Your Expert Witness Issue No. 44

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contents IN THIS ISSUE 7

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Opening Statement

NEWS 9 NCA chief calls for continued enforcement co-operation post-Brexit 9 New group ensures justice is seen to be done 9 MoJ is ‘robbing Peter to pay Paul’, says Law Society ROAD TRAFFIC ACCIDENT INVESTIGATION 10 Motor crash investigation enters the world of the black box 10 'ULQN GULYLQJ LQFLGHQWV LQFUHDVLQJ 'I7 ¿JXUHV VKRZ 13 Summer peace set to be shattered by crash testing 13 Mr Loophole calls for outright ban on phoning while driving FORENSICS 14 Forensics in crisis: regulator makes stark prediction 14 &HUWL¿FDWLRQ JDLQHG IRU ERG\ FDPHUD XVH BUILDING & PROPERTY 15 /HDVHKROG PDUNHW LV DFWXDOO\ JURZLQJ UHVHDUFK ¿QGV 15 3URIHVVLRQDO 6WDWHPHQW UHÀHFWV QHZ PHDVXUHPHQW VWDQGDUGV

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INVESTIGATION & LITIGATION SUPPORT 16 Due process? Leave it to the experts 16 Code governs use of covert surveillance by employers CULTURAL, RELIGIOUS & ETHNIC ISSUES 17 The cultural, religious and ethnic factors at play in the problem of loneliness WILLS, LEGACIES & CHARITABLE BEQUESTS 18 The GDPR deadline looms for charity fundraisers 19 Legacy sector comes together for annual gathering 19 Education through the power of play 19 Surgery saves lives 20 If you Will, we will 20 Funding helps enhance quality of life 21 Minister encourages lawyers to support legacy giving 21 Support for small charities makes the agenda 21 Help for those with failing sight 22 Horses’ plight sparked the beginning of a dream 23 Regulator publishes updated register and changes to code 23 Legacies – the gift of life 24 How to support those who support victims 24 Charity carries on the work of its founder 25 $QQXDO FDPSDLJQ ¿QGV D OLQN WR WKH SDVW 25 +ROLGD\V KHOS ERRVW FRQ¿GHQFH RI \RXQJ FDQFHU SDWLHQWV 25 Supporting the maritime community

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A to Z WEBSITE GUIDE 26 Our A to Z guide to the websites of some of the country’s leading expert witnesses.

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MEDICAL ISSUES 29 Medical Notes

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NEWS 31 Bawa-Garba case prompts multiple reviews and international outcry 31 Doctors fear condemning themselves 32 MedCo in firing line over fee hike 33 Prescription errors prompt Hunt to action 33 Randox affair takes another twist 35 NHS chief joins calls for fee cap in clin neg cases 35 NHS cybersecurity still not up to scratch 36 Junior doctors welcome review of assessment 36 CQC publishes report on Huntercombe HEARING LOSS 37 Hearing charity flags up the danger of loud music 37 Some Underground journeys loud enough to damage hearing, claims BBC ORTHOPAEDICS 38 Orthopaedic association marks centenary of WWI establishment 39 Lawyers need access to the best medico-legal opinion 41 Research centre secures funding for another five years 41 Study raises neurological anxieties of hip MoM toxicity

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PAIN 42 New chronic pain charity launched 43 The back of litigation 44 What is the role of a pain management programme?

UROLOGY 45 The role of the urological expert witness DENTISTRY & MAXILLOFACIAL SURGERY 47 Take back primary care support services, says BDA 47 Maxfax committee chair pledges training refocus 47 Surgeon helps Richard fight his war HERNIA REPAIR 48 Inguinal hernia repair can result in some difficult complications

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CARDIOLOGY 49 Reduction in heart death rate at a ‘near standstill’ 49 Heart doctors warn of steroid risk PSYCHIATRIC & PSYCHOLOGICAL ISSUES 50 MUPS: attempting to explain the unexplained is a challenge in medico-legal cases 51 Psychiatry chief welcomes addiction review 51 BPS offers new guidance on refugees 53 New research is leading to rapid progress in PTSD treatment OPHTHALMOLOGY 55 NICE guidance could open door for cost-savings in AMD care 55 RNIB speaks from the heart on PIPs PLASTIC, RECONSTRUCTIVE & HAND SURGERY 57 Patients stay awake during hand surgery OBSTETRICS & GYNAECOLOGY 58 International awareness day puts spotlight back on FGM 59 MRI scans help understand brain injury in prem babies 59 Maternity champions can improve care, says midwives’ union

EXPERT CLASSIFIED 60 Expert Witness classified listings 63 Medico-legal classified listings www.yourexpertwitness.co.uk

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Opening Statement [THE DEMISE OF local newspapers and subsequent fall-off in local court reporting is a recurrent theme

in discussions of trends in news delivery. The absence of professional news reporting can lead to a vacuum being filled by rumour and – even more ominously – ‘fake news’.

The establishment by HM Courts and Tribunal Service of a group to promote press reporting of court proceedings is to be welcomed by anyone keen to see the administration of justice reported accurately and fairly. The ‘legal establishment’ has taken plenty of flack in recent years for its tendency to shroud itself in obfuscation and even secrecy, so it is particularly significant that the initiative comes from HMCTS itself.

• One of the arduous parts of the judicial process is the processing and serving of the myriad papers that the system requires. That part of the process is the stock-in-trade of process servers, who take a great deal of the strain in those circumstances. We look at some of the nitty gritty of the job.

• The whole judicial system is creaking under the strain of underfunding, and that stress is not eased by shifting resources from one part of it to another, according to the Law Society. That august body has described the process as ‘robbing Peter to pay Paul’, predicting that no good will came of it.

Similarly, the Forensic Science Regulator has criticised the funding cuts to the service, arguing that, as a result, standards are not being met. She calls for the regulator to be given statutory status. The sight of a major provider going into liquidation, leaving police forces to pick up the bill, doesn’t help.

• One area where technology is moving forward in the field of forensics is in the analysis of crash data. The computers now being installed in cars are giving crash investigators unprecedented access to information about what a vehicle was doing just prior to, and during, a collision. Add into that the data collection devices associated with some insurance policies and an even clearer picture is possible, enabling accurate assessment of causality.

• Motoring offences have come under the spotlight in a number of ways recently, including the collapse or abandonment of a number of prosecutions for drug driving because of the activities of some personnel at the Randox site in Manchester. Two high-profile motoring lawyers are now raising the possibility that the process used to test samples way before the alleged misdemeanours there could lead to further challenges.

• One of those lawyers is Nick Freeman – known to the press as ‘Mr Loophole’ because of his success in securing acquittals on technical grounds for a number of celebrities. Mr Freeman has come out as an advocate of banning the use of hands-free mobile phones while driving.

• Further woe in motoring circles has come with the release of figures from the Department for Transport showing a marked increase in the number of incidents involving at least one driver who was over the drinkdrive limit. Worryingly, that includes increases in the number of fatalities and injuries as well as the total number of crashes.

• Evidence that lawyers can add to the public good has emerged from research by the Behavioural Insights Team. It shows that raising the issue of leaving a legacy with clients when they are making their will can treble the possibility of them doing so. Civil Society Minister Tracey Crouch has written to lawyers urging them to do so.

• Which brings us to Brexit. The director general of the National Crime Agency has added that body’s voice to those of security chiefs in calling for the continuity of information exchange across borders following the UK’s departure from the European Union. We should all say ‘Amen’ to that. q

Ian Wild

Ian Wild, Director of Business Development Your Expert Witness

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NCA chief calls for continued enforcement co-operation post-Brexit [ONE OF THE issues under scrutiny in

the Brexit negotiations has been the close co-operation of all European partners in law enforcement. There has been concern expressed that such co-operation must continue, with the intelligence services of the UK, France and Germany making an unprecedented joint statement on the issue.

On 17 February the National Crime Agency joined the debate. Its director general Lynne Owens said: “Since before the referendum, the NCA and its partners in policing and wider law enforcement have clearly stated our need to work closely and at speed with European countries to keep people in the UK safe from threats including organised crime, child sexual abuse, cyber-attack and terrorism.

“The ability to work in this manner with our European partners benefits us all, increasing our ability to disrupt criminal activity and

protect our citizens from national threats as well as local level volume crime at the heart of our communities.

“We are confident that these requirements are being taken into account by the Prime Minister and officials responsible for negotiating Brexit, and that there is commitment to our position that we need to retain our ability to share intelligence, biometrics and other data at speed.”

The NCA statement cited the disruption of the so-called Avalanche network as an example of cross-border success.

The Avalanche network was used as a delivery platform to launch and manage malicious software attacks and money mule recruiting campaigns. It caused an estimated €6m of damage in concentrated cyberattacks on online banking systems in Germany alone.

Worldwide, the monetary losses associated with malware attacks conducted over the Avalanche network are estimated to be in the hundreds of millions of euros. The global effort to take down the network involved the crucial support of prosecutors and investigators from 30 countries.

The operation to dismantle the Avalanche network involved law enforcement agencies across Europe, co-ordinated through a command post hosted by Europol at its headquarters in The Hague.

From there, NCA officers worked with Europol’s European Cybercrime Centre and representatives from a number of involved countries to ensure the success of the operation. Hosted within the UK were 2,600 domains which were seized and, where possible, blocked to deny criminals access to computers they had infected. q

New group MoJ is ‘robbing ensures justice is Peter to pay Paul’, seen to be done says Law Society [HER MAJESTY’S COURTS AND TRIBUNAL SERVICE

(HMCTS), part of the Ministry of Justice, has launched an initiative to promote the reporting of court proceedings by local press.

A group of representatives from HMCTS and the media will aim to develop new ways to build strong relationships between media organisations and their local courts and improve and promote the existing guidance to staff relating to media access. They will also explore how transparency and openness are embedded into HMCTS’ £1bn reform and modernisation of courts and tribunals.

The changes introduced through digital reforms will mean there are many more ways to access justice without the need to travel and physically attend court. For cases that do need to go to court, there will be more modern and well-connected courtrooms.

The group includes representatives of the Society of Editors and the News Media Association.

Ian Murray, executive director of the Society of Editors, said: “Nothing can be more important for local communities than to have faith that justice is being delivered fairly on their behalf and that can only be done by reporting court proceedings. The Society is grateful to HMCTS for initiating this procedure.”

Santha Rasaiah, legal, policy and regulatory affairs director of the News Media Association, added: “Court reporting is essential to open justice. The NMA warmly welcomes this HMCTS initiative to help the courts and news media, local and national, to work together in furthering and facilitating press access and reporting.” q

[DEPRIVING ONE beleaguered portion of the criminal justice

system to fund another could inflict further instability on the underpressure system, the Law Society has warned.

In a statement, the society explained: “The Ministry of Justice (MoJ) wants to cut payments to defence solicitors who prepare serious cases for trial – on the grounds of MoJ budgetary constraints – while finding extra money for the advocates who represent those clients in Crown Courts.

Law Society president Joe Egan said: “The MoJ needs to develop a coherent plan for addressing the underfunding crisis across the whole of the defence professions. Increased fees for advocates will be of no use if there are no litigators left to instruct them.”

The government’s announcement comes just three months after further legal aid cuts were imposed on defence solicitors who work on some of the most serious cases.

Joe Egan added: “Litigation and advocacy services in the criminal justice system are both suffering a crisis caused by years of underfunding. It is not rational for the MoJ to argue that they have to cut one part of the system because of their own financial pressures, but then find additional money to pay advocates for working on the very same cases. Robbing Peter to pay Paul simply isn’t in the interests of justice.

“Regardless of their funding, advocates depend on litigators undertaking effective case preparation work. This is increasingly impossible with all the cuts that have taken place in recent years, including the most recent cut in December 2017.” q www.yourexpertwitness.co.uk

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Motor crash investigation enters the world of the black box [MODERN road traffic accident investigation is rapidly

entering the same space as airline crash investigation. A combination of diagnostics stored within a car’s on-board computer and a trend for informatics connected to insurance policies means that the position, speed, condition and road activity of a vehicle can be determined electronically – together with what the driver was doing at the time of an accident and whether they had lights lit, were using a mobile phone or even if they were asleep.

In some cases the information can be garnered instantly and remotely.

Specialist crash investigator Forensic Collision Investigation and Reconstruction Ltd (FCIR) explain: “Many modern vehicles store vital information about a vehicle around the time of a crash.

This includes approach speed, an indication as to whether the vehicle was being braked and the throttle position, to name but a few.”

The data from the on-board computer – known as the ‘event data recorder’ – can be downloaded and analysed using specialist equipment from electronics experts Bosch. It is similar to the kit used to diagnose faults with modern cars.

As FCIR point out: “This data can be complex and consequently it is a requirement of Bosch that only analysts with specialist training can interrogate this data.”

The specialist crash investigator can then THE DEPARTMENT FOR TRANSPORT apply forensic skills to interpret the data has published provisional estimates on from the computer to determine whether a ‘personal injury drink drive’ crashes in fault contributed to the crash.

Great Britain for 2016. The figures show a Forensic road traffic experts Elliot statistically significant rise in all key crash data Forensics know how important that can be. where at least one driver is over the alcohol “The very nature of a car accident will often limit. That includes the number of fatalities, the leave those involved looking for answers. number killed or injured and the total number Determining whether there was a fault with of crashes. any of the vehicles involved can help the The figures show that between 200 and 280 drivers involved to understand more about people were killed when at least one driver was what happened, and ensure that any issues over the drink drive limit. There was a 7% rise can be identified and addressed. in overall drink drive casualties of all severities “There are a number of checks which from 2015, to 9,050, and an estimated 230 fatal can determine significant details about a drink drive accidents. Drink drive accidents of collision, all of which can be combined to all severities rose by 6% to 6,080. build up a full picture of the circumstances Commenting on the statistics, Joshua Harris, that led to the accident.” director of campaigns at road safety charity Where the accident has led to injury or Brake, said: “These figures must be a wake-up even death, determining the cause and call for the government, forcing them to act now ascertaining if there was fault can be the to eradicate the menace of drink-driving from lynchpin of a criminal investigation and trial. our roads. The number of drink drive-related Another addition to the electronic deaths, injuries and total crashes in 2016 all surveillance of a vehicle is the ‘black increased from levels which were already unacceptable. This deeply concerning trend box’ installed by insurers, which many highlights the urgent need for the Government to enforce an effective zero tolerance drinkyounger drivers are using to help reduce driving level across the UK. premiums. One broker quotes an instance “Research has shown even very small amounts of alcohol dramatically affect safe driving: where the device alerted monitors to an drivers with just 20-50mg alcohol per 100ml of blood are at least three times more likely to accident involving a young driver who had die in a crash than those with no alcohol at all. fallen asleep at the wheel. The car had “The current drink-driving limit [80mg/100ml] gives a false impression that it is safe to left the road and would have been unseen drink and drive. Only by changing this perception can we eradicate the needless loss of by passing officers. The GPS positioning life caused by alcohol on our roads. Brake is calling for the Government to implement system on the ‘black box’ allowed an effective ‘zero tolerance’ drink-drive limit of 20mg per 100ml of blood, making clear to emergency services to recover both vehicle drivers that not a drop of alcohol is safe.” q and driver. q

Drink driving incidents increasing, DfT figures show [

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Summer peace set to be shattered by crash testing >BRUNTINGTHORPE AIRFIELD AND PROVING GROUND in

Leicestershire will resonate to a different sound on Midsummer Day than is traditionally associated with the ‘longest day’. This year, 21 June will see the annual crash test and research day of the Institute RI 7UDIÂżF $FFLGHQW ,QYHVWLJDWRUV ,7$,

Sponsored by Leica Geosystems and the National Salvage Group, the day will be organised along similar lines to last year’s event, but with a wider variety of crash tests at a range of speeds. For the ¿UVW WLPH DGGLWLRQDO WHVWLQJ ZLOO EH XQGHUWDNHQ LQYROYLQJ PRWRUF\FOHV carrying a dummy rider being propelled into impact with a stationary car. There will again be an area dealing with gathering data from ORZ VSHHG LPSDFWV IRU WKH EHQH¿W RI WKRVH GHOHJDWHV IURP WKH insurance industry studying whiplash injuries. Some of the vehicles LQYROYHG LQ DOO W\SHV RI WHVWV ZLOO EH ¿WWHG ZLWK WHOHPDWLFV HTXLSPHQW There will be a range of delegate participation opportunities, including driving specialist vehicles such as large goods vehicles, EXVHV DQG ¿UH HQJLQHV 7KHUH ZLOO DOVR EH YHKLFOH KDQGOLQJ RSSRUWXQLWLHV LQFOXGLQJ GULYLQJ YHKLFOHV ZLWK XQGHULQÀDWHG W\UHV incomplete wheel braking, steering a curved path on the limit of

adhesion and driving at least one type of autonomous vehicle.

