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ExpertWitnessTrainingDayOxford
10th May2019
PaulSankey
AddressingtheLegalIssues:BreachofDuty
• Bolam vFriern HospitalManagementCommittee• ECTledtomusclecontractionsandfractures• Theallegation:negligentfailuretogivemusclerelaxantandstrappatientdown• Themedicalevidence:2schoolsofthought
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AddressingtheLegalIssues:BreachofDuty
• Thelegaltest:• Didthedoctoractinaccordancewithapracticeacceptedasproperbyaresponsiblebodyofmedicalpractitionersskilledinthatparticularart.• Aresponsiblebodycanbeaminority
BolithovCityandHackneyHealthAuthority
• Boysuffersrespiratoryarrestsonward• Resusteamfailtoattendtwice• Herecovers• The3rd time,theyfailtoattendandhesuffersbraininjury• Thedefence:staffwouldn’thaveintubatedeveniftheyattended• Argumentastowhetherfailingtointubatewouldhavebeennegligent• Expertevidence:areasonablebodywouldnothaveintubated
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BolithovCityandHackneyHealthAuthority
• HouseofLordsclarifiedtheBolam test• Thebodyofopinionmustbe‘capableofwithstandinglogicalanalysis’• iereasonable=responsible=rational
AddressingtheLegalIssues:BreachofDuty
• RemembertheBolam test• Definethestandardofcarefortherelevanttime• BearinmindBolitho• Avoidmisleadingwords(substandard,poor,notgoldstandardetc)• Avoidreferringtobreachofduty(leaveittothejudge)
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AddressingtheLegalIssues:Causation
• BarnettvKensington• Arsenicinthetea…• AttendsA+E• Dischargedinbreachofduty• Buttreatmentwouldnothavesavedhim• Failsthe‘butfor’test• Nocausation
AddressingtheLegalIssues:Causation
• GreggvScott• Lymphoma:GPbreachesdutytorefer• 9monthdelay• Chanceofsurvivalreduced:42%to25%• Prognosiswasalwayspoor– probably wouldnothavesurvived
• Breachnotchangedtheprobableoutcome• Failsthe‘butfor’test• Nodamagesfor‘lossofchance’• Nocausation
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AddressingtheLegalIssues:Causation
• Wilsher vEssexAreaHealthAuthority• Prematurebabygivenexcessiveoxygen• SuffersblindnessfromRLF• 5possiblecauses• Excessiveoxygencontributed• ButevenwithoutithewouldhavehadRLF• Failsthe‘butfor’test• Nocausation
AddressingtheLegalIssues:Causation
• BaileyvMOD• Braininjuryfromaspiratingaftervomitting• 3causes:
• post-surgicalweakness• Pancreatitis• Negligentresuscitation
• Expertscannotanswerthe‘butfor’question
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AddressingtheLegalIssues:Causation
• Claimantsucceedsif:• Medicalsciencecannotanswer‘butfor’question• Indivisibleinjury• Breachmadeamaterialcontributiontoinjury• Materialcontributionwas‘morethannegligible’
AddressingtheLegalIssues:Causation
• Butfortest• Dealingwithprobability(<50%chance)•Materialcontribution•Mindyourlanguage:‘possible’,‘may’,‘could’etcareslipperywords• Don’tsitonthefence
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AddressingtheIssues:Condition
• Diagnosis• Thepatient'sexperience• Pain• Function• Work• Leisure• Rememberbalanceofprobabilities
AddressingtheIssues:Prognosis
• Differentfrompastevents:possibilitiesmatter• Whatisthepercentagechance?• Whenwillithappen?• Whatwillbethecost?• Howmuchtimeoffwork?• Howmuchcare?
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AddressingtheLegalIssues:Advice/Consent
• MontgomeryvLanarkshire• 1st pregnancy• Elevatedriskofshoulderdystocia• MrsMnotadvised• LestsheelectforC-section(‘notinthematernalinterest’)• Shoulderdystocia>hypoxia>CP
AddressingtheLegalIssues:Advice/Consent
• Decisionofthelowercourts• Nonegligenceinmanagementofbirth• Advicetomotheracceptable–noneedtowarnheroftherisk• Bolam testapplies– aresponsiblebodyofobstetricianswouldhavedonethesame
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AddressingtheLegalIssues:Advice/Consent
• Anadultpersonofsoundmindisentitledtodecidewhich,ifany,oftheavailableformsoftreatmenttoundergo,andherconsentmustbeobtainedbeforetreatmentinferringwithherbodilyintegrityisundertaken.
AddressingtheLegalIssues:Advice/Consent
• Thedoctoristhereforeunderadutytotakereasonablecare• toensurethatthepatientisawareofanymaterialrisksinvolvedinany• recommendedtreatment• oranyreasonablealternativeorvarianttreatments.
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AddressingtheLegalIssues:Advice/Consent
• Thetestofmaterialityiswhether,inthecircumstancesofaparticularcase:• i. areasonablepersoninthepatient'spositionwouldbelikelytoattachsignificancetotherisk,or• ii. thedoctorisorshouldreasonablybeawarethattheparticularpatientwouldattachsignificancetoit.
AddressingtheLegalIssues:Advice/Consent
Sotheroleofexpertevidenceistoassesstheadequacyofadviceasto:§whatwouldconstitutereasonabletreatmentoptions;and§whatmedicalrisksareinvolvedintreatmentbutnot:§whetheraparticularformoftreatmentshouldbediscussedwithpatients;or
§whetherparticularrisksshouldbediscussedwithpatients.
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AddressingtheLegalIssues:Advice/Consent
• Thefaut vJohnson•Medicaladviceastorisksandbenefitsofsurgeryandconservativemanagementinaccurate•Medicalevidenceneededastothecorrectfigures
AddressingtheLegalIssues:Advice/Consent
• WebstervBurtonHospitalsNHSFoundationTrust• Womanshouldhavebeenwarnedofassociationbetweenunusualfindingsandantenataldeath• CourtofAppealrejectedviewsofbothexpertsonconsent
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YourCV
• Accurateandsufficientlydetailed• Demonstrateyouhavethattherightscopeofpracticetocommentonbreachofduty• