKR soon after I did the osteotomy, although the result looked perfect and the cartilage seemed to be improved. Most will however progress and in many years still require conversion to a TKR. This has been reported as being difficult or easy, depending who you read. It still remains that an early osteotomy when the patient is young, followed by a TKR many years later, is a good option.

Many patients have TKR’s and some are very disappointed, usually due to continuing pain. This can be associated with patients who have major pain and little Xray change. Patients who are disappointed after TKR argue that they should have been given more conservative treatment. It is useful to know what is available in that area. Given the short term benefits of non-operative treatment, one wonders whether this would have made any difference. The rapid follow-on of arthroscopy after arthroscopy within months of each other results in a very disappointed patient with no relief and probably a worse knee. This is often a cause of complaint leading to litigation.

Clearly, consent is very important and would need to take into consideration the usual complications such as infection, DVT and PE as well as failure and a full explanation of technique and possible outcome. The outcome needs to be fully explained and written down in a medical note as well as on a consent form. Osteotomy can be particularly troublesome when the patient notices a sudden change in the shape of his limb which he didn’t expect.

Early arthritis should be treated stage by stage and not immediately by a TKR. It is also an area where there are claimants looking to the courts for redress! By going into all the options in great detail and recording everything, the surgeon may be able to protect himself. Sometimes, suggesting internet sites for patients to visit in order to help their decision can be most useful. q

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Liver expert famed for plane crash transplant ‹ WHILE WORKING AT THE Queen Elizabeth Hospital in Birmingham

in 2010, leading liver expert Simon Bramhall was involved in the dramatic transplantation of a liver that had been on board a private jet that crashed in fog at Birmingham International Airport en route to the hospital. According to Mr Bramhall, the recipient would ‘certainly have died’ without the liver, which mercifully survived the crash unscathed.

With around 10-15 instructions per year as an expert witness in his specialist area, which covers the whole spectrum of liver, biliary and pancreatic surgical matters, Mr Bramhall carries out medico-legal work in criminal cases in addition to medical negligence work. His client base is reasonably evenly split between claimant and defendant.

Mr Bramhall was a consultant surgeon at the liver unit of Queen Elizabeth Hospital between 2002 and 2014, performing liver transplantation, pancreatic cancer surgery and liver surgery. He is now a consultant general/upper GI (HPB) surgeon.

In addition to his surgical duties, Mr Bramhall has been involved in tutoring and examining medical students and supervising postgraduate students in higher degrees, management and research.

He has published peer review papers, abstracts and book chapters and also has given presentations and invited lectures nationally and internationally.

He is a member of the West Midlands Surgical Society, the Midland Gastroenterological Society, the Association of Surgeons of Great Britain and Ireland and the Association of Upper GI Surgeons. q

Expert trichologist addresses the root of the problem ‹ ONE PART OF THE body that appears to generate more than its fair

share of attention and even distress is the hair. Turn on the television at any time of day and there are adverts for shampoos, conditioners, tinting products and even, not so long ago, a clinic endorsed by international sportsmen.

So when people start to lose their hair there is a need for answers. That is where experts such as Marilyn Sherlock of the Wiltshire Trichology Centre, in Salisbury, come in.

Says Marilyn: “There are some 50 reasons for hair falling suddenly and the only answer is diagnosis. Once the reason for the hair loss is found, the cause of that loss must be treated; then, in many cases, the hair will stop falling. There may be a systemic health reason or scalp scarring disorder. If so, this needs diagnosis in order to prevent it getting worse.”

In addition to being the chairman and a Fellow of the Institute of Trichologists, Mrs Sherlock acts as an expert witness in civil and criminal cases, dealing with in excess of forty cases per year. She has been registered with the Law Society’s List of Expert Witnesses since 1995 and became a member of the Academy of Experts in 1997.

Mrs Sherlock has experience in the preparation of expert reports in cases of hairdressing negligence, accidental injury and surgical damage to the scalp and hair. She has given evidence in court in both hairdressing negligence and in criminal cases involving actual bodily harm, rape, kidnap and murder. q

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Problems in store as cuts take toll of rehabilitation services ‹ THE GOVERNMENT IS

facing a ‘ticking time bomb’ by reducing access to support and rehabilitation services for brain injury survivors, according to a report issued in May by Headway, the brain injury association.

The result of simultaneous cuts to local authority budgets and welfare benefits reform are having a detrimental effect on the physical and psychological wellbeing of brain injury survivors and their carers, says the charity.

In addition to the human cost in the short term, the long-term implications could impact on wider society as reduced access to vital services will lead to more people becoming reliant on more expensive long-term state support.

The study of people directly affected by brain injury has revealed that in the past two years 48% of those receiving rehabilitation and support to regain their independence have lost access to vital services as a result of cuts to local authority or NHS funding. More than two thirds (70%) of respondents stated they will require increased and more expensive long-term support from the state in future if they do not

receive the help they need now.

“We are deeply concerned with the findings of this report,” said Headway’s Luke Griggs. “People who desperately need help to cope with life after brain injury are being abandoned. This study makes it abundantly clear that the raft of funding cuts and welfare reforms are causing harm to the lives of some of society's most vulnerable people. They are being cut out of society due a lack of access to vital support services.

Not only is this morally wrong but it also demonstrates a shortsighted approach.”

He added: “Cutting rehabilitation services or reducing access to them is a false economy as it reduces the chances of people with brain injury regaining their independence. This in turn is likely to lead to an increased reliance on state support in the long term as people are less able to maximise their recoveries and care for themselves.

“This ticking time bomb of a problem will only be defused by a radical change in policy on a national level and a commitment at local level to helping people to be independent.” q

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Psychology and brain injury rehabilitation

By DR NEIL PARRETT of Re:Cognition Health

‹ ALTHOUGH ALL MEMBERS of a brain injury rehabilitation team

have equally vital roles, clinical neuropsychology1 has long been considered a pivotal component of brain injury rehabilitation in the statutory and voluntary sector, particularly in the post acute phase.

Indeed, world leading services such as the Brain Injury Rehabilitation Trust and the Oliver Zangwill Centre have put psychology at the heart of their rehabilitation services, with the day to day running lead by clinical and neuropsychologists. Despite this, it is often the role that is least understood, although it can be vital in ensuring that community neurorehabilitation programmes are a success.

My own understanding of neuropsychology is that it occupies a unique position, bridging the gap between the diagnostic expertise of medical specialties such as neurology and neuropsychiatry and the more practical, therapeutic interventions of speech and language therapy, occupational therapy and physiotherapy. With a broad knowledge, grounded in a rigorous ‘scientist-practitioner’ model of doctoral training, neuropsychologists should be able to think at the various different levels of assessment and intervention required to ensure a successful fit between the ideal evidence based interventions and the more pragmatic aspects of supporting people with unique needs in often challenging circumstances.

I would therefore advocate the involvement of a neuropsychologist in all brain injury rehabilitation cases from the earliest possible opportunity. However, despite a number of years working in this area as both an expert and treating clinician, I continue to be surprised by the late stage at which I am often asked to get involved in rehabilitation cases.

Although many case managers come from rehabilitation service backgrounds, many do not. As a result, their understanding of what a psychologist does can often be extremely limited. The expectation of

my service can often be no more than to provide therapy to the client in the context of cognitive difficulties. In fact, face-toface therapy in the brain injury population is often one of the more minor aspects of the role of the neuropsychologist. The majority of the work I do tends to be leading the integrated, goal directed, multi-disciplinary team meetings. I am also involved in providing training, supervision and guidelines for the support workers as well as family work focused on adjustment and acceptance of both the change in circumstances and the rehabilitation process itself.

The second common situation when I become involved at a later point is when the client is refusing to see a psychologist, often because they do not have insight or understanding of the problems they are experiencing. In these situations the resistance is often because the client will equate psychology with therapy, which is only for ‘mad’ people. However, as already described, this is not necessarily going to be the case. The involvement of the psychologist to help direct the rehabilitation programme is probably the most important aspect of the work and therefore, beyond an initial meeting, the agreement of the client is not necessarily crucial to their involvement, particularly given that a substantial portion of our clients will lack the capacity to understand their treatment needs.

Another reason why it might be wise to consider involving a psychologist from the earliest opportunity is when the expert witness in a case, who is usually key in determining the effectiveness of a rehabilitation intervention, is the neuropsychologist. Post-Lofflin, making sure all the eggs line up is of paramount importance and therefore having a neuropsychologist on your team is likely to be extremely useful in justifying the programme that has been designed.

Of course, I accept that my thoughts come from a significantly biased position. However I hope my discussion offers some insight into why I think that, after the case manager, the early involvement of a neuropsychologist with expertise in rehabilitation can make the difference between a successfully run case, understood by the experts, and one that may lack direction and be open to criticism. q • Dr Neil Parrett is lead clinician for brain injury rehabilitation at Re:Cognition Health and neuropsychology liaison for the East London NHS mental health service. He also provides consultation to a number of rehabilitation services including the Regard Partnership and Enable Care and is a trustee for Headway North London. Please contact him on 020 3355 3536 or at NParrett@re-cognitionhealth.com.

NB 1

‘Neuropsychologists’ is used here as short hand to describe clinical

1

psychologists with expertise in neuropsychology. ‘Clinical Psychologist’ is in fact

1

the title protected by the Health Professionals Council (HPC), therefore beware of

1

individuals claiming to be a neuropsychologist. The most important things to

1

look for when identifying a psychologist are registration with the HPC and

1

experience of rehabilitation, as opposed to just cognitive assessment, in their CV.

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The lawyers that Think Rehab! ‹ ONE OF THE principal elements of any package of redress for an injured person is the road back to fitness and the return to a normal life.

The Association of Personal Injury Lawyers (APIL) has launched a Think Rehab! campaign to raise awareness among lawyers of care and rehabilitation facilities.

Sports injuries need careful rehabilitation ‹ REHABILITATION IS A particularly important part of treating

sports injuries, according to the NHS Choices website. Such a programme aims to return the injured body part to normal function by gradually introducing it to movement and exercise.

According to NHS Choices: “With most sports injuries, after the initial recovery it helps to move the injured part as soon as possible to help speed up the healing process. Gentle exercises should help improve the area’s range of motion. As movement becomes easier and the pain decreases, stretching and strengthening exercises can be introduced.”

The site counsels against attempting to do too much, too quickly.

“Start by doing frequent repetitions of a few simple exercises before gradually increasing the amount that you do,” it advises. “Avoid painful activities and do not return to your sport until you have no pain, and full strength and flexibility have returned to the injured area.”

It recommends consulting a healthcare professional, such as a physiotherapist or sports injury specialist, who can help design a suitable rehabilitation programme and advise about which exercises to do and the number of repetitions. q

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APIL lawyers are committed to ensuring the injured people they act for make the best and quickest possible recovery after an injury. They are, according to the association, the ‘gateway to finding the care, financial help and benefits which will speed recovery’.

Personal injury lawyers can also help to obtain a number of benefits from the negligent party or their insurers: • Upfront payments for things like taxis to • hospitals • Domestic care • Equipment and adaptations to make • life easier during recovery – • wheelchairs, ramps at home etc • Early private medical treatment such as • physiotherapy • Arranging a flexible return to work • Retraining, if needed, to give access to • future employment APIL also points out that benefit advisers can offer help and guidance and that health insurance can cover the cost of medical treatment. It can also provide a lump sum, in certain circumstances, or pay regular amounts during a period of injury or incapacity. q • For more information contact www.apil.org.uk.

New code of conduct proposals explained by experts ‹ THE FAMILY JUSTICE COUNCIL (FJC) and British Psychological

Society (BPS) have released proposals for a new Code of Conduct for expert witness psychologists in the family courts. The code will be for expert witness psychologists only, designed for them to follow alongside the pre-existing code of conduct for all expert witnesses.

A summary of the new guidelines has helpfully been provided by family law expert witness consultants Carter Brown.

On the role of the expert witness, Carter Brown says: • They should be instructed when their expertise is necessary for a • decision to be made in a case • They will provide psychological profiles of individuals or family • members • They will assist the court by using psychological formulation to • produce assessments The summary goes on to explain the skill areas involved in the assessments and the factors the assessments need to take into account.

“Whilst specific techniques will vary,” says the report, “expert witness psychologists will tend to carry out an assessment based on standardised tests, interviewing and observation, and reviewing of medical or other professional records. Information from varied sources over time will inform the process of triangulation, from which an opinion is formed.”

Carter Brown then address the regulatory bodies with whom expert witness psychologists should be registered. In the UK they

should be registered with the Health and Care Professions Council and/or the British Psychological Society, and use their protected job title if they have one. EU based experts should be registered with an organisation which is a member of the European Federation of Psychologist Associations, while other overseas experts should abide by the code of conduct for overseas expert witnesses, issued by the FJC. After discussing particular issues regarding the nature of the family court and of the evidence to be given, issues of competency are addressed. Finally, Carter Brown’s summary lists a number of expectations the court will have of a psychologist expert witness.

The company welcomes the new Code of Conduct, stating: “This draft code seems reasonable. With the exception of a few minor changes to CVs and registration with the Information Commissioner, it is merely a codification of our standard practices with psychologists and other experts.” q

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Traumatic brain injury and clinical neuropsychology

By DR CHRISTOPHER R PLOWMAN BSc MSc Clin Psych D CPsychol AFBPsS Consultant Neuropsychologist

‹ THE MOST AUTHORITATIVE figures available

estimate that there were nearly 170,000 UK admissions to hospital with a non-superficial head injury (TBI) in 2011-121. The severity of the TBI (typically classified as mild, moderate or severe) is usually determined by factors such as whether a loss of consciousness occurred, and for how long; any reduction on measures of awareness (usually determined on a 3-15 point scale called the Glasgow Coma Scale); the length of time of confusion or disorientation, known as post-traumatic amnesia; and the presence or otherwise of abnormality upon brain scanning. However, the functional outcome is of more significance than the classification, certainly for the claimant and their families, and this is where the clinical neuropsychologist comes in.

