Your Expert Witness Issue No. 38 (1YWQ)

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contents IN THIS ISSUE 7

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Opening Statement

NEWS 8 Historic occasion sees a woman’s hand on the tiller of justice 8 Lawyers welcome online court proposals FINANCE 9 Money laundering – new directive brings due diligence to the fore CCTV & DIGITAL FORENSICS 10 Report into bulk powers welcomed by government 11 Murder trial shows value of CCTV 11 Illicit phone use in prison can now be terminated remotely 12 Updated aid to CCTV testing published 12 Expert analysts have international careers RTA INVESTIGATION 13 Could driverless cars pose challenges for investigators as well as insurers?

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OCCUPATIONAL HEALTH & SAFETY 14 Provisional workplace fatality figures published 14 Food industry conference to debate good H and S practice 15 Landmark ruling sets proportional compensation 15 Food safety expertise is no poisoned chalice 16 For this kind of expertise you need a head for heights ENVIRONMENTAL ISSUES 17 Legal challenge launched to fracking in Yorkshire 18 Dorset man escapes prison for illegal waste oil site 19 Dr Robin Szmidt talks rubbish and recycling BUILDING & PROPERTY 20 Lawyers accuse government of ‘legislation by stealth’ over buy-to-let tax changes 20 Peterborough regulates private rentals 21 Homebuyers take risks by foregoing surveys, says insurer

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WILLS, LEGACIES & CHARITABLE BEQUESTS 23 Dates published for legacy giving event 23 Failing sight brings with it so many problems!

24 If you Will, we will 24 Pancreatic cancer – together we can take it on 25 Ethical aid helps people to help themselves 25 Charity carries on the work of its founder 26 Surgical research benefits from legacy giving 26 New litigation guidance published by Charity Commission 27 Short breaks offer a normal life and boost self-confidence 27 Charities debate Brexit 27 Legacies – the gift of life for threatened primates

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MEDICAL ISSUES 31 Medical Notes

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NEWS 33 Annual report details NHS negligence claims 33 Government consults on expanding scope of CQC ratings 35 Duty of Candour goes under the spotlight 35 Proposals on litigated cases 37 Government’s obesity ‘damp squib’ panned 39 Hospital visits for CVD soar, research finds 39 BAAPS responds to CQC proposals 39 Scar-free healing within a decade is the goal INSTRUCTING THE CORRECT EXPERT 41 Perils and pitfalls await the unwary expert 43 One year on, MedCo is dealing with start-up glitches 43 Deadlines announced for medical experts NOISE INDUCED HEARING LOSS 45 The personal stereo revolution may not be music to insurers’ ears 45 Noise at work can lead to PI claims

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ARTHROPLASTY 46 Focus on total hip replacement PAIN 49 Chronic postsurgical pain and consent UROLOGY 51 The role of the urological expert witness CT IMAGING 52 And the CT shows... undue reliance on modern technology causes problems PSYCHIATRIC & PSYCHOLOGICAL ISSUES 55 Why developmental trauma must be addressed in the Family Courts 55 Smartphone app can help predict potential suicides 56 Special measures can help vulnerable patients in court 56 Workplace injuries can be psychological 57 The financial, psychological and social cost of brain injury

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VIEWPOINT 58 Public health issues in Britain today

A to Z WEBSITE GUIDE 28 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

EXPERT CLASSIFIED 60 Expert Witness classified listings 62 Medico-legal classified listings www.yourexpertwitness.co.uk

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Opening Statement [ONE OF THE MOST momentous appointments to Prime Minister Theresa May’s new cabinet

was that of Elizabeth Truss as Justice Secretary and, by definition, Lord Chancellor. Ms Truss is the first woman to hold either post – a fact brought to the fore by the Lord Chief Justice. The judiciary is traditionally a male institution, despite strides made recently to address that fact, and the appointment brings with it both a message and a movement forwards.

Gone is the Liz Truss of DEFRA – lampooned for her enthusiasm for pork farming. The new Elizabeth Truss is a person of gravitas with responsibility for preserving this country’s tradition of justice for all.

• The MoJ is still bubbling with new processes and procedures. Following Jackson and LASPO, the introduction of fixed costs regimes and the furore over Legal Aid, there are proposals going forward for the establishment of an ‘online court’ for low-value monetary claims. The proposal, made in Lord Justice Briggs’s final report, is for a system akin to dispute resolution, with a judge making a determination. The Law Society, in its response to the Briggs report, placed its emphasis on the continuing role solicitors must continue to play in ‘helping clients navigate the new system and ensuring that they are able to access justice’.

• New technology is at the heart of the controversial proposals for the use of bulk powers for the collection of data, as outlined in the Investigatory Powers Bill. The Bill, now passing through the House of Lords, contains powers seen as crucial by the government to deal with crime and terrorism in the digital age. The extent and scope of the powers, however, have led to it being dubbed the ‘Snooper’s Charter’. The Bill is very much the baby of PM Theresa May, who was instrumental in it being introduced while she was Home Secretary.

• One of the areas of crime the bulk powers proposed will be used for is in the detection and prosecution of money launderers. Dirty money is cleansed for a range of criminal activities, from the personal enrichment of felons to the underwriting of drugs deals and the financing of terrorist activity. Often these strands are interlinked.

No area of business is exempt from the attentions of money launderers, a fact emphasised by regular contributor to these pages Derek Williamson, a forensic accountant and expert witness. In an overview of the legislation he points out that firms could henceforth be held liable for the unscrupulous activities of employees if they cannot show that measures were put in place to prevent such behaviour. Solicitors are a prime target for such activity because of the large amounts of client money they hold.

• The use of technology has also created a need for specialist expert witnesses, with forensic analysis of everything from mobile phone records to computer hard drives being used to aid both prosecution and defence. One of the most ubiquitous – and visible – devices for detecting and solving crime is CCTV. CCTV can do more than just identify perpetrators; careful analysis can determine the speed and direction of vehicles as well as the height and direction of movement of individuals.

To be of use, however, CCTV images must be of adequate quality. The Home Office has made available a kit to enable operators to assess the clarity of their images.

• Charities have had a rough ride from the press recently, despite the increasing importance of the work they do as the state draws back its boundaries. Some of that important work forms the subject matter of the latest feature on legacy giving in this issue. All forms of charity work – from overseas development aid to medical research – relies on funding from legacies and solicitors form an important source of information for those contemplating leaving such a gift. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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Historic occasion sees a woman’s hand on the tiller of justice [

PICTURED IS THE swearing in of Elizabeth Truss as the new Lord Chancellor.

She is the first female holder of the office and also the first female Minister of Justice.

Describing the occasion as ‘historic’, Lord Chief Justice Lord Thomas said: “A longstanding monopoly has been swept away, and it is plainly not before time.”

He added: “Today is an historic occasion.

It marks another step in the evolution of your great office, one that has for so long formed and continues to form the fulcrum between the judiciary and government.”

In her speech Ms Truss said: “The fundamentals of civilisation and liberty depend on the rule of law. It is our

safeguard against extremism, oppression and dictatorship – the separation of powers keeps the executive in check.

“It is the basis of our prosperity, which is sustained by secure contracts and free trade; and it shapes the fabric of our free society – the order, the stability, the equality and the individual freedom that we all love and respect.”

Setting out her priorities, she declared: “I am a great supporter of reform and modernisation throughout the courts and tribunals system; and that urgent task will be high on my agenda in the months ahead, as I know it is for senior members of the judiciary.

“As the first woman Lord Chancellor, I am proud to be part of our constantly evolving justice system.”

Lawyers welcome online court proposals [

PROPOSALS FOR AN online court, made in a comprehensive review of the structure of the civil courts in England and Wales, have been given a cautious welcome by the Law Society of England and Wales. The Law Society said it supports modernisation of the justice

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system and is pleased that the root-and-branch review conducted by Lord Justice Briggs recognised the important role that solicitors will play in ensuring the success of the online court.

Law Society chief executive Catherine Dixon said: “The final report on the online court indicates that IT may improve court efficiency.

Importantly, it also recognises the vital role solicitors will play in helping clients navigate the new system and ensuring that they are able to access justice.

“We are particularly pleased that Lord Justice Briggs has recommended that cost recovery should be possible and that, if a client wins their case, they will be able to recover the cost of their solicitor’s fee for initial advice and legal expertise. This was a key recommendation made by the Law Society in its response to Lord Justice Briggs’s earlier report.”

The Law Society sounded a note of caution on the importance of ensuring online courts do not limit access to justice because of how they are configured.

Catherine Dixon continued: “It is vital that ordinary and vulnerable people using the online court are not prejudiced when claiming against large organisations. Clarification is also needed about which claims will and will not be included as part of the online court.”

On the role of solicitors she said: “Solicitors are ideally placed to support those who choose to use the online court, as they can advise at an early stage about the merits of the claim. Solicitors can also help clients to understand and comply with procedural requirements, thereby speeding up the process and reducing cost.

“Ensuring that people can choose to use a solicitor when using the online court – and allowing for the cost of initial legal advice – will help ensure the new online court gains public confidence, is genuinely open and accessible and supports access to justice.

“We welcome the efficiency savings that an online approach to civil justice could offer to lower value claims, but it is critical that legal advice remains available to help consumers navigate the online court. Not all court users are IT-savvy, and we will continue to work with HM Courts and Tribunals Service and the judiciary to ensure the work to develop the online court does not inadvertently shut anyone out of the justice system, particularly the most vulnerable in our society.

“The Law Society acknowledges the considerable work that Lord Justice Briggs and his team have put into this final report, and we look forward to continuing to work with the government and others on the modernisation of our justice system.” q

Money laundering – new directive brings due diligence to the fore

By DEREK WILLIAMSON of Goddards Accountants

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AS WE ALL KNOW, the EU Anti-Money Laundering directive came into force on 26 June last year, with member states having two years to turn the directive into law. The directive covers banks, accountants, solicitors and any business making or receiving cash payments worth at least €10,000,

regardless of whether the payment was made in a single transaction or via a series of linked transactions. As always, the directive is vague: ‘gambling operators’ could also be subject to the new rules.

The new regime has brought into force new customer/client due diligence checking requirements, together with new obligations to report suspicious transactions and maintain records of payments. Of course, all solicitors already do this.

Professional firms will also have to install internal controls to prevent money laundering and terrorist financing activities, if they have not already done so. Since June this year all limited companies now have to file lists of ‘people with significant control’ as part of their annual return. That is supposed to expose individuals and so reduce the risk of money laundering.

In May this year, just before the Anti-Corruption Summit, David Cameron revealed plans to require all foreign companies buying property in the UK to disclose their true owners in a public register. The government’s intention is to go further than merely requiring firms to prevent bribery and tax evasion.

Indeed, should an employee be charged with money laundering, the company will be deemed liable if it cannot show that it had put procedures in place to prevent money laundering and fraud.

Money laundering problems clearly afflict the largest banks around the globe. Here it is not ‘cash’ that is laundered, but millions of dollars or pounds – usually emanating from Mexico, Columbia or the Middle East.

Solicitors need to carry out due diligence when receiving funds from clients, even for property purchases. Did the funds come from the sale of another property owned by the client, or was it from a third party? If so what due diligence has been carried out on them? It is not enough to accept the claim by the client that it is a loan from a friend.

Whether it is a large firm or a tiny practice, the potential for money laundering is always present. Anywhere that money flows there is the danger that the proceeds of financial crimes will be washed through the financial system. q

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Report into bulk powers welcomed by government [ THE GOVERNMENT HAS welcomed

the publication of a report into the operational case for the use of bulk powers, as contained in the Investigatory Powers Bill.

The Independent Reviewer of Terrorism Legislation, David Anderson QC, and his expert team assessed the specific question of whether the operational case for the powers has been made. The review team critically appraised the need for bulk capabilities, considering whether the same result could have been achieved through alternative investigative methods.

The report, published on 19 August, concluded that: • Bulk interception is of ‘vital utility’ to the security and intelligence agencies and that alternative methods fall short of providing the same results. In one case assessed by the review team, in which a kidnap had taken place in Afghanistan, the report found that: “Without the use of bulk interception, it was highly likely that one or more of the hostages would have been killed before a rescue could be attempted.”

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• Bulk acquisition of communications data is ‘crucial in a variety of fields, including counterterrorism, counter-espionage and counterproliferation’ and its use cannot be matched by data acquired through targeted means.

• An operational case for bulk equipment interference has been made in principle and there are likely to be cases where ‘no effective alternative is available’.

• Bulk personal datasets are of great utility to the security and intelligence agencies and, in vital areas of work, there is ‘no practicable alternative’.

Prime Minister Theresa May, who as Home Secretary initiated the review, said: “I am grateful to David Anderson for this report, which follows a detailed and thorough review in which the government has provided unfettered and unprecedented access to the most sensitive information about our security and intelligence agencies’ capabilities.

“Mr Anderson’s report demonstrates how the bulk powers contained in the Investigatory Powers Bill are of crucial importance to our security and intelligence agencies. These powers often provide the only means by which our agencies are able to protect the British public from the most serious threats that we face.

“It is vital that we retain them, while ensuring their use is subject to robust safeguards and world-leading oversight which are enshrined in the Investigatory Powers Bill.”

The wide scope of the powers to intercept communications contained in the Bill – dubbed the ‘Snoopers Charter’ – was the subject of fierce criticism by a number of civil liberties groups during its passage through the Commons earlier in the year. q

Murder trial shows value of CCTV [

THE TRIAL OF Sarah Williams and Katrina Walsh for the murder of Lancashire woman Sadie Hartley was notable for the amount of CCTV evidence used to illustrate every step in the prosecution’s case.

The pair thought they were planning the perfect murder, but – as a report on the investigation on the Lancashire Constabulary website points out: “There is no such thing as the perfect murder as the two of them were soon to learn.”

The report continues: “Thanks to modern policing techniques like CCTV, analysis of mobile phone use and tracking vehicles by using our automatic number plate recognition cameras we were able to track the movements of both Sarah Williams and Katrina Walsh,

both on the day of the murder itself and in the weeks and months leading up to it.”

The report contains CCTV images from a ferry as the pair travelled to Germany and from a flower shop as they bought flowers for a reconnaissance trip. The BBC also carried CCTV footage of a farm where evidence was hidden and of the arrival of their car in Helmshore.

The Lancashire Constabulary report concluded: “There is no doubt that the dedication and work of the officers and staff involved in this investigation was critical in solving this crime and bringing the killers to justice.” q

Illicit phone use in prison can now be terminated remotely [

POLICE AND PRISON OFFICERS will have new powers to cut off the illegally-held mobile phones used by inmates to continue criminal activities after being locked up. Nearly 15,000 mobile phones and SIM cards were recovered in jails last year, with recent high profile cases linking behind-bars criminality with drug dealing and smuggling guns into the UK. Under new measures, introduced in the Serious Crime Act, prison governors will no longer have to physically find illegally-held mobiles in jails or use expensive mobile phone blocking technology to stop their use. Prison staff or the police will instead be able to cut off the phones remotely just by producing evidence that a given mobile number is being used illicitly.

Once a number is identified, they will be able to apply to the courts for a Telecommunications Restriction Order (TRO). That means mobile networks can be instructed to blacklist the phone remotely, making it completely unusable.

Recent examples of criminals using phones in prison include an offender using a concealed mobile to plot his escape after being jailed for gun crimes. The attempt was foiled by police and the prisoner was sentenced to an additional five-and-a-half years in prison.

Security Minister Ben Wallace said: “Criminals are locked up to protect communities from their actions – so it is totally unacceptable for them to continue their life of crime behind bars.

Telecommunications Restriction Orders will give us the power to disconnect the phones prisoners use to continue orchestrating serious crimes while in jail.

“This government will act wherever necessary to cut crime and keep our communities safe – and to restore the public trust that is so vital to our justice system.”

The new powers will operate within the Serious Crime Act 2015 and provide mobile network operators with the legal framework to ensure unauthorised mobile phones are put beyond the reach of criminals. They will be overseen by the Investigatory Powers Commissioner who will examine the effectiveness of TROs by looking at a variety of indicators, including the number issued and the number of phones disconnected. q

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Updated aid to CCTV testing published [ IN AUGUST the Home Office’s Centre for Applied Science

and Technology (CAST) published updated information on Testing CCTV Image Quality.

CAST has developed a range of tests to assist system installers and owners to robustly assess the performance of their CCTV systems. The tests are designed to be simple to use and produce results that are easy for a non-technical person to understand. The test system helps with common problems like video compression, changeable viewing resolution and variable transmission bit rate/bandwidth, which can all result in the unpredictable quality of digital CCTV images.

The kit is a set of test images and instructions about how to produce and use them. It includes tests for human identification, vehicle registration number legibility, colour rendition and resolution.

Human identification test

The purpose of the test is to help system commissioners and auditors to demonstrate the CCTV system under review is capable of providing images that can be identified. It consists of 12 human faces from which a random selection is presented to the camera at an appropriate distance. An operator attempts to match the presented face to a reference list. The operator’s

accuracy is then scored and used to evaluate the capability of the CCTV system to record identifiable images at that distance.

Vehicle registration number (VRN) legibility test

The purpose of this test is to evaluate whether a CCTV system can provide images suitable for reading a VRN. The test kit specifies nine segments of VRN characters. A random selection of those segments is shown to the camera at an appropriate distance. An operator attempts to match the presented VRN to a reference list and their accuracy is scored.

Colour rendition test

The test will help to establish whether a CCTV system can provide images with reasonably accurate colour information. The test kit includes a basic colour chart, which is presented towards the camera at a suitable distance. The operator can then verify the level of match between the colours on a reference chart and the colours seen through the imaging system.

Other test targets included in the system are A3-size versions of the legacy Rotakin test pattern, which allows system testers to use the updated guidance and methods to establish system acuity. q • The test kits can be obtained via the Home Office website at Gov.UK.

Expert analysts have international careers [

THE ROLE OF forensic analysis of evidence is nowadays very much an international one – and perhaps nowhere is that illustrated more than in the work of Audio Video Forensics, the British company that specialises in the analysis of voice and video footage for lawyers and law enforcement agencies around the globe.

A recent case saw the company applying its expertise in a fatal accident inquiry in the Czech Republic. Analysis of CCTV was employed to determine the speed of the vehicle involved in a crash that left a woman dead, while the whole gamut of site safety procedures was examined by the use of a headcam worn by a forklift truck driver.

The case was just one of many taking analysts from the firm around the world. They have been employed by the United Nations during an investigation into the Marikana incident in South Africa and by the British military to unmask the fake photographs alleged to show the mistreatment of prisoners in Iraq.

More recently, the firm’s expertise was used in the Glasgow bin lorry inquiry. Audio Video Forensics were engaged by the Procurator Fiscal to analyse multiple CCTV images from around the crash scene to determine the speed of the vehicle.

Said company principal Iain MacArthur: “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.”

Iain founded the company following a successful career involving highend sound equipment in both the music and film industries. He was part of the team at industry leader AMS-Neve that developed the flagship DFC Digital Film Console – used to mix the sound on around 70% of the world’s blockbuster films. The machine won for AMS-Neve’s R&D department a coveted Scientific and Technical Award from the Academy of Motion Picture Arts and Sciences (the technical ‘Oscars’) in 1999.

He is now also much in demand as a speaker at conferences and training events for solicitors in criminal practice, lecturing on the techniques available for forensic analysis of audio and video. q

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Could driverless cars pose challenges for investigators as well as insurers? [

THE NEWS OF the trialling of the first ‘driverless’ taxi service in Singapore in August brought back under the public gaze the growing use of autonomous technology in vehicles and the prospect in the near future of fully autonomous cars.

The advent of such vehicles poses issues for the legal profession, the insurance industry in particular and also – for nothing is perfect – accident investigators.

The main issue for the insurance industry is that of liability. The Association of British Insurers (ABI) has asserted that in cases where the vehicle is fully autonomous and there is no opportunity for the driver/ passenger to intervene, then liability will rest with the manufacturer. Indeed, the motor industry itself, in a report for the Society of Motor Manufacturers and Traders

by KPMG published last year, accepted that ‘…liability will shift from drivers to manufacturers’.

As long ago as 2014, the ABI’s motor policy adviser Scott Pendry said in an address to the Parliamentary Advisory Council for Transport Safety: “The key change – and the potential shift to product liability – comes when the driver is not expected to oversee or monitor the vehicle and when they have ceded full driving responsibility to the car itself. Our initial view is that if a system fails on a fully autonomous vehicle causing it to crash, liability would rest with the vehicle or system manufacturer. This potential shift in liability would only occur when a driver has actively given complete control to the vehicle and has no option to intervene.”

For accident investigators the main change in determining the cause of an accident could lie in determining possible technological failures and/or interventions. Will accident investigators now need to be software engineers in addition to all the other skills required?

Insurance Broker Adrian Flux includes, in what it claims to be the UK’s first policy designed for driverless cars, cover for accidents where: • Updates or security patches for things like the driverless operating • system, firewalls, electronic mapping and journey planning systems • haven’t been successfully installed in the vehicle within 24 hours of • the owner being notified by the manufacturer or software provider – • subject to an additional policy excess • There are satellite failures/outages that affect the navigation • systems, or if the manufacturer’s operating system fails or other • authorised software fails • Caused by failing when able to use manual override to avoid a • collision or accident in the event of operating system, navigation • system or mechanical failure • Your car gets hacked or an attempted hack results in loss or • damage.

That last point is where the determining of electronic interference may be part of investigating the cause of an accident.

In a somewhat chilling view into the future, Scott Pendry postulated the following set of scenarios: “A key data challenge is the threat associated with the deliberate misuse of a car’s data systems. Autonomous systems will rely heavily on internet connectivity making them intrinsically vulnerable to cyber manipulation. Hackers may be able to override a car’s system to re-route it toward a particular destination, or overwhelm it with high volumes of internet traffic. And by intercepting and tampering

with mobile communications and vehicle software updates, cybercriminals could transmit malicious code or, in the worst case scenario, send new and dangerous instructions to the vehicle’s software systems.” q

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Provisional workplace fatality figures published [

IN JULY the Health and Safety Executive (HSE) released provisional annual data for work-related fatal accidents in Britain’s workplaces. The long-term trend has seen the rate of fatalities more than halve over the past 20 years; however, the provisional figures for 2015/6 indicated a slight increase from the previous year, from 142 to 144.

The HSE called on all sectors to learn lessons to ensure workers return home safe from work. Its chair Martin Temple said: “One death at work or life needlessly shortened, is one too many and behind every statistic lies a real story of loss and heartbreak and families left to grieve. Britain has one of the best health and safety systems in the world, but we should always be looking to improve and to prevent incidents that cost lives.

“This year HSE travelled the country asking industry representatives, employers, unions, workers and others what they could do to help Britain work well. The response was hugely encouraging and I would like to ask people to deliver on the commitments made, that will help keep Britain’s workers alive.”

The new figures also show the rate of fatal injuries in key industrial sectors: • 43 workers died in construction, the same as the average for the • previous five years.

• In agriculture there were 27 deaths, compared to the five-year • average of 32.

• In manufacturing there were 27 deaths, compared to five-year • average 22. The figure includes three incidents that resulted in a total • of eight deaths.

• There were six fatal injuries to workers in waste and recycling, • compared to the five-year average of seven, but subject to • considerable yearly fluctuation.

Comparisons of fatal injuries by country of the UK or region are based on where the accident occurred. After taking industrial composition into account, those regions and countries with seemingly higher rates are not statistically different to the rest of Great Britain.

In 2015/16 the highest fatal injury rates across all countries and regions were Wales (0.93 per 100,000 workers), Scotland (0.60) and Yorkshire and the Humber (0.58). When averaged across a five-year time period to 2014/15, to take into account the relatively small numbers and to ‘iron out’ some of the yearly fluctuations, those regions with the highest fatal injury rates were also Wales (0.81), Scotland (0.73) and Yorkshire and the Humber (0.70).

The statistics again confirm the UK to be one of the safest places to work in Europe, having one of the lowest rates of fatal injuries to workers in leading industrial nations.

A more detailed assessment of the data will be provided as part of the annual Health and Safety Statistics release in early November. As this draws on HSE’s full range of sources, including changes in non-fatal injuries and health trends, it will provide a richer picture on trends. q

Food industry conference to debate good H and S practice [DELEGATES AT THIS year’s National Food and Drink

Manufacturing Health and Safety Conference will hear how some of the industry’s leading names have reduced sickness absence, improved productivity and created more resilient workforces through promoting staff health and wellbeing.

Experts will deliver latest-thinking around combatting fatigue in shift workers, catering for the safety and health requirements of an aging workforce, preventing musculoskeletal disorders and developing safety

leadership throughout a business whatever its size.

The two-day conference, taking place in October, has been organised by the Food and Drink Industries Group of the Institution of Occupational Safety and Health (IOSH), in conjunction with the Food and Drink Manufacture Health and Safety Forum.

It is aimed at anyone working in the food and drink manufacturing industry that has a passion for improving safety and health performance, including safety and health leaders, worker representatives and managers and consultants.

Delegates will hear from more than 20 speakers during the conference, including representatives from Marks & Spencer, 2 Sisters Food Group and the Bakers Food & Allied Workers Union (BFAWU).

The keynote address is to be given by Philip White, head of the HSE’s operational strategy division.

Paul Fenner, chair of the organising committee, said: “While the safety and health performance of the UK’s food and drink manufacturing sector continues to improve, there is no room for complacency.

“The conference reflects the challenges of being a leader in this very fast and dynamic working environment, and poses innovative and practical solutions to everyday issues that companies are facing.

“By businesses having a holistic approach to safety and health management and continually looking for the opportunities to improve, it not only benefits employees but the companies as a whole.” q • The conference will be held at Forest Pines Hotel and Golf Resort in Broughton, North Lincolnshire, on 4-5 October.

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Landmark ruling sets proportional compensation [ ON 29 JULY the Court of Appeal ruled that asbestosis sufferers could be entitled to

proportional compensation from as low as 2.3% from negligent employers, based upon the number of years worked. The historic ruling confirmed that proportional compensation is applicable even if the employer’s overall contribution to the condition was minimal.

The ruling relates to retired electrician Albert Carder, who was exposed to asbestos while working at Exeter University. Although most of his asbestos exposure occurred earlier in his career, lawyers at specialist firm Moore Blatch, who represented Mr Carder, calculated that his employment at the university contributed 2.3% toward his asbestosis.

The Court of Appeal upheld the calculation and the judgement made by the High Court in July 2015 that Mr Carder was entitled to compensation. At the time Exeter University’s insurers appealed, arguing the proportion of the exposure was minimal and had made ‘no discernible difference to his condition’.

Moore Blatch asbestos disease lawyer John Hedley commented: “This decision is very important and will influence other asbestos cases. Whilst there is a long established principle around minimal contributions to asbestos exposure by employers, this case helps define what minimal actually means. We can confidently say this contribution can be as low as 2.3% or even less. Whilst the compensation is not substantial, it will help Mr Carder and the ruling will help many other people who are in a similar position.”

Mr Carder said: “It’s a huge relief for this case to have finally been settled and to also know that I can return to court should my condition deteriorate, which is of great comfort to me and my family. When I started my career asbestos was thought to be such a wonderful thing; unfortunately we were not made aware of the dangers.”

Mr Carder’s overall damages from his total exposure to asbestos were assessed at approximately £67,500, with the university’s contribution confirmed to be £1,713. q

Food safety expertise is no poisoned chalice [

RUNNING PARALLEL TO the field of workplace health and safety is the issue of consumer safety, with its high-profile specialism of food safety. One practitioner with expertise in both fields is Himmat Rai of Sentinel Safety Solutions Ltd. Following a career as an enforcement officer in both health & safety and food safety, Mr Rai became a consultant and is now well respected as an expert witness in both fields.

He is well placed to assist instructing lawyers and insurers as an expert witness and has extensive experience in undertaking site investigations, preparing expert witness reports and giving evidence in court with respect to criminal and civil litigation matters. In particular, he has experience of lengthy cross examinations.

Mr Rai’s area of expertise encompasses the investigation of workplace injuries and fatalities, risk assessment, risk management and employer’s liability.

He is also an expert in food safety, food contamination, HACCP evaluation and food processing. In particular he is versed in issues regarding food poisoning and food-borne injury investigation, food emergencies, food recalls and insurance-related matters such as public and product liability.

Mr Rai is the author of Food Emergencies – A Practical Approach to Prevention & Control and a speaker at industry conferences & seminars.

One client, David Hetherington of Margetts and Ritchie Solicitors, said of him: “In a health and safety prosecution of one of our supermarket clients, Himmat Rai’s thorough report and authoritative evidence at the trial were important factors in our client’s acquittal on all seven charges.” q www.yourexpertwitness.co.uk

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For this kind of expertise you need a head for heights [

FALLS FROM HEIGHT continue to be the most common cause of work-related accidents across the construction and industrial sectors – a fact attested to by the experts at Simian Risk Management Ltd. As specialist work-at-height consultants and training providers, they are often called upon to provide expert opinion and reports in a wide range of scaffolding and work-at-height related cases.

Such cases include falls from access equipment and falling object incidents, through to major scaffolding collapses. The practice benefits from a team of experts with extensive scaffolding and workat-height experience, ensuring they can match a consultant with relevant expertise to the needs of the case.

Their work as experts in the field means that they fully understand their duty to the court and will accept instructions for both civil and criminal cases – for the claimant, defendant or prosecuting authorities or as a Single Joint Expert. However, most of their work to date has been for the defence.

Understanding current practice and keeping abreast of changes in the law, standards, ACoPs, industry guidance and good practice is their strength.

Their position within the industry means that, with constant changes in legislation and the fast-moving pace of industry guidance, they are wellplaced to advise on practical interpretation, case law, provenance and state of knowledge at the material time.

As consultants they are represented on committees with the Health and Safety Executive as well as on trade bodies – these include the

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National Access and Scaffolding Confederation (NASC), Construction Industry Scaffolders Record Scheme (CISRS), Construction Industry Training Board (CITB), Prefabricated Access Suppliers and Manufacturers Association (PASMA) and the Temporary Works Forum (TWF). There they help to review, establish and publish industry guidance.

Keeping abreast of industry performance standards is a vital part of the company’s knowledge base and by actively undertaking inspections, audits and training courses, they ensure that their experts are up to date with good practice – maintaining their position at the leading edge of height safety.

In addition, as one of the UK’s largest independent accredited training providers for scaffolding qualifications and work-at-height training courses, Simian Risk Management are well placed to report on training and competence aspects of cases. They are also represented and actively involved in the governance of several industry-accredited training schemes and qualification awarding bodies.

When retained on a case they know the importance of being responsive, meeting deadlines for reports and promptly responding to questions. Beyond expert reporting, they have provided specialist technical advice and investigations for insurers, lawyers and counsel – in preparation for proceedings and in court. To ensure there is no conflict of interest in any potential cases, they carry out thorough checks prior to accepting an instruction. q

Legal challenge launched to fracking in Yorkshire [

LAWYERS ACTING FOR local resident group Frack Free Ryedale and Friends of the Earth have launched a legal challenge to the decision by North Yorkshire County Council (NYCC) to allow fracking near the North Yorks Moors National Park.

Lawyers Richard Stein and Rowan Smith of Leigh Day have applied to the High Court for a judicial review of the decision on the grounds that: • The council has failed to properly assess the climate change impact of the fracking through its failure to consider the environmental impact of burning the shale gas extracted to create electricity at a nearby power station in Knapton • The council has failed to secure long term financial protection from the fracking company against environmental damage of the area Leigh Day argues that the decision taken by NYCC on 23 May was unlawful.

The consultation exercise carried out by the council on the fracking plans resulted in over 99% of respondents rejecting the plans. Despite this almost-total rejection

of fracking in Ryedale, the council voted to allow Third Energy, which is owned by Barclays, to frack in the village of Kirby Misperton in Ryedale.

Said Richard Stein, a partner in the firm: “Nearly everyone who responded to the council’s fracking consultation in Ryedale rejected the plans. Local residents believe that fracking carries serious risk, including to their health, water supply, and to the local environment.”

David Davis is a retired chartered surveyor from Hovingham, Rydale. He declared: “Concerned local residents have spent many hours considering the application, submitting evidence and raising their concerns in front of the planning committee. Despite all this, the county council have let the people of North Yorkshire down by failing to address these crucial factors.

“Our only recourse is to challenge this decision in the courts and hope that justice will be served.”

Jackie Cray, a retired vicar from Kirby Misperton who runs the local parent and

toddler group, added: “North Yorkshire County Council has a moral and legal responsibility to ensure against harm to current and future generations. We believe that they have failed in that duty in two key areas – climate change as well as making sure that there is enough money to clean up if anything went wrong. We call on the High Court to ensure that this crucial decision for our village and the wider population is made lawfully.”

Simon Bowens, Yorkshire and Humber campaigner for Friends of the Earth, said: “Shale gas is a dirty fossil fuel and it is the responsibility of North Yorkshire County Council to require a full assessment of the impact this fracking application would have on the climate. They failed to do that, and this is why we believe the courts need to consider the way that this decision was arrived at by seven councillors in May.” The case will now proceed to the Permission Stage where the Court will decide whether or not a full hearing should be carried out. This is likely to happen in the next few weeks. q

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Dorset man escapes [ A ROGUE WASTE operator has been given a suspended

prison sentence and ordered to pay £20,000 costs for running an illegal waste cooking oil storage and processing plant in the Dorset countryside. The case was brought by the Environment Agency.

Waste oil was being kept at the site at Keepers Paddock in Sherborne in an ‘ad hoc and haphazard fashion’. That resulted in neighbouring properties and a stream being polluted. When two of his neighbours complained, the man, Stuart Allen, threatened them with violence.

The Environment Agency was first alerted in November 2014 after neighbours started finding cooking oil in their drains and in a pond. There were also complaints about oils on the highway. Dye tracing showed the pollution was coming from a ditch bordering Keepers Paddock.

In January 2015, Environment Agency officers, armed with a magistrates warrant and accompanied by police, visited the site and found Allen was operating an illegal waste transfer station. It was estimated approximately 60,000 litres of mixed oils and food products were being stored at the site. Some of the materials were contaminated with plastics, wood and human wastes.

Last year Allen was served with a series of Anti-Pollution Works Notices by the Environment Agency which required him to clear the site of waste oil by a certain deadline. None of the notices were complied with.

When questioned, Allen said he’d taken over the running of the business from his ageing father. He collected approximately three tonnes of waste oils a week from catering businesses across Dorset, South Somerset and East Devon. He didn’t consider

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prison for illegal waste oil site cooking oils to be harmful. Spillages were dealt with by ‘scraping it up’.

A spokesperson for the Environment Agency said: “In addition to polluting soil and watercourses, illegal waste sites spoil the countryside by creating an eyesore and harm the local economy by undercutting legitimate waste businesses. The flammability and other potentially hazardous characteristics of waste oils also present a risk of fire and explosions.”

At Taunton Crown Court Allen was given a four-month prison sentence suspended for 18 months, ordered to carry out 200 hours of unpaid community work and made the subject of a Criminal Behaviour Order prohibiting him from operating a waste oil or any other waste business for 10 years. The judge told him that, if he appeared before the court again, he would be sent to prison. q

DR. ROBIN SZMIDT of Target Renewables Ltd

...talks rubbish and recycling [

‘LIFE USED TO BE SO MUCH SIMPLER.’ That’s something we hear all the time, but nowhere is it more true than in the waste, recycling and renewables sector. Traditionally our rubbish would simply go to a hole in the ground – landfill! Things have changed dramatically and today the things we used to unthinkingly throw away we now expect to be sorted, re-used and recycled.

Our rubbish is no longer just waste but is considered a resource and is processed in purpose-built facilities for sorting, cleaning, re-use and recycling. This is often associated with energy recovery and energy generation. Waste recycling facilities may be large infrastructure projects and are long-term investments by companies and communities.

Development of such projects comes with a unique set of problems. Waste by its nature is diverse and the facilities to process it have to be robust and flexible with a long lifespan of maybe 25 years or more.

When large projects are started there always has to be an estimate as to how well a facility will perform and this usually becomes a contractual obligation for contractors and sub-suppliers.

However, throughout the world, building what was considered technology for a life-time solution has seen a number of benchmark projects fail. Waste is by its nature variable and so performance and reasons for failure may be rather difficult to measure. Arguments often revolve around promises made by technology suppliers compared to the real-life performance of the plant. Terms and conditions and performance guarantees of the original agreement, and their interpretation, are then brought sharply into focus.

In some cases the promises made were, with hindsight, unrealistic and perhaps reflect the dangers of scaling-up earlier projects. In others, underperformance might be due to not building as was specified or down-grading the specification to meet a price target.

The facility might have been built as expected but the operator may be at fault by accepting different wastes than originally specified or by failing to carry out routine maintenance and monitoring. Overall, fault can potentially lie with any or all of the parties involved and can be very difficult to actually determine.

Underperformance of a waste or recycling facility may have a surprising knock-on effect.

A local authority is obliged to achieve a certain level of recycling and may have entered a service agreement or bought a facility to achieve this.

Failure or underperformance of the facility may not just be a technical issue but can have a major financial consequence if recycling targets are missed. Penalties can be substantial and longterm and so compensation and damages may be sought, first from the operator and then passeddown to suppliers and sub-suppliers. Teasing out obligations and responsibilities from multiple parties can be very complex indeed.

Even when operations are running well there are many other challenges. Waste regulation is specific and there are important differences across the UK. Those that export waste or recyclate must do so only under specific rules.

Changes in business activity may mean a move from one set of controls, regulation and legislation to another and operational changes may also mean that permissions and consents have to be revised. Businesses may find it hard to keep up, even with the best of intentions. On the whole, regulators work with waste processors to ensure compliance and best practice but if things go wrong, particularly if pollution or personal injury occurs, then action usually results.

The waste and recycling sector has worked hard to increase its level of professionalism and training and so it is important in selecting an expert that he or she has proven real-life experience in the field and is fully qualified, for instance as a member of the Chartered Instution of Wastes Management. q • Dr Robin Szmidt has been involved in the waste industry for more than 20 years, working both in the UK and internationally. He has acted as an expert witness in cases concerning pollution and odour from organic waste and recycling facilities, export and use of recyclate as well as acting as a technical assessor on behalf of investors for energy and waste plant. Target Renewables Ltd is an independent company specialising in advice and consultancy in the sector. www.yourexpertwitness.co.uk

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Lawyers accuse government of ‘legislation by stealth’ over buy-to-let tax changes [

THE LAW SOCIETY has criticised the government for the way changes to the law on taxation for buy-to-let properties have been introduced by amendments to the Finance Bill during the committee stage in the House of Commons.

The society described them as ‘significant amendments’, setting a ‘disturbing precedent of avoiding proper consultation and scrutiny’.

The changes, which alter the way buy-to-let properties will be taxed, may result in many investors paying income tax rather than a capital gains tax on their investment, creating uncertainty for taxpayers, the society said.

It chief executive Catherine Dixon commented: “By introducing a significant change in this way, the government is denying the public the chance to consider and comment on these proposals. The way these changes were introduced, in particular without consultation on the draft legislation before it was added to the bill at such a late stage, starts to feel like legislation by stealth.

“No matter what the policy proposals, proper consultation and process is vital to maintain public confidence in our democratic institutions.”

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The Law Society has made representations to the government, prepared by its corporation tax sub-committee, setting out how the amendments will materially change some investors’ tax obligations.

“If the government did not intend to make a material change, they need to clarify the language in the bill before it is passed,” said Catherine Dixon. “If they are intent on these changes, they should submit them for proper public consultation and legislative scrutiny.” q

Peterborough regulates private rentals [FROM THE BEGINNING of September, all those who

privately rent or are agents acting on behalf of private landlords in Peterborough will be able to apply for a landlord licence for every individual property, according by a report by the Royal Institution of Chartered Surveyors (RICS).

Moreover, the city council in Peterborough has decided to implement a selective licensing system in certain wards of the local authority area. All properties within those areas must have a licence by 1 December or face penalties.

The RICS has been identified as an accredited association, which means that properties managed by its professionals are eligible for a discounted rate of £50 per property. However, the licence must be applied for by 30 November to be eligible for the discount. All properties registered after this date will incur the full cost of £600, excluding any newly rented properties that occur after that cut-off date. The licence will run for five years.

Properties excluded from needing a licence include those managed by housing associations or the local authority, buildings regulated by other legislation, holiday lets and tenancies under long leases. q

Homebuyers take risks by foregoing surveys, says insurer [

RESEARCH CARRIED OUT by insurance company Churchill has revealed that 13 million homeowners have needed unexpected building work completed on their property since moving in. Over half of those who had major building work said knowing that in advance would have influenced their decision to buy the property.

Moreover, seven million did not have a survey completed on their current property.

This includes 3.5 million people who did not have any type of independent checks completed and 3.6 million who assumed a mortgage valuation was sufficient. According to surveyors the most common three problems that can be detected by a building survey are damp, roof issues and subsidence.

“

13 million homeowners have needed unexpected building work completed on their property since moving in

”

The number of people who have at least a base level survey has increased over time: from 63% cent 20 years ago to 91% in the past 12 months. However, having a comprehensive building survey done has reduced significantly, from 28% 20 years ago to just 6% in the past 12 months.

Martin Scott, head of Churchill Home Insurance, said: “It’s encouraging to see the number of people having a survey has increased over time. Only by having a qualified surveyor assess a property are prospective buyers fully informed of the true state of that property, so it is an essential part of the buying process. Those relying on a mortgage valuation alone should be wary as this is just a cursory look at a property from a mortgage lender to assess how much it is worth, not a survey looking at the state of the property.”

Nearly a quarter of surveyors reported having clients who needed expensive building works done to their property soon after moving in, which would have come up in a more comprehensive survey. One homeowner had a HomeBuyers report that missed the full extent of subsidence affecting the property, while others needed roof repairs, had problems with dry rot, damp or heating issues – all of which would have come up in a full building survey.

Responding to the report for the RICS, its residential director Andrew Bulmer FRICS said: “If ever there was a subject needing mythbusting, this is it. As this data shows, every year hundreds of thousands of home buyers still rely on a lender’s mortgage valuation, assuming that it is some sort of survey. It isn’t. The lender obtains a simple valuation of the property to make sure they can lend safely, and these are sometimes completed without visiting the property using just a desktop valuation.

“The message for home buyers is clear. A home is the most expensive purchase you will ever make and going down a cheaper route will be a false economy if works are required. There are various levels of survey, and it is vitally important to have a qualified surveyor look at your property if you truly want to know what you are buying.” q www.yourexpertwitness.co.uk

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In this latest special feature on legacy giving to charities we carry profiles on a cross section of the wide range of organisations who benefit from the security such gifts allow – from aid for ethical farming in the developing world to cutting edge medical research at home.

September has become established as the time when charities promote the idea of leaving a legacy in wills. For a number of years the consortium behind the event, Remember A Charity, has come up with eye-catching themes and this year is no exception.

It’s no secret that charities have had a mixed press recently, with criticism being expressed over what has been seen as overzealous litigation. The Charity Commission has issued guidance.

Finally, Brexit makes its inevitable presence felt.

Dates published for legacy giving event [

REMEMBER A CHARITY has unveiled plans for this year’s legacy awareness week. Remember A Charity in your Will Week will return on 12-18 September. The campaign theme will be to call on the British public to ‘pass on something legendary’, tweeting their advice for future generations at #MyWisdom and remembering a charity in their will.

This year marks the seventh year of Remember A Charity’s legacy giving week, during which charities, government, solicitors and willwriters will all come together to encourage the public to leave a gift to charity in their will. The consumer campaign will feature a short film that showcases donors’ inspirational words for future generations.

Following last year’s Extreme Will-writing campaign, which saw men and women in their 70s write a charity into their will at 10,000ft in the air before skydiving back down to earth, this year’s campaign will again celebrate the legendary nature of legacy donors and fundraisers alike.

Remember A Charity’s director Rob Cope said: “With this year’s consumer campaign, our focus is to give charities a range of resources that will help them deliver a strong legacy message that they can tailor for their own supporters. We want to encourage as many charities as

possible to participate in Remember A Charity Week 2016, joining the consortium and shining a spotlight on legacy giving.”

After last year’s event, Oxfam reported a ‘significant increase’ in the amount of web traffic to its legacy page and requests for legacy packs, having promoted campaign messages via social media and in its charity shops.

The charity’s director of fundraising, Tim Hunter, said: “Remember a Charity gave us a focus and that enabled us to get our retail network of 700 shops involved, communicating the importance of legacies to both the people who come into them as well as our volunteers.”

Dominique Abranson of WaterAid added. “Remember A Charity is central to our new legacy strategy. Having a national week organised externally galvanised all our staff far more than if we’d tried to create our own legacy week.”

Charities joining the consortium before Remember A Charity Week will receive promotional materials and a toolkit, equipping them for promoting legacies effectively to their stakeholders and supporters.

All member charities are also promoted on the campaign website at www.rememberacharity.org.uk. q

Failing sight brings with it so many problems!

[DO YOU HAVE a family member, friend or neighbour whose sight

is going? Reading, recognising friends, living skills are all affected when you lose your sight – and it’s much harder if you live alone.

The National Federation of the Blind of the UK (NFBUK) keeps its members in regular contact with information, help and updates on the organisation’s campaigning work. The charity also issues bi-monthly news magazines – in audio, braille or electronically – which its blind and partially sighted members can read independently. It also encourages members to play a fuller part in society. q • For further information contact NFBUK on 01924 291313, email admin@nfbuk.org or vist www.nfbuk.org. www.yourexpertwitness.co.uk

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If you Will, we will

Ronnie and Anne Corbett cutting the ribbon at Last Chance’s new Kent centre, Snowy safe at last and a new friend for Alan

[

LEGACIES MEAN SO much to the team at Last Chance Animal Rescue. These wonderful gifts have helped them to rescue, rehabilitate and re-home so many abandoned, abused and unwanted dogs, puppies, cats, kittens, rabbits and guinea pigs who otherwise would have had no future.

The charity understand the wishes of its kind benefactors who have considered them in their Wills. A spokesperson said: “We know they want their generous gift to us to be used directly to save lives, provide the very best of care and to find loving homes.

“Legacies really do provide the gift of life and Last Chance Animal Rescue can now, after much planning and prudent use of funds, offer our life saving services to so many more needy pets. We are delighted to announce we now have a second rescue and re-homing centre in Kent, giving hope and a true last chance to so many.

“Sadly we cannot thank those who have enabled this wonderful achievement but are extremely grateful to all those who are currently considering helping us now and in the future to continue our work.” q

Pancreatic cancer – together we can take it on [ PANCREATIC CANCER is a tough disease – tough to diagnose,

tough to research and tough to treat – but at Pancreatic Cancer UK they are taking it on. For too long the disease has been sidelined but they are determined to make sure that everyone affected by it gets all the help they need.

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Leeann Wilmer, the charity’s head of events, community and individual giving, said: “We provide expert, personalised support and information via our Support Line and through our range of publications. We fund innovative research to find the breakthroughs that will change how we understand, diagnose and treat pancreatic cancer. We campaign for change – for better care, treatment and research and for pancreatic cancer to have the recognition it needs.

“One of our key objectives over the next five years is to increase investment in the most cutting edge, innovative research. We believe that a minimum annual investment of £25m into pancreatic cancer research will start to lead to transformation for patients. For our part, we will commit to increase investment in the most cutting-edge, innovative research across the UK and to fund the best and brightest leaders of the future.

But we need help to achieve this, now and long into the future.

“Remembering us in a Will is an incredible way to support the fight against pancreatic cancer in years to come. Together we can take on pancreatic cancer.” q

Ethical aid helps people to help themselves [ TO FEED THE HUNGRY without exploiting animals – that is the

aim of aid charity Vegfam. It has been achieving this since 1963 by funding sustainable, self-supporting overseas projects.

The charity has provided seeds and tools for vegetable growing, fruit and nut tree planting, irrigation and clean water supplies – some solar or wind powered.

Vegfam also provides emergency relief in times of crisis and disaster.

It is professionally operated entirely by volunteers and all funding comes from supporters’ donations alone. As little as £5 enables a family in India to be self-sufficient in fruit, nuts and vegetables or a family in Africa to have access to safe water.

Vegfam-funded projects provide food security for children and adults worldwide, improving their livelihoods and alleviating hunger, malnutrition, starvation and thirst. Beneficiaries include people suffering from disease such as HIV-AIDS, disabilities, homelessness, hunger and thirst, caused by natural disasters or war.

Many are in marginalised communities, orphanages, refugee sanctuaries, schools and colleges. Others are trafficked women and children, villagers and tribal people. They are often out of reach of the major charities and Vegfam is sometimes their only hope of help.

The projects are carried out by other charities, NGO’s, indigenous organisations and by people who are committed to helping their fellow human beings in practical and sustainable ways which do not exploit animals or the environment.

In the past 10 years alone, Vegfam funding has helped over 500,000 people in more than 20 countries, helping people to help themselves.

All donations and legacies are gratefully received and make a real difference to people’s lives. q

Charity carries on the work of its founder [

FOR OVER 30 YEARS the famous animal hospital known as Tiggywinkles has been working to rescue, treat and rehabilitate sick, injured and orphaned British wildlife. Over that time they have proved beyond doubt that most wild animal and bird casualties can be saved and returned to the wild.

Although they specialise in hedgehogs – indeed, they derive their name from St Tiggywinkles, the name of their specialist hedgehog ward, inspired by the animal character created by Beatrix Potter – their wealth of expertise in the care of a wide range of species can now be passed on to others.

In addition, their commitment to practical education plays a vital part in the conservation of wildlife. As an accredited centre, opportunities are available for students aged 16 and over to gain a City and Guildsapproved qualification via their Apprenticeship in Animal Care scheme.

Tiggywinkles was founded by Les Stocker, who sadly passed away in July. In a tribute, Les was described as ‘…a steadfast ambassador, achieving his goal to turn wildlife rehabilitation into a profession’. In another he was referred to as the ‘the spiritual heart of Britain’. He was awarded an MBE by The Queen and given the title Laureate in the 1990 International Rolex Awards for Enterprise, for his work in wildlife conservation and establishing Europe’s first wildlife teaching hospital.

More recently, he gained the prestigious Honorary Associateship of the Royal College of Veterinary Surgeons.

The charity is happy to commemorate all who generously remember the Wildlife Hospital Trust in their will by inscribing their name on a plaque in its Remembrance Garden. Gifts are also welcome in the form of a donation or by becoming a Friend of Tiggywinkles. q www.yourexpertwitness.co.uk

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Surgical research benefits from legacy giving

[THE ROYAL COLLEGE OF SURGEONS OF ENGLAND (RCS) is

a registered charity and is internationally recognised as one of the world’s leading professional bodies for surgery – promoting surgical research, education and training throughout the UK. They are not part of the NHS and for over 200 years have safeguarded standards in clinical practice.

There are many reasons you might find yourself under the care of a surgeon and the work of the RCS is not limited to specific illnesses or specialties. Rather, through surgical research and education it supports better care for all ages – from minor day surgery to life-saving emergency trauma.

Although the medical profession and medical researchers continue to strive for the cure for many diseases and cancers, in many cases surgery remains the most effective treatment; and the procedure has the highest impact on cancer survival.

The RCS relies heavily on donations and legacies to develop and maintain its varied programme of clinical research, surgical education and heritage conservation. Operations are now safer, less invasive and more effective, with better outcomes. The range of procedures that can be performed safely and routinely has expanded dramatically. That would not have been possible without high-quality research.

Surgery saves lives – and a gift will help those who put theirs in the hands of a surgeon. q

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New litigation guidance published by Charity Commission [ THE CHARITY COMMISSION has published new guidance for

charities on embarking on or defending legal action. Charities and litigation: a guide for trustees (CC38) was published on 6 August.

According to the Charity Commission: “The prospect of taking or defending legal proceedings is often a difficult and complex matter for trustees that can present significant risk to a charity.”

The new guidance clarifies the issues that trustees need to consider when faced with litigation and helps them comply with their legal obligations, as well as their duty to act in the best interests of their charity.

The commission says that decisions on whether or not to take or defend legal action should be made in accordance with the principles set out in its existing guidance on decision making: It’s your decision: charity trustees and decision making (CC27). Trustees should also identify and address the potential risks and impact of litigation on their charity and its beneficiaries.

In applying those principles to decisions involving litigation, the guidance highlights the need for trustees to take and consider legal advice, to assess the economic prospects of success or failure and the impact on the charity, and consider whether their intended actions are proportionate in all the circumstances and in the best interests of the charity.

The guidance also indicates when trustees need to protect themselves against the adverse risk of costs and outlines alternative ways to resolve the issue in dispute that trustees should explore before legal action, such as mediation and negotiation.

The guidance also contains detailed information on charity proceedings, a specific category of legal claim concerning the internal administration of charities which require authorisation from the commission. This includes how to make an application to seek the commission’s consent, to help trustees prepare for these typically time sensitive situations.

The commission finalised the guidance following valuable input from the Charity Law Association’s specialist working group.

Kenneth Dibble, chief legal advisor at the Charity Commission said: “Legal action can present significant risk to a charity’s beneficiaries, assets and reputation, but in some circumstances it may be the best or only option. This guidance aims to help trustee bodies reach a justified decision on litigation and, crucially, to manage risk effectively by assessing the challenges and costs their charity might face and deciding how to deal with them.

“We encourage any trustees thinking of engaging in litigation to read our new guidance, apply the principles set out in our existing guidance on decision making, and to contact us as a matter of priority if they require our protection from adverse costs or authorisation to proceed.” 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.

”

Charities debate Brexit [THE RECENT BREXIT vote has had an effect on planning for

the charity sector, as it has for virtually every walk of life. The possible impact on legacy giving of an EU exit will be debated at a Civil Society Fundraising First Thing breakfast event Are we wrong to bank on legacies in a post-Brexit world? on 13 September at CIWEM in London.

The event is the third interactive breakfast debate this year in the Fundraising First Thing series. The panel will debate the possible implications of Britain leaving the EU on fundraising budgets. They will also discuss the projected outlook for legacy income as well as the economic impact on the value of existing legacies, and consider how charities can ensure best practice and future-proof this essential income stream.

The event is designed to provide space for charities to debate with other charities. q

[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.

Legacies – the gift of life for threatened primates [THE RESCUE AND provision of sanctuary for monkeys who have

suffered abuse and neglect is the mission of animal charity Wild Futures.

They are also dedicated to protecting primates and their habitats worldwide.

Flora and fauna around the world are endangered by climate change, habitat destruction and the bush-meat and pet trades. For some species it is too late and the future of what remains lies in our hands, so the gift of a legacy to Wild Futures is ‘…the gift of life and a future for primates and our wonderful planet’.

The charity’s holistic approach makes it unique in providing sanctuary to rescued monkeys, supporting projects overseas, campaigning for primate welfare, educating people to protect primates worldwide and promoting a sustainability and ethical ethos. International recognition of that is demonstrated by the fact that its safe haven for monkeys – The Monkey

Sanctuary in Cornwall – is the only sanctuary in the whole of Europe to be accredited by the Global Federation of Animal Sanctuaries.

For over 50 years they have rescued monkeys suffering with psychological trauma, diabetes and metabolic bone disease. With spacious, natural enclosures, companionship of their own kind and specialist care, the monkeys learn to enjoy life again. Meanwhile, Wild Futures strives to end the cruel trade in the hope that one day their work will be done.

They receive no government funding, so the generosity of those that remember Wild Futures is essential to enable them to continue their work. A legacy can be the gift of a life worth living and a wild and safe future for all. q • Call 01503 262532, email giving@wildfutures.org or visit the webiste at www.wildfutures.org.

www.yourexpertwitness.co.uk

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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 Jeffrey AC Meek LLP Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

Forensic Accounting Reports: • Personal injury • Valuations • Commercial disputes • Divorce • Fraud • Proceeds of crime • Negligence

www.abc-translations.co.uk

www.jeffreyacmeek.co.uk

Dr Asef Zafar MBBS MRCGP

Dr Joshua Adedokun

GP and experienced Expert Witness specialising in reports for clinical negligence, personal injury and accident claims

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

www.uk-doctors.org.uk

www.expertpainreports.co.uk

British Weather Services

Mr Kim Hakin FRCS FRCOphth

• Legal weather reports • Weather data • Site investigations • Expert witness in court • Call: 07860 912216

Consultant Ophthalmic Surgeon and Expert Witness on ophthalmological matters

www.britishweatherservices.co.uk

www.kimhakin.com

Professor Charles Claoué

Mr Marcus Ornstein

Consultant Ophthalmic Surgeon • trauma • cataract • corneal and external disease • refracture surgery

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

www.dbcg.co.uk

www.marcusornstein.co.uk

Mr Chris Makin

Mr Mark Duxbury

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

Consultant Surgeon – medicolegal work relating to general surgery and specialist liver and pancreatic surgery

www.chrismakin.co.uk

www.markduxbury.info

DentoLegal

MD5 Ltd

Specialising in the preparation of evidence-based Breach of Duty & Causation and Condition & Prognosis Dental Reports

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

www.dentolegal.com

www.md5.uk.com

Expert in Mind

Medical Illustration UK Ltd

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

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

www.expertinmind.co.uk

www.migroup.co.uk

FHDI - Kathryn Thorndycraft

Mr. Michael Hodge

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

Maxillofacial and Oral Surgeon.

• Personal Injury • Criminal Cases • Clinical Negligence

www.fhdi.co.uk

www.consultantoralandmaxillofacialsurgeon.co.uk

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Mr Michael Thompson

Mr Simon Bramhall

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

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

www.expertcolorectalsurgeon.co.uk

www.simonbramhallhpbsurgeon.co.uk

Munro Consulting

Stockport Psychology Services

Expert Witness services relating to the design, construction and maintenance of highways

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

www.munro-consultants.co.uk

www.sps.uk.net

Professor Roger James

Dr Thomas C M Carnwath

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

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

www.independenthealthconsultant.co.uk

www.psycholegal.org

Sector Forensics Ltd

Mr William Stuart Hislop

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

Consultant Oral and Maxillofacial / Head and Neck Surgeon.

Specialist in ablative and reconstructive surgery.

www.sectorforensics.co.uk

www.wshislop.co.uk

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MEDICAL NOTES [

AFTER A RELATIVELY quiet period, as reported in the previous incarnation of this column, the medical profession is once again the subject of unwelcome news attention. The junior doctors are preparing for the most extensive and prolonged strike in the history of the NHS and the chief executive of Southern Health has sparked more controversy – this time by resigning her position and moving to a similarly-paid job elsewhere in the NHS. • Problems associated with Southern Health came to public attention following an inspection by the Care Quality Council (CQC). It was the latest in a series of actions by the CQC, including the imposition of what it terms special measures on a number of NHS trusts. The government, in the form of the Department of Health, is proposing extending the scope of the body to include the issuing of its ratings – from ‘outstanding’ to ‘inadequate’ – for such sectors as cosmetic surgery. The proposals have been broadly welcomed by doctors. However, the BAAPS has cautioned against reliance on ratings alone and say patients must ensure their surgeon is up to the job, not just the clinic.

• Elsewhere in government circles, the new PM has been busy shaping her policies, including the much-awaited strategy on teenage obesity – now downgraded to a ‘plan’. The disappointment among campaigners and almost the entire medical profession has been tangible. Gone are the recommendations to ban ads for sugary snacks before the watershed (a concept probably rendered obsolete by catch-up TV), to restrict ‘two-for one’ offers and to reduce sugar content in drinks.

What remains, to no-one’s surprise, is the so-called sugar tax, or soft drinks levy. Odd that the only bit to survive is the bit that generates revenue for the government!

The BMA was among those attacking the watered down proposals. Sugar has long been recognised as detrimental to the long-term health of the population, children in particular. The prospect of a legacy of heart disease and type 2 diabetes also drove Jamie Oliver to denounce the PM as having ‘let British children down’.

• An alarming illustration of the growing problem of heart disease came with figures published by the British Heart Foundation showing a large increase in hospital visits connected with cardiovascular problems in recent years – 1.7 million in 2013/14, an increase of 47,000 in three years. Scotland has the highest rate by population of the nations of the UK. • Despite the increase in hospital visits for cardiovascular disease, the fatality rate from heart disease and stroke has fallen dramatically in recent years. One of the reasons for declining death rates from a number of causes, including heart attack and stroke as well as cancer, has been the near miraculous advances in technology. One of the marvels of the technological age in medicine has been the CT scan, offering rapid and accurate diagnosis. The growing reliance on technology for answers can, however, be a double-edged sword. A leading vascular surgeon explains instances where a CT scan will miss the existence of such threats as pulmonary embolism. As the writer points out, no test is 100% accurate.

• A technology that has been in existence somewhat longer is the replacement hip, a procedure that has benefited many thousands of patients over the decades. Invented in this country, there have been advances over the years, not least to reduce the problems associated with the release of metal ions. That issue threatened a legislative avalanche recently, which did not materialise.

• The process of obtaining consent is one fraught with potential pitfalls for surgeons. One of the commonest is ensuring the patient is provided with sufficient information regarding the risks of the surgery. An expert in pain medicine looks at the issue of chronic post-operative pain and what information patients should receive on its risks. q

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Annual report details NHS negligence claims [ON 21 JULY the NHS Litigation Authority (NHS LA) published its

Annual Report and Accounts for 2015/6, ahead of its AGM which took place on 16 August.

The report reveals that the NHS paid out more than £1.4bn to patients and their legal representatives in 2015/16, compared to £1.1bn the previous year. The rise reflects the high numbers of new claims received over recent years which are now falling for payment, although last year new claims fell. A 43% increase in claimant legal costs was another significant factor in the rise, the report says.

As in previous years there were a large number of claims. However, the number of new clinical negligence claims fell by 4.6% to 10,965

Government consults on expanding scope of CQC ratings [A CONSULTATION IS being carried out by the Department of

Health on proposed changes to Care Quality Commission (CQC) performance assessment regulations to enable it to issue ratings for additional sectors following inspection.

Announcing the consultation, the DoH said: “The Care Act 2014 requires the Care Quality Commission to carry out performance assessments of providers of health and adult social care services. These performance assessments are provided in the form of a rating.

“When ratings were introduced in 2014 they were limited to NHS trusts and NHS foundation trusts, GP practices, adult social care providers and independent hospitals. The government would like the CQC to develop ratings for other sectors that they regulate and is seeking views on this issue.”

The healthcare sectors envisaged by the proposals include cosmetic surgery providers, independent community health service providers, independent ambulance services, independent dialysis units, refractive eye surgery providers, substance misuse centres and termination of pregnancy services.

Prof Edward Baker, deputy chief inspector of hospitals at CQC, said: “Our ratings of NHS trusts, general practices, independent hospitals, and adult social care services are supporting providers to improve and importantly, helping people to make informed choices about their care.

“Through our ratings of ‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’, never before has the public had such clear and accessible information about the quality and safety of their services.

“The Department of Health’s consultation proposes to extend the types of services that we are able to award these ratings to in the interests of continued transparency and so that we can make sure people receive the safe, high-quality and compassionate care they deserve.

“Extending the scope of our ratings to cover these additional services would allow us to celebrate even more good and outstanding care that is out there and to help the public be even clearer on those services that need additional support to improve.” q

compared with 11,497 received in 2014/15. The largest number of new claims for an individual specialty was for orthopaedic surgery at 14% of the total – continuing a year-on-year trend. That specialty, however, only accounted for 7% of the value of claims. By far the greatest value of claims received was in the field of obstetrics at 42% – also following a year-on-year trend.

The report marks the 20th year of the NHS LA, and highlighted significant changes in approach. In particular the year saw the introduction of a pilot mediation service.

The report says: “Focusing specifically on fatal and elderly care claims, the pilot sought to determine how we can increase the take up of mediation by claimants and their legal advisers in all claims.

“The pilot was evaluated positively and in the coming year will extend and expand the service as a result. We hope that this will increase the number of disputes resolved without going to court.”

The report also sets out the NHS LA’s increasing role in supporting and incentivising NHS organisations to improve patient safety, including through learning from clinical negligence.

NHS LA chief executive Helen Vernon said: “The key to reducing the growing costs of claims is learning from what goes wrong and supporting changes to prevent harm in the first place.

“We want to reduce the need for expensive litigation. This means increasing the use of mediation in the NHS, early transparency, saying ‘sorry’ and demonstrating that lessons have been learned to prevent the incident happening again.” q

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Duty of Candour goes under the spotlight [

PATIENT SAFETY CHARITY AvMA (Action against Medical Accidents) has published a report on how the Care Quality Commission (CQC) has been regulating the statutory duty of candour. The study shows that CQC inspections of NHS trusts in 2015 were inconsistent and often superficial in how they assessed compliance with the duty; and that even where they identified there was noncompliance, there was little or no evidence that the CQC was taking steps to ensure that NHS trusts improved.

The study analysed 90 reports on CQC inspections of NHS trusts carried out in 2015 and responses to a Freedom of Information Act request to the CQC. Key findings included: • 23 of the inspection reports were either superficial in how they dealt with the duty of candour or did not refer to it at all (6 cases) • 34 of the reports contained criticism of how a trust was implementing the duty of candour, but only 14 of these went on to make a recommendation to improve • Even where recommendations had been made to improve, the CQC could not provide a single example of a trust having responded about the action they would take to improve • The CQC did not know how many individual reports of potential non-compliance it had received from members of the public or

other external sources, or whether the CQC had looked into any of these AvMA chief executive Peter Walsh said: “Having fought so hard to get a statutory duty of candour, we are deeply disappointed about how the CQC has regulated this so far. We still believe the duty of candour is potentially the biggest breakthrough in patient safety and patient rights in modern times, but we have always said that its success will depend to a large extent not only on the goodwill of providers, but on robust regulation by the CQC.

“The public have a right to expect that the CQC gives this fundamental standard the priority it deserves, and for it to be seen to be doing so, if we are to move from a situation where dishonesty and cover ups are simply frowned upon to one where they are no longer tolerated.

“We are grateful for the CQC’s cooperation and acknowledge that since this study was carried out they have made some improvements to the way they cover duty of candour in their inspections, but we need to see much more.” q

Proposals on litigated cases [ON 21 JULY AvMA presented draft proposals to ministers designed to ensure that there is

always a review of litigated cases and a ‘patient safety letter’ provided to the claimant. The letter would cover any patient safety lessons that have been learnt from the case and any measures that have been put in place as a result, as well as any lessons from the investigations conducted – including whether the duty of candour had been complied with. Copies would also have to be sent to commissioners of services, NHS Improvement and the CQC. In a statement AvMA said: “We believe this would create an overdue discipline on NHS bodies to maximise learning rather than simply process cases. It is a sad fact that although the NHS Litigation Authority more recently has taken a keen interest in patient safety, there is little evidence that litigated cases have been proactively examined for the learning they can provide.” q

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Government’s obesity ‘damp squib’ panned [ THE BRITISH MEDICAL ASSOCIATION was just one of

a cohort of organisations responding to the publication of the government’s long-awaited and much-hyped childhood obesity plan with a mixture of disappointment and dismay.

Professor Parveen Kumar, chair of its board of science, said: “Given the UK has one of the highest levels of obesity in Western Europe, with one in three children overweight or obese by the time they leave primary school, the government should be doing everything in its power to tackle this problem. Instead it has rowed back on its promises by announcing a weak plan rather than the robust strategy it promised.

“Although the government proposes targets for food companies to reduce the level of sugar in their products, the fact that these are voluntary and not backed up by regulation, renders them pointless. Targets are also needed to reduce levels of saturated fat and salt in products – and these must be backed up by regulation.

“Poor diet has become a feature of our children’s lives, with junk food more readily available, and food manufacturers bombarding children with their marketing every day for food and drinks that are extremely bad for their health. It is incredibly disappointing that the government has failed to include any plans for tighter controls on marketing and promotion.”

The Royal College of Paediatrics and Child Health (RCPCH) was equally scathing. Its president, Professor Neena Modi, said: “The UK had an opportunity to be a world leader in protecting infants, children and young people against obesity and a host of related crippling, life-long non-communicable diseases. I am extremely disappointed that the long-awaited strategy has been replaced by this weak ‘plan’ which provides no bold action, and instead relies on physical activity, personal responsibility and voluntary product reformulation.

“Exercise is good but exercise alone will not curb obesity. It would take an hour of hard exercise to work off one chocolate chip muffin. And what is deeply saddening, because they can't exercise personal responsibility, is the failure of the state to protect infants and children. A baby born to an obese mother is already on a pathway to obesity, a toddler given a fizzy drink or a bag of crisps doesn’t know that it’s better to drink water and eat an apple.”

Comparing the plan to previous anti-smoking measures, she

said: “Obesity kills as surely as smoking; government took on the tobacco industry effectively, although it was a tough challenge, and can do it again now. The RCPCH has a responsibility to advocate on behalf of infants, children and young people. For their sake we call on Government to revisit their ‘plan’ and turn it into the powerful, effective multi-sectoral strategy that is so necessary.”

A long-term campaigner for improved child nutrition is celebrity chef Jamie Oliver. In his response he details six measures he has lobbied to be included – only one of which, the so-called ‘sugar tax’, has been included.

Campaigning organisation Action on Sugar offered a similar response, saying: “As predicted, Theresa May has failed the nation with the release of such a weak ‘obesity plan’ despite the fact the leaked draft of the report was publically slammed for being far too unambitious last month. It is appalling that the plan was not only not strengthened, but significantly weakened.

“The majority of Public Health England’s evidenced-based actions to reduce sugar consumption and to tackle obesity have been scrapped, including restrictions on the marketing and advertising of, and promotions on, products high in sugar, salt and saturated fat.”

The charity is equally scathing of attempts to harness Olympic success to back up the failings: “Furthermore, diverting attention to the Rio Olympics by suggesting that the focus on school sports is an opportunity to create ‘future GB Olympians’, in response to the published obesity plan, shows a complete lack of understanding of the issue at hand.”

One of the few voices from outside the food and drink industry to welcome the measures was that of the British Association for Applied Nutrition and Nutritional Therapy (BANT).

In a statement it said: “BANT welcomes the government’s plans for tackling childhood obesity and in particular the proposal for a levy on sugar for producers/importers. Obesity is a complex issue and the government’s proposals will set the background for establishing the changes needed to engender a long-term cultural shift which allows healthy behaviour adaptations to an environment which offers so many opportunities for unhealthy indulgence, either knowingly or in ignorance. BANT will be considering what tools it can offer to help this public health drive.” q www.yourexpertwitness.co.uk

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Hospital visits for CVD soar, research finds [ THE NUMBER OF hospital visits

due to heart disease and stroke is on the increase, according to research funded by the British Heart Foundation (BHF).

In 2013/4 there were around 1.7 million hospital visits for cardiovascular disease across the UK, an increase of 46,000 over three years. The increasing number of hospital visits may be partly due to an increasing and ageing population and improving survival rates. It is putting heavy pressure on the healthcare system.

Dr Nick Townsend, a BHF-funded researcher at University of Oxford, said: “Despite large reductions in mortality from heart disease and stroke, these conditions have remained a substantial burden to the UK, with rises in treatment and hospital admissions for all cardiovascular conditions. There is some evidence that improvements have not occurred equally for men and women or between the countries of the UK: 80% of these increased admissions are men.

“Although these are promising trends for

mortality and stroke admissions in women, prevalence and treatment are increasing over time for all heart disease and stroke.”

The study also found that the burden of cardiovascular disease was different between nations in the UK. Scotland had highest death rates and prevalence of cardiovascular disease in the UK and the

authors say this is potentially because of its higher levels of deprivation.

In Scotland, 4.3 per cent of the population are living with coronary heart disease, compared with 3.9 per cent in both Wales and Northern Ireland, and 3.3 per cent in England.

The study did observe however that the death rate for heart disease and stroke has fallen by 70% over the last 35 years, with 341,000 deaths due to cardiovascular disease in 1979 down to 155,000 deaths in 2014.

In a statement the BHF said: “We believe advances in medical research leading to better diagnosis and treatments have helped dramatically reduce the number of deaths from heart disease and stroke.

But these increasing hospital visits for CVD are placing a massive burden on the healthcare system and more research is urgently needed to prevent, diagnose and treat heart disease.”

Currently, around seven million people in the UK are living with cardiovascular disease. q

BAAPS responds to CQC proposals [THE British Association of Aesthetic Plastic Surgeons (BAAPS) has responded to the proposal to include plastic surgery clinics in an expanded range of service providers to be rated by the CQC. Consultant plastic surgeon and former BAAPS president Douglas McGeorge commented: “At the British Association of Aesthetic Plastic Surgeons we welcome – and indeed, have been calling for during the last decade – as much government scrutiny

Scar-free healing within a decade is the goal [

THE HEALING FOUNDATION has changed its name to The Scar Free Foundation. On 19 July, at an event at The Royal College of Surgeons of England, the charity published its Scar Free Strategy and formally changed its name.

The foundation is setting down the bold ambition of achieving scar-free healing within a generation, building on over 15 years of pioneering research in disfigurement, wound healing and aesthetics research.

Its research strategy envisages a multi-disciplinary and scientific but clinically-driven focus of work over the next 10 years to kickstart a global research movement set to deliver new treatments for patient in both the medium and long term.

Unveiling the change, its chief executive Brendan Eley commented: “We have an excellent track record of research in this area, which is an excellent foundation on which to build our scar free strategy.

We have a challenging fundraising task ahead, but with the single, focused goal of the new charity and the incredible support we receive from organisations like BAAPS and their members, we know that scar free healing within a generation can happen.” q

as is possible of the cosmetic sector. This is an arena where regulation has historically been lax and many practitioners can engage in procedures they are not trained or even qualified to perform.

“However, it is important to stress that the CQC regulates facilities: that is, clinics rather than clinicians. Their remit entails a facility or practice’s aspects such as equipment, record-keeping and administrative areas, so we still call for the public to remain extremely vigilant of – and query – their surgeon’s experience and accreditations.

“At the BAAPS we have always stressed not to be swayed by flashy adverts or offers and to ‘choose a surgeon, not a clinic’.

Members of our organisation must undergo strict criteria to join, such as a number of substantive consultant posts, and thus represent the vast majority of, if not all, NHS-trained plastic surgeons specifically trained in aesthetic or cosmetic practice.” q

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Perils and pitfalls await the unwary expert [

IN ITS NEW Guidance on the Instruction of Experts in Civil Claims, which came into force in December 2014, the Civil Justice Council (CJC) states: “Experts always owe a duty to exercise reasonable skill and care to those instructing them, and to comply with any relevant professional code.

“However, when they are instructed to give or prepare evidence for civil proceedings they have an overriding duty to help the court on matters within their expertise (CPR 35.3). This duty overrides any obligation to the person instructing or paying them. Experts must not serve the exclusive interest of those who retain them.”

A substantial part of the guidance deals with single joint experts, stating: “The CPR encourage the use of joint experts. Wherever possible a joint report should be obtained.

Single joint experts are the norm in cases allocated to the small claims track and the fast track.”

The British Medical Association sums up the duties of a medical expert thus: “Expert evidence should be – and should be seen to be – independent, objective and unbiased.

In particular, an expert witness must not be biased towards the party responsible for paying his or her fee. The evidence should be consistent regardless of who is paying for it.”

There are myriad pitfalls the expert must avoid. They include the very real possibility of a conflict of interest and the risk of straying outside an area of expertise.

Writing in BMJ Careers last year, Melanie Rowles admonished: “Before you accept instructions, you should also ensure that you do not have any conflicts of interest, such as knowing or having worked with any of the doctors concerned. Doctors cannot act as independent expert witnesses if they are familiar with the people involved.”

It is also crucial for an expert to ensure they only give an opinion on issues within their area of expertise – an issue brought into stark relief by the case of Dr Waney Squier in March.

The GMC has this to say on the matter: “You must only give expert testimony and opinions about issues that are within your professional competence. If a particular question or issue falls outside your area of expertise, you should either refuse to answer or answer to the best of your ability but make it clear that you consider the matter to be outside your competence.”

One issue that has come under particular scrutiny recently is that of concurrent expert evidence, or ‘hot-tubbing’, where all the experts in a case are quizzed at the same time. A report into the practice and its use in English litigation was published by the Civil Justice Council on 1 August. The report was produced by a working group under the chairmanship of Professor Rachael Mulheron of Queen Mary

University of London, with Maura McIntosh of Herbert Smith Freehills as deputy chair.

In its Executive Summary, the authors of the report state its achievements: “First, by means of surveys distributed to the judiciary, legal practitioners and expert witnesses, it has been possible to gain a better understanding of how the process of concurrent evidence is operating in English courtrooms, why (and in what areas of litigation) judges and legal practitioners are (or are not) using that process, and whether the overall aims of concurrent expert evidence are being achieved.”

The report is the first by the working group, which was set up to consider and review a series of discrete topics relating to civil litigation. The group’s work will ultimately feed into the Ministry of Justice’s PostImplementation Review of the Jackson reforms, which is due in early 2018. q

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One year on, MedCo is dealing with start-up glitches [

IN MAY THE annual conference of the Association of Personal Injury Lawyers was addressed by Lord Faulks, then minister at the Department of Justice (pictured). Among the subjects of his address was an appraisal of the first year of operation of MedCo, the body set up by the government to facilitate the sourcing of medical reports in soft tissue injury claims brought under the MoJ’s new Pre-Action Protocol for Low Value Personal Injury Claims in Road Traffic Accidents.

Lord Faulks said: “The new portal introduces much needed independence and breaks the financial links between the solicitors who request medical reports and the medical experts and organisations who provide them. MedCo is also about improving the quality of reports and is introducing a robust new accreditation scheme for medical experts.”

Not everything had gone according to plan, a fact acknowledged by MedCo. His Lordship said: “Following the implementation of MedCo, a number of practices have emerged which have the potential to undermine both the government’s policy objectives and public confidence in the system. Such behaviour was not envisaged by the government when the system was developed, and has subsequently been considered as part of the MoJ’s recent review of MedCo. “The government is firm in its belief that practices such as registering multiple ‘shell’ MROs [medical reporting organisations] on the system must stop. The results of the review were published on 24 March which set out detailed measures to be implemented to address these practices.”

The existence of the so-called ‘shell’ organisations was still the subject of MedCo attention as recently as August, when the agency posted a notice on its website stating: “MedCo is continuing to

receive multiple registration applications for non-HVN [high-volume national] MROs, despite the stated intention to remove ‘shell companies’ from the system when the MoJ publishes its new definition of an MRO and related qualifying criteria.”

The statement followed similar action taken in May. “The MedCo Board anticipates that all ‘multiple registered’ nonHVN MROs will be made non-operational and removed from the MedCo system when the Ministry of Justice implements its new policy on multiple registrations and the new definition of an MRO. In these circumstances, and in accordance with the terms of the agreements signed by those companies, registration fees will not be refunded.”

All-in-all, though, according to Lord Faulks: “The government is pleased with

the work of MedCo one year in. The system is currently being used by authorised users to source over 40,000 medical reports a month, and the MedCo Board is able to analyse management information from the system to successfully identify a large number of attempts to circumvent the system by lawyers, MROs and experts.” q

Deadlines announced for medical experts [ON 25 JULY MedCo published the deadlines for uploading case data by experts.

The announcement read: “MedCo has contacted MROs and Direct Medical Experts to inform them that on completion of a medical report, case data must be uploaded to the MedCo system within a maximum period of six months from the date of their selection by the instructing party. Full details of the information required to be uploaded can be found in the Data Validation Rules document located on the MedCo website.

“Having analysed management information, MedCo is additionally in the process of communicating directly with specific MROs and Direct Medical Experts regarding their failure to upload medical case data.

“MROS and Direct Medical Experts are required to upload medical case data as part of the MedCo Data Contributor Agreement. Organisations and experts found to be in breach of the Agreement may be subject to enforcement action.

“The information required to be uploaded does not constitute personal data within the meaning of the Data Protection Act 1998 and therefore no consent is required.” q

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The personal stereo revolution may not be music to insurers’ ears [ A POSSIBLE EMERGING trend in noise-induced

hearing loss (NIHL) is among the population in general, associated with the explosion in the use of personal listening devices (PLDs). The sight of half of the population walking the streets with headphones clamped to their ears could be storing up a hearingloss disaster for the future.

The issue was highlighted in a recent article by Amy Teece of law firm Norton Rose Fulbright, who wrote: “PLD manufacturers typically provide volume warnings, and many incorporate functions within the device to limit volume levels.

However, focusing solely on the volume ignores overall daily noise exposure, meaning prolonged use of headphones at a safe level could actually be unsafe.

“Young people pose a significant claims risk to insurers, as their ears are medically more susceptible to the effects of noise exposure and the scale of the problem may not become evident for many years.”

She continued: “In addition, the Consumer Protection Act (CPA) 1987 creates a regime of strict liability for defective products. Under the CPA a product is defective if ‘the safety of the product is not such as persons generally are entitled to expect’.

Consumers are entitled to expect appropriate information and warnings regardless of age or vulnerability, so warnings will need to be extremely clear and obvious in order to deem a product safe.” q

Noise at work can lead to PI claims [

ACCORDING TO THE Health and Safety Executive, around 17,000 people in the UK suffer from deafness, tinnitus or other ear conditions caused by excessive noise at work. The legislation covering the issue is the Control of Noise at Work Regulations 2005.

According to the Association of Personal Injury Lawyers (APIL): “Over time, a noisy working environment can cause long-term hearing damage. People can find themselves asking people to repeat themselves frequently and turning the volume up on the radio and television. If you have hearing problems having worked in a noisy environment you may be able to make a claim for compensation; even if you no longer work there.”

A leading manufacturer of noise monitoring equipment is Pulsar Instruments. The company said in its August blog: “Excessive levels of noise disrupt, distract, or detract from regular functioning. And while people mainly think of noise pollution as an urban problem, overexposure to noise at work remains the main cause of irreversible hearing loss.

“This is especially true in industries such as construction, manufacturing and engineering where long term exposure to loud or persistent noises combined with poor protection has the biggest impact on our health and productivity. Hearing loss at work is avoidable through prevention, so don’t get complacent!”

The HSE is encouraging employers to invest in low-noise machinery and equipment via participation in the international Buy Quiet campaign.

Say the HSE: “Employers sometimes find it difficult to achieve

adequate noise control through engineering methods and rely on personal hearing protection programmes. This is not appropriate as the hazard, or noise source, is still present.

“Improvements in the quality of noise information supplied with work equipment are slowly trickling through to the market. However, some manufacturers of work equipment could do more to reduce risk from noise at source and improve the quality of noise information supplied with their products.” q

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Focus on total hip replacement

By MR NIKHIL SHAH, Consultant Orthopaedic and Trauma Surgeon, Centre for Hip Surgery, Wrightington Hospital UK Sir John Charnley has been credited for designing and developing the first successful total hip replacement, or low frictional torque arthroplasty, in the sixties at Wrightington hospital in Lancashire.

It revolutionised the treatment of thousands of patients who were effectively crippled by severely painful disabling hip arthritis. Indeed, the Charnley hip continues to show some of the best long term survivorship in the orthopaedic literature with results now reaching well into the fifth decade.

This brief article will trace some of the principles and developments associated with total hip replacement.

[FIGURE 1 shows an X-ray of a Charnley

hip replacement at 33 years after implantation in a young and active patient who had painful hip arthritis. The surgery was performed using the approach of trochanteric osteotomy which was then fixed with wires. Nowadays many different surgical approaches have been developed to implant a hip prosthesis.

Fig 1 With changing demographics, an everincreasing young population performing physically demanding activities are presenting for hip replacement surgery.

Although the Charnley hip was often erroneously deemed to be suitable only for elderly patients, a logical analysis will tell us that 40-year survivorship data can only be reported if the patients were young at the time of surgery!

Another successful design that has produced outstanding long-term results in both young and old patients is the highly successful Exeter total hip replacement developed by Ling and colleagues.

A total hip replacement basically consists of a stem that is fixed to the femur and a

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socket that is fixed to the acetabulum (socket of the hip). Both the Charnley and Exeter designs were fixed with cement. The two components articulate with each other by what is referred to as the ‘bearing’.

Charnley introduced the use of PMMA cement to fix the components to bone. He also experimented with different materials.

After his initial experiments with Teflon as a material were unsuccessful he developed, along with his engineer, the use of high density polyethylene (HDPE) as the material of choice to manufacture the socket. The original designs had a stainless steel femoral head matching up with a ‘plastic’ or HDPE socket.

These ‘gold standard’ designs continue to be the benchmark against which all new designs and bearings will be compared. Not only has it been successfully used in primary osteoarthritis, but in a variety of other conditions that lead to painful degeneration of the hip – such as inflammatory arthritis, avascular necrosis or post-traumatic arthritis following acetabulum fractures.

Fig 2 Figure 2 shows an X-ray of a hip which has developed accelerated secondary post-traumatic arthritis many years

following a severe fracture of the hip socket which was damaged in a road traffic collision. The fracture was fixed with plates and screws and helped the patient to function well for a number of years. After the hip developed arthritis a few years later it was treated with a cemented total hip replacement to improve pain and restore function.

However cement was thought by some surgeons, particularly in North America, to be the weak link and the misnomer ‘cement disease’ unfortunately became the buzz word leading to various attempts to develop cementless fixation for the stem and socket, particularly in many North American and European centres.

Unfortunately many of the earlier cementless designs did not perform too well, although a handful did. As we learned more about the failure mechanisms, and as engineering concepts and processes became better, even the cementless hip designs have become more reliable in providing good outcomes.

Whilst the orthopaedic community continues to debate the relative merits and disadvantages of cemented versus cementless fixation, suffice it to say that well-performed, good designs of both types can provide durable fixation and give good long term outcomes.

The debate has therefore now shifted to the bearing components. The original bearings consisted of metal femoral head moving within a polyethylene socket. Over the years other bearing combinations have been developed such as ceramic, all-metal bearings and Oxinium.

Ceramic bearings have excellent wear properties and hold a lot of promise in younger patients, although they are expensive and known to be brittle. Whilst they were hoped to be significantly better

compared to established designs, the current orthopaedic literature has failed to show a major advantage of hard-on-hard ceramic bearings compared to the gold standards.

The all-metal design, of course, is wellknown to most and has received a lot of adverse media attention recently. Metal-onmetal resurfacings and replacements were thought to be suitable for active younger patients based on engineering data of reduced wear, improved movement and stability, and better lubrication regimes.

Many such designs came on to the market in an uncontrolled fashion in a relatively short period of time and several thousand got implanted.

Unfortunately the metal ion released from the large diameter bearings caused adverse soft tissue reactions in many hips leading to early failure requiring revision surgeries.

This resulted in many unfortunate patients suffering from pain and needing additional surgery. It is perhaps not known to many that Charnley had experimented with the concept of resurfacing and discarded it almost half a century before it made an attempt to come back!

Regrettably this was not the first design to show high failure rates. There have been other attempts to develop hip designs that have also failed and ultimately been withdrawn from the market. Such failures

in high volumes have resulted in efforts at national and international level to improve the regulation of how prostheses are introduced into the market and prevent future harm to patients in large numbers.

The UK has been a pioneer in introducing ‘beyond compliance’ – a service to support the safe and stepwise introduction of new or modified implants such as joint replacements.

Better understanding and manufacturing also led to improved plastic components which would show less wear. It was recognised that cross-linking the chains of the polyethylene significantly improves the long term wear properties. Over the last two decades there has been growing interest and increasing usage of highly cross-linked polyethylene. The results so far have been promising and future research will probably be focussed on improving the wear properties of the bearing that is implanted. Looking at current evidence, the combination of using a ceramic head on a highly cross-linked polyethylene socket promises to be an excellent bearing choice for the future, particularly in young patients.

The genius of John Charnley did not stop with just designing one of the world’s best known and longest surviving hip prosthesis, but went much beyond that.

He predicted, decades earlier, the need for setting up national joint registries to

monitor the performance of various designs of hip replacements. The Scandinavian registries and now the UK national joint registry have played an important role in informing practice and monitoring prosthetic performance.

Other developments have revolved around minimal access surgery, designed to reduce surgical insult and improve recovery times, and computer navigation to improve reproducible placement of implants and reduce outliers. However their long term benefits are not yet apparent. Recent advances have also focussed on making the operation safer and better for patients and improving the overall patient experience by better education, counselling and pain management with accelerated rehabilitation protocols which encourage patients to start mobilising soon after surgery and allow them to go home much earlier.

Not every innovation will necessarily stand the test of time and some may be retrograde and even harmful.

Future developments are bound to be driven by evidence and also by global economic constraints in healthcare provision. All innovation should ultimately be patient-centric and aim to improve the care we give to our patients by making total hip replacement, considered to be the ‘operation of the century,’ even better and safer for our patients. q

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Chronic postsurgical pain and consent

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

[

FOLLOWING AN OPERATION, it is normal to experience acute postoperative pain associated with the surgical trauma.

Standard painkillers such as anti-inflammatories and morphine may be used to manage this acute pain. Unfortunately, a minority of patients go on to subsequently develop chronic postsurgical pain that may last months or even years and may be resistant to conventional painkillers.

The overall incidence of chronic postsurgical pain in general is approximately 5-10% but the risk varies between procedures: thoracotomy (40-50%), mastectomy (20-30%), amputation (50-80%), laparoscopic cholecystectomy (10-20%), inguinal hernia repair (9%). Risk factors for chronic postsurgical pain include severe acute postoperative pain, surgical trauma to major nerves, repeated procedures and also psychological vulnerability – however, in individual cases the exact mechanism may be unclear.

Many cases of chronic postsurgical pain are due to ‘neuropathic’ pain (nerve pain). This is often characterised as a burning, sharp, shooting or gnawing pain or as a sensation like an electric shock. It may be associated with demonstrable sensory loss and paradoxical hypersensitivity within the same anatomical location.

The internal organs themselves may also become sensitised after surgery, this is termed ‘visceral hypersensitivity.’ The symptoms may not necessarily emerge immediately after the operation itself and in some cases may manifest weeks later.

Postoperative neuropathic pain is largely not a surgical failure and many cases may settle over time if managed appropriately.

The best way to minimise the risk of chronic neuropathic pain is to use minimally invasive techniques, to avoid nerve damage or

traction and to encourage regional anaesthesia where possible.

The early identification and referral of patients with neuropathic symptoms to pain specialists may also minimise the risk of chronicity.

For surgical consent to be valid, the patient must have sufficient information to make a choice which includes a thorough overview of the risks. Some surgeons may be in denial regarding the risk of their patients developing chronic postsurgical pain and therefore neglect to mention the inherent risk. The ‘Bolam Test’ asks whether a doctor’s conduct would be supported by a responsible body of medical opinion – ie other surgeons. However, following the judgement in the case of Montgomery versus Lanarkshire Health Board this has changed and represents a move away from medical paternalism:

“

The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.

”

Indeed, chronic postsurgical pain may develop after a perfectly executed and technically flawless operation and surgeons should not be held responsible for causing the condition itself. However, surgeons do have a duty of care to make their patients aware of the risk of developing this potentially disabling condition, in order to help them decide for themselves whether or not to undergo a particular treatment.

The process of obtaining informed consent for surgical procedures often fails to provide sufficient information to prospective patients. As a result, some patients who are undergoing major surgery may be unaware of the risks they face. In this situation there could be an argument to say the doctor may be in breach of their duty of care in the process of obtaining informed consent for surgical procedures by failing to provide sufficient information.

As a result, some patients who are about to undergo major surgery may be unaware of the risks they face and their doctor or surgeon may be in breach of their duty of care to inform patients of the risks to which a reasonable person in the patient’s position would be likely to attach significance.

Failure to warn of chronic postsurgical pain in high-risk operations may be considered a form of clinical negligence.

It is therefore of paramount importance to raise more awareness of this issue within the surgical profession. q www.yourexpertwitness.co.uk

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The role of the urological expert witness

By CHRIS DAWSON MS FRCS LLDip, Consultant Urologist

[

MEDICOLEGAL WORK involving a urological expert witness can generally be divided into three areas: personal injury, medical negligence and criminal cases.

Personal injury cases: These cases commonly result from road traffic accidents. In some instances the claimants have multiple injuries involving pelvic trauma – they are left with urinary problems, due to urethral injury, or erectile dysfunction, from pelvic nerve and blood vessel trauma.

Causation in these severe cases is usually straightforward for the urologist. Treatment with PDE5 inhibitors such as Viagra or Cialis may help the erectile dysfunction, while urethroplasty or reconstruction may be required where there has been severe urethral trauma.

Abdominal trauma may also lead to renal damage or, rarely, loss of a kidney. The urologist can comment on prognosis and the risk of damage to the other kidney in later life.

Medical negligence: Compared to other specialties the rate of medical negligence cases appears low, but testicular torsion cases feature regularly.

Following the onset of pain, due to twisting of the testicle around the spermatic cord, early intervention is required to prevent ischaemia and the loss of the testis. The signs can be difficult to diagnose.

Where diagnostic uncertainty exists the affected scrotum should be explored surgically as soon as possible. In my experience most claims result from instances where the torsion is misdiagnosed as infection (orchitis) and the claimant sent home, representing with continued pain at a later time.

Ischaemia can occur as soon as four hours after the onset of torsion, with the potential for loss of the testis. Reports in this area usually require a view on liability and causation, and often condition and prognosis as well, in view of the risks to future fertility from the loss of the testis.

A common area requiring medical negligence reports from a urology expert is ureteric damage occurring during gynaecology procedures. The

ureter runs close to the female cervix and is prone to injury at that site during hysterectomy, removal of large ovarian cysts or emergency caesarian section. The bladder may also be damaged during these procedures. I have also been asked to comment on ureter and bladder damage occurring during colorectal procedures.

Liability will be a matter for the expert witness in gynaecology or surgery, leaving the urology expert to comment on causation and condition and prognosis.

Another area for medical negligence reports is the development of cauda equina syndrome (CES) after an alleged delay in treatment for severe back pain. CES develops when damage occurs to the distal part of the spinal cord. The nerves in that area innervate the bladder, lower bowel and anus, and the genitalia.

The degrees of CES that result can vary, but at its most extreme it leads to an underactive bladder with incomplete emptying. There is also typically loss of anal tone and perianal sensation. There may be complete loss of erection in men and lack of vaginal/genital sensation in women. Urology reports focus on matters of causation, and condition and prognosis.

Criminal cases: In my experience the opportunity for urology expert reports in criminal cases is limited, and predominantly involves rape or sexual assault cases.

The reports are usually commissioned by the defence and suggest that the alleged offence could not have taken place because the defendant suffers from erectile dysfunction. The role of the expert will be to examine the defendant’s records and the claimant. In routine clinical care the fact that the patient claims to have erectile problems is taken for granted, whereas in criminal cases the veracity of the defendant is for the court to decide. There is no available test to prove the defendant is incapable of having a penile erection. q

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And the CT shows… undue reliance on modern technology causes problems

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

[

IN RECENT YEARS there have been huge advances in medical management and treatment of patients with a wide range of illnesses. Prominent amongst these is computerised axial tomography, more generally referred to as CT imaging.

A CT scan gives high resolution x-ray images of our patients which is invaluable in the diagnosis of many conditions, including in my own field of vascular surgery. Detailed images of blood vessels are essential in the management of diseases of arteries and veins. Radiologists are now skilled in the interpretation of the images obtained from these investigations. The diagnosis is not automatically apparent from the images – which may have been degraded by technical problems related to the patient or possibly other issues – and so interpretation by a skilled expert is essential.

CT imaging offers much more detailed images of the internal workings of the A pulmonary embolism removed at post-mortem examination. The blood clot formed in human body than ever before. This has the veins of the legs and then travelled via the right side of the heart into the main artery led to considerable reliance being placed to the lungs where it completely blocked the circulation on the results of these investigations.

One of my colleagues refers to this as the ‘and the CT shows…’ syndrome. A call from one of the junior staff but a CT scan failed to confirm this. Treatment continued as for indicates that a patient with abdominal symptoms has arrived in a chest infection. Another CT scan was done after two further the emergency department, and the CT shows some finding. In days when the diagnosis was still not clear. Again, the CT images clinical medicine a working diagnosis is generally reached on the were reported as excluding a pulmonary embolism. The patient’s basis of the medical history of the current event combined with condition deteriorated with failing respiratory function. One week detailed clinical examination. Some blood tests can often be done after the onset of symptoms, the earlier CT scans were reviewed fairly quickly to assist in the diagnosis. Before CT imaging was and the appearances of a pulmonary embolism were recognised. widely available, detailed appraisal of this information led to a The patient’s condition slowly improved on anticoagulant treatment, working diagnosis on which treatment could be based. These days, but after a protracted period of respiratory failure and low blood a CT scan can be arranged rapidly and the results often trump the pressure, he suffered both liver and kidney failure. clinical or blood tests findings.

In a second case, a patient presented with a 2 to 3 month history Considerable reliance is placed on CT findings, but no test that of increasing shortness of breath and malaise, including weight I know detects 100% of a particular pathology or is completely loss. She had received treatment for asthma, but this had not reliable in excluding the pathology when, in fact, it is not there! All improved the symptoms. A chest x-ray was normal but blood tests tests have some false negative and false positive results. So CT showed reduced blood oxygen levels. A d-dimer measurement, findings, as with all investigations, should be carefully appraised in as an assessment of the presence of thrombosis, was three times the context of the clinical and other pathology findings. the upper level of normal, suggesting that pulmonary embolism was the cause of the illness. A CT scan was done and reported Problems in the diagnosis of pulmonary embolism as negative for pulmonary embolism. The d-dimer result was In one case where I advised, the claimant underwent a major interpreted as a false positive due to the presence of a rare abdominal operation and appropriate treatment was given to inflammatory disease of the lung. The patient was discharged prevent post-operative deep vein thrombosis. On the second with a diagnosis of asthma but returned five days later in a worse day following surgery the patient became unwell with low blood state. The blood oxygen level was low, heart rate was high, oxygen levels. The most likely diagnosis was pulmonary embolism blood pressure was low and an ECG showed classical findings

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associated with a pulmonary embolism. The chest x-ray showed a region of minor shadowing. Very few conditions give rise to such a clinical picture apart from pulmonary embolism. The CT findings were recorded in the clinical records from the earlier attendance and the diagnosis of pulmonary embolism was not considered further. The patient died about eight hours after admission. Postmortem examination confirmed that the cause of death was pulmonary embolism and no other disease process was found.

In both cases, there was clear clinical evidence of pulmonary embolism, but the clinical findings, blood tests and conventional x-rays were disregarded in the light of the CT angiogram findings.

As I noted above, no investigation is perfect and all carry the risk of missing the diagnosis that is really there, or finding a diagnosis that isn’t. The management of pulmonary embolism relies on the use of the anticoagulant drug heparin. This should not be given where there is a risk that it will cause haemorrhage, but in neither of the cases mentioned above was there a contraindication to treat with heparin. Heparin treatment in pulmonary embolism is very effective and prevents death in 98% of patients overall and in 85% of those with massive pulmonary embolism, where the blood pressure is low and the circulations is compromised. If there is some doubt about the diagnosis, due to conflicting clinical evidence and the outcome of CT imaging, heparin can usually be given safely with the benefit of preventing death or serious illness should the CT findings prove to be a false negative.

It could be said that to ignore the majority of clinical evidence and results from blood tests in favour of one imaging investigation could comprise substandard treatment. No single investigation should trump the remainder of the clinical information and tests. The whole clinical picture should be evaluated in order to reach an appropriate working diagnosis. Despite the advance of modern technology, over-reliance on any one investigation invites misdiagnosis. q

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Why developmental trauma must be addressed in the Family Courts

By Dr ANDREW DERRY, Consultant Clinical Psychologist

[SINCE THE late 19th century, psychological trauma has been

increasingly recognised as one of key precursors to mental illness, although it was not until the 1980s that the psychological effect of trauma was formally recognised as a diagnosis.

Developmental trauma, such as physical or sexual abuse, has been found to differ from adult trauma in a number of important ways: it often occurs over longer periods of time, it is often perpetrated by a carer and it impacts on a child’s developing brain.

The effect of trauma can be plotted along the developmental pathway, from early poor emotional regulation, childhood disorders and personality development to adult mental health, substance abuse, poor relationships and bad social adjustment in adulthood.

Measuring the prevalence of developmental trauma is not an exact science and depends on definitions of trauma. When we include a broader definition of neglect and emotional harm, we can estimate that the majority of the 62,210 children subject to child protection plans will have suffered some developmental trauma – making it one of the single greatest health challenges in our society today.

Assessing developmental trauma in parents is often key to understanding parental difficulties and the risk of harm to children in cases brought before the Family Courts. The consequences of developmental trauma, such as adult mental health or personality problems, substance abuse and abusive relationships, form the key parental factors most closely associated with harm to a child.

Whether or not a parent can resolve their parenting difficulties is

often determined by whether they can address those traumatic experiences. In the Criminal Courts, understanding the influence of developmental trauma on criminal behaviour can often be central to assessing the risk of future offending, as well as making recommendations for intervention.

Developmental trauma may not present the typical constellation of post-traumatic stress disorder (PTSD) and symptoms can often be confounded with other diagnoses – such as conduct disorders or ADHD in childhood, or personality and mental health disorders in adulthood.

Complex developmental trauma is notoriously difficult to address psychologically within the timescales now set by the Family Courts. Yet some short-term interventions such as cognitive behaviour therapy (CBT) or eye movement de-sensitisation and reprocessing (EMDR) have been shown to help people regulate their psychological response to traumatic reminders. In more complex cases, individuals often need to develop their skills for coping with intrusive or distressing reminders before the developmental trauma can be addressed.

For professionals working to protect children in the Family Courts, understanding developmental trauma is central to formulating psychological interventions for both children and parents, to prevent the cycle of abuse progressing from one generation to the next. q • Dr Derry is a Consultant Clinical Psychologist at Psychology Experts.

Smartphone app can help predict potential suicides [

RESEARCH PRESENTED AT the Royal College of Psychiatrists’ International Congress in June showed how a smartphone app and a computer test can help identify suicidal patients.

Researchers at Harvard University are developing technology-based ways to prevent suicides. The university’s Professor Matthew Nock and his team hope to identify those patients most at risk.

The app requests information on a patient’s suicidal thoughts and behaviours throughout the day at specific and random intervals. The information is then sent to a central database and can be analysed for underlying trends.

The technique is called ‘ecological momentary assessment’ and it aims to capture real time information about suicidal thoughts and behaviours rather than asking patients to recall such events that have occurred in the past. By gathering real time information, it is hoped that new insights about potential triggers for suicidal thoughts and behaviours can be discovered as well as better ways of predicting future suicide attempts.

Dr Mayowa Oyesanya of the Royal College of Psychiatrists said: “These novel approaches to suicide risk assessment have the potential to improve upon current methods of identifying patients at high risk of attempting suicide. By gaining an insight into patients’ implicit suicidal associations we can create tests that are difficult to falsify and straightforward to run.

“Using mobile smartphone technology we can also gain an insight into people's suicidal thoughts and behaviours as they occur in their lives rather than in the lab. Hopefully we can gain new insights about the ways in which suicidal thoughts and behaviours occur in people’s lives and why they do.” q www.yourexpertwitness.co.uk

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Special measures can help vulnerable patients in court [ A PAPER PUBLISHED in the BJPsych

Bulletin – the journal of the Royal College of Psychiatrists – outlined ways in which special measures can be implemented to help people with psychiatric problems cope in the courtroom.

In the abstract to Vulnerable patients going to court: a psychiatrist's guide to special measures, Penny Cooper and Janet Grace write: “There have been significant changes to how vulnerable people are treated in the court system, including the introduction of special measures to support people both as witness and as accused.”

The abstract continues: “It is not uncommon for psychiatric patients to be involved in court proceedings and as many psychiatrists know (some from first-hand experience) going to court can be a stressful event. In addition, mental illness, neurocognitive impairment or developmental disorder can create a barrier to access to giving evidence or to being able to take part in a trial.

“In recognition of this, major changes in the judicial approach have been made, including the use of ‘special measures’ for certain witnesses. This article summarises the latest judicial approaches and considers their clinical applications.”

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The authors explain how the criminal justice system has ‘led the way in making adjustments for vulnerable witnesses and defendants’.

“Any person under 18 years or whose ability to take part in a trial, either as a defendant or a witness, is affected by a mental or physical disorder or impairment of their intellectual or social functioning is potentially vulnerable and eligible for

special measures. The person's views must be taken into account. Even if no party applies for them, the judge can decide that special measures should be used.”

The paper goes on to explain recent changes in the law, describe best practice and ground rules hearing, and how other courts are now following suit. The authors cite a number of case studies. q

Workplace injuries can be psychological [

IT IS OFTEN very easy to forget that an accident at work that results in a physical injury may also lead to certain people developing psychological injury. That is the view of Usheena Patel, a solicitor with Hodge, Jones and Allen.

Writing on the firm’s blog, she points out that: “A psychological injury is no less traumatic compared to a visible physical injury and can have a long lasting effect.” She goes on to point out the potential legal consequences.

“An employer has a responsibility and duty of care that includes an employee’s mental health as well as their physical well-being. An employer must take reasonable steps to minimise the risk of both a psychological injury and physical injury. Failure to do so can leave an employer liable for compensation.

“Mental and emotional distress is a common feature of workplace accidents but can be harder to treat unlike the physical aspects of an injury.”

She concludes: “There are a great many sensitivities to be considered around mental health issues at work. If you are experiencing psychological symptoms that are affecting your wellbeing, it is important that you seek guidance from your GP.” q

The financial, psychological and social cost of brain injury [ TRAUMATIC BRAIN INJURY costs a total of £15bn nationally

every year and puts young people at higher risk of poor mental health and offending, according to research published by the Centre for Mental Health.

The report, Traumatic brain injury and offending: An economic analysis,, found that head injuries, in which the brain is damaged by impact, double a person’s risk of later mental illness. These injuries dramatically increase the risk of earlier death and can play a significant role in increasing the risk of future offending – by up to 50% according to some studies.

The report was funded by the Barrow Cadbury Trust, which also supported an evaluation of the Disabilities Trust’s brain injury linkworker service at a young offender institution as part of its Transition to Adulthood (T2A) programme.

Traumatic brain injuries cause about 160,000 people to be admitted to hospital in the UK each year, and about 1.3 million people are living with disabilities resulting from these injuries. Injuries at a young age can result in serious and long-term impairments in brain development.

The economic cost of £15bn a year includes the costs of lost work, health and social care and premature mortality.

In addition, an estimated 60% of adult offenders in the UK have had a traumatic brain injury, six times higher than the rate among the wider population. The report finds that the long-term cost of head injury in a young offender is some £440,000.

Deborah Fortescue from the Disabilities Trust said: “The prevalence of brain injury within the criminal justice system should no longer be ignored. We have a great opportunity to think differently; we must screen for brain injury throughout the criminal justice system, train staff to address their needs and embed specialist services.

Ultimately we need to understand the pathways to crime, so that we can learn which of the multiple factors and circumstances appear to support positive outcomes for those people who have a brain injury, but never come into contact with the criminal justice system.”

Peter McCabe, chief executive of charity Headway, said: “There is clear evidence that brain injury is over-represented in the criminal justice system and this needs addressing. It is vital that all agencies better identify brain injury at the earliest possible stage in the criminal justice system. Doing so can ensure that people receive appropriate support – whether perpetrators, victims or witnesses of crime.

“More must be done to provide prisoners living with brain injury with rehabilitation and support services to help reduce reoffending behaviour. It’s also worth remembering that rehabilitation can often be more effective than incarceration.”

The study follows the publication in June of a paper in Advances in Clinical Neuroscience and Rehabilitation detailing the instances of offending by children and young people with acquired brain injury. The paper was written by Louise Blakeborough MSc, on behalf of United Kingdom Acquired Brain Injury Forum.

In it she states: “Loss of memory, loss of concentration, decreased awareness of one’s own or others emotional state, poor impulse control and particularly poor social judgment are all consequences of brain injury. It is also associated with greater

mental health problems, higher rates of depression or mood disorder and/or childhood developmental disorders. Brain injury is potentially more damaging in younger people because of the potential to disrupt cognitive development which can lead to an increased tendency for offending behaviour.” q

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Public health issues in Britain today

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

[

IN JULY 1948, at Park Hospital in Manchester, the National Health Service was launched by Health Secretary Aneurin Bevan, in order to provide a service that was free to all citizens at the point of delivery. The NHS was to provide specialist consultants in hospitals to cater for serious injuries and diseases to patients on an individual basis and a GP service to treat individual patients presenting with non-life threatening illnesses and injuries. In the area of public health, the NHS had responsibility in the epidemiological and clinical sectors for the prevention of disease among the population as a whole.

In this universe everything changes except for that principle – and religious beliefs. Let us look at the area of public health.

Until the 1970s, epidemiological public health was run by medical officers employed by local authorities. Politics, economics, academics and the law have as much to do with patient care as medicine, so in the 1980s, due to financial constraints, the epidemiological sector was reduced in size and function.

In keeping with the English cultural custom of ‘nice moves’ – that is sacking by promoting – all medical officers were promoted to become consultant community physicians, employed by Primary Care Trusts and given hospital management roles.

Now, the responsibility for public health has been given back to local authorities and is run by consultants or directors. Cost cutting is still ongoing and increasingly some public health managers are not doctors, so as to reduce the wage bill. The future is uncertain but there will always be a need for such a service.

Clinical public health used to be known jointly as community paediatrics and the school health service. This service was run by clinical medical officers, health visitors, school nurses and administration staff based in local health clinics.

The service was terminated gradually between 1997 and 2000 due to national economic considerations. The main functions of the service for children included intensive child surveillance, immunisation and regular supervision of nurseries and care homes. It also covered the

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management of educational difficulties and the issuing of appropriate work certificates to every child on leaving school.

After birth, every child was visited at home by a midwife until they were 15 days old. After the first two weeks the child received home visits from health visitors and attended child health clinics to be seen by a clinical medical officer. That continued until the age of four.

These visits were compulsory and provided support for both parents and children. Every child was supervised in a nursery by a visiting medical officer until they reached five years of age. After this time, until reaching the age of 16 or 18, each child was supervised by a fulltime school nurse who had good liaison and communication with their teachers and head teachers.

Every child was examined and assessed for developmental and health issues by an independent community clinical medical officer, who was not the family doctor and had an objective approach. These examinations were carried out at the local child health clinic at the ages of six weeks, eight months, two-and-a-half years and four years. Once at school a child was examined at the age of five, 10 and 15 years.

Child negligence, physical abuse and sexual abuse were detected over time and managed via close supervision by health staff: especially the independent doctors and nurses.

On leaving school, every child was given a fitness for work certificate – either with no conditions, or a condition such as a need to wear glasses. Two copies were kept on file, two were sent to the Home Office and two were sent to the Ministry of Defence. A large number of armed and other service personnel would be serving abroad. These forces were mainly men, as it was physically hard work, with the support of the women’s forces.

Every child's care was shared equally by their parents and the government and this is still the case today. Then, as now, the Family Courts dealt with litigation cases as and when necessary.

Clinical public health was an excellent service which no longer exists due to national financial constraints. These days, if a social worker has to visit a family in a suspected or alleged case of child abuse, they must visit the home, often accompanied by a police officer.

It is no wonder that, in the UK today, cases of child neglect and physical and sexual abuse are hard to detect, deal with and eliminate. There may be similar problems in other countries and solutions will only be found through constructive discussion. q

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