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4 OPENINGSTATEMENT byMartinaWilson,Business

developmentmanager

5 Allchangeinhealthand safety?

6 Knowingwheretodrawthe line...getanexpertonyour sideinboundaryand constructiondisputes

8 ExpertDetermination–isit ADR?

9 Thecharteredsurveyorasan expertwitness

10 ‘Heythat’smyland!’11 Onaroll...residentswin

skateboardingparknoise nuisanceclaimsagainst council

12 SatNavForensics

14 TextilesandFraud15 Complexlossofearnings

claims–wheretostart16 ‘Let’sstartatthevery

beginning,averygoodplace tostart’–Ausefulguidefor solicitorsinstructedin financialservicesclaims

17 VeterinaryForensic Entomology

MEDICALISSUES19 Anaesthesiaandnegligence

claims–getanexpertonthe case

21 Expertisewithvitalevidence inmind

24 Handlewithcare...thedifficult issueofchildabuseandthe law

25 IsVasectomysafe?26 What,really,isahernia?28 Establishingasoundcasefor

noiseinducedhearingloss

29 A21stcenturydisability30 Puttinglegalissuesunder

themicroscope–forensic medicine

31 Takeastepintheright direction–callanexpertin podiatry

32 Gynaecologyprocedurestop listofmedicalnegligence claims

33 MedicolegalIssuesin LaparoscopicSurgery

35 Pitfallsinthediagnosisof headandneckcancers

37 Factorsinmedicalnegligence claims

38 Compensation–howmuchis aninjuryworth?

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RECENTWEEKShaveseenthefirstspateofjudicialrulingsunderthelandmarkMentalCapacityAct,gearedtomakingnewprovisionrelatingtopersonswholackcapacity.

Thisnewactwillimpactonmanyareasoflegalpractice,includingtheworkoflegalpsychologists,whoseremitincludesestablishingaperson’scompetenceandintelligence–atopiccoveredindepthinthisissue.

Althoughtheactwasadoptedbyparliamentin2005,andeffectivein2007,itisonlynowthatthefirstcasesaretestingkeyprovisionsofthenewlegalboundariesitestablishes.

Onedisturbingcasetowhichtheactappliedinvolvedawoman–MrsA–whosufferedasignificantlearningdisabilitywithanIQinthebottomonepercentofadultsofherage.

Priortomeetingherhusband,MsAhadtwicebecomepregnant.Apre-birthassessmentbeforeeachchildconcludedthatshelackedtheabilitytomeetherchild’sneedswithoutconsiderablesupport.HertwochildrenweretakenawayatbirthandMrsAherselfcameunderacourtguardianshiporderandbeganusingcontraceptionadministeredbyamonthlyinjection.

Subsequently,MrsAmarriedherhusband,MrA–whoalsofellinthebottomonepercentinIQ.MrAwantedchildrenandMrsAdidnot–andthemattersoonbecameanissueofseverecontentionwithregularargumentsandMrsAreportingthatherhusbandhadshoutedather,hadhitorpunchedher,orbrokenhouseholditemsinatemper.

MrAtriedtostophiswifefromhavingcontraceptiveinjections,andsometimesblockedcontactwiththesocialservices.Whenthesocialservicesdidvisit,MrAwouldnotlethiswifespeaktothemalone.InMrA'spresence,MrsAindicatedthatshenolongerwishedtousecontraceptionandsignedaletter,writtenbyMrA,statingthatshenolongerwishedtobecontactedbysocialservices.

Finally,thecourtofprotectionbecameinvolvedandthelocalauthorityaskedthecourttodeclarethatMrsAlackedthementalcapacitytodetermine,amongotherthings,whethersheshouldbeadministeredwithcontraceptivedevices.

Thenewlegalapproachplacedanovelquestionbeforethecourts:underwhatcircumstancesdoesanindividualhavethecapacitytomakehisorherowndecisions?TheMentalCapacityActestablishedtheframeworkunderwhichthisquestionisaddressed.

Incourt,oneexperttestifiedthatMrsAdidhavetherequisitecapacitytomakedecisionsaboutcontraceptives,whilstasecondexpertthoughtthatMrsAlackedtherequisitecapacity:

Intheend,thejudge,MrJusticeBodey,concludedthatMrsAshouldfostertheverycapacityshepresentlylacks,sothatshemightdeveloptheabilitytomakeaninformeddecisionaboutthematterforherself.HeruledthatMrsAshouldhaveaccesstotheprofessionalsupportsherequiresandaskedMrAtohonourhisassurancegiventothecourtthathewouldnotpreventthis.

Withwarmregards

MartinaMartinaWilsonBusinessdevelopmentmanager

OpeningStatement

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Allchangeinhealthandsafety?by JIMTASSELLMSc DipSH CMIOSHEVERYONEINTHEsafetyworldisawaitingthepublicationofLord

YoungofGraffam'sdeliberationsonhealthandsafetywithinterest.Muchhasbeensaid,notleastbyLordYounghimself,aboutthepresentpublicperceptionofhealthandsafety.Youwouldhavetohavebeenlivingonaveryremoteislandtobeunawareoftheissuessurroundingconkers,hangingbasketsandeventhegrittingofpavementslastwinter.Evenso,itisagoodmomenttopickoversomeoftheunderlyingissues.

Isthereaburdenofinappropriateenforcement?TheHealthandSafetyExecutiveareasimpleandhighprofiletarget,althoughmostcommentatorsforgetthatmuchhealthandsafetyenforcementisactuallydonebylocalCouncils’EnvironmentalHealthOfficers(EHOs).Society(oratleastthepress)seemstobedemandingvigorousactionagainstperceivedpoorbusinessessuchasthosewheretherearefatalaccidentsormajorincidentsliketheBuncefieldexplosion.Lookingawayfromthesehighprofilecategoriesthough,enforcementactionhasbeenprettystaticrecentlyandcomparedtotenyearsagoitisdown.Thereiscertainlynostatisticalevidenceoftheheavyhandofbureaucracyinaformalsense.ButwhatabouttheinformalactionsofInspectors?Therearenocomparablefiguresotherthannumbersofvisits,whicharealsowelldown.ApartfromvisitsbyEHOsdrivenbyfoodsafetyinspectiontargets,businessesusuallyrunforseveralyearsbetweeninspections.Fromacomplianceperspective,twocommontriggersforcompaniestoseekexternalassistancearefollowinganinspectionorinanticipationofonefollowinganaccident.Sadly,Inspectorssometimesseemtotalkastrangelanguageoftheirownandaconsultantisneededtoactastranslator.Themostcommontopictocauseproblemsremainsriskassessment.

Istherereallyanexplosionofclaims?Onecanlookinvainforreliablestatistics.Theconsensusseemstobethatthecompensationcultureisamyth.Thenumberoftraditionalemployersliabilityclaimshasnotmushroomedinthelasttenyears.Butaretheseanaccuratebarometer?Mostmajorpublic-facingbusinessesaregettingincreasinglysophisticatedintheprocessingofrunofthemillclaimswithoutrecoursetotheirinsurers.Theymayfaceclaimsacrossaverywiderangeoftopicsthesedays,notjustfortraditionalaccidentsbutontopicslikeproductandfoodsafety.Oneofthefactorsindealingwithclaimsisthepublic’sperceptionoftheorganisation,particularlyiftheyadoptarobustposition.Manypotentialclaimsgetsortedoutinformally,possiblysimplybysensibleactionbyastoremanagerlongbeforeacasehitstheirheadoffice,letaloneinsurers.Butthesesimplesolutionsstillcarryacost.Wehavenofiguresforthembutcontactsinretailingsuggestthattheyarerising,judgingbythesizeofreservessetasideforthem.Thetimebetweenincidentandclaimhasalsobeenreducing,whichperhapssuggeststhatthepublicarebecomingevermoretunedintotheir‘rights’.

Lookingfromtheconsumerend,itisn’tthelegislatorswhohavedrivenclaimsrecently,althoughimplementingEUDirectiveshasprovidedbettergroundsforthem.Thecourtsprovidethemechanismsforresolvingclaimsbutarenotthetriggersforthem.Insurersnegotiateandpayout(ornot),

thenrecoupthefundsfromtheirclients.No,thekeydriveristhepotentialclaimant,althoughweshouldpondertheimpactonthemofdaytimeTVadvertising.Somepeoplearestillreluctanttoraiseclaims,evenwheretheyhaveasoundcause.Buttheirfamilyandworkmatesarenotalllikethem.Wehaveprobablyallheardofcaseswheretheclaimantonlyactedfollowingpressurefromtheirmatesinthepub.Itishardnottobecynicalinthinkingthatthereisaprevailingviewthatifsomethinggoeswrong,it’sboundtobesomeoneelse’sfaultandthereisalwaysatleastagoodholidaytobehadoutofit.Itisdifficulttodivorcetheseviewsfromthoseonbenefitentitlement,redundancyandotherimpactsofthecurrenteconomicclimate.Buthowcangovernmentinfluencethesedeeplyentrenchedattitudes?Wouldchangesinlegalprocessesmakemuchpracticaldifference?

Lookingahead,therearesignsofchangingfactorsthatmayincreasethelikelihoodofclaims.Theseincludeanageingworkforceandaswinginfocusfromsimpleaccidentstolongtermhealthissues.TheLabourForceSurveyreportedbytheHSEsuggeststhatlostworktimeduetohealthproblems,suchasbackinjuriesandstress,faroutweighsthatduetodiscreteaccidents.Alsonowonthehorizon,andnotbeforetime,areproposalsforregistrationofhealthandsafetyconsultants.

So,whateverLordYoungcomesupwith,willitdomuchtogettotherootsofsociety’spresentattitudesto‘elfansafety’?Idoubtit,andI'msureitwon’treducetheneedforhealthandsafetyprofessionalstoassistbusinessesbothinpreventingaccidentsandillhealthandinadvisingthevariouspartiessortingouttheconsequencesofthem.q

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Knowingwheretodrawtheline......getanexpertonyoursidein

boundaryandconstructiondisputes

BOTHBOUNDARYANDconstructiondisputesarecomplexareasrequiringspecialistskillsandknowledge-whichiswhereenlistingacharteredsurveyorasanexpertwitnesscanproveaninvaluableassetinachievingasuccessfuloutcome.

Boundary disputesFarmoreboundarydisputesoccurbetweentheownersoftwo

adjacentresidentialpropertiesthanbetweencommercialneighbours.Residentiallandownerstendtotackletheirdisputesemotionally,seekingperceivedjusticeratherthanrationallyevaluatingthesituationthenconsideringamicablesolutionstothedispute.Boundarydisputescanbethecauseofuntoldmisery,inconvenience,badrelationshipsbetweenneighboursandultimatelythelossinvalueofland.

ThegeneralpositionoftheboundariesineachregisteredtitleisrecordedbytheLandRegistryusinganadaptedlargescaleOrdnanceSurveyplan.Howevertheplanmightnotaccuratelyrepresentthetruegroundpositionsoftheboundaries.InfacttheexactpositionsoflegalboundariesarealmostnevershownonregisteredtitleplansandarenotshownonOrdnanceSurveymaps.

Sowhathappenswhenadisputearises?Thekeytoresolvingadisputespeedilyandsuccessfullyistoseekexpertadviceassoonaspossible.Inthefirstinstance,thisadvicecanbefromeitheracharteredlandsurveyororacharteredsurveyorspecialisinginboundarydisputes.Theycanthenlookatallaspectsoftheproblemandadviseonwhetherornottheplaintiffhasacase.

Charteredsurveyorsspecialisinginboundariesareprofessionaladvisorswithrelevantknowledgeofbothpropertyissuesandthelaw.Theywilllookattheproblem,prepareanytechnicaldatathatmayhelpsolvethedisputeatanearlystageand,ifnecessary,provideacourtwiththeappropriateadviceandinformationneededtomakeajudgement.

Theycanalsoadviseonalternativedisputeresolutionprocedures,whichwouldavoidtheneedtogotocourt.

Accuratelyidentifyingtheboundarybetweentwoproperties,forexample,oftenrequiresspecialistknowledge.TheredlinedrawnaroundapropertyontheLandRegistryplanonlyshowsthegeneralboundary.Itdoesnotidentifywhethertheboundaryrunsalongthecentreofahedgeoralongonesideofit.OrdnanceSurveymapsare

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equallyunreliablebecause,aspartofthemappingprocess,theydonotmarkexactpropertyboundaries.Soalinesurroundingthepropertyisnotnecessarilythepropertyboundary.

Acharteredlandsurveyorwillnotonlysurveytheland,checkdeedsandtheplansattachedtothem,butwillrefertohistoricaldocumentsandaerialphotographs.

Aboundarycanchangeovertimeformanyreasons:adivertedwatercourse,orawoodenfencethatmovesslightlyeverytimeitisreplaced.Thereasonforsuchchangesisrarelyrecordedandcanleadtodisputes,especiallyiftheownerhaslosttherighttomovetheboundarylinebacktoitsoriginalposition.

Construction disputesGiventheexpenseanddisruptiontoabusinesswhena

constructiondisputearises,nottomentionthepotentialdamagetobusinessrelationships,disputeavoidanceshouldbeparamount.

However,disputesaresometimesunavoidable.Inthiscase,charteredsurveyorscanactasexpertwitnessesforadiverserangeofclientsincludingcontractors,employers,consultants,publicauthoritiesandothers.

Charteredsurveyorsaregenerallyengagedbecausethey‘addvalue’tothedisputeresolutionprocessandnotthroughanyformalrequirement.Whenpartiesfindthemselvesinaconstructiondispute,theymayemployacharteredsurveyorastheirrepresentative,oras

anindependentandimpartialexpert.Charteredsurveyorshaveawiderangeofskillsthatthepartiestoadisputecanmakeuseof.

Mostcharteredsurveyorswillalreadyhavegoodexperienceofnegotiationintheirdaytodayworkloadandtheycanusethistogoodadvantagewhendisputesarise.Negotiationcomesatthebeginningofthedisputeresolutionspectrumandisaninformalandnon-bindingprocessinwhichthepartiescontroltheoutcome.

BothmediationandconciliationarenowwellestablishedintheUKconstructionindustry.Charteredsurveyorsmaybeinvolvedinassistingtheparties,ortheymayhavehadthespecialisttrainingtobecomemediatorsorconciliatorsthemselves.Inmediationandconciliation,thepartiesretaincontroloftheprocess.However,thedistinguishingfeaturefromnegotiationistheadditionofaneutralthirdparty–‘themediatororconciliator’–whoaidsthepartiestowardsasettlement.Thetermsofthesettlementultimatelyliewiththeparties.

IntheUKconstructionindustrytheterm‘adjudication’isusedalmostexclusivelytodescribedisputeresolutionunderPartIIoftheHousingGrants,ConstructionandRegenerationAct1996(HGCRA).

Theprocessinvolvesathirdparty,theadjudicator,actingasthetribunalinadispute.Theadjudicator’sdecisionisbindingonthepartiesunlessoruntilthedisputeisfinallydeterminedbylegalproceedings,byarbitrationorbyagreementoftheparties.Manycharteredsurveyorsalsoactasadjudicators.q

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Expert Determination

–isitADR?by CHRISMAKIN

WHENFRAMINGTHECivilProcedureRules,LordWoolfhadtheclearintentionofencouragingpartiesindisputetogoawayandsettletheirdifferences,perhapswiththehelpoftrainedprofessionals.WeseethisinCPR Part 1 – The Overriding Objective:

1.4(1) Thecourtmustfurthertheoverridingobjectivebyactively managingcases.

1.4(2) Activecasemanagementincludes: (e)encouragingthepartiestouseanADRprocedureif

thecourtconsidersthatappropriate.andfacilitatingthe useofsuchprocedure...

ByfarthemostpopularformofADRismediation,butisexpertdeterminationADR?Let’slookatthisprocessinmoredetail.

ExpertDetermination(ED)isnotarbitration.Bothareprivatesystemsofdisputeresolutionleadingtoabindingresult,butwithdifferences.Expertdeterminersaresubjecttolittleornocontrolbythecourt,andfromtheirdecisionsthereisvirtuallynoappeal,whereasarbitrationisbasedonstatute,andthecourthasextensivepowerstooverturnanunfairaward.CaselawonEDwouldfillaveryslimvolume!Thearbitrator,likethejudge,mustbasehisdecisiononlyontheevidencepresented,whereastheexpertdeterminercanmakehisownenquiriesandinvestigations,anddoesnotevenhavetopresenthisfindingstothepartiesbeforeannouncinghisdecision.

Partiesindisputemust,withtheiradvisers,considercarefullythebestmethodofresolvingtheirdifferences.Atoneextremeislitigation:closelyboundbystatuteandcaselaw,withfixedprocedures,andthedecisiontakenbyajudgeallocatedtothecase.Oncetheprocessstarts,thepartieslosecontrol;it’slikedancingwithagorilla-thedancestopsonlywhenthegorillachoosestoletgo.Inarbitration,thepartieshavethechoiceofarbitrator;butagain,oncetheprocessstarts,thepartieslosecontrol.Mediationisattheotherendofthespectrum:thepartieschoosethemediator,andstayincontrolthroughouttheprocess.Thecasesettlesonlyifthepartiesagree,andifitfails(fewdo!)theirlegalrightsareintact,andtheycanstillhavetheirdayincourt.

EDsitssomewherebetweenarbitrationandmediation.Thepartieschooseadeterminerwiththeskillsrelevanttothedispute,andhethencontrolstheprocess,butonlyonthetermsagreedattheoutset.

Thisisthefundamentaldifference:theEDprocessiscontrolledbycontract,notbystatuteandcaselaw.Buttheproceduretendstofollowanestablishedpattern,sothatbothsidesfeelthatithasbeenfair.FormanydisputestheRulespublishedbytheAcademyofExperts(www.academy-experts.org)aresuitable.Basedlooselyonthecourtprocess,theclaimantmakesSubmissionstotheexpert,thedefendantmakesaResponse,andtheclaimantmakesaCounter-Response.Eachincludesalltheargumentswhichanadvocatewoulduseattrial,andalltherelevantdocuments.Forvery

complexdisputes,IhavemyownprocedurewherebybothsidesmakeSubmissions,ResponsesandCounter-Responses.

Oncetheexperthasconsideredallofthese,possiblymadehisownenquiriesandaskedquestionsoftheparties,hisdecisionisissued.Thefindingisnormally‘non-speaking’–thatis,withoutstatingreasons.ThatmayseemdisappointingafterallthetroubletakentoproduceSubmissions,butthatiswhatthepartiesneed–anendtothedispute.

Howthenisadeterminerappointed?Eitherfromadisputeresolutionclauseinacontract,incaseofpossiblefuturedispute,oronceadisputearises.Forexample,inthesaleofacompany,itisnormalforthevendors’andpurchasers’accountantstogettogetherandagreethecompletionaccountswhichwillfixthepriceoftheshares.Thesale/purchasecontractwillprovidethat,iftheycannotagree,anexpertshallbeappointedbythePresidentoftheInstituteofCharteredAccountantsinEngland&Wales.Aswithotherprofessionalbodies,thePresidenthasasecretariattodealwithrequests,andIamfrequentlyappointedasexpertinsuchmatters.

Oranappointmentismadeonceadisputearises.This,forexample,ishowIcametobeappointedtodeterminetheclosingcapitalaccountofasolicitorwhohadretired,whenhiscontinuingpartnerscouldnotagreehisentitlement.

These,briefly,aretheadvantagesoftheprocess:•Privacy:onlythepartiesareevenawareofthedispute•Speed:adisputecouldberesolvedinaslittleas30days.I

confessthatoneofminelastedforsevenyears,butitwashugelycomplex,andforexamplewehadtowaitafewyearsforadecisiononoverseastrustsfromtheTaxCommissioners

•Choice:thepartiescanappointtherightexperttounderstandtheproblem

•Final&binding:absentfraudormanifesterror,thereisnoappealagainsttheexpert’sdecision,whichiswhatthepartiesneed–finality

•Impartiality:theexpertwillactfairly•Relationships:EDisatechnicalprocess,farlesslikelytodestroy

businessrelationshipsthanahard-foughtcourtcaseSoisitADR?Yesandno!Itisanalternativetogoingtocourt,

andthepartiescanchoosetheirexpertandthedetailedtermsofhisappointment.Afterthat,allmustactunderthecontracttheyagreedattheoutset.Andquitesoontheyshouldseeanendtotheirdispute,withagoodchancethattheywillcontinuetodobusinesstogether.q

Chris Makin has practised as a forensic accountant and expert witness for 21 years. most recently as Head of Litigation Support at a national firm. He has been party expert, single joint expert, Court appointed expert and expert adviser in hundreds of cases, and given expert evidence about 70 times. He performs expert determinations, being on the panel of the President of the ICAEW, and accredited by the Academy of Experts. He also practises as a civil and commercial mediator, and has mediated a vast range of cases, with a settlement rate to date of 80%. www.chrismakin.co.uk

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Thecharteredsurveyorasanexpertwitness

UNTILSOME10yearsagoitwascommonforCharteredSurveyorstoarriveataCourtHearingwithverydifferingviews.Inmatrimonialcasesforexample,onepartywouldusuallyaimforahighvaluationofthematrimonialhome,andunsurprisinglytheother(thebuying)partywouldadvocatealowvaluation.Twovaluers,withequallycontrastingfigures,usuallyputtheJudgeinsomedifficulty.

SinceLordWolff’sreporton‘AccesstoJustice’ledtotheCivilProcedureRules,from1999theworldhaschangedforexpertwitnesseswhoprovideevidenceonawiderangeofmattersanddisciplines.

Theskillsofthelegalprofessionensurethatcasesarewelladvocated–the‘hiredguns’aimingforthebestdealfortheirclients.Inlandandpropertydisputes,todaysvaluesmeansubstantialsumsareatstake,sotheroleofthevaluerandsurveyoriscrucial.

TheCPRrules,andfollowingcloselytothem,theGuidanceNotesandPracticeStatementfromtheRICS,meanthatCharteredSurveyorsmustnowgiveevidencewhichisimpartialandunbiased,andespeciallyuninfluencedbythepartyinstructingorpayingforthatevidence.Itisnotuncommonfordisappointedclientstoquerythenatureofthesurveyor’sadvice,butultimatelyahopelesscaseisbestwellidentifiedattheoutset,ratherthanmonths(orevenyears)laterwithobviouscostimplications.

TheroleoftheCharteredSurveyorhasthusevolvedandmanycompaniesnowhavespecialistswithindividualskillsandexperience.Thewitnessboxisnotforthefainthearted.Disputesarevaried–surveyorscanforensicallyexamineboundaryproblemsandbuildingdisputes,valuerscanassesstheworthofalltypesoflandandpropertieswithalltypesofproblemsandissues.Intimesofrecession,lendersinvariablytrytooffsetlossesbyclaimsofnegligenceagainstthevaluesplacedwhentimesweregood,soretrospectivevaluationshavebeenverypopularinthecurrentrecession,especiallywiththeadventof‘confetti’lettersfromnowinnofeelawyers.

TheCPRrulesseethatthetwoexpertsmustnowmeettoaddresstheissues.Itiscommonforvaluerswhoreachconclusionsfromtheirownassembledcomparableevidence,tonarrowthegapbynegotiationandtheconsiderationoffurtherevidence.Memorandumsofagreement(anddisagreement)thenfollowtoassistthecourtinnarrowingtheissues.Theresultsoftheexpertsmeetingcansometimeslimitthesolicitor’snegotiations,buttherulesforbidanyundue‘pressure’tobeputontheexperts.Solicitorsareallowedtoattendexpertsmeetings,butnottointervene,excepttoanswerquestionsputtothembytheexperts,whichhasledtosomeinterestingdiscussions!

Intheolddays,theflowoflegalaidsawmanycasesdragforyearsandonlysettledonthestepsofthecourtroom.ThecostsoflitigationtodayremainimmensebutitisclearthattheCPRruleshavenowcreatedtheopportunityofearlysettlements,aidedbyunbiasedreportingfromexperts.

TheemergenceoftheroleoftheCharteredSurveyorasanExpertWitnesshasundoubtedlyenhancedtheprofileofvaluersandsurveyorsintheeyesofthepublic.q

by DEWIPRICE, Chartered Surveyor

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‘Heythat’smyland!’ by CARLCALVERTof Calvert Consulting

“HEY,THAT’SONMYLAND!”“No,it’snot:Iamonlyreplacingthatoldhedgewithaproperfence.”

Andso,withbothpartiesbelievingthattheyareintherightaboundarydisputeisabouttotakeoff.

Ofcourse,theingredientsmaybealittledifferentbutthecircumstancestendtobeverysimilar.Inanyeventthereisabeliefbyonepartyatleast–theothermaybejust‘pushinghisorherluck’–thattheboundaryiswelldefined,thatthedefinitiononthegroundisinaccordwithwhattheyboughtandhaveoccupiedformanyyearsandthateitherthereisnocontraryevidence,orifthereis,thenitisinferiortotheirownevidence.

So,solicitor,friendorlandsurveyor?Asolicitorknowsthelawbutisoftennotinapositiontounderstandmapsandwhatthelinesonthemaprepresent.Asajudgetoldme,“MrCalvert,IcanscaleameasurementontheplanbutIneedyoutotellmewhatthelinerepresents.”

Afriendmaybeabletohelpbutcanbesubjectiveandnottellhisfriendwhathedoesnotwanttohear.TheCharteredlandsurveyorhastobeobjectiveunderRoyalInstitutionofCharteredSurveyors’rules,andifitcomestopreparinganythingforcourt,thenPart36ofCPRandpracticedirections.

ThefollowingthreeCourtofAppealcasesshowthatunderstandingthegroundanditsportrayalarepartoftheprocessofobtainingasolutioninlaw.

Thefirstpointisthereliabilityofthetopographic,thatisOrdnanceSurveymappingatthattime.InHorn & Anor v Phillips & Anor (2003)EWCA Civ1877,LordJusticeJacobssaidoftheconveyanceplan:

“Thisdocumentisintendedtotransfertitletoland.Itgivesaprecisemeasurement–Ipassover‘orthereabouts’,whicheverybodyagreeddidnotmakemuchdifference.Tomymindtheclearintentionistoindicateexactlywherethatlineissupposedtobe.Sorelevantly,thismapisnotambiguous.TrueitisthatotherpartsofthemapmaybenotverysatisfactorybecausetheOrdinanceSurveyisnotverysatisfactory,butinitsrelevant

respectonecanseeexactlywherethebeginningandtheendofthelineis,andifyougotothelandyoucanseeexactlywheretheyare.”

Thesecondpointreferstowhatwasontheground,Cook v J D Wetherspoon plc (2006) EWCA Civ 330,isthecaseinpoint.SirMartinNourse,indismissingtheappealstatedthat;“(theDefendant)reliesonthesefeaturesandalsoonthefollowingpassageinthereportofthesinglejointexpert:

‘6.ThephysicalandlogicalendoftheWheatsheafsiteisdefinedbythenorthernedgeoftheconcreteapronrunningaroundthecarparkwhichIbelieveisrepresentedbythedashedlineontheOrdnanceSurveyplan,albeitthatthislineisdrawninslightlythewrongpositionduetoinaccuraciesintheOrdnanceSurveymappingsystemwhichtheyacknowledge’.”

Thefinalpointreferstoapresumptioninlaw,thatofhedgeandditch.InAlan Wibberly Building Ltd v Insley (1997) CCRTF 96/0813/C,LordJusticeWardstates:

“Thisisaboundarydispute.Tohearthosewords,‘aboundarydispute’,istofillajudgeevenofthemoststalwartandamiabledispositionwithdeepforebodingsincedisputesbetweenneighbourstendalwaystocompel,asthisonedid,someunreasonableandextravagantdisplayofunneighbourlybehaviourwhichprofitsnoonebutthelawyers.Fortunatelythisappealisdifferent.Ablyarguedasithasbeenbybothcounsel,itcrisplyraisesapointoflawofsomeimportance,especiallyinruralEnglandandWales.Thatquestion,forthemomentquitebroadlystated,isthis:whereadjoiningfieldsareseparatedbyahedgeandaditch,whoownstheditch?”

Sotherewehaveit.Mapsonlyshowwhatthesurveyorchosetoshowwhatexistedonthegroundatthetimeofsurveyaccordingtohisorherskillandtherulesunderwhichtheyoperated.TheCharteredLandSurveyorismerelyatranslatorofthepicture(themap)tothewordpeople(thelawyers)withanunderstandingoftheirlanguage.q

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NOISENUISANCEFROMskateboardingparksisarelativelynewphenomenon-andonethatisnowincreasinglyresultinginsuccessfullegalactionfromnearbyresidents.

In2001,thefirstofthelandmarkskateboardnoisecasescametothefore.Inordertofacilitatetheconstructionofnewcounciloffices,NorthWiltshireDistrictCouncil(NWDC)relocatedaskateparktoasiteinMonktonPark,Chippenhamwhichwaswithin55metresofresidentialproperties.DespiteadvicefromtheirownEnvironmentalHealthDepartment,theskateparkwasofficiallyopenedonthe17thFebruary2001.Onthe18thFebruarytherewasaformalcomplainttothecouncilfromanearbyresident.

Thecouncilthenemployedanindependentnoiseconsultant,whoindicatedthattheskateboardnoiseneededtobereducedby20-30decibels.Suchareductionwascompletelyimpracticalforskateboardingactivitieswithoutclosingtheskatepark,whichthelocalauthoritydidnotdo.TheOmbudsmanbecameinvolvedandconcludedthattheuseoftheskateparkwasastatutorynuisancetothenearbypropertiesandhadbeenallowedtocontinuewhenitcouldhavebeenabatedbyclosingtheskatepark.CompensationwaspaidtoanumberofthecomplainantsandtheskateparkwassubsequentlyclosedbyNWDC.

InthecaseofRichardson v Devizes Town Council,in2001thecouncil(DTC)hadinstalledaskatepark30metresfromMrRichardson’shouse.AlanSaundersAssociateswereretainedasanindependentnoiseconsultantbyMrRichardsonandfoundthatthenoiseimpactfromtheskateparkonMrRichardson’spropertyconstitutedaserioussourceofannoyance.MrRichardsonsuedDTCandthejudgenotedthattherewasan‘actionablenuisance.’DTCwereorderedtoremovetheirskateparkequipmentwithin28daysand90%ofcostsanddamageswereawardedagainstthem.

In2002OxfordCityCouncil(OCC)constructedaskateparkinanexistingrecreationgroundatAristotleLane,Oxford.Localresidents,whosehouseswereaslittleas30metresfromtheskatepark,complainedtoOCCandinstructedAlanSaundersAssociates,whoconcludedthatnoiselevelscouldbeconsideredtocauseseriousannoyancetotheresidents.WhenOCCsubsequentlyinvolvedtheirEnvironmentalHealthDepartment,thisopinionwasconfirmed.OCCpermanentlyclosedtheskateparkonthe29thMay2002.

