Your Expert Witness Issue No. 36 1YWN

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contents IN THIS ISSUE 7

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Opening Statement

NEWS 8 Criminal justice system improving, but can do better 8 Top judge calls for end to ‘needless dispute of science’ 8 Bin lorry tragedy: families and driver to receive legal aid 9 Compulsory microchipping will protect dogs, people and livestock 9 Timber thieves stumped by DNA profiling BUILDING & PROPERTY 10 Powered gate checks urged following prosecution 10 Guidance on flood risk updated 11 Get plant design right from the start, urges Axion Consulting CCTV, MOBILE & VIDEO FORENSICS 12 Lawyers insist professional privilege must be maintained 12 UK IT professionals back Apple stance in FBI debate 13 It’s the forensic detection that unmasks the wrongdoers

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WILLS, LEGACIES & CHARITABLE BEQUESTS 15 Legacy giving on the rise as fundraising goes under the spotlight 16 Enriching the lives of people with learning disabilities 17 Small charities have their say 17 Short breaks offer a normal life and boost self-confidence 18 Delivering a supporting role 18 Removing the stigma of mental illness 19 Humane research can benefit humans and animals 19 Our nearest animal relatives are this charity’s prime concern 20 Fundraising board members announced 20 Legacies can help pioneering research FINANCE 21 Divorce – what has been hidden can often be revealed

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A to Z WEBSITE GUIDE 22 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

EXPERT CLASSIFIED 51 Expert Witness classified listings 54 Medico-legal classified listings

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

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

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MEDICAL ISSUES 25 Medical Notes

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NEWS 27 Medical tribunal reforms now in place 27 New mental health strategy welcomed by profession 28 Steam therapy poses burns risk 28 Patients being contacted in hep C healthcare worker case CLINICAL NEGLIGENCE 29 Medical technology can have its own victims 31 Claimant’s Part 36 offers result in damages uplift 31 Dental nurse suspended for performing facelift 32 When ‘never’ in the NHS really means 1,000 times 33 The diagnosis of prostate cancer THE USE OF EXPERTS IN THE FAMILY COURT 34 Report finds new rules have led to new role for social work experts 35 Social workers’ body welcomes guidance on recording of meetings 35 This acknowledged expert leads a team of specialists

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ORTHOPAEDICS 36 Getting it right first time – a requirement, not an aspiration 37 Orthopods react to virtual clinics 37 Hip implants under the spotlight again PLASTIC SURGERY 39 Botox report highlights regulation issues 39 Plastic surgeons pioneer 3-D tissue printing 39 Life-changing surgery being denied by CCGs PAIN MEDICINE 41 What is a pain medicine specialist?

OPHTHALMOLOGY 43 Brain injury can be seen in the eyes 43 Training raises awareness among healthcare workers 43 Quality standard developed for eye patients with dementia

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VARICOSE VEINS 44 Varicose veins in 2016 – the fading of traditional varicose veins surgery GP’S & PATIENT CARE IN THE NHS 46 Is today’s NHS ‘awful’ – or ‘awfully good’?

REHABILITATION 49 When language barriers can get in the way of an assessment 50 New version of code reflects litigation changes 50 Specialist rehabilitation is cost-effective www.yourexpertwitness.co.uk

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Opening Statement [

THEY’RE AT IT AGAIN: taking money from the general public and using it to promote their own political ideology and trying to influence the outcome of the democratic process. Not the charities; not the Royal Family: the tabloids!

Headlines screamed from the front pages accusing charities of taking a stance to promote an ‘in’ vote in the EU referendum. Actually, the coverage was sparked by Charity Commission guidelines on what actually does constitute legitimate charity campaigning on the issue.

It was, unfortunately, the latest in a number of ambushes of charities in recent months by both the press and politicians. It followed proposals to limit the role of the RSPCA in prosecuting animal cruelty cases and complaints about aggressive fundraising by charities.

The Etherington Report proposed a regulatory body for fundraising. Interestingly, the report recognised that charities who gain most of their funding from legacies should have to shoulder a lighter burden of the funding of the body – recognising that legacies are a source of funding that causes little criticism. There have been a few, high-profile cases of charities being seen to be too aggressive or too forward in claiming legacies, but the process is still one that receives widespread support from government and the legal profession. Your Expert Witness is pleased to be helping to promote this worthiest of causes.

• Another time when the disposal of someone’s assets is the subject under discussion is in the case of divorce. Particularly when large amounts of money are involved, there is a well-documented tendency to hide assets from the other party. In line with Newton’s third law, however, there is an equal and opposite effort from forensic accountants to discover assets that one party has sought to conceal. Regular contributor Derek Williamson of Goddards gives an insight into the lengths people go to in order to hide their assets, and the methods available to forensic accountants to bring them to light.

• Divorce isn’t the province of the rich, of course, and often the hardest-hit victims are the children. Family courts are burdened with the Solomon-like task of finding a way to preserve some kind of world for children affected. Family court experts have been taken out of the firing line to an extent in recent years. Fewer experts are instructed now – and in a less confrontational setting. Independent social workers have a role to play, particularly where the family setting has been toxic for the children involved.

Skilled social workers – together with a whole multidisciplinary team – are also called upon to rebuild the lives of children shattered by abuse at the hands of those they should be able to trust. Almost every month a new story emerges demonstrating the depths adults will sink to in their abuse of children.

There have been reports of acts of depravity occurring within the family – with parents and even grandparents being accused – or perpetrated by strangers. The internet has proved a ready vehicle for those keen to lure and trap the unwary. The story told on Radio 4’s PM programme by Alicia Kozakiewicz of her ordeal when aged only 13 stunned and sickened this listener.

Those with the ability to bring children subject to such behaviour back to anything approaching a normal life can only be admired by the rest of us.

• In other arenas – in particular the scientific field – expert witnesses have been accused of nit-picking when it comes to questioning the smallest detail of accepted wisdom. That, at least, is the view of Lord Neuberger. The president of the Supreme Court used the pages of the renowned journal Nature to plead for a more restrained approach. He suggested the use of primers, as used in such hearings as those regarding patents. Asking scientists to agree to agree could indeed be asking for the earth. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Criminal justice system improving, but can do better [ A REPORT FROM the National Audit Office (NAO) has found that the criminal justice

system is not currently delivering value for money. Although the management of cases has improved since 2010, the NAO found that nearly two-thirds of cases still do not progress as planned and there is significant regional variation in the performance of the system.

At Crown Court, a victim of crime in North Wales has a seven in 10 chance that the trial will go ahead on the day it is scheduled, whereas in Greater Manchester the figure is only two in 10. The large variation in performance across the country means that victims and witnesses will experience very different levels of service.

Trials that collapse or are delayed create costs for all the participants, including the Crown Prosecution Service (CPS), victims, witnesses, defence lawyers and Her Majesty’s Courts and Tribunals Service (HMCTS).

The head of the NAO, Amyas Morse, said: “Delays and aborted hearings create extra work, waste scarce resources and undermine confidence in the system. Some of the challenges are longstanding and complex; others are the results of basic avoidable mistakes. The ambitious reform programme led by the ministry, HMCTS, CPS and judiciary has the potential to improve value for money by providing tools to help get things right first time, but will not in itself address all of the causes of inefficiency.” q

Top judge calls for end to ‘needless dispute of science’ [

THE PRESIDENT OF the Supreme Court, Lord Neuberger, has called on experts to desist from a needless challenging of the detail of scientific fact in court cases. Instead, he has suggested the use of ‘primers’ on various scientific topics to lay out general principles which are not under dispute.

Writing in the scientific journal Nature, Lord Neuberger said: “Testimony from expert witnesses – and I have heard a lot in my career as a judge – is a long-standing and important feature of legal proceedings.

The scientists, engineers, inventors and technologists who offer their opinions in court are encouraged to agree on basic points before a trial begins. But they often do not agree as much as we hope. That tends to lengthen the time taken to crossexamine them and contributes to justice being an expensive, drawn-out and stressful experience for all involved.”

He suggests that primers would help both judges and the justice system. They are, he said, used in patent disputes.

“Both sides allow their expert witnesses jointly to present points on which they

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agree, and which will not be disputed.

This effectively sets a baseline for the ensuing arguments, which can still diverge significantly.”

He conceded that such documents would not be appropriate for all cases but cited examples, such as forensic science, DNA

profiling and computer forensics, where general principles could be set out.

The main benefit would be in the savings in time and expense they could produce. q • The article appeared in the 3 March issue of Nature at www.nature.com/news/.

Bin lorry tragedy: families and driver to receive legal aid [

THE SCOTTISH GOVERNMENT has agreed to make legal aid available to the families involved in the 2014 Glasgow bin lorry tragedy.

Justice Secretary Michael Matheson said: “Private prosecutions are, and should remain, exceptionally rare in Scotland. However, in light of the unique and special circumstances of this case, which raises fundamental questions that have not previously been tested in case law, Scottish ministers believe it is in the public interest that all parties are adequately represented. As such, ministers have agreed to make legal aid available for the families of the bin lorry tragedy.”

He added that driver Harry Clarke would also receive legal aid, saying: “In line with human rights requirements that anybody facing potential criminal prosecution must be legally represented, legal aid will also be made available to the driver of the bin lorry, Mr Clarke.

“The issue of whether there are exceptional circumstances to justify a private prosecution is a matter for the High Court alone and does not form part of this legal aid decision.” q

Compulsory microchipping will protect dogs, people and livestock [

FROM 6 APRIL it will become compulsory for dog owners in England to have their animals microchipped. The new rules protect the welfare of dogs and promote responsible ownership.

They will also make it easier to track down the owners of dogs that carry out attacks on people or who run wild on agricultural land and worry livestock.

According to DEFRA, every year over 102,000 dogs are picked up, having strayed or been stolen. With the introduction of the new rule it is hoped they will stand a greater chance of being returned to their owners. It is also expected that local authorities and the charities which feed, kennel and home lost dogs will make around £33m in annual savings with dogs being returned to owners.

Commenting on the new law, Animal Welfare Minister George Eustice said: “We are a nation of dog lovers and we want to make sure they stay safe. Microchipping our dogs will not only reunite people with their lost or stolen pets, but also help to tackle the growing problem of strays.

“Microchipping is vital for good dog welfare and a simple solution for responsible pet owners to provide peace of mind and ensure your muchloved dog can be traced.”

Already, 83% of dog owners have had their four-legged friend painlessly implanted with a microchip and their details updated on a national database.

Paula Boyden, veterinary director of Dogs Trust, added: “Dogs Trust welcomes the new legislation as we have long campaigned to

make microchipping compulsory. Losing a dog is an extremely upsetting time for both dog and dog owner and microchipping increases the likelihood that a dog will be reunited with their owner in the event they are lost, making it an essential part of animal welfare law in England.

It is vital that the microchip details are kept up to date.”

The procedure is inexpensive – ranging from £10 to £30 – with many charities and animal shelters offering to carry it out for free. q

Timber thieves stumped by DNA profiling [

DNA TESTING OF wood at a university in Australia has led to the landmark prosecution of four timber thieves in the United States.

Researchers at the University of Adelaide in South Australia were approached in 2012 by officers from the US Forest Service following the felling and theft of bigleaf maple trees from the Gifford Pinchot National Forest in Washington State. Bigleaf, or Oregon maple, is a high-value timber used for furniture, piano frames and decorative tableware.

DNA taken from bigleaf maple stumps was matched with wood samples seized from the mill of the alleged thieves. Four defendants were charged with the theft and recently pleaded guilty, in a case that marks the first time the US government has prosecuted for illegal interstate trade of wood products under the Lacey Act. The Lacey Act is an American wildlife protection law that was amended in 2008 to include plants – making it illegal to trade in wood products that have been illegally sourced.

University of Adelaide research fellow Dr Eleanor Dormontt manages its timber tracking activities. Dr Dormontt said the university became involved in 2012 when a US Forest Service agent read an article in local trade magazine Timber West about the work of Professor Andrew Lowe – a world leader in using DNA methods to identify timber – and his team in Adelaide.

The agent contacted Professor Lowe and a joint project was initiated.

Researchers from the university’s Environment Institute developed DNA markers for the bigleaf maple population. They joined the US Forest Service and timber tracking specialists Double Helix Tracking Technologies, with help from World Resources Institute, to develop the first DNA profiling reference

database for the species. It’s the only one of its kind for trees that has been validated for use in court proceedings.

“With this technology, wood buyers can verify whether or not bigleaf maple has been legally harvested,” said Professor Lowe, who is also chief scientific officer at Double Helix. q

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Powered gate checks urged following prosecution [

POWERED GATE OWNERS are being urged to have their gates checked for safety after a court heard how a defective works gate collapsed and seriously injured an employee.

The advice has been issued by the Door and Hardware Federation (DHF), whose Powered Gate Group represents the leading manufacturers, suppliers, installers and maintainers of powered automatic gates and gate automation equipment.

A court heard that a leaf of the telescopic gate came out of its runners and collapsed on the man. As a result of the accident in Caerphilly the man was hospitalised for 10 days and was off work for a year.

Advanced Gate Ltd, Mid Glamorgan, pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc. Act 1974, was fined £20,000 and ordered to pay £5,000 costs.

The court heard how the company was contracted to manufacture and install the gate system. An investigation by the Health and Safety Executive into the incident found that the underlying failure of the gate mechanism was as a result of inadequate design, assessment and control measures to ensure the gate was safe for use.

DHF general manager and secretary Michael Skelding said: “This case underlines how important it is that automated gate owners – and all those responsible for their maintenance – must insist that the company used to install or do work on a powered gate employs properly qualified installation engineers.

“Unfortunately, unsafe installations are still being carried out by untrained personnel which results in gate installations which do not comply with legislations and are potentially dangerous. As an industry we are determined to keep on raising safety standards and confine accidents caused by dangerous gates to the history books.” q

Guidance on flood risk updated

[THE LAW SOCIETY has issued a revised Flood risk practice note

to solicitors, reflecting increased concerns over homes and businesses in flood-prone areas. The practice note covers the issues and resources that solicitors need to be aware of when acting for buyers: from Environment Agency flood maps and specialist surveys to insurance.

The Environment Agency estimates that one in six homes in England – 5.2 million – are at risk from flooding. In Wales, more than 200,000 properties are at risk from sea or river flooding and 230,000 properties are at risk from surface water flooding.

In December last year, 16,000 properties were flooded in England following storms that hit over the Christmas period, as well as earlier in the month.

Solicitors play a vital role in the home and business-buying process, the Law Society said in a statement, and they help to protect buyers by alerting them to the most important issues relating to a property, including the risk of flooding.

Law Society president Jonathan Smithers, who in his practice has specialised in property work for many years, said: “Flooding is a growing risk for property in England and Wales. Solicitors help clients investigate the environmental threats to their property. This revised practice note is a condensed toolkit for all solicitors advising buyers about flood-prone properties.” q

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Get plant design right from the start, urges Axion Consulting [

FAILURE BY PROCESS PLANT designers and investors to take into account fast-moving changes in the composition of waste infeed materials could cost them dearly in the long run should future disputes arise over performance and quality issues, warns Axion Consulting.

The Manchester-based resource recovery specialist says demand is rising for its engineering expert advice on recycling and waste processes in cases of industrial and commercial disputes.

Axion offers a range of expert witness, due diligence and arbitration advice services in cases of industrial and commercial disputes.

Issues covered for clients by Axion’s qualified and experienced engineers include litigation, arbitration and technical support for insurers and loss adjusters.

“We are getting involved in more dispute resolution cases as some processing plants, often built in the last decade, experience issues due to the changing nature of waste materials and the rapidly changing end markets for recovered materials,” observes Axion director Roger Morton.

“The composition of waste is changing rapidly due to changes in packaging and disposal habits, so it’s vital to plan for this right from the start of the contract. Locking a particular fixed waste composition and fixed output product specifications into the design may not allow enough future flexibility – leaving operators vulnerable to costly disputes should the plant not be able to cope.”

Designing a plant capable of handling a wide variation of waste composition may be more expensive at the outset, he advises, but it makes sense to build it for a range of materials that can reduce the risk of future problems.

Waste processing facilities can underperform for a variety of reasons. It may be that the waste is not the right composition or it could be a result of inadequate plant design, leading to over-loading of ‘bottleneck’ sections of the plant which in turn cause poor separation efficiency, blockages and excessive breakdowns. Resolving where the blame lies for these issues can require detailed and lengthy analysis to unravel the causes.

Early consultation with engineers during the contractual process to include flexibility within the plant’s capabilities is important, advises Roger Morton: “Innovation within the waste sector means we’re now working with changing feed materials, evolving end markets and rapidly-developing technology.

Construction and operation contracts that allow more collaborative working between

local authority clients, plant operators and plant builders will mitigate the need for action in the future.”

As well as offering consulting services to the waste management sector, Axion’s experience of running its own large material recycling operation provides unique insight that helps clients.

“As we also operate in the market commercially, we know the prices of recovered fuel, recycled metals and recycled plastics and we know our own operating costs so we can make credible and realistic assessments of the issues facing processing plants and the likely commercial impact of failures,” added Roger.

“And because our plant specialises in processing non-metallic fractions from end-oflife vehicles – a niche sector – there is rarely a conflict of interest. Get the experts involved

at the start, instead of the end. Acting at the contract-forming stage will save money for all parties in the long run.”

Axion Consulting, part of the Axion Group, develops and evaluates novel resource recovery processes, tests and operates innovative recyclable collection systems as well as offering business planning and financial analysis.

It can supply the expertise, knowledge and necessary skills to implement projects in the circular economy sector, with a specific focus on working with supply chains to deliver successful outcomes, which are both environmentally sound and economically viable. q • For more information call Axion Consulting on 0161 426 7731 or visit the website at www.axionconsulting.co.uk. www.yourexpertwitness.co.uk

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Lawyers insist professional privilege must be maintained [THE LAW SOCIETY has welcomed a

recognition on the part of the government that legal professional privilege needs statutory protection in the Investigatory Powers Bill.

However, the professional body expressed concern that the protection may not go far enough.

In a statement issued on 2 March – the day after the publication of the Bill – the society said: “The government responded to our long-standing concern that the special status of legal professional privilege in surveillance legislation must be acknowledged in statute and not simply in codes of practice.

“We will now be scrutinising and evaluating the detail of the Bill and urging the government not to push through this important legislation without taking time to consider fully all the implications.”

Its president Jonathan Smithers declared: “Legal professional privilege is vital to the administration of justice. It protects a client’s fundamental right to be candid and confidential with their legal adviser without fear that someone is listening in.

“We made significant representations to the government, including giving evidence to the joint bill committee to emphasise and highlight the importance of legal professional privilege, and are pleased that our principle concern – that protection must be in the bill itself – has

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been heard. However, we are concerned that the protection does not go far enough. We now urge the government not to proceed too quickly and in the absence of full scrutiny of the implications.

“Intelligence agencies and the police need surveillance powers to protect us, but proper

scrutiny of the Investigatory Powers Bill by Parliament would ensure that the bill is fit for purpose when it becomes law. We will engage with the government and Parliament to ensure that the right balance between security and safety and clients’ rights to protection of their legal professional privilege is achieved.” q

UK IT professionals back Apple stance in FBI debate [WITH THE Apple/FBI debate raging, a recent survey of British

Computer Society (BCS) members revealed that 76% of IT professionals tend to ‘disagree’ or ‘disagree strongly’ that in order to protect national security, companies should weaken or defeat their own security measures to provide authorities with access to content that has been encrypted – indicating that a significant margin of IT professionals support at least an element of Apple’s position.

David Evans, director of policy at BCS, said: “From our survey it’s quite clear that IT professionals do not agree that companies should be asked to weaken or defeat their own security measures to provide authorities with access to encrypted content.”

Mr Evans continued: “We do not want to see any organisation standing against a lawful attempt to fight crime and terrorism. Yet the implications of both the UK’s Investigatory Powers Bill and the FBI’s desire to crack Apple’s software have exercised the technical community for a reason. Part of this may be because of a difference in political views and emphasis on liberty versus security. Part of this may also be that the technology community really understand the implications of what is being asked in these cases, while the general public don’t.” q

It’s the forensic detection that unmasks the wrongdoers

[STOCKPORT-BASED AUDIO VIDEO FORENSICS have the

perfect background and experience to offer a range of specialist forensic services. That includes the provision of audio video and still image evidence for law enforcement agencies, military clients and private legal companies.

Having achieved an enviable reputation since the company’s inception 21 years ago, it will come as no surprise to learn that AVF have worked on a great many high-profile cases, as managing director Iain McArthur explained: “Our work has been crucial in many serious criminal cases throughout the UK, Ireland and the Middle East. We have dealt with audio and video evidence from CCTV and covert recordings in highly complex high-profile cases, such as the Rhys Jones murder enquiry, the trial of Levi Bellfield, the death of the ITN journalist Terry Lloyd, the Baha Mousa enquiry in Iraq and the Daily Mirror Iraq fake photo enquiry, which resulted in the departure of Piers Morgan.”

Other high-profile cases undertaken by the company include the Glasgow bin lorry enquiry, the Millie Dowler murder enquiry, the News of the World ‘sting’ on world snooker champion John Higgins, the analysis of the footage of the Mark Duggan shooting for the BBC which sparked the UK riots in 2011 and the audio analysis of the gunshots in the death of Raoul Moat for Sky News.

Iain McArthur added: “We have extensive experience in assisting the investigation of serious crime, including murder, paedophilia, arson, robbery, fraud, military crimes, rape, GBH, aggravated burglary and so on. We have conducted many crime reconstructions – from on-site height estimations to video preparation for BBC’s Crimewatch.”

Audio Video Forensics Ltd is the brainchild of Iain McArthur. In founding the company he was able to draw on his vast experience working with audio and video for many years, both in recording studios and the film industry. In particular he worked in the research and development department of renowned pro-audio manufacturer AMS-Neve, developing audio mixing desk technology for the film industry.

Iain worked on AMS-Neve’s flagship product the DFC – Digital Film Console – on which over 70% of the world’s blockbuster films are mixed.

In 1999, while he was working there as lead software test engineer, the company’s R&D department was awarded a Scientific & Technical Award (an Oscar) by the Academy of Motion Picture Arts & Sciences for the DFC. Why not join the many organisations that are already reaping the benefits of working with Audio Video Forensics? They include Special Branch, SOCA, HM Revenue & Customs, Special Investigation Branch (SIB) of the Royal Military Police, Romanian Police Force, Hungarian Secret Service and the UNIIC (United Nations Independent Investigation Committee) plus many more. q • For further information visit www.audiovideoforensics.com, tel: 07714 245303 or email mail@audiovideoforensics.com. www.yourexpertwitness.co.uk

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In this latest in our series of special features on legacy giving, we look at a momentous year for charities. A new report looks set to shake up fundraising, while legacies continue to be seen as a valuable source of income. We also look at the impact of the changes on small charities and find out who will be serving on the board of the new Fundraising Regulator.

Legacy giving on the rise as fundraising goes under the spotlight [

LAST YEAR SAW legacy giving in the UK at an all-time high, as measured by the umbrella organisation Remember A Charity. The organisation says it continued to make significant progress towards its goal of making charitable will writing the social norm.

“While it has been a challenging year for fundraising, by working together the consortium has had its most successful year to date,” it said.

The proportion of people who say they have included charitable legacies in their wills is now at 17% – the highest level since Remember A Charity began monitoring in 2002. The campaign also saw record support from Government this year, including the Cabinet Office, HM Treasury, Scottish Government and the Department for Culture, Media and Sport.

The percentage of solicitors and will writers who ‘always or sometimes’ prompt their clients has also increased, from 53% to 66% in the past five years – again, the highest level since its market research commenced in 2002.

The results came despite a number of news stories emerging criticising the fundraising efforts of some charities and the publication of the Etherington Report on the regulation of fundraising activities.

The report, published in September, included the setting up of a Fundraising Regulator. The regulator and its board will be funded by a levy on charities that spend more than £100,000 on fundraising.

In the report, Sir Stuart Etherington recognised that charities who gain more of their income from legacies than from traditional fundraising should not be disproportionately penalised.

The report says: “A levy on fundraising expenditure introduces proportionality across the sector, ensuring that small organisations which may benefit from one off donations or wills do not get unduly burdened.”

Similarly, it rejected the notion of a levy on income for similar reasons, saying: “Smaller charities which engage in little or no fundraising and instead rely on legacies could be disproportionately hit.”

In general the report was welcomed, together with a report from the Public Administration and Constitutional Affairs Committee (PACAC) of the House of Commons, which warned the Etherington proposals represent the ‘last chance’ for self-regulation of charity fundraising. The committee said if the trustees in the sector fail to put their house in order, statutory regulation must follow.

The Institute of Fundraising said of the PACAC report: “The IoF has welcomed the committee’s broad support for the new system to regulate charity fundraising. Universal application, stronger sanctions and more effective regulation are all things that our members had been calling for and welcome.

“The report’s emphasis on the role of trustees and governance in driving forward changes to fundraising within their organisations is an important contribution.”

Specialist solicitors Stone King echoed the sentiment: “There is a welcome emphasis on the need for a shift in focus away from charities viewing fundraising simply as a way to raise money, towards charities and their trustees taking responsibility for a better relationship with their donors and the wider public – Sir Stuart stressed that this was not simply a fundraising issue but also a governance issue.” q

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Enriching the lives of people with learning disabilities [

CAMPHILL FOUNDATION PROVIDES much-needed financial support to projects which enhance the quality of life of adults, children and young people with learning disabilities. Camphill communities throughout the UK and Ireland offer safe and supportive environments, in a variety of semi-rural and urban settings, where individuals can feel at home and develop their personal abilities and interests.

There is also a strong sense of belonging to a diverse but cohesive intentional community and supported living network. Work opportunities abound, giving a real sense of meaning, purpose and achievement, which is essential for a person’s well-being.

Camphill Foundation supports development projects such as the building of new accommodation, establishing new workshops and facilities, developing agricultural and horticultural activities, providing new equipment and various educational, training, cultural and social initiatives. Support is often in the form of grants to help projects get started and loans at a low rate of interest, usually over several years.

Supporting Camphill Foundation also means fostering a new understanding and recognition of people with disabilities and enabling them to develop and make use of their astonishing talents and skills as fully engaged, talented and co-responsible members of the community carrying out important and meaningful work which is both fulfilling for them and of great value to others. q • For more information and to help the foundation achieve their aims visit www.camphillfoundation.net.

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Small charities have their say [FOLLOWING THE ETHERINGTON REPORT, a joint forum was

held on 4 February between the Small Charities Coalition and the Institute of Fundraising. The event gave small charities the opportunity to raise the main issues surrounding potential changes to fundraising regulation directly with the CEO of the new regulator, Stephen Dunmore, and the chair of the Fundraising Preference Service working group, George Kidd.