Attendance at the crash test and research day is not confined to members of the ITAI and is free of charge to those who register in advance.

7KH ,QVWLWXWH RI 7UDIÂżF $FFLGHQW ,QYHVWLJDWLRQ H[LVWV WR SURPRWH road safety by improving the technical and general knowledge DQG VNLOOV RI SHUVRQV LQYROYHG LQ WKH ÂżHOG RI LQYHVWLJDWLQJ URDG WUDIÂżF FROOLVLRQV ,W SURPRWHV WKH IUHH DQG RSHQ H[FKDQJH RI knowledge and provides a forum for communication, education and representation, through all of which it aims to enhance expertise.

It also seeks, through the collective knowledge of its members, to improve the standards of safety of vehicles and roads of all kinds. T • For more information visit www.itai.org/crash-day.

Mr Loophole calls for outright ban on phoning while driving > PERHAPS ONE OF the more surprising interventions in

terms of road traffic accident cases has been the assertion by celebrity lawyer Nick Freeman that the use of ‘hands-free’ mobile phones while driving should be banned.

The lawyer, known as ‘Mr Loophole’ because of his success in winning acquittals for celebrity defendants – among them, some charged with using their phones at the wheel – has said he believes the penalties should be the same as for drink driving.

Speaking at a charity lunch in Manchester, Mr Freeman told the packed audience: “It`s the one thing I would like to change about the law above all else. “Everyone thinks that if you’re using a phone and you’re hands-free, then you are fine and dandy.

But speaking on a mobile phone is a major cause of distraction, irrespective of whether the call is hands-free or not. “In my opinion, any form of use of a phone, except for an emergency, should be banned. The reality is that if you`re using it legally or illegally – hand-held or hands-free – the distraction level is the same. “In fact, in terms of distraction it has been

equated with just below the level at which you’re permitted to drink and drive – which means the chances of you having an accident using hands-free increases four-fold. The stakes are just too high.�

In 2016 psychologists at the University of Sussex found driving while talking on a hands-free phone can be just as distracting as talking on a hand-held mobile. The study, published in the Transportation Research Journal, revealed this was because conversations cause the motorist to visually imagine what they’re talking about.

Freeman added: “I realise people use the car as an extension of WKH RIÂżFH Âą , GR LW P\VHOI ,I ,ÂśP GULYLQJ IURP P\ RIÂżFHV LQ Manchester to London and I’ve got 30 calls to make, it’s the perfect time to do it. “But if you`re doing that, you’re involved in conversations that require concentration.

And if you’re just talking, you’re thinking about your conversation; the journey has gone and you don`t remember those last 20 miles. “It is time the government acted to put an end to the menace of hands-free and they need to impose a penalty commensurate with drink driving.� T

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Forensics in crisis: regulator makes stark prediction [THE FORENSIC SCIENCE REGULATOR, Dr Gillian Tulley, has

For these reasons, statutory powers are urgently needed so that the warned that falling prices and continuing cuts to funding for forensic regulator can ensure that all providers of forensic science deliver work science work are eating into essential services. She issued the warning to quality standards that are fit for the criminal justice system. in her annual report, published on 19 January.

The publication of the report came just a week before the collapse of Already, the regulator said, scientists have been required to give a major forensics firm, which went into receivership leaving police forces expert advice based on interim forensic reports because some police with a multimillion-pound bill to ensure vital forensics were completed in forces have refused to pay for the scientists to produce an admissible cases involving serious crimes, including rape and murder. q statement of evidence in court. Often there is little time left for practitioners to prepare reports on complex cases or keep up with scientific developments.

Dr Tully said: “There are a lot of hardworking and committed forensic scientists doing their best, but they are not always supported by the system they work in. A year ago I warned that funding was too tight, and WITH CCTV RECEIVING a mixed press now even more money has been taken out of in recent years, good news was reported in the system. We cannot continue on this path.

January when security firm Eboracum became “I urge the government to put the role of the the first private security firm to gain independent regulator on a statutory footing now, to enable certification from the Surveillance Camera me to ensure that all organisations providing Commissioner. The company provides a range of forensic science evidence in the criminal justice services in York. system, meet the high standards required.�

Body-worn cameras have become important items of equipment and are now deployed The failure of some police forces to give with operatives across the company and have enabled the provision of evidence leading to sufficient priority to achieving quality standards successful prosecutions. Body-worn cameras have also been used to deter assaults on staff in their own forensic science work is of great and prevent crime. concern to the regulator, the report said.

Eboracum were committed to being transparent in demonstrating high standards and The regulator also highlighted that a ethical use of their body-worn cameras and therefore decided to undertake voluntary number of small forensic businesses have certification assessment against the surveillance camera code of practice. q chosen, for financial reasons, not to move towards reaching the required standards.

Certification gained for body camera use [

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Leasehold market is actually growing, research finds [LEASEHOLDS ACCOUNTED FOR more than 30% of all

properties sold in 2017 – 5% more than in 2016 – according to analysis of Land Registry data carried out by online estate agent Sellhousefast.uk.

The analysis was carried out following the government’s announcement of a crackdown on ‘unfair and abusive practices within the leasehold system’. Comparing data from previous years, Sellhousefast.uk found that the leasehold system is very much alive in both England and Wales; perhaps more alive than ever before.

In 2016 leasehold properties accounted for 27% of all properties sold – a 1% increase from 2015 when leaseholds made up just over a quarter of the property market. Instead of decreasing, the sales of leasehold properties have been increasing, even though the government announced its intention to act early last year.

Robby du Toit, managing director of Sellhousefast.uk, commented: “We are yet to see how the government will solve the issue of the existing leaseholders and how the latest measures will affect the property market. I’m afraid that existing leaseholders will probably have to lower the asking price considerably if they want to sell. I can’t imagine who will want to buy a property with preposterous ground rents, especially now that the government has promised to set the ground rents on new long leases – for both flats and houses – to zero.

“Another thing that worries me is that a lot of leaseholds are held by investors who obviously want to make the most out of their investment. I’m concerned that they might try to exploit the loopholes in the new measures to continue to profit from the leasehold system.”

Significantly, of all the flats sold in 2017 only 3,312 – or 2.13% – were freeholds, which means, says Sellhousefast.uk, that freehold flats are virtually non-existent.

Alex Highman, one of the flat owners in Gemini Park in Borehamwood who decided to buy-out their freehold, explained: “If you have a landlord who is co-operative and allows you to change the site and make it better, then buying the freehold is pointless. Of course, once you own the freehold you no longer need to pay ground rent and renewing your lease is far cheaper. It all comes down to a balance of whether it’s worth the cost to those buying.

“Due to our purchase of the freehold we can now pursue with the co-operation of everyone on site, as we have chosen to retain the Residents Association, bettering the site and making it a safer happier place to live.”

Over the past few years a number of cases have been highlighted where leaseholders of apartments in blocks have been landed with either massive increases in ground rents or huge bills for building work – some of which was only needed because of faults in building work carried out in the past. q

Professional Statement reflects new measurement standards [ON 1 MAY an updated version of the

Royal Institution of Chartered Surveyors’ Property Measurement 2nd Edition becomes mandatory for RICS professionals and RICS regulated firms. The update follows the release of new International Property Measurement Standards (IPMS): Residential Buildings, the second in a series of measurement standards developed by a global coalition of professional bodies.

The institution’s Professional Statement has been updated and now includes both IPMS: Office Buildings and IPMS: Residential Buildings.

That, says the RICS, is a crucial step in professionalising real estate measurement practices in the sector.

Recent research found huge measurement variances around the world, depending on which measurement standard is used. Measurements for apartments can vary by up to 27%, while measurements for houses can vary by more than 50%.

An important aspect to note in the updated Professional Statement is that it applies to all properties and includes IPMS measurement updates to office and residential buildings.

According to the RICS: “The Professional Statement will be further updated over time to include IPMS

measurements for other building classes – such as industrial, retail and mixed-use buildings – as those standards become available.”

A second element is that it includes the RICS IPMS data standard aimed at software developers and measurement data users.

Again, according to the RICS: “The data

standard aims to provide consistency and improves how the data attributes and elements of an IPMS measurement are captured.

“The updated Professional Statement is an important milestone for our sector as we move toward professionalising measurement practices across all specialisms.” q

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Due process? Leave it to the experts

[TRYING TO GET the right legal documents processed and

where they need to be can often be an arduous or potentially dangerous process, especially during a court case. For the lawyer it can slow up proceedings and add difficult-to-justify expense to a case; for the individual seeking justice it can be a stressful and awkward process – particularly for those inexperienced or unfamiliar with it.

According to specialist process servers Eclipse Legal Services: “For millions of people around the UK and the wider world that are involved in a court case, it can be overwhelming trying to effectively serve documents.”

That is where a process server can help. They are trained to deal with all types of situations and legal scenarios, which can provide a helping hand.

Viewers of mainstream TV will be familiar with the jovial professional tasked with serving papers on people who may or may not deserve everything they get. We are urged to side with the team attempting to exact payment from the ‘businessman’ who has gained loans and other money by dishonest means and is avoiding paying it back. Or there is the unfortunate family which is the victim of circumstances and who our hero is forced to evict.

The reality can be very different, as Eclipse Legal Services explains: “Depending on the type of legal document you are trying to serve, the process can potentially be dangerous. For example, if you need to issue an ASBO or an injunction it may be that the recipient is known for being volatile or potentially dangerous. Seeking the help of a local process server will take away any risk and put the job in the hands of specialists that are trained to deal with all kinds of situations.”

If a lawyer is not familiar with the process of serving legal documents or is working on a case that is new to them, a trained

process server can offer a lot of knowledge and experience. Trained to deal with many different types of situations and scenarios, process servers can ensure that legal documents are served even in the most sensitive or unusual circumstances.

In terms of the financial savings to both legal practices and companies such as insurance brokers or credit companies, the outsourcing to a team of professionals will take the strain off and ensure that time is spent on other important matters. q

Code governs use of covert surveillance by employers [

TO MEMBERS OF the general public, the work of the private investigator conjures up a view of following people around or using covert cameras to catch people out: benefit claimants playing football (or refereeing, in one case) while supposedly being unable to walk, or neighbours secretly sabotaging property in order to terrorise residents.

The public sees such investigators as somehow ‘unsavoury’ – a world away from the glamourous world of Sherlock Holmes. But such work is routinely necessary in a number of areas of legal work, from divorce proceedings to personal injury cases.

The Information Commissioner’s Office has published a code of conduct specifically for employers carrying out surveillance of employees, most often to determine bogus illness claims.

The code says that, before considering arranging for covert surveillance to be carried out on an employee, the employer's senior management should carry out an impact assessment to decide if and how to carry out the surveillance.

The impact assessment should clearly identify the purpose behind the covert surveillance and consider alternative ways in which the surveillance might be carried out. The employer must have reasonable grounds for its belief in the employee's misconduct and must be satisfied that notifying the employee about the surveillance would prejudice detection of the malpractice.

The forthcoming coming into law of the General Data Protection Regulation will place on employers more stringent conditions for the justification of carrying out surveillance of any type. q

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What are the cultural, religious and ethnic factors at play in the problem of loneliness?

By DR BASHIR QURESHI FRCGP FRCPCH Hon FFSRH-RCOG AFOM-RCP Hon MAPHA-USA Hon FRSPH • Expert Witness in Cultural, Religious & Ethnic issues in Litigation • Expert Witness in GP Clinical Negligence • Expert Witness in Community Paediatrics and Clinical Public Health

[LONELINESS IS A sad feeling of social isolation due to a lack or loss

of like-minded friends and family members. The feeling can occur even in people in relationships, marriages, families and jobs; but it is more severe in those whose marriages or relationships break up. In addition to the social factors, loneliness can occur due to mental illness, physical disability, social isolation or a combination of these causes. Loneliness can cause mental, physical and social problems – and even lead to early death.

Loneliness differs from being alone by choice; good companionship is better than being alone, which is in turn better than being in a bad relationship or marriage. Some intellectual writers and those who do creative work need to be alone occasionally to achieve successful results from their efforts.

The Seven Ages of Man (or person!) is a reality – people change over time and if both partners do not change at the same time they may face a breakdown of their relationship in later years, when they need it most.

It is said that Shakespeare was an intellectual loner.

Prime Minister Theresa May appears to have some lone thinking skills and has appointed Sports and Civil Society Minister, Tracey Crouch MP, as the UK’s first ‘Minister for Loneliness’. The Prime Minster asserted that loneliness is a sad reality of modern life for an estimated nine million British citizens. Indeed, she would help lonely hearts of all ages and backgrounds – especially the elderly, who are living much longer due to the excellent National Health Service, which is still mostly free at the point of delivery and unique to the UK. Let us hope for the best through this timely move.

Cultural approaches to loneliness

There are three major cultures in the world: Western, Eastern and Westernised Eastern, along with many subcultures. Each one has measures to deal with loneliness. Many less or non-religious people – such as secularists, agnostics and atheists – follow the customs of their own country, state and education, to cope with loneliness.

In 1969, after doing five years of hospital service in East London, I started my first job as a part-time, salaried general practitioner in West London. After the morning surgery, the senior partner used to send me to do home visits. Some of the patients, however, had no medical problem.

When I asked the senior partner, he told me that those patients were war veterans and lonely people who now had no visitors at all; therefore, we should visit and ask them how they are coping. Occasionally, they used to cry on my shoulder. I listened and consoled them, then booked a visit for the following week. Social services were also helping them.

Britain still leads the way for free National Health Service and social care.

Religious management of loneliness

Judaism, Christianity, Islam, Hinduism, Sikhism and Buddhism are the six major religions worldwide, and there are many smaller religions or sects. Each one has developed its own religious practices to keep followers out of the grip of loneliness. Their places of worship – synagogues, churches, mosques, gurdawaras and temples – play very important roles in controlling loneliness, especially in easing its adverse emotional effects.

All religions provide help for lonely people, both from religious leaders and volunteers. They help people at their places of worship – by prayers, sermons and by home visits, providing free food when needed and introducing them to other worshippers. Religious healers existed before doctors and psychiatrists took over the treatment of patients, and they are still around to help today.

Every ethnic group also has its own ways of dealing with loneliness.

Finally, it is worth considering that one of the most common causes of loneliness is a dispute over property and money left by family members.

Money makes the world go round, and tribal mediators, legal mediation experts, solicitors and courts are the most common sources to get justice and support for such lonely people. q

www.yourexpertwitness.co.uk

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For the many thousands of people working for charities around the country, the past couple of years have provided a number of difficulties. In addition to the current storm surrounding two of the most prominent overseas aid charities, the sector has undergone reform of the way fundraising is undertaken, with the establishment of the Fundraising Regulator and the publishing of a Public Register. That register has now been updated and a new version published.

In May a further reform comes into play, this time as a result of European legislation.

The General Data Protection Regulation becomes law in less than three months time and charities have to ensure they comply.

Despite all the tribulations, charities continue to benefit from the generosity of donors who leave legacies in their wills. Campaigns to increase awareness of that form of giving are becoming increasingly inventive, with a ‘pirate’ radio station drafted in alongside 1960s celebrities, and the government urging lawyers to do their part in reminding clients of the possibility of leaving a gift.

The GDPR deadline looms for charity fundraisers [ONE INEXORABLE DEADLINE has been gradually focusing the

minds of charity fundraisers and legacy managers and it is set to fall on 25 May – now less than three months away. That is the coming into law of the General Data Protection Regulation (GDPR). There has been a great deal of trepidation and some confusion among charities about what the new regulations will hold for charities’ use of personal data, and an equal amount of advice from a number of sources.

In particular, the Institute of Fundraising has been working with the Fundraising Regulator to produce ‘bite size’ GDPR guidance for fundraisers in six easy-to-understand parts.

The guidance gives a brief overview of GDPR for charities and for fundraisers, looks at different fundraising methods – community, corporate, trusts and legacy fundraising – and identifies ways in which personal data is likely to be used in each case. It also provides links to other more

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detailed guidance already available from key authoritative sources including the Information Commissioner, the Fundraising Regulator and the Direct Marketing Association.

In a joint blog on the regulator’s website, Gerald Oppenheim and Stephen Service of the Fundraising Regulator and Daniel Fluskey of the Institute of Fundraising write: “We have heard from charities that there is some confusion navigating through the different pieces of guidance that are out there, and the almost daily blogs offering training programmes, on-line portals, seminars and the like, often provided at some cost to charities.”

The central message is that GDPR is evolution not revolution in data protection law.

As Messrs Oppenheim, Service and Fluskey point out: “This is about getting things right, not just complying with the law, essential as that is, but also about building on all the changes for the better in charity fundraising that

have been made since the difficult days three years or so ago now.”

In terms of what the regulation means in terms of legacy fundraising specifically, there is an opportunity to improve ways of working and collaborating, according to Chris Millward, CEO of the Institute of Legacy Management.

Writing in The Fundraiser in January, he said: “The new regulations will undoubtedly bring about changes to the whole legacy process, from fundraising through to administration, and it is vital that those working across all charity departments are fully aware of the regulations, their implications and what they will have to do to comply.”

Millward pinpoints two specific areas that need to be addressed: consent and legitimate interest.

Consent, he says, will be required to make or send any direct marketing communications by e-mail, text, or phone. “This may be relevant, for example, if you wanted to keep next of kin and family members updated on the work of your charity in the future, or encourage them to give an inmemoriam gift.”

Legitimate interest is a complex area involving a balance between rights and obligations.

There are, however, opportunities to be gained from the need to develop new ways of working. Says Millward: “Renewed ways of working will ultimately ensure that more people have the opportunity, in the most appropriate way, to consider leaving a gift in their will. And we hope that this will lead to an increase in vital legacy income to fund the work of charities.” q

Legacy sector comes together for annual gathering

Surgery saves lives

[SURGEONS SAVE AND improve the quality of people’s lives

every day. Patient care and wellbeing is the heart and drive of the Royal College of Surgeons (RCS). They are a registered charity, independent of the NHS, and for more than 200 years have safeguarded the standards of clinical practice.

There are many reasons why you may find yourself under the care of a surgeon – few people have not benefited, either directly or indirectly, from advances made in surgery. The charity’s work is not limited to specific illnesses or areas of disease but supports better care for all ages, from minor day surgery and the removal of cancer, to life-saving emergency procedures and trauma care.

In every case, the patient places their trust in the hands of the surgeon. Although this trust is well founded, there is a need to invest continually in education, research and training to ensure that surgeons – and the care they provide is – the best in the world.

While the medical world continue to strive for the cure to many diseases and cancers, in many cases surgery remains the most effective treatment.

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

[THIS YEAR’S annual conference of the Institute of Legacy

Management (ILM) will be held on 11 May at 155 Bishopsgate, next to Liverpool Street Station in the City of London.

Described as the biggest event in the legacy calendar, this year’s event will offer delegates a unique blend of news and views from the world of legacies.

As always, the agenda will be diverse and of interest to all those working in the sector. Highlights include an update on the external market, a panel discussion on a topical issue facing the legacy sector, plus the ILM’s annual awards ceremony.

The event as a whole also offers a fantastic networking opportunity for like-minded legacy professionals to meet with each other and share their experiences.

Every year the conference is a sell-out. Last year, 250 delegates convened for an enjoyable and thought-provoking day – and 93% of those who responded to the post-conference survey said the conference was ‘good’ or ‘excellent’ overall. q

Education through the power of play

[ACTION FOR SICK CHILDREN is currently focusing on its two main

projects – Dental Playbox and Magical Power of Play Appeal.

The Dental Playbox project is a preventative programme to educate the under fives, through the powerful medium of play, in the importance of good oral hygiene, sensible eating and drinking – along with visiting the dentist on a regular basis. In 2017, the scheme reached almost 7,000 children!

The Magical Power of Play Appeal supports the invaluable work of health play specialists by providing play resources for hospitals across the UK. These resources help to improve the hospital journey for sick children through distraction and recovery. In 2018, Action for Sick Children hopes to provide a Magical Power of Play Appeal box to ten children’s wards across the UK. q www.yourexpertwitness.co.uk

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If you Will, we will [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 A new friend for Alan 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

Funding helps enhance quality of life

[FUNDING AN ever-changing variety of projects which enhance

and enrich the lives of vulnerable people with learning disabilities is the function of Camphill Foundation UK and Ireland.

The foundation provides the financial support that can enable new initiatives to start-up, help to create or improve facilities, or provide vital opportunities for creative and fulfilling work. It often provides that extra bit of help needed to enhance quality of life.

Independence and freedom of choice are fine ideals, but they can only become a reality with the right level of support, both financial and personal.

True quality of life means combining individual choice and fulfilment with social belonging and responsibility. The projects supported by Camphill Foundation improve and enrich that quality of life for people with learning disabilities by providing new work or social and cultural opportunities which enhance the development and wellbeing of both the individual and the community.

For further information on leaving a legacy, enabling that work to continue, visit www.camphillfoundation.net q

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Minister encourages lawyers to support legacy giving [THE IMPORTANT ROLE played by

solicitors in bringing the possibility of leaving a legacy in a will – and the emphasis placed on that role by government – was underlined in December, when Civil Society Minister Tracey Crouch MP (pictured) wrote to more than 8,000 solicitors, asking them to make clients aware of the option of including a charitable gift in their will.

Ms Crouch said: “We want to increase awareness of legacy giving and make it the norm, so as many charities can benefit as possible.

“There are many ways we can boost recognition. Employers can promote the scheme when providing information about pensions and retirement. Legal firms could also talk clients through the process of legacy giving when discussing their will.”

She pointed to the work done by umbrella body Remember A Charity in encouraging solicitors to promote legacy giving through its campaign supporters scheme.

Its director Rob Cope explained: “The legal community has such an important role to play in making the public aware of all the options when writing a will. While we always encourage people to consider their friends and family first, it is critical that solicitors also make clients aware that they can support charities in this way too.”

Research from the Behavioural Insights Team has shown that solicitors can treble the number of legacy gifts made simply by referencing the option of including a charity.

Rob Cope added: “People have all sorts of misconceptions about gifts in wills, often believing that you have to choose between family and charity, or that you need to be

wealthy to leave a legacy. The reality is that even a small amount can make a massive difference to the good causes people care about.”

Of course, solicitors and other professionals can only raise the issue if there is a will being written; research published in January by Macmillan Cancer Support showed that nearly two thirds of adults in the UK have not made a will – that includes 42% of those over 55.

The survey of over 2,000 adults found a range of will-related errors, with one in five wills still including an ex-partner, not yet including children or grandchildren, a new relationship or including someone that they plan to remove.

The charity also discovered that 1.5 million

people have unknowingly made their will void by getting married, as marriage automatically revokes a previous will.

Craig Fordham, director of legacies at Macmillan Cancer Support, said: “Macmillan wants to help people take charge of their will and think about the type of legacy they want to leave behind. The start of the year is the perfect time to get your affairs in order and make arrangements for your loved ones and the causes closest to you.” q

Support for small charities makes the agenda

[ON 25 JANUARY the Institute of Fundraising (IoF) and the Department of Culture,

Media and Sport (DCMS) hosted a summit to discuss and identify ways to upscale existing and identify new fundraising initiatives.

Following the publication last year of the report Fundraising Support for Smaller Charities, the IoF called for key charity sector funders, sector bodies and charities to invest greater resources and energy in supporting fundraising activities for smaller charities.

The summit achieved one of the key recommendations made in the report. It brought together charities, membership bodies and foundations, and included a warm welcome from the Minister for Civil Society, Tracey Crouch, who commended the guests for their efforts to overcome the fundraising skills gap in the charity sector.

The outcomes of the summit will be considered by DCMS to inform their policymaking and will feed into the IoF’s response to the upcoming DCMS consultation on a new Civil Society Strategy. q

Help for those with failing sight

[FAILING EYESIGHT is nothing short of a personal catastrophe.

Do you have a family member, friend or neighbour who is gradually losing their sight?

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

The National Federation of the Blind of the UK (NFBUK) keeps its members in touch with general information, help and updates on what’s going on.

The charity produces bi-monthly news magazines and circulars in audio, braille or electronically, which members can read independently. It also encourages blind and partially sighted people 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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Horses’ plight sparked the beginning of a dream [THE YEAR IS 1983 and it is the coldest winter for 20 years.

Stories of ponies and cobs being abandoned by their owners on Rainham Marshes in Essex were hitting the headlines. Doctor’s receptionist Paula Clark, who was involved in raising money for a number of sanctuaries, was sitting at home in tears after reading the story of these poor horses.

When her husband Ernie returned home from work Paula showed him what was happening and they vowed to take action and help the animals that needed them. The story of Hopefield Animal Sanctuary had begun.

They went to the marshes where 16 horses were already dead and others were starving. They took tanks of water to them, also bales of hay and feed. They even got a vet to examine some of them. Paula and Ernie started to raise money to buy the horses and move them to other sanctuaries and helped those sanctuaries to raise funds.

They then put out a call out for some land to start up their own sanctuary. A lady from nearby Pitsea had half-an-acre to offer, so Paula and Ernie started their dream: Hopefield. They began taking horses with the intention of fostering. They would bring the horses back to health and then find them nice homes.

The first horse they fostered out was Pye. Soon after they heard that the fosterers were trying to sell him, so Ernie took them to court, which cost £4,000. Ernie finally got Pye back in a terrible state, and both Paula and Ernie promised they would never rehome again: the animals had a home for life.

As the sanctuary grew Ernie and Paula both gave up their jobs to look after the animals that so badly needed them. They soon moved to a piece of land in Langdon Hills and were there for three years.

Hopefield was still growing, so they knew it wouldn’t be too long before they would have to move to an even bigger piece of land.

Paula put another call out for land and they came across the land that Hopefield sits on today. It is owned by Tesco, who kindly let Hopefield use it for a peppercorn rent. Through the years Paula and Ernie had their ups and downs, but never gave up. Their work was recognised by a number of awards, including MBEs for both of them. Their hard work has inspired many people and saved hundreds of animals’ lives.

Sadly, Paula died of cancer in September 2009. Ernie kept his promise to Paula to continue their work, but also sadly died of cancer two years later.

Since their passing the work has continued with four new trustees. They include music star Leona Lewis, as well as Paula and Ernie’s son Lee, plus David Schlaich and Nicola Carson. There is also a general manager, Lianne Angliss.

Said Lianne: “We have continued to rescue horses and farm animals, but have found that over the years the type of animals we are having to help has greatly changed, with people getting more and more into exotic species. We have opened a reptile room, which soon filled up, and have also taken in many exotic mammals, including raccoons, tanukis, a skunk, marmosets and many more. We also now have birds of prey as well.”

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Music star Leona Lewis is one of Hopefield's trustees The sanctuary is now open more to the public and has become a visitor attraction as well. That generates funds that go directly to the animals, making the future more secure. It also helps with educating people about the correct care the animals need.

Said Lianne: “We will continue to make Hopefield grow and to help as many animals that we can.” q

Regulator publishes updated register and changes to code

>ON 1 FEBRUARY the Fundraising Regulator re-launched its Public Register, following several updates

designed to improve transparency. The register now states whether an organisation is a ‘Registered Charity’ or ‘Levy Paid’. That allows it to differentiate between smaller fundraising charities completing registration and larger organisations that are within the scope of the regulator’s levy.

Organisations that are within the scope of the levy but have not paid will be shown on the Public Register as ‘Levy Unpaid’, allowing members of the public to identify the charities supporting the independent regulation of fundraising across the sector.

The Public Register also shows commercial fundraising organisations that are not charities, but which have completed registration with the regulator. They are listed as ‘Registered Commercial Supplier’.

7KH UHJLVWHU ZLOO EH XSGDWHG RQ D GDLO\ EDVLV WR UHĂ€HFW QHZ SD\PHQWV PDGH 2UJDQLVDWLRQV already registered will have three months from the point at which their registration expires to renew payment before being removed from the Public Register.

The regulator’s chief executive, Stephen Dunmore (pictured), commented: “These updates to the Public Register directly respond to feedback from the sector urging us to increase transparency regarding payment of the fundraising levy. We would like to thank the organisations that have committed WR VXSSRUWLQJ WKH ZRUN ZH GR ZLWK WKHP WR LPSURYH IXQGUDLVLQJ VWDQGDUGV DQG LQFUHDVH SXEOLF FRQÂżGHQFH FRQÂżGHQFH in the sector.â€?

The Fundraising Regulator has also updated its Code of Fundraising Practice to take account of the new data protection laws to be brought in by GDPR. The changes are published alongside a summary of consultation responses received from data protection specialists, sector bodies, charities and the public EHWZHHQ 2FWREHU DQG 'HFHPEHU ODVW \HDU 7KH QHZ UXOHV ZLOO FRPH LQWR HIIHFW IURP 0D\ DW WKH same time that GDPR is incorporated into UK law.

Stephen Service, policy manager at the Fundraising Regulator, said: “The code’s message is clear: data protection is not an afterthought, but a starting point for good fundraising practice. It is more important than ever that fundraisers know the provenance of any personal data they hold and have a clear basis for processing it.� T

Legacies – the gift of life >ANIMAL CHARITY Wild Futures rescues

and offers sanctuary to monkeys who have suffered abuse and neglect. They are dedicated to protecting primates and their habitats worldwide – they are endangered due to climate change, habitat destruction and the bush-meat and pet trades.

For some species, it is too late. The future of all that remains lies in our hands, so leaving a legacy to Wild Futures is the gift of life and a future for primates and our wonderful planet.

Wild Futures’ holistic approach makes them unique – providing sanctuary to rescued

monkeys, supporting projects overseas, campaigning for primate welfare, educating to protect primates worldwide and promoting a sustainability and ethical ethos.

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. T • For more information call 01503 262532, email giving@wildfutures.org or visit the webiste at www.wildfutures.org.

www.yourexpertwitness.co.uk

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How to support those who support victims [THE LEADING independent charity in

England and Wales for people affected by crime and traumatic incidents is Victim Support. Last year the service offered support to nearly a million victims of crime: victims whose lives had in many cases been torn apart by the crime they’d experienced.

In 2016-17 Victim Support also helped over 1,200 witnesses through their court experience. But its work doesn’t stop there – they continue to help victims rebuild their lives once the court process is over until they no longer need support.

Victims and witnesses often report that giving evidence in court is both ‘re-traumatising’ and ‘terrifying’. Victim Support has supported children as young as three in preparing to give evidence in court and continues to work with families and other professionals.

They support young witnesses in a range of ways: pre-court visits, offering practice on live video links, setting up meetings with judges and advocates and using stories, games and activities to help children build up their confidence and self-esteem. That combination of practical and emotional support ensures that children are fully prepared for the court process and have the best chance of giving their very best evidence.

17-year-old Lara said: “Vanessa from the witness service was brilliant, going above and beyond what I expected. She provided support throughout my court case, starting from her giving me and my family details of what would happen in court, right over to her helping me to write my statement. As well as the emotional and practical support, just having a familiar face was really reassuring.” q • For further information please call 07940474581, email legacies@victimsupport.org.uk or visit www.victimsupport.org.uk.

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 2016. 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

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Annual campaign finds a link to the past [REMEMBER A CHARITY’S annual campaign to raise awareness

of legacy giving attracted an unprecedented level of celebrity support in 2017. The campaign focused on the 1960s – decade of The Beatles, pirate radio and ‘Swinging London’.

The campaign attracted support from such names as Twiggy and Ringo Starr. It took as its launch pad the resurrection of the iconic 1960s pirate radio station Radio Caroline – headlined by the station’s Emperor Rosko.

Campaign leader Rob Cope said: “For many of our target baby boomer audience their defining years were set in one of the most culturally influential decades in history: the 1960s. They grew up campaigning against the threat of wars, campaigned for human rights,

Holidays help boost confidence of young cancer patients

“

For me the charity has not only allowed me to rebuild the loss of confidence but has enabled me to do so in a safe and homely environment with like minded peers – that has a support group effect

”

demanded equality and changed the face of music forever.”

The campaign resulted in the re-launch of not-quite pirate radio with a new station, Last Pirate FM. It became a platform for a week of entertaining music, content and nostalgia to help the nation have their say about the world they’d like to pass on.

Rob Cope continued: “Online content was viewed over two million times and visits to the campaign website, where people could enquire about legacy giving, went up by 160%. Campaign tracking also revealed that the action of leaving gifts increased from 11% in 2011 to 16%, making it an unprecedented success for us.

“Not only did our campaign give the charities a voice, we gave all their supporters a chance to have their say with Last Pirate FM, on the roadshow, online and on the radio.” q

[THIS QUOTE FROM Dave sums up the value of the work undertaken by the Youth Cancer Trust. The organisation provides free therapeutic activity holidays for teenagers and young adults – those aged between 14 and 30 – from the UK and Ireland who are suffering from cancer.

The young people who stay at the Trust are often depleted and lacking in confidence from the effects of cancer and its treatment. The service helps promote well being and encourages independence – which in turn helps boost self esteem.

Being with other people of a similar age, who understand what it’s like to have cancer, helps reduce the sense of isolation which often accompanies a cancer diagnosis as a young person.

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 Dave. q • For more information visit www.youthcancertrust.org.

Supporting the maritime community [SEAFARERS UK has been helping people in the maritime

community for 100 years, providing vital support to seafarers in need and their families, as well as to those in education or training who are preparing to work or serve at sea.

They do this this by giving grants to organisations and projects that make a real difference to people’s lives, across the Merchant Navy, Fishing Fleets, Royal Navy and Royal Marines.

Last year they gave grants totalling £3.17 million to over 60 maritime welfare charities. Seafarers UK receives no government funding and is heavily dependent on public donations and legacies to maintain its grant-making. q • To support Seafarers UK or to find out more about their work, visit the website at www.seafarers.uk or email seafarers@seafarers.uk 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 Mr Jeremy P Crew MA MD BChir FRCS Translations and Interpreting for the Legal Profession since 1997.

Specialists in Personal Injury and Clinical Negligence.

Consultant Urological Surgeon Medical reports on all legal aspects of urology.

Reports in some cases based on hospital notes only.

www.abc-translations.co.uk

www.oxfordurology.co.uk

Mr Antony M. Visocchi

Dr Joshua Adedokun

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

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

www.dentalexpertwitness.co.uk

www.expertpainreports.co.uk

Mr Chris Makin

Dr Lars Davidsson (LSM) MRCPsych MEWI

• Chartered Accountant • Accredited Civil Mediator • Accredited Expert Determiner

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

Specialist in PTSD, anxiety disorders & mood disorders.

www.chrismakin.co.uk

www.angloeuropeanclinic.co.uk

David Berry PhD FRC Path MFSSoc MRSC

Mr Marcus Ornstein

Independent Toxicology Consultant Specialist in toxicology with particular emphasis on drugs (both prescribed and illicit) and alcohol.

Senior Lecturer (teaching) and recently retired general surgeon with expertise in general surgery, breast disease, hernia and abdominal trauma. T: 020 8423 8236 E: markornstein@gmail.com

www.toxicologyservices.co.uk

www.marcusornstein.co.uk

Dr David Usher BSc DPhil FCIEHF

Mr Mark Duxbury

Consultant Ergonomist: Identifying ergonomic issues behind work-related injuries. Assessing the equipment provided and the risk management system in place.

Consultant Surgeon – medicolegal work relating to general and laparoscopic surgery, specialist liver and pancreatic surgery, and hernia and gallbladder surgery

www.interactionofbath.com

www.markduxbury.info/medicolegal

Emma Ferriman Ltd

MD5 Ltd

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

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

www.emmaferriman.co.uk

www.md5.uk.com

Expert in Mind

Medicolegal Associates Limited

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

Expert Witnesses in Pain Medicine for clinical negligence and personal injury cases acting for the defendant and claimant. T: 0207 118 0650

www.expertinmind.co.uk

www.medicolegal-associates.com

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.forensichandwriting.co.uk

www.consultantoralandmaxillofacialsurgeon.co.uk

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www.yourexpertwitness.co.uk

Mr Michael Thompson

Sector Forensics Ltd

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

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

www.expertcolorectalsurgeon.co.uk

www.sectorforensics.co.uk

Dr Nigel Kellow MB BS FRCA MBA

Mr Simon Bramhall

Consultant in Anaesthesia & Pain Medicine • Spinal cord and nerve injuries • Complications relating to anaesthesia • Fibromyalgia • CRPS • Back & neck pain

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

www.kellow.com

www.simonbramhallhpbsurgeon.co.uk

Premex Group Ltd

Stockport Psychology Services

A leading provider of independent medical reports Choose from a panel of experts providing national coverage in every specialism

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

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Robert Hensher FRCS FDSRCS

Dr Thomas C M Carnwath

Consultant Oral and Maxillo-Facial Surgeon Subspeciality interests: • Dental Implantology • Salivary Gland Surgery • Temporomandibular Joint Replacement

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

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MEDICAL NOTES [ACCORDING TO President Donald Trump the US is in the grip of an opioid epidemic. And what happens on

the other side of the Atlantic usually finds an echo in this country. Sure enough, there has been a sharp increase in addiction levels for prescription painkillers, and Health Secretary Jeremy Hunt has announced a ‘landmark’ review of prescribing practices. A headline in the November edition of The Pharmaceutical Journal asked whether the problem is ‘a crisis hidden in plain sight?’

Technological advance has a habit of outstripping the ability of society to control it and its consequences. So it has been with advances in pharmaceutical technology. The development of synthetic opioids such as fentanyl, which is more than 100 times as potent as morphine, has led to breakthroughs in the treatment of pain from cancer and other debilitating diseases. It has also spawned a double-whammy of addiction issues: prescription of more and more powerful painkillers has led to addiction among the law-abiding, while the technology has been seized by the illegal recreational market.

• The review was welcomed by the president of the Royal College of Psychiatrists, Professor Wendy Burn, who also commented on another review – this time into the rising use of antidepressants. In the mind of many people, the two are linked – falsely so.

Research has found that depressants are effective in many cases, a point made by Professor Burn.

• Issues related to prescriptions led to a second set of headlines in February. Those headlines screamed that prescribing and dispensing errors in the NHS lead to ‘up to 22,000 deaths’ per year. As with all such headlines, that figure was grossly misleading. The real figure, though, is bad enough: at least 1,700 people die each year as either a direct or indirect result of errors associated with the administration, dispensing or prescribing of medicines.

Mr Hunt asked why doctors are still hand-writing prescriptions, when an electronic system exists. Again, nothing is that simple.

Given the extent of the chaos caused by the WannaCry attack last year, maybe Mr Hunt should be careful what he wishes for.

• Despite the wake-up call of the cyber attack, it seems many trusts still do not have their IT systems up to scratch when it comes to security, according to the House of Commons Public Accounts Committee. They are trying, though, says the head of NHS Digital. Reminds me of my school report.

• The recent, seemingly-endless rise in the use of opioids for pain relief is now being tempered, albeit slightly, in the use of other, non-addictive methods. One such is the development of a pain management programme. The multi-disciplinary approach can be of great benefit in mitigating claims, particularly when it is offered early on.

• Issues surrounding money seem to be an ever-present in medicolegal circles. Lawyers won’t be so happy to hear that the NHS Confederation is among the bodies calling for a cap on fees in clinical negligence cases. It follows the announcement that the MoJ plans to increase the small claims limit from April next year. Medical agencies are already reeling from what for some will be a 100% increase in charges levied by MedCo. • The main launch pad for all the controversy over claims was, of course, the controversy over whiplash. The traditional expert to turn to in such cases was the orthopaedic surgeon. Indeed, orthopaedic surgeons carry out more operations than almost any specialism. This year sees the centenary of the British Orthopaedic Association, which was founded towards the end of World War One. They have our congratulations.

• I have refrained from commenting on the controversy surrounding Dr Hadiza Bawa-Garba. That is partly because I suspect there are developments yet to emerge – possibly even before this publication is printed – and partly because…I’m lost for words. q

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Bawa-Garba case prompts multiple reviews and international outcry [THE OUTCRY OVER the conviction

and subsequent erasure from the Medical Register of Dr Hadiza Bawa-Garba over the death in 2011 of six-year-old Jack Adcock has resulted in the establishment of two reviews of the use of the manslaughter gross negligence charge in medical cases.

On 6 February Health Secretary Jeremy Hunt announced a ‘rapid review’ under the chairmanship of Professor Sir Norman Williams, former president of the Royal College of Surgeons. It is tasked with reporting back by the end of April.

Announcing the review, Jeremy Hunt said: “The only way we can reduce mistakes in the NHS is to learn from every single one, and the tragic case of Dr Bawa-Garba raises many important questions about how the health system supports staff to be open and transparent when things go wrong.”

The review was welcomed by Charlie Massey, chief executive of the General Medical Council. He said: “We welcome the announcement today from the Secretary of State to conduct a rapid review into whether gross negligence manslaughter laws are fit for purpose in healthcare in England.

“Doctors are working in extremely challenging conditions, and we recognise that any doctor can make a mistake, particularly when working under pressure.”

The GMC overruled its own disciplinary panel to impose the lifetime ban on Dr BawaGarba – a decision upheld by the High Court in the hearing that sparked the furore.

The GMC then announced its own review into how manslaughter by gross negligence is applied to medical practice. The review will be led by Dame Clare Marx, chair of the Faculty of Medical Leadership and Management.

Her review will bring together defence organisations, patient representatives and legal and criminal justice experts from across the UK to analyse how existing processes can be improved.

Dame Clare said: “Gross negligence manslaughter convictions involving medical professionals at work are rare but it is clear that there is a critical need to examine the wider issues around how these cases are initiated and investigated by the various agencies across the UK, and the expertise and consistency applied to those investigations.”

The GMC aims to complete its review by the end of the year.

The case attracted international attention, with the Sydney Morning Herald quoting Dr Brad Frankum, president of the Australian Medical Association in New South Wales, as saying: “How on earth was the doctor convicted of manslaughter? We don't understand it.

“Generally, criminal convictions have been against those with criminal intent or who were unethical or doing something illegal, whereas this case is different and it's truly disturbing.” q

Doctors fear condemning themselves [A GREAT DEAL of trepidation and fear was generated among the medical profession as a

result of stories circulating that the ‘reflections’ – notes produced by doctors following an incident to learn from the incident – were used against Dr Bawa-Garba in either the trial or the fitness-topractice hearing.

Despite assurances from both prosecution lawyers and Dr Bawa-Garba’s own defence lawyers that no reference had been made to her reflections, fears persisted and many press reports emerged of doctors threatening to adapt their reflections so as not to offer evidence against themselves. The threat even ran to a boycott of assessments, as they include the reflections.

Dr Chaand Nagpaul, BMA council chair, commented: "It is important that patient safety is not undermined through clinicians being deterred from engaging with reflective practices about patient care for fear of reprisal.”

Professor Wendy Burn, president of the Royal College of Psychiatrists, added: “Reflective practice in medicine is designed to make patients safer by creating a culture where doctors can learn from previous experience and develop their skills throughout training.”

A statement from the Academy of Medical Royal Colleges, representing all specialties, read: “All staff must be encouraged and be able to reflect honestly, openly and safely, and without the fear of recrimination, as part of the vital learning process. The threat of this being used in a potentially negative way may potentially promote a lack of candour as well as loss of learning opportunities.” q

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MedCo in firing line over fee hike [THE CHAIRMAN of the Confederation

of Medical Agencies (CMA) Ben Elsom (pictured) has criticised MedCo for the new annual charges to be levied on its members as ‘bureaucracy out of control’. He has also criticised the MoJ for failing in its duty of oversight in allowing MedCo to impose disproportionate charges on its members.

The confederation has announced that it is to seek urgent meetings with MedCo and the MoJ on behalf of its members. MedCo – the government-appointed not-for-profit organisation that administers the instruction of medical experts in whiplash claims – has announced it is to increase the fees it charges member organisations by up to 100% from April.