Theassessmentmethodswhichweredevelopedandusedintheabovecaseshavebeenadoptedbysomelocalcouncilsforassessingthenoiseimpactonresidentsandthesuitabilityofsitesforaskatepark.Theseassessmentmethodshavealsobeenusedwhenlocatingmanysuccessfulskateparksoveranumberofyears.

Mostpotentialsitesfornewskateparksareinrecreationgroundsorparksandhaveasimilarbackgroundnoiseclimate.Inthesecircumstances,Ihavedevelopeda’ruleofthumb’forthelocationofskateparksinrelationtotheclosestresidentialproperties.Myruleisthattoavoidcomplaintsfromresidents,askatepark,ifvisible,needstobe200metresfromresidentialproperties.Ifmitigationmeasuresintheformofearthbundsorfencesareincludedinthedesign,thenadistanceof100metresisacceptable.Thesedistancesaremeasuredfromthecentreoftheskateparktotheboundaryoftheresidentialproperties.

Despitetheabovecases,theFieldsinTrustorganisation(formerlytheNationalPlayingFieldsAssociation)advisedintheirSix Acre Standarddocument,adistanceof30metresasappropriateforaskateboardparkclosetoresidentialproperties.IntheircurrentpublicationPlanning Design for Outdoor Sport and Play: 2008thedistancehasbeenrevisedto50metres.Toquotetheirownpublicity“...ourwellrespectedindustrybibleisusedbyover70%oflocalauthoritiesintheUK.”

Thisdocumentisthereforeadvisingmanylocalauthoritiestolocatetheirskateparksatadistancefromresidentialpropertywhichislikelytoresultinanactionablenuisance.

OnlytimewilltellwhattheOmbudsmanthinksofthispractice.Inthemeantime,manymoreresidentswillhavetheirlivesblightedbyinappropriatelysitedskateparks.q

Onaroll......residentswinskateboardingparknoisenuisanceclaimsagainstcouncils

by AlanSaunders of Alan Saunders Associates

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SATNAVDEVICESHAVEbecomesocommonplaceinmodernsocietythatIwonderifinafewyearswhenIexplaintomyyoungchildrenwhethertheywillbelievemewhenItellthemthatweusedtodrivetoplacesbysimply‘knowing’howtogetthereorbyreadingamap.

Yet,theSatNavhasn’tbeenaroundverylong.TheGlobalPositioningSystem(GPS)wasestablishedin1973bytheUSDepartmentofDefenseandcomprisesofatleasttwenty-foursatellites(therearecurrentlytwenty-nineoperationalsatellitesinorbit).Thesesatellitestransmitasynchronisedtimesignal,which

allowsadeviceonearthtocalculatehowfarawayeachofthesatellitesare(basedonhowlongithastakenthesignaltoreachthedevice),andcanthentriangulateitspositionprovidedithasreceivedsignalsfromatleastthreesatellites.

Whilstintendedasamilitaryproject,in1983aSovietinterceptorshotdownacivilianKAL007thathadstrayedintoprohibitedairspaceduetonavigationalerrorskillingall269peopleonboard.Followingthis,USPresidentRonaldReaganannouncedthatGPSwouldbemadeavailableforcivilianusedonceitwascompleted.

ByDecember1993,GPShadachievedinitialoperationalcapacity,andin1996,recognisingthegrowingimportanceofGPSincivilianuse,USPresidentBillClintonissuedapolicydirectiveestablishingGPSasadual-usesystemandestablishedaninteragencyGPSexecutiveboardtomanageitasanationalasset.

ItissometimeshardtobelievethatthefirstTomTomdevicedidn’treachtheshelvesinHalfordsuntilaslateas2004,althoughpriortothatitwaspossibletoinstallTomTomsoftwareonPocketPCsequippedwithaGPSreceiver.

Inordertoreceiveasignal,theSatNavdevicemusthaveaclearviewofthesky,andIalwaysgetakickwhenTVshowslike24somehowmanageto‘track’peopleinthesubwayormulti-storeycarparksusingGPS.

So,historylessonover,whatcanwelearnfromaSatNav?Quitealotactually.Dependingonthemakeandmodel,differentdevicesretaindifferentqualityandquantityofdata.AdeviceIexaminedrecentlyhadmaintainedalogofthepast240plannedjourneys,inadditiontothelastfew‘recorded’locationswherea

SatNavForensics

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‘GPSfix’hadbeenobtainedandstored.Oneoftheseinparticularshowedthedefendantgoingtothewrongaddressandthenplottinganewroutetothecorrectaddressjusthalfamileaway.

Somedeviceswillrecorddatesandtimesofjourneys,otherswon’t.Likewise,somedeviceswillmaintain‘tracklogs’whereassomeotherswon’t.

SomeSatNavdeviceswillconnecttoamobilephoneviaBluetooth,andcanmaintainacopyofincomingtextmessagesaswellaslogsofcallsmadeandreceivedbythemobilephonewhilstinthecar.

Ofcourse,itisn’tjustTomTomdevicesthatareofinterest,onecasewewereinstructedoninvolvedsmugglingdrugsacrosstheEnglishChannel.ThehandheldGPSreceivershadpreviouslybeenexaminedbyanotherfirmofexperts,buttheyhadfailedtoextracttracklogswhichenabledustoprovidedetailsoftheprevioustwodozenorsojourneysacrossthechannelbyboat,includingthedatesandtimesofdepartureandarrival.

WhenwestartedconductingforensicexaminationsofSatNavdevicesmostofthedatahadtobedecodedmanually,buttodaytherearemanytoolsatourdisposaltohelpusinterpretthedatawhichhelpstremendouslyinprovidingafastturnaroundandkeepingthecostsdown.

Ofcourse,thetruepurposeofaSatNavistoensurethatusmenneverhavetoadmitdefeatandasksomeonefordirections,whichperhapsistherealreasontheyaresopopular.q

by PAULVELLAof Evidence Matters

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TextilesandFraudby JULIANELLISOBE M.Phil C.Text FTI MRSC MAE, Chartered Textile Technologist

THETWOTYPESofcasedescribedbelowindicatesomeofthewiderangeofcasesthatthetextiletechnologistcandealwith.

Counterfeittextilesarebigbusiness,becauseofthemark-uponsomebrandedgoods.Whenexaminingitemsinrelationtocounterfeitingprosecutions,thetaskisparticularlydifficultiftherehasbeenadelaybetweentheseizureoftheallegedlycounterfeitgoodsbyTradingStandardsandtherequestforexpertexaminationfromthedefence.Theproblemarisesbecausecountersamplesfromanimpeccablesourcearemuchmoredifficulttoobtain,astheseasonmayhavechangedandidenticalgoodsarenolongeravailable.Thereforeexaminationmusttakeplacecomparingsimilargoods.

Themostobviousindicatorsarethelabels.Arethelabelsthesamestyle?Isprintingthesamecolour?Isthecardonwhichthelabelsareprintedofthesameweight?Arethereserialnumbersonthelabels?Iftherearemanysimilaritems,aretheserialnumbersrepeated?Aretherespecialsecuritythreadspassingthroughthelabelsinbothgenuineandallegedlycounterfeitgoods?

Theembroideryisthenextareatobeconsidered:thereisusuallysomeonmostbrandedgoods.Isthequalityofthestitchingofasimilarstandard?Isthebackingfabrictotheembroideryofthesametype?Isthedesignexactlythesame?Hastheembroiderybeenputonthegarmentbeforeitwasstitchedtogether,orwasitaddedafterwards?

Thenthegarmentitself.Arethenumberofstitchesperinchintheseamsthesame?Arethebuttonssewnoninthesameway?

Theseandmanysimilarareasofexaminationwillallprovidecluesastothepossiblegenuinenessofthegoods.Unfortunatelyfortheunsuspecting,counterfeitersoftenshowtheircustomergenuinegoodsassamples,butwhentheclothingisdeliveredmostorallarefoundtobefake,oftenmeaningthatthepoorcustomerisleftwithafinancialloss,ormusttaketheriskoftryingtosellthem.

Somegoodsaremadeinthesamefactoryasthegenuineones,usingidenticalfabricandspecificationstothegenuinearticles:insuchcasesnormallyonlythelabelsarefake,makingthedeterminationadifficultone.Thegoodsaresimplyunauthorised,butdonotactuallydamagethereputationoftheownerofthebrand,sincethegoodsareoftheirnormalstandard.

Inalmostallcases,thebrandownersaredesperatetoprotecttheirbrands,althoughsomecoulddomuchmoretohelpthemselves,suchasusingspecialsecuritymarkersintheirlabelsandusingserialnumbers.Theretailermustshowthathehastakenappropriateprecautionstopurchasefromagenuinesource:ifhehas,thenhehasanadequatedefence,butbuyinggoodsfromsomebody‘metinthepub’isnotcountedasbeingdulydiligent!

Inacompletelydifferentareaoffraudulentactivity,Iwascalleduponafewyearsagotoexamineproductionandotherrecordsofatextilecompanywhohadsufferedaseriousfire.Whenalargeinsuranceclaimwasmadeforlossofbusinessfromtheeffectsofthefire,theinsurerssuspectedthattheclaimwasratherhigh,andaskedmetoseeiftheclaimtalliedwiththelevelsofproduction

theyhadbeenachieving.WhenIwastoldthattheloomshadbeendeclaredacompletelossinthefire,IcommentedthatIwassurprised,becausetodestroyaloomitisusuallynecessarytobreaktheframe,inthesamewayastheLudditeshadalmost200yearsago.Itisusuallypossibletoreplacemostofthesmallpartsreasonablycheaply,sincetheytendtobesubjecttowearandthereforeareconsumables;theonlylargeparttoreplaceisthedrivemotor,buttheyarerelativelyinexpensive.

Whenworkingmywaythroughthehugeamountofpaperworkrelatingtoproductionfigures,Icameacrossafaxwhichread“Themachinery:theloomsare80%OK.Itneedscleaningandreplacingoftheplasticparts.Thejobiseasybuttimeconsuming.WearegoingtoclaimfromtheInsuranceforwriteoffandtrytomovethesemachinestoourfacilityat...ItalldependsonwhattheInsurancewillsaytomorrow.TheseloomscanberunningagainbytheendofFebruary.Themachineryatthepreparationdepartmentisalldamaged80%.Wedonotneedthesemachinesifwemovethelooms.”

Thatis,ofcourse,exactlywhattheydid,movingtheloomsacrossEurope,andrepairingthem.Ivisitedthefactoryandfoundalmostalltheloomsnotonlyrepaired,butrunninginproduction.

Despitethisdamningevidence,theclaimantspersisted,butatarbitrationtheynotonlyfailedintheirbidforbusinessloss,butademandwasmadeforthemtorepayalltheirpreviousinsurancepayouts.

Itwasunusualtofinddamningevidence,butnolesssatisfyingforthat!q

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Complexlossofearningsclaims–

wheretostart

THEESSENTIALTASKSinassessinglossofearningsaretodetermine: •Actualpostaccidentearnings; •Likelyfutureearnings;and •Thelevelofearningsthatitappearstheclaimantwould

haveenjoyedbutfortheaccident.Thisinvolvesunderstandingtheclaimant’ssourcesofpreandpost

accidentincome,howprofitablethesewereandwhatwasrequiredtoachievetheselevelsofprofitability.

Thisissimpleinprinciple,andforrelativelystraightforwardcasessuchasthoseinvolvingemployedpersonswithstablepastandfairlypredictablefuturecareerpathsandearningspatterns,itisalsosimpleinpractice.However,therearetheother,moreinteresting,casesonwhichthisarticlefocuses.

Factorsthatcanmakeassessinglossofearningsdifficultinclude: •Relativelyshortpre-accidenttrackrecords; •Incompletefinancialrecords; •Unusualfinancialarrangementsandaccountingpractices; •Businessesoperatinginrapidlychangingsectorsofthe

economy; •Theaffectsofothersignificanteventsunconnectedtothe

accidentShorttrackrecordsorvolatileeconomicsectorsrequireonetolookat

suchfactorsastheindustryingeneral,howotherfirmsfaredovertherelevantperiod,whatthebusinessplansandbudgetshadbeenandhowtheindividualscontrollingthebusinesshadperformed(ornot!)againstbudgetsinthepast.

Incompletefinancialrecordsmayrequireaccountsreconstructionworkinordertodeterminepastperformance(preandpostaccident).

Someindividualscombineself-employmentwithtradingthroughlimitedcompaniesandjointventureswiththirdparties.Theymayinvolveother‘partners’whomayormaynotcontributetohowtheincomeisearnedorhowprofitablethebusinessesactuallyare.Itisimportanttoseparatesuchthingsasprofitsharingarrangementsputinplaceforreasonsoftaxplanningfromtherealoperatingrevenuesandcostsofthebusiness,whichmayhavebeenaffectedbytheincapacityoftheclaimant.

Assessinglossindifficultcasestendstorequireacombinationofdetailedinvestigativeandanalyticalworkandtheabilitytostandbackand‘seethewoodforthetrees’.Athoroughunderstandingisrequiredofhowthebusinessworksandwhatthelimitingfactorsare,andthuswhatthenecessarycoststructurewouldbeforagivenlevelofactivity.

Myterm‘moreinteresting’isthatofaforensicaccountantwhoenjoysdistillingrelevantfinancialdataandtrendsfromtheoftenincompleteand

Lossofearningscanariseinapersonalinjurycaseand,likelossofprofitsinbusinessinterruption

claims,assessingthiscanrequiretheexpertiseofaforensicaccountant.

BILL WHITE, a Forensic Services director atBaker Tilly, explains some issues that arise

in the more complicated cases.

chaoticjumbleofdocumentationandassertionsthatsomeclaimants,anddefendants,produce.

TohelpwiththesimplerquantumissuesBakerTilly’sForensicServicesteamhasdevelopedaPC-basedtoolboxwithnumerouspagesoffacts,statistics,calculatorsandothertools,includingGrosstoNetEarningsandOgdenInteractiveformultipliercalculations.Registrationisfreeatwww.bakertilly.co.uk/forensictoolbox.q

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‘Let’sstartattheverybeginning,averygoodplacetostart’Ausefulguideforsolicitorsinstructedinfinancialservicesclaims

WHENSOMEONEputswordstoawellknownsonginyourheadyoucan’tstopsingingthembutwhenitcomestoafinancialservicesclaim,‘Let’sstartattheverybeginning’,istheonlyplacetostart.

ThismaysoundperfectlylogicalbutIreceivemanyclaimenquiriesthatonlydetailthelossscenarios,suchaswhenitallwentwrong.Yet,whenmakingaclaimagainstafinancialadvisor,bank,investmentbank,etc.,(or‘firms’,usingtheFSAterm),foranyfinancialservicesclaimitisessentialtoreviewallthehistory,andgorightbacktothebeginning.

Let’stakeatypicalscenario.Aclientcomestoyoustatingtheybelievetheywereilladvisedandhavelostasubstantialsumofmoney,say£100konaninvestmentof£300k.Thelossbecameevident6monthsagoandthefirmhasdeclinedtocompensatetheclientfollowingaformalwrittencomplaint.Theclienttellsyouthatithappenedforvariousreasonsbutmostimportantlybecausetheyhadbeenadvisedtoinvestinaparticularinvestmentfundasitwaslowriskandhadbeenatopperformingfundforthelast10years.Thenitcompletelybombedandnowyourclientis£100kdown.Beforethis,theinvestmentstheclientheldweresuccessfulandtheclienthadmadegoodprofitsonhisinvestments.