As part of a wider consultation, the two organisations conducted a joint survey to get the views of smaller charities on the recommendations of the review. The results of the survey showed that almost half of respondents are ‘not very familiar’ or ‘not at all familiar’ with the review of fundraising self-regulation conducted last summer.

There was strong support (from over 80% of respondents) for the review’s key recommendation for self-regulation with a stronger relationship with statutory regulators. However, a lack of familiarity among smaller charities on plans coming into effect for future fundraising regulation which will affect them, demonstrate that more and better engagement with smaller charities is vital.

The issues of public trust and confidence are being felt differently across smaller charities. Around half (49%) said that there had been ‘not very much’ or ‘no’ impact on their organisation, while 46% said there had been ‘some’ or ‘a great’ impact.

According to the IoF, there ‘seems to be a general agreement that stronger sanctions are needed’, with 52% thinking that the new regulator should be able to issue ‘cease and desist’ orders on fundraising activity, and 43% thinking that it should be able to issue compulsory training orders. The least popular possible sanction was ‘clearance of future campaigns’ (16%).

The most popular option for the funding of the new regulator was for it to be ‘funded by charities that fundraise from the public’ and who spend more than £100,000 on fundraising (38%) – though it should be noted that almost as many (34%) thought that funding should come from government.

While a fifth of respondents (21%) thought that the greater oversight of trustees would have ‘a great deal’ (6%) or ‘quite a lot’ (15%) of impact on their organisation, 72% said that trustees already play a clear role in or contribute to and set strategy for fundraising.

Speaking about the findings, IoF chief executive Peter Lewis said: “These results drive home the importance of involving and informing smaller charities about the changes taking place. Fundraisers working in smaller charities perform amazing work, often with very limited resources, and so it is really important that the views of the whole of the fundraising sector are heard on these issues. We are delighted that both Stephen Dunmore and George Kidd are joining today’s event which demonstrates their desire to listen the views of fundraisers from all charities.”

John Barrett of the Small Charities Coalition commented: “With over 150,000 registered small charities in England and Wales, and thousands

more who are too small to register, it is essential that the views of these organisations are taken into account during fundraising regulation reform. It is important to remember that the potential changes will have a disproportionate impact on smaller charities, as they will inevitably find it harder to comply than larger and better resourced charities. Therefore, the system needs to be affordable and compliance simple.” q

Short breaks offer a normal life and boost self-confidence

“

The Youth Cancer Trust gives amazing support, love and dedication to hundreds of young adults affected by cancer, without them I truly don't think I would have become the person I am today. They have given me back my confidence and made me realise that I can live a normal life, have fun and have the most amazing experiences like other young people who haven’t had cancer.

”

[THAT QUOTE FROM Kirsty sums up the value of the work done

by the Youth Cancer Trust. The organisation provides free therapeutic activity holidays for teenagers and young adults – those aged 14-30 – from the UK and Ireland who are suffering from cancer.

The residential breaks are designed to provide a safe space for young people with cancer to be with others of a similar age going through a similar experience, thus reducing the sense of loneliness that often accompanies a cancer diagnosis during their formative years. The activities are designed to help rebuild confidence and boost self-esteem, and include horse riding, sailing and water sports.

The charity receives no government funding and relies entirely on donations, such as those from legacies, to help support the needs of young cancer patients like Kirsty. q • For more information visit www.youthcancertrust.org. www.yourexpertwitness.co.uk

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Delivering a supporting role [THE ACTORS’ BENEVOLENT FUND was established in 1882 with

the aim of helping professional actors and stage managers who are unable to work through injury, ill health or age. The acting profession has grown enormously in that time – with the need for help increasing in proportion.

The Fund provides support to some 230 beneficiaries of whom 190 receive regular financial help. It also provides assistance with general household expenses, the cost of replacing household equipment, mobility aids, physiotherapy, osteopathy, a shortfall on nursing home fees and holiday costs. Additionally it advises on entitlement to state benefits and on debt management.

During the year a number of beneficiaries are visited by the Fund's welfare adviser or a council member. The Fund aims to ensure that as many of them as possible, some of whom have been beneficiaries for a long time, have personal direct contact with a Fund representative.

The Fund's image may be that it only assists the elderly, however the reality is different. Although reflecting a national ageing trend with around two thirds of beneficiaries over 60, the rest are much younger with the youngest being in their early 20s. Illness or accidents can strike at any age, with a propensity of physical injuries afflicting the younger beneficiaries.

With no state funding, the Fund relies heavily on donations, legacies and investment to sustain the income required to support its beneficiaries. It remains as relevant today as ever and needs all the support it can get to help those for whom the show does not go on.

• For further information visit www.actorsbenevolentfund.co.uk.

Removing the stigma of mental illness Many people will experience mental illness at some point in their life, and a range of national charities play a crucial role in improving care and helping people recover. But the stigma around mental health is still preventing people raising it as a topic when they are considering beneficiaries in their will. So how can you help clients discuss it openly? DANIEL WALSHE from the charity Rethink Mental Illness considers the challenge.

[

THE EMOTIONAL PULL of a charity is often extremely strong and linked to personal experience. One in four people will experience mental health issues in their lifetime. It always amazes me to see the bond our supporters have between what we do and how they can help when they leave us a gift in their will.

It’s a major commitment which supports the help we provide to one of the most stigmatised groups in society. Solicitors who prompt their clients to remember leaving a gift to charity will invariably lead the person to think about what matters most to them in life.

When writing a will, the priority for most people will always be to take care of their family, friends and other loved ones. It’s at this point that more people are considering leaving a gift to a charity which they have a personal connection to. According to research by Smee and Ford the proportion of gifts in wills had risen to 7.3% in 2013.

Gifts in wills are one of the most important ways people can show their support for a charitable cause. Although the numbers are rising, it’s often an opportunity which is overlooked. All too often it’s simply a case of solicitors’ clients not realising this is an option.

This is where the legal profession can play a vital role. Strict rules prevent solicitors from suggesting a client should leave specific gifts in

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their will. However, Remember A Charity’s 2013 research, in conjunction with the Cabinet Office, showed that three times as many Britons would, if reminded by their solicitor, leave a gift in their will to a charity they feel close to.

So, when discussing the composition of a will with a client, simply reminding them that they might want to think about a cause or causes which mean a lot to them is a good first step.

The sad fact is that people with severe mental illness die, on average, 20 years earlier than the rest of the population and are often dependent on family members as long term carers. So, clients with mental illness in the family may be thinking about how they will support a loved one after they die, and if the subject of mental illness does crop up, be prepared to talk about it openly. It may be a difficult topic for your client too, at first, but our experience shows that once its in the open, it can be a huge relief to talk about it. q • For further information contact Daniel Walshe, High Value and Legacy Manager at Rethink Mental Illness – www.rethink.org, email daniel.walshe@rethink.org, tel 020 7840 3032.

Humane research can benefit humans and animals [A FUTURE OF medical research that does

not involve the use of animals is the goal of The Humane Research Trust: a registered charity that encourages and supports new medical research without the use of animals, with the objective of advancing the diagnosis and treatment of disease in humans.

The Trust encourages scientists to develop innovative alternatives to the use of animals, helping to eliminate the suffering that occurs in medical research and testing. In particular, the Trust supports research involving donated human tissue, which it believes fulfils the best ethical and scientific justifications for investigations into human conditions.

It also seeks to disseminate the results of

such research, benefitting both the scientific community and the public, and promotes the stimulation of interest in research which is not dependent on animals.

Spring 2014 saw the 40th anniversary of The Humane Research Trust, although its origins lie farther back in time. In the late 1950s there was a growth in the use of live animals in laboratory research, which prompted a small group of people to found a new charity that would work with medical researchers in order to develop skills and techniques which would replace the use of animals. That charity was The Lawson Tait Trust, whose roles and activities were later taken over and expanded by The Humane Research Trust.

The Trust has financed university research fellowships and other projects covering a wide area of techniques and human diseases, and has an excellent record of bringing about change – for the benefit of both people and animals.

In many cases, innovative research would not have been able to proceed without its support. It relies entirely upon voluntary fundraising efforts and is run by a Board of Trustees from different walks of life not active in medical research. q • For further information visit the website at www.humaneresearch.org.uk, visit the facebook page at www.facebook.com/ TheHumaneResearchTrust or on Twitter @humane_research.

Our nearest animal relatives are this charity’s prime concern [

THE ONLY UK-REGISTERED CHARITY that provides sanctuary for rescued monkeys and supports similar projects overseas is Wild Futures. That is in addition to campaigning for primate welfare and educating to protect primates worldwide.

All too aware that flora and fauna around the world are becoming more endangered at every moment, Wild Futures is working hard to protect primates and habitats worldwide.

For some species it is too late: they are gone forever. The future of all that remains lies in our hands.

Says the charity: “We believe that education is vital in changing things for the better and our campaign’s work has led to much positive change for primates. The time to act is now, so leaving a legacy to Wild Futures is the

greatest gift that someone who cares about primates and the environment can give.”

Wild Futures receives no government funding, so financial support is vital to allow it to continue its work. Its haven for monkeys saved from mistreatment is The Monkey Sanctuary in Cornwall – the first sanctuary in the whole of Europe to be accredited by the Global Federation of Animal Sanctuaries.

Wild Futures has been rescuing monkeys from conditions of abuse and neglect and offering a safe home for life at its sanctuary since 1964. With spacious, natural enclosures, companionship of their own kind and specialist care, monkeys learn to enjoy life once again.

“By focusing on primates and their protection,” the charity says, “we aim to ensure a wild and safe future for all.” q

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Fundraising board members announced

Legacies can help pioneering research

[

ON 11 FEBRUARY Lord Grade, chair of the new Fundraising Regulator, announced the eight people who will make up its board. The appointments were confirmed at Fundraising Live, Civil Society Media’s annual conference for the fundraising sector.

Lord Grade also promised to listen carefully to concerns about the Fundraising Preference Service – intended to allow donors to opt out of all charity communication – and suggested that it would take into account ‘the legitimate right of charities to raise funds from the public’.

In his address he said: “I am delighted that today we have been able to announce the members of our board. You will notice that we have not yet struck the right balance between regulatory experience, fundraising expertise and wider knowledge of the charitable sector. We are in the process of recruiting two additional members with fundraising expertise.”

The board members announced were: George Kidd, chair of the Fundraising Preference Service working group; Suzanne McCarthy, chair of the Institute of Fundraising’s standards committee; Margaret Moore, a trustee of Sue Ryder; Sacha Deshmukh, chair of War Child and vice chair of Citizens Advice; Michael Smyth, chair of Community Links; John Stoker, director general of the National Lottery; and Jenny Williams, former chief executive of the Gambling Commission.

Theresa Shearer, chair of the Fundraising Working Group in Scotland, will also attend board meetings until such time as charities who raise funds in Scotland consider the options presented to the group.

Lord Grade said the next steps would see the creation of a standards committee and an adjudication and complaints committee. An advisory group to represent the views of consumers will also be recruited.

The regulator will be independent, own the Fundraising Code of Practice, and be funded by the levy on the larger fundraising charities, he said. It will work closely with the Charity Commission, the Information Commissioner, the Institute of Fundraising and the Public Fundraising Association.

Lord Grade accepted that regulators only succeed if they have the support of the sectors they regulate, and he was aware that his new organisation has to be ‘fair, transparent, proportionate and ready to listen to the genuine concerns of the sector as well as the concerns of the public’.

Welcoming the appointments, Richard Taylor, chair of the Institute of Fundraising, said: “It is good to see that the new Fundraising Regulator will have considerable regulatory experience on its board.

We agree with Lord Grade that the board needs to balance that regulatory experience with fundraising expertise, and we welcome the commitment that the appointment of people with fundraising expertise will now be made.

“We also welcome the commitment, reflecting the Etherington Review, to embed fundraising expertise alongside regulatory expertise in both the standards committee and the adjudication committee.” q

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[

WITH 4.2 MILLION surgical operations carried out every year in England alone, the aims of the Royal College of Surgeons (RCS) to maintain and advance surgical standards in patient care have never been so important.

While some operations are minor, others are life-saving or will dramatically enhance the quality of life. In every case, the patient places their trust in the hands of the surgeon.

As a registered charity, independent of the NHS, the RCS is reliant on donations and legacies to develop and maintain its varied programme of clinical research, surgical education and training.

Today's surgeons perform operations barely dreamt of by their predecessors – and the achievements of tomorrow’s surgeons will depend upon the provision of resources and equipment to advance their knowledge and skills. Without the support of friends and donors, pioneering research into new technologies such as keyhole surgery, treatment of diseases including cancer and organ transplantation would simply not be possible. q

Divorce – what has been

hidden can often be revealed

By DEREK WILLIAMSON of Goddards Accountants

[

IN DIVORCE PROCEEDINGS it is often the case that one party claims that the other has hidden assets and has failed to declare them on the Form E financial statement. It is in such cases that the expertise of the forensic accountant comes into play.

Forensic accounting is the specialist practice area used to investigate details of financial issues, which can then be used in negotiations or in court. In family cases that regularly involves valuing business assets and calculating capital gains liabilities or how much income a business generates so that the figures can be used in financial settlements.

In addition, forensic accounting is used to find ‘hidden’ assets.

The types of assets most commonly hidden are cash, bonds, mutual funds, the cash value of insurance policies and variable annuities, stocks, travellers’ cheques, savings bonds and bearer municipal bonds.

Converting cash into assets such as art, jewellery, antiques, vehicles and collectibles is often used by one party in the divorce.