Although research has found a strong correlation between TBI severity and residual cognitive deficits – ie the more severe the injury, the more likely this will result in significant and permanent cognitive impairment – the reported effects and recovery from brain injury can

be unpredictable. Whilst neuroimaging and brain scans may be useful in aiding diagnosis, they can be incomplete and misleading, thus representations of a brain’s structure obtained through scans do not always correlate to the claimant’s functioning or pathology. Equally importantly, they say little about the behavioural changes that may have occurred following a brain injury. A comprehensive and detailed neuropsychological assessment can help to fill these gaps. It seeks to objectively determine an individual’s ability to perform a number of cognitive tasks along with areas of strengths and weaknesses, as well as providing a more functional explanation of the effects of traumatic brain injury. In addition, the best reports will also reference background information and incorporate behavioural observations, with the test results being supported by, and supporting, the clinical picture.

A detailed neuropsychological assessment is essential in helping to determine and quantify the impact that an injury has had on a claimant’s cognitive functioning. It aims to establish any organic pathology or brain damage which may have occurred as the result of the index accident for which the claimant wishes to seek compensation. Neuropsychological assessments typically use standardised tests. This means that most tests have been administered on thousands of individuals, often within a nonneurological population, to establish a base-rate of ‘typical’ or ‘normal’ cognitive functioning. This allows a claimant’s results to be compared with the unimpaired or ‘normal’ population, a process which will expose any weaknesses or abnormalities which might be due to the accident.

The process of neuropsychological assessment entails specifying the diagnostic possibilities and estimating their relative likelihood by acquiring information about a patient’s symptoms and the anatomical system involved, as well as considering psychological and social factors. The acquisition of any new information – such as employment records, family interviews and witness statements – is then used to re-evaluate the probabilities, rule out certain opinions and decide on the most likely diagnosis. There are, of course, many other explanations for neuropsychological impairments which may not be related to the index accident. In a medico-legal context it is important to consider and quantify the relative impact of these other factors – which can include learning disability, progressive neurological conditions, psychiatric conditions and medical history – and to identify subtle changes which may not be evident from utilising other measures of investigation.

In addition, it is important that the clinical neuropsychologist bears in mind other factors which may have impinged upon a person’s test performance, including fatigue, pain or discomfort, medication effects, substance abuse, past medical conditions or poor motivation.

A traumatic brain injury can be a devastating event, but obtaining an accurate measure of its consequences is the first step on the road to recovery. q 1

NHS Health and Social Care Information Centre (England).

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Honesty is the policy in the NHS – at last! ‹ ON 27 NOVEMBER a statutory ‘Duty of Candour’ – a legal duty to be open and honest

with patients or their families when things go wrong that can cause harm – came into force in the NHS. It was described as ‘an historic moment for the NHS in England’ by the campaigning organisation Action against Medical Accidents (AvMA).

AvMA has campaigned for such a duty for two decades and, together with the recommendation of Sir Robert Francis following the Mid Staffordshire public inquiry, helped persuade Health Secretary Jeremy Hunt to agree to it. Successive governments had refused to go as far as making ‘honesty when things go wrong’ a statutory requirement.

The Duty of Candour is one of a set of statutory ‘fundamental standards’ contained in the Care Quality Commission (CQC) regulations under the Health and Social Care Act. The Duty of Candour applies to all NHS trusts in England from 27th November 2014 and in April 2015 will be extended to cover GPs and other primary care practitioners as well as private healthcare and social care providers registered with the CQC. It will be regulated by the CQC, which has severe sanctions available for NHS trusts who do not comply including, ultimately, criminal sanctions.

Peter Walsh, chief executive of AvMA said: “This is the biggest advance in patient safety and patients’ rights in the history of the NHS. For over 65 years the system has frowned on cover ups but in effect has tolerated them. Not only has this caused gross injustice and harm, but has meant the NHS continued to fail to learn lessons to improve patient safety.

We applaud the Government for having the courage to give zero tolerance to cover ups.

However, we now need serious investment in awareness raising and training for staff to help realise the full benefits of this bold initiative and make cover ups a thing of the past.”

Mr Walsh paid tribute to the patients and families who have suffered as a result of dishonesty from the NHS and who have helped make the Duty of Candour a reality. q

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‹ AvMA was established

in 1982 as Action for the Victims of Medical Accidents by its founder, Peter Ransley, following public reaction to the television play Minor Complications. The name was changed in 2003 to Action against Medical Accidents.

The legal reforms of Lord Woolf and the creation of agencies such as the National Patient Safety Agency and Commission for Health Audit and Inspection followed years of AvMA raising these issues and campaigning.

AvMA is also responsible for making clinical negligence a specialism within legal practice.

BOOK REVIEW

New edition updates clinical expert’s companion volume The Effective and Efficient Clinical Negligence Expert Witness

by Michael R Young BA BDS MSc

‹ ONE OF THE areas of litigation that has seen major growth in recent

years has been clinical negligence – the NHS Litigation Authority reported a rise in clinical negligence claims by almost 18% over the year from March 2013 to March 2014. Those acting as expert witness in these cases have consequently witnessed a rise in their numbers.

Hitherto, one of the most widely used and respected guidance tomes for expert witnesses in medical negligence cases has been How To Be an Effective Expert Witness by Michael R Young. That book was described by the Academy of Experts as ‘...a clear and reliable guide to the clinician who would wish to be considered an expert witness’. The accolade goes on to declare: “This work deserves to become the Vade Mecum for the clinician acting as an expert witness.”

Michael Young is, among many other things, a dental graduate and a reviewer in the British Dental Journal said of that first volume: “The key elements fundamental in becoming an excellent expert witness are summarised in a coherent fashion by Dr Young. The aspiring medical or dental expert witness will not find a better guide and

I recommend this book without reservation.”

Those comments are reproduced proudly in a follow-up to the book by Dr Young, which if anything is even more comprehensive. The Effective and Efficient Clinical Negligence Expert Witness sets out to ‘...provide advice, help and guidance to anyone who is thinking about becoming a medical or dental expert witness.

It may also be of use to doctors and dentists who are already working in this field but who want to further develop their skills as an expert.’

The unique nature of the book – representing the perspective of both expert and clinician – is reflected in the fact it has two forewords.

Fellow dental expert witness Lawrence Aitken says in his: “If you like the idea of analysing case histories, reading the medical literature and writing reports for lawyers, and are either already involved, or are seriously interested in, working as a clinical negligence expert witness then this book is definitely for you.”

He goes on: “This book is important because it covers in great detail every area that is relevant, necessary and important to the clinician acting as an expert witness. It tells you how to engage with solicitors, set your fees and, most importantly, how to write good English.”

The other foreword is provided by barrister Mike Hill who says: “This is a practical, insightful guide written by the best of teachers. Mike has plenty of experience and it is great to see that it is being put to such good use.

And it is needed too. Clinical negligence expert evidence is not a sport for wimps. Your view will be challenged, picked over and, in some cases, simply attacked. In those circumstances this book will be invaluable to you. It will prevent you from making mistakes in the first place and will assist you when it is wrongly suggested that you have.”

The structure of the book is that of a pathway from an explanation of what an expert is and does, through how to prepare and write reports, to an examination of the court process. Bringing the book up to date, there is an explanation of the impact of the Jackson reforms and a debate on ‘paper versus technology’.

On the theme of technology, there is an electronic version of the book which links to audio interviews with experts. The interviews are also available on the website of the book’s publishers, Otmoor Publishing – visit http://www.otmoorpublishing.com/audio/the-effective-and-efficient-clinicalnegligence-expert-witness.

Finally, at the end of the book there is a list of useful contacts and examples of various reports. Indeed, a significant element of this book is coaching in the writing of good English – as the author himself says the book is not a legal textbook, the legal framework within which the expert works is constantly changing. R • Michael Young is also a widely published author of fiction and plays as well as ‘Managing a dental practice the Genghis Khan way’ which won the Diagram Prize in 2011.

Photograph of Michael Young reproduced by kind permission of Stephen Ward Photography, Leeds

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Plastic surgeons call for better informed press reporting ‹ DESPITE A RISE of almost 8,000% in reporting of cosmetic

surgery in the mainstream media over the past 20 years, many products and techniques promoted directly to the press and public actually have very few, if any, published scientific articles behind them, according to research presented to the Annual Scientific Meeting of the British Association of Aesthetic Plastic Surgeons (BAAPS) in September.

The study looked into some of the most popular treatments and found not only that clinical papers on them are scarce, but also that those studies that did take place followed very low numbers of cases (one trial just tracked two patients), usually for a very short amount of time. Moreover, well over a third of the authors involved admitted to conflicts of interest. The BAAPS called for the media and public to use a measuring system similar to those used in surgical journals which ‘grades’ the levels of evidence behind new procedures and claims.

The conference heard that, whereas in 1991 there were only 45 articles in national newspapers dealing with cosmetic surgery, by 2013 there were 3,568 – a rise of 7,900%. The amount of mainstream coverage achieved by just four of the most popular aesthetic devices was 24 times the number of clinical papers behind them – almost 600 articles in the consumer press, against 25 in medical journals.

The way the surgical arena evaluates even early or experimental data published in respected outlets such as the Aesthetic Surgery Journal and Plastic and Reconstructive Surgery is by using a colourcoded ‘evidence pyramid’ which classifies the level of research behind study conclusions. They can range from the most basic expert opinion or claim (lowest tier) through to small studies, then more exhaustive trials and long-term analysis (highest). The pyramid was presented to surgeons at the conference, and in turn the BAAPS offered a simplified version for the media and public to be able to accurately gauge the amount of proof behind new product claims.

According to consultant plastic surgeon and outgoing BAAPS president Rajiv Grover: “We know that, due to the ‘normalisation’ and growing acceptance of aesthetic treatments, there has naturally been a stratospheric rise in media reporting in this area. Journalists in the consumer press have had their work cut out – increasingly addressing issues such as risks, complications and the importance of regulation in the sector. I don’t envy the challenges of reporting credible developments from such a murky field, but that doesn’t mean the cosmetic surgery sector should be allowed to stitch people up.”

The research found that media reports of complications and regulation in cosmetic surgery have risen by over 17,000% and 20,000% respectively since 1991. Three quarters of consumer press coverage involves publicity driven by a commercial provider or practitioner offering the treatment and 15% involved celebrity endorsements.

Rajiv Grover continued: “In the clinical world, there is widespread use of ‘tiers’ which allow us to determine how much research backs findings, so we can make informed decisions based on evidence that goes further than skin deep. However, without a similar filter, there are pitfalls for those who might be swayed by weak data, manipulated photos or paid-for celebrity endorsements. There urgently needs to be a traffic light or warning system for new devices and techniques promoted to the public.”

According to Preston-based consultant plastic surgeon and BAAPS trainee member Reza Nassab, who conducted the studies Evidencebased Hype and Cosmetic Surgery in the Press: “The evidence supporting many new devices is of low level and the results are variable. The public may not be aware of all research findings and results – increased education is needed to ensure people understand that treatments may not be as effective as portrayed in their marketing materials. Organisations such as the BAAPS and the new National

Institute for Aesthetic Research are ideally placed to promote education in this area.”

The National Institute for Aesthetic Research was launched a year ago as a joint initiative by the BAAPS and leading charity The Healing Foundation. q

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Insurers and claimants clash over whiplash ‹ THE ANNUAL CONFERENCE of the Motor Accident Solicitors

Society (MASS) saw battle lines being drawn between the Government and insurance industry on one side and claimant solicitors on the other regarding medical panels for soft tissue injuries – in particular whiplash.

The outgoing chairman of the MASS, Craig Budsworth, warned that doctors may be unwilling to join up to an organisation being set up to allocate experts to specific cases. They may feel that, as instructions will be allocated on a random basis, their expertise will go unrecognised and they would have to pay a fee without being guaranteed work.

James Dalton, head of motor insurance at the Association of British Insurers, told the conference: “Developing an IT system that randomly allocates independent and accredited medical experts to claimant lawyers is critically important in working towards the delivery of fundamental reform of the medico-legal reporting system. That is why the insurance industry has committed to fund the development of the MedCo system and we continue to work with key stakeholders through the Ministry of Justice to determine the key policy issues.”

The debate came after an announcement in October by Justice Secretary Chris Grayling that the MoJ was capping the fee for an initial whiplash report at £180. The MoJ said the move was “…the latest stage of the government’s plan to tackle insurance fraud and turn the tide on the growing compensation culture.”

In the same announcement, the MoJ said: “The change is part of a number of new measures to drive out dishonest whiplash claims – bringing down the amount being paid out unnecessarily by insurance companies on fraudulent claims and enabling them to pass on savings to honest customers.”

The claims by both government and the insurance industry that there is widespread fraud involved in insurance claims were attacked by the new chair of the MASS, Susan Brown.

She said: “Allegations of dishonesty or exaggeration are already raised on a regular basis with a view to persuading claimants either to abandon their claims altogether or, more often, to accept a low offer rather than face the ordeal of having to prove that they are not dishonest and run the risk that a judge will not believe them.

“And how many honest claimants pursuing genuine claims will be prepared to take the risk of proceeding to court if the possible outcome is that they will come out with nothing other than a bill for the insurers’ solicitors’ costs? We will have a fight on our hands when acting for these claimants, to support them and gather the evidence needed to demonstrate that they are not dishonest.” q

APIL joins MoJ in attacking pre-medical settlements ‹ IN OCTOBER A NUMBER of changes to rules surrounding

whiplash claims were announced by the Ministry of Justice. As well as increasing pressure on fraudulent claims, one of the measures was described as: “Discouraging insurers from settling whiplash claims without a medical report confirming the claimant’s injury. In the past insurers have settled claims without evidence in order to deal with them quickly – meaning some questionable claims are not challenged.”

In its response to the consultation on the issue in September, the Association of Personal Injury Lawyers (APIL) attacked the practice of making pre-medical offers, stating: “It is a disreputable practice and contributes to fraud, as the necessary checks and balances within the legal process are bypassed to pay

compensation as early as possible. Delivering this ban is one of the key stepping stones to building and delivering an improved scheme. Only by taking such a hard line will the Government show all involved that it is serious in tackling insurance fraud.”

It goes on specifically to address the issue of litigants in person pursuing claims without a medical report: “Any litigant in person pursuing a claim for personal injury should be required to be medically examined. APIL objects to insurers settling claims without the claimant having been examined and a report prepared detailing the effect of the injury upon them. It should therefore follow that any litigant in person should be examined by an accredited expert under what we hope will be a new and improved process.” q www.yourexpertwitness.co.uk

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The biter bit

By DR ANTHONY CLARKE, FRCP Consultant in Rheumatology & Rehabilitation, Bath

‹ YESTERDAY’S PAPER REPORTED that a bus driver had been sent to

prison for being involved in a scam to claim large sums of money from motor insurers for a faked road traffic accident. A few days earlier, I was reading another expert witness journal in which there were two papers on whiplash injury. Although both articles mentioned the high, and rising, incidence of chronic whiplash in Britain compared to other countries, neither addressed the possibility that fraud, exaggeration or malingering are of importance in assessing claims for whiplash or other pain related conditions.

Reel back two years, and I am watching a surveillance disc of a young man injured in an industrial accident in which he received soft injuries to his dominant arm. I had seen him six months before, when he told me that he had developed intense pain in the arm and was looking to amputation as a cure for his impairment. The arm was held into his body and he would not let me touch it. The footage showed, among other things, the claimant looking directly into the camera and throwing, repeatedly, a tennis ball for his dog with his so-called useless arm. The claim was withdrawn and I thought no more about it, as my account had been settled.

I was then telephoned by my instructing solicitor asking if I would take my main and supplemental reports (which included my review of the surveillance) to a solicitor so that I could swear an affidavit that the contents were correct. The next thing I know, I have received a witness summons and am on the first floor of the Royal Courts of Justice in London.

The insurers had put the case before the court that the claimant had signed a witness statement containing a number of items that were untrue and therefore there had been a contempt of court. The judge agreed and the claimant received a custodial sentence of 18 months. I was not called to give evidence as the claimant, now the defendant, accepted that he had bourn false witness.

I was later told that a similar case a few weeks previously, using the same strategy, had resulted in a twelve month prison sentence for another fraudulent claimant.

The growth of the claims industry has been a significant driver to overestimated claims. A claimant may have suffered from loss of amenity and continuing symptoms which are the responsibility of the defendant. That does not, however, stop a claimant from exaggerating. The problem for the court is to differentiate between the genuine level of impairment related to the accident and ‘over-egging’. This, of course, includes the often difficult task of assessing any psychological damage that may have occurred.

The courts have been well ahead of the medical profession in declining to differentiate between the physical and psychological consequences of trauma.

To the best of my knowledge I have never seen a claimant who has been part of an organised attempt to defraud. I have seen twenty or so who have tried to work the system, either by exaggerating their clinical symptoms or attributing their complaints to an incident, such as a road traffic accident, despite there being other obvious causes for their condition, most often a pre-existing health issue such as chronic back pain.

This is perhaps best represented by a claimant I saw with established chronic fatigue syndrome who had a minor road traffic accident (RTA), with a significant worsening of her symptoms. Several years later she was pursuing a large claim against the driver of the other vehicle because of continuing symptoms which she attributed to the RTA. Careful examination of the GP and hospital notes did confirm that her fatigue had worsened after the RTA, but then had started to improve. The claimant then suffered a burst ovarian cyst, complicated by peritonitis. Not surprisingly her condition deteriorated significantly. The claimant dismissed this episode and continued to blame the RTA for all her problems. It was, of course, the only incident in her life for which compensation was available. The claim was settled for a small amount.

More frequently, I see claimants who are deliberately lying about their level of disability, often with a developing crescendo of impairments with worsening loss of amenity. A claimant I saw injured his neck in a sky-diving accident. He developed neurological signs and symptoms with good evidence of nerve damage on MRI. He saw a neurosurgeon and was listed for surgery. On the way home he was involved in an RTA. There appeared to be no evidence, however, that he had sustained further neurological damage and a few weeks later underwent a successful decompression of his cervical spine. However, he went on to pursue a claim for personal injury against the driver of the other vehicle.

He, and his legal team, dismissed the sky-diving accident as having any part to play in his continuing pain, and also said that because of the RTA he had lost his business. This was refuted by the accountancy expert witness and careful examination of extensive surveillance material and Facebook entries showed that he was not demonstrating any loss of amenity. There was nothing to suggest that he had catastrophisation or fearfulness. When confronted with the expert evidence, the claim was withdrawn.

It is uncomfortable for doctors not to accept that the person in front of them is being anything other than frank and honest. Indeed, because of our culture of medical confidentiality, it is assumed that patients will always tell the truth. Litigation can change that.

At the same time, our adversarial legal system can lead even the most independent-minded expert to ‘take sides’. At the point where there is a conference with counsel, the line of attack or defence often becomes almost set in tablets of stone. However, the duty of the expert is to the court and each piece of evidence needs to be assessed as to the effect that it has on the claim, including whether criminality or over-egging the pudding is involved. It may be uncomfortable but we all need to be on the lookout for those individuals who are working the system. They are defrauding the public and stigmatising genuine claimants.

To return to whiplash, all competent authorities agree that a small number of victims of low velocity rear-end shunts will suffer lasting symptoms.

These individuals deserve compensation. It is our job as expert medical witnesses to assist the court in properly identifying those who are pursuing legitimate claims, while weeding out those who are not. Claimants also need to be made aware by their legal teams that there can be severe penalties, including custodial sentences, which can, and are, being applied by the courts. q

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Expert surgeons assess injuries to the face ‹ ALTHOUGH MANY MEDICAL expert witness reports concern

cases of alleged clinical negligence, some areas of practice involve treatment of injuries sustained as the result of negligence or outright criminal behaviour by others and the expert may be called upon to describe the extent of injury and likely treatment needs – in order, sometimes, to assess compensation.

One of those areas is the specialism within oral and maxillofacial surgery that deals with dental injuries. According to the British Association of Oral and Maxillofacial Surgeons (BAOMS), such injuries include “…damage to the teeth, lips, gums and tongue. They can result from sport or road traffic accidents, as well as fights and falls. The most common injury is a broken or lost tooth.”

In the case of broken teeth, the BAOMS says: “If the broken tooth has left a sharp edge that might cut into your tongue, lips or cheek the edge may have to be smoothed with a drill or a temporary filling inserted.”

Where the tooth has come out of its socket altogether it is known as an avulsed tooth. According to the BAOMS: “The treatment is usually to

re-insert it as soon as possible into the socket and then use a splint to keep it in the right place and prevent further movement. How successful this will be depends on how long the tooth was out of the socket and how well it was looked after whilst it was out.” q

Maxfax conference: call for abstracts ‹ THE British Association

of Oral and Maxillofacial Surgeons has issued a call for abstracts of papers for its Annual Scientific Meeting, which will take place at Liverpool’s Arena and Convention Centre from 22-24 July next year.

The theme of the conference will be Reconstruction, which is one of the core areas of interest of the president elect of the association, Professor James S Brown. Professor Brown (pictured) is the senior consultant and clinical lead of the Regional Maxillofacial Unit at Aintree University Hospital in Liverpool.

In his introduction to the Preliminary Information and Call for Abstracts document, he comments: “The theme of this meeting is inevitably reconstruction as the core which reflects my interests, but the intention is to emphasise the common areas of interest which make us all oral and maxillofacial surgeons.

“Whether we specialise in deformity, oncology, trauma etc, we operate in the same anatomical region and have many areas in which lessons can be learnt and excellence achieved through teamwork and co-operation.”

The call for abstracts is for 40 ten-minute presentations and 20 four-minute ‘poster pop-ups’ to be selected. “But,” says Professor Brown, “elements of reconstruction will be considered for all sessions and excellent abstracts will always be included.” q • For more information visit www.baoms.org.uk.

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GDC consults on fitnessto-practice changes ‹ THE GENERAL DENTAL COUNCIL (GDC) has begun

consulting on a key change to its rules that, if approved, will ‘significantly improve’ its fitness to practise processes. The consultation opened on 17 November and will close on 12 January next year.

Announcing the consultation, the GDC said: “The GDC is responsible for ensuring that every dental professional registered to work in the UK is suitable to be registered and meets its professional standards. One of the ways in which it does this is by investigating complaints or concerns about the fitness to practise of registrants.

“Since 2010, there has been a 110% increase in the number of complaints about GDC registrants. Outdated processes prove a significant limitation when dealing with this increasing caseload, and the GDC has long been campaigning for legislative change to be able to update them.”

The move follows a consultation carried out by the Department of Health on an amendment to the Dentists Act 1984 to allow the GDC to change its procedures. q

Patient recall welcomed by dentists’ body ‹ THE BRITISH DENTAL ASSOCIATION (BDA) has responded to

BDA granted judicial review of retention fee ‹ IN DECEMBER THE British Dental Association will

be taking its own regulatory body to court. The move follows a long-running dispute between the BDA and the General Dental Council over an increase of over 50% in its fees. The result was the granting of judicial review of the process by which the GDC arrived at its decision to increase its annual retention fee (ARF).

It was announced on 30 October – the day the GDC met to set the ARF – that the hearing would take place on 15 December. The process was set in motion on 17 October.

However, the BDA has warned dentists not to withhold payment of the new ARF. In a statement issued on 5 November it stated: “Given the on-going legal challenge, we know that many dentists are considering delaying their ARF payments until the case is heard. However, GDC registrants should be absolutely clear that they cannot practise professionally without the appropriate registration.

Practising dentistry without GDC registration is a criminal offence.” q

news that NHS England is recalling approximately 22,000 patients of Desmond D’Mello in Nottinghamshire, following allegations of breaches of infection control.

The chair of the BDA General Dental Practice Committee, Dr John Milne, said: “There is absolutely no excuse for putting patients at risk.

We champion the highest standards in dentistry, and rigorous infection control procedures need to be at the heart of any practice, large or small.

“Clinical experts from Public Health England have established there is low risk of exposure. But today these patients need some reassurance, and recall is therefore a sensible precaution.

“Dentists across the UK are setting high standards and any exceptions are both regrettable and rare. But today’s news does raise questions about the current inspection regime. We’ve long argued that dental experts need to be on the front line for inspections. We must ensure we have inspectors who know what good practise looks like, and we will be working closely with the Care Quality Commission to make that a reality.” q

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Your dental expert witness

profiling Professor Paul Tipton ‹ PROFESSOR PAUL TIPTON has

extensive experience as an expert witness in cases involving dental negligence as well as personal injuries sustained to teeth and supporting structures. Having developed a high level of expertise in the medico-legal field, dealing with such cases from a legal report and treatment perspective, he is able to act in cases relating to: • Prosthodontics • Dental Implants • Cosmetic Dentistry • Aesthetic Dentistry • Temporomandibular Joint (TMJ) • Restorative Dentistry • Tooth Loss • Dental Bridgework • Dental Veneers Professor Tipton gained his Masters Degree after two years study at the Eastman Dental Hospital and London University graduating with an MSc in Conservative Dentistry. The following year he began teaching the new MSc in Restorative Dentistry at Manchester University and now runs his own Restorative, Cosmetic and Implant courses from his Tipton Training Academies in Leeds, Manchester, London and Liverpool.

The experience Professor Tipton has in dentistry means he is THE Dental Expert Witness. He is a founding member of the Academy of Expert Witnesses, a member of the British Academy of Experts, the Expert Witness Institute and the Association of Personal Injury Lawyers as well as being a Fellow of the Royal Society of Medicine.

In 1992 Professor Tipton was awarded the D.G.D.P. from the Royal College of Surgeons and appointed a member of the BDA Independent Practice Committee. In 1999 he was awarded Specialist status in Prosthodontics from the General Dental Council. He regularly lectures at home and abroad and is renowned for his one-year Restorative and Cosmetic Dentistry and Implantology courses, where over 2,500 dentists have graduated during the last 20 years, and for his numerous articles on Implantology and Cosmetic and Restorative dentistry.

He is on the editorial board of Private Dentistry magazine and Restorative and Aesthetic Practice and was a founding member of the British Academy of Aesthetic Dentistry and the British Academy of Cosmetic Dentistry. He is currently President of the British Academy of Restorative Dentistry (BARD).

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Professor Tipton now runs his own Restorative, Cosmetic and Implant courses from his Tipton Training Academies in Leeds, Manchester, London and Liverpool.

Over this time Professor Tipton has represented many patients as their dental expert witness receiving numerous plaudits for his work. Monic Bhakri of Attwood Solicitors was certainly impressed. “We instructed Professor Tipton with regards to a personal injury matter which involved complex issues involving the restructuring of the tooth as a result of an accident, " she said. “With his specialist expertise he provided us with a thorough in-depth analysis of the claimant’s injuries and the solution to resolve the severely damaged tooth. Professor Tipton was concise and efficient and provided us with a thorough dental report. I would most certainly recommend him in the future for such cases involving complex dental injuries.”

Problems with jaw joints can also lead to personal injury claims, including those relating to whiplash which is the most common head and neck injury in vehicle accidents without a direct head impact. Whiplash injury affects the temperomandibular joint (TMJ) in around a third of cases, many of which go unreported to the solicitor as symptoms are not initially

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linked to the accident. If untreated, whiplash injury can lead to osteo-arthritis and other jaw joints problems in later life. Professor Tipton can also act in these cases and advises that all whiplash injury affecting the neck should also be screened for TMJ injuries.

As a leading specialist in the field of dentistry, Professor Tipton is committed to delivering expert witness advice – whether acting for the defendant or the claimant – in a timely, professional and concise manner.

Communication is paramount throughout the entire process in order that he can provide the courts with clear, accurate reports to assist them with their decisions. Although based in Manchester, Professor Tipton also works out of London and is available for all cases across the UK and Ireland. q • To speak to one of Professor Tipton’s team for further information or to enlist his service please call 0161 348 7843 or 0161 348 7844 or you can email enquiries@drpaultipton.co.uk.

Professor Tipton’s personal website has a lot more information on his experience – please visit www.drpaultipton.co.uk/expert-witness. www.yourexpertwitness.co.uk

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Industrial hearing loss is still taking its toll Despite a series of regulations governing exposure to noise at work, there continues to be a steady flow of cases regarding noise-induced hearing loss caused by noise at work.

‹ NOISE INDUCED HEARING LOSS (NIHL) is usually described

Cases on which he has accepted instructions mainly involve people who have operated in and around high noise levels for much of as ‘damage to the inner ear structures due to repeated exposure to their working life. Noise regulations ensure that workers’ hearing is loud noise over a period of time’. It occurs when the sensitive hair protected. The Control of Noise at Work Regulations are in force with cells inside the cochlea become damaged, resulting in a sensorineural the exception of the music and entertainment sectors. hearing loss. The cells will not usually repair or replace.

Other cases involve personal injury claims as the result of an Problems usually develop gradually but are most severe following accident – for instance car accidents where an individual has resulting exposure to high frequency sound. The resulting hearing loss, centred deafness, nasal facial injuries or whiplash, and which can lead to mostly around the frequencies of 3, 4 and 6 KHz, tends to be similar other ear problems such as tinnitus. in each ear and will inevitably get worse if the individual continues to In many cases defendants may deny either the facts of the hearing be exposed to the noise. loss and tinnitus or its causation and therefore examination by an Individuals can also experience sudden hearing loss due to expert is essential. It is possible to claim many years after the noise exceptionally loud noise, such as an explosion, which is known as exposure was first experienced, although this will be subject to some acoustic trauma. Exposure both to sudden and continuous noise can time limitation. cause tinnitus, resulting in the individual hearing sounds such as In Mr Lancer's experience, around 5-10% of cases of NIHL will fail, ringing, buzzing or whistling – the common link being that the sounds either due to well-preserved hearing or to other disease processes perceived do not have an external source. having been responsible for the symptoms. Many of the cases for Tinnitus can occur suddenly or very gradually. For some the which he has provided a medico-legal report have, however, resulted condition can be temporary, for example after a music concert, in a settlement. however continued exposure to loud noise may make it permanent.

Mr. Lancer also assesses investigations and writes medico-legal Although symptoms can take several years to develop, legal action reports where negligence has been alleged in everyday clinical should be taken swiftly once a problem has occurred, as there is a practice, especially with regard to operations and their complications limited time to make a claim: three years from the date of knowing relating to ear, nose and throat conditions, and how these problems that hearing problems are linked to industrial noise. affect the individual. R A solicitor will conduct checks to ensure a claim is genuine and that the defendant company or insurance policy still exists.

Medical records are then checked and, if no previous issues are raised and there is a reasonable likelihood of MR JACK LANCER is a consultant ear, nose and throat success in the case, an expert surgeon with a special interest in otology and rhinoplasty. in noise-induced hearing loss is With regard to medico-legal work, he attends court 4-6 times instructed. a year and compiles many medico-legal reports. A significant Such an expert is Yorkshire majority of the instructions accepted relate to noise induced based consultant ENT surgeon hearing loss (NIHL).

Mr Jack Lancer. Mr Lancer will Prior to retirement from the NHS in 2013, Mr Lancer held make an appointment with the the position of Senior ENT Consultant in South Yorkshire. individual concerned, conduct He was appointed as a consultant ENT Surgeon in 1988 a hearing test and write an and spent 35 years working in the NHS. While training he independent report. If areas of held positions in Sheffield, Cambridge and Zurich and was a contention can be agreed with consultant surgeon in Rotherham and Doncaster. the defence, the case may be He now only works in private and medico-legal practice, settled out of court by means of seeing patients and writing medico-legal reports based compensation. If not, the case around his specialist areas of interest, including otology may proceed to court and a (ear disease), rhinoplasty – including ‘nose jobs’ – and most resulting judgement. other aspects of general and routine ENT. With 26 years experience of Although predominantly servicing the areas of Rotherham, For further information contact medico-legal practice, Mr Lancer Doncaster and Sheffield, Mr. Lancer is prepared to travel for Mr Jack Lancer on 01777 817160 writes many hundreds of reports pre-arranged industrial deafness case appointments within a email jacklancer88@gmail.com each year and offers a short 150-mile radius. R waiting time for an appointment.

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Data collection project looks to reduce deaths and injuries ‹ IN OCTOBER THE Royal College of Obstetricians and

Gynaecologists (RCOG) launched a new five-year project – Each Baby Counts – which, by 2020, aims to halve the number of stillbirths, early neonatal deaths and brain injuries occurring in the UK as a result of incidents during term labour.

Stillbirth rates in the UK remain stubbornly high, the RCOG says, and current estimates suggest that around 500 babies a year die or are left severely disabled – not because they are born too soon, too small, or with a congenital abnormality, but because something goes wrong during labour.

Some babies who are starved of oxygen at birth survive but are left with a severe brain injury, sometimes known as cerebral palsy. Sadly many of these babies will not survive infancy, or will suffer with a life-long disability.

From January 2015, the Each Baby Counts project, which is part funded by the Department of Health, will begin collecting and analysing data from all UK maternity units in order to identify lessons learned to improve future care.

According to the RCOG: “Bringing together the results from local hospital reviews of these cases will enable us to make recommendations for key actions to improve practice. The action plans will then be monitored by measuring the trends and geographic distribution of deaths and severe brain injuries in the future.”

Professor Alan Cameron, RCOG vice president for clinical quality, said: “Stillbirth, neonatal death or the birth of a baby at full term but with brain injuries are life-changing and tragic events which often affect women and their families for many years. At the RCOG we do not accept that all of these are unavoidable tragedies and have committed to reducing this unnecessary suffering and loss of life by 50% by 2020.

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“Our task is to collect data from all UK units to identify avoidable factors in these cases. We will monitor where these incidents occur and why.

Sharing of this sensitive data will provide us all with a unique opportunity to improve the care we provide and save lives.”

Professor Zarko Alfirevic, co-principal investigator for the Each Baby Counts project, added: “Most pregnant women receive exemplary care during labour in our NHS hospitals, but tragically some babies die or are left severely brain-damaged. Currently, when these events occur they are investigated locally. However, because the lessons learned from these local reviews are not being shared, opportunities to improve care at a national level are being missed.

“The Each Baby Counts project aims to pool the results of local investigations to gain a national picture and develop actions to prevent these tragedies from recurring.

“This is one of the most ambitious and exciting projects in women’s health in the UK at the moment. Our goal poses a significant challenge but we are confident that we will achieve it.” q

How to manage pregnancy Doctor’s advice – not doctor’s orders!

By DR BASHIR QURESHI FRCGP, FRCPCH, FFSRH-RCOG, AFOM-RCP, Hon. FRSPH, Hon. MAPHA-USA What to do Firstly, get a pregnancy test done when your period is one or two weeks overdue. This can be done free of charge at your GP surgery or your local pharmacist which may be more reliable and believable than self testing. Once you have a positive result it is important to make a first appointment with your GP and, of course, make sure you follow their suggestions.

Your antenatal, delivery and postnatal care would normally be shared by the GP, the practice nurse, the midwives (at both the surgery and hospital) and the hospital’s consultant obstetrician and his team. You will need to attend the hospital for consultations, diagnostic blood tests and ultrasound scans as well as for other appropriate investigations and follow ups.

It is important to keep all the appointments, follow strictly the advice given and keep a positive attitude as this will help your carers to help you. The reward should be a healthy pregnancy, a calm delivery and a beautiful baby – even if he or she learns to cry before learning to smile!

Make sure you keep a good relationship with your spouse/partner, relatives, friends and employers – if only because you might experience hormonal mood swings.