Theinstructingsolicitorasksthefinancialservicesexperttoprepareareportonthisparticularfundandwhytheclientshouldneverhavebeenadvisedtoinvestinit.Hesendstheexpertallthedocumentshisclienthas,

includingthevaluationatoutset,arecentvaluation,copyofthecomplaintletterandvariousproductdocuments.Whattheexpertwillalsoneedarenumerousotherpapersfromtheclient’sfile.Theseshould‘startattheverybeginning’oftherelationshipwiththefirmandmaypre-datetheinvestmentcomplaintbymanyyears.

Inparticular,theexpertwillneed:-Copiesofthe‘clientquestionnaires’thathavebeencompletedoverthe

years,preferablyfromthefirstmeeting.Therewillbeatleastoneandmaybemanymore.Theexpertwillbelookingtoseeiftheyarefullycompleted,datedandsignedbyyourclientandtheadvisor.

‘Letter(s)ofrecommendation’.Thesearelegallyrequiredwheneveradviceisgiven,nomatterhowbigorsmallaninvestment,andshouldbedatedbeforetheinvestmentadviceisgiven.Theselettersshouldstatewhathasbeenrequestedoftheadvisorandthebasisonwhichhe/shebelievestherecommendationissuitable.Thiscoverstheterm,riskcategoryandgeneralsuitabilityoftheinvestmentfortheclientforhis/herpersonalcircumstances.Itisimportanttorememberthatfinancialadviceshouldfittheclient,nottheclientfittheproduct.

Termsofbusiness,filenotes,includinganyinternalnotes,memos,researchundertakenbythefirm,secondopinionsfromlinemanagersorcompliance,comparativeand/oralternativeproductsandwhythesewerenotselectedandfinallywhatcommissionorenhancedtermstheyreceivedforthefirmortheclient.Basicallyeverythingthefirmhasontheclient’sfile.

Shouldyoudoubtthatsuchdisclosurewilloccur,FSArulesdictatethataclientisentitledtoseeeverythingontheirfileincludinginternalnotesandcomments.Thefirmisentitledtochargefortheirtimeanditmaytakeamonthorso,butanylongerandtheyriskpunishmentfromtheFSA.Afurtherpointtonoteisthatallfirmsmustkeeprecordsforaminimumof3yearsonanymatter.Mostadvicemustbekeptforatleast6yearsor,inmattersofpensiontransfers,fortheremainderoftheclient’slife.

Betweentheclient,thesolicitorandtheexpert,theclaimantisnowgettingclosertobeingabletoputtogetherajustifiedclaim.Thiswillstartwiththeclient’sfirstquestionnaireandtherecommendationstheadvisormade.Afinancialservicesexpertcanspendconsiderabletimereviewingthecompletenessandaccuracyofthesedocumentsandanyrecommendationsthatfollowed.Theinformationtheexpertgainsfromthisearlyperiodiscriticaltoformingaviewastowhethertheclaimforlosseshasvalidityorisanon-runner.Thisreviewwillberepeatedeachtimeadviceissoughtorgivenandconsideranychangesmadetotheobjective,riskandtimescaleofanyoftheinvestmentproposalsthefirm/advisorhasmadeand/oriftheclient’sfinancialneedshavechanged.

Oncethisprocesshasbeencompleted,agoodexpertwillreviewallotherrelevantinvestmentsthefirmhasadvisedonforyourclientandmakeappropriatecomment.Causationforyourclient’slossesmayhaveoccurredmanyyearsearlier,butduetopastpositivemarketconditionsdidnotcauselossorconcerntoyourclientatthattime.However,thesecouldjustaslikelyhavecausedlossesifmarketconditionshadbeendifferent.

Agoodfinancialservicesexpertwillthenassistyouwiththebasisfortheclaimandthecriteriathatwillhavethebestchancesofsuccess.Theywilloftenfindaspectsnotpreviouslyconsideredwhichgiveitmoreweight.

So,‘havingstartedattheverybeginning’wefounditwas‘theverybestplacetostart’asitgivesusthegroundsforcausation,andthereasonswhyyourclientwasmiss-soldorilladvised.Itcanthenbedeterminedhowbesttotaketheclaimforward,eitherviatheFinancialOmbudsmanService(FOS),whichdealswithclaimsupto£100k(butdoesnotallowclaimsforcosts)orthecourts.

Yourchoicemaybeinfluencedbythecosts.FOSmakenochargetotheclaimantsothisroutehasthebenefitoflimitingcoststothelegaladviceandtheexpertreport,whereasthecourtsystemundoubtedlymeansthecostsarelikelytoescalatebutshouldbeabletobereclaimedifsuccessful.q

by GrahameGoodyer IMC MAE MEWI

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VeterinaryForensicEntomologyby PETERBATES, Ph.D. MSB. C.Biol. FRES – Veterinary Entomologist

Forensicentomologyisusedbylawenforcementagenciesthroughouttheworldtoestimatethepointofdeath(post-mortemintervalorPMI)ofahumancorpsethroughtheanalysisofitsinvertebratefauna.Forensicentomologycanalsobeusedtoaidintheenforcmentanimalhealthregulations.

UndertheAnimalWelfareAct(2006)(updated2007)itisanoffencetocauseunnecessarysufferingtoanyanimal.Reasonablestepsmustbemadetoensurethattheanimal’sneedsarecontinuallymet,includingprotectionagainstpain,injury,sufferinganddisease(includingectoparasiteinfestations).ThewelfareoffarmedanimalsisadditionallyprotectedbytheWelfareofFarmAnimals(England)Regulations2007,whichallowsforCodesofRecommendationsforthewelfareofanimalstobeproduced.AlthoughtheseCodesarenotstatutoryrequirements,livestockfarmersarerequiredbylawtoensurethatallthoseattendingtotheirlivestockhaveaccesstotherelevantCodesforthespeciesfarmed.Althoughtheirmainaimistoencouragefarmerstoadopthighstandardsofhusbandry,Codesmayalsobeusedtoback-uplegislativerequirements.Whereapersonischargedwithawelfareoffence,failuretocomplywiththeprovisionsofawelfarecodemaybereliedonbytheprosecutiontoestablishguilt.AnyonefoundguiltyundertheActmaybebannedfromowninganimals,finedupto£20,000orsenttoprison.

Domesticlivestockcanbeattackedbyanumberofectoparasites(parasiticinsects,mitesortickslivingontheskinofthehost),allcapableofcausingconsiderabledistressandpossibledeathofthehost.ConsequentlyactionsrequiredtopreventortreatectoparasitesareincludedintherelevantCodeofRecommendations.FailuretofollowtheCodescanresultinconsiderableanimalsuffering,whichcanbeconsideredunnecessaryaseffectivechemicaltreatmentsareavailabletopreventorcureinfestations.However,chemicaltreatmentisnotfoolproof.Itisimportantthattheectoparasiteisidentifiedcorrectlyandthecorrecttreatmentapplied.Skillisrequiredinapplyingatreatmenteffectively,someproductsdonotclaim100%efficacyandinsomecasestheectoparasitehasdevelopedresistancetothetreatment.Consequently,itisofparamountimportancetodifferentiatecasesoftreatmentfailurefromthoseofdefiniteneglect.

Ectoparasitesaffectingsheepincludescabandblowflystrike,bothwidespreadthroughouttheUKandmakingupthebulkofveterinaryforensicentomologyinvestigations.SheepScab,causedbythemitePsoroptesovis,isaformofdebilitatingallergicdermatitisresultinginwoolloss,intenseirritation,epileptiformseizures,scabformationanddeath.InadditiontotheAnimalWelfareAct2006thediseasealsofallsundertheSheepScabOrder(1997),givingLocalAuthorities(LAs)themeanstoimprovethecontrolofscabandprosecutewhenownersofinfestedsheepdonottakeappropriatecontrolmeasuresvoluntarily.Ageingthedurationofscabinfestation(andthereforetheperiodofneglect)iscrucialtoasuccessfulprosecution.Unfortunatelythisisnoteasy.Earlylesionsarevirtuallyundetectable,this‘sub-clinical’phase(characterisedbylowmitenumbersandsmalllesions)canlastforamatterofdays,weeks,monthsorevenyearsbeforethelesionprogressesintotheactive(visible)clinicalphase,eventuallycoveringthewholeofthesheep.Thedurationofthesub-clinicalphasecanbeinfluencedbybreedofsheep,parasitevirulenceandpreviousexposuretoscab.Thustheanimalwiththelargestlesionisnotnecessarilytheanimalwiththeoldestlesion.

Blowflystrike(invasionoflivingsheeptissuebylarvae(maggots)

ofthegreenbottle,Luciliasericata),ifnottreatedcancauseconsiderablesufferingandmortalitywithinaflock.Amethodmustthereforebeavailablefortheauthoritiestoestimatethedurationofstrikeonanindividualanimalinorderforaprosecutiontobesuccessful.Onesuchmethodcomparesthespecies,life-stage(instar)andsizeofinfestinglarvaeagainststandardlarvalgrowthcurvesforvaryingtemperaturerangesforthemajorflyspeciesassociatedwithstrikeintheUK.Althoughtargetedtostrikeinlivesheep,themethodhasalsobeenusedtoagelarvaetakenfromstrikecasesaffectingcats,dogs,poultry,pigsandwildlife.

OnlyasmallproportionoftheL.sericatapopulationwillstrikesheep,thevastmajorityareinvolvedintheenvironmentallyusefultasksofdisposingofdeadbodiesandcarrion.Consequently,wheredeadsheepareconcerneditisimportanttoknowiftheanimaldiedfromtheeffectsofblowflystrikeorwasstruckafterdeath.

TheEUAnimalBy-ProductsRegulationsbroughtintoeffectinMay2003prohibitstheon-farmburialorburningoffallenstock(animalsthathavediedthroughnaturalcauses)duetotheriskofdiseasespreadthroughgroundwaterorairpollution.Animalsmustbetakento/collectedbyanapprovedagentforincineration.Prosecutionscanoccurwhencarcasesareleftinsituorillegallydumped.InthesecasesitispossibletodeterminethePMIofthesecarcassesandthereforehowlongthecarcasehasbeenabandoned.q

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Anaesthesia and negligence claims –

getanexpertonthecaseby DAVIDMLEVY MB ChB FRCA, Consultant Anaesthetist

40YEARSAGO,anaesthetistsinhospitalandisolatedsitematernityunitsweresummonedtoprovidegeneralanaesthesia(GA)forwomenundergoingCaesareansection(CS)andforcepsdelivery.

Theestablishmentoflabourepiduralservicesledtothedevelopmentofobstetricanaesthesiaasasubspeciality.Nowadays,residentobstetricanaesthetistsarepartofmultidisciplinaryteamsinhospitalobstetricunits.

Analgesia and anaesthesiaAnalgesiaispainrelief(inlabour,orafterbirth).Anaesthesiais

moreprofound-theabolitionofsufficientsensationtoallowoperativedelivery(byforcepsorCS).

Regional blockade‘Regional’anaesthesiameanstheselectivenumbingofapartofthe

body.Inobstetrics,painiseliminatedbyfreezingthesensorynervesastheyenterthelowerendofthespinalcord.Localanaestheticand/oropioid(morphineormorphine-likedrugs)canbeintroducedintoepidural,subarachnoidspaces(orboth).TheregionalanalgesiarateintheUKis22.5%.

Forplanned(elective)CS,thevastmajorityofUKanaesthetistsinjectdirectlyintothesubarachnoidspace.Thisisaspinalanaesthetic.

ClaimsArecentreviewidentified841anaestheticclaimsagainstthe

NationalHealthServiceLitigationAuthority(NHSLA)inthe12yearsbetween1995and2007.Regionalanaesthesiawasthesinglelargestcategory,comprising44%ofclaims(ofwhichhalfwereobstetric).

Threequartersofthe246obstetricanaesthesiaclaimsinvolvedregionalanaesthesia.‘Damagingevents’werenervedamage,inadequateanaesthesiawithresultingpain,andbackpain.Otherinjurieswere‘duraltap’(ofwhichmorelater),epiduralhaematoma(bleedinginthevertebralcolumn),drugerror,andhighblock/hypotension(lowbloodpressure).Burnsandpressuresoreswerecomplicationssecondarytothesensoryblockade.Claimsrelatedtoinfectionincludedepiduralabscessandmeningitis.

Complications of regional anaesthesia‘Duraltap’isaccidentalmeningealpuncturewithanepiduralneedle,

whichhasanincidenceofroughly1%.Womenwhosustainaduraltapcandevelopasevere,characteristicallyposturalheadache,causedbyleakageofCSF.Theheadacheisworseonsittingupandrelievedbylyingdown.

Ifalargedoseoflocalanaesthetic,intendedfortheepiduralspace,reachesthesubarachnoidspace,theblockcanbehighenoughtoimpairthenervesupplytothediaphragm(mainbreathingmuscle)andcausecessationofbreathing.Thisisknownasa‘totalspinal’.

Iflocalanaestheticisinjectedinadvertentlyintoanepiduralvein,symptomsandsignsoflocalanaesthetictoxicitycanarisefromtheeffectofhighconcentrationsoflocalanaestheticinthecentralnervoussystem(CNS).

Magneticresonanceimaging(MRI)hasshownthattheconusmedullaris(lowestbitofthespinalcord)commonlyextendsbelowthelevelofthebodyofthefirstlumbarvertebra.Amedicolegalcaseseriespublishedin2001describingdamagetotheconusmedullarisledtoanauthoritativerecommendationthatspinalneedlesshouldnotbeinsertedhigherthanthespinousprocessofthe3rdlumbarvertebra.

General AnaesthesiaInthe1960sand1970sGAwasusedformostelectiveand

emergencycases.TheUKObstetricAnaesthetists’Association’snationaldatabaserecordedarateofGAforCSof11%in2005.12%oftheobstetricanaesthesiaclaimshandledbytheNHSLAinvolvedgeneralanaesthesia.Awareness,airway/breathingproblemsandfailuretoprovidegeneralanaesthesiawerethe‘damagingevents’.

ObstetricGArequiresthatoncethepatientisanaesthetised,abreathingtubeisplacedintothetrachea(windpipe).Theincidenceoffailuretointubatethetracheaintheobstetricpopulationisreportedconsistentlyasaround1in250.Unrecognizedoesophagealintubation(placementofthetubeintothegullet)willresultinhypoxia(deprivationofoxygentomotherandbaby)andultimatelydeathifnotcorrectedpromptly.Suchaneventualityin2010wouldbeconstruedasnegligent.

Historically,useofdeliberatelylowconcentrationsofanaestheticagent(topreserveuterinetone)andavoidanceofopioids(topreventneonatalrespiratorydepression)wereresponsibleforahighincidenceofawareness.Inthe1960sitwasacceptedthat1in20womenwouldbeawakeatsomepointduringCS.Itisnowwellappreciatedthatpost-traumaticstressdisorderwillfollowwakefulnessunderanaesthesia,andthatawarenessisalmostalwaysnegligent.

Inanycaseofneonatalhypoxicischaemicencephalopathyafteroperativedelivery,theconductofanaesthesia(andwhetheritwastimelyordelayed)willinevitablybescrutinised.

Major haemorrhageIntheUK,awomandieseverytwomonthsfromhaemorrhagein

childbirth.Theobstetricanaesthetistisresponsibleforinfusingblood,coagulationfactorsandspecialiseddrugs,aswellasmonitoringthewoman’soverallcondition.

Pre-eclampsiaAnothercauseofmaternalmortalityworld-wideisthesyndromeoften

identifiedbyhighbloodpressureandproteinintheurine.Obstetricanaesthetistscontrolbloodpressurethatthreatenstocausebrainhaemorrhage,andtreatkidneyfailureandpulmonaryoedema(fluidonthelung).q

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Expertisewithvitalevidence

inmindPSYCHOLOGISTSSPECIFICALLYtrainedinlegalissues,aswellasthosewithnoformaltraining,areoftencalledbylegalpartiestotestifyasexpertwitnesses.

Incriminaltrials,anexpertwitnessmaybecalledtotestifyaboutavastrangeofissuessuchaseyewitnessmemory,mistakenidentityandfitnesstoplead(incourt)-tonamejustafew.

Psychologistswhofocusonclinicalissuesoftentestifyspecificallyaboutadefendant'scompetenceandintelligence.Moregeneraltestimonyaboutperceptualissuesmayalsocomeupintrial.

Theterm‘legalpsychology’hasonlyrecentlycomeintousage,primarilyasawaytodifferentiatetheexperimentalfocusoflegalpsychologyfromtheclinically-orientedforensicpsychology.

Together,legalpsychologyandforensicpsychologyformthefieldmoregenerallyrecognizedas‘psychologyandlaw’.Followingearliereffortsbypsychologiststoaddresslegalissues,psychologyandlawbecameafieldofstudyinthe1960saspartofanefforttoenhancejustice.

Psychologicalissuescanhaveagreatbearingontheoutcomeofatrial–takeeyewitnessmemory,forinstance.Thiscanbedividedintothreestages:

Stage1:AtthetimeoftheincidentWhenwitnessinganincident,initialinformationismemorised,however,

researchdemonstratesthattheaccuracyofsuchinformationcanbeinfluencedbyseveralfactors.

Takethedurationoftheincidentforexample.InanexperimentcarriedoutbyCliffordandRichards(1977),anindividualisinstructedtoapproachanumberofpoliceofficers.

Theyaretoldtotalktotheofficersforeither15or30seconds.Thirtysecondsaftertheconversationhasbeencompleted,theexperimenterasksthepoliceofficertorecalldetailsofthepersonthey’vejustbeenspeakingtousinga10-pointchecklistcontainingquestionsabouttheperson’sappearancesuchashaircolour,facialhairetc.Theresultsofthestudyrevealedthatinthelonger30secondcondition,policeweresignificantlymoreaccurateintheirrecall.

Stage2:TimebetweenwitnessinganincidentandrecallThisstageisconcernedwiththeperiodofretentionbetweenseeingan

incidentandthesubsequentrecollectionofthatincident.Researchhasconsistentlyfoundthatthelongerthetimebetween

witnessinganincidentandrecallingit,thelessaccuratetherecollectionofthatincidentbecomes.Therehavebeennumerousexperiments,usuallyrelatedtoastagedevent,thatsupportthiscontention.

MalpassandDevine(1981),forexample,comparedtheaccuracyof

witnessidentificationsafterthreedays(shortretentionperiod)andfivemonths(longretentionperiod).

Thestudyfoundnofalseidentificationsafterthreedays,butafterfivemonths,35%ofidentificationswerefalse.

Stage3:GivingevidenceThefinalstageintheeyewitnessmemoryprocessrelatestotheability

ofthewitnesstoaccessandretrieveinformationfrommemory.Inalegalcontext,theretrievalofinformationisusuallyelicitedthroughaprocessofquestioninganditisforthisreasonthatagreatdealofresearchhasinvestigatedtheimpactoftypesofquestioningoneyewitnessmemory.

Themostsubstantialbodyofresearchhasconcernedleadingquestions,whichhasconsistentlyshownthatevenverysubtlechangesinthewordingofaquestioncaninfluencesubsequenttestimony.

OneofthemostnotableresearchersinthisfieldisElizabethLoftuswhohasbeeninvestigatingeyewitnesstestimonyforover30years.Inoneof

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herstudies,participantswitnessedafilmofacaraccidentandwereaskedtoestimatethespeedofthecarsinvolved.

Onegroupofwitnesseswereaskedtoestimatethespeedofthecarswhenthey‘contacted’eachother,whilstasecondgroupofwitnesseswereaskedtoestimatethespeedofthecarswhenthey‘smashed’eachother.Onaveragethefirst‘contacted’groupgaveanestimateof31.8milesperhour.Whereas,theaveragespeedinthesecond‘smashed’groupwas40.8milesperhour.

Fitness to pleadPsychologistsareincreasinglybeingaskedtocommentonfitnessto

beinterviewedandfitnesstoplead.Theoutcomesandaccuracyoftheseassessmentsgreatlyimpactonthecriminaljusticeprocess.

InthelawofEnglandandWales,fitnesstopleadisthecapacityofadefendantincriminalproceedingstocomprehendthecourseofthoseproceedings.TheconceptoffitnesstopleadalsoappliesinScotslaw.ItsUnitedStatesequivalentiscompetencetostand.

Iftheissueoffitnesstopleadisraised,ajudgemayfindadefendantunfit.Thisisusuallydonebasedoninformationfollowingapsychiatricevaluation.

InEnglandandWalesthelegaltestoffitnesstopleadisbasedonR v Pritchard.Theaccusedwillbeunfittopleadifheisunableto:

•Comprehendthecourseofproceedingsonthetrial,soastomakea•properdefence;•Knowthathemightchallengeanyjurorstowhomhemayobject;•Comprehendtheevidence•Giveproperinstructionstohislegalrepresentatives.

Iftheissueisraisedbytheprosecution,theprosecutionmustprovebeyondreasonabledoubtthatthedefendantisunfittoplead.Iftheissueisraisedbythedefence,itneedonlybeprovedonthebalanceofprobabilities.

InScotlandthetestisbasedonHMA v Wilson,andhastwoelements:

•Tobeabletoinstructcounseland•Tounderstandandfollowproceedings.

Ifthejudgedeterminesthatthedefendantisunfittoplead,evidencewillbeheardandthejurywillbeaskedtodeterminewhetherthedefendantdidtheactormadetheomissionchargedagainsthim/herastheoffence.

Thisprocessavoidsthedetentionofinnocentpersonsinhospitalmerelybecausetheyarementallyunfit.Ithasbeenheldthatthereferencetothe‘actoromission’meansthatthejuryshouldnotnormallyconsiderwhetherthedefendanthadtherequisite‘mensrea’(theLatintermfor‘guiltymind’)whichisusuallyconsideredoneofthenecessaryelementsofacrime.q

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Handlewithcare......thedifficultissueofchildabuseandthelaw

CHILDABUSEISprobablythewidestknowntypeofabuseandinvolvesmanycomplexfactorsrelatingtolegalissues.Dealingwiththisdifficultsituationsensitively,whilstattemptingtoprovidelegalevidenceistheroleofthechildpsychologist.

Psychologistsmaycompletechildabuseinvestigationsforgovernmentorprivateagencies,foraparentmakingallegationsagainstanotheradultorparent,foraparentbeingaccusedofchildabuse,forthecourtaspartofacustodyorvisitingrightsriskassessment,oraspartofthetreatmentofachildoradult.

Working Together to Safeguard Children – A guide to inter-agency working to safeguard and promote the welfare of children 2006defineschildabusethus.Abuseandneglectareformsofmaltreatmentofachild.Somebodymayabuseorneglectachildbyinflictingharm,orbyfailingtoacttopreventharm.Childrenmaybeabusedinafamilyorinaninstitutionalorcommunitysetting,bythoseknowntothemor,morerarely,byastranger.Theymaybeabusedbyanadultoradults,oranotherchildorchildren.

Withchildabuse,theabusercanbeamemberofthesamefamily,arelative,friendorstranger.Theabuseusuallystartswiththegroomingprocessandthenescalatestoemotional,physical,orsexualabuse.Childabusehowevercanbeanyformofcrueltytowardsachild,whoisanypersonundertheageof18.Abusecantakeplaceinmanydifferentlocationsfromthehometoaresidentialcarehome,orwhilstthechildisinthecareofanypublicbodyorinstitution.

Onceanallegationofchildabusehasbeenmade,itmustbeinvestigatedtodeterminewhetherthereisabasisfortheallegation.Psychologistsarefrequentlyaskedtoevaluatechildrenandadultstoassesswhetherapatternofabuseisevident,toidentifypersonal,familyandoutsidestressorsthatarecontributingtotheabusepattern,orcreatingahighrisksituationforabusetooccur,andtodeveloprecommendationstoeliminatetheabusethatisidentified.

Recommendationsmayincluderemovingachildfromparentalorresidentialcare,removingaparentorotheradultfromthehousehold,implementingsupervisedvisitsordiscontinuationofvisits,changingparentalcustodyandtreatment/rehabilitationforthechildortheabuserorboth.

Childabuseinvestigationsusuallyinvolveclinicalinterviewswithallinvolvedparties,andcollectinginformationfromallappropriatesources.Psychologicaltestsmaybeemployedtoassessmentalfunctioning,identifypossiblepsychologicaldisordersorproblems,oridentifyabuseriskfactors.Frequently,thefindingsarepresentedincourt,andthecourtdetermineswhetherthereissufficientdatatodetermineifabusetookplace,andwhodidit.q

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Is Vasectomy safe?

IN1890,VASECTOMYwasfirstsuggestedasanalternativetocastrationformenwithenlargedprostates.Intheearly1890’s,itwasalsosuggestedasa‘treatment’forcertaincriminalsandundesirables,andforatime,enforcedsterilisationwaslegalforsome.Itwasn’tuntil1948thatvasectomycameintocommonuseasaformofpermanentcontraception.Atthistime,theoperationwasperformedthroughanincisiononeachsideofthescrotum,aloopofvasdeferenswouldbebroughtthroughtheincision,asegmentremovedandtheendstiedoff.In1974,no-scalpelvasectomy(NSV)waspioneeredbyDrLiShunquanginChina,carriedoutthroughasinglemid-lineincisionorpuncturewoundunderlocalanaestheticandisnowtherecommendedmethodofvasectomyinBritain.

Morethan65,000vasectomiesaredoneeachyearintheUK–inhospitals,clinicsand,increasingly,inGPsurgeries.Thereisarecognisedprogramme(viatheFacultyofSexualandReproductiveHealth)fortraininginNSVandthefacultyhasalistof24registeredtrainersthroughoutthecountry.Surgeonsareencouragedtoundertakeaminimumof50operationseachyear,toconductregularauditsoftheirworkandattendregularcoursestokeepup-to-date.

VasectomyisnowcommonlycarriedoutinGPsurgeriesandclinicsandhasaverylow,rarelysevere,complicationrate(perhaps<2%riskofinfection,excessiveswellingorbruising).Amoreseriouscomplicationofvasectomyisdevelopmentofachronicpainsyndrome(PVPS),whichcanoccurmanymonthsorevenyearsafteravasectomy.Thisisoneofthetwocommonestreasonsforlitigation,asitcanbedifficulttotreatandoccasionallybecomequitedisabling.Publishedpapersquoteanythingfrom5-30%.However,thereisalargevariationindefiningPVPSandwithinmyorganisation,BritishAssociationofNo-ScalpelVasectomists(BANSV,affiliatedwithASPC-AssociationofSurgeonsinPrimaryCare)webelievetheincidenceislower,perhapsbelow5%.

Theothercommonreasonforlitigationisfailureoftheoperation.Failureiswell-recognised,andarateof1:2000(after‘confirmation’ofsterility)isgenerallyquoted.Failuredoesnotimplysub-standardcare,although,ofcourse,sub-standardcarecanresultinfailurebutisextremelydifficultto‘prove’.Earlyfailure,recognisedwheninitialpost-vasectomysementestsstillshowlivesperm,isslightlygreaterthan1:2000

Litigationoftenarisesbecauseinformedconsenthasnotbeenobtained.‘Informed’meansthatthepatienthasbeenadvisedoftheactualprocedure,howitwillbedone,irreversibility(havingtheoperationreversedisnotalwayssuccessful)aswellasrecognisedriskandcomplicationsandfailure.Inaddition,alternativemethodsofcontraceptionshouldalsohavebeendiscussed,inparticular,long-actingreversiblecontraceptives(LARCs).Allthismeansthatthepatientshouldbemadeawareofalternativestovasectomy,aswellasriskof:excessiveswelling,bruising,infection,chronictesticularpainandeventesticularatrophy(wherethebloodsupplytoatesticleisinadvertentlycutoffduringtheoperation,resultinginthetesticle‘dying’onthatside,andeventuallyneedingtoberemoved;whenthishappens,itcanbeduetosub-standardcareduringtheoperation,butnotnecessarily).Theseissuesshouldbewrittenontheconsentformwhichthepatientsigns,oratleastinaninformationleafletthatthepatienthashadachancetostudybeforehand.

Onthedayofoperation,thepatientshouldbeencouragedtoaskquestions,andstepsshouldbetakentoensurethatthepatientunderstandsthenatureandimplicationsoftheoperation,andthatitistherightmethodofpermanentcontraceptionforhimandhispartner,aswellastherisksandfailurerateslistedabove.

Itgoeswithoutsayingthatalltheaboveshouldbeproperlydocumentedinthepatient’smedicalrecord,aswellasaproperrecordoftheoperationitself,includinganyproblemsordifficultiesencounteredeitherbeforetheoperation,duringorafter.Appropriateinformationshouldbeprovidedregardingpost-operativecare,inparticularwhatthepatientshoulddo,andwhomtocontact,ifanyconcernsarise.Lackofproperrecordsmakesitmoredifficultforasurgeontodefendhim/herselfwhenacomplaintarises.

Finally,itshouldbestressedthatsterilitycannotbeconfirmeduntilappropriatesementestshavebeencarriedoutandanadditionalmethodofcontraceptionshouldstillbeuseduntilsterilityisconfirmed.Traditionally,twoconsecutivecleartestswererequired.However,itisnowrecognisedthatonecompletelyclearsampleatleastfourmonthsafterthevasectomyissufficienttoconfirmsterility,asevidenceshowsthattheriskofpregnancyafteroneclearsampleisthesameasaftertwo.Also,‘specialclearance’cansometimesbegiveniftherearestillonlyasmallnumberofnon-motilespermpresentatleastsevenmonthsaftertheoperation.

Complaintsstillarisewhenthepartnerbecomespregnantsay12monthslater,buthehasnotdoneanysementestsandjust‘assumed’hewouldbeOK!Youcan’tblamethesurgeonforthat,assumingthatproperadviceandinformationhavebeengiven,includingreminderletterswhenspermtestsarenotreceivedbackattheexpectedtimes.q

by DRTONYFELTBOWER MB BChir DRCOG AFOM CUEWcert

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An embryological journeyIfonlyitweresosimple.Afterall,herniaearecommonininfantsand

youngboyswhohardlystrainatall(excepttofilltheirnappies)andweallstrainfromtimetotimebutmostofusneverdevelopahernia.InorderformetoexplainIneedtotakeyouonajourney.Comewithmetothestart,inamother’swomb.Oneofthelastbitsofmaledevelopmentinthefoetusistheappearanceoftestesinthescrotum.

Earlier,eachtestisdevelopswithitskidneyonthebackwallofthe

abdomen;butiteventuallybreaksfreeandmigratesdownandroundtothefrontandthenthroughatunnelinthemusclesofthegroin,oringuinal,region.Thistunnelleadstotheneckofthescrotumandthenondowntowheremosttestesendup.Anyproblemwiththisleadstoundescended testis,acommoncongenitalabnormalitywhicheitherrightsitselfinthefirstfewyearsoflifeorneedsasurgicaloperationtocorrectit.

A muscular tunnelIfthistunnel,calledtheinguinal canal,didnotexist,normaltesticular

descentcouldnotoccur.Sothisisanaturalcanal,whichweallhave–menandwomen–leadingfrominsidethetummytooutsideandisnot,infact,a‘weakness’atall(butseebelow).Althoughwomendonot‘need’suchacanalweallhavethesamebasicanatomysoitisthere,albeitmuchnarrowerthaninmen.

Itisanobliquetunnelthroughthethreelayersofmuscleoftheanteriorabdominalwallanditisthisobliqueness,withmuscleatthefrontprotectingthedeepopeningandmuscleatthebackprotectingthesuperficialopening,whichpreventsusallfromhavingherniaefrombirth.

What,really,isahernia?Hernia?That’sstraightforward–it’sjustaweaknessinthemusclesallowingtummycontenttocomethroughthetummywallasalumpwhichispushedoutbyaheavystrain.Sowhat'stheproblem?

by MARCUSORNSTEIN MB ChB FRCS The wandering testisSothesceneisset.Asthetestisfloatsthroughthecanalittakeswithita

tubeofperitoneumwhichclosesoffbehind.Butif,asiscommon,thetubedoesnotcloseproperlytummycontent,beitboweloromentum(thefattytissuewhichliesoverthebowelinallofus),caneasilyslipintoit.Thisiswhyherniaearecommoninmaleinfantsandboys.Butthistubeofperitoneummaystaypartiallyclosedandemptyforaverylongtime:until,oneday,thatproverbialstrainpushesaloopofboweloromentalfatintoit.Thiscanbemanyyearslater,eveninoldage.Anditcanalso,andoftendoes,occurwithoutanymemorablestrainingeventatall.

The dilemmaYouwillnowunderstandwhytherearesurgeonswhosayallherniaehave

acongenitalbasisevenifastrainis‘thelaststraw’whichbringsoneintobeing.Sotheirviewisthattherecanneverbeanyliabilityforaherniasincetheyoccurcommonlywithoutstrainingandeveniftherewasastraintheherniawasgoingtohappenanyway,soonerorlater.Butmoreonthislater.

Are there different types of herniae?WhatIhavedescribediscalledanindirect inguinal hernia.Butthereare

others–direct inguinal herniaand,indifferentpartsofthebody,femoral hernia,umbilical or paraumbilical hernia,epigastric herniaandrareronessuchasSpigelian hernia.Incaseyouwerewondering,ahiatus herniaisratherdifferent(anotherarticle,anotherday?).Theaetiologyofaherniaatthenavelisobvious,afterallthatiswheretheumbilicalcordcamethroughtheabdominalwall,andtheothers,includingdirectinguinalhernia,morecloselyfitthe‘weakmuscle’idea.

Direct inguinal herniadiffersfromtheindirectvarietyinthattheperitonealsachaspushedforwardsthroughweakmusclesintheinguinalregionratherthandownthecanal.Itismorecommoninoldermenand,ratherfewer,olderwomenbutthereisnoageatwhichitbecomestheexclusivetypeofgroinhernia;Ihaveseenlargeindirectherniaein80yearoldsandafewdirectherniaein20yearolds;youjustcan’ttell.

What difference does the type of hernia make? Butdoesitmatter?Certainlynotfromatherapeuticpointofview,these

days,becauseallherniaearerepairedinthesameway–usingthenon-tensionmeshtechnique.Itusedtomakeadifferencewhenherniaewererepairedbystitchingandthereweredifferenttechniquesfordifferenttypesofhernia.Themodernoperation,though,isverystraightforwardandcaneveneasilybeaccomplishedunderlocalaswellasgeneralanaesthetic.Inessence,theherniaispushedbackandapieceofmeshplacedovertheposteriorwalloftheinguinalregiontocovercompletelythewholearea.Themeshispermanentandbecomesincorporatedinscartissuewhichistoughsorecurrencesarefarlesscommonthantheyusedtobeinthedayswhenweusedstitcheswhichcould‘cutout’.Intheverybesthandsrecurrenceratesarearound0.1%althoughmostsurgeonsaccept1%or2%recurrencerates.

The repair and recoveryThisrepaircanbeaccomplishedthroughaninguinalincision,thesocalled

‘openapproach’,orfromwithintheabdominalcavityusinglaparoscopic,orkeyhole,surgeryandthereareprosandconsforeachapproach.AfteranytypeofherniarepairIwouldexpectmostpatientstobebackatalltheirnormaldailyactivitiesbyabouttwoweeks,orevenmorequicklyafteralaparoscopicrepair.Iamsorrytosaythatmanydoctorshavenotyetrealised

left inguinal canal

Hernia mesh

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thisfundamentalchangefromthedayswhenherniaeweresuturerepaired,eventhoughthisoperationhasbeencommonplaceformorethantenyears.Patientsmustbewarnedaboutbruisingandswellingbutacompetentnon-tensionmeshherniarepairshouldnotremainpainfulforlongunlessanervehasbecomeinadvertentlytrapped.

What are the legal implications?Ihavementionedthedilemmaoftheaetiologyofherniae.Butevenifthis

isso,anditapplieslessobviouslytodirect inguinal herniaandmanyothertypes,thefactisthatthepatientmayhavecontinuedformanyyearsbeforedevelopinghis/herherniaormaynothavedevelopeditatall,haditnotbeenforthatexceptionalstrainingepisodeshortlybeforeitdeveloped.

Aquestionwhichismoredifficulttoanswerishowsoonafterastrainmustaherniaappearfortheonetobeconsideredtohaveledtotheother?Afterall,mostherniaeoccurwithoutanyobviouspredisposingeffortsandbothstrainingandherniaeareverycommonsocoincidencesmustbeexpected.Myopinionisthatsomething–discomfort,painoranactuallump–shouldhavebeennoticedbytheclientwithin,say,48hours.InthecasesIseethisisusuallywhathappensandapatient,forsuchhe/shenowis,hasvisitedhis/hergeneralpractitionerandtheproblemisnotedinthemedicalrecords.Itmaynotyetbedefinitelydiagnosedasaherniabutatleastthereisanoteaboutagroinstrain.Sowhataboutthatalternativediagnosis?

Is a groin strain different?Amusculargroinstraincanbedifficulttodifferentiatefromasmallhernia.

Groinstrainsareusuallyrelatedtoprolongedactivity,particularlysportingactivity,ratherthanasuddenstrain,butnotalways.Theyareduetotearingofmuscleorligamentfibresandonlyrarelywilltherebeanassociatedhernia.Theycancauseagreatdealofmorbidity,overaperiodofmanymonths,buttheydousuallysettlewithoutsurgicalintervention.Foraselectfewthatdonotsettlethereisanoperation,sometimescalled‘Gilmore’sgroinrepair’,inwhichthemuscleandligamentatthetopofthethighisreinforcedwithstitchesorstaples.Butyouneedtoknowthatthereissomedisagreementinsurgicalcirclesaboutwhether‘Gilmore’sGroin’isorisnotarealdiagnosisandhowmuchtheoperationisnomorethanaplacebo.

Are herniae painful?Groinstrainsarealwayspainful.Butareherniae?Thelargemajorityof

herniae,atallsites,arenotpainful.Theyarejustswellingswhichusuallydisappearwithrecumbencyandreappearandenlargewithactivity.Maybe10%ofinguinalherniaearepainfuland,byandlarge,thistendstobethesmalleroneswhicharemorelikelytobenippedbystrongermusclesbeforetheyhavebeenstretchedaroundalargerdefect.Thereisnoreasontostopworkingorliftingjustbecauseyouhaveahernia–itusuallydoesnotincreasethepainanditdoesnotincreasetheriskofstrangulation.Eveniftheherniaenlargesthismakeslittledifferencetothemeshrepair.

Are there any risks?Yes.Ibelieveallherniaeshouldberepairedassoonasisconvenient

becausetheyall,largeandsmall,riskstrangulation.Astrangulated herniaisonewhereabowelloophasbecomesocompressedatitsneckthatbloodcannolongerflowthroughitsbloodvessels.Andanytissuewithoutabloodsupplywilldieunlesstheflowisrestoredsoon,sothisisasurgicalemergency.Thereisastagebeforestrangulationwhentheherniaismerelyobstructedbutthis,too,requiresanurgentsurgicalopinionbeforeitdevelopsintoafull-blownstrangulation.Thereseemstobenoobviousreasonwhyaherniashouldsuddenlystrangulate;itcanhappenduringsleeporwhilstworking.

Does it matter whether the hernia is reducible or not?

No.Smallerherniaearealmostalwaysreduciblebutprobablyatgreaterriskofstrangulationbecausetheirnecksaretighterandlargeherniaebecomeirreducibleeventhoughtheirneckshavebeenwidelystretched.Whetherornotthegroinswellingcanbepushedbackhasnobearingonwhetheritwillobstructorstrangulatenoworlater.

What is the liability and causation?Therearemanymythsabouthernia–straining,timeoffwork,painand

dangers.Herniaandstrainingarebothcommon.Bothusuallyhavenosevereconsequence.Ifyoubelieveincoincidenceallherniaejusthappen.ButIamconvincedstrainingcancauseaherniaandifthiswasduetounexpected,unusualand/orunplannedactivityatworktheemployermaybeliable.Iamalsoconvincedthattherecoveryfromthemodernmeshoperationisrapidandthereisnoreasonto‘takeiteasy’oravoidliftingandstraining,evenstraightaway(buttherepairwillbetootendertoallowanythingtoostrenuousforthefirstfewdays!).

Surgicalfolkloreisstubbornandslowtochange.Ifapatientisadvisedtostopworkingwhatelseisheexpectedtodo?Andifheisadvisedtotakesixweeksoffworkafterhisrepairthatisthesurgeon’sorgeneralpractitioner’smistake,notthepatient’s.

Finally,sincerecurrenceisnowsounusualcontinuingpost-operativepainhasbecomeaproblem.Thereshouldbenogreatpainafterthefirstfewdaysbutachronicneuralgiatypepaindoesoccurduetoinadvertentandlargelyunavoidablebruisingorcrushingofnervesduringtherepair.Iteventuallysettlesbutthiscantakemanymonths,evenayear,andisnecessarilyadifficulttimeforthepatient.Therearemanoeuvrestohelp,rangingfromanalgesictabletstofurthersurgerytoreleasescartissue.

ConclusionSonowyouknow.Oneofthecommonestsurgicalproblemsisnot

straightforward.AndIdidn’t,foramoment,imagineyouwouldhavethoughtotherwise!q

Inguinal incision Laparoscopic surgery

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usuallyrelatetonoisefromanindustrialsource-frequentlyfromexposureoccurringinthedaysbeforeearprotectionwasmandatory.Inordertoqualifyforcompensationtheclaimantmusthaveademonstrablehearinglossandalsoahistoryofnoiseexposure.

Currentlegislationdictatesthatexposuretoanyambientnoiseover85decibelsforeighthoursrequiresmandatoryuseofeardefenders.Duetothenatureofthedecibelscale,athreedecibelincreaseinsoundintensitywillhalvetheamountoftimethatnoiseexposureisallowed;forexample,88decibelswouldonlyallow4hoursofexposure,91decibelsis2hours,andsoon.

Whenassessingtheseclaimants,itisessentialtoensurethatthereissomehearingloss,andalsotonotetheiremploymentrecordorhistoryofnoiseexposure.TheemploymentrecordcanusuallybegarneredfromtheNationalInsuranceContributionsSchedule.Mostnoise-inducedhearinglossshouldbebilateral,exceptinthosewhohavehadnoiseexposurefromfirearmsuse,whenthisisnormallyunilateral.Apasthistoryshouldbelogged,includinganyhearinglossriskfactors,suchaspasteardiseaseorothersystemicillnessessuchasmeningitisorrenalfailure.

Whenexaminingtheclaimants,theyusuallyhavenormal-lookingearswithnoothersignsofeardisease.Themainstayofinvestigation

Establishingasoundcasefor

noiseinducedhearingloss

by HughWheatley

NOISE-INDUCEDHEARINGlossisarelativelycommoncomplaintintheelderlypopulationandiscausedbyexcessiveexposuretonoise.

Thenoisecanbefromanysource,buthearingdamageclaims

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DAMAGETOHEARINGfromexposuretonoiseremainsacommonprobleminthe21stcentury,despitetheregulationofoccupationalnoiseexposureinmostdevelopedcountries.

IntheUK,approximately170,000peoplesufferdeafness,tinnitusorotherearconditionsasaresultofexposuretoexcessivenoiseatwork.Theresultinghearinglosscannotbecured,butispreventable.

Exposuretoexcessivenoiselevelsleadstoatemporaryhearingimpairmentwhichcangoontobecomepermanentifnoiseexposurecontinues.Thedamagedependsbothonthelevelofnoiseanditsduration.Itisthoughtthatequal‘doses’ofnoisewillcausethesamedegreeofdamage.Thereforeexposuretohighintensitynoiseforashortperiodmaycausethesamedamageasprolongednoiseatalowerlevelifthe‘doses’areequivalent.

Damagefromexcessivenoiseexposuretypicallyaffectstheabilitytohearsomeofthehigherfrequenciesfirst,e.g.at4Kz,butasexposure

GrahamJ.CoxMB BS BDS FRCS (Eng) FRCS (ORL),consultant surgeon,expert witness

ACONSULTANTENTsurgeonattheJohnRadcliffeHospitalinOxfordandaMacmillanHeadandNeckSurgicalOncologistforfifteenyears,GrahamJ.CoxMBBSBDSFRCS(Eng)FRCS(ORL)hasservedasanexpertwitnessinmanyindustrialnoiseinducedhearinglosscases,aswellasinbothprivateandNHSTrustmedicalnegligencecases.

MrCoxhascontributedtonationalguidanceinheadandnecksurgicaloncology,hasadvisedtheNationalCancerActionTeamandNICEinthisareaandhasmadenumerouspresentationsatinternationalspecialistmeetingsandworkshops.

HehasaparticularinterestinqualitymanagementinmedicineandisaSpecialistAssociateoftheGeneralMedicalCouncil.HehasledDeaneryQualityAssurancevisitsandhasservedasViceChairoftheSpecialistAdvisoryCommitteeinENTforthesurgicalRoyalColleges.Assuch,hehasbeeninvolvedincurriculumdevelopmentinENTsurgery,andinsettingstandardsinpostgraduatemedicaleducation.q

Profiling...

Establishingasoundcasefor

noiseinducedhearingloss

A21stcenturydisability by GERARDREILLY

andassessmentiswithpuretoneaudiometry.ThisshouldbecarriedoutinasoundproofboothbyatrainedaudiologistaccordingtotheBritishSocietyofAudiologyStandards.

Whenlookingattheaudiogram,thereisacharacteristicdipat4kHzsuggestiveofnoise-inducedhearingloss.Theaudiogramcanthenbeanalysedandtherearetwoformulaethatcanbeappliedtoit.ThefirstoftheseistheDSSformula,whichwillgiveahearinglossindecibeltermsofnoise-inducedhearinglossoverandabovethatwhichisexpectedduetoage.Thishasabiastowardsthebetterhearingear.TheotherformulaisthatasdescribedinthepapersbyKing,ColesandLuttman,whichgivesapercentagehearinglossoverandabovethatwhichwouldbeexpectedforage-associatedhearingloss.

continues,theabilitytohearotherfrequenciesisalsoaffected.Thehearinglossmaynotbenoticedintheearlystagesbutasthehearingworsens,individualsusuallycomplainthattheyhavedifficultyunderstandingspeech,especiallyinthepresenceofbackgroundnoise.Thehearingimpairmentisoftenassociatedwiththedevelopmentoftinnitus,whichitselfcanbeasdisablingasthehearingloss.

Theageingprocessalsoaffectshearinganditisimportanttotakethisintoaccountwhenassessingthecausesofhearingloss.

TheControlofNoiseatWorkRegulations(2005)whichcameintoforceon6thApril2006,andwhichsupersedepreviousregulations,governthelimitsofnoiseexposureonadailyorweeklybasisandalsoadviseabouttheprovisionofhearingprotectionintheworkplace.(seehttp://www.opsi.gov.uk/si/si2005/20051643.htm).Iftherecommendationsoftheseregulationsareadheredto,damagetohearingfromexposuretoexcessivenoiseshouldbecomeathingofthepast.q

Thefinalreportshouldcovertheclaimant’shistory,historyofthehearingloss,andhowthedisabilityaffectstheclaimant.Itshouldalsocoverthehistoryofnoiseexposure,whichisnormallyemployment-based.Theaudiogramshouldbeappended,togetherwiththecalculationsofhearingloss.

Therearemanycausesofhearinglossandmostclaimantswhopresentwithaclaimfornoise-inducedhearinglosswillbetheelderly,andwillthereforenaturallyhavesomehearinglossduetoage(presbyacusis).Thisshouldbedetailedinthereportandthehearinglossshouldbequantifiedaccordingtotheformulaoutlinedbrieflyabove.Thisreportshouldalsodealwithanypastmedicaloraudiologicalhistorythatcouldcontributetoahearingloss.q

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Puttinglegalissuesunderthemicroscope

–forensicmedicineFORENSICMEDICINEisthebranchofmedicineconcernedwiththeresolutionofcriminalorcivillegalissuesbytheapplicationofscientificmedicalknowledge.

ThespecialtyofforensicmedicineisoftenreferredtoaslegalmedicineinEuropeandinSpanish-speakingcountries.

Onebranchofforensicmedicineisforensictoxicology,whichdealswiththeinvestigationoftoxicsubstances,environmentalchemicalsorpoisonousproducts.Forensictoxicologyisactuallyamixofmanyotherscientificdisciplinessuchaschemistry,pathologyandbiochemistry.Italsosharestieswithsomeoftheenvironmentalsciences.

Forensictoxicologistsperformscientifictestsonbodilyfluidsandtissuesamplestoidentifyanydrugsorchemicalspresentinthebody.

Aspartofateaminvestigatingacrime,aforensictoxicologistwillisolateandidentifyanysubstancesinthebodythatmayhavecontributedtothecrime,suchas:alcohol;illegalorprescriptiondrugs;otherchemicals;poisons;metalsandgases,suchascarbonmonoxide

Workinginalab,theforensictoxicologistperformstestsonsamplescollectedbycrimesceneinvestigators.Theyusehighlysophisticatedinstruments,chemicalreagentsandprecisemethodologiestodeterminethepresenceorabsenceofspecificsubstancesinthesample.

Thefieldofforensictoxicologyhasgrowntoincludedrugtestingforemployers,testingofanimalsamplesforwildlifecriminalinvestigators,testingfor‘daterape’drugsandperformance-enhancingsubstances.

Inthecaseofdrugmisuseintheworkplace,drugmisusecanharm

themisuserbothphysicallyandmentallyand,throughthemisuser’sactions,otherpeopleandtheenvironment.

Drugmisusecanbeaseriousproblemnotonlyforthemisuserbutalsoforthebusinesswheretheyworkand,sometimes,fortheirco-workers.Thepossessionofsomedrugsisillegal,exposingthemisusertotheriskofcriminalchargesaswellascausingharmfuleffectstotheirhealth.Anemployerwouldbebreakingthelawiftheyknowinglyalloweddrug-relatedactivitiesintheirworkplaceandfailedtoact.

EmployershaveageneraldutyundertheHealthandSafetyatWorkAct1974toensure,asfarasisreasonablypracticable,thehealth,safetyandwelfareatworkoftheiremployees.TheyalsohaveadutyundertheManagementofHealthandSafetyatWorkRegulations1999,toassesstheriskstothehealthandsafetyoftheiremployees.Ifanemployerknowinglyallowsanemployeeundertheinfluenceofdrugmisusetocontinueworkingandhisorherbehaviourplacestheemployeeorothersatrisk,thentheemployerisbreakingthelaw.Employeesalsohavealegaldutytotakereasonablecareofthemselvesandotherswhocouldbeaffectedbywhattheydoatwork.

Drugscanaffectthebrainandthebodyinanumberofways.Theycanalterthewayapersonthinks,perceivesandfeels,andthiscanleadtoeitherimpairedjudgementorconcentration.Drugmisusecanalsobringabouttheneglectofgeneralhealthandwell-being.Thismayadverselyinfluenceperformanceatwork,evenwhenthemisusetakesplaceoutsidetheworkplace.

Forensictoxicologistsalsoworkoncasesinvolvingenvironmentalcontamination,todeterminetheimpactofchemicalspillsonnearbypopulations.Investigatorsrelyontheforensictoxicologisttomakereliableconclusionsabouttheimpactaspecificamountofaspecificsubstancewouldhaveonaparticularindividual.q

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Specialist in forensic podiatry and biomechanicsA PODIATRIST AND specialist in gait/walking, pathomechanics, biomechanics and general anatomy, David G. Blake B.Sc.,M.Ch.S.,S.R.Ch. is the principal podiatrist at the Nuffield Hospital Wolverhampton, in addition to providing medico-legal reports.

He routinely uses slow motion and freeze frame digital video camera equipment to analyse gait clinically to assess and diagnose anatomical and skeletal conditions. Forensic podiatry and CCTV footage analysis are key areas of his practice.

Mr Blake is a preferred provider of podiatry services to West Midlands Police (Occupational Health). He has also provided a number of forensic podiatry reports and acted as an expert witness for Greater Manchester Police specifically in murder inquiries. He has presented his findings in Inner Crown Court, London on behalf of the defence. His last two cases have resulted in successful prosecutions on behalf of Greater Manchester Police/CPS.

Legal precedent of CCTV/gait analysis started at The Old Bailey in 2000 and personal acceptance of Mr Blake’s specialism as being deemed scientific was given in English Crown Court in 2009.

Mr Blake has been practicing for 16 years, 10 of which have been spent at the Nuffield Hospital Wolverhampton.q

Takeastepintherightdirection-callanexpertAPODIATRISTISqualifiedbytheireducationandtrainingtodiagnoseandtreatconditionsaffectingthefoot,ankleandrelatedstructuresoftheleg.

IntheUK,individualsmaynotusethetitle'chiropodist’or‘podiatrist’unlesstheyareregistrantsoftheHealthProfessionsCouncil(HPC).Theyareprotectedtitlesandtheirusebynon-registrantsisunlawful.Thisprotectionextendstotitlesincludingtheadjectivalformse.g.‘podiatricsurgeon’or‘chiropodypractitioner’.SuchregistrationisnormallyonlygrantedtothoseholdingaspecialisedBachelorsdegreeorDiplomainpodiatryfromoneofthe13recognisedschoolsofpodiatryintheUK.

ThescopeofpracticeofUKpodiatristsonregistrationaftertheirdegreeinpodiatricmedicineincludesbiomechanics,podopaediatrics,surgery,orthotics,highriskpatientmanagementandsportsinjuries.

Becausepodiatriststreatsuchavastarrayoffootandlowerlimbproblems,thescopeformedicalerrorishigh.Takediabeticfootcare,forexample.Commonreasonsformedicalnegligencelitigationinthisareaincludefailureto:assessthepatientadequately;explainreasonsforinterventions;obtaininformedconsent;takeactionwhenpatientsdidnotattendappointments;educatepatients;requestnecessaryinvestigations;maketimely/appropriatereferralsandprovideadequatetreatments.q

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Gynaecologyprocedurestoplistofmedicalnegligenceclaims

AHIGHPROPORTIONofallmedicalnegligencecompensationclaimsintheUKinvolveerrorsinobstetricsandgynaecologyprocedures.

Gynaecologicalerrorsrangefromdelaysinconfirmingpregnancyandmis-diagnosinggenitalcancertoaplethoraofinjuriesthroughmismanagementofsurgicalinstrumentsandunnecessaryoperations.Asthisfieldofmedicineissocomplex

andinvolvesmanydifferentdisciplines,proceduresandsurgery,thepossibilityofmedicalnegligenceishigh.

Mistakesmadeduringante-natalcareandbirthcanalsoleadtoseriousproblems–andinsomecases,eventhedeathofaninfant.Therecanalsobefailuretodetectseriousabnormalitiesoftheunbornbabydespitescanning.

TheRoyalCollegeofObstetriciansandGynaecologistsestimatethatover85%ofwomenwhohaveavaginalbirthwillsuffersomedegreeofperinealtraumaandofthese60-70%willneedsuturing.Perinealtraumaaffectswomen'sphysical,psychologicalandsocialwell-beingandcandisruptbreast-feeding,familylifeandsexualrelations.Itisvitalforwomen'sfuturewell-beingthatinjuriestotheperineumarecorrectlyidentifiedasquicklyaspossible.

Otherinjuriescanarisefromdifferenttypesofgynaecologicaltreatment,includingcontraceptiveprocedures,terminationofpregnancyandsurgery.

Side-effectsrelatingtoinjectedhormonecontraceptivesmayalsooccur–andwherecontraceptivedevicesarefittedorterminationoccurs,theremaybeperforationofinternalorgans.

Insomecasesfailuretodiagnosecertainconditions,suchascervicalcancer,canhavetragicconsequences.

Acompensationclaimcanalsoarisein‘wrongfulbirth’cases,whereababyisconceiveddespitesterilisationorothercontraceptiveprocedures.Side-effectsrelatingtoinjectedhormonecontraceptivesmayalsooccur–andwherecontraceptivedevicesarefittedorterminationoccurs,theremaybeperforationofinternalorgans.

Themostcommontypesofgynaecologicalclaimsarisefromcomplicationsassociatedwithsurgery.

Commongynaecologyerrorsinclude: • Unnecessaryhysterectomies • TVT(TensionFreeVaginalTape)damagetoobturator

nerve • Delayeddiagnosisofcervicalcancerandsmeartest

errors • Keyholesurgery(laparoscopy)errors • Nervedamage • Retainedswabsandretainedinstruments • Damagetoorgans(suchasthebladder,boweland

uterus)particularlyduringCaesariansection • Failingtonoticedamagetoorgans(suchasthe

bladder,bowelanduterus) • Episiotomyinthewrongplaceandinadequaterepairs

toepisiotomyandtears • Failuretodiagnosethirddegreetearsafterchildbirth • Mistakesleadingtohysterectomy • Injurytobladder,boweloruterusduringhysterectomyq

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Medicolegal Issues in

LaparoscopicSurgery

OVERTHEPASTtwodecades,therehavebeenrapiddevelopmentsinmedicaltechnology,whichhavefacilitatedtheabilitytoperformsurgicaloperationsusingminimallyinvasiveorlaparoscopic(‘keyhole’)surgery.Modernlaparoscopicequipmentincludinghighdefinitionsystems,providethesurgeonwithanexcellentviewoftherelevantanatomy.‘Keyhole’surgeryhasmanyadvantagesforpatientsintermsofarapidrecoveryfromsurgery,lesspost-operativepainandbettercosmeticresults.Nevertheless,laparoscopicsurgeryisassociatedwithspecificrisksandcomplicationswhichareonlyseeninminimallyinvasivesurgery.Thesemaybeinadditiontoknowncomplicationsassociatedwithtraditionalopensurgery.Severalfactorsinfluencetheoutcomeofclinicalnegligenceclaimsinrelationtolaparoscopicsurgery.

Complications during Access to the AbdomenThefirststagecommontoalmostalllaparoscopicabdominal

proceduresinvolvesgainingaccesstotheabdominal(peritoneal)cavityandinsufflatingtheabdomenwithcarbondioxide(pneumoperitoneum).ThiscanbeachievedbyuseofeithertheVeressneedleorbyopencutdowntoinsertthefirstportintotheabdomen.Althoughmanygeneralsurgeonsnowprefertheopentechnique,bothareacceptableifperformedsafelyandinthecaseofmorbidlyobesepatientsundergoinglaparoscopicweightlosssurgery,theuseoftheVeressneedleisthepreferredtechnique.Anumberofcomplicationsmayariseduringaccesstotheabdomensothefirstlaparoscopicportmustbeinsertedinacarefulcontrolledmanner.Indiagnosticlaparoscopy75%ofcasesofallegedclinicalnegligencerelatetobowelorvascularinjuries.Damagetothesmallbowelmayoccurduringplacementofthefirstportbutifthisisrecognizedandtreatedcorrectly,aclaimfornegligenceisunlikelytosucceed.Incontrast,injurytomajorbloodvesselssuchastheaorta,inferiorvenacavaandiliacvesselsusuallyindicatesafailureofthesurgeontouseadequatecarewheninsertingtheportasthesestructuresaresituatedonthebackoftheabdomen(retroperitoneal).Inthissituation,majorlifethreateningbleedingmayoccurandclaimscannotusuallybedefended.

Oncethefirstlaparoscopicporthasbeeninserted,thesurgeonmustensurethattheyhaveanadequateviewbeforeinsertingfurtherportsunderdirectvision.Forthisreason,ifabowelormajorvascularinjuryoccursduringinsertionofthesecondorsubsequentports,anyclaimfornegligenceislikelytosucceed.

The Nature of the Injury

Theverynatureofaninjurysustainedduringalaparoscopicprocedurehasamajorinfluenceonwhetheraclaimissuccessfulornot.OneofthecommonestgeneralsurgicalproceduresundertakenintheUKislaparoscopiccholecystectomyforthetreatmentofgallstones.Oftennowperformedasadaycase,thishasbecomethestandardtechnique,almostcompletelyreplacingthetraditionalopenoperation.Themostseriouscomplicationoflaparoscopiccholecystectomyisinjurytothebileductwhichaccountsforalmosthalfofclinicalnegligenceclaimsinrelationtothisprocedure.Injuriesvaryintheirseveritybutmayhaveseriousandlife-longconsequencesforthe

patient.Majorsurgeryisusuallyrequiredtorepairtheinjuryanddespiteasuccessfulrepair,thepatientwillbeatriskofcomplicationsinthefuture.Theincidenceofbileductinjurieshasfallenoverthepasttwodecades,largelyasaresultofbettertraining,butstilloccursinapproximately0.3%ofcases.

Acrucialpartofalaparoscopiccholecystectomyistoclearlydefinethebiliaryanatomybeforedividinganystructures.Iftheanatomyisnotclear,orsignificantbleedingoccurswhichobscurestheoperativefield,thesurgeonmustconverttoanopenoperationwhichisnecessaryinupto5%ofcases.Criticismmayarisewhereasurgeonfailstoconverttoanopenoperationasaresultofwhichdamagetomajorstructuresoccurs.Bileductinjuriesmaynotberecognisedbeforethepatientisdischargedhomebutwhereaninjuryisrecognisedimmediately,thesurgeonmustseekadvicefromaspecialisthepatobiliarysurgeonascorrectsurgicalrepairhasasignificanteffectonlong-termoutcomeforthepatient.Abileductinjuryimpliesthattheanatomyhasnotbeenadequatelydisplayedduringtheoperation.Thisrepresentsabreachofdutyofcareandanyclaimfornegligence,isverydifficulttodefend.

Delay in the Management of a Recognised Complication

Inothercases,itisnotthenatureofthecomplication,buthowthatcomplicationismanaged,whichinfluencestheoutcomeofaclaim.Post-operativebleedingisarecognisedcomplicationofanylaparoscopicoperation.Bleedingmayoccurfromtheoperativesitesuchasthecysticarteryinlaparoscopiccholecystectomyortheappendiculararteryinlaparoscopicappendicectomy.Alternatively,significantbleedingmayoccurfromtheportsitesontheabdominalwall.Ifbleedingisrecognizedearly,thepatientreturnedtothetheatreandbleedingcontrolled,aclaimfornegligenceisunlikelytosucceed.If,however,thereisafailuretorecognisebleedingandtotreatitappropriately,thismaybelifethreateningandresultinasuccessfulclaimfornegligence.

Inlaparoscopiccholecystectomy,thesecondcommonestreasonforamedicolegalclaimisabileleak.Thisisarecognisedcomplicationanddoesnotnecessarilyimplythatthesurgeonhasperformedasubstandardoperation.Indeed,ifabileleakisrecognisedandtreatedcorrectly,thepatientshouldmakeafullrecoveryandaclaimfornegligencemaynotbesuccessful.Amajorissuecitedinmanycaseshowever,isthatadelayoccursintheinvestigationanddiagnosisofapossiblebileleakwhichresultsinmismanagementofthiscomplication.Thismayresultinanincreaseinmorbidityandevenprovefatal.Failuretorecogniseandtreatanyrecognisedcomplicationoflaparoscopicsurgeryappropriatelymayrepresentabreachofdutyofcareandaclinicalnegligenceclaimunderthesecircumstancesislikelytosucceed.

Experience & Subspecialty of the Operating Surgeon

Allsurgery,whetheropenorlaparoscopic,mustbeperformedbyappropriatelytrainedsurgeons.Surgeonsintrainingmustbe

by JAMESDEVANS LLM MB BS MD FRCS(Eng) FRCS(Gen-Surg)

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adequatelysupervisedinamannerappropriatetotheiroperativecompetencyandexperience.Therehavebeenseveralclinicalnegligencecasesinwhichlaparoscopicprocedureshavebeenperformedbyajuniordoctoroperatingindependentlyandunsupervisedbyaconsultant.Alltraineesurgeonsmustbeappropriatelysuperviseduntiltheyhavesufficientoperativeexperienceinagivenprocedureandhavebeenassessedanddeemedcompetenttoundertakethatprocedureindependently.

Increasingsub-specialisationwithingeneralsurgery,meansthatconsultantsurgeonsmustalsobeabletodemonstratewhererequiredthattheyaudittheirownresultsandthattheyundertakelaparoscopicprocedureswithsufficientfrequency.Inthecaseoflaparoscopiccholecystectomy,itisrecommendedthatsurgeonsshouldundertakeaminimumof40proceduresperyear(NHSInstituteforInnovationandImprovement2006)whichmeansthatthisoperationwillincreasinglyonlybeundertakenbyspecialistuppergastrointestinalorhepatobiliarysurgeons.

The Impact of Clinical Guidelines Thereareavastnumberofclinicalguidelinesinmedicine,some

ofwhichhavepotentiallyveryimportantmedico-legalimplications.Acutepancreatitisisaverycommonacutesurgicalemergencywhichismostcommonlyduetogallstones.GuidelinesissuedbytheUKWorkingPartyonAcutePancreatitisin2005,establishedthatpatientsdiagnosedwithacutegallstonepancreatitisshouldhavedefinitivetreatmentoftheirgallstoneswithintwoweeksofdischargefromhospitalorpreferablyduringthesamehospitaladmission.Therehavenowbeenanumberofsuccessfulmedico-legalclaimsinrelationtopatientsdischargedafteranepisodeofacutepancreatitis,whohavesubsequentlydiedfromseveregallstonepancreatitiswhilstonthewaitinglistforacholecystectomy.ManyhospitalsintheUKhowever,struggletomeettheseguidelinesoftenduetoalackofresourcesandanintervalofseveralweeksorevenmonthsmaypassbeforealaparoscopiccholecystectomyisperformed,duringwhichtimethepatientisatriskofanotherattackofpancreatitiswhichcouldbefatal.

Negligence Due to Failure of Informed Consent Anypatientundergoinglaparoscopicsurgerymustbeconsented

forthepossibilityofconversiontoopensurgery.Themostcommoncomplicationofalllaparoscopicproceduresisdamagetothebowel,citedinapproximatelyonethirdofclaimsreportedtotheNHSLA.Althoughtheriskisonly1in1000,ifabowelinjuryoccurstheconsequencesarepotentiallyveryseriouswiththeneedformajorsurgerytorectifytheproblemandpotentiallongtermsequelae.Furthermore,inpatientswhohaveahistoryofpreviousabdominalsurgery,theriskofbowelinjuryissignificantlyhigherandthismustbeemphasizedtothepatientduringconsent.Similarly,inlaparoscopicherniarepair,surgeonsmusthaveanadequatediscussionduringtheconsentprocessexplainingtheadvantagesanddisadvantagesofbothlaparoscopicandopenherniarepair.Thelaparoscopicoperationisassociatedwithasmallbutdefiniteriskofveryseriouscomplicationssuchasmajorvascularorbowelinjurywhichinsomecaseshasresultedindeath.

ConclusionsTheincreasingutilizationof‘keyhole’surgeryhasbeenparalleled

byasteadyriseintheproportionofclinicalnegligenceclaimsinrelationtolaparoscopicsurgery.Thevastmajorityofclaimsaresettledoutofcourtandexpertwitnesseshaveavitalroleinthisprocess.q

• Mr Jim Evans is a Consultant General and Upper Gastrointestinal Surgeon at the Countess of Chester Hospital NHS Foundation Trust and Honorary Consultant Upper GI Surgeon at the North East Wales Trust. His medico-legal practice is based at Nuffield Health, The Grosvenor Hospital, Chester.

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Pitfallsinthediagnosisof

headandneckcancersby MRGRAHAMCOXMB BS BDS FRCS(Eng) FRCS(ORL) Consultant ENT surgeon and Macmillan Head and Neck Surgical Oncologist, Oxford.

HEADANDNECKcanceristhesixthcommonestcancerintheUKwithabouteightthousandnewcaseseachyear.Justasthetreatmentofthesedifficultcancersiscomplex,theassessmentofpotentialmedicalnegligenceinthisfieldrequiresanin-depthunderstandingofthebehavior,treatmentandeffectsofthischallengingdisease.

GrahamCoxisConsultantENTsurgeonattheJohnRadcliffeHospitalinOxfordandaMacmillanHeadandNeckSurgicalOncologist.Hehascontributedtonationalguidanceinheadandnecksurgicaloncology,andadvisedtheNationalCancerActionTeamandNICEinthisarea,makingnumerouspresentationsatinternationalspecialistmeetingsandworkshops.

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Theincidenceofheadandneckcancersisincreasingrapidly,probablyduetolifestylechangeincreasingexposuretoknownriskfactorssuchasalcohol,andalsotoviralcausessuchasexposuretothehumanpapillomavirus.

ThediseasehashadincreasedpublicexposurewithanumberofcelebritiessuchasMichaelDouglas,JohnDiamond,AlexHigginsandAnthonyMenghella,developingthedisease.Likemanycancers,thesurvivalrateisoftenincreasedifthediagnosisismadeearly,andifthediseaseisidentifiedatanearlystage.Thetreatmentnecessaryisoftenlessradicalwithfewerlongtermsideeffectscomparedtothatrequiredforlatestagedisease.

Michael Douglas, one of a host of celebrities to suffer from papilloma virus

Althoughtheneedtoidentifythediseaseatanearlystageiswellrecognised,andpathwaysareavailableforpromptreferralforaspecialistopinion,manypatientsarestillreferredtospecialistcentreswithadvancedstagediseasewhichcanbedifficulttotreat,andhasaworseprognosis.

Oneofthereasonsforthis,isthatmanyofthesymptomscausedbyheadandneckcancersaresimilartothosecausedbycommonproblems,orvariantsofsymptomsmuchmorecommonlyduetobenigncauses.Symptomssuchashoarseness,swallowingproblemsormouthulcersarecommon,butrarelyaretheyduetocancerofthemouth,pharynxandlarynx.

Therearehoweveroftendifferencesinthepatternofthesymptomswhenthereisamalignantcausewhichshouldgiverisetosuspicionofaseriouscause.Somesymptomsshouldhowever,resultinapromptreferralfromtheonset.Theguidanceavailableforthepublic,dentistsandGP’sshouldhelppreventlatereferral;butalltoooftentheadviceisunheeded.Evenwhenpatientsarereferredappropriately,therecanbedelaysinthediagnosticpathwayinhospitaldepartments,increasingtherisktothepatient.

Headandneckcanceristreatedinspecialistcentresduetothe

“many of the symptoms caused by head and neck cancers are similar to those caused by common problems...”

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FactorsinmedicalnegligenceclaimsMEDICALNEGLIGENCEclaimsinvolvingcancerofteninvolveoneofthefollowingfactors:

• Failuretodiagnose–thiscanbedue toadoctoreithermissingor misinterpretingsymptomsor misinterpretingtestresults

• Delayindiagnosis–thiscanbe

causedbydelayedreferralsto specialists,delaysincarryingouta biopsyorfailuretoactquicklyenough inreactiontotestresults,aswellas manyotherfactors

• Misdiagnosis–somepatientsare

diagnosedashavingcancerwhen theydonot.Thiscanleadtothem havingtoenduredifficultand painfultreatmentssuchas chemotherapyunnecessarily

complexityofboththesurgeryandnon-surgicaltreatmentrequiredtotreatthedisease.

Thenecessaryexpertiserequiredtotreatthediseaseshouldalsobeutilisedtoassessthepossibleeffectsofdelayedormisseddiagnosis.Againtheeffectsofdelaysareoftendifficulttoassess,especiallyinrespecttoquestionsofcausation.Thecancerscanbehavedifferentlydependingonwhichsiteisaffected,andduetosubtledifferencesinthecancerbehaviourwhichcanvaryfromtumourtotumour.Providingarobustexpertviewisnotalwaysstraightforward.q

Surgeons are able to remove head and neck tumors through the mouth

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AnkleInjury:

Forfracturesandligamentoustearsresultinginmoderatedisabilitysuchas

difficultywalkingonunevengroundoronstairs:£6,500to£13,500.

Severeinjuryinvolvingalongperiodoftreatmentandsomepermanentdisability:

from£15,000to£25,000.

FootInjury:

Minor:£1,000to£6,000.Moderate:£3,000to£12,500.

Severe:£12,500to£37,000.

Lossoffoot:

Onefoot:£46,000to£60,000.Bothfeet:£93,000to£110,000.

KneeInjury:

Lacerations,twistingorbruisinginjurywithcompleterecovery:upto£3,250.

Ongoingsymptomssuchasaching/discomfort/occasionalpain:upto£6,500.

Torncartilageormeniscus,dislocation,ligamentousdamage;injuriesresultingin

minorinstabilityorweakness:from£7,000to£13,000.

Severeinjuries:£13,000to£52,500.

LegInjury:

Simplefractureoftibiaorfibula:upto£5,000.Severeleginjuriesincluding

simplefractureoffemur:upto£7,000.Fractureswhererecoveryisincomplete:

from£8,500to£14,000.Permanentdisability,requiringcrutches,limitedwalking

ability:£25,000to£75,000.Deglovinginjury,grossshortening:£42,000

to£100,000.

Lossofleg:

Belowtheknee:£45,000to£100,000.Abovetheknee:£47,000to£150,000.

Hip&PelvisInjury:

Minorinjuriesincludingfractureswhichresultinnopermanentdisablementupto

£6750.Severeinjuriesneedinghipreplacements:upto£13,000.

ShoulderInjury:

Minorinjurysuchassofttissuedamagecausingconsiderablepainbutrecovery

almostcompletewithinoneyear:from£2,000to£3,750.Moderateinjuriessuch

asfrozenshouldercausinglimitationofmovementanddiscomfortforuptotwo

years:£3,750to£6,000.Dislocatedshouldercausingpaininshoulderandneck,

achinginelbow,weaknessofarmandhand:from£6,000to£9,000.

ArmInjury:

Simplefractureswithfastandcompleterecovery:£1,000to£3,000.Serious

fractureswithgoodrecovery:£9,000to£19,500.Seriousfractureswherethereis

significantorpermanentdisability:from£19,500to£29,000.

Lossofarm:

Belowtheelbow:£52,500to£60,000.Abovetheelbow:£60,000to£75,000.

Lossofbotharms:£132,500to£165,000.

NeckInjury:

Minorwhiplashinjury(recoverywithintwoyears):£750to£4,250.Moderate

Whiplashinjury:£4,250to£7,750.Severeneckinjury:upto£82,000.

HeadInjury:

Minorinjuriesinvolvingnobraindamage:upto£7,000.Minorbraindamage

whereagoodrecoveryhasbeenmadebutsymptomssuchaspoor

concentrationandmemoryproblemscontinue:upto£23,500.Moderatebrain

damage:£23,500to£120,000.Moderatelyseverebraininjury:£120,000to

£155,000.Veryseverebraindamage:£155,000to£220,000.

Compensation–howmuchisaninjuryworth?MOREANDMOREpeopleareapplyingforaccidentinjurycompensationbecausetoreceivecompensationfromanaccidentthatwasnotthefaultofanindividualistheirlegalandcivilright.However,thelawiscomplexandexpertguidanceisneededonmanyaspectsofthissubject.

Basically,anindividualisentitledtobecompensatedforallthelossesthattheyhavesufferedasaresultofanaccidentforwhichtheywerenotliable.Thismayincludedamagetoclothingandproperty(includingacar),lossofearningsandanyinsuranceexcesswhichtheymayhave.

Inaddition,compensationshouldbepaidforthepainandsufferingcausedasaresultoftheaccidentandthetheconsequentinjury.Finally,itisalsopossibletoclaimforanyfuturelossessuffered,suchasaninabilitytoworkandlossofpromotionprospects.

Lawyersgenerallysplittheamountofcompensationintotwoseparatecategoriescalled‘general’and‘special’damages.Basically‘specialdamages’areallthosewhichareeasilyquantifiable-suchaslossofearnings,medicalexpenses,taxifares,ruinedclothes.‘Generaldamages’arethemoredifficulttoproveasthesehavetobe‘assessed’–iesomemonetaryvaluehastobeplacedonthepainandsufferingthatanindividualhasgonethrough,aswellastheirpossiblefuturelossofearningsandhowtheinjurymayaffecttheirgenerallifestyleinthefuture.q

Thesearesomeestimatesofwhatiscommonlyawardedfordifferenttypesofinjuries.Additionalcompensationmaybepaidforotherrelatedexpensesandlossofearnings.

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