In their attempts to conceal assets, partners may often involve relatives or acquaintances who may or may not be aware that they are party to the concealment. Repayment of non-existent debts to friends or relatives is often used as a smokescreen – as may also expenses for gifts, travel, rent or college tuition.

Where one party owns a business they may use it as a vehicle to conceal assets, by paying salaries to fictitious people or skimming cash from the business – or even undervaluing stocks and writing off as bad debts valid debts collected in cash.

Trying to find such assets or prove unreported income is often one of the most difficult jobs during the divorce process. Being aware of the ways individuals move assets into the hands of their partners or behind false documents, and of the techniques needed to find those hidden assets, can result in their discovery.

If one of the partners to the divorce does not have documents to prove the whereabouts of their assets, however, identifying even ‘easy to find’ assets can prove costly. In those cases, one has to ask if the cost of the investigation is worth the potential value of the assets which are assumed, at that point, to be hidden? Remember, they may not actually exist.

However, through diligent and effective preparation it is possible to discover assets not disclosed or acknowledged by the other party.

In a recent case we were advised by the wife of some public company shares she ‘thought’ her husband had owned. We were able to ascertain which shares they were, when they were sold and the fact that sales proceeds were not banked in the UK. As a result, we ultimately found over £6m in hidden assets.

We have also used self-assessment tax returns and company CT600 corporation tax returns to investigate hidden assets and reported our concerns about under-declaration to HMRC. Their subsequent investigations have proved very useful in finding these assets.

In our experience, the use of a forensic accountant has always proved of benefit when searching for hidden assets in divorce proceedings. q

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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.

Professor David Warwick

The Medicolegal Practice of Donald Campbell Consultant Neurosurgeon.

Expert on the entire range of hand and wrist conditions seen in medico-legal practice with over 4,500 reports written over 20 years

www.aaamedicolegalreporting.co.uk

www.handsurgery.co.uk Expert Forensics

Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

Independent forensic consultancy service run by experienced forensic practitioners.

www.abc-translations.co.uk

www.expertforensicsltd.co.uk

Dr Aman Ranu

Expert in Mind

Expert Witness in Clinical Forensic Medicine.

Injury interpretation • Drink/drug driving cases

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

www.expertphysician.info

www.expertinmind.co.uk

Building Design Workshop

FHDI - Kathryn Thorndycraft

• Architects • Expert Witnesses • Personal Injury/Disability Housing Needs • Project Managers

Examining documents & handwriting – to determine authenticity • to expose forgery • to reveal aspects of origin

www.expertsbdw.com

www.fhdi.co.uk

Mr Chris Makin

Forensic Accounting Solutions

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

Forensic accountants specialising in investigating, advising and reporting on quantum issues

www.chrismakin.co.uk

www.fas-partnership.co.uk

Coates-Greetham Forensic Meteorologist

Dr Joshua Adedokun

Interpreting the weather for the Legal and Insurance Sectors. Civil and criminal cases welcome

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

www.coates-greetham.co.uk

www.expertpainreports.co.uk

D & HB Associates Ltd

Mr Kim Hakin FRCS FRCOphth

Experts in Road Traffic Offences • Accident investigation • Stolen vehicles • Tachograph analysis

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

www.dandhb.com

www.kimhakin.com

David Bunker Arbitrator & Mediator

Mr Marcus Ornstein

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

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

www.david-bunker.com

www.marcusornstein.co.uk

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Maurice W McLain

Professor Roger James

Consultant in Accident & Orthopaedic Surgery.

Specialist in whiplash and sports injuries.

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

mauricemclain@btconnect.com

www.independenthealthconsultant.co.uk

MD5 Ltd

Sector Forensics Ltd

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

• Computers • e-Disclosure • Compliance • Indecent Images • Mobile Phones • e-Discovery • Intellectual Property • Fraud

www.md5.uk.com

www.sectorforensics.co.uk

Medical Illustration UK Ltd

Mr Simon Bramhall

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

Consultant General/Upper GI and HPB Surgeon. Significant medico legal work undertaken in his area of expertise.

www.migroup.co.uk

www.simonbramhallhpbsurgeon.co.uk

Mr. Michael Hodge

Stockport Psychology Services

Maxillofacial and Oral Surgeon.

• Personal Injury • Criminal Cases • Clinical Negligence

Specialising in Public & Private Family Law, Personal Injury, Clinical Negligence & Criminal cases

www.consultantoralandmaxillofacialsurgeon.co.uk

www.sps.uk.net

Mr Michael Thompson

Dr Thomas C M Carnwath

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

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

www.expertcolorectalsurgeon.co.uk

www.psycholegal.org

Mrs Robyn Webber

Mr William Stuart Hislop

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

Consultant Oral and Maxillofacial / Head and Neck Surgeon.

Specialist in ablative and reconstructive surgery.

www.robynwebber.com

www.wshislop.co.uk

www.yourexpertwitness.co.uk

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MEDICAL NOTES [

UPHEAVAL AND TURMOIL in the NHS seems still to be the never-ending source of news stories – giving rise to a steady stream of litigation. There appears to be two strands to the causes of the stories: the small number of ‘bad apples’ seen in every profession in every era who misuse their professional training; and the more modern phenomenon of mistakes stemming from trying to stay focused on shifting ground. The latter is against the backdrop of the attempts by government to prune the budgets of health authorities and alter the criteria for being able to bring successful claims.

The war cry of the embattled junior doctors rings in the ears as we read about mistakes made that shouldn’t have been made – tired doctors make mistakes!

That brings the attention to research carried out by the Press Association into so-called ‘Never Events’ in the NHS. These incidents – which the NHS says should never happen if procedures are followed – have totalled nearly 1,200 from April 2012 to December last year. Worryingly, the figures for the nine months to last December total 254 – consistent with the previous three years if extrapolated. That is after the number of types of incident defined as a Never Event being reduced from 25 to 14.

• Examples of cases where professional training has been abused are rare, but growing. That is possibly because of greater candour in the NHS and a more rigorous regulatory regime, leading to more instances being investigated and prosecuted. Some of the more shocking are recent trials involving healthcare workers abusing elderly and vulnerable patients. Others are more bizarre and involve the seemingly wacky world of cosmetic procedures. They include claims that debarred nurses were administering Botox at so-called Botox parties, and one case where a dental nurse performed a facelift on her friend at her home!

• As we go to press, reports are emerging of possible concessions from the government on the upper limit of fixed costs in clinical negligence claims. It was claimed that the length of time it takes to get the NHS to come to a settlement was keeping costs beyond what the Jackson reforms had recommended – a fact conceded by Health Minister Ben Gummer.

He is quoted as saying in a debate in Westminster Hall: “Many claimants have been immensely frustrated – as have the clinicians involved – by the length of time that trusts and the Litigation Authority have had to respond to claims, the length of time it often takes to reach a resolution and the fact that there is often too much defence, delay and prevarication.”

• One case where the Jackson reforms were used to good effect by the claimant involved invoking Section 36. A case reported by Penningtons Manches resulted in their client winning an uplift in their damages because the NHS trust involved had not responded to the numerous offers to settle. Hoist with its own petard.

• The only time most of us come across pain measurement is when receiving treatment or coming round from anaesthetic after a procedure. We are asked to calculate our pain ‘on a scale of one to ten’ – this writer’s shriek of “TWENTY SEVEN!” was the talk of the post-operative care unit that day.

For many people, however, living with pain is a daily and debilitating experience.

With pain having been recognised by the court as a legitimate cause for compensation, and involving as it does both subjective and objective elements, it has become necessary to involve experts in calculating more accurately the type and severity of pain in order to assess compensation.

The role of the expert in pain medicine is explained by Dr Stephen Humble, together with their relationship to other specialties. q

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Medical tribunal reforms now in place [

FROM THE START of 2016 a number changes to the Medical Act came into force, including changes to the running of disciplinary hearings by the Medical Practitioners Tribunal Service (MPTS).

One of the changes means that the General Medical Council (GMC) can appeal against tribunal decisions to the High Court of Justice in England and Wales, the Court of Session in Scotland and the High Court of Justice of Northern Ireland when it considers the tribunal has not adequately protected patients. Doctors already have a power to appeal to the High Court against MPTS decisions.

The MPTS makes independent decisions and operates separately from the investigatory role performed by the Fitness to Practise arm of the GMC. The landmark law changes will also see reforms to the way the GMC investigations and MPTS hearings are handled. These include: • The MPTS being placed on a statutory • footing • Cutting the length of hearings with robust • case management • Giving the MPTS the power to award costs • if either the GMC or the doctor fails • to comply with directions and behaves • unreasonably in the conduct of • proceedings • Introducing a legally qualified chair • instead of a chair and legal assessor in • some hearings GMC chief executive Niall Dickson said: “The new right of appeal and the establishment of the MPTS as a statutory body are huge strides in UK professional regulation. This will help us to make sure doctors receive the support they require and patients receive high quality care.

“The new law underlines the separation of our investigations from the tribunal service and thereby strengthens our role as a patient safety organisation. These changes will also make investigations and hearings more proportionate, faster and more efficient.

“We have been campaigning for the right to appeal MPTS panel decisions for some time and although we may not use the power often, the changes are essential for patients, professionals and healthcare systems across the UK.” Before these changes only the Professional Standards Authority (PSA), the watchdog responsible for overseeing the UK’s healthcare professional regulatory bodies, could consider referring cases to the relevant court. Six decisions have been challenged by the PSA in the past three years, with the

majority resulting in more serious outcomes following agreement between the parties.

His Honour David Pearl, chair of the MPTS, said: “These changes make it clear that the MPTS is an operationally separate tribunal, underlined by the GMC’s new right of appeal and the responsibility on the part of the MPTS to report directly to Parliament each year.

“Our ambition is to reduce the average length of MPTS hearings, to reduce the pressure on doctors and witnesses. With these changes, I’m confident we will be able to achieve that.” q

New mental health strategy welcomed by profession [

ON 15 FEBRUARY the Royal College of Psychiatrists issued its response to NHS England’s much vaunted report The Five Year Forward View for Mental Health, launched by Prime Minister David Cameron.

The college’s president, Professor Sir Simon Wessely, said: “The Royal College of Psychiatrists welcomes the publication of the report, the new national strategy for mental health to 2020, and the announcement that more than £1bn a year of additional funding will be invested in mental health care. As part of the Mental Health Taskforce, the college has played a pivotal role in the development of this strategy.

“The commitments in the mental health strategy are a major step towards ending the separation of head and body. The increased resources to improve the psychological care of those with physical illness and the physical health of those with mental disorders is to be strongly welcomed and is what the college has been calling for, for years. It will take sustained work to bring mental health onto an equal footing to physical health, ending decades of inequality.

“Likewise the commitments to ending out of area acute inpatient care and the provision of full coverage across England for perinatal services and A&E psychiatry services are things that the college has also called for.

“The college also welcomes the guarantee of funding to enable 600,000 more people to access psychological therapies. This, combined with the promised expenditure to double the reach of individual placement and support for people with severe mental illness, could support 29,000 people to find and stay in work by 2020.

“Strategies don’t deliver themselves though, people do. As doctors who specialise in mental health, psychiatrists in England are already playing a key role in the diagnosis and treatment of patients with serious mental health conditions. These frontline mental health professionals also deserve the support the strategy promises.” q

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Steam therapy poses burns risk [

CHILDREN ARE AT risk of burns if they undergo steam inhalation to relieve the symptoms of respiratory tract infection and congestion, a study has found. Researchers at the Welsh Centre for Burns and Plastics Surgery found that 16 children between the ages of one and 15, who were admitted between January 2010 and February 2015, were treated for steam inhalation therapy scalds.

The most common reason for the steam therapy was to relieve symptoms of the common cold – with nine patients citing that as the reason for the treatment.

The average size of the burns was 3.1% but ranged between 0.25% and 17.0% of the total body area. One child was managed surgically and one needed treatment in a high-dependency unit, while the remainder were treated with dressings.

The total cost of treatment for all patients was £37,133, said researcher Sarah Al Himdani and colleagues. Writing in the British Journal of General Practice, they said: “Steam inhalation is postulated to provide relief of respiratory congestion by loosening respiratory secretions, but there is a lack of evidence to support the improvement in objective outcome measures such as viral titres in nasal washings.”

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They added that there is a lack of awareness among primary care physicians of the potential risks of burns associated with steam inhalation therapy.

In the study, 17 out of 21 GPs surveyed recommended steam inhalation to their patients, while eight out of 19 GPs recommended it for children under the age of five.

“Strategies to prevent steam inhalation burns occurring should be implemented by health professionals,” the researchers said.

“These include not recommending the practice to parents, advising parents of the dangers associated with it and informing parents of the lack of evidence demonstrating that it has any beneficial effects for patients.” q

Patients being contacted in hep C healthcare worker case [

PATIENTS WHO MAY have been treated by a former NHS Lanarkshire healthcare worker are being contacted as part of a patient notification exercise which has been endorsed by the UK Advisory Panel for Healthcare Workers Infected with Blood Borne Viruses.

The former healthcare worker tested positive for hepatitis C infection in 2008 and immediately stopped carrying out healthcare procedures and did not return to clinical practice.

NHS Lanarkshire is working with other NHS boards and health agencies in other parts of the UK to notify patients who may have had a surgical procedure carried out by the former healthcare worker between 1982 and January 2008. Advice from Scottish and UK experts is that the risk of the hepatitis C virus having been transmitted to a patient during surgery involving the healthcare worker is low.

Patients – mainly from Lanarkshire, but also across Scotland and the rest of the UK – have been sent letters informing them of the situation and recommending that they arrange an appointment for a blood test. Of the 8,383 patients being contacted 7,313 are from Lanarkshire.

Patients are also receiving a detailed question-and-answer sheet which includes information about hepatitis C and how to arrange to be tested. Health Protection Scotland has endorsed the recommendation that people take up the offer of a blood test to ensure that anyone who does have the virus can receive the right treatment. Treatment for hepatitis C is known to be highly effective. q

Medical technology can have its own victims [IN THE HIGH-TECH world of modern

medicine a great deal of reliance is placed on medical imaging – scans, x-rays and other diagnostic tools. In some cases those investigations can appear to reveal serious conditions, leading to fears that on further investigation prove unfounded. Such ‘victims of medical imaging technology’ are referred to by the acronym VOMIT. Richard Hayward, a paediatric neurosurgeon, first described VOMITs in a BMJ personal view in 2003. He described the incidental discovery of abnormalities in patients who were being investigated for other diseases by modern highly-sensitive scanners and the anxiety and problems these discoveries generate.

For example, a brain scan performed on a child with migraine headaches showed a brain cyst. This incidental discovery led to referral to a neurosurgeon and caused huge parental anxiety for what turned out to be a harmless congenital abnormality.

VOMITs are generally regarded as an unwanted consequence of modern medicine and the product of over-investigation of patients’ symptoms by doctors.

However, imaging errors can also result in claims for clinical negligence, as demonstrated by the following case history

described by oncologist and expert witness Professor Chris Nutting: “A patient was admitted to hospital for a knee replacement. As part of the preoperative assessment, a chest X-ray was performed which was passed as satisfactory by the anaesthetist. The operation was successful and the patient discharged home.

“However, 18 months later the same patient developed a cough and chest pain and was diagnosed with advanced, incurable lung cancer. The pre-operative chest X-ray was reviewed and in retrospect a small lung tumour was visible which had previously been missed. A clinical negligence investigation concluded that there was failure to diagnose lung cancer at the time of the knee replacement and that this amounted to breach of duty.

“The small tumour could potentially have been cured by surgical removal, but due to the 18-month delay in diagnosis the tumour grew and spread, becoming incurable.

Causation was proven and the claimant’s family were awarded a significant sum for loss of earnings and life expectancy.

“In my experience, claims against missed radiological findings are becoming increasingly common. Breach of duty is

Professor Chris Nutting often easily established as the previous imaging is available and can be viewed retrospectively. Causation is also usually straight forward, as the outcome of treatment for a small, early stage cancer is almost always materially better than that of a late cancer diagnosis.” q

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Claimant’s Part 36 offers result in damages uplift [A CASE HAS been reported by solicitors

Penningtons Manches where the Jackson reforms have resulted in a tangible benefit for a claimant against an NHS trust. The case involved the admitted negligence of oncology doctors in failing to carry out a venous thromboembolism (VTE) risk assessment of the likelihood of developing a blood clot when their client was admitted to hospital in June 2010 following bladder cancer surgery the previous month.

Penningtons quoted NICE guidance on ‘venous thromboembolism: reducing the risk for patients in hospital’ as requiring that all patients are assessed for their risk of blood clots when admitted to hospital.

Following a procedure the patient was diagnosed as having a pulmonary embolism (PE). Although the PE was successfully treated, he was left with a number of permanent aftereffects including breathlessness, chronic leg swelling and the need for warfarin medication.

As a result of these, he has been left significantly restricted in his day-to-day activities and requires daily care and assistance.

The patient pursued a claim against the trust for its failure to carry out the VTE risk assessment and the hospital admitted that it was negligent in failing to do this over a number of days. Between the medical experts on both sides there was a large measure of agreement that, at the time of the events, a VTE risk assessment would have revealed that the claimant had a number of significant risk factors, including the death of his mother due to PE. The High Court found in favour of the patient in early January 2016. The award included a 10% uplift on his damages for beating his own Civil Procedure Rules Part 36 offers made prior to trial. Indemnity costs and interest were also awarded under the provisions of Part 36. It was one of the first costs-budgeted clinical negligence cases to have reached trial following the Jackson reforms of April 2013. As the claimant came within budget, the court saw fit to award a significant interim payment on account of costs.

What was in dispute between the parties is what would have occurred if the hospital had not been negligent and had done the VTE risk assessment. The patient’s case was that his level of risk factors for VTE should have resulted in the provision of heparin to prevent a blood clot and that, had he been given heparin, it would have prevented the development of his embolism.

The trust argued that he would not, in any event, have been given heparin because of a concern about abdominal ulceration or bleeding and that, even had he been given heparin, this would not have prevented the development of the PE. It therefore admitted negligence but argued that the patient would have suffered the same outcome even with non-negligent care.

The parties and their experts were unable to reach agreement as to whether heparin was mandated or whether it would have prevented the development of the pulmonary embolism.

The case therefore proceeded to trial mainly on those issues.

Lucie Prothero of the clinical negligence team at Penningtons Manches, said: “The case was unusual in that, although the parties agreed on

many points in respect of breach of duty, there were very strong arguments by both sides as to whether heparin would have been given with a proper VTE risk assessment and as to the benefit of giving heparin.

“We are pleased with the result and the damages will go some way towards assisting our client in his day to day life with his disabilities. But it was unfortunate that, in the face of its admitted failings, the trust chose to take this case all the way to trial rather than engage in any settlement negotiations.

“Our client was not keen to litigate against the hospital and sought to try to settle his claim at several points in the case by making reasonable Part 36 offers. No Part 36 offers were received from the trust and it refused to engage in a joint settlement meeting. Our client therefore had no option but to see his case through to trial.

“Consequently, the loss of this case has resulted in costs penalties for the trust and an increase in our client’s damages. This case demonstrates the importance of all parties in litigation taking the new provisions of Part 36 of the Civil Procedures Rules seriously as it proves they really do have teeth.” q

Dental nurse suspended for performing facelift [

A DENTAL NURSE from Bradford has been removed from the General Dental Council’s (GDC) list of registered dental professionals on the grounds of misconduct after performing a facelift on a friend.

In a statement the GDC said: “The allegation against Ms Adele Royston related to her conduct as she performed the facelift at her friend’s home using local anaesthetic on or around 17 February 2014 – both procedures she was not entitled to perform.”

In considering the allegations of misconduct, the Professional Conduct Committee (PCC) stated: “Ms Royston deliberately placed a member of the public at serious risk of physical harm by performing a surgical procedure that she was not entitled to perform. The procedure involved the use of a local anaesthetic which, similarly, she was not qualified to administer.

The procedure had been long in gestation and had involved a significant degree of planning and preparation.”

Her removal from the register was delayed for 28 days, in which time she was able to appeal.

The PCC made an order of immediate suspension which covered the appeal period. q

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When ‘never’ in the NHS really means 1,000 times [

ANALYSIS BY the Press Association of data on so-called ‘Never Events’ in the NHS was widely reported in February.

Never Events are described by the NHS as ‘serious incidents that are wholly preventable, as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’.

According to the data, nearly 1,200 such events were reported in the period from April 2012 to the end of December last year – 290 in 2012-13, 338 in 2013/14, 306 in 2014/15 and 254 from April to the end of December 2015.

The NHS says: “Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event.”

Never Events include incidents such as wrong site surgery, retained instrument post operation or the wrong route administration of chemotherapy.

According to the BBC, incidents included the case of a man who had a whole testicle removed

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rather than just a cyst and another in which a woman’s fallopian tubes were taken out instead of her appendix.

Others included the wrong legs, eyes or knees being operated on and hundreds of cases of foreign objects such as scalpels being left inside bodies after operations. Patients’ lives were put in danger when feeding tubes were put into their lungs instead of their stomachs. Others were given the wrong type of blood during transfusions or the wrong drugs or doses of drugs.

Commenting on the data, Katherine Murphy, chief executive of the Patients Association, said: “It is a disgrace that incidents which are supposed ‘never’ to happen are still so prevalent. With all the systems and procedures that are in place within the NHS, how are such basic, avoidable mistakes still happening? There is clearly a lack of learning across the NHS, or even within individual trusts.

“These patients have been very badly let down by poor processes and utter carelessness. It is especially unforgivable to operate on the wrong organ, and many such mistakes can never be rectified, leaving patients harmed for life.”

A revised Never Events Policy and Framework was published on 27 March last year. It includes changes to the definition of what a Never Event is and a reduction in the types of incident that are included on the list from 25 to 14 incident types. q

The diagnosis of prostate cancer In this brief article, consultant urologist CHRIS DAWSON MS FRCS LLDip, details the difficulties in the diagnosis of prostate cancer. The case described is fictitious, but based on the author’s clinical experience.

[KEVIN, AGED 56, presented to his GP

with some difficulties passing urine. For about three months he had noticed a slight hesitancy before passing urine and a reduction in his urinary flow. He had also started to get out of bed once or twice a night.

His GP listened to the story and arranged for a blood test for prostate specific antigen (PSA), an enzyme found in the blood of men which has a role in male fertility. He did not examine Kevin’s prostate at this initial consultation.

The PSA value came back at 4.2 ng/ml which is slightly raised for a man of Kevin’s age. By now Kevin’s symptoms had improved on the medication given at the initial consultation and so the GP arranged to see Kevin again in six months time.

Unfortunately, because of work commitments, Kevin did not make this appointment and it was nearly a year before he saw his GP again. His symptoms had begun to deteriorate by this time so the GP retested the PSA but did not examine Kevin’s prostate.

The PSA value had risen to 8.3 ng/ml. Alarmed by this change in the result the GP referred Kevin urgently to the local urologist for an opinion.

In line with national guidelines, Kevin was seen two weeks later when examination of his prostate showed a firm left side with a hard nodule.

The urologist arranged for an urgent MRI followed by a prostate biopsy. The MRI confirmed abnormalities in the left side of the prostate gland, corresponding to the rectal examination findings, and the biopsy showed moderately aggressive cancer.

Kevin was seen urgently by the urologist and offered treatment with either surgery or radiotherapy, eventually opting for radical prostatectomy surgery to remove his prostate.

Kevin and his family were devastated by the diagnosis of cancer and concerned at what they believed to have been a delay in diagnosis by his GP. A review of the notes by an expert witness concluded that Kevin’s initial PSA was raised above the age specific reference range and that this alone should have led to a referral to the urologist for consideration of a biopsy.

The expert was also critical that the GP did not examine Kevin’s prostate as this may well have shown changes that would have reinforced the

need for an urgent referral. It was therefore concluded that a breach of duty had occurred in Kevin’s care.

However the expert also pointed out that the cancer was found to be organ confined on the specimen removed at surgery and that Kevin’s chance of complete cure remained high.

Moreover, given that his cancer was moderately aggressive on biopsy, it was felt that an earlier biopsy would have led to the same treatment options as Kevin was given when his cancer was diagnosed.

Prostate cancer is notoriously hard to diagnose in some men. A raised PSA is not diagnostic of cancer, nor is a palpable abnormality in the prostate. Nevertheless either abnormality should be followed by an urgent urology referral for advice. The usual response would be, as in Kevin’s case, an MRI scan of the prostate and after appropriate counselling, a biopsy.

Furthermore a negative MRI scan and negative biopsy results, whilst obviously good news for the patient, do not exclude the diagnosis of prostate cancer and urology monitoring is usual practice in such cases to determine if further investigations are required. q

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Report finds new rules have led to new role for social work experts [DECEMBER SAW THE publication of a review commissioned by the

Ministry of Justice into the appointment of experts in the family court. The study was prompted by changes to the way the family court can instruct experts, reflected in new Family Procedure Rules on 31 January 2013 and later enshrined in legislation with the Children and Families Act 2014.

It was carried out by members of the Analytical Services team at the Ministry of Justice, academics from Coventry University and the Forensic Psychology Practice.

The findings of the study were presented in a report – The use of experts in family law: understanding the processes for commissioning experts and the contribution they make to the family court – which explores the processes by which experts are appointed in light of the new rules and also aims to develop an understanding of the contribution experts make to just and timely decisions in the family court.

The new rules changed the threshold for permission to put expert evidence before the court from ‘reasonably required’ to ‘necessary’ to resolve the case justly. In making its decision, the court should consider: • Whether the evidence could be provided by another source, such as • one of the parties or professionals already involved in the case • The issues to be addressed by the expert evidence and the questions • to be put to the expert • The cost and impact on the court timetable of obtaining the evidence According to the report: “The changes are encompassed within Practice Direction 25B (PD25B). This also sets out guidance for experts, including the duties of an expert, the content of the expert’s report and arrangements for an expert to attend court.

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“The practice direction is supplemented by an annex detailing the 11 national standards for experts. The aim of the standards is to improve the quality of expert evidence by setting minimum criteria that an expert must meet in order to be appointed by the court.”

The mixed-methods study comprised two phases. Data collection exercises in phase one included an online survey and focus groups with professionals involved in family law proceedings, interviews with the judiciary and a quantitative case analysis to examine the timeliness of expert reports. In phase two, materials from closed family law cases were used to guide discussion and evaluate aspects of the expert process during discussion groups.

On the use of independent social workers the report has this to say: “Independent social workers (ISWs) may be appointed as experts to undertake parenting capacity or kinship assessments in addition to the evidence that is routinely provided in public law cases by local authority social workers.

“Participants across phase one believed that the appointment of ISWs had declined, and since the introduction of the new rules they were appointed only in unique circumstances. Examples of such circumstances may be where there was a specific issue of trust between the local authority and the family, or if the local authority social worker did not have the capacity to complete assessments.

“On the whole, it was felt that local authority social workers were relied upon in the majority of cases to be the primary source for this type of evidence. It was noted by social workers and judges that this had led to a marked change in social work practice, including the provision of additional training for social workers and through the creation of dedicated social work assessment teams.”

A major thrust of the report concerned the decline in the frequency of appointing experts in the family court, from an astonishing 91% of public law cases in 2004.

The report states: “Participants across the study noted that the new rules had been widely implemented and believed that the stricter threshold to commission experts had resulted in fewer experts being appointed. This was consistent across all professional groups and geographic regions.” q

Social workers’ body welcomes guidance on recording of meetings [THE TRANSPARENCY PROJECT, the

charitable body set up to promote greater transparency in Family Court proceedings, has published guidance about the recording of social workers by parents where there is local authority involvement with the family.

The guidance is intended to be used by parents, their advisers and representatives, and by professionals – who might include social workers, social work managers, independent reviewing officers and local authority lawyers.

This project was prompted by discussion generated at a conference organised by the Transparency Project last June, when the topic of parents recording their interaction with social workers was raised by participants. The result was the sending of Freedom of Information Act requests to all local authorities in England and Wales to establish whether there was a consistent approach when parents ask to record their meetings with social workers.

The organisation’s chair Lucy Reed said: “Our research suggests that the response of some local authorities to requests for recording or when suspecting or finding out that recordings are being made covertly, may

be based on fear and distrust – professional anxiety appears to focus on the potential misuse of information or harassment of professionals.”

The guidance explores the question of recording from the perspective of parents and professionals and considers reasons for and against recording, including some common misapprehensions about what law does and does not apply. It includes general information about the potential issues arising from use of any recording, for example the distribution of a recording on the internet or the use of it in evidence at court.

The vice chair of the British Association of Social Workers (BASW), Maggie Mellon, said social workers should allow such recording and be happy to put their practice ‘on the record’.

She said: “We welcome this guidance, which follows on from concern the Transparency Project had when it surveyed local authority practice in this area. It is going to be very helpful to our members, as it offers a straightforward explanation of why various pieces of legislation, often cited as barriers to transparency, are no such thing.

“It offers clarity that data protection legislation about recording, storing and sharing of personal information by social services and other agencies does not apply to parents and families in relation to their own personal information.

There is a clear explanation of the difference between the right to make a recording, and what an individual can do with a recording they have made.

“As social workers, the more we do to be open the better. Some forums, such as child protection case conferences, use language that is so inaccessible to parents that we should not be surprised if some parents do record the discussions that take place covertly. Social work agencies need to look at their recording policies to ensure they are family friendly.

“The FOI responses from local authorities show that many councils have incorrect policy and procedures, so the responsibility really is on social workers themselves to question whether guidance used in their workplace is fit for purpose and where necessary we would encourage members to use BASW’s endorsement of this guidance to encourage a change of policy by their agencies.” q

This acknowledged expert leads a team of specialists [

ONE OF THE leading independent consultancies in the field of child protection and other challenging areas of family law is the Leonard Consultancy. Its director, Marcella Leonard, is an independent social work consultant who has specific experience in the fields of sexual trauma, psychosexual therapy, sexual offending and child protection.

Marcella has recently completed a post as co-ordinator of public protection arrangement in Northern Ireland, working with 14 criminal justice and child protection agencies in delivery of public protection.

She has extensive experience of working with local authority departments, the voluntary and independent sectors, solicitors, service users directly, universities and training establishments, regulatory bodies, NHS organisations and government offices.

She is regularly involved in radio and TV discussions regarding social work practice. Her specific skills have led to her carrying out assessments for statutory and voluntary sector organisations, acting as an expert witness in courts and undertaking social work practice case reviews for legal services and safeguarding boards.

Leonard Consultancy also has contracts with a team of highlyexperienced and qualified professionals who individually are delivering practice, training and consultancy throughout the UK, Ireland and internationally, for example in Abu Dhabi, New Zealand, Australia, Canada and Gibraltar.

As an associate team they collectively deliver quality, bespoke assessments, training, consultancy and reviews of police and social work practice. These associates include police, probation, psychology and psychiatry experts and all hold professional registrations. q www.yourexpertwitness.co.uk

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Getting it right first time – a requirement, not an aspiration [IN FEBRUARY the British Orthopaedic

Association (BOA) published a Professional Guidance to implementing Getting it Right First Time in England.

The Getting it Right First Time (GIRFT) report was produced by Professor Tim Briggs and published in March last year by the BOA. A pilot had identified significant variations in practice and outcomes in terms of device and procedure selection, clinical costs, infection rates, readmission rates, and litigation rates.

For example, long term deep infection rates for hip and knee replacement vary between 0.2% and 5% and statistics show an average return to theatre as a result of complications of between 0% and 7%.

The report itself identified both variation and scope for quality improvement in terms of procedure volumes, implant selection and infection rates.

According to a BOA statement: “This was not simply a snap-shot of orthopaedic practice in the country, but is intended by NHS England to be a recurrent audit which will be used to influence aspects of orthopaedic delivery. Our guidance aims to provide

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appropriate clarity on how to implement GIRFT and should be used in conjunction with GIRFT performance dashboards and National Joint Registry data.”

At the launch of the report, Professor Briggs commented: “Our approach has enabled us to take a consolidated view of all the available data and metrics relating to each trust’s clinical and financial performance and to then engage with each management team and group of clinicians to use this evidence to reflect on variation in clinical practice, management approach and variation in prosthesis selection.”

According to the BOA, all discussion of data within the implementation framework of GIRFT is consistent with the principles of the BOA’s position statement on outcome data, trauma and orthopaedic surgeons and units.

Specifically, the new guidance embodies the ethos that ‘…all individuals or units that are highlighted as having variance issue… must act upon this information to review their data, consider the reasons for variation and whether any further action or alteration to practice is required’. q

Orthopods react to virtual clinics [FOLLOWING THE establishment of a number of ‘virtual’ orthopaedic

clinics – or virtual fracture clinics – in parts of the UK, the British Orthopaedic Association issued a statement in October clarifying its position on the issue.

In its statement the BOA says: “It is the BOA’s position that the current BOAST 7 guidelines regarding fracture clinic services still stand and that any change in service or models of care should be audited and evaluated

Hip implants under the spotlight again [A REPORT IN The Telegraph has brought the controversy

over DePuy hip implants back into the news. The newspaper revealed on 25 January that the company had admitted ‘an error in the measuring techniques’ when making the controversial metal-on-metal implants. According to the report, some of the measurements had been made while the implants were hot and consequently expanded.

The company recalled a number of its metal-on-metal implants in 2010 and discontinued production of another version, the Pinnacle Ultamet, in 2013.

The paper quoted Tom Joyce, a professor of orthopaedic engineering at Newcastle University, as saying that, if implants were made to an incorrect size or were defective because of production problems, they could be more likely to fail and it was important for patients to be regularly tested.

“You would want to keep a close eye on the patient. It would be important for a company to tell the regulators immediately so they could investigate and warn patients if necessary,” he said.

Boz Michalowska of Leigh Day, lawyers for over 300 patients implanted with the company’s Pinnacle Ultamet, commented: “The revelations published by The Telegraph are highly concerning. It is incumbent upon any manufacturer of medical devices, particularly those that will be implanted inside patients, that the very highest levels of production and manufacturing control are in place to safeguard all patients.

The evidence that is now emerging may indicate that such safeguards were not in place at DePuy, leaving patients exposed to unnecessary and foreseeable risks that could have been discovered much sooner.”

DePuy is reported to have told The Telegraph that it investigated the problem and found no safety issues. q

prospectively. Where new services are introduced, adequate safeguards must be put in place to ensure that patients receive appropriate assessment, management, support, information and follow up.

“The facility must be available so that any patients deemed appropriate are reviewed by a trauma orthopaedic consultant within 72 hours either directly or by review of the case notes and imaging. When this assessment is nondirect, then the outcome should be conveyed to the patient by appropriately trained staff who have the option of offering an immediate clinical review if felt necessary.

“Some models being looked at involve telephone consultation, where it is thought appropriate by the trauma orthopaedic consultant who has knowledge of the clinical history. Safe provision of such services would not normally be feasible within the current tariff structure for a virtual review in the English NHS, and therefore special arrangements will normally need to be made with trusts and commissioners.

“The BOA welcomes research into all aspects of improving patient care and encourages publication of the results of such trials of new fracture clinic models. BOAST 7 is due to be reviewed in two years, by which time further data should be available to update its recommendations and set standards for outpatient management.” q

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Botox report highlights Plastic surgeons pioneer 3-D tissue printing regulation issues [A REPORT BY the BBC claiming that nurses who have been

suspended are continuing to prescribe and administer Botox has once again propelled the issue into the news.

The associations representing aesthetic surgeons have continued to highlight the lack of regulation in the sector. As recently as December the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) commented on reports in the press of doctors prescribing Botox ‘remotely’.

The NHS advises all patients looking to have Botox to have a faceto-face consultation with their doctor before having a procedure, BAPRAS says, but an undercover report from The Times indicated that treatments are still being given with no proper assessment from medical professionals, and doctors are in some cases remotely prescribing Botox which could potentially be used by untrained practitioners.

BAPRAS president Nigel Mercer urged doctors to follow the regulations. “These stipulate that doctors should have first-hand experience of the patient before they can prescribe Botox. It isn't up to the doctor to decide what they can or cannot prescribe remotely: this is a decision for the GMC.” q

Life-changing surgery being denied by CCGs

[

PLASTIC SURGEONS AT the Welsh centre for Burns and Plastic Surgery in Morriston Hospital are working with engineers and scientists to develop 3-D printed tissue – made from human cells – for the first time. They hope that, in a few years’ time, patients who have lost all or part of their ear or nose through trauma or cancer could have reconstruction using new tissue which is grown from their own cells.

The use of 3-D printing to manufacture prosthetics and implants from materials like plastic or titanium is becoming more widespread; but bioprinting – using human cells instead of man-made material – is still a very new science.

The team at Swansea have already succeeded in bio-printing small pellets of living tissue, proving that the delicate cells can survive the 3-D printing process. They have also developed a jelly-like support structure, which can be used as the ink for printing the intricate shape of an ear or nose and, critically, is compatible with the human cells.

The next stage is to blend the jelly and cartilage cells together and 3-D print them into bespoke tissue for reconstructive surgery. The resulting part will need to be strong enough to not only withstand the surgical procedure to attach it to the patient, but survive indefinitely as healthy tissue afterwards.

Professor Iain Whitaker, consultant plastic surgeon and chair in plastic and reconstructive surgery at Swansea University Medical School, explained: “We want to try and help people who were born with defects or who have lost parts of their ear or nose as a result of trauma or cancer. We are using human cells, growing them up, to combine them with a printable material, 3-D print them and implant them into the human body.” q

[A HUGE PROPORTION of Clinical Commissioning Groups (CCGs)

are ignoring official guidance by not funding potentially life-saving surgery, according to research quoted by the British Association of Aesthetic Plastic Surgeons (BAAPS).

Following obesity treatment such as gastric bands, bypasses or sleeves, post-bariatric patients can be left with almost two people’s worth of skin, says the BAAPS, which results in functional problems such as reduced mobility, hygiene issues and infections and a heavy impact on their psychological wellbeing, as well as impeding their ability to work.

A study by a leading plastic surgeon specialising in post-bariatric contouring and ‘body lifts’ has revealed that NICE-accredited national commissioning guidelines specific to the removal of overhanging, excess skin is being ignored by over 100 out of 108 CCGs across the country; and that 42 do not fund the surgery at all. One CCG admitted funding just three out of 66 cases referred and two CCGs had only funded seven between them.

“We are only half-treating these patients, who have previously been severely obese,” says the author of the study Mark Soldin, a consultant plastic surgeon at St George’s Hospital and BAAPS member. "They have successfully shed, in many cases, half their body weight or more, and we know around 70% of them will require body contouring due to the excess skin folds.

“Yet under a short-sighted (and rather convenient) misunderstanding of the term ‘cosmetic’, they are left in a cruel limbo where they can’t yet quite feel whole. Many of the patients I see tell me that they feel ‘disabled’ and incomplete. The removal of these folds cannot be classified as simply aesthetic – it is life changing and in some cases life-saving.” q www.yourexpertwitness.co.uk

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What is a pain medicine specialist?

By DR STEPHEN HUMBLE MBChB MSc PhD FCARCSI, consultant in anaesthesia and pain medicine at Medicolegal Associates Ltd

[

A PAIN MEDICINE SPECIALIST is a doctor with specialised training and expertise in all aspects of the diagnosis and management of painful conditions. The field encompasses a wide spectrum, including acute, chronic and cancer pain.

In the UK, pain medicine is a subspecialism under the auspices of the Royal College of Anaesthetists. The vast majority of British pain specialists are therefore consultant anaesthetists who have undergone a significant additional

period of specialised training. This typically takes the form of an accredited full-time pain fellowship within a recognised pain management centre as part of a (RCoA) pain training programme.

Pain medicine specialists are often required for medico-legal cases where there is a relative lack of robust diagnosis, causation and prognosis. As the courts now recognise chronic pain as a compensatable condition in its own right, having an expert report from a consultant in pain medicine can make a significant difference to the overall amount awarded to a claimant.