In a letter to users, MedCo said: “MedCo is a not-for-profit organisation and its usual policy has been to abate fees using surplus funds from previous years. However, if there is significant risk of financial calls on the surplus this policy cannot be maintained.

“The board has concluded that there is a significant ongoing risk of litigation resulting from the audit programme to implement the MoJ Qualifying Criteria. This, combined with uncertainty relating to the proposed personal injury reforms, as well as increased

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operating costs, has made it necessary to increase fees in April 2018.”

The annual subscription fee for High Volume National MROs will be £150,000 plus VAT and for Regional Based MROs £20,000 plus VAT. Ben Elsom responded by saying: “These fee increases cannot be justified at any level. MedCo announced in its annual results in December that it had nearly five million pounds in surplus cash. To announce that due to the risk of litigation it needs to

increase the fees to our members by up to 100% is absurd and incapable of justification.

“While we are aware that some litigation has taken place, it should not be the responsibility of our members to foot the legal bill for the mismanagement of MedCo by the current board of directors. The membership fees that MedCo passes on to our members is already in the CMA's opinion flawed in its design, possibly in breach of the Competition Act 1998 and places an unfair burden on the small businesses that we represent.”

He went on to explain that the fees to be charged to its Tier 2 members would be equivalent to 11% of the income per instruction for the average number of instructions they receive.

“Other organisations set up by government, such as the Claims Management Regulator – which is a selffunded body – charge fees based on the preceding years income of the company.

That appears, on the face of it, a more fair and balanced method of recovering the costs of managing the service.

“On behalf of the CMA membership we call on the new Secretary of State for Justice to review the MedCo operation and government policy in this area as a matter of urgency.” q

Prescription errors prompt Hunt to action [THE NEWS THAT errors involving

medication are responsible for at least 1,700 deaths per year in the NHS – and possibly many more – has drawn comment from the pharmaceutical industry.

The figure emerged from research carried out at the universities of York, Sheffield and Manchester as part of a Short Life Working Group for the Department of Health and Social Care. The researchers found that as many as one in 12 prescriptions contain an error and errors involving drug administration – which can range from an error in prescribing or dispensing to a delay in giving a dose in a healthcare setting – could run to 237 million per year. More than half happen when drugs are given and a fifth when prescriptions are written.

The report was highlighted by Health Secretary Jeremy Hunt in a speech to the World Patient Safety, Science and Technology Summit in London on 23 February.

Mr Hunt pointed to the fact that many prescriptions were still being hand-written as a major cause for concern. Despite the widespread rollout of the Electronic Prescription Service across the NHS, two-thirds of hospitals and some GPs still write paper prescriptions.

“It can’t be right that hospitals are recording vital information like prescriptions using pen and paper; yet only one third of trusts use e-prescribing effectively, despite these systems halving the risk of error,” said Mr Hunt.

Sandra Gidley, chair of the English Pharmacy Board of the Royal Pharmaceutical Society, said: “While the vast majority of prescriptions

prescribed in the NHS are safe, it would be extremely worrying for patients that medication errors contribute to thousands of deaths a year.

It is essential that the Secretary of State and the health professions build a culture of transparency and openness. This will play a significant role in reducing medication errors.

“This latest research underlines the importance of pharmacists having access to vital information from a patient's record to enhance safety.

We now need to build on this by enabling pharmacists to update a clinical record with details of any treatment they provide.”

She highlighted the particular issue of tracking the prescription records of patients who move from hospital to their own homes or to care homes and vice versa.

“Patients who move in and out of hospital and other settings are at high risk of medication errors as the right information about medicines is often not transferred with them. Pharmacists can and have been playing a vital role in reducing medication errors through transfer of patients between care settings. We strongly believe that every care home should have a named pharmacist dedicated to improving medicine safety.”

Mr Hunt also announced that pharmacists will no longer be prosecuted for honest medication mistakes; similar changes for doctors and other staff are also being considered after the outcry over the gross negligence manslaughter conviction of Dr Hadiza Bawa-Garba.

Mr Hunt commented: “Part of the change needs to be cultural: moving from a blame culture to a learning culture, so doctors and nurses are supported to be open about mistakes rather than covering them up for fear of losing their job.” q

Randox affair takes another twist [THE FALLOUT OVER the Randox Testing Services scandal

took another turn in December, when it emerged that thousands of drug-driving convictions dating from before the reporting scandal that engulfed the company last year may also be challenged because of doubts over the reliability of the processes used by Randox for analysing drug driving samples prior to May 2016.

The claims were made to the Yorkshire Post by two leading motoring lawyers – Alison Ashworth of Ashworth Motoring Law in Lancashire and Manchester-based Nick Freeman (Mr Loophole).

They said that other labs would take two separate samples from the vial of driver’s blood to get an aggregate result, whereas Randox tested single samples.

According the Yorkshire Post, the National Police Chiefs Council’s lead for roads policing, Suzette Davenport, wrote to police forces to warn them the method being deployed by Randox could lead to ‘increased challenges in court’.

Nick Freeman said: “I’m of the view all 10,000 cases where there have been convictions will be set aside because of the process that was deployed in analysing the samples of blood. Unless they are able to satisfy the courts they have followed the correct process, the readings are unreliable.”

That view was reinforced by Ms Ashworth, who told the paper: “I would challenge the prosecution evidence in any of the 10,000 cases. In my view, this is compromised evidence which should not be relied on.

“From a defence perspective, I would suggest that all of the cases affected should be challenged as serious concerns can be raised over the quality of the evidence used to secure the convictions.” q www.yourexpertwitness.co.uk

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NHS chief joins calls for fee cap in clin neg cases [NIALL DICKSON, chief executive of

the NHS Confederation – which represents organisations across the healthcare sector – has responded to the announcement by the Department of Health and Social Care that a group of experts will work on introducing a new cap on the amount of costs that lawyers can recover in NHS clinical negligence cases.

Mr Dickson said: “Last month, with others, we called on the Justice Secretary to reform the handling of clinical negligence claims. Today’s announcement is a step in the right direction. It must surely be fair to cap the amount lawyers can charge for their costs, and we welcome the decision to set up a group to work on this. We trust that the government will act quickly on its recommendations.

“We are also pleased that ministers have signalled their determination to tackle the wider issue of clinical negligence claims. The rising cost is now unsustainable and already means that vast resources that could be used by the NHS are being diverted elsewhere.

“We fully accept that there must be reasonable compensation for patients harmed through clinical negligence, but this needs to be balanced against society’s ability to pay. Money that is used for this purpose cannot be spent on frontline care.

“We also accept that the greatest prize is safe care – no health system can eliminate mistakes

but the campaign to put safety at the heart of the NHS is critical. The irony is that excessive claims and a blame-first approach undermine the open and learning culture which is so important for safe care.”

The Association of Personal Injury Lawyers responded to the Department of Health announcement by stating that: “Patient safety must not pay second fiddle to NHS costs reforms.”

Its president Brett Dixon said: “Analysis of information provided by NHS Resolution in

response to a freedom of information request shows that failures of maternity care represented a quarter of the damages paid out to injured patients in 2016/17. Failure in maternity care has been identified for years as a major problem for the NHS, yet little seems to have changed.

“The urge to streamline costs and procedures must go hand-in-hand with a real, systemic, consistent reduction in avoidable injury. Only then will the NHS become more efficient, and only then will we see an end to the needless suffering of patients.” q

NHS cybersecurity still not up to scratch [ALL 200 NHS TRUSTS assessed for cybersecurity vulnerabilities have failed to meet the standard required, the Law Society reports.

In a Commons Public Accounts Committee hearing on last year's WannaCry attack, NHS Digital’s deputy chief executive Rob Shaw said that the Department of Health and Social Care’s findings do not mean the trusts had failed to take any action to boost cybersecurity.

Mr Shaw said the standards set out by National Data Guardian represent a ‘high bar’, adding that, while some trusts have a ‘considerable amount’ of work to do, others are ‘on the journey’ to meet requirements.

Simon Stevens, the chief executive of NHS England, told the meeting: “A whole bunch of things need to change.” q

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Junior doctors welcome review of assessment [DOCTORS LEADERS HAVE described as ‘a welcome

development’ plans to improve how doctors in training are assessed, appraised and receive feedback.

The comment was in response to the unveiling of recommendations

by Health Education England (HEE), following a year-long reassessment of the annual review of competence progression (ARCP) process.

BMA junior doctors committee chair Dr Jeeves Wijesuriya said: “Our members have repeatedly raised concerns with the ARCP process, noting that it can be inconsistent, with variations across specialties and locations, and often appears to be a ‘tick-box exercise’ with little opportunity for education or professional development.

“It is therefore a positive step that this review states clearly that the consistency of ARCP panels is vital, alongside a need for better decision making and providing meaningful feedback following the panel.”

Dr Wijesuriya continued: “Many education supervisors have raised concerns regarding the time and resources that they have to carry out their roles, and as a result we wholeheartedly welcome the call for adequate support and time in job plans to ensure this crucial work takes place and that appropriate training and support is provided.”

Professor Wendy Reid, HEE’s director of education and quality, added: “The assessment process remains an important part of ensuring patient safety, as it provides evidence of the progress doctors in training are making and assures the public that they are in safe hands. What we have to make sure is that it works for all involved.

“We know there is variation in how the system works across the country and there are many reasons for that. There needs to be a more standardised and consistent approach so doctors in training go through the same process regardless of where they are based and what hours they work.” q

CQC publishes report on Huntercombe [ENGLAND’S Chief Inspector of Hospitals has published a report on

Huntercombe Hospital in Norwich, following an urgent inspection. CQC carried out its inspection over eight days in November and December last year as result of concerns about how the service was being run.

Huntercombe Hospital was a low secure and psychiatric intensive care facility, which provided in-patient child and adolescent mental health services for people aged between five and 18. The service provided care to people with a range of mental health disorders detained under the Mental Health Act.

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CQC found significant concerns during its inspection and took immediate action to protect those using the service, including enforcement action to remove the hospital’s registration. The Huntercombe Group then closed the service and all the young people using it were found alternative care by NHS England.

Deputy Chief Inspector of Hospitals (lead for mental health) Paul Lelliott said: “Our inspection found a service that was not effectively managing risks to the young people in its care, or protecting them from carrying out acts of self-harm or aggression. Staff failed to manage the safety of the hospital’s physical environment, too, and as a result young people had access to dangerous items which they could harm themselves with. Although staff reacted to incidents on the wards, they did not take action to prevent incidents occurring or escalating.

“Additionally, the hospital had not learned lessons from serious incidents or taken effective action to reduce the risks of similar events happening again. Staff failed to report some incidents and managers did not review or investigate all serious incidents robustly, openly and transparently.

“When the provider did investigate an incident, it did not take effective action and, despite giving repeated assurances that it had put measures in place, serious incidents of a similar nature continued to happen.

“There were insufficient numbers of skilled and experienced staff on wards to meet the needs of patients; we found staff did not always treat the young people with dignity and respect and the ward environment was unclean.

“That is why, following our inspection, we took urgent action to restrict the service and protect the young people using it. The provider subsequently decided it would close the service and all those using it were found suitable alternative care.” q

Hearing charity flags up the danger of loud music [ NATIONAL CHARITY Action on

Hearing Loss used the occasion of UK Tinnitus Week in February to urge young people to protect themselves from prolonged exposure to loud music. Four million are estimated to be at risk of hearing damage from over-amplified music.

Tinnitus – the ringing, hissing, buzzing or roaring sound in one or both ears where there is no external sound source – currently affects one in every 10 adults in the UK and can have a detrimental effect on a person's life, their relationships with family and friends and their ability to sleep, concentrate and work. While there are ways of managing the condition there is currently no cure.

The charity’s senior audiologist Gemma Twitchen explained: “Listening to loud music on a night out or from your personal music player can affect your hair cells, a bit like the way a fresh patch of grass is affected by someone trampling over it. After a few times the grass will stand upright and tall; however, over time if people continue to trample over it, it will become flat.

“This is similar to what happens to your hair cells: continued exposure can permanently damage your hearing and lead to tinnitus, which could mean that

listening to music, which so many young people love, becomes less enjoyable.

Action on Hearing Loss is funding research to find a cure for the condition, but while its scientists are working towards a breakthrough, the charity wants to

encourage everyone to wear earplugs when going to concerts and other noisy spaces such as gyms, and invest in noisecancelling headphones when listening to music through their personal music players to avoid developing tinnitus. q

Some Underground journeys loud enough to damage hearing, claims BBC [A BBC television programme has claimed that parts of the London Underground are ‘loud

enough to damage people’s hearing’. The claim was made during the filming of an episode of Inside Out London, broadcast on 29 January.

The BBC team used noise meters supplied by the University College London (UCL) to record sound levels in Zones One and Two over a period of a week. The loudest recorded journey through central London was between Liverpool Street and Bethnal Green, which peaked at 109 decibels – louder than a helicopter taking off nearby, the BBC said.

Dr Joe Sollini of UCL’s Ear Institute told the programme it was concerning, as any sounds in a workplace at or above an average of 85 decibels over an eight-hour period would mean hearing protection would have to be offered.

“Hearing loss accumulates over our lifetime,” he said. “If someone was on a noisy Tube line every day for long journeys, it is perfectly possible this could increase the risk of hearing loss and potentially tinnitus.”

The programme quoted London Underground’s Nigel Holness, who said: “While customers travelling on our network can experience noise, higher volumes tend to be for short periods of time and Health and Safety Executive guidance on noise suggests it is highly unlikely to cause any long-term damage to customers’ hearing.” q

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Orthopaedic association marks centenary of WWI establishment [ON 2 FEB the British Orthopaedic

Association (BOA) marked its centenary – an occasion that is being observed with a series of events throughout the year.

The BOA was established towards the end of World War One by 12 surgeons.

Their common aim was to treat the many soldiers suffering traumatic and severe limb injuries in combat. The first meeting of the 12 members was held in Roehampton (right) and laid the groundwork for an organisation that has led the world in orthopaedic advances for a century. Today the association has over 4,700 members committed to transforming the lives of the patients they care for.

Its current president, Mr Ananda Nanu, said: “The BOA was born out of the desire to help the soldiers left severely injured in the First World War. Since that time there have been enormous leaps in orthopaedic and trauma care by the surgeons operating in this field. For example, 90% of joint replacements now last the patient’s lifetime. Over a quarter of all surgeries performed by the NHS are for musculoskeletal procedures and we realise this high demand is a direct result of the dramatic

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improvement in the quality of life for so many patients.

“At the BOA we are proud to be contributing to a trauma care system that is one of the best in the world, leading many aspects of research, and an educational system for surgeons which leads

the way for other countries around the world. All built on the determination and vision of 12 people who said ‘we have to make a difference’.�

Orthopaedic surgeons focus on musculoskeletal disorders and injuries of bones, muscles and joints, providing treatment such as back surgery and hip or knee replacements. These types of problems are the most common cause of disability in the UK, affecting around one in four of the adult population (9.6 million) and over 12,000 children.

An early president of the association, from 1920-25, was Sir Robert Jones. He was an eminent proponent of orthopaedic surgery during the latter part of the 19th century, and a founder of the shortOLYHG %ULWLVK 2UWKRSDHGLF 6RFLHW\ IURP In 1902 he gave his name to the Jones Fracture – the fracture of WKH ¿IWK PHWDWDUVDO RI WKH IRRW ¹ ZKLFK KH GLVFRYHUHG LQ KLPVHOI He had injured his foot while dancing several months earlier, and had thought the injury was to a tendon in the foot. He asked a colleague, Dr David Morgan, to X-ray his foot, and a fracture above WKH EDVH RI WKH ¿IWK PHWDWDUVDO FDXVHG E\ D FURVV VWUDLQ WR WKH bone, was found. That also established Jones as an early proponent of X-rays in orthopaedics.

British orthopaedic surgeons continued to be pioneers of groundEUHDNLQJ WHFKQRORJ\ 7KH ¿UVW WRWDO KLS UHSODFHPHQW LQ WKH ZRUOG ZDV SHUIRUPHG LQ E\ %2$ PHPEHU 3KLOOLS :LOHV RI WKH 0LGGOHVH[ Hospital. Although Wiles’s case records were lost during World War Two, one patient is reported to still have their implant in situ 35 years later.

Hip and knee replacement procedures developed in the 1960’s were carried out by BOA members, and are today commonplace throughout the world. There are now over 150,000 operations like WKLV FDUULHG RXW HDFK \HDU LQ WKH 8. DORQH EHQH¿WLQJ WKRXVDQGV RI adults and children by enhancing their quality of life.

Now, 100 years later, the BOA describes its vision as â€œâ€Śa vibrant, sustainable, representative orthopaedic community delivering

Sir Robert Jones high-quality, effective care to fully-informed patients. We seek to achieve this by ensuring that the government’s health care reforms take full account of the need for properly resourced and accessible musculoskeletal services. This is important given the UK’s demographics and the fact that musculoskeletal disorders account for annual expenditure of some £5bn. Trauma and orthopaedic practitioners really can transform our patients’ lives.� T

Lawyers need access to the best medicolegal opinion >THE BRITISH ORTHOPAEDIC ASSOCIATION has a Medico-

Legal Committee, whose aim is to focus on the association’s role in providing medico-legal assistance in all aspects of trauma and orthopaedic practice. It offers an oversight of legal matters in relation to the safe practice of orthopaedic and trauma surgery, and the preparation of reports for the courts The committee also has a responsibility to inform members of the association of the changes in law relating to the practice of trauma and orthopaedic surgery, report writing and giving evidence. It co-ordinates the position of the BOA in response to government and legal profession changes in policy in relation to medico-legal expert and professional witness practice.

The Medico-Legal Committee also gives advice to external agencies regarding appropriate expertise to deal with medicolegal questions, both nationally and internationally. It has produced a guideline document for orthopaedic and trauma surgeons appearing as expert witnesses in legal cases.

With the introduction of new rules for low-value whiplash injuries, the role of expert witness in such cases is not always carried out by orthopaedic surgeons. It is essential that those representing victims of accidents can access the best available opinion in those cases. T www.yourexpertwitness.co.uk

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Research centre secures funding for another five years [THE Arthritis Research UK Centre for

Sport, Exercise and Osteoarthritis has been awarded a further £2m from Arthritis Research UK to continue its research into improving the understanding of the effects of sport and exercise on joint health and osteoarthritis.

Established in 2013, the centre is a consortium of six universities led by Nottingham University Hospitals NHS Trust. The six are Nottingham, Oxford, Southampton, Bath, Loughborough and Leeds.

It is an established group of world-leading researchers in sport and exercise medicine, orthopaedics, rheumatology, skeletal muscle biology, physiotherapy, podiatry, occupational therapy, epidemiology and physiology.

The first five years of the centre’s funding, from 2013, focused primarily on research with elite sportspeople – including Olympic athletes, professional footballers, cricketers and rugby players.

The next five years’ research, to 2022, will build upon existing research findings to answer the various questions relating to recreational athletes and exercisers, including: • Can we identify risk factors and phenotypes (body types) that • predict the onset and progression of symptomatic • osteoarthritis (OA) in athletes and exercisers?

• What is the effectiveness of conservative interventions • for the prevention and management of OA to enable lifelong • physical activity?

• How can we identify the effects of sport and exercise on the • quality of life for those at risk of, or currently living with, OA in • terms of physical, psychological and social wellbeing?

Professor Mark Batt, director of the centre, said: “Having learned a great deal about the impact of sport and exercise on joint and muscle health by working with athletes over the

last five years, this funding will enable us to answer fundamental questions about preventing, treating and transforming the lives of people with osteoarthritis.

“The centre has established expert teams from a wide range of disciplines, who have collaborated nationally and internationally to improve our understanding of the effects of exercise and injury on musculoskeletal health, including osteoarthritis. Now we will be able to continue to expand our knowledge and develop the next generation of researchers in these fields, working directly with patients, communities and sports people.”

Osteoarthritis is the most common form of arthritis and is estimated to affect over 8 million people in the UK. It is a long-term condition that can affect any joint, but is most frequently seen in the small joints of the hands, the spine, hips and knees. It causes pain, stiffness and swelling in the joints, which can in turn lead to a lack of mobility and the ability to carry out day-to-day activities.

One in 10 of the world’s population aged 60 years and older is estimated to have symptoms of osteoarthritis, but little has been known about the triggers which lead to its development or how it could be prevented.

Natalie Carter, head of research, liaison and evaluation at Arthritis Research UK, says: “Through working with elite footballers, cricketers and rugby players, the centre has already significantly increased our understanding about the potential long-term impact of sport on the joints. Over the next five years, we hope this research will also help us to pinpoint links and uncover risk factors for osteoarthritis in the wider population, which could in turn lead to innovative ways to treat or prevent the condition and improve the quality of life for people living with osteoarthritis.” q

Study raises neurological anxieties of hip MoM toxicity [ IN RECENT YEARS there has been much press reporting and

regulatory activity over the possible problems of toxicity associated with certain types of hip replacement – in particular metal-on-metal replacements (MoM).

The Medical and Healthcare products Regulatory Agency (MHRA) has issued two device alerts: the latest, in June last year, involved the recall of thousands of patients with the implants for X-ray and other investigations. One study, published in Orthopaedic Proceedings – a supplement of the Bone and Joint Journal – estimated the cost to the NHS of carrying out the tests as being at least £5.4m.

Most of the reporting, particularly in the press, has revolved around the possible cancerous effects of the alleged toxicity.

A less-widely reported possibility, however, relates to the psychological and neurocognitive effects of cobalt and chromium toxicity related to the implants.

A study reported in the 2017 edition of BMC Psychiatry addresses that issue. The study, Neuropsychiatric symptoms following metal-onmetal implant failure with cobalt and chromium toxicity, was carried out by a team led by Professor Ben Green of the University of Chester.

In the abstract to the article, the team note: “After MoM hip resurfacing, higher cobalt and chromium concentrations in blood have been associated with structural changes in visual neurological pathways. There are reports of metallosis following MoM hip implant failure, but little is known about the specific impacts of chromium and cobalt metallosis from these implants.”

The researchers state that cobalt toxicity from such implants has been known since the 1970s, but: “To the best of our knowledge

psychiatric symptoms following MoM implants have never previously been described.”

The study concluded: “We found neurocognitive and depressive deficits after cobalt and chromium metallosis following MoM implant failure. Larger studies of neurocognitive effects are indicated in this group. There may be implications for public health.”

Those implications were raised by the chair of the Commons Health and Social Care Select Committee, Dr Sarah Wollaston, in a series of communications with Health Secretary Jeremy Hunt and the MHRA. q

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New chronic pain charity launched [ THE FIRST UK CHARITY for people living with chronic

regional pain syndrome (CRPS) has been established. CRPS UK is focused on helping people with the condition to live the best lives they can. It aims to do it by providing a supportive environment in which people can find out about CRPS and get in touch with a community of people who know what they are going through.

According to CRPS UK, specialist treatment can be the key to lessening the impact of CRPS and helping people with the condition to live rich and fulfilling lives. They state: “We are working with specialist treatment centres to provide a grant scheme for patients with CRPS who are experiencing financial difficulty, to help them to afford travel expenses to and from hospital.”

Initially that will be for people attending the Royal National Hospital for Rheumatic Diseases in Bath, where the charity is based.

“Going forward, we also aim to improve research, diagnosis and treatment of CRPS. We will be promoting awareness and education about CRPS in primary health care, which should lead to more patients receiving timely diagnosis and intervention.”

According to another specialist centre, the Walton Centre in Liverpool: “CRPS is a condition that isn’t well understood and is often difficult to diagnose. Its main feature is persistent pain in an arm or leg, usually after trauma.

“It is often associated with changes in temperature, swelling and sensitivity and is sometimes referred to as reflex sympathetic dystrophy (RSD), Sudeck’s atrophy or algodystrophy.” q

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The back of litigation

By IVAN RAMOS-GALVEZ LMS, FRCA, FFPMRCA, Consultant and Expert Witness in Pain Medicine at Medicolegal Associates Ltd, Royal Berkshire Hospital and Spire Dunedin Hospital

[THE LOWER BACK is the area of the back situated between the

inferior border of the rib cage and the creases of the buttocks. At any given time, 33% of the population will suffer from lower back pain. Over a one year period this increases to 65% and across a lifetime, 84% of us have at some point suffered from it. However, only 20% of sufferers will attend their GP to seek treatment or advice. Overall, this means approximately 2.6 million people in the UK annually will consult their GP. Lower back pain is more prevalent in women in their 30’s onwards.

The natural progression of lower back pain when treated is one of rapid improvement both in pain and disability over the first month.

Clinically, there is very little change after the third month. However, 62% of sufferers still complain of lower back pain one year after the onset of the first episode. More worryingly, 16% of those unable to work as a consequence of the initial episode will not have returned to work a year later.

When contemplating a personal injury claim, by virtue of the statistics, the likelihood is that claimants would have suffered lower back pain before the index event. With only 20% of back pain sufferers consulting their GP, primary care records are not always an accurate reflection of their previous level of fitness. Only the experience and knowledge of an expert witness can untangle this conundrum.

In suspected clinical negligence, early involvement from an expert is vital when preparing to issue the claim. The expert can help to target key indicators in the case as well as identify weak areas which require further investigation. This can reduce costs and manage the claimant’s expectations.

The challenge for the clinician when confronted with a relapsing patient is to establish whether this is a new episode in recurring back pain or a completely new problem manifesting itself as back pain?

Whilst the tendency is to blame it on the historic non-specific lower back pain returning for yet another crippling episode, care and consideration have to be exercised in order to exclude a potential new diagnosis.

Malignancy, infections, inflammatory processes, trauma and wear and tear have to be considered depending on the presentation of the current condition – as well as age group, other co-morbidities and associated symptoms. If the symptoms persist, and more importantly deteriorate, the threshold for a revised diagnosis has to be lowered.

An easy error to be avoided is overinvestigating and over-medicalising the process. This could potentially lead to a serious situation where any change in a repetitive pattern will be met with the expectation of a full set of investigations to be promptly delivered. Patients may resort to ‘doctor-shopping’ in the quest for a diagnosis, for someone who will sell them hope in the shape of pioneering treatments – or treatments only they perform!

The situation for most of these patients

is therefore complex. They feel pain and may experience disability as a result which cannot be seen by those around them. The understanding and support they receive in the early stages tends to fade over time and they can feel isolated and that nobody believes them. This is the point when they can fall into a downward spiral of low mood and self-esteem, making them feel worthless.

At the other end of the scale, some patients try to keep things as normal as possible and they soldier on pushing themselves and suffering the consequences in the shape of frequent relapses. They will eventually join the previous group in the downward spiral.

There is a third group of sufferers whose support network invalidates them and their efforts completely and takes over all activities on account of their ‘disability’. These patients can suffer from ‘enabling families’ promoting a secondary gain that can be financial or affective.

The appropriate management of back pain is a multidisciplinary approach involving close co-operation between primary and secondary care practitioners. This will include pain specialists, spinal surgeons, rheumatologists, general practitioners, physiotherapists, clinical psychologists, clinical specialist nurses, occupational therapists and osteopaths – all of whom play an important role.

Needless to say, the opportunities for litigation can arise at all points throughout this long journey. There may be a case of clinical negligence due to a missed diagnosis or a treatment perceived as ‘going wrong’.

Or a case for a personal injury claim when a fall, slip or road traffic accident results in persistent lower back pain.

The role of an expert can be vital in differentiating what could be a complication from a negligent action. The expert can offer insight into an uncommon presentation of an unusual disorder which, by virtue of its rarity, only a very specialised unit may have been expected to investigate, diagnose and treat.

They will also help to differentiate what might be a case of exaggeration of symptoms against a genuine claim and provide valuable insight for decisions related to acceleration of long-standing injuries against expected wear and tear.

Importantly they can provide a prognostic opinion both in terms of resolution of symptoms and of the likelihood of the patient returning to the pre-existing level of function. q • Dr Ivan Ramos-Galves is a consultant in pain medicine with a sub speciality in spine surgery at the Royal Berkshire Hospital and Spire Dunedin Hospital in Reading.

He is an expert for both clinical negligence and personal injury claims and can be instructed through Medicolegal Associates Ltd on 020 7118 0650 or email: info@medicolegal-associates.com www.yourexpertwitness.co.uk

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What is the role of a pain management programme?

By Dr DEEPAK RAVINDRAN MD FRCA FFPMRCA FIPP, consultant pain and musculoskeletal specialist at the Berkshire Pain Clinic

[ A RECENT DEFINITION

of pain highlights its distressing nature – associated with actual or potential tissue damage – which is often accompanied by sensory, emotional, cognitive and social components.

Chronic pain is considered to be any pain lasting three months or more and its practical management, especially with on-going litigation, can be quite challenging. Most clients will respond well to a simple regime of physiotherapy and other complementary measures, and outcomes are usually good with a relatively good prognosis.

However, we know that in cases such as serious road traffic accidents, the story is not that simple. Imaging results and the consequent prognosis may not match and pain, being subjective, outstays its welcome. Initial attempts at physiotherapy are not always successful and medication and other injections do not last long.

Multidisciplinary input then becomes necessary.

While most clients will get benefit from the simpler sequential approach of physiotherapy and then medication, the more complex cases will benefit from a pain management programme (PMP) approach.

What is a PMP?

A PMP is delivered by an interdisciplinary team, usually in a group setting. They form part of an integrated approach to the management of pain. It is fundamentally different from the conventional approach in the sense that its rationale rests on proper client education, the limits of medical treatment and its success in eliminating pain, and teaching valuable self-management skills. The content is often delivered using the principles of cognitive behavioural therapy.

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It can be provided as both inpatient and outpatient and can also be personalised: for example, there are programmes specifically devoted to complex regional pain syndrome (CRPS). Successful outcomes will include pain relief, together with improved function and quality of life on reduced medication. A standard PMP will usually involve 8-12 half-day sessions, or 30-36 hours in total.

More complex clients may require intensive programmes, for example 15–20 full days, which is delivered in an inpatient setting.

PMPs are often an excellent tool for rehabilitation in the medicolegal arena, but the timing has been debated and evidence would seem to indicate that, if litigation is on-going, client outcomes are not achieved consistently. It can be argued, however, that suitability for a PMP should be based on the impact of pain, and clients should not be discriminated against on the basis of on-going litigation. There are no new research papers that offer an evidence-based outcome and it is often left to the court to decide on the timings.

Since there is often considerable delay in legal proceedings, it can be argued that a delay in providing a PMP to an eligible client could result in a poor outcome being delivered at the conclusion of a case.

PMPs are expensive in terms of client and staff time, the skills of the professionals involved and other resources. Often, the professionals involved are both psychologists and physiotherapists.

More economical options, including online versions, are now available within the NHS and can be considered.

It becomes important, therefore, to instruct the right medicolegal expert, who will be able to take a detailed and accurate history to make a clear diagnosis and review the need and timing of a PMP, should it be warranted. A careful comparison needs to be made between the objective signs and subjective complaints of pain to exclude other diagnoses and offer a range of opinion.

Often in such cases the statement of prognosis can fall outside the remit of the orthopaedic expert and advice is sought from the pain management expert – and in many cases a psychiatry expert as well, as there is often a complex interplay in chronic pain claims. In such claims, pre-existing issues such as a traumatic childhood, previous injuries and an exaggerated reaction can give a valuable insight into the claimant’s condition and likely level of functioning after the index accident.

A chronic pain claim can become very high value and is often complex in its presentation. In order to litigate effectively and obtain a good outcome, advisors should select the expert team carefully, have a thorough knowledge of the case and agree on a clear prognosis, including a pain management programme, that can often bring about savings in damages. q

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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Take back primary care support services, says BDA [ THE BRITISH DENTAL ASSOCIATION (BDA) has urged

the government to take NHS primary care support services away from troubled sub-contractor Capita. In a letter to NHS England chief executive Simon Stevens, dentist leaders have called on the government to think beyond simple contingency planning, and make a decisive break in light of Capita’s dismal long-term performance.

According to the BDA, NHS dentists have been unable to work – in some cases for up to a year – owing to issues getting the ‘National Performer Number’, which is required to provide NHS services. Services to patients have therefore been affected.

Administration of the National Performers List used to be managed by NHS England, but was contracted out to Capita alongside other primary care support services in September 2015.

Before Capita won the contract the average application turnaround time was approximately six weeks.

The BDA says that, despite pledges to deliver compensation payments to dentists affected, practitioners have faced unexplained delays of up to four months in receiving payments.

The BDA is aware of NHS practices that are risking closure as a direct result of this failure. GPs and optometrists facing similar challenges have also raised concerns.

BDA chair of general dental practice Henrik Overgaard-Nielsen said: “We have reached the stage where we can no longer ask NHS England to seek greater efficiencies from Capita or make contingency plans. Continuity of care now requires that these contracts are taken back in-house by the NHS, so dentists can get back to work.

“This isn’t a request to plan for ‘what ifs’, but to act on facts.

Capita has demonstrably failed, and our members should not have to suffer as a result of its grotesque mismanagement. The financial impact on some of our members is now reaching critical levels, and the fact that compensation for past failures is not being delivered only adds insult to injury.

“Paperwork that once took six weeks to process is to taking up to a year. Patients are suffering. Systems critical to delivery of care have been contracted out for no gain, and our profession should not have to keep paying the price.” q

Maxfax committee chair pledges training refocus [THE NEW CHAIR of the Specialty Advisory Committee (SAC) responsible for oral and

maxillofacial surgery (OMFS) has pledged to refocus surgical education away from a ‘tick box’ culture.

Emma Woolley, consultant OMFS surgeon and director of medical and dental education at the Betsi Cadwaladr University Health Board in Bangor, North Wales, said: “One of the key things I want to do as the new SAC chair is assess the quality of training and education in the most meaningful way; and to do this I think we need to move beyond the tick box culture that has developed.

“I believe strongly that there is a difference between training and education: training teaches the specific knowledge and technical skills, but this is not enough for true expert practice as an OMFS surgeon. Surgical education is about learning overall global competence and we need to focus on the holistic development of our junior colleagues as professionals. The introduction of the new surgical curricula in August 2018 will, I believe, address this explicitly for the first time.”

She called on colleagues who are trainers to enact the new curricula so that “…all the training programme directors and trainees are up to speed with its philosophy and what it’s trying to teach and assess. The role is also about working closely with the Joint Committee on Surgical Training around meaningful quality assurance assessment of programmes and surgical education”. q

Surgeon helps Richard fight his war [CONSULTANT cranio-oral and

maxillofacial surgeon and BAOMS luminary Rob Bentley was featured in a BBC2 Horizon documentary in February as he carried out high-risk reconstructive cranioplasty that played a key role in the road to recovery for stroke patient Richard Gray.

The programme, My Amazing Brain: Richard's War, followed the story of Richard and his fouryear recovery from a life-changing catastrophic stroke, recorded by his documentary film-maker wife Fiona Lloyd-Davies.

The documentary hears from Rob Bentley and other surgeons involved in his care, together with the clinicians and therapists who were integral to his remarkable recovery.

They describe the life-saving, high-risk reconstructive surgery through to the intensive rehabilitation programmes that chart the recovery process. q

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Inguinal hernia repair can result in some difficult complications

By M H ORNSTEIN FRCS, Hon senior lecturer and retired consultant surgeon

[RESEARCH INDICATES THAT some 25% of adult males will

develop an inguinal hernia, and there were some 69,000 repairs carried out last year in the NHS in England. The complications that follow apply to both open and laparoscopic (key-hole) repair, although less commonly after laparoscopic repair. That, however, has its own problems.

The repairs are almost invariably done using a ‘mesh’, a dozen or so proprietary preparations of which are available. The mesh can be likened to a net curtain, with considerably larger spaces between the threads of man-made fibre. It is used to reinforce the weakened area in the lower portion of the anterior abdominal wall through which fat and/ or intestine has protruded.

The recurrence rate for hernia repair has been reduced from some 10-15% to 1-3%, but this has been accomplished at a price. There are two difficult-to-treat potential complications: post-inguinal hernia repair chronic pain syndrome, which is common, and infection, which is rare.

Post-inguinal hernia repair chronic pain syndrome

Some 10% of patients having inguinal hernia repair suffer pain beyond the expected post-operative discomfort lasting a week or two.

That is the post-inguinal hernia repair chronic pain syndrome, and most cases settle in a matter of a few weeks or months. However, in 2-3% of cases the pain is debilitating and does not settle for many months or years.

The aetiology of post-inguinal hernia repair chronic pain syndrome is poorly understood, but is most likely multi-factorial. A major element, however, is entrapment of a nerve or nerves – either in scar tissue around the mesh, which is not due to any breach of the duty of care owed to the patient, or by a poorly placed suture or staple injuring a nerve, which is a breach of the duty of care.

There is, unfortunately, no reliable way of differentiating between the two except by surgical exploration, which most surgeons reserve for patients in whom all other treatments – and there are many – have failed. The plan in exploring a painful hernia repair is to find and divide the involved nerve or nerves. That is usually, but not always, successful, at the cost of an area of anaesthetic skin at the neck of the scrotum or upper thigh. If a wrongly-placed suture or staple is found it can, of course, be removed.

In a few cases the patient is deemed ‘allergic’ to the mesh and it has to be completely removed. Apart from the surgery itself,

the management of the syndrome is by specialists in pain relief – usually anaesthetists.

Infection

The other complication – infection – is uncommon and is also not usually considered to be due to any breach of the duty of care owed to the patient. It is problematic because bacteria are difficult to eradicate when there is a ‘foreign body’, in this case the mesh, in the tissues.

It is important to differentiate infection from the more common occurrence of swelling, due to fluid which naturally collects in the space previously occupied by the hernia: a so-called ‘seroma’. That is a normal response and can be aspirated or allowed to absorb spontaneously, and is not a factor in either the post-inguinal hernia repair chronic pain syndrome or the occurrence of infection.

If infection does occur it usually manifests by tissue swelling, redness, tenderness and a purulent discharge from the surgical incision wound. Initial management is with antibiotics, perhaps even administered intravenously for a few days, and that is effective in some 5-10% of cases.

If, though, the infection has not been eradicated by, say, three months, the chance of success diminishes greatly. A common problem is when the infection seems to come under control with cure of the physical signs, including drying up of the wound discharge, only for the wound to break down again after another few weeks. It heals again and the cycle is repeated, so surgeons, particularly trainees, are repeatedly lulled into a feeling that all is well.

Mesh removal

There is only one course of action, drastic as it is, to guarantee healing of a mesh infection. The mesh has to be removed, following which infections usually settle within days – even after months and sometimes years of ‘recurrent’ wound breakdowns. Unfortunately, mesh removal can be difficult because the scarring and loss of tissue planes make dissection hazardous. Patients need to be warned that even an orchidectomy may become necessary.

Furthermore, there is a high risk of a recurrent hernia after mesh removal – although, perhaps surprisingly, not in all cases – so most patients will require another repair some six months or so after all the infection has settled. If the first operation was ‘open’, as is usually the case, the repair of a recurrence should be laparoscopic.

It is, therefore, a breach of the duty of care owed to a patient for a surgeon to fail to explore and remove an infected mesh after a three month trial of antibiotics has failed to cure the infection. q

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Reduction in heart death rate at a ‘near standstill’ [PROGRESS IN REDUCING premature deaths from coronary heart

disease – those under 75 – is slowing to a near standstill, according to figures from the British Heart Foundation (BHF).

Although there was a small fall in deaths from the disease in 2016, research shows that the death rate declined by just 11% between 2012 and 2016, compared to 24% between 2007 and 2011.

In 2016, 22,615 people died from coronary heart disease in the UK before they reached the age of 75: the equivalent of 434 people every week. In total, more than 66,000 people of all ages lost their lives to the disease, which remains one of the UK’s single biggest killers.

The slowdown in progress could soon spell the end of decades of continuous decline in deaths from heart disease unless research is accelerated to improve diagnosis and treatment.

According to the BHF, ensuring that more people with conditions like high blood pressure and high cholesterol are treated effectively – irrespective of where they live – could bring down the number of people who die prematurely from coronary heart disease in the UK each year.

BHF chief executive Simon Gillespie commented: “Medical research has helped us make huge strides in saving the lives of people suffering heart attacks in the UK, meaning seven in 10 people now survive.

However, we can’t get complacent and think the disease is beaten.

“To keep up the pace of progress, it’s essential that charities and public bodies work together to provide the best possible care for those at risk of heart disease, and fund the promising areas of research that will save more lives.” q

Heart doctors warn of steroid risk [THE British Cardiovascular Society (BCS) has warned that

people may be at increased risk of dying early from heart attacks and strokes by misusing anabolic steroids. Speaking on behalf of the BCS, Dr Aneil Malhotra gave the warning amid concern that steroids are now being taken by hundreds of thousands of people.

A recent report from the Office of National Statistics revealed that the number of young people in the UK using anabolic steroids has significantly increased, with four times as many people using the drug now as there were last year.

As well as heart attacks and strokes, NHS guidelines show people who misuse anabolic steroids also risk health problems like infertility and mood swings. q

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MUPS: attempting to explain the unexplained is a challenge in medico-legal cases

By DR PAUL MCLAREN, Consultant Psychiatrist

[IT HAS LONG been recognised that ‘medically-unexplained physical

symptoms’ (MUPS) present significant challenges to clinicians and courts. In such cases, patients can present with physical symptoms in any organ or system which are inconsistent with what we know about the workings of the body.

A terminology has evolved and MUPS is a simple descriptive term for when, in the absence of evidence of malingering, a claimant has distressing and disabling symptoms which cannot be attributed to physical or ‘organic’ pathology. Such symptoms are sometimes also referred to as ‘functional’.

It is possible that symptoms are unexplained because medical science has yet to get to grips with the pathology: conditions such as chronic fatigue syndrome and fibromyalgia are probably best considered in that category at the present time. In other cases inferences are made about psychological mechanisms, such as unconscious conflicts, generating the symptoms – as in what was known as hysteria.

It was dramatic cases of hysteria – some involving blindness or paralysis – that were cured by hypnosis or talking cures, which laid the foundations of dynamic psychiatry in the 19th century, and were used as powerful evidence for the unconscious.

Hysteria is no longer used as a diagnosis, but the construct has remained essentially unchanged and encapsulated in diagnoses such as conversion disorder and somatoform disorder. The most recent manifestations are somatic symptom disorder (SSD) and functional neurological symptom disorder (FNSD).

In the case of SSD, no inferences were made about unconscious

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psychological mechanisms and most of the somatic symptoms in this disorder cannot be demonstrated to be incompatible with physical pathology. But the focus of the diagnosis is on having physical symptoms and ruminating about them to an extreme degree.

With FNSD, incompatibility with known pathological processes must be present. While there have been bold attempts to clarify a ‘murky taxonomy’, we know little more today about the brain processes which underpin conversion disorder than the 19th-century pioneers.

MUPS frequently present in medico-legal cases, as in general practice, and it is important to be open to their early recognition in any cases where there is a combination of physical and psychological symptoms.

Classical hysteria in adults was associated with childhood trauma and traumatic events can still lead to MUPS and somatoform disorders, SSD or conversion disorders, through psychological processes which are still poorly understood.

These conditions can be chronic and severely disabling, and empathic explanation and timely psychological treatment will improve prognosis.

In some cases the psychological disorders will be superimposed on diagnosed physical pathology, but it is difficult for psychiatric experts to make a firm diagnosis unless the physical medicine experts – usually neurological and orthopaedic – are clear about which symptoms are medically unexplained and which are not.

Psychological treatment can make a significant difference, but it needs to be engaged early and only after the patient has had a clear explanation of the case formulation. q

Psychiatry chief welcomes addiction review [THE president of the Royal College of

Psychiatrists has issued a response to the announcement that Public Health England (PHE) is to carry out a review into prescription addiction.

Professor Wendy Burn said: “We welcome a review to look into how to prevent people from becoming dependent on prescription drugs and to improve the lives of those suffering from addiction. Addiction is a serious mental illness and the rising number of deaths by opioids makes this review timely, especially as cuts to addiction services have been as big as 30% and the specialist psychiatric workforce is declining.”

In January PHE announced it had been commissioned by the Parliamentary Under Secretary of State for Public Health and Primary Care to review the evidence for dependence on, and withdrawal from, prescribed medicines.

The review will be public-health focused and will cover commonly-prescribed medicines, authorised for adults who have non-cancer pain, anxiety, insomnia or depression. It is due to report in early 2019.

The aim is to bring together the best available evidence on prevalence and prescribing patterns, together with the nature and likely causes of dependence or discontinuation syndrome (withdrawal) among some people who take those medicines. It will also look

at effective prevention and treatment of dependence and discontinuation syndrome for each drug category.

Professor Burn also commented on the review looking into the rising number of prescriptions of antidepressants.

She added: “Antidepressants are an effective, evidence-based treatment for depression

and anxiety disorders. For many people antidepressants are potentially life-saving. NICE guidelines state that antidepressants are most effective when combined with talking therapies, but too often these services are not available.

“We hope the review will also look into how we can ensure more people have access to psychological therapies.” q

BPS offers new guidance on refugees [NEW GUIDELINES HAVE been produced by the British Psychological Society (BPS)

for psychologists working with refugees and asylum seekers. Produced by the society’s Presidential Taskforce on Refugees and Asylum Seekers, chaired by Professor Bill Yule of King’s College London, they offer guidance on supporting different client groups, such as adults, families and children, young people and unaccompanied minors. There is also guidance on working in the wider community and in settings such as the workplace and nurseries, schools and colleges, in addition to the practicalities of working with interpreters.

Former BPS president Professor Jamie Hacker Hughes, who set up the taskforce, said: “The number of refugees and asylum seekers in the UK, Europe and across the world has increased dramatically since 2015. This developing worldwide crisis has resulted in headlines about thousands of people experiencing traumatic events, crisis and disaster with alarming frequency.

“As a discipline and a profession, psychology has a wealth of knowledge, experience and talent to apply in this area to help improve the lives of those who have fled their countries and are seeking safety. Psychological evidence and practice can help to equip individuals, organisations and communities with the knowledge, skills and understanding that they need in order to help them navigate challenging experiences in a complex world.” q

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New research is leading to rapid progress in PTSD treatment

By PROFESSOR STEPHEN MARTIN MRCPsych

[THE SCIENCE behind diagnosis, causation and treatment of

post-traumatic stress disorder (PTSD) is advancing very quickly, with implications for experts in keeping up to date and with the potential to affect claims.

Diagnostic criteria

The American Psychiatric Association’s DSM-5 diagnostic criteria are the gold standard in the UK courts. That is not because the World Health Organisation’s parallel ICD 10 system is flawed; rather that most research is American, so DSM-5 comes up most often in quoting papers in evidence and its use falls into place logically. Importantly, though, it is accepted internationally that PTSD equates between the APA and WHO systems.

In December a working group of the American Psychiatric Association proposed the addition of persistent trauma response to DSM-5 criteria.

If accepted, PTSD with fewer symptoms than the minimum threshold would then have to be classified, not as an adjustment disorder, but as ‘Other Specified Trauma and Stressor-Related Disorder’. That could be helpful in UK courts, with more emphasis on chronicity than an adjustment disorder claim.

Debate also persists over the inclusion or exclusion of emotions experienced in witnessing trauma which were omitted in DSM-5. A large Australian study of 933 women perinatally suggests that those symptoms should be re-introduced as important PTSD predictors, alongside anger, shame and guilt. That finding brings together the close relationship of PTSD and depression generated by trauma.

Causation

There is now good consistency in the findings of quality functional brain scan studies of PTSD. The brain areas involved are the memory, fear and arousal circuits.

One extraordinarily large sample taken by Cornell University found a specific pattern in patients who had both PTSD and major depressive disorder after trauma – a helpful substantiation of the true existence of PTSD-depression after trauma, which is known to have a worse prognosis. That severity seems to come from wider brain circuit dysfunction.

The group at Cornell, led by John C Markowitz, is now attempting to tie in stress hormone analysis, causing functional brain damage subtending PTSD symptoms, and how the symptoms respond to treatment. There is already a large literature on stress hormones and neurotoxicity – in other words how fear chemistry physically damages brain connections. Watch this space, as there might be some scans and blood tests used in court with predictive validity in a few years time, when PTSD diagnosis, severity and prognosis is debated.

It has been found repeatedly that early, appropriate treatment improves prognosis. Interim payment for care should not be allowed to drag, in the interest of any party.

Two good recent studies have shown that PTSD is more common

with whiplash – hyperarousal in particular – and that it predicts a longer course of illness.

False memory

John Jay College of Criminal Justice in New York has reported some striking findings in a careful study into false memory.

Participants claimed to have seen 26% of clips which were actually removed from a fatal accident video. They were also more likely to fabricate the most traumatic material.

Psychotherapy

Cognitive behaviour therapy (CBT) is effective and widely-funded in civil claims. Less widely practised, but now with an equal if not better evidence-base for effectiveness in PTSD, is interpersonal psychotherapy (IPT). IPT avoids distressing exposure and reliving treatment, but focuses on transition, isolation, dispute and bereavement. IPT may work better for patients who have both depression and PTSD. It has been proven that IPT has fewer drop-outs than CBT and twice as many patients prefer it as a less distressing option.

Medication

There is a new school of thought on adding in dopamine-blocking drugs to psychotherapy. That makes a good deal of sense in reducing arousal and promoting healthy function of fear and emotional regulation chemistry in the limbic system. Low-dose antipsychotics like amisulpride are cheap, well-established and tolerated, and several similar medicines have been shown to act as antidepressants. It is early days in clinical trials, but worth considering these medicines right now in severe, chronic and treatment-resistant PTSD cases.

Implications for loss mitigation

Whether the lawyer is for the claimant or the defendant, accuracy of diagnosis and prognosis is crucial in PTSD cases. On the back of that you plan the most suitable treatment for recovery as quickly and completely as possible. Watching for comorbid depression, using the best psychotherapy for the individual client and careful medicine choices are crucial in best recovery and loss mitigation. q • Professor Stephen Martin has 30 years experience as an expert witness and carries out CPD training for law firms in mental health. Enquiries and article reference details are available from profsmartin@gmail.com www.yourexpertwitness.co.uk

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NICE guidance could open door for cost-savings in AMD care [PEOPLE WITH SUSPECTED late age-

related macular degeneration (wet active) should be referred to a macular service within one working day, according to new guidance from the National Institute for Health and Care Excellence (NICE), published in January.

According to the Macular Society, over 600,000 people in the UK are affected by age-related macular degeneration (AMD).

AMD refers to changes that occur in the central area of the retina (macula) as a person ages. It affects that person’s ability to perform daily activities such as driving, reading and recognising faces. So-called wet AMD is caused by abnormal blood vessels forming underneath the macula and damaging its cells.

The new guideline recommends that people with late AMD (wet active) are offered anti-vascular endothelial growth factor drugs within 14 days of referral to the macular service. The drugs are injected into the eye and prevent the abnormal growth of blood vessels.

Professor Mark Baker, director of the Centre for Guidelines at NICE, said: “AMD can be a life changing condition for people if it is not identified early on. There are around

26,000 new cases of wet AMD in the UK each year and if left untreated over half will become visually impaired or blind within three years. Therefore the need to provide timely diagnosis and treatment is important.”

One of the findings included in the guidance states there are “…no clinically significant differences in effectiveness and safety…” between the drugs currently licensed (ranibizumab and aflibercept) and an alternative, bevacizumab – marketed as Avastin.

The finding has been welcomed by the Royal College of Ophthalmologists, which stated: “Furthermore, the lower cost of bevacizumab compared to ranibizumab and aflibercept, means that bevacizumab is the more cost-effective treatment.” However, many doctors are unwilling to prescribe Avastin because it is ‘off-label’.

In a joint statement with NHS Clinical Commissioners (NHSCC) – the body representing clinical commissioning groups – RCOphth says: “Local clinical commissioning groups have struggled to secure agreement with their providers to implement care pathways using bevacizumab because of anxieties about clinicians not adhering to the

guidance from the doctor’s regulatory body, the General Medical Council (GMC), about the use of ‘off-label’ medicine.

“The NHSCC and RCOphth are working with the GMC to clarify the GMC position given the conclusions in the NICE guidance and the use of bevacizumab in the management of wet AMD for over 10 years, which pre-dates the UK licensing of both ranibizumab and aflibercept.”

That clarification was quick to come. In a response issued by the GMC, its chief executive Charlie Massey said: “In an ideal world a licensing solution for using Avastin would be found, as the rigours of the licensing regime provide important assurances of patient safety. However, in the absence of this and given the clinical support for using Avastin, including from the Royal College of Ophthalmologists, we want to reassure doctors that this prescribing decision alone would not raise fitness to practice concerns, providing doctors are applying the broader principles of our guidance.” q

RNIB speaks from the heart on PIPs [FAZILET HADI, deputy chief executive of RNIB, has

responded to the publication on 14 February of the Work and Pensions Select Committee report on PIP and ESA assessments. The report found that “…public contract failures have led to a loss of trust that risks undermining the operation of major disability benefits.”

In his response, Fazilet Hadi said: “This report highlights exactly what many blind and partially sighted people tell RNIB: they are routinely failed during the PIP and ESA assessment and decision-making processes. The system needs radical reform to make it accessible, fair, and to rebuild their trust.”

The report came on St Valentine’s Day, to mark which the RNIB had sent a ‘Valentine’s card’ to the DWP, which read: “Dear DWP, we write with a heavy heart. We’ve had a long, sometimes difficult, relationship. Things started well. We both want to support the same people; we both want to make a difference.

“But it’s time to be honest about what’s gone wrong with Personal Independence Payments. We tried talking to you, we sent you other letters. Nothing changed. Perhaps we don’t want the same things after all? It’s not just our heart that your incompetence and lack of empathy is breaking. You’re hurting the people we care about. We’ve been left to pick up the pieces.

“To get things back on track you need to change. Let’s talk.

Yours in hope, RNIB” q www.yourexpertwitness.co.uk

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Patients stay awake during hand surgery [HAND SURGERY IS NOW being carried

out at the James Cook University Hospital in Middlesbrough while the patient is awake.

Trauma experts at the hospital have been piloting a new ‘hand block’ service which uses a local anaesthetic to numb the nerves so patients can stay awake to watch their operation and chat to their consultant throughout the procedure.

The nerves can be temporarily numbed above the collar bone, below the collar bone or in the arm pit. An ultrasound machine is used so the team can see precisely where the injection is going.

As patients do not have to be put to sleep there is less risk of nausea, vomiting and the complications associated with having a general anaesthetic, which can lead to claims. It also means patients can go home – and eat and drink – immediately afterwards.

Said hand and plastics surgeon Anna Barnard: “In the past some patients had to stay overnight, but now we can get them home straight after the procedure and follow them up with a phone call two days later. They should have the full feeling back in their arm four to 24 hours later.”

As well as being better for patients, it frees up theatre recovery beds and there are significant savings in terms of nursing costs.

One of the first patients to undergo the hand block surgery at the hospital was David Dixon (pictured, with Anna Barnard and her team).

David injured his finger during a goalkeeping save and saw it swell to twice its normal size. At first he thought nothing of it but was shocked to discover he needed an urgent operation.

“I was a little bit nervous about going under general anaesthetic and said I would prefer a local anaesthetic – as luck would have it they were about to start the hand block surgery,” he said. “The actual operation was quite surreal. It was weird having someone operate on you while you were talking to them.” q

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International awareness day puts spotlight back on FGM

[AN INTERNATIONAL DAY of Zero

Tolerance for FGM – a day to raise awareness of female genital mutilation (FGM) and to encourage concrete action against the practice – was held worldwide on 6 February.

In the UK the Royal College of Obstetricians and Gynaecologists (RCOG) expressed its support for the World Health Organization’s definition, which states that any form of cutting or surgery to the genitalia for cultural or non-medical reasons should be classed as FGM. In a statement they said: “The RCOG strongly opposes all forms of FGM and believes the practice is a form of abuse and a fundamental violation of the rights of girls and women, including the human right to physical, sexual and reproductive health and wellbeing. In the absence of any medical necessity, FGM can have devastating and long term consequences for girls and women.”

It is estimated that at least 200 million

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girls and women alive today have undergone some form of FGM. In England and Wales, where it is outlawed, it has been suggested that 137,000 women and girls from FGMpractising countries have undergone FGM, including 10,000 girls under the age of 15 years. A further 60,000 girls under 15 have been identified as being potentially at risk of FGM each year.

FGM is internationally recognised as a human rights violation and a form of child abuse – breaching the United Nations Convention on the Rights of the Child – and is a severe form of violence against women and girls. The Sustainable Development Goals in 2015 called for an end to FGM by 2030 under Goal 5 on Gender Equality, Target 5.3: Eliminate all harmful practices, such as child, early and forced marriage and FGM. Professor Janice Rymer, vice president for education at the RCOG, said: “The harmful effects of FGM on girls and women can be

devastating. We are committed to supporting clinicians providing health care and support to women who have been affected by FGM, as well as the women themselves.

“Our clinical guidelines provide clear advice for health professionals on the care of women with FGM before, during and after pregnancy. It also includes advice on the legal and regulatory responsibilities of doctors caring for women with FGM. We also have published information for women who have experienced FGM to help them understand their treatment options and where to seek support.

“Last year we collaborated with the Royal College of Medicine and other key partners to produce a series of powerful videos to create awareness around the consequences of FGM for girls and women.

“By giving a voice to the girls and women affected, we hope to raise awareness of the tragic consequences of this form of abuse and ultimately to empower practising communities to abandon FGM.” q

MRI scans help understand brain injury in prem babies [A TEAM AT Edinburgh University has carried out research into the

effect that being born ‘too early’ has on the brain and how to improve the future outcome for preterm babies.

The team at the Jennifer Brown Research Laboratory (JBRL) – a part of the university’s MRC Centre for Reproductive Health – is also looking at why some premature babies grow and develop well, while others experience difficulties.

JBRL’s scientific director Professor James Boardman said that three questions need to be answered in order to reduce the number of children who grow up with difficulties after premature birth. They are: How can we identify babies who are likely to have impairment so that we can target the right interventions at the right babies; what are the biological factors that lead to atypical brain development; and what are the protective factors that enable some preterm babies to do very well?

The JBRL has been using MRIs to scan babies’ brains and then using the pictures to show new ways of measuring brain growth and development.

Professor Boardman continued: “We are looking at how premature birth alters the brain pathways that are needed for emotional processing, social functioning, learning, movement and vision. These changes may underlie the difficulties that some children experience later in life.”

He added that the team is looking at what leads to brain injury and what leads to resilience. They bring the babies back for studies at several points as they grow and develop over the early years.

Maternity champions can improve care, says midwives’ union [NEW GUIDANCE DESIGNED to enable and empower the

Left: brain connections from an MRI scan of a sleeping baby, colour-coded by direction of connection. Right: an ‘atlas’ of the newborn brain, made by using computers to merge the MRI scans of many babies. Photo courtesy of the Jennifer Brown Research Laboratory The researchers recruited a group of women, who allowed for their placentas to be examined post-birth and consented to MRI scans on their babies. Professor Boardman paid tribute to the group, saying: “We wouldn’t have the information we now have without them. They give their time generously to help save and improve the lives of babies in the future.”

The Jennifer Brown Research Laboratory was set up 15 years ago by Sarah Brown and her husband, former Prime Minister Gordon, as part of the work of charity Theirworld in memory of their first child Jennifer.

She was born at 33 weeks and died 10 days later. q

work of maternity safety champions could help to improve services, according to the Royal College of Midwives (RCM). Published by NHS Improvement, the guide is for maternity safety champions – typically frontline healthcare professionals such as midwives – and for those working at board and regional levels. It gives broad descriptions of the various roles of champions and suggests how they can promote best practice in maternity services.

RCM chief executive and general secretary Gill Walton said: “The RCM welcomes the publication of this important guidance. Our maternity services are continuing to improve and deliver the safest possible care to women and their babies and that’s why it is so vital we support those who have stepped up to become maternity safety champions within our maternity services.

“The RCM is here to support members so that they can deliver safe, high-quality care and we will be signposting maternity safety champions to these new resources.” q

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