Finally, nutrition in pregnancy is vital for both your own and your baby’s health. It is important to have a balanced diet containing 400g of carbohydrates, 100g of protein and 100g of fat on a daily basis and to take some folic acid vitamin. You will need all of these in proportion but be careful as, taken in excess, they can cause problems.

Think of your dinner plate being made up of a balanced diet – one third should be carbohydrates such as bread, rice and potatoes; one third should be vegetables and fruits; the final third should again be divided into three parts containing protein such as meat, low fat products and milk.

Please make sure that you take breakfast, lunch and dinner (or high tea in Scotland!) and eat enough healthy food just for one, not for two – every baby is usually clever enough to take his or her share.

Take a 90 day course of 400 mcg of folic acid in early pregnancy, obtained from your GP or pharmacist, to prevent megaloblastic anaemia and deformity in the baby. Your GP will not give you iron tablets routinely in order to avoid overdosage as this can can harm a baby’s liver but he will give it if your blood results show iron deficiency anaemia.

What not to do Make sure you do not miss any of your appointments, either with your GP or at hospital, or any antenatal classes which may be in your area. This is an investment and it will ensure a healthy pregnancy and a pleasant experience.

Do not ignore the information about pregnancy readily available on the internet, in newspapers, on radio and television and in the literature given to you by your GP, midwives and practice nurse. These are educational but remember that each author would legally and tactfully advise you to always consult your GP, so please do this if there is anything in this abundance of information that you are unsure of. Of course, you can also consult your mother or mother in law, if you are on good terms with them, as they have a wealth of experience.

Almost all foods are good for you in small amounts but in large amounts many things

can harm you, including cheeses and alcohol.

You can eat hard cheeses but do not eat soft cheeses because they contain water which can harbour bacteria such as listeria which can cause listeriosis disease.

Don’t panic. If it is your first pregnancy, keep calm and stay in full control – consult other mothers and health professionals with a smile.

If you are from an ethnic minority culture in the UK, please use all the advice that is available to you in this country. Also consult your family and religious advisers as they will all help you. Please remember never to take Allopathic (English) medications along with alternative medications because they may potentiate, neutralise or over-do the effects and side effects of each other.

So, good luck in your healthy pregnancy.

Please keep smiling, as this will help others to help you, and always ask for help when you need it – we all need each other! R

Dr Bashir Qureshi ‹ DR BASHIR QURESHI is an expert witness in cultural, religious and ethnic issues in litigation

as well as in GP clinical negligence.

Since 1992, he has acted in cases of medical negligence, discrimination in employment, personal injuries, accidents, murder inquiries, family or marital disputes, child abuse, sexual abuse, immigration, asylum and numerous other litigation cases. He is able to write reports, offer advice and give evidence in tribunals or courts.

Dr Qureshi is the author of Transcultural Medicine which deals with the treatment of patients from different cultures, religions and ethnicities in relation to their medical needs, legal positions, political dimensions and economic considerations. In a clear, credible, compelling and compassionate way, the author outlines their varying needs and also gives practical tips in fairly managing patients from different backgrounds. The book is aimed at doctors, nurses and other health professionals as well as those solicitors who work in multicultural areas.

Dr Qureshi has also written over 300 articles in medical and health journals in the UK since 1981 and is still keen to write more. He also lectures widely on transcultural medicine at meetings, conferences and courses in Britain, the USA and around the world. Since 1981 he has given around 400 such lectures and has a list of 50 talks although he can devise a relevant talk to suit the audience.

Having had media training, Dr Qureshi broadcasts widely on patient care and health promotion issues. He was a regular participant in the BBC TV programmes by Kilroy Silk and other documentaries. As the two photos below show – taken over 50 years apart in 1964 and 2014 – he has often been a guest in the corridors of power. R

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Royal Colleges team up to combat bullying ‹ THE Royal College of Obstetricians and Gynaecologists (RCOG)

and the Royal College of Midwives (RCM) have joined forces to try and eradicate bullying and undermining behaviour in the workplace through a new web-based toolkit launched on 28 November.

According to the RCOG, previous General Medical Council (GMC) trainee surveys have shown that undermining and bullying behaviour is a problem for trainees in obstetrics and gynaecology. The GMC’s most recent report covers bullying and undermining behaviour and their plans to work with others to combat it in clinical environments.

The new toolkit is a free comprehensive resource providing links to information and to help tackle undermining behaviour in the workplace. It is aimed at trainees, members, fellows, midwives, nurses and GPs and is

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also applicable to other specialties at an individual as well as a trust and strategic level.

Dr Jo Mountfield (pictured) is a consultant obstetrician and Director of Education at University Hospital Southampton. She is also Head of School at Health Education Wessex and the RCOG workplace behaviours advisor.

She said: “A culture of undermining and bullying has been and continues to be a prevalent concern within the NHS. Both the RCOG and the RCM are committed to addressing this and doing all we can to help our trainees and members. This new toolkit is one way we can help combat the problem and raise awareness of it.

“It is vital that doctors can work to the best of their ability and this toolkit will assist in achieving this by ensuring that those experiencing undermining behaviour or tasked with tackling it have easy access to helpful resources.”

Cathy Warwick, chief executive of the Royal College of Midwives, commented: “There is a real need to ensure that inappropriate behaviours within the NHS are addressed quickly, efficiently and in the right way.

Ideally they would not happen in the first place and this toolkit can help to stop it occurring.

“Also, bullying and undermining behaviour not only affects the individual concerned, it can also have an impact on their ability to deliver the best possible care to people using NHS services.” q

AVIATION

CCTV/VIDEO/IMAGE ANALYSIS

BUILDING, PROPERTY & CONSTRUCTION

COMPUTER & MOBILE FORENSICS

EMPLOYMENT CONSULTANTS

ENVIRONMENTAL ISSUES

FORENSIC SERVICES

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METEOROLOGICAL CONSULTANTS

HANDWRITING ANALYSIS TREE CARE

HIGHWAY LAW VEHICLE & ROAD TRAFFIC ISSUES

VOICE/SOUND TRANSCRIPTION & ANALYSIS

WEB DESIGN

METALLURGISTS

WOOD & TIMBER

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MEDICO-LEGAL EXPERTS ACCIDENT & EMERGENCY

CARDIOLOGISTS

ANAESTHESIA

CHARITIES

CLINICAL NEGLIGENCE

BREAST SURGERY

COLORECTAL SURGEONS

DENTAL EXPERTS

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LUNG TOXICOLOGY

MEDICAL PHOTOGRAPHY FORENSIC MEDICINE

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NEUROLOGISTS

GENETICS

NEUROSURGEONS

LIVER SURGEONS

OBSTETRICS & GYNAECOLOGY

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OCCUPATIONAL THERAPY

OPHTHALMIC SURGEONS

ORAL & MAXILLOFACIAL SURGEONS

OSTEOPATHS

ORTHOPAEDIC SURGEONS

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PAIN MANAGEMENT

PLASTIC SURGEONS

PODIATRIC CONSULTANTS

PATHOLOGY

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PHYSICIANS

PHYSIOTHERAPISTS

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PSYCHOLOGISTS

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SPORTING INJURIES

TOXICOLOGY CONSULTANTS

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