Solicitors often find it useful to seek the opinion of a consultant in pain medicine where the claimant’s symptoms do not fit with the reported pathology.

For complex cases associated with significant or ongoing pain or hypersensitivity their opinion is very useful in determining a prognosis. It can be considered remiss if the opinion of a pain medicine specialist is not sought for patients with complex chronic pain disorders and it can have a significant bearing on a case and any award made.

Medical evidence from a credible pain expert also makes an allegation of malingering or ‘putting it on’ very difficult to be pursued with confidence.

Pain medicine specialists can offer a comprehensive multi-dimensional assessment and report incorporating internationally validated scores for pain, function and psychological disorder which are well recognised.

GPs and other hospital specialists typically refer patients with the most complex chronic pain disorders to pain medicine specialists.

They undertake a biopsychosocial approach to diagnosing and managing patients with conditions that can have a disabling impact on their quality of life – such as neck and back pain, joint pains, neuropathic pain, complex regional pain syndrome, phantom limb pain, failed back surgery syndrome, fibromyalgia/chronic widespread pain syndrome and chronic postsurgical pain.

Most pain medicine specialists work in the NHS but some also work in private practice. A relatively small number also undertake work in the medico-legal field after undergoing appropriate expert witness training.

In the NHS, pain medicine specialists usually work within the setting of a multidisciplinary clinic which may employ other health professionals with specialist expertise such as physiotherapists and psychologists.

As such, their practice needs to combine appropriate pathophysiological knowledge relevant to the nervous system as well as the musculoskeletal system.

They need to be acutely aware of the need to recognise and manage psychological issues such as personality disorder, anxiety and depression from which a high number of patients suffer in addition to their pain.

Essentially, the remit of a pain medicine specialist spans a broad spectrum of complex disorders.

Pain medicine specialists use a broad range of techniques in order to treat patients and manage symptoms that cannot necessarily be cured. In addition to medications, they may use X-Ray or ultrasound-guided injection based therapy for patients with conditions such as spinal pain and also for patients where surgery is not safe or not indicated.

In the most challenging cases, patients may be enrolled in pain management programmes that utilise psychological techniques such as mindfulness or acceptance and commitment therapy combined with education and physical rehabilitation.

The area of practice for pain medicine specialists may overlap with other hospital specialisms, but no other single specialty combines the scope or range of expertise of a pain expert.

Rheumatologists diagnose and manage arthritis and other disorders for the joints, while neurologists diagnose and manage diseases of the nervous system. Orthopaedic surgeons diagnose and operate on diseases of the musculoskeletal system, while spinal surgeons diagnose and operate on disorders and injuries to the spine.

Therefore it is usually recommended, and is of great benefit to a personal injury or clinical negligence claim, for a pain expert to be instructed in addition to these other specialists. q www.yourexpertwitness.co.uk

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Brain injury can be seen in the eyes [THE LETTER TO UK governments from more than 70 medical

experts urging the banning of tackling in matches involving under-18s has caused an upsurge in attention to the issue of injuries sustained while playing rugby union.

The head injuries caused to minors have been likened to those in car crashes and there is now a greater likelihood of litigation for compensation being initiated.

Medico-legal experts have pointed out that the increase in compensation claims has led to a need for a proper evaluation of the level of injury sustained – both subjectively and objectively.

In a recent article, consultant ophthalmologist Mike Potts discussed

ways in which the visual effects of head injury can be used to evaluate both elements – everyone is familiar with the ‘follow my finger’ routine engaged in by doctors treating players on the pitch.

He pointed out that modern automated visual field testing is recognised by the DVLA as being extremely reliable in assessing injury.

While most injuries and their concomitant visual effects fade with time – a process that can be confirmed by repeat testing – deviation from the pattern will throw up more worrying causes.

Mike Potts asserts that an assessment of a patient’s visual skills by a ‘competent neuro-ophthalmologist’ will often result in the detection and measurement of such brain injury. q

Training raises awareness among healthcare workers [

IN DECEMBER THE RNIB published the latest in its ‘expert’ series of articles on understanding sight loss, based on research data.

In the article, Joanne Dick, RNIB vision support officer for complex needs, and Dr Janet Finlayson of Glasgow Caledonian University, discussed their research into vision awareness training provided by RNIB and its effectiveness in raising awareness among health and social care professionals of the vision needs of people with learning disabilities.

People with intellectual disabilities are ten times more likely to have a visual impairment, compared to the wider population, yet lack of awareness of the particular vision needs of people with learning disabilities among health and social care professionals can act as a barrier to them accessing appropriate care and treatment.

In 2014, RNIB, in collaboration with Glasgow Caledonian University and NHS Greater Glasgow and Clyde, secured funds from the Scottish Government to conduct a research project to evaluate vision awareness training. They have designed and delivered training to health and social care professionals who support people with learning disabilities.

During the 12-month evaluation period, vision awareness training was delivered to 104 health and social care professionals who work with people with learning disabilities.

Ninety (87%) completed pre- and post-training

questionnaires, using repeat measures, to determine training outcomes.

The RNIB report states: “Our vision awareness training was found to be effective in significantly increasing health and social care professionals’ knowledge and awareness of the vision needs of people with learning disabilities, and their confidence in recognising

signs of sight loss and recommending eye test referrals for their clients. Our vision awareness training, therefore, does help address a recognised barrier to effective vision health care delivery for people with learning disabilities.”

The findings were published in the British Journal of Visual Impairment. q

Quality standard developed for eye patients with dementia [THE ROYAL COLLEGE OF OPHTHALMOLOGISTS and the VISION 2020 UK

Dementia and Sight Loss Committee have developed a quality standard to help eye clinics and ophthalmology departments provide high-quality care for patients with dementia.

In a statement, the RCOphth said: “Patients with dementia and their carers can benefit from being identified in advance of attending their appointment in order for eye clinic staff to be aware of and identify ways to best support the needs of these patients. The quality standard identifies simple and easy steps that can be taken to enable services to be designed and adapted to meet the needs of people with dementia.”

Seven quality statements have been designed, based on the NICE format for quality standards to help ophthalmology departments assess their services. These statements address staff training, support to participate in decisions about care, the design of clinical areas, waiting times and appointment durations, provision of information, assessment of vision and referral for support.

Paul Ursell, consultant ophthalmologist at Epsom and St Helier University NHS Trust and VISION 2020 UK Dementia and Sight Loss Committee member, commented: “This piece of work highlights the breadth of what should be considered in providing care to patients with dementia in an eye clinic – it requires liaison between the patient, carers, all staff, managers and commissioners of care within the care pathway.” q www.yourexpertwitness.co.uk

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Varicose veins in 2016 – the fading of traditional varicose veins surgery

By PHILIP COLERIDGE SMITH DM MA BCh FRCS Consultant Vascular Surgeon and Medical Director, British Vein Institute and Emeritus Reader in Surgery, UCL Medical School

A patient undergoing endovenous laser ablation of varicose veins under local anaesthetic, with combined use of ultrasound guided foam sclerotherapy

[

IN RECENT YEARS, there has been a considerable change in surgical practice in the field of varicose veins surgery. The original methods of treatment date back more than 2,000 years but were improved in 1905 and 1908 by the introduction of ‘varicose veins stripping’ in which the diseased veins were removed in their entirety.

These treatments were performed under general anaesthesia and led to significant post-operative pain and a recovery period of about one month. The long term outcome of treatment was satisfactory.

In the last 15 years a number of new methods of treatment have been introduced which can be accomplished under local anaesthetic. These include thermal ablation methods where a tube is passed along the diseased vein for a distance of 20-50cm. The tube is used to contain a heating method which may be a laser fibre optic, an electrically heated catheter or a tube delivering super-heated steam. The vein is anaesthetised and the heat applied to destroy it without removing the vein (pictured).

An improved method of injecting varicose veins known as ‘ultrasound guided foam sclerotherapy’ has been popularised. In this method, injections of foam are made into the diseased saphenous veins and associated varices under ultrasound guidance. Local anaesthesia is not required for this treatment.

More recently a rotating catheter system (mechanico-chemical ablation) and cyanoacrylate glue have been used to treat the veins.

The efficacy of these treatments is very similar and is comparable to the ability of surgery to treat varicose veins. The main difference is that all of these treatments have a greatly reduced post-operative recovery

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time with most patients experiencing little post-treatment discomfort.

Return to work is usually within one to three days, in contrast to much longer period of recovery following varicose veins surgery.

The National Institute for Health and Care Excellence (NICE) has published advice on which treatments are accepted as safe and effective for use in the NHS. NICE Clinical Guideline 168 (July 2013) offers advice on the relative efficacy of the modern treatments. Thermal ablation methods are recommended as the first line treatment, if it is feasible to use one of these techniques. Otherwise, ultrasound guided foam sclerotherapy is recommended.

Where none of the modern methods of treatment is considered to be feasible, conventional surgery is recommended. This information confirms that all currently used treatments are acceptable forms of management but emphasis is placed on the modern methods which permit rapid recovery and return to work.

Change in practice

Detailed information on NHS treatments is collected and published as Hospital Episode Statistics. In 2000 almost all patients with varicose veins were managed surgically. In 2009/10 the NHS provided 35,600 episodes of varicose veins treatment of which half were conventional surgery and half used the newer minimally invasive treatments. In 2014/15 32,700 treatment episodes were provided. Of these, surgical treatment was used in 23% and thermal ablation procedures were used in half of all treatments. Foam sclerotherapy was used in 18% of treatments, some in combination with thermal ablation methods. There

has clearly been a substantial change in the way varicose veins are treated in the last 15 years.

The data I have cited relates entirely to NHS practice. Patients treated in private medical practice are not included and this accounts for about 10,000 treatments per year. No detailed statistics are published for this group but it seems likely that a similar change in practice has taken place.

The Health and Social Care Information Centre have recently published the results of a study on patient reported outcome measures (PROMs) amongst varicose veins patients.1 PROMs have become the main outcome measure of treatments provided by the NHS – and many healthcare providers in other countries. They provide an estimate of efficacy of treatments for conditions which curtail lifestyle rather than life expectancy.

The outcome of treatment was assessed by three measures: EQ5D (a five item questionnaire concerning general health), EQ VAS (a visual analogue scale) and AVVQ (a 13 item questionnaire concerning symptoms of venous disease). The study compared the scores taken before treatment commenced with those afterwards. In general, similar results were obtained from all treatments, although slightly more patients reported improvement after surgical treatment than the less invasive treatments.

The average AVVQ score (range 0-100), relating to symptoms of venous disease, improved by 8.95 points after surgical treatment, 7.6 after thermal ablation and by 6.24 after foam sclerotherapy. In randomised clinical trials, similar improvements in AVVQ have been reported in all treatment groups, so the findings here imply some form of bias in patient allocation or measurement of the outcome.

The complications reported by patients were also studied, including wound problems and bleeding. 31% of patients reported one or more complications after surgery, 16% after thermal ablation and 11% following foam sclerotherapy. This reinforces the view from earlier work that surgical treatment is associated with a higher level of postoperative complications than the more modern treatments.

vein thrombosis, may be considered substandard practice.

Adverse events after surgery include wound problems (bleeding, infection, healing, scars), post-operative pain and bruising, damage to adjacent structures (cutaneous nerves, motor nerves, major arteries and veins, lymphatic vessels) and problems related to general anaesthesia.

Adverse events after thermal ablation techniques are more limited and include thermal damage to nerves that accompany saphenous veins leading to loss of sensation or a painful neuritis. Skin burns may also occur occasionally.

Adverse events following foam sclerotherapy include lumps and bruising related to treated veins which may resolve only slowly in some cases and phlebitis (inflammation of treated veins).

In the longer term, recurrence of varicose veins may also occur.

All of these problems should be discussed with patients prior to their treatment. Failure to provide adequate information of the problems associated with a particular technique may lead to allegations of substandard treatment should problems arise postoperatively.

Conclusions

In the UK there has been a widespread move by surgeons towards minimally invasive methods of treatment for varicose veins. These lead to more rapid recovery following treatment with equivalent efficacy. Most patients can now be managed under local anaesthesia, avoiding complications which may arise following general anaesthesia. The new methods of management are associated with a different spectrum of potential complications which should be discussed with patients before treatment begins. q REFERENCE 1

A study on varicose vein treatments, Patient Reported Outcome Measures

(PROMs) in England, PROMs Team, Health and Social Care Information Centre, February 2016.

Implications for clinical practice

Varicose veins practice has become more complex in recent years with the development of modern methods of treatment. These require substantially different surgical skills compared to varicose vein stripping techniques and some surgeons may still be in the conversion phase of their training. Modern treatments require skills in ultrasound imaging and ultrasound guided injection. Not all vascular surgeons have so far achieved full competence in these areas.

Good medical practice dictates that patients should be advised of the details of treatment as well as the frequently occurring and serious risks of any treatment which is proposed. In addition, patients should be advised of possible alternative methods of treatment. With the significant range of treatments currently available, consultations on this subject can be more protracted than previously. However, most surgeons will have a preferred method of treating varicose veins of a particular pattern and will advise patients accordingly.

This is acceptable since all treatments for varicose veins have similar outcomes and the quality of the outcome is likely to be better where a surgeon has most experience of the technique.

However, surgery has a higher frequency of adverse events than the less invasive treatments, and this should be discussed with patients where it is advocated. Failure to comply with these recommendations from the General Medical Council could amount to substandard care.

What can go wrong?

Varicose veins treatments carry a range of adverse events that varies according to the method of treatment. All treatments carry a low risk of post-operative deep vein thrombosis. Patients at increased risk can be identified using NICE Clinical Guideline 92 (January 2010) and can receive prophylactic anticoagulant drugs where necessary. This advice includes patients treated as day cases or outpatients. Failure to comply with the advice offered, resulting in a post-operative deep www.yourexpertwitness.co.uk

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Is today’s NHS ‘awful’ – or ‘awfully good’?

By DR BASHIR QURESHI FRCGP FRCPCH Hon FFSRH-RCOG AFOM-RCP Hon MAPHA Hon FRSPH • Expert Witness in Cultural, Religious & Ethnic issues in Litigation • Expert Witness in GP Clinical Negligence • Author, Transcultural Medicine

[THE PATIENT IS the most important

person in the NHS and, indeed, we are all patients at one time or another – including doctors, academics and politicians. While some diseases are curable or manageable, others are incurable and, of course, a 100% success rate in saving patients’ lives would be impossible to achieve. Nobody doubts that doctors, usually supervised by other doctors, always do their best in caring for patients.

In the early days of the NHS, from 1948 to 1967, each GP practice was run by a doctor with his wife as a receptionist – they provided 24 hours care for every patient along with their families and for this reason they were called ‘family doctors’. When treatment was unsuccessful and a patient died, the GP and sometimes the consultant were invited to the funeral service. Those were the days!

Winds have changed in the NHS. Now when a patient dies some relatives, especially widows, try to find faults with the management of the case by GPs, consultants and hospitals. Blame has become the name of the game. In their state of bereavement, they complain to practice managers, NHS managers and the General Medical Council (GMC). Eventually, they hire a solicitor, sometimes with Legal Aid, to go to court for monetary compensation.

Solicitors for both claimants and defendants earn their livelihood from their clients and do their best to win their cases in the courts. There are cultural differences among solicitors – in England an instructing solicitor may commission an impartial expert witness, who signs a statement that he/she is responsible only to the court even if they are gently pressurised by the instructing solicitor to favour their client.

I have written many such impartial reports.

Recently, I received a query from Northern Ireland in which the solicitor was very honest and wrote to me saying that it would compromise their case fatally if I were to write a negative report. I politely declined the request because as an impartial expert witness it is my duty to tell the truth, the whole truth and nothing but the truth.

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Doctors orders – or disorders In days gone by, a doctor’s orders were happily obeyed by all patients, who even used to give presents to their doctor at Christmas time. Furthermore, pharmaceutical companies used to organise free educational foreign trips for doctors and expensive medications with patent names were prescribed for patients.

Today, we might call this an incentive or bribe – as there is no such thing as a free lunch. In my experience doctors today face a number of risks.

A great number of patients are satisfied and join the pro-doctor patients groups.

However, some articulate and vocal patients demand and expect from doctors more than they should, including further investigations, expensive medications and referrals to consultants. A few doctors go along with these demands to reduce their own stress levels. If they do not get what they want, some patients make complaints against doctors to practice managers, NHS managers, the GMC and will even take the matter to a tribunal or a court,

demanding monetary compensation.

Although a patient can make a complaint against a doctor, a doctor cannot complain against a patient who may be making aggressive demands to the authorities. This is unfair and damaging to the doctor.

Under duress, some doctors may make complaints against their colleagues. For example, doctors trained at one medical college may be inclined to be unkind to those trained at other colleges when they are serving on NHS and GMC complaints panels.

Some doctors get so stressed by complaints and hearings that they leave medical practice altogether through loss of self-confidence – there have even been cases of suicide.

Others, when faced with an investigation letter, do not respond by the required deadlines and fail to seek the help available from the Medical Defence Union or the British Medical Association (BMA) and this may result in unnecessary punishments.

Some of the Royal Colleges, who are expected to create high standards for patient care, use patients associations as shields from the Government’s austerity measures.

In fact, their past office holders are often recruited to run the Care Quality Commission (CQC), formed by the Government to visit and assess GP practices. The BMA has been critical and practices have been closed and doctors have left, due to occupational stress from these visits. Some of the doctors go on to become self-employed locums.

Doctors and medical organisations often claim that they are the patients’ advocates.

Politicians gently mock them implying that they cannot represent patients when they are paid for treating them. This is taken as a conflict of interest which is more of a taboo in Britain than in countries abroad.

Junior doctors in Britain wanted to receive double pay for working on Saturdays, however the BMA negotiators and the Department of Health did not agree, in spite of ACAS mediation, and the junior doctors have resorted to strike action. I heard the Prime Minister say in a TV interview that he respects

junior doctors but cannot allow them to have a ‘veto’ on Government policy.

In a democracy, demonstrations are often counterproductive and negotiation, with give and take on both sides, is the only approach which can bring a ‘win win’ situation.

Politicians’ tactics

Also in a democracy, only the majority have authority – especially when it comes to governing the country. Politicians are trained to deal with realities while academics are trained to define qualities. I do not know why it is only in the UK that academics do not like politicians and vice versa. In fact, many of our politicians, civil servants and academics are trained together at Oxford, Cambridge and the London universities. Prime Minister’s Questions every Wednesday in the House of Commons is both an informative and entertaining event!

Politicians of whatever party are clever and govern tactfully. If they like people, they move the goal posts towards them, if not then they move them further away – and keep moving them. As readers who have watched the TV series Yes, Prime Minister will know, the actual legislative work is done by civil servants who prepare the Green and White Papers. Although I hope I am right in thinking that our real ministers have more influence than the fictional ones.

Politics, economics and the law have as much to do with patient care as medicine. In these days of austerity – with the need to finance foreign wars and aid – there is less money to run the NHS. Politicians are aware of the public backlash to austerity measures and therefore they persuade the public of the need to do what they feel is necessary. ‘Divide and rule’ is a tactic which has been used by rulers worldwide over the centuries – if they do have to reduce GP services, the government will no doubt appoint some senior GPs to oversee the policy.

My experience bears testament to the wisdom of British politicians who have taken a number of measures as their preferred options. These include:

• Annual appraisals and revalidation every five years for doctors to renew their GMC registration and licence to practice. Their colleagues are paid to examine them – consultants examine consultants and GPs examine GPs – as they are best qualified to find merits and faults. This controls and may even reduce the number of doctors – for which the government is not to be blamed and could even be praised.

• The establishment of the Care Quality Commission – a legislative body, staffed by experienced doctors. They visit every GP surgery to assess them and pick up any faults – even so far as finding mould on the surgery doorsteps! Many surgeries have been closed and more will likely follow with Urgent Care Clinics and Walk In Centres replacing them.

• Hospital consultants can only treat patients if they are referred by a GP. Every GP referral is screened by a Clinical Commissioning Group Referral Assessment Committee, made up of local GPs who on occasion return some referrals back. GPs

are discouraged to re-refer such cases but nobody gets the blame if a patient suffers as a result. If no patients were referred to hospital by their GP there would be no need to have consultants in hospitals – and that would certainly reduce strains on the NHS budget!

• Long terms follow up of those patients with chronic and complicated diseases have been transferred from hospital consultants to GP practices.

• Similarly, there have been cuts affecting junior doctors – both in their numbers and salaries – along with an increase in their workload and duty hours. This, of course, means that in the future there will be fewer consultants. Some consultants are now called ‘Fellows’ – they are indeed jolly good fellows!

So, take your pick. Patients, along with those NHS staff who do not have a say, may describe today’s NHS as ‘awful’ – but the politicians, who wield power, may well call it ‘awfully good’. Nevertheless, the fact remains that money makes the world go round! q

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When language barriers can get in the way of an assessment A key element in determining the extent of brain injury and consequently the impact on everyday life and any future disability, employment prospects and need for support is a neuropsychological assessment. One of the specialists in the field is DR LINDA MONACI, a Consultant Clinical Neuropsychologist working both in the NHS and privately (also as an expert witness). Having qualified in Italy and worked in Sweden, she then moved to the UK where she completed the training required to practice as a consultant clinical neuropsychologist in the NHS. She can also carry out assessments in Italian and she has experience of working through interpreters.

[

CARRYING OUT COGNITIVE assessments in a different language presents various difficulties. Often the aid of an interpreter is needed who must have clear and specific instructions about the process to avoid compromising the assessment. Even if that is achieved, a translation may compromise the standardisation of the material and affect the interpretation of the results.

Let’s give an example: if one is asked to describe the word ‘apple’, that may not be so much of an issue; but if the word is ‘encumber’ or ‘ominous’ there could be issues related to the translation itself. Some languages may use more than one word to express the same concept – thereby giving the meaning away.

Even if the translation gave a single word there could be other issues, such as the length of the word and the frequency of use in a particular language. That would make a comparison with the norms based on the English words not valid.

The literature, in particular research carried out by Monica Rivera Mindt and her team (2008), suggests that bilingualism is associated with lower language scores in all spoken languages, which is thought to be due to the executive function costs of inhibiting one or more languages and the frequency of use.

When asking for similarities between words – which is meant to assess the ability to think in abstract terms – one needs also to take into account cultural differences. Cultural factors and expectations can also impact upon the assessment process, especially with nonwestern cultures where similarities between abstractions may be based on different factors, as outlined by Victor Nell (1999) working in South Africa and by Richard Nisbett and Yuri Miyamoto in the US (2005).

Furthermore, people from different cultures are likely to have been exposed not only to different social, cultural and linguistic factors, but also to different information and experience. Non-verbal abilities can also be affected. For instance, Monica Rosselli and Alfredo Ardila (2003) found significant

differences in performance on non-verbal tests among different cultural groups in Columbia.

Educational opportunities may also differ between different countries and they may not be appropriately summarised purely by the number of years in education. The American academy of Clinical Neuropsychology (AACN) (2007) recommends caution when assessing individuals whose primary language is not English and who belong to distinctive cultural or socio-demographic groups, and those with unusually low levels of education. For those groups, test norms may be limited because of insufficient normative data or validity studies.

A third party, such as the interpreter, being present can also affect test performance.

That would be particularly true for small communities living in the UK, where it is possible that the interpreter knows the client and their family. According to the AACN (2007) and the British Psychological Society (2008), whenever possible the use of friends or family members as an interpreter should be avoided.

Sometimes, however, individuals may feel reassured by their presence.

The presence of a third party during test

administration is not discussed in British professional guidelines, but it is usually discouraged by professional guidelines in the US. In cases where the person to be assessed does not speak English, other data sources – such as direct observation and supplementary information about everyday functioning from third parties – become very important as reliable indicators of functioning pre and postinjury. Gathering such information during the assessment is in accordance with professional guidelines from the AACN and it is particularly important in the case of a modest premorbid level of abilities, such as low literacy levels and unskilled jobs.

In my view, there do not appear to be any culture-free formal cognitive tests currently available. That highlights the importance of clinicians needing to be aware of the many variables that can affect test performance among different populations when carrying out neuropsychological assessments. It is, therefore, necessary to take into account the whole clinical picture in order to be able to draw any conclusions. q www.yourexpertwitness.co.uk

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New version of code reflects litigation changes [

A NEW VERSION of the Rehabilitation Code – the document that lays down protocols for the early introduction of rehabilitation programmes in personal injury cases – became active on 1 December last year.

Published by a joint rehabilitation working party of the International Underwriting Association and the Association of British Insurers, the code provides a framework in which insurers and claimant lawyers can collaborate to consider the health needs of injured people.

Although voluntary, it is attached to the Pre-action Protocol that explains the conduct and steps expected of claimants, defendants and their respective representatives before commencing legal proceedings for personal injury claims. Research has consistently shown it to be well established and widely used by claims handlers, personal injury lawyers and providers of rehabilitation services.

The 2015 code represents the third revision, bringing it into line with the changing claims environment – most notably legal developments and new ways of working in the NHS. The biggest difference this time is that there is a separate section for lower-value claims, defined as claims with a value up to £25,000 or below, where the code recognises the need for a more streamlined process. In the more serious cases it encourages rehabilitation case managers to work proactively with treating NHS clinicians.

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The working party has also published, for the first time, a guide for rehabilitation case managers and people who commission them, which is separate from the code but intended to complement it. The decision to produce the guide followed concern expressed by insurers and claimant lawyers about the outcome of some rehabilitation cases.

Matthew Scott, chair of ABI’s personal injury committee, said: “Rehabilitation can play a crucial part in helping people recover from injuries, and the Rehabilitation Code plays an important role of ensuring those patients get the right treatment as speedily as possible.

Insurers, claimant lawyers and rehab providers have worked closely together during the

update of the code to ensure it remains as relevant and effective as possible. Those who are unfortunate enough to be hurt in an accident deserve quality care that puts their interests first, and insurers are committed to playing their part in providing that.”

Neil Sugarman, vice president of the Association of Personal Injury Lawyers, declared: “A truly collaborative approach between lawyers and insurers can help to get the right rehab in place quickly, speeding up the recovery of the injured person, offering a better quality of life and an earlier return to work. These are all factors in restoring a sense of normality, which is often the most important consideration for injured people.” q

Specialist rehabilitation is cost-effective [

A RESEARCH PAPER published in the Open BMJ – a free online resource from the British Medical Journal – has shown that specialist rehabilitation can be highly cost-efficient for all neurological conditions, producing substantial savings in on-going care costs, especially in high-dependency patients.

The research used data from the UK Rehabilitation Outcomes Collaborative national clinical database collected between 2010 and 2015 from all 62 specialist rehabilitation services in England.

The participants were working-aged adults aged from 16 to 65 years with complex neurological disability. All groups showed significant reduction in dependency between admission and discharge on all measures. q

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