Expert Witness Magazine

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MEDICAL ISSUES

27 New tribunal will hear fitness-to-practise cases27 Whiplash debate heats up29 Former MP case brings plea law into spotlight29 Psychologist offers guidance on assessing child evidence31 A specialism born of warfare31 Profession welcomes Howe report, but victims remain unimpressed33 MPs call for regulation of plastic surgery ads34 Dentists dispute OFT findings34 Horse rider loses injury appeal35 How I work as a locum GP and avoid complaints37 Olympic drug testing lab gains accreditation37 Drug and alcohol conference set for Brighton39 Varicose Veins – the risks of minimally invasive techniques43 What’s in a name?45 How to make sure a surgeon is operating on the right patient and in the right place47 Sports and leisure experts combine to promote safety47 Lords launches Olympic legacy sports medicine inquiry

IN THIS ISSUE4 Opening Statement5 Expert testimony to come under scrutiny7 Workplace accident ruins kickboxer’s career7 Public are invited to nominate honorary silks7 Jail for would-be barrister25 The perfect venue in inspirational surroundings

DIGITAL FORENSICS9 Obtaining data in conjunction with an expert witness instruction

PLANNING & CONSTRUCTION11 First REIT to launch in September11 Resolving disputes is an expert activity13 RICS launches new residential policy13 Appeal Court rules in ‘house or flats’ dispute

FINANCIAL 15 Law Society and Trading Standards issue property trust warning15 Law firms the target of online fraudsters16 Customers may be right, but the stakeholders are always left – The importance of effective stakeholder engagement19 Is your expert dual qualified?

FURNITURE20 FIRA’s experts have unrivalled knowledge

ARBORICULTURAL ISSUES22 Institute of Chartered Foresters Directory of Consultants23 Tree disputes - getting to the root of the problem24 Cases involving trees require specialist arboricultural advice

EXPERT CLASSIFIED48 Expert witness classified listings53 Medico-legal classified listings

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OpeningStatement

4 www.yourexpertwitness.co.uk

Expert witnesses in the Family Court have come under the spotlight,with the quality of psychological experts being the subject of a debatein Westminster Hall. The secret nature of proceedings in the court weresaid to be the reason there had been no ‘quality control’. The reportfollows a study by academics at the University of Central Lancashire,which found inconsistencies.

The Legal Aid, Sentencing and Punishment of Offenders (LASPO)Act has finally become law, after facing an almost unprecedentedbarrage of criticism, attempts at amendment and outright oppositionin the House of Lords. The main critic from the opposition benches,Lord Bach, said parts of it are “not just bad but actually wicked” andan attack on the “disabled, poor and vulnerable, and those least ableto defend themselves”. He was nearly as scathing on the LiberalDemocrat peers who voiced concerns but didn’t vote against the Bill.“They spoke with one voice then voted with a completely differentvoice,” he said.

The Law Society is urging City law firms to fund an initiative to helpplug what it has called ‘the justice gap’. The initiative will also monitorand challenge the implementation of LASPO.

Meanwhile, the next target of the lawyers’ wrath is the proposalsto hold hearings in secret, excluding even the defence lawyers. Agroup of 50 specialist lawyers have written a response to the Justiceand Security Bill, objecting particularly to the move to force judgesto accede to the government’s application for a closed materialprocedure even when they feel it is not necessary. That, they say, is acontradiction of an assurance given by Mr Clarke in May.

Lord Howe has published his report on the PiP implants scandal– more particularly, on the Department of Health and regulatory body’shandling of the affair. Unsurprisingly, his Lordship found they had allacted quite properly, a view not shared by the victims of the scandaland their legal representatives.

In the next issue of Your Expert Witness there will be a special reporton dentists and maxillofacial surgery experts, as well as a look at thework of personal injury lawyers and their association, APIL.


Experttestimonytocomeunderscrutinyn ThequalityofexpertwitnessreportsinthefamilycourtswasputinthespotlightataWestminsterHalldebateon24May.

JusticeMinisterJonathanDjanoglysaidthattheruleswouldbechangedtoensureexpertreportsareonlyusedwhentheyare“necessarytodetermineacase”.

TheMinisteradded:“Expertevidencewillofcoursecontinuetobeimportantinsomecasestoensureafairandcompleteprocess.Whereexpertevidenceisrequired,weareworkingtoensurethatitisofhighqualityanddeliveredpromptly.

“Themainelementsareraisingthethresholdforthecourttopermitanexperttobeinstructed;requiringexpertwitnessevidencetobenecessary,ratherthanreasonablyrequired;andinfamilyproceedingsconcerningchildren,therewillbealistoffactorsthatthecourtmustexplicitlyconsiderindecidingwhethertopermitanexperttobeinstructed.Thosefactorsincludetheimpactonthechildofadelayandundergoinganassessment,thecost,andwhethertheinformationcouldorshouldbeprovided

byoneoftheparties,suchasthelocalauthority.Wewillalsorequirethecourttoexercisebettercontroloverthequestionsputtotheexpertandrequiresolicitorstoundertakepreparatoryworkearlierintheprocesstoreducedelaysintheexpertsbeginningwork.”

ThedebatecameinthewakeofgroundbreakingresearchcarriedoutbytheUniversity

ofCentralLancashire(UCLan),whichshowedthatthequalityofpsychologicalexpertsandtheirreportsshowsomeinconsistencies.

Evaluating Expert Witness Psychological Reports: Exploring Quality,waspartfundedbytheFamilyJusticeCouncilaspartoftheircommitmenttoexpertwitnessworkandthecontinuedreviewofstandardsacrossallexpertwitnesses.

Thestudyexamined126expertpsychologicalreportssubmittedinfamilycourtproceedingsfrom180courtbundlesacrossthreecourtsintheUK.Courtproceedingstookplacebetween2009and2011andcoveredbothadultandchildassessments.q

Justice Minister Jonathan Djanogly


Workplace accident ruins kickboxer’s careern ThesportingcareerofaformerEnglandkickboxerhasbeenendedafterhewasinjuredinanaccidentatwork,acourthasbeentold.

ZakDavisofLincolnshirewasburieduptohiswaistwhenatrenchcollapsedatthehousingdevelopmenthewasworkingoninAugustlastyear.On13JunetheNottinghamshireengineeringcompanyheworkedforwasfinedfortheincident.

MrDaviswaslayingdrainpipesinatrenchbeingdugbyanexcavator.Ithadbeenrainingheavilyduringthedayandwhilehewasinthetrenchthediggeroperatornoticedthewallsbeginningtocrack.Heshoutedawarning,butbeforeMrDaviscouldescapehewashitbythefallingmaterial–includingalargelumpofconcrete–andwaspinneddownbyhislegs.Hedislocatedandfracturedhishipsocketandshatteredhispelvis.Heneeded10hoursofsurgeryandisstilloffwork.

AninvestigationbytheHealthandSafetyExecutivefoundPhilWatsonCivilEngineeringLtdhadfailedtoassessthegroundconditionsandtheeffectthattherainwouldhave,andfailedtoinstallmeasurestopreventatrenchcollapse.ThecompanypleadedguiltytobreachingRegulation31(1)oftheConstruction(DesignandManagement)Regulations2007.Lincolnmagistratesfinedthefirm

£10,000andorderedittopayfullcostsof£2,141.

AfterthehearingHSEInspectorTonyMitchellsaid:“Excavationworkisahighriskactivity,buttherisksareforeseeableandpreventable.

“Thesitehadpreviouslybeenafarm.Ithadbeendemolishedandtherubblespreadonsiteastopfill.Thesubsoilbeneathitwaspredominantlycompactedsandysoil,sothegroundconditionswerepoor.However,thiswasnotproperlyidentifiedashighriskbeforeworkstarted.Therainmadethesoilstructuremoreunstableandthetrenchcollapsedbecauseitwasnotsufficientlysupported.

“Thisincidentcouldhavebeenpreventedbytheuseofmechanicaltrenchsupportsorbyslopingthetrenchsidesfurther.Instead,amanhasbeenleftwithlife-changinginjuries.”q

Public are invited to nominate honorary silks

n NominationsarecurrentlybeinginvitedbytheMinistryofJusticeofpeopleforappointmentasQueen’sCounselhonoris causa(honorarysilk).TheMinistryofJusticeintendstorecommendanumberofpeopletoHerMajestyforappointmentnextspring.Thelegalsectorandthewiderpublicareinvitedtomakenominations.

Tosuggestsomeoneforappointment,thenominatorshouldgivereasonsforbelievingthatthepersonnominatedhasmadeamajorcontributiontothelawofEnglandandWalesoutsidepracticeinthecourts,includingwhatthepersonhasdone,whereandhowthatamountstoamajorcontributionbeyondwhatmightnormallybeexpectedforsomeoneinthatperson'sposition.

NominationformsareavailablefromtheMinistryofJusticewebsiteatwww.justice.gov.ukandmustbereturnedby31July.q

Jailforwould-bebarristern LawgraduateMariousPimm,fromCambridgeshire,hasbeenjailedforayearforfalselyclaimingtobeabarristerandofferinghelptoabankruptplumberandawomangoingthroughadivorce.Hetookchequestotalling£4,000inrelationtothebankruptcyandpocketedmorethan£1,000for‘work’chasingupadebtconnectedwiththedivorceproceedings.

ThejuryheardhowPimmwouldmeetpotentialclientsinTheBoatInninWhittlesey–describedinonereportasa‘pop-upoffice’–andwouldoftendiscusson-goingcases.Heissaidtohaveevenjokedabouthiswigbeing‘itchy’whenhewasincourt.

DetectiveConstableMarkYendley,wholedtheinvestigation,said:“PimmusedhisknowledgegleanedfromstudiesatLincolnUniversitytofoolpeopleintothinkinghewasaqualifiedsolicitor.

“AlotofpeopleinWhittleseywereupsettodiscovertheyhadbeentakeninbyhisliesandarepleasedhehasnowbeenbroughttojustice.”

Pimmhadconsistentlydeniedthecharges,sayinghehadnevertoldanyonehewasabarrister,andisexpectedtoappeal.q

Former England kickboxerZak Davis


Rapid Turn-Around of Mobile Phone andComputer Evidence

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Obtainingdatainconjunctionwithanexpert witness instructionTONY SYKES of IT Group UK Limited discusses some common pitfalls

n Whenasolicitorwritesoremailswithnewinstructionsforacaserequiringexpertservices,individualsandcompanieslikeITGroupusuallydeploystandardproceduresnotdissimilartothoseusedintypicalcommercialcontracts.Mostcaseshaverequiredaquotationorestimatetohavebeenpreparedinadvanceoftheinstructions.Acknowledgmentoftheinstructionswithreferencetothequotationisusuallydespatchedbyreturntotheinstructingsolicitoralongwithtermsandconditionsandanyqualificationsregardingtimescalesetc.

Assumingallisacceptable,thenthebigquestionsareoften:HaveIbeengiveneverything?WhatfurtherinformationdoIneedtodothejob?WheremightIgetthatfrom?

Informationalsohastobeproportionate.Ifyouhavequotedjustafewhundredpoundstoconsideranissueandtowriteareport,youwillhavedifficultyiftheinstructingsolicitorsthensendyou4or5leverarchfilesofcorrespondencewithnoindicationofwhichpartsarerelevant.Othercommonlyencounteredproblemsarewiththequalityofthecopying.Ifthecaseinvolvescomputerrecordsortelephonedata,asisoftenthecaseforITGroup,thensometimesthecopiesarealmostillegible,beingphotocopiesofPDFs.Similardifficultiesoccurinmedicalcasesandincasesinvolvingaccidentswherehand-writtenaccountsarephotocopied.

AtITGroupweregularlyaskforelectroniccopiesofkeydataor,ifthatisnotavailable,thenwedeploystate-of-the-artOpticalCharacterRecognition(OCR)techniquestoturnpaperrecordsintoelectronic,searchablerecords.ButextremecarehastobetakenasOCRisnotalways100%reliableandanythingreliedonhastobecheckedcarefullyagainst‘original’disclosure.Eventhatdoesnotguaranteecompletedataintegritybecauseyoucanonlycheckwhatyouhavefound–itisnotpossibletocheckwhatyouhavenotfound.

Inmanycases,thedataneededtoundertaketheinstructionhasnotyetbeenobtainedandsometimesweareaskedtoassistinidentifying

•Tony Sykes, Senior Partner in IT Group, is a Chartered IT Professional and a Chartered Electrical Engineer. He has twenty years’ experience as an IT and Electrical Engineering Consultant and is an experienced Expert Witness. IT Group provides a broad range of consultancy services including due diligence, business process review, QA audit, insurance assessment, forensic IT / telecoms / electrical systems examination and expert services.

Cases include:

• London Borough of Southwark v IBM

• Kingsway Hall Hotel v RedSky IT Limited

• Watford Electronics v Sanderson CFL

• Sam Business Systems v Hedley & Co

• Autoroute Circuits v Life Racing Limited

• Epsom Telford Limited v Revenue and Customs

• Automotive Latch Systems v Honeywell International Inc

• Anglia Autoflow Ltd v Wrightfield Ltd

• Discovision Associates, Pioneer Electronics Capital Limited and• Pioneer Electronics (USA) Inc v Disctronics (UK) Ltd

• Horace Holman Group Ltd v Sherwood International Group Ltd

For further information visit www.itgroup-uk.com.

whatmayberequiredandhowthatmaybesecured.Incriminalcasesweoftenmakecontactwiththeofficerinthecaseandthentypicallygetdirectedtotheforensicengineerwhoconductedtheoriginalexaminationsoflaptops,mobilephones,calldatarecordsetc.Ourownindependentchecksmaythenthrowupnewareasofdatathatmightberelevant.

Difficultiesariseintwotypicalscenarios:thefirstbeingwhentheProsecutionhasdecidednottouseforensicITortelecomsdataandwethenhavetogothroughtheprocessofadvisingtheinstructingsolicitorsonhowtoobtainaCourtOrderforspecificdisclosureofrecords.Anaddeddifficultyisthatveryoftenthereiscriticaltimepressure,notofourmaking,whenatrialislooming(orsometimeshasalreadystarted)andthereisnotevenameansinplacetogetdata,letaloneanalyseitandreportuponit.Inthesecircumstances,itissometimesimpossibletodoathoroughjob.

ThentherearetheissuessurroundingtheDataProtectionActandtheRegulationofInvestigatoryPowersActwhichcropupformostexpertsatsomepoint.IntelecomstherearesometimesadditionaldifficultieswithISPsandmobilephoneserviceproviders,typicallyduetothevolumeofrequestsfordataforforensicanalysis.Knowledgeandexperienceofthesepitfallsanddifficultiesdoeshelpintheplanningandexecutionofforensicexpertservices.q

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n TheUK’sfirstsocialhousingrealestateinvestmenttrust(REIT)willbringtogether10housingassociationsfromacrosssoutheastEnglandandplanstoraise£500mbylistingonthealternativeinvestmentmarketinSeptember.AnymoneyraisedwillbeusedtofundnewhomesandtobuySection106sites.InMayWinckworthSherwoodSolicitorsannouncedthatitisadvisingonthestructureoftheorganisation.

ItwillbeanaggregatedREITprovidingmediumandsmallerhousingassociationswithaccesstonewequityfundingovera40-yearperiod,replacinggrantandlong-termdebtfinancing.Returnswillbeindexedtosocialhousingrents,keepinglandlordandinvestorliabilitiesmatched.Theassociationswillcontinuetomanagethehomesthroughoutthe40-yearperiod,withownershiprevertingtothemattheendoftheperiod.

Accordingtothelawfirm,despiteanobviousneedformoresocialandaffordablehousingintheUK,thewithdrawalofGovernmentdevelopmentgrantandunavailabilityofbanklendingmeanssocialandaffordablehousingdevelopmentareatall-timelows.AREITisdesignedtoraisesignificantamountsofprivatesectorfundingforinvestmentinsocialhousing.

KeithJenkins,SeniorPartneratWinckworthSherwoodsaid:“Untilnow,landlordshave

reliedonraisingcashfromgrantfundingfromgovernment,throughbankdebtorfrominvestorsonthedebtcapitalmarkets.Thisisnotalwayssuitableorviable.Governmenthasbeenseekingwaysofbringinginstitutionalequityinvestorsintothesocialhousingmarketthroughatax-efficientREITmodelforanumberofyears.

“TheaggregatedREITmodelprovidessecurityforassociationsandreleasesfundsformuchneedednewhomes,whilstofferinggoodreturnsforinvestors.WehavehadconsiderableinterestinouraggregatedREITfromassociationsandinvestors.”

WinckworthSherwood’saggregatedsocialhousingREITstructurehasbeenlaunchedinadvanceofthecloseon27JuneoftheTreasury’sconsultationonhowREITsmight

Resolving disputesisanexpertactivityn Oneofthemostsignificantdevelopmentsinthefieldofconstructionandpropertydisputeshasbeentherapidgrowthofalternativedisputeresolution(ADR).AstheRoyalInstitutionofCharteredSurveyors(RICS)pointsout,“alternativedisputeresolutionisoftencheaperandquickerthantakingacasetocourt”.TheRICShasawell-establishedDisputeResolutionService(DRS)whichitclaimsistheworld'slargestproviderofalternativedisputeresolutionservicestothepropertyandconstructionindustries,witharound10,000appointmentstoresolvedisputeseachyear.

Withover30yearsunderitsbelt,theserviceis“workingonacontinuousdevelopmentofnewproductsandservicestomeetclients’needs”.Itsimpartialityandthequalityofitsdisputeresolversmeanitcanclaimtoinspireconfidenceinthepartiestoadispute.

AllitsmanagementandadministrationsystemsareaccreditedtoBSISO9001:2008.Theservicealsoprovidesaccesstoapanelofhighlyexperiencedexpertwitnessesinallareasofpropertyandconstruction.

AccordingtotheRICSwebsite:“Wheretwopartiescannotagreeontheappointmentofasinglejointexpert(SJE),anapplicationcanbemadetothepresidentofRICStomakeanimpartialnomination.”

ThesinglejointexpertisselectedfromRICSDisputeResolutionPanel.RICSsinglejointexpertsareexperiencedinallareasofpropertyandconstructiondisputes,including:

•Buildingsurveying•Commercialproperty•Compulsorylandpurchaseorders•Constructiondisputes•Dilapidations•Planninganddevelopment

•Retailproperty•ValuationThepanelmembershavemanyyearsofexperienceactingas

expertwitnessesinbothjudicialandtribunalproceedings.q

•Further information is available from RICS at www.rics.org/drs.

beusedinsocialhousingtoattractinstitutionalinvestors.

KeithJenkinssaid:“TheconsultationcouldbereadasanexaminationofhowtheGovernmentcoulduseREITsasawayofcompellinghousingassociationstopermitprivateinvestment.OurmodelgivesassociationstheopportunitytoadoptaREITundertheirownterms,ratherthanbeingcompulsorilyREITed.”

WinckworthSherwoodisalsoadvisingonthestructureofasecondREIT,tobelaunchedintheautumn,thatwillbuyopen-marketpropertiesbuiltbylargehousingassociationsatawholesaleprice,providingsecurityofsaleofmarketstockfortheparticipatingassociationstoreleasefundsforinvestmentinsocialhousing.q

First REIT to launch in September


Appeal Court rules in ‘house or flats’ disputen Judgeshavedecidedthatasix-storeybuildingshouldbeclassedasablockofflatsratherthanahouse.

AdisputeregardingapropertyinChelsea,LondonoveritsclassificationwasrecentlyheardintheCourtofAppeal.

LeaseholderMagnohardhadbeentryingtoacquirethefreeholdforthepropertyfromEarlCadoganandCadoganEstates,butthelatterarguedthiswasnotpossiblesincethebuildingwasablockofflats.

Thecourtruledthat,sincethepropertyincludesthreesmallshopsalongsidethesixresidentialsuites,aswellasaflatforthehousekeeperandacommunalentrancehall,itwouldbeunreasonabletocallitahouse.

MarkVinall,apartneratWinckworthSherwoodSolicitorsspecialisinginenfranchisementandleaseholdpropertymatters,commented:“TheCourtofAppealhasdeterminedthatablockofflatsisnota‘house’forthepurposeofaleaseholderofabuildingseekingtoacquirethefreeholdtitletoitpursuanttotheLeaseholdReformAct1967,onthebasisthattherelevanttestiswhetheritisreasonableratherthanpossibletocallagivenbuildinga‘house’.

“Inthiscase,asoriginallyconstructed,thebuildingcomprisedsixresidentialsuites,acommunalentrancehall,ahousekeeper’sflatandthreesmallshops.”q

RICSlaunchesnewresidentialpolicyn On31MaytheRoyalInstitutionofCharteredSurveyors(RICS)launchedalandmarkresidentialpolicytohelptheorganisationchangethefaceofthesectorandpromptgovernmenttoeasetheon-goingpressurecausedbythehousingcrisis.

Afunctioning,professionalisedandaccessiblehousingmarketisineveryone’sinterest,RICSsays,anditislookingtoencouragethegovernmenttodeliverlegislation,policyandregulationthatbenefitstheconsumer,theresidentialsectorandtheBritisheconomy.Sincetheendoflastyear,RICShasbeenconsultingitsmembersandfirmsacrosstheUK.Onemessagewasparticularlyloudandclear–thereisaclearroleforprofessionalstandardsandexpertisetohelpconsumerstomakeinformedchoiceswhenbuying,sellingorrentingapropertyandRICSshouldbeleadingthewayindeliveringthis.

Theeconomicsituation,coupledwiththepoliticsofthecoalition,hascreatedaunique

politicalclimatewhereevensensibleandbeneficialsuggestionstochangegovernmentpolicyfallvictimtotheneedtoreducethedeficitasquicklyaspossible.

However,RICSbelievesthatboththeimmediateandlong-termissuesinthemarketneedtobeaddressedandthegovernmentmustdeliverlegislation,policyandregulationthatprovideuswiththehomesthatweneed,whereverweneedthem.

Thereportcovers:•Measurestogetthestagnantproperty•marketmoving.•Theneedformandatoryregulationof•bothsalesandlettingsagents.•Providingconsumerswiththeright•informationwhenbuyingorselling.•NewwaysofboostingBritain’swoefully•lowhousingstock.•Tacklingproblemsassociatedwith•socialandaffordablehousing.Theinstitution’sglobalresidentialdirectorPeter

Boltonstated:“Todeliverrealinfluenceinthecorridorsofpower,RICSneedstohaveaclearresidentialpolicy.Inputtingthislandmarkworktogether,wemetwithourmembersandfirmsofallsizesfromrightacrossthecountry.WhatcameacrossloudandclearisthedesperateneedtoreformsectionsofthemarketandgenerategrowthrightacrosstheUK.

“Wewillnowtaketheserecommendationstothegovernmentwiththeaimofhelpingthemtoimprovetheresidentialpropertysectorforthoseoperatingwithintheindustryandthepublicasawhole.ChangeneedstohappenifwearetoseeaneconomicallyviableandprofessionallydrivenresidentialsectorandIstandreadytoworkwithmembers,government,otherindustrybodiesandconsumerorganisationstoachievethis.”q


LawSocietyandTradingStandardsissuepropertytrustwarningn TheLawSocietyhasjoinedwiththeNorthEastTradingStandardsAssociation(NETSA)inissuingawarningtoconsumersalertingthemtotherisksofusinganunregulatedwillwritertoprepareaPropertyProtectionTrustWill.

ThewarningcomesfollowingnumerouscomplaintstoNorthEastTradingStandardsfrommembersofthepublicinrelationtoaninfluxoffirmspromotingtheseproductsandusingscaretacticsandhigh-pressuremethodstosellthem.

ThecomplaintsfollowasimilarpatternandfocusonattemptstosellPropertyProtectionTrustWillsorAssetProtectionTrusts,whicharedesignedtohelphomeownersprotectthevalueoftheirhomeandsafeguardtheirshareofapropertyintheeventofchangingcircumstances,suchasthedeathofapartner.Ithasbeenclaimedthattransferringownershipofthepropertyconcernedintothetrustwouldmeanthatalocalauthoritywouldnotbeabletoclassthehouseasanassetwhencarryingoutameanstesttoassesswhetheritwillpaycarehomefees.

HowardTurton,theRegionalEnforcementmanagerofNETSA,warned:“Thepotentiallimitationsofsuchproductsarealsonotalwaysconveyedtothehomeowner.Localauthoritieshavealegalrighttooverturnanygiftsintosuchtrustswheretheycanprovethattherehasbeena‘deliberatedeprivationofassets’.Forthisreason,customerswhotakeoutanAssetProtectionTrustorsimilarcouldfindthemselveschallengedbythelocalauthorityatalaterdate,especiallyifcarehomefeesarerequiredsoonafterthetrustarrangementisputinplace.”

Thefirmsmakingthesecallsareunregulatedandmaynotevenbequalifiedorentitledtoundertakethiswork.TheLawSocietyhasbeenrunningacampaigntowarnconsumersofthedangersofusingwillwriterswhoarenotproperlyqualified.Itiscallingforwillwriterstoberegulatedattheearliestopportunitytostoptheexploitationofconsumers.

TheLegalServicesBoard,theindependentbodyresponsibleforoverseeingtheregulationoflegalservicesinEnglandandWales,releasedproposalsattheendofApriltobringwillwritingandestateadministrationserviceswithinthescopeoflegalservicesregulation.Theproposalswould,forthefirsttime,seetheseservicesbroughtwithinthelistof‘reservedactivities’andallthosewhoprovidesuchserviceswouldberegulated.

LawSocietypresidentJohnWottonsaid:“Withoutregulation,willwritingprovidershavethefreedomtomarketanddeliverserviceswithoutmeetinganyprofessionalstandards,tothedetrimentofconsumersor,veryfrequently,theirfamilies.Thepreparationoftrustdeedsrelatingtorealorpersonalestateforthepurposesoflaw,inparticular,isanoffence,unlessapersonisauthorisedorexemptunderthe2007LegalServicesAct.KeyelementsofpreparingaPropertyProtectionTrustfallwithinthedefinitionofareservedactivity.Consumersneedtobeawarethatreservedactivitiescanonlybecarriedoutbyasolicitororotherauthorisedperson,oranexemptperson,andthatunregulatedwillwritersmaynotbelegallyentitledtopreparethesesortsoftrusts.”q

Law firms the target of online fraudstersn LawfirmsintheUKarebeingtargetedbyinternationalhackers,accordingtoareportintheLaw Society Gazette.ThejournalquotesformerassistantUSattorneySethBerman,nowtheLondon-baseddirectorofdigitalriskmanagementandinvestigationsfirmStrozFriedberg.

Hewarnedfirmstostrengthenonlinesecuritytoprotectclients’data.HiswarningfollowsthenewsthataRussianhackermayhavestolensomesixmillionLinkedInpasswords.

SaidBerman:“Thesecurityandrisklandscapeischangingrapidlyandit’stheverynatureoflawfirmsthatmakesthemanactivetarget.We’refacinganincreasinglysophisticatedarrayofadversaries,whichmakesitmoreimportantthaneverforlawfirmstorecognisetheseverityofsuchthreats.

“Thereisnodoubtmostlawfirmsrecognisetheirobligationsandhavetakenstepstoshieldclientdata.Butthesectorisunusualinthewayitdealswithinformation,whichseespersonaldetailsofindividualpartners,associatesandlawyersreadilyavailableonfirms’websites.

“Lawfirmsneedtorealisethattheyarebeingtargetedandmusttailorpoliciesandtrainingtoaddressthisthreat.”q


Customers may be right, but the stakeholders are always leftThe importance of effective stakeholder engagement

by DR DARRELL JAYA-RATNAM, DIEMconsulting Ltd

n AstheOlympicsapproach,theShardreachescompletionandargumentsaboutcapacityatHeathrowresurface,moreisheardfromthoseconsideredtobethebroaderstakeholdercommunity–thepeopleofthelocalarea,investors,corporateboards,lobbyistsandpoliticians.Itshowshowinthemodernagedifferentgroupsandentitiesaresointertwined.Italsohighlightstheimportanceofgettingyourstakeholderengagementright.Notjustholdingconsultations,asoftenrequiredbylaw,butactuallyhavingapropertwowayinteractionthattakesaccountofstakeholderinputsindecisionmakinginawaythestakeholderscanbuyinto–eveniftheydon’tagreewiththeresult.

The importance of being earnest – about stakeholder engagement

Atthemostbasicleveltherearetworeasonsstakeholderengagementneedstobedonewell–thelawandmoney!

Intermsoflaw,forawholerangeofmajorprojects,fromshopstoschoolstoairports,itisalegalrequirementtoholdconsultations.Likewiseforcompanies,theCorporateGovernanceCode2010(alegalrequirementforpubliccompanies)requirescompaniesto…“ensurethatasatisfactorydialoguewithshareholderstakesplaceandusetheirAGMtoencourageinvestorparticipation”.

MeanwhiletheCompaniesAct2006(alegalrequirementforalltypesofcompany)specifiesthatakeydutyofdirectorsisto“promotethesuccessofthecompanyforthebenefitofitsmembersasawhole…”.Thisimplicitlyrequiressomeengagementwith‘members’(theequivalentofshareholdersforaclosedcompany)toillicitwhat‘success’isfromtheirpointofview.

Intermsof‘money’(orcosts),poorstakeholderengagementcanleadtobothorganisationalandpersonalfinancialloss.Considerthefinancialimpactofprotests(and,intheextreme,theriotofApril2011inBristol)overnewsupermarketopeningsorthetreatmentofanimalsinfarmsthatsupplythem.Thenthereistheincreasingnumberofattempted(somesuccessful)shareholderrebellionsthisyearoverexecutivepay(Aviva,Barclays,Cairn,HSBC,Prudential,Cookson,Resolution,888Holdingsetc)orissuessuchassuccessionplanning(DeutscheBank).Finally,considerthecostsofrepeatedconsultationsandpossible‘u-turns’ongovernmentpolicies,schoolsbuildingprogrammes,NationalTrustforests,routesofraillinks,airportsandeventhesubsequentuseofOlympicvenues.

Thesetworeasonsoftenthencombinewhenlegalchallengesaremadeovertheconsultationprocessthatwasconducted.Thisistypicalformajorprojectsbutmomentumisalsobuildingtochallengedirectorsovertheirconsultationwithshareholderspriortomajorstrategicdecisions.

Acceptable poor consultation practiceDoasearchon‘publicconsultation’andyou’llusuallyfinditdescribed

asthreestages:notification,consultationandparticipation.You’llalsooftenfindareferenceto‘Arnstein’sLadder’whichisaframeworkforunderstandingthedifferentlevelsofcommunityparticipation.However,ifyouthenlookatArnstein’sLadderyouwillseethat‘consultation’falls

undertheheadingof‘tokenism’.Alas,alltoooftenthisisallitturnsouttobe.Notintentionally,perhaps,buteffectively.

Fromourworkhelpingcorporatesandgovernmentministriesgainstakeholderbuy-intomajorinvestmentsweseetwoproblems:

•Defining‘stakeholder’toobroadlyandhencenotgettinganyclear•viewsfromanywell-definedgroup.•Relyingtoomuchon‘stakeholder’input(verbalandwritten)but•thenprovidingnofeedbackastowhetherandhowitwastakeninto•account.

Knowing your true stakeholderThefirstchallengeisbeingclearonwhoyourstakeholdersreally

are.OnerathergooddefinitionisgivenbyFreemanin1984:“Anygrouporindividualwhocanaffect or [be] affected bytheachievementofan organisation’s objectives”.

Theitalicshavebeenaddedtohighlightthetwokeyaspectsofthedefinition.First,itisatwowaythingbetweentheorganisationandstakeholder.Second,itisabouttheorganisation’sobjectivesnotjusttheorganisation’sactions.Toooftenpeopleassumeastakeholderisanyonewhocanbeimpactedbyanorganisation.Bylinkingittoanorganisation’sobjectivesyoufocusonthosewhocanhelporhindertheorganisation.Inotherwords,theyarethepeoplewhohaveastakeinwhethertheorganisationsucceedsorfails(hence‘stake-holder’).

Toooftenstakeholderengagementsandconsultationsarehandicappedrightfromthestartbyspreadingthenetsowidelythatnoclearviewcaneverbeheard,letaloneconsensusreached.Thecynicsamongusmightsaythatthisiswhatbigorganisationslikewhen‘consulting’priortoamajorinvestment,suchasanewsupermarket,butIprefernevertoassumemalicebeforefullydiscountingincompetence!

Seeing is believingThenextchallengeistoensurethereisaclearaudittrailofinputs

madeandhowtheylinktodecisionstaken.Typicalconsultationstaketheformoflargeorsmallmeetings,wherestakeholdersmakeverbalinputs,ortheycaninvolveaprocessofcollatingwritteninputs.Theseareafinestartbuttoooftentheyappeartobetheend.Iemphasis‘appear’becausemostorganisationsinvolvedinaconsultation,whetherbychoiceorlegislation,willtrytotakestakeholderviewsintoaccount.

Theproblemis,howdoesanexecutive,orminister,properly


understandandtakeintoaccountwhatcouldbemanycontradictoryviews.Andevenifheorshedoes,howdotheydemonstratetheyhavedonesotothestakeholders,especiallytothosewhodisagreewiththeenddecisionandwhowillnaturallyassumetheyweresimplyignored?

Inourexperiencetheanswerliesinfindinganappropriatevisualrepresentationofthevariousinteractingdrivers.Therearemanytechniquesusedtoprovidea‘picture’ofdifferentproblemsincludingbenefitsmaps,causalmaps,influencediagrams,flow-charts,value-chains,decisiontreesandissuetrees.Choosetheonethatbestallowsyoutodescribetheissueathandbutthen,crucially,duringtheconsultationencouragethestakeholderstohighlightwhichareatheywanttoaddressandrecordtheirinputagainstthatpartofthepicture.

Thishasseveralbenefits.Firstly,stakeholderscanseewheretheirconcernsfitinrelationtoalltheothers.Secondly,byactivelydemonstratingithasbeenrecordedintheappropriateplaceitincreasesbuy-intotheoverallframeworkusedtomakeanyfuturedecision.Fromtheorganisation’sordecisionmaker’spointofviewitisagreatwayofrepresentingtheconflictingissues.Butmostimportantly,onceadecisionismade,itprovidesameansofpresentingbacktothestakeholderhowtheirinputswereused(notignored)andhowsomewereoutweighedbyothers.Whilsttherewillalwaysbesomewhochallengeaspectsoftheevidenceused,inourexperiencetheprocessofinputting,capturingandpresentingbackthewholestakeholderpicturehugelyreduceschallengeandgreatlyincreasesthebuy-innecessaryforimplementation.

Closed-loop stakeholder engagementTorefertothetitleofthispiece,customerscancomeandgo,they

mayturnoveratdifferentrates,butthestakeholdergrouptendstobemuchmorestable.Whilstanawfullotofeffortandmoneyisputintounderstandingcustomerneeds,toomuchreliancehasbeenplacedonexecutivesandboardstounderstandwhatstakeholderswantandneedandtoactappropriately.Themodernworldistoocomplexforthatandsoorganisationsneedtoconsulteffectively.

Ratherthantheeffectively‘open-loop’consultationofthepresentday(onlyasmallsubsetofstakeholdersevergettogenuinely‘participate’inthedecision)closingtheloopthroughencouragingstakeholderstoinputagainstsomerepresentationofthewholeissue,capturingtheirviewsinavisualwayandthenusingthis‘stakeholderdevelopedframework’toexplainthedecisioncanhelptogaintruebuy-inandreducethechanceofexpensivelegalchallengesanddelays.q

•Dr Darrell Jaya-Ratnam is the founder of DIEMconsulting Ltd which specialises in helping firms generate evidence on the impact of different strategies and investments in order to gain stakeholder support and buy-in. He also lectures on Corporate Strategy at Birkbeck College of the University of London and at the Defence Academy on the Role of the Board. He has written on business modelling in a number of corporate risk publications.


Is your expert

dual qualified? by CHRIS MAKIN

n Intheolddays,areasonablycompetentcharteredaccountantcouldfeelquitecomfortablegivingexpertevidenceattrial,withoutspecialtraining,andwithoutfeelingthatoneneededtobeamemberofthatexaltedprofessionofexpertwitnesses.

Butnowit’sverydifferent.Thereisnoplaceforenthusiasticamateursor‘wannabees’incourtsoflaw.Solicitorsmustspecialise,andmustworktoeverhigherstandards(andforlessreward?).Sotoomusttheaccountant,whoprofessestobeanexpert,becomeamemberoftwoprofessions–anexcellentaccountant,ofcourse,butalsoatrainedandexperiencedexpertwitness.

Youwillchooseyourexpertscarefullysoasnottowasteyourowngoodworkordamageyourclient’sinterests,andthatmeanschoosingsomeonewhoisalsoamemberofthatsecond,cruciallyimportant,profession.

Ihavebeenafull-timeexpertaccountantnowforover23years,afterIpassedmyauditpracticetootherpartnersonbeingappointedexpertdefenceaccountanttothechairmanofBarlowClowes.Foryoungerreaders,thiswasthefirstreallybigPonzischeme,likeBernardMedoffwithacoupleofnoughtsoffthefigures!Iworkedonthatcasefull-timewithateamofsixforeightmonths,andmyreportof43ringbinderswasagreedbytheSeriousFraudOffice.Ourclientwasfound‘notguilty’onallcharges,whereasPeterClowestheMDwasjailedfor10years.Nowtherewasnoturningback–Ihadnoclients,soIhadtobecomeafull-timeforensicaccountant.IhadlearnedalltheskillsatTheAcademyofExperts–whereIamnowafellow–butfoundatlatertrialsthatIwasoftenupagainstacharteredaccountantwhohadn’taclueaboutexpertevidence,andwhodidhisclientnofavoursatall.

Irememberoneearlycasewheremyvaluationofabusinesswaschallengedbyawannabee.Hisreportwaslightweight.Atthestartofthetrial,thejudgesaidthathehadoftenreliedontheopinionsofMrMakin(me!!)whenhewasatthebar,andheldhiminveryhighregard,sohewouldrecusehimselftoanotherjudgeifthatcausedtheothersideanydifficulty.Theothersideabandonedtheclaimduringa10-minuteadjournment.

Thiswasnotgood.Notonlydidsuchamateursnothelptheclient,buttherewasariskofthecharteredaccountancyprofessionbeingbroughtintodisrepute,asProfessorSirRoyMeadowalmostdidtothemedicalprofession.

SowhenIbecameamemberofthecommitteefortheForensicSpecialInterestGroupatICAEW,theideaIbroughtwasforanaccreditationscheme–fortheICAEWtoawardakitemarktothosememberswhohadtakenthetroubletolearnthissecondprofession,andwhocouldbereliedontowriteaCPRcompliantreporttoahighstandard,tomanageameetingofexperts,tounderstandPart36,tounderstandthedynamicsofmediationandtogiveexcellentexperttestimony.

Ittook8yearstodevelop,butnowwehaveit.OnecannowbeaccreditedasaforensicaccountantbyICAEWinpartnershipwithTheAcademyofExpertsasanaccreditedexpertwitness.Lookoneitherorganisation’swebsite,andyouwillfindlistsoftheveryfewaccountantswhohavereachedthisgoldstandard.

AndnowwehaveJones v Kaney,wheretheSupremeCourt

removedfromexpertstheimmunityfromsuitwhichtheyhadalwaysenjoyed.Thiswasashockingexampleofanexpertbeingoutofherdepth.MissKaney,aclinicalpsychologist,wascajoledbyheropposingexpertintosigningaJointStatementofExpertswhichhehaddrafted,whichdidnotreflectwhatshehadagreed,andwhichshelateradmittedshehadnotevenread!Therewasdiscussionamongtheirlordships,aboutwhetherthiswoulddiscourageexpertsfromacting.Ithasn’t,atleastnotamongtheforensicaccountantsIknow.Andnorshouldit–thedabblersshouldbediscouraged,certainly,butseriousexpertshavenothingtofeariftheycontinuetoactwithreasonablediligenceandcompetence.Thepointisthatbeinganexpertaccountantisnotsimplyasexythingtodobetweenaudits,asperhapsitwasbackintheday,butaseriousprofessionalactivity,onlytobepractisedbymembersofthatsecondprofession.

AndnowwehavetheHotTub,whereattrialbothexpertssitinthewitnessboxatthesametime(ifspaceallows!)andthejudgechairsadiscussionbetweenbothcounselandbothexperts.Itsavestime,andallowstheimportantmatterstobeflushedout.Anyofthemcanaskquestionsofanyother,andeveryonemustbeontheirtoesandknowtheircaseinsideout.Sothereisnoplaceforthepartnerfromthebigfirm,withateamofaccountantsworkingforhim,whotakesoverthecasewhenthetrialisimminent.Theaccountantgivingtheevidencemustknoweveryscrapofdetailandbeintellectuallynimbleenoughtoseethecaseintheround,toseethegapsintheotherside’sevidenceandtomeetchallengesevenfromtheexpertaccountantfromtheotherside.Thisisverydifferentfrombeingcross-examinedataleisurelypacebyabarristerwhoseknowledgeoffinancialmattersmaybeshallow–itisnotforthefainthearted.

TheHotTubhasbeenusedinAustraliaforsometime,andtoalimitedextentinarbitrationsintheUK.NowLordJusticeJacksonbelievesitleadstosavingsincosts,sonextitmaywellbeusedinacourtnearyou.

Themoraleisself-evident:chooseyourexpertaccountantverycarefully,anddon’tletadabblerspoilyourgoodwork.Itisessentialtohavean‘expert’whoisanexpert.q

•Chris Makin was one of the first 30 or so chartered accountants to become an Accredited Forensic Accountant and Expert Witness – see www.icaew.com and follow ‘Find a Chartered Accountant’. He is also an accredited civil & commercial mediator and an accredited expert determiner. He has given expert evidence at least 70 times and worked on a vast range of cases over the last 23 years. For CV, war stories and much more go to www.chrismakin.co.uk.


FIRA’sexpertshaveunrivalledknowledgen FIRAInternationalisacknowledgedastheworld'sleadingindependentfurnitureresearchandtechnologycentre.Expertiseinthetesting,assessmentandcertificationoffurnitureiscombinedwithinformationandadvicetoprovideacomprehensiveservicetothefurnitureindustry.

Disagreements,whetherbusiness-to-businessorbusiness-to-consumer,areoftenresolvedbyusingFIRA’steamoffurniture,ergonomics,environment,materialsandmanufacturingexperts.Unfortunately,undercertaincircumstances,agreementcannotbereachedandalegalcaseensues.InthesesituationsFIRA’sconsultantscanofferinvaluableexpertwitnessskillsandexperience.

FIRAspecialistshaveawideknowledgeofhowfabrics,structures,cabinetsurfacingmaterials,componentsandcompletepiecesoffurnitureshouldperforminuse.ThismeansthatFIRA’sexpertwitnesseshaveunsurpassedknowledgeofalllegalandregulatoryaspectsoffurnitureinbothdomesticandnon-domesticenvironments.

ThroughitsExpertWitnessService,FIRA’sspecialiststaffcanassistwithanyproblemsrelatingtofurniture,providingon-sitevisitsifrequired,orexaminationoffaultsunderlaboratoryconditions.Ifnecessary,problemscanbereproducedtoshowhowaproductwasfaulty.Manufacturers,suppliers,retailers,lawyersandenforcementauthoritiescanallbenefitfromthisservicedeliveredbyFIRA,arecognisedauthorityinthefield.

FIRA’sexpertsfrequentlystandasexpertwitnessesincriminalandcivilcourts.AllFIRAexpertwitnessesaremembersoftheCharteredInstituteofArbitrators,trainedtoCPR35,aswellasbeingspecialistsintheirownfield.

FIRA’sExpertWitnessServiceofferstheabilitytogatherevidence,totest,toinvestigateandtoprovidefirstclassreportingincourtwithunrivalledknowledgeofthesubjectandexperienceincourt.ProductionofUKASaccreditedtestreportsandprovisionofexpertopinion,accompaniedbyoralevidenceincourt,frequentlyresultsinasuccessfuloutcome.

OnlyFIRAcanprovideexpertswiththesecredentialsforfurnitureandrelateditems.FIRAhasanumberofexperiencedexpertwitnesseswhoarebasedacrosstheUK,withspecialisimscoveringthewhole

spectrumoffurnitureproducts,componentsandrelateditems.Theseinclude:

•Furniturefittingsandinstallation(includingkitchensetc)•Firesafetyofupholsteryproducts•Finishesandsurfacingmaterial•Finishingprocesses•Fabricandupholsteryproblems(includingbeds)•Identificationoftimberdefectsandqualityproblems•Glassinfurniture•Boardmaterialsandmoistureproblems•Structuralstability,strengthanddurability•Fitnessforpurpose•Manufacturingproblems•Ergonomics•Healthandsafety•Manufacturing•Productsafety•Timberdefectsandqualityissues•Arena,stadiumandauditoriumseating•Contractanddomestickitchens•Universityaccommodation•HotelfurnitureFIRA’sexpertwitnessesincludethehighlyqualifiedergonomist,

LeventCaglar.Leventhasbeenpractisingergonomicsforover20years,withmuchofhisworkbeingonergonomicsinrelationtohealthandsafety,theofficeenvironment,inputintofurnituredesign,riskassessmentofVDUworkstationsandmanualhandlingoperations.Heisaparticularspecialistonequipmentandmachinerythatcausesdamageorstraintopeople’sbacksandsitsonnumerousnationalandinternationalstandardscommittees.ThismeansthatLeventisextremelywellqualifiedtoworkonfurnitureergonomicsandhealthandsafetylitigationcases.q

•For more information regarding FIRA’s Expert Witness Service please contact Sue Calver on 01438 777700 or email [email protected].

CaseStudy1n Thefaulthadarisenonacoatingthathadbeenappliedtobathpanels.Theyellowingwasnoticedwhenthefinishwasappliedandthenthepanelwaspackaged.Whenthepanelwasremovedfromthepackagingtherewasadistinctyelloweffect.Thisyelloweffectappearedtodiminishwhenthepanelwasexposedtonaturaldaylight

ReplyTheexposuretimeinthewindowisto

simulateaperiodofservicewhenaproductmayhavebeenondisplayinaretailwindow.

InthecaseoftheAshveneeredsamplesallareaswereassessedatequaltoorgreaterthanagreyscaleratingof3

(moderatecolourchange).However,inadditiontothecolourchange

oftheveneer,thecolourchangeobservedonthesampleoflacquer‘A’whenappliedtoasamplebondedwithUF(Urea-formaldehyde)wasadistinct‘green/yellow’shade.

Inaddition,tothecolourchangeoftheveneer,thecolourchangeobservedonthesampleoflacquer‘A’whenappliedtoapanelbondedwithPVA(Polyvinylacetate)wasaveryslight‘green/yellow’shade.Thisindicatesthelacquer‘A’ismoresusceptibletocolourchangewhenappliedtoapanelbondedwithUFadhesive

Thislevelofcolourchangeislikelytobe

unacceptable,asdistinctshadingdifferenceswillbecomeparticularlyapparentwhenviewedundervariablelightingconditionswithinaroom.q


FocusonFIRAExpertWitness:Sue Calvern SueCalverhasworkedforFIRAforovertwentyyears,primarilyinresearchandtechnology,andiscurrentlyFIRAProjectManagerintheTechnicalServicesdepartment.

Sue’sroleinvolvesprojectleadership,consultancyandexpertwitnesswork,managingresearchprogrammes,probleminvestigationandresolutionandsheisarecognisedfurnitureexpert.

Sueisexperiencedinprovidingexpertwitnessstatementsandevidenceincourtcases,andprovidesexpertopiniononalltechnicalissuesrelatingtobusiness-to-businessandconsumer-to-businessdisputes,includingpersonalinjuryandvaluationofloss.SueisamemberoftheCharteredInstituteofArbitratorsandhascompletedtrainingontheCivilProceduresActaffectingexpertwitnesses.

SueistheFIRArepresentativeoneightBritishStandardstechnicalcommittees,includingthefurnituretestmethodscommitteeofwhichsheisChair.SuealsorepresentstheUKontwoEuropeanStandardCommitteesconcernedwithfurniturematerialsandperformanceattributes.Additionally,SuerepresentstheUKinthefurnitureCOST(EuropeanCo-operationinScienceandTechnology)action.

Furthermore,SueistheTechnicalProjectManageronassignmentssuchasaTSBfundedprojectonutilisinglasersinfurnitureapplications,theSustainableFlameRetardantsproject,aventuredesigningfurniturethatreducesworkplacenoiseandanEUinvestigationintothecolorationofsoftwoodswithUVlight.SuehasalsoworkedonaDTIprojectonpowdercoatingforexternaluseandanEUprojectondevelopmentoftestmethodsforfurniture.

AdditionallySuecarriesoutriskassessmentsoffurniture,including

compliancetotheGeneralProductSafetyRegulations(GPSR)andevaluationsoffaultsandfurnitureuseandmisuse,includingassessmentofalloperationalfunctions.

Sueisalsoapresenterofcoursesspecialisingincabinetandofficefurniture,materialsandfittedfurnitureinstallations,aswellasbeingtheauthorofarticlesforUKandinternationaljournals.q

CaseStudy2n Socialhousingkitchensareshowingsignsofdeteriorationshortlyafteruseduetodamagebywaterspillage.

ReplyTenantsshouldbeeducatedinthecareofanewkitchenandclear

careinstructions(perhapsingraphics)shouldbegiventoeachtenantbeforetheyareabletousethekitchen.Mostimportantlytheymustbeawarethatallspillagesshouldbewipedup.

Arollfrontstainlesssteelsinkunitwouldbemoresuitableforlifestyleswherealotofwaterisfrequentlyspilledontothesurface.

Careshouldbetakenwhenspecifyingthefurnitureandconsiderationgivenastothelifestyleofsometenants,eveniftheyareprovidedwithcareinstructionsitisdoubtfuliftypicalkitchenmaterialscouldwithstanddamage.

Theminimumworktopoverhangshouldbegreaterthanorequalto10mmtoreducewaterspillageintocupboards.Theworktopshouldbelevelorslightlybackwardstodiscouragesmallspillagesfallingoverthefrontedge.Thiswilltendtoproducepoolsofwateratthebackoftheunitandthetenantsmuststillbeawarethattheyshouldwipeupallspillagesimmediately.q


Treedisputes

n Resultingincasesinvolvingdamagesofhundredsofthousandsofpounds–andevenmoreseriousissuesincludingviolenceanddeath–treesareoftenthefocusofsometimescomplexlegalissueswherespecialistexpertiseisneeded.

Forexample,inonecaseinvolvingcrackinginfourterracedblocksofflats,aresultofdesiccationofthesubsoilbytheactionofencroachingrootsfromaplanetree,thedefendantwasorderedtopayover£570,000whichtheclaimanthadbeenforcedtospendonunderpinningworkstorectifythedamage.

Theclaimanthadpreviouslygiventhedefendantnoticeoftheexistingdamageand,althoughthetreerootsweresubsequentlypruned,thedefendantrefusedtoremovethetreeandtheclaimantcommencedtheunderpinningworks.

TheHouseofLordsfoundthattheactionofthetreerootsindehydratingthesoilandinhibitingrehydrationwasacontinuingnuisancewhichgavegroundtotheclaimant’saction.

LordCookestatedthat,applyingtheconceptsofreasonablenessbetweenneighboursandreasonableforeseeability,adefendant,havingbeengivennoticeofthenuisanceandtheopportunitytoabateit,mightfairlybeexpectedtobearthecostofreasonablynecessaryremedialworks,andthepartyonwhomthecostfellmayrecoverit.

Anothertree-relatedlegalissuewhichisbecomingevermoreprominentistheproblemofdisputesinvolvingLeylandiigianthedges.

Therearenowaround55millionLeylandiiintheUKwiththousandsofpeoplelockedindisputesarisingfromthem–someofwhichhaveevenledtoviolencebetweenneighboursand,inonecase,anallegedmurder.

Leylandii(picturedabove)canleadtolackoflight,restrictedviewsandevendamageinneighbouringgardens,butstill300,000aresoldeachyear.ManyhouseholdersbuyLeylandiitocreateprivacy–notrealisinghowfasttheygrowandhowmuchitcoststogetthemtrimmed.

In2003adisputeoversuchahedgeevenledtothedeathoftwomen.RobertDickenson,52,wasarrestedafterallegedlyshootingdeadhisneighbour,66-year-oldGeorgeWilson.Dickensonwasfoundhangedinprisonwherehewaswaitingtoappearincourtonamurdercharge.

LeylandiiisthemostplantedandthemosthatedhedgeinBritainandtreeexpertssaywestillhavenotseentheultimateheightforaLeylandii,whichcouldbe200ftplus–excitingfromaforestrypointofview,butnotsoexcitingifyou’reinaneighbouringbungalow!

Othercommontree-relatedissuesresultinginlegalactionincludedisputesoveroverhangingbranchesencroachingonneighbouringpropertyand‘dangerous’treeswhichareonthepointofcausingdamageorinjury.TreeFellingLicencesandvariousmatterssurroundingTreePreservationOrdersandtreesinConservationAreascanalsoleadtolitigation.Indeed,violationofaTreePreservationOrdercanleadtoanunlimitedfineinCrownCourt.q

getting to the root of the problem


Cases involving trees require specialist arboricultural advicen Almosteveryonelikestrees.Theyprovidemanybenefits,fromtheaesthetictobiodiversityandfromcleaningtheatmospheretoprovidingtimber.However,theycanbecomeproblematicwhenthingsgowrong.

Althoughrelativelyrare,treescancausepersonalinjuryanddeathwhentheyfailandthisoftenresultsinlegalproceedings.Asrecentlyas17Junethreeyoungboysaged9werecrushedwhenatreefellonthematWandsworthCricketClub.TherehavebeenanumberofkeylegalcasesinvolvingtreerelatedinjuriesinrecenttimesincludingPoll v Bartholomew(2006)EWHC(QB)BristolwhichwasthecasethatpromptedtheestablishmentoftheNationalTreeSafetyGroup(NTSG)todevelopacommonsenseapproachtotreeriskmanagementandbalancetherisksposedbytreesagainsttheenvironmentalbenefitstheyprovide.

Theissueoftreeriskmanagementisliveandthesubjectofmuchdebate.ItiscertainthatcasesofthisnaturewilloccurinthefutureandtheserequirespecialistarboriculturaladvicesuchasthatprovidedbyLiverpoolbasedDealga’sTreeConsultancy.

Treesalsocausesubsidencedamagetolowrisebuildings.Thiscanresultininsurancecompaniestakingactionagainsttreeownersorthosewhohaveeffectivecontroloverthetreessuchaslocalauthoritiesthathaveprotectedthetreeswithtreepreservationorders(TPOs).Thecaselawinthisareaiswellsummarisedin:

•Solway v Hampshire County Council(1981)79LGR449•Patterson v Humberside CC(1996)Const.L.J.64•Delaware Mansions v Westminster City Council(2002)1AC•(HouseofLords)•Jones v Portsmouth City Council(2002)EWHC1568TCC•Loftus-Brigham v LB Ealing(2003)EWCACiv.1490Nevertheless,treerelatedsubsidenceisamajorproblemfor

landowners,insurersandcouncilsalikeandrequiresveryspecialisedadvice.

Likewiseintheareaofplanninganddevelopmenttreesareoftenconstraintstoproposeddevelopments.SpecialistarboriculturalconsultantssuchasDrDealgaO’Callaghancananddoadvisedevelopers.Theyassistthemtoobtainplanningpermission,undertaketreeconstraintsplansand,ifthesystemfails,actasexpertwitnessesatappealsandpublicinquiries.DrO’Callaghanhasactedinmanylargeappealsandinquiriesincludingthe2ndrunwayatManchester

AirportandBeconsfieldServicesontheM40.Hehasactedforbothdevelopersandlocalplanningauthorities.

Treesarealsomajorcausesofunplanned interruptionstothesupplyofelectricity.Networkoperatorshavestatutoryobligationstominimisetreerelatedoutagesandtoensure,insofarasisreasonablypracticable,thattheiroverheadnetworksaresecurefromtreedamageintimesofabnormalweathersuchasmajorstormevents.Toachievethis,thenetworkoperatorssometimeshavetoexercisetheirpowersunderSchedule4,Paragraph9ofthe1989ElectricityAct.ThisofteninvolvestheminhearingsbeforeinspectorsfromtheDepartmentofEnergy&ClimateChange(DECC).Thisisaveryspecialisedareaofworkthatrequiresbotharboriculturalknowledgeandexperienceinutilityarboriculture.

OccasionallypeopleundertakeworktotreesthatareprotectedbyTPOswithoutfirstobtainingconsentfromthelocalplanningauthority(LPA).ThisisacriminaloffenceunderSection210ofthe1990Town&CountryPlanningActandLPAsdoinitiateprosecutions.TheareaofTPOlawiscomplexandspecialisedandtypicallyoutsidetheexperienceofmostsolicitorsunlesstheyspecialiseinplanning.Onlyexperiencedspecialistarboriculturalconsultantsshouldbeengagedasexpertsincasesofthissort.

Competent,qualifiedandexperiencedarboriculturalconsultantsarenotallthatcommonbutthosewhoare,likeDrO’Callaghan,areregisteredwithYourExpertWitnessandintheInstituteofCharteredForesters’RegisterofConsultants,www.chareterdforesters.org.q


n AfourstarhotelnestlingwithintheUK’shistoricalheartlandofWarwickshire,boasting119rooms,CoombeAbbeytrulyisauniqueandstunningvenueforweddings,conferencesandspecialoccasions.

Setin500acresofparkland,overlookingformalgardensandatranquillakeandoriginallybuiltasaCistercianAbbeyinthe12thCentury,CoombeAbbeyhasnowbeenlovinglyrestoredtoitsformerglorybyitscurrentownersNoOrdinaryHotels.

ConvenientlylocatedafewmilesfromtheM1andM6,closetomajorbusinesscitiessuchasCoventryandBirminghamaswellashistoricaltownssuchasWarwickandStratford-upon-Avon(Shakespeare’sbirthplace),CoombeAbbeyisalsoanidealbaseinwhichtoexplorethemidlands.

DiningatCoombeAbbeyisafeastforallthesenses,whatevertheoccasion.Subtlelightingandlavishfurnishings,combinedwithunobtrusiveyetattentitiveservice,makesdiningatCoombeAbbeyatrulymemorableexperience.Theyofferclassicaldishes,locallysourcedingredients–wherepossiblewithanoriginaltwist–andafineselectionofwinestocomplement.Menuschangeregularlyandthroughouttheyeartheyoffervariousdiningoffersyoucan’tpossiblyresist.

ForthoselookingtohostaspecialeventintheprivacyoftheirownexclusivediningroomCoombe’sprivatediningroomscanaccommodateanythingfrom10to120guests,allowingyoutohostyourownpartyinacandlelitsuite.Theyalsoofferaneventplannerservicetomakeyouandyourguests’timeatCoombeallthemorememorable.

WhynotlivelikeLordesandLadyesofabygoneeraandenjoyaheartyfeastfitforaKing!Thehotel’sawardwinningMediaevalBanquet,whichhasbeenrunningfor40years,providesaveryentertainingandfunnightoutwhereyoucandressupinfullmediaevalattiretoenhanceyourexperience.

Thistrulyisanoordinaryhotel!q

The perfect venue in inspirational surroundings


Newtribunalwillhearfitness-to-practisecasesn On11JunetheGeneralMedicalCouncil(GMC)launchedtheindependentMedicalPractitionersTribunalService(MPTS):thebiggestshake-upoffitness-to-practisehearingssincetheywereestablishedin1858.

TheMPTSisanewimpartialadjudicationfunctionfordoctorsandakeypartoftheGMC’sfitnesstopractisereforms.BasedinManchester,itispartoftheGMCbutoperationallyseparatefromtheregulator’scomplainthandling,investigationandcasepresentation.ItisalsoaccountabletoParliament.

ThetribunalischairedbyHisHonourDavidPearlwhohasheldarangeofseniorjudicialrolesincludingPresidentoftheCareStandardsTribunalandCommissioneroftheJudicialAppointmentsCommission.Heisresponsibleforappointing,training,appraisingandmentoringMPTSpanellistsandlegalassessors.

Hesaid:“EstablishingtheMPTSassuresthosewhocomeintoourprocessesthatweareindependentofinvestigationsintodoctors’fitnesstopractise,thattheappointmentofpanellistsforhearingsisseparateandthatalldecisionsaremadecompletelyimpartially.Oneofmyearliestprioritiesistomakeimprovementstothewaythatpanellistsaretrainedandperformancemanagedthroughregularappraisalandqualityassurance,whichwillbolsterthequalityofdecisionmaking.”

Thepanelscan,inthemostseriouscases,removeorsuspendadoctorfromthemedicalregisterorplacerestrictionsontheirpractise.TheMPTScanalsotakeearlyactiontoensurepatientsafetybyconsideringcasesbeforeafullfitness-to-practisehearing,whereitmaybeappropriatetoplacerestrictionsonadoctor’s

practiseimmediatelyorsuspendtheirpracticewhileinvestigationsproceed.

NiallDickson,theChiefExecutiveoftheGMCsaid:“ThelaunchoftheMPTSisthebiggestchangetodoctors’fitness-to-practisehearingsformorethan150years.Itrepresentsakeypartofourreformsanddeliversaclearseparationbetweeninvestigationsandthedecisionsmadeaboutadoctor’sfitnesstopractise.

“Althoughpanelsalreadymaketheirdecisionsindependently,itisimportantthattheirautonomyisclearandthattheoversightoftheirworkisquiteseparatefromourinvestigatoryactivity.WehopethattheMPTSwillstrengthenprofessionalandpublicconfidencethatourhearingsareimpartial,fairandtransparent–thefactthattheserviceisledbyajudicialfigurewhohasadirectlinetoParliamentshouldprovidethatassurance.”q

n Opinioncontinuestobedividedonthereformoftheproceduresforclaimingforwhiplashinjury.AtthebeginningofMaytheJusticeSecretaryKennethClarkeandTransportSecretaryJustineGreeningmadeajointannouncementofproposalsforanaccreditationsystemfordoctorswhoassesswhiplashclaims.

AccordingtheLaw Society Gazette:“Reformofthewhiplashclaimssystemhasbeenimminentsincethestartofthisyear,whenPrimeMinisterDavidCamerondescribedBritainasthe‘whiplashcapitalofEurope’.”

On14JunethesamejournalquotedthechairmanoftheFamilyDoctorAssociation,DrPeterSwinyard,ashavingcomeoutinfavourofthereforms,inparticulartherequirementtoseeaspecialistinthefield.

DrSwinyardsaid:“Youalwaysassumepeoplearenotlyingtoyou,butwiththebestwillintheworldyousometimeshaveahunchthingsarenotastheyseem.

“I’vebeeningeneralpracticefor27yearsandthenumberofpeoplecominginjusttohavetheirwhiplashdocumentedisverymuchhigherthanitusedtobe.Itwouldbegreatlyinthepublicinteresttohavespecialistslookingatthisdiagnosis.Ifpeoplearesufferingfrom‘compensationitis’,thesoonerthey’reweededoutandsentontheirwaythebetter.”

TheBritishMedicalAssociationhasbeenmorecautiousinitswelcomewarningthat,ifGPswerestillexpectedtoreferpatients,thatwouldnoteasethepressureonfamilydoctors.

Theinsurancecompanieswelcomedthereforms,whilethepresidentoftheAssociationofPersonalInjuryLawyers(APIL),KarlTonks,saidinastatement:“Beforeitannouncesaraftofpropositionswhichriskbarringgenuinelyinjuredpeoplefrombringinglegitimateclaims,theGovernmentmusthaveawiderdebateabouttherealissues,anditmustalsoholdtheinsuranceindustrytoaccount.”q

Whiplash debate heats up


Former MP casebrings plea lawinto spotlight

The case of the former Labour MP who wasjudged unfit to plead on 21 charges related toexpenses claims is a high-profile example of anarea of law that is often misunderstood and iscurrently under review.

Margaret Moran was assessed by twopsychiatrists, including one commissioned by theprosecution, who agreed she was not fit to plead.The prosecution was consequently dropped.

The law on fitness to plead has been thesubject of a consultation by the Law Commission,which is due for report this summer.

PsychologyDirect describes itself as “The UK’slargest network of independent psychologists”. Itprovides experts to act as expert witnesses in allmanner of legal situations, including assessmentof whether a defendant is fit to plead.

In its discussion on unfitness to plead it refersto the consultation and summarises the currentlaw thus: “The law on unfitness to plead isconcerned with whether or not an accused isable to stand trial and, if not, the procedure thatshould be used to deal with that accused. Where

the issue of unfitness to plead arises, the courtdoes not consider the accused’s guilt, but rathertwo distinct issues. First, there is the questionof whether the accused is ‘under a disability’which renders it inappropriate for him or her tobe tried. This can be due to a disability causedby a physical impairment or a mental disorder.An example would be an accused who, as aresult of very low intellectual ability, is unable tofollow the process of his or her trial. Secondly, ifthe court finds that the accused is under such adisability, the jury must determine whether or notthe accused did the act or made the omissioncharged. There is no statutory provision for thelegal test of whether or not an accused personis unfit to plead. The test itself, known as thePritchard Test, is covered by the common law.”

Interestingly, CPS guidance recognisesthat a mental impairment may be caused orexacerbated by the prospect of the trial. Theguidance states: “…in some cases the defendantmay have become disturbed and depressed bythe mere fact that his or her conduct has been

discovered, and any suggestions that continuingthe criminal proceedings will significantly worsenthe defendant’s condition should be evaluatedcarefully. In serious cases, where a prosecutionis plainly needed unless there is clear evidencethat continuing the case would be likely to resultin a permanent deterioration in the defendant’scondition, it may be appropriate to obtainan independent medical report. Where theprosecutor is satisfied that the probable effecton the defendant’s health outweighs the publicinterest considerations in favour of a prosecution,the case should be discontinued and full reasonsrecorded on the file.”

It is important to recognise the distinctionbetween unfitness to plead and the defence ofinsanity, which the Law Commission has alsorecognised as needing reform as it lags behindcurrent psychological thinking.

Former Labour MP Margaret Moran


Psychologist offers guidance on assessing childevidence

The March issue of Counsel magazine carried an article by DrSarah Krähenbühl, an associate member of PsychologyDirect,chartered psychologist and lecturer in psychology at StaffordshireUniversity and The Open University. The article reported on extensiveresearch undertaken by Dr Krähenbühl on interviewing strategies usedin children’s forensic interviews. She has highly specialised skills in thearea of child testimony. She is also a joint holder of a research grant fromthe British Academy to fund a project examining ground rule implementationin Achieving Best Evidence (ABE) and associated effects on children’stestimony.

In the past two years Dr Krähenbühl has written over 20 expert witness reportsconcerning the reliability and credibility of children’s evidence, competency and/orcognitive ability for the Family or Criminal Courts and has given evidence in theFamily, Magistrates and Crown Courts in both England and Wales and Scotland. Inthe article in Counsel she explained that she has “…come to realise that there is a lackof understanding and awareness of the role of the expert witness and what he/she canand cannot do in the assessment of children’s testimony.”

She has also found that the quality of the information obtained during the interviewing of achild witness “varies considerably”.


The biggest scandal to have hit the plasticsurgery profession took a new turn with thepublication on 14 May of health minister LordHowe’s review of the PiP breast implantsaffair. Lord Howe found that, although theregulator acted appropriately and followedscientific and clinical advice, there is room forimprovement and serious lessons must belearned.

Lord Howe was tasked with looking intowhether the Medicines and Healthcareproducts Regulatory Agency (MHRA) andthe Department of Health acted properlyboth before and after information about theimplants came to light. He made a numberof recommendations for improvements tothe operation of the MHRA, including thatit should identify ways of gathering betterevidence on the safety of devices, broaden itsapproach to analysing reported problems withhigher risk medical devices and find betterways of communicating with the public.

The review also calls for the operationof the European regulatory system to beimproved and for health professionals andproviders to be better at reporting problemswhen they occur.

Two of the leading professional bodies inthe field broadly welcomed the report butrepeated calls for a mandatory register ofimplants.

The president-elect of the BritishAssociation of Aesthetic Plastic Surgeons(BAAPS), Rajiv Grover, said in astatement: “We welcome the findings of theGovernment’s review into the PiP scandal,

and agree in particular that there shouldbe a better system of reporting for medicaldevices, with data gathered from a widerset of sources that should be routinelyreviewed. For the last few years, BAAPShas been championing the reinstatementof a compulsory implant register that wouldmonitor not just breast but all types of implantput into the body. The register is part of ourregulation proposals put forward earlier thisyear and would immediately address all therecommendations put forward in this report,as would a mandatory safety audit basedon the model that BAAPS requires of all itsmembers.”

Tim Goodacre, chairman of theprofessional standards committee of theBritish Association of Plastic, Reconstructiveand Aesthetic Surgeons (BAPRAS), said:“BAPRAS welcomes the findings of LordHowe’s review and we hope that this will leadto improvements in the regulatory systemfor medical devices. We urge members tovigilance and rapid reporting of adverseevents, especially involving new productsand devices and will encourage heightenedawareness in both NHS and private sectorsthrough every means at our disposal.

“We also welcome improved systemsfor the detection of trends, and the betterresponsiveness of the MHRA to earlydetection and improved communication withother governmental and European institutions.

“We naturally also support fully therecommendation that a well-designedBreast Implant Registry be re-established,

and believe that such a process could actas a model or template for other higher riskimplanted devices.”

Not everyone was heartened or reassuredby Lord Howe’s findings, however. A medicalnegligence specialist who represents over100 women affected by the scare wasscathing about the peer’s statement that: “TheMHRA had to balance the need to provide fullinformation against the risk of causing undueconcern to women when they did not haveclear evidence of potential harm.”

Stephanie Fallon of Merseyside-basedLindsays Solicitors, said: “It is this findingthat has caused consternation amongthose women who have been deprived ofan opportunity to make a decision as towhether or not they wished to retain implantscontaining industrial grade silicone and a highrupture rate in their bodies.

“It is not an executive decision to be madeby a regulatory body but a decision to betaken by the women themselves, havingregard to all of the relevant information.”

Plastic surgery as a specialist discipline in medicine has its origins in the work done during andafter the First World War in the reconstruction of the faces of servicemen mutilated in the fighting.One of the pioneers was Major, later Sir Harold Gillies of the Royal Army Medical Corps, whoworked at Queen Mary’s Hospital in Sidcup – at the quirkily-named Plastic Theatre. Gillies wenton to develop the processes used in reconstruction for cosmetic purposes.

There are two associations representing the discipline in the UK: the British Association ofPlastic, Reconstructive and Aesthetic Surgeons (BAPRAS), which was originally the BritishAssociation of Plastic Surgeons, and the British Association of Aesthetic Plastic Surgeons(BAAPS). Many members of both organisations offer expert witness services.

The NHS makes the distinction between plastic surgery for reconstruction following injury orillness and that carried out for elective cosmetic purposes. As the BAAPS points out, however,all surgery carries with it risk and should not be carried out without that risk being assessed.

orhowever,

assessed.

A specialism

born of warfare

Profession welcomes Howe report, but victims remain unimpressed


MPs call for regulation of plastic surgery adsn AccordingtoareportpublishedbytheAllPartyParliamentaryGroup(APPG)onBodyImage,thereareanincreasingnumberofpeopleintheUKwithanegativebodyimage,withnearly75%ofrespondentstotheconsultationreportingthat‘media,advertisingandcelebrityculture’wereperceivedtobethemainsocialinfluencesonbodyimage.

Moreover,accordingtothereport:“Theover-relianceonidealised,digitally-alteredimageshasalsostimulatedconsumerdemandforproductsandservicestoachieveaparticularlook,suchascosmeticsurgeryandsupplements.”Thoseseekingcosmeticsurgerywereseenasconsumersratherthanpatients,thereportsaid.

Respondingtothereport,BAPRASsaiditagreedwiththerecommendationforaseparatecodeofregulationstobedrawnupgoverningcosmeticsurgeryadvertisingandcalledforanoutrightbanonsuchadvertsinpublicplacessuchasbillboardsandpublictransport.TheBAAPSalsoannouncedthatitisfundinglong-termresearchintopsychologicalassessmentofpatients.

ConsultantplasticsurgeonandBAAPSpresidentFazelFatahdeclared:“Wefullysupportthegroup'srecommendationfortheestablishmentofaseparatecodeforcosmeticsurgeryadvertising.Theunrestrictedads,whichweseeontelevisionandonthesideofbusesareclearlyhavinganegativeimpactonvulnerablepeopleandparticularlychildren,andshouldbeseverelyrestrictedifnotbannedoutright.”

Thereportalsofoundthatoneinfivecosmeticsurgerypatientscouldbesufferingfrom‘imagineduglysyndrome’orbodydysmorphicdisorder(BDD).Therecommendationscallformandatoryscreeningofpatientspriortoundergoingcosmeticsurgeryandfurtherresearchtoassessthe

long-termimpactonpatients’psychologicalwellbeing,whichBAAPSiscurrentlyundertaking.

FazelFatahcontinued:“TherecentreportbytheNationalConfidentialEnquiryintoPatientOutcomeandDeath(NCEPOD)intocosmeticsurgeryfoundthatroutinepsychologicalcheckswerecarriedoutinlessthan35%ofsites.AtBAAPSwehaveheldanumberofscientificmeetingsonthisthemeovertheyears,andarecurrentlyfundingresearchincollaborationwiththeCentreforAppearanceResearchattheUniversityoftheWestofEnglandintodevelopingareliablepsychologicalassessmenttooltoberoutinelyusedineveryconsultationtomakesurethatpatientswhomayhaveBDDorotherpsychologicaldisordersareidentifiedandadvisedappropriately.”

TheresearchisbeingconductedbypsychologistandBAAPSmemberProfessorNicholaRumseyoftheCentreforAppearanceResearchattheUniversityoftheWestofEngland(Bristol)andclinicalpsychologistattheRoyalFreeHospital,AlexClarke.q


DentistsdisputeOFTfindingsn AstudybytheOfficeofFairTrading(OFT),publishedon29May,foundthataround500,000dentalpatientseachyearmaybeprovidedwithinaccurateinformationbydentistsregardingtheirentitlementtoreceiveparticulardentaltreatmentsontheNHS.Asaresulttheymaypaymoretoreceiveprivatedentaltreatment.

Thereportalsoraisesconcernsaboutcontinuedrestrictionspreventingpatientsfromdirectlyaccessingdentalcareprofessionals,suchashygienists,withoutareferralfromadentist.TheOFTconsiderstheserestrictionstobeunjustifiedandlikelytoreducepatientchoiceanddampencompetition.

Otherissuesofconcernhighlightedinthereportincludethecomplexityofthecomplaintsprocessforpatientsandinstancesofpotentialpressuresellingbydentistsofdentalpaymentplans.

InresponsetheBritishDentalAssociation(BDA)claimedthatthereportfailstotakeapracticalviewofthecomplexitiesandrealitiesofdentalcare.

DrSusieSanderson,chairoftheBDA’sExecutiveBoard,said:“Researchbybodiesincludingtheregulatorofdentistry,theGeneralDentalCouncil,confirmsthatthevastmajorityofpatientsarehappywiththecaretheyreceive.TheOFT’sownresearchalsoconfirmsthistobethecase.

“Thisreporttreatsdentistrypurelyasamarketanddentalcareasacommodity.Indoingso,ithastakenasimplisticviewofdentalcarethatfailstotakeintoaccountthehugesumsofmoneydentistsinvestinsurgeriesandignorestheuniqueroleinscreeninganddiagnosisthatdentistsaretrainedtoperform.Dentistryisnotacommodity,itisthedeliveryofhealthcaretorealpatients.Failingtounderstandthatservesneitherdentistsnorpatientswell.”

•In the next issue of Your Expert Witness, a special feature will present some of the issues involved in facial and dental injuries. In addition, the area of clinical negligence and malpractice will be considered.q

Horse rider loses injury appealn Anactivitywhichcommonlyleadstofacialinjuryisfallingfromhorses.Itisalsoanareawherelitigationoftenfollows.However,recentrulingsintheCourtofAppealmaystemtheflowofsuchclaims.InFebruarythecourtdismissedanappealbyawomanwhowasthrownfromhorsewhenitreared.Thehorsetrodonherface,causingtheinjury.

Herclaimforcompensationagainstthehorseowner,whowasofferingtorehomeitwiththeclaimant,wasrejectedatNewcastleCountyCourt.Thejudgeruledthat,asanexperiencedrider,shehadassumedtheriskofinjurywhenshechosetoridethehorse.

Thelady,aMrsGoldsmith,appealed,claimingthatthehorsehadbuckedmoreviolentlythanisusual,buttheappealwasrejected.Thecourtruledthatshehad“voluntarilyacceptedtheriskofinjurywhenridingthehorse”.q


How I work asa locum GP andavoid complaintsby DR BASHIR QURESHI FRCGP, Hon FRSPH.• Expert witness in cultural, religious & ethnic issues in litigation.• Expert witness in GP clinical negligence.

n Retireddoesnotmeantiredagain,itmeansexperienced.IamretiredfromtheNationalHealthServicebutIdolocumGPworkbecauseIcannotdogardeningathome.Fromthetimeoneisbornuntilthetimeonedies,everyonehastofilltime.Iwasluckytobebornasapositivethinkerandtoremainso.IbelievethatevenGodonlyhelpsthosewhohelpthemselves.

InadditiontolocumGPwork,Iwearmanyhatsincludingbeinganexpertwitnessincultural,religiousandethnicissuesinlitigationandalsoinGPNegligence.BeforesayinganythingIcheckthreethings:DoIhavesomethingnewtosay?(whichIalwayshave).Isthereanyonewillingtolistentome?HowmuchshouldIsaynowandsaylater?SomepeoplelistentomelikeaSamaritan,buttakenonotice,whereasothersfinditthoughtprovokingandhelpful.Criticismisalsoapositiveactivityandawaytolearn.IenjoyknowingthatIamaBritishcitizenandthatBritainisademocracy.Iamawarethatinademocracyeveryonebuteveryonehasarighttobeheardbeforebeingignored.Thechairmandecides.He/shemayaskforavoteifthecommitteeagrees,otherwisetheitemistakenonboard.Onlyaleaderisoftenelectedbuttheirappointeesareselected.Toliveandletliveisthebestpolicy,aseveryonehastheirownway.

IenjoywhateverIdo,includinglocumGPwork.Theperkinthisworkisthatnothingcanhappenwithoutmysignature.Ihavetobeskilful,careful,tactfulandhelpful,withouttakinganyrisktomyself.Locumworkisamatterofsupplyanddemand.Theprincipalswouldtrybeforetheybuy.Itisagoodbusinessandthereisnoreasontocry.Irespectidealistsandfollowrealistsbutlistencarefullytobothandtakebalancedsteps.Alocum’sjobisasgoodashis/herlastperformance.Youcanoftenwinbutnotalwaysandonemustrememberthateventuallyweareallanswerableforwhatwedo.OneofmyGPtrainersusedtosay“AsaGP,dorightandfearnoman;donotwriteandfearnowoman”.Inthegoldenolddays,GPswroteinpatient’snotes,sometimeillegibleeventothemselves,andtherewerenosolicitorsorjudgestoreadtheirnotes.Nowitisaneraofcomputers,auditsandlitigation.Everythingchangesinthisworldexceptthisprinciple.

MysuggestionstofellowgeneralpractitionersintheUKwouldbe:•Politics,economicsandlawhaveasmuchtodowith‘patientcare’•asmedicine.•Academicsandpoliticiansonlysometimeloveeachother.GPs•needthemboth.•Neversay‘never’or‘always’asanythingcanhappeningeneral•practice.•Ageneralpractitionerdoesknowandisexpectedtoknow•somethingabouteverything.

•Aspecialistknowsandisexpectedtoknoweverythingabout•something.•AGPshoulddealwithwhatispossibleandmustrefertoa•specialistthatwhichisnot.•Hospitaldoctorscanonlyseepatientsreferredbygeneral•practitioners.•Patients’confidentialitylawsmustbefollowedinBritain.Write•notesclearly.Remember,thesenotesmaybereadbypatients,•lawyers,witnessesandjudges.•Nooneisimmunefromlaw.Idealistsgettrappedinbreaches•morethanrealists.•Alocumisakintoabusdriverorapilot–checkeverythingand•drivesafely.

Please bewareDonotbecometotallysubjective.Thereisnosuchthingas‘my

patient’.Youonlyneedonepatienttocomplainagainstyouandyouwouldchange.

Please rememberDoeverythingobjectivelyandprofessionally.Writenotes

medicolegally.Listentoacademicsbutremainarealist.Changewithchangingrules.q


Olympicdrugtestinglabgainsaccreditationn InAprilthelaboratorythatwillcarryoutdopingtestsfortheLondon2012OlympicandParalympicGamesreceiveditsaccreditationfromtheWorldAnti-DopingAgency(WADA).TheWADAaccreditationprocess,whichspannedatwo-yearperiod,wasbasedontwointernationalstandards–ISO/IEC17025andtheInternationalStandardforLaboratories–whichrequiredthelaboratorytoundergoaseriesofrigorousteststoestablishitsanalysiscredentials.

Thelaboratory,inEssex,hasbeenprovidedbypharmaceuticalcompanyGlaxoSmithKline(GSK)andwillbeoperatedbyleadinganti-dopingexpertsfromtheworld-renownedDrugControlCentreatKing’sCollegeLondon,supportedbyscientistsfromaroundtheworld.

JonathanHarris,headofanti-dopingattheGames’organisersLOCOG,said:“TheWADAaccreditationisagreenlightsignalthatthelabisready.ThesuccessfulpartnershipbetweenLOCOG,GSKandKing’shasenabledustopresenttoWADAabrilliantlaboratoryforKing’stooperateatGamestime.”

WADAPresidentJohnFaheysaid:“AchievingWADAaccreditationmeansthattheLondon2012Anti-DopingLaboratorywilloperatetothehigheststandardsofsampleanalysisduringtheOlympicandParalympicGames.

“Dopingathletesmustknowthatthereisaverygoodchancetheywillbetestedthissummerandthateverythingscientificallypossible–andwiththeassistanceofgrowingintelligence-willbedonetomakesurethattheireffortstocheataredetectedbytheexpertsatthelaboratory.”

Over6,250sampleswillbeanalysedthroughouttheOlympicandParalympicGames–upto400eachday,whichismorethanatanyotherGames.Thelaboratory,whichmeasuresthesizeofseventenniscourts,willbeinoperation24hoursaday,sevendaysaweek.

ProfessorDavidCowanisheadoftheDepartmentofForensicScienceandDrugMonitoringatKingsCollege,anddirectorofitsDrugControlCentre.Heplayedakeyroleinthesuccessful2012Olympicbidandhasbeeninvolvedinthescienceofanti-dopingacrossfourWinterOlympicGames,twoSummerOlympicGamesandseveralCommonwealthGames.Hehasprovidedexpertwitnessstatementsinnumerousdopingcases,includingattheCourtofArbitrationforSportandtheFA.

ProfCowan,picturedbelowattheopeningofthefacility(right)withOlympicsMinisterHughRobertson(left),said:“Theselaboratoriesarethemosthigh-techlabsinthehistoryoftheGames,analysingmoresamplesthaneverbefore.Wehavedeveloped,withGSKsupport,super-fastandsuper-sensitivetechnologiestobeabletodetectuseofprohibitedsubstances.Ourroleistoensuretheefficientandeffectiveoperationofthelabtodeliverrobustanti-dopingtestingfortheGames.”

Therearejust35accreditedanti-dopinglaboratoriesintheworldandtheKing'slaboratoryistheonlyoneintheUK.q

DrugandalcoholconferencesetforBrightonn Brightonwillbethehoston5Julyofthe16thSussexDAAT(DrugsandAlcoholToday)conference,togetherwiththenationalDrugsandAlcoholTodayexhibition.TheconferenceisstagedinpartnershipwithBrightonandHoveDrugandAlcoholActionTeam.

AfullprogrammeofseminarsandContinuingProfessionalDevelopment(CPD)eventswillbetakingplacealongsidetheconference,centredonanumberofmainsubjectheadings,includingTheBigPicture,FamiliesandYoungPeople,MainstreamingRecoveryandEngageandInfluence.SpeakerswillcomefromtheNHS,universities,nationalandlocalgovernment,charitiesandexpertwitnessserviceAfentisForensics.

Accordingtotheorganisers:“AsoneoftheWorldHealthOrganisation’sHealthyCities,BrightonandHovehasbeenworkinghardtopromotehealthandreduceinequalities.Nolonger‘DrugDeathCapital’oftheUK,thecityisstillbattlingsubstancemisuseissueswith,forexample,hospitaladmissionsforalcohol-relatedillnessincreasingattwicethenationalrateanddrinkingamongyoungpeoplerisingalarmingly.Wherebettertodiscoverthecuttingedgeinitiativesandinnovativeapproachesneededtomakeprogressinthesector?”q


VaricoseVeinsthe risks of minimally invasive techniquesby Philip Coleridge Smith DM MA BCh FRCSConsultant Vascular Surgeon and Medical Director, British Vein Institute and Reader in Surgery, UCL Medical School

n TheNHStreatsabout35,000patientsperyearforvaricoseveinsandaboutanother10,000aretreatedinprivatehospitals.Thisisacommonlyundertakenoperationbutvaricoseveintreatmentsareamongstthemostcommongivingrisetomedicalnegligencelitigationingeneralandvascularsurgery.

Inrecentyearsseveralnewmethodshavecomeintousewhichrequiresurgeonstouseanewrangeofskillsandequipmenttocurevaricoseveins.Theseofferlessinvasivetreatmentsbutsurgeonsareoftenlessfamiliarwithnewtechniquesandthismayalsogiverisetocomplicationsoftreatment.

Eachtypeoftreatmentcarriesrisksspecifictothattreatmentaswellassomeproblemswhicharecommontoalltreatments.

Varicose vein surgerySurgeryforvaricoseveinshasbeen

undertakenformorethan2,000yearsalthoughcurrent‘veinstripping’techniqueshaveonlybeeninusesincethebeginningofthe20thcentury.Varicoseveinslieclosetootherimportantstructuresincludingarteries,veinsandnerves.Surgeryperformedinasubstandardwaymaycausedamagetothesestructuresincludingligationorstrippingofthemainarteryorveintothelegordamagetoamajormotornerveleadingtodisablingparalysisofthelimb.Sucheventsaffectonlyaverysmallproportionofoperationsbutareverylikelytogiverisetoaclaimfordamages.Cutaneousnervesprovidingsensationtotheskinrunclosetomanyvaricoseveinsandcommonlysufferdamageduringvaricoseveinsurgeryleadingtosomelossofnormalsensationintheskininupto20%ofpatients.Fortunatelymostofthesecasesimprovewithtimeandamorelimitednumberofpatientsexperiencelongtermnumbnessoftheskin.

Followingvaricoseveinsurgerybruisingofthelegisinvariableandmoreseverehaemorrhagemayalsoarise.Woundinfectionsarefairlycommonandscarsmaypersistintheleg,especiallyifincisionstoremovevaricoseveinsaremadeinasubstandardmanner.Lesscommonly,deepveinthrombosismaycomplicateanytreatmentforvaricoseveins.Appropriateprecautionsshouldbetakentominimisetheriskofthesecomplications,especiallythepreventionofpost-operativedeepveinthrombosis.

Patientsmayfindthattheoutcomeoftheirtreatmentisdisappointing.Perhapstheyhadbeengivenunreasonableexpectationsoftheoutcomeoftreatmentorthesurgeonmayhaveundertakensurgerywhichwouldnotbelikelytoimprovetheappearanceofthelimb.Suchclaimsmaybemoredifficulttopursue.Ihaveprovidedadviceincaseswhereapoorcosmeticresulthasbeenshowntobeduetoasubstandardtechniqueandafavourablesettlementhasbeenobtainedfortheclaimant.

Modern varicose vein treatments

Inthelastdecadeortwoseveralnewwaysofcuringvaricoseveinshavebeenintroduced.Theseuseanumberofdifferentstrategiestodestroytheveinsbutwithoutremovingthemfromtheleg.Veinsobliteratedbythesetreatmentsarereabsorbedbythebodyinthemonthsfollowingtreatment.Ingeneralthemoremodernmethodsareassociatedwithfarlesspost-operativediscomfortandamorerapidreturntonormalactivitiesandaretobewelcomed.However,duringthe‘learningcurve’fornewmethodsoftreatmentanumberofunintendedconsequencesmayarise.Inaddition,thenewmethodsoftreatmenthavecomplicationsspecifictothetechnique.

Thenewmethodsoftreatmentincludetheuseofskillswithwhichmanysurgeonsusedtoconventionalsurgicalmethodsareunfamiliar.Minimallyinvasivemethodsnecessitateultrasoundguidedtreatmentwhichisnotastandardsurgicalskillandrequiressignificantamountsoftrainingtogainbasiccompetence.Caremustbetakenduringtreatmentsinceheatingorinjectingthewrongsectionofveincanleadtoineffectivetreatmentorcauseunintendeddamagetonearbystructures.Manyveinshavenearbynerveswhichmaybedamagedbythermalablationoftheassociatedvein.Patientsshouldbeawareoftherangeofcomplicationsthatmayariseafterthenewtypesoftreatment.

Thethermalablationtechniquesarethemostwidelyusedoftheminimallyinvasivetreatments.Acatheterispassedalongtheveintobetreatedandusedtoheattheveinbyeitherelectricalorlaserenergy.Anothermethodheatstheveinusingsmallpuffsofsteamintroducedviathecatheter.Allofthesemethodsrequirethetreatedveintobesurroundedbyasubstantialvolumeof

dilutelocalanaestheticsolutiontopreventpainwhichwouldotherwiseresultfromheatingthevein.Temperaturesinvolvedrangefromabout120oCwithelectricalheatingto800oCwithsomelasersystems.Thesolutionalsoinsulatesthesurroundingstructuressuchasnervesandtheskin,preventingthesefrombeingdamagedduringheatingofthevein.

Oneofthehazardsofthermalablationisthatifheatisappliedtothewrongthingthenittoomaybedamaged.Greatcaremustbetakentoavoidheatingtheskinandskinburnsarearecognised,thoughinfrequent,complicationofthistreatment.Sensorynervesrunningadjacenttotheveinmayalsobedamagedleadingtoregionsofparaesthesiaandnumbness.Thermalablationtechniqueshavebeeninuseformorethan12yearsandsothebenefitsandpossibleadverseeventswhichmaybeencounteredarewellknown.

Duringultrasoundguidedfoamsclerotherapy,afoamedsclerosant,isinjectedintotheveinstobetreatedunderultrasoundguidance.Thismethodisamodernversionofinjectiontreatmentsoriginallydescriedmorethan165yearsago.Creatingfoamfromdrugswhichhavebeenusedtoinjectveinsfordecades,multipliestheefficacyoftreatmentbyabout20-fold.Longtermeradicationofvaricoseveinshasbeenshownfollowingthistreatment.Ultrasoundimagingisrequiredtoplacethetreatmentinpreciselytherightlocation.Experiencedpractitionerscanreadilyidentifyveinswhichrequireinjectionandguideaneedletothecorrectplace.Averysmallnumberofinstancesofinadvertentintra-arterialinjectionhasbeenreported.Ifamajorarteryisinjectedwithfoamseveredamagetothelegresultswhichmaynecessitateamputationofpartofthelimb.

Morecommonadverseeventsincludethe


retentionofexcessthrombuswithinthetreatedveinleadingtolumpsandbruisinginthelegs.Thesesometimesbecomeverytenderduetothedevelopmentofthrombophlebitis(inflammationofthevein).Skinpigmentationmayariseovertreatedveins,sometimestakingmanymonthstoresolve.Immediatelyfollowinginjectioninflammatoryfactorsarereleasedfromthetreatedveinsandtravelbythebloodtothelungs.Thismayleadtotightnessofthechestorcoughinginafewcases.Inpatientswithmigraine,containingcirculationoftheinflammatoryfactorsmayleadtovisualdisturbance,experiencedbymigrainepatientsearlyintheonsetofanattack.Bothoftheseproblemsresolvewithin10-30minutesinmostcases.

AmorerecenttechniqueisClariVein™inwhichacatheter,equippedwitharotatingwirepoweredbyanelectricmotor,ispassedalongthevein.Astherotatingwireiswithdrawnitcausesdamagetotheliningofthevein.Atthesametimeasclerosantisinjectedviathecatheterintotheveintocompletethetreatment.Theoutcomeofthistechniqueisprobablyfairlysimilartothatwhichmaybeobtainedbyultrasoundguidedfoamsclerotherapy.Thisisafairlynewmethodanddetailedlong-termstudieshavenotyetbeenreported.

AfurthertechniquewhichremainsintheearlystagesofevaluationisSapheon™whichcomprisesacathetersystemusedtodelivercyano-acrylateglueintothesaphenousvein.Thisobliteratestheveinbystickingthewallsoftheveintogether.Onlylimiteddataofefficacy

andhazardsofthistechniquehassofarbeenpublishedandsocompleteunderstandingofitssafetyandefficacyisyettobeestablished.

Table1summarisesthecomplicationsofvaricoseveintreatmentsincommonuse.Alltreatmentsmightincurtheremoteriskofpost-operativedeath(<1in100,000)butsurgeonswouldnotnormallymentionthistopatientssinceitmightunnecessarilyraiseconcernsaboutthetreatment.Thiscomplicationhasbeenomittedfromthetable.

PatientsshouldbewarnedofthepossibilityofthecomplicationsthatIhavementionedinthistablebeforeundergoingtreatment,aspartofgoodclinicalpractice.Claimsarisingfrompost-operativecomplicationsinthe‘commoncomplications’columncanprobablybedefendedunderthesecircumstances.Inthe‘seriouscomplications’column,theproblemsofdamagetomajorarteries,veinsandmotornerves(followingsurgicaltreatment)shouldneverhappenandclaimsarisingfromtheseproblemsmaybedifficulttodefend.Similarargumentsprobablyapplytoskinburnsfollowingendovenousthermalablationmethods.

Post-operative deep vein thrombosisDeepveinthrombosismayoccurfollowingany

treatmentforvaricoseveins.Thisismorelikelytooccurinsomepatientsthaninotherssoselectiveuseofpreventivemeasuresisconsideredappropriate.Patientswithaprevioushistoryorfamilyhistoryofvenousthromboembolismorthrombophlebitis,theelderly,thosewithseverevenousdisease(e.g.legulcers)orvery

largevaricoseveinsaremostatrisk.Mosttreatmentsforvaricoseveinsincludetheuseofcompressionstockingsorbandagesandthesemaybesufficientinpatientsassessedasbeingatlowrisk.ForthoseatmoderateorhighriskofDVTadditionalmeasuresshouldbetaken,mostcommonlytheinjectionoflow-doselowmolecularweightheparin.Manufacturersofthesedrugsrecommenda7-10daycourseoftreatmentfollowingsurgerybutitiscommonpracticetouseonlyasingledoseonthedayoftreatmentinviewofthereluctanceofpatientstoinjectthemselvesfollowingdischargefromhospital.However,anobservationalstudyfoundnoevidencethatthisstrategyreducedtheriskofDVTfollowingvaricoseveinsurgery.IntheeventofaDVToccurringundersuchcircumstancesitcouldbearguedthattheDVTwouldhavebeenavoidedhadtheclinicianscompliedwiththemanufacturer’srecommendations.

Ingeneral,theoutcomeofminimallyinvasivetreatmentsisexcellentinskilledhands.Thehazardsofthesetreatmentsareprobablyfewerthanthoseofconventionalvaricoseveinsurgery.Certainlythepost-operativecourseislessuncomfortableforthepatientandamorerapidrecoveryfromtreatmentcanbeexpected.q

References:• Goodwin H. – Litigation and surgical practice in the

• UK. BrJSurg2000;87:977–9

• van Rij AM, Chai J, Hill GB, Christie RA. – Incidence of

• deep vein thrombosis after varicose vein surgery.

• BrJSurg.2004;91:1582-5

TAB

LE1

Complications of varicose vein treatment. This table includes the more important complications of treatment but is not intended to be exhaustive.

Treatment Examples Common Complications Serious Complications

Varicose vein surgery

•Strippingoperations•Phlebectomy,hook•phlebectomy,removalof•varices

•Post-operativebruisingandpain•Woundinfection•Lymphaticproblems:lymphleak,lymphocoele•Sensorynerveinjury•Scars•Poorcosmeticoutcome•Recurrenceorpersistenceofvaricoseveins•Thrombophlebitis•Complicationsarisingfromgeneralanaesthesia

•Damagetomotornerves•Damagetomainarteryorvein,eg•femoralartery,femoralvein•Deepveinthrombosis•Lymphaticinjuryresultingin•lymphoedema

Thermal ablation techniques

•Endovenouslaser•ablation,endovenous•radiofrequencyablation,•steamablation

•Post-operativebruisingandpain(much•lessthanfollowingvaricoseveinstripping•procedures)•Sensorynerveinjury•Thrombophlebitis•Poorcosmeticoutcome•Indurationovertrackoftreatedvein•Recurrenceorpersistenceofvaricoseveins

•Skinburns•Deepveinthrombosis•Fractureofcatheter/laserfibre••leadingtoretentionofpartofthe•cathetersysteminthepatient’sleg•(rare)

Foam sclerotherapy

•Foamsclerotherapy•ofsaphenoustrunks,•saphenoustributariesand•ofvaricoseveins

•Post-operativebruisingandlumps(muchless•thanfollowingvaricoseveinsurgery)•Transientchestsymptomsand/orvisual•disturbance•Thrombophlebitis•Poorcosmeticoutcome•Recurrenceorpersistenceofvaricoseveins•Indurationovertrackoftreatedvein•Persistentskinpigmentation–lastingmany•months.

•Deepveinthrombosis•Severeallergytosclerosantdrugs•(rare)

ClariVein™ •Mechanicallyassisted•sclerotherapy

•Notfullyestablished

Sapheon™ •Endovenousglue•occlusionofsaphenous•trunks

•Notfullyestablished


n “Thereissomedebateastotheappropriatediagnoseswhichhavebeenreachedinthiscase.”ThisisaquotationfrominstructionsIamworkingonatthemoment.Thereareexpertreportsfromageneralpractitioner,anorthopaedicsurgeonandapsychiatrist.Theallegedinjuriesareasaresultofaroadtrafficaccident,resultinginchronicpain.Thediagnoseslistedinclude‘softtissuepain’,‘whiplashinjury’,‘fibromyalgia’,‘depression’and‘achronicpaindisorder’.Ihavebeenasked,ineffect,tosaywhichisthecorrectone,orwhethertheremaybeabetterone.Thetemptationistosay,“Idon’tknowanditdoesn’tmatter.”

Itdoesmatterbecausethesizeofanyawardmaydependonthefinaldiagnosis.Itdoesnotmatterbecauseadiagnosisisalabelappliedbyanexternalobserverinanarbitraryway.Taxonomy,thedisciplineofclassifyingobjects,isanimprecisescience.Itsatisfiesabasichumanneedtocompilelistsandplace‘things’inboxes.Onecertainwaytoupsetapatientisnottoofferthemadiagnosis.Weallseemtocravetheneedforourailmentstobesqueezedintolittlepigeon-holes.Oneproblemwiththisapproachisthatolddiagnoseschangeandnewonesaredefined.Whatdoesnotchangeistheconstellationofsignsandsymptomsthattheindividualpatientexhibits.

Inthepainarenawehaveseveralspecialitiesandprofessionsinvolved.Apartfromthosementionedabove(includingmine),wealsohaveanaesthetists,painphysicians,physiotherapists,psychologists,osteopathsandchiropractorsforstarters.Weallhavedifferenteducationalbackgroundsandatendencytouseverydifferentprofessionalvocabularies.Ofparticulardifficultyisthesystemofclassificationthatpsychiatristshaveadopted.ThisistheDiagnostic & Statistical Manual of Mental Disorders (DSM),firstpublishedbytheAmericanPsychiatricAssociationin1954,withthelastrevision,DSM-IV,in1994.ThenextfullrevisionisduetobelaunchedinMay2013.Duringthesetwodecadestherehavebeenmajorchangesinmedicalthinkingandthereremainsthe

What’sinaname?by DR ANTHONY CLARKE, BSc MB BS FRCPConsultant in Rheumatology and Rehabilitation, Bath

considerabledifferencebetweenpsychiatricpracticeintheUSAandEurope.Whatiscertainisthattherewillbesignificantchangestotheclassificationin2013andyetthesignsandsymptomsoftheindividualpatientwillnothavechanged.However,courtshaveshownconsiderablerelianceonDSM-IV.

Fibromyalgiaisaninterestingexampleofadiagnosisthathasgraduallygrowninitsscopeandbecomeaveritabledustbinofweird,unconnected,symptoms(butnotsigns).Originallyitwasdescribedasatriadofdefinedtriggerspots,sleepdisturbanceandmuscularpain.Itwasseenasaphysiological(orpsychological,dependingonyourbackground)reactiontopaindisruptingdeltawaveandrapideyemovementsleep.Mostauthoritiesagreedthatfibromyalgiawasnotadiseaseorillness.Assuchitisaneasilytreatablecondition,especiallyifthecauseoftheinitiatingpainwasdealtwith.Pacing,painreliefandimprovementinsleephygiene,introducedassoonasthesymptomsappear,willinevitablyleadtoresolution.However,thankstotheinternetandthelitigationprocess,wearenowfacedwithabewilderingrangeofsymptomscomplainedofbyclaimants,allattributedtotheindexincident.

Thereisabigindustryouttherejumpingonthetaxonomybandwagon.Overrecentyearsitstartedwithwhiplash,movedontofibromyalgiaandnowtocomplexregionalpainsyndrome.Allthreeoftheseconditionsexistasdefined.Thereis,however,noscientificexcusetoaddaplethoraofnon-specific,non-associatedsymptomswhichpopupontheinternet.Becauseofthissloppythinkingwearenowinthepositionthatallthreeconditionshaveledtosubstantialclaimsandcoststotheinnocentmotoristoremployer.Wehaveallseengenuineclaimantswiththeseconditions,themajorityofwhomhavebeencompensatedwithmodestsums.Wehavealsoallseenclaimantswhoconsciouslyorunconsciouslyexaggeratetheirsymptomsandlossofamenity,oftenencouragedbylessthanscrupulousclaimscompanies.Iamdealingwithoneclaimatthemomentinwhichitsuggestedthatthecostoffuturedogwalkingwouldbe£220,000!Weneedtolookatwhathappenstopatientsoutsidethelitigationprocess.Allthreeoftheseconditionsaretreatableandforthemostpartself-limiting.Thatdoesnotmeanthatallpatientswillimprovebuttherehastobeverygoodevidencethattheclaimantisgenuineforaclaimtobejustified.

Weneedtogobacktobasics.Theissuesare:1.Doestheclaimanthavesymptomsthatareattributabletothe1.indexincidentorfailureofdutyofcarebythedefendant?2.Isthereclearevidenceofcontinuity?3.Isthereclearlossofamenity?4.Isthereanyotherexplanationforthesymptoms?5.Whatistheprognosis?Weshouldbelessconcernedaboutartificiallysqueezing

claimantsintolittlediagnosticboxesthanweedingouttheunworthyclaimantfromthedeserving.Weshouldcertainlyresistaninexorableriseinclaimsrelatingtodisordersthatareartificialandwhichdonotmirrorwhatisseeninnormalclinicalpractice.q


Howtomakesureasurgeonisoperatingontherightpatientandintherightplaceby MR IAN FORSTER MBBS FRCS FRCS(Ed), Consultant Orthopaedic Surgeon

n Wrongsitesurgeryis,despiteeverchangingsafeguards,amajorcomplicationwhichisdevastatingforthepatient,thefamilyandthesurgeon.Therewere40claimsinEnglandin2005which,consideringthenumberoforthopaedicandotheroperationsthatareperformed,isreassuringlysmall.However,despiteanincreasingnumberofcheckspriortosurgerytheseclaimshavenotdisappearedasyet.

Thefirststageofanyoperationistoobtainconsent.Thisisnotonlyjustbeforetheoperationbutisongoingfromthefirstout-patientconsultation.Clearlyathoroughknowledgeofallproceduresthesurgeonperformsisessential.Thesurgeonneedstoknowhowtodotheoperationandwhentodotheoperationbut,mostimportantly,whennottodotheoperation!It’simportanttobesurethepatientsknowwhattheyarelettingthemselvesinforandthatitisrightforthem.Atthefirstconsultation,whenanoperationisrecommended,thesurgeonneedstogointoallthebenefitsandpitfallsinvolved.Thishelpsthepatientmakeuptheirownmind.Ifthereisanydoubtmypracticeistoarrangeanotherappointmentforfurtherdiscussion.

Thereisafurtheropportunitytodiscussmattersatthepre-operativeassessmentclinicwhenpatientscomingformajorsurgeryarecheckedastotheirmedicalstate.Atthattimeitiscustomarytodiscuss,indetail,everythingthepatientwillundergoand,again,thepossiblecomplicationsandthepreventionofthosecomplications.

Finally,thesurgeonformallyexplainstheprocedureingreatdetailonthedayoftheoperation.Consentformsthesedayshaveexpandedtoincludedetailsofalmosteverythingthatissaid.Thepatientisexpectedtobetakenthrougheachstatementbeforesigningandisgivenhisowncopy.Allcommonandmajorcomplications,includingtheoutcomeaftersuchacomplication,shouldbediscussedandwrittenontheform.Ifacomplicationismissed,andthenhappens,thenthiscouldbeconstruedasnegligence.

Ifthepatientdoesnotunderstandwhatisbeingsaiditisnotnowpossibletogetarelativetosignforhim,althoughthisusedtobethepracticeyearsago.Thesedaystwocompetentsurgeonsneedtoagreethattheprocedureisnecessaryandthentheoperationcanhappen.Thisdoesnotmeanthatthefamilycannotbeinvolvedinthedecisionanditisimportantthattheyarefullyinformed.

Despitethis,indisputesastowhetherthecorrectconsenthasbeentaken,myexperienceisthatsolicitorsdon’tusuallyadvanceacaseon

thisalone.Clearlywhenthishappensitisoneperson’swordagainstanotherandisaverygreyarea.

Atthetimeofconsentitisusualforthesurgeon(orasuitablytraineddeputy)tomarkthelimb.Inotherbranchesofsurgerymarkingislessusualbutinorthopaedicsitisobligatory.Thearrowusedmustbevisibleintheoperativefield.Somesurgeonswritethenatureofoperationandsignit.Itshouldbedonewithapermanentmarker.

Onleavingthewardachecklistiscompletedwhichincludesbothmarkingandconsent.Patientsdonotleavethewardwithoutthischecklistbeingcorrectlyfilledin.Inthetheatretheformshouldbecheckedagainandalsointheanaestheticroom.Whenthepatientiswheeledintotheatrethereisaspecific‘time-out’beforeevenpreppingthearea.ThenotesandX-raysarechecked,thechecklistitselfandthewristbandofthepatient.Allpatientshaveawristbandwhilstinhospitalwhichincludestheirname,theirnumberandanyallergies.

Youwouldhavethoughtthatwithallthesecheckswrongsitesurgerywouldnothappenbutunfortunatelythisisnotthecase.Becausetherearesomanychecksitneedsanumberofpeopletobe‘offtheball’foramistaketooccur.Clearlyanysuchmistakeleadstonegligenceclaimswhichareindefensible.

Inaddition,suchamistakewillusuallybefollowedbyadetailedenquirybythehospitalitselftofindoutwhatexactlyhadgonewronganditsfutureprevention.

Disputesaboutwhethersufficientinformationhasbeengiventoallowproperconsentarealwaysdifficult.Intruth,theenquirycanbesolongaftertheeventthatthememoryofbothpatientandsurgeonmaynotbeperfect.Whatiswrittenontheconsentformhelpsbutdoesn’tshowexactlywhatwassaid,onlythesubjectsdiscussed.

Wrongsitesurgery,however,isstraightforwardandthisisunlikelytobedefended.q


Lords launches Olympic legacy sports medicine inquiry

The House of Lords Science andTechnology Committee has launched a shortinquiry into sports and exercise science andmedicine. It will consider how the legacy ofthe London 2012 Olympic and ParalympicGames can be used to improve understandingof the benefits exercise can provide both forthe wider public and in treating a wide range ofchronic conditions.

In a statement the committee noted that theGovernment spend approximately £100m ayear on high performance sport and recentlyinvested £30m in the establishment of a UKNational Centre of Excellence for Sports andExercise Medicine. Their Lordships will explorehow robust this science is and how lessonslearnt from the study of elite athletes can beapplied to improve the health of the populationgenerally.

Research suggests that increased exercisecan provide significant health benefits for arange of health conditions, from heart diseaseand diabetes to mental health problems suchas depression. However, the committee isconcerned that medical practitioners maynot be adequately trained and resourced tounderstand how to include increased exercisein treatment programmes and will look at howthe Olympics can be used to deliver wideraccess to sports medicine.

The committee started taking oral evidenceon 12 June with officials from the Departmentof Health and the Department for Culture,Media and Sport giving evidence. Over thecourse of the inquiry the committee also expectto hear from representatives of the NHS andUK Sport as well as other experts.

Commenting, Lord Krebs, Chairman of theCommittee, said: “There is significant interestin the Olympics right across the country andthe Government have committed to providing alasting legacy from the Games. The committeewill consider how the significant sums ofmoney that are being invested in improvingthe performance of elite athletes in a range ofsports can provide transferable knowledge thatcan be of benefit to the whole population.

“There is an ever-growing body of evidenceshowing that increasing the amount ofexercise people take can be of huge benefitin treating a wide range of chronic conditions.However, we are not convinced that healthprofessionals currently have the skills orsupport to prescribe appropriate trainingregimes for their patients.

“It is widely agreed that the LondonOlympics must deliver a legacy. Our inquirywill seek to establish how the Governmentcan ensure that improved public health is asignificant part of that legacy.”

The Royal Society for the Prevention ofAccidents (RoSPA) and the FIA (FitnessIndustry Association) have entered into anew partnership aimed at improving thequality and safety of the sport and physicalactivity industry. The two organisations willwork together on policy, industry initiatives,training programmes and campaigns.

RoSPA is recognised as a leader in theproduction of accident investigation andexpert witness reports for both play andsporting injuries, and has a subsidiarycompany, RoSPA Playsafety Ltd, thatspecialises in the sector.

FIA members will benefit from accessto RoSPA services, including a telephonehelpline giving free initial advice on waterand leisure health and safety issues, andpreferential rates on RoSPA consultancy,membership and playground inspections.They will also be able to report anyincidents or near-misses for inclusionin the Water Incident Database (WAID),which is hosted by RoSPA on behalf of theNational Water Safety Forum (NWSF).

David Rushton, RoSPA’s head ofeducation and leisure, said: “RoSPA iscommitted to the guiding principle thatsport and physical activity should be assafe as necessary, not as safe as possible.A quest for absolute safety in this spherewould surely erode many of the benefitsto be gained from maintaining an activelifestyle. We are delighted, therefore, to bepartnering with the FIA – an organisationthat shares our commitment to promotingquality in the industry and ‘prevention inproportion’.

“Working together, we will be able toprovide thousands of health and fitnessoperators and suppliers, in both the publicand private sectors, with the informationand advice they need to take a balancedapproach to health and safety. We hopethis will raise standards of health andsafety management across the industry,thus reducing unnecessary injuries, whilealso promoting the many benefits ofphysical activity.”

David Stalker, the FIA’s chief executiveofficer, said: “One of the FIA’s core aimshas always been to improve quality andstandards across the physical activitysector and to help our members preventaccidents in their facilities. Our Codeof Practice and Health CommitmentStatement have gone a long way to

encouraging a vigorous but balancedapproach to health and safety in leisuremanagement.

“This partnership builds upon ourcommitment to health and safety and offers

FIA members access to key resourcessuch as the RoSPA helpline, helping thoseworking at the coalface of the sector tokeep updated and access support whenthey need it.”

Sports and leisureexperts combine

to promote safetyImage courtesy of Freeimages.co.uk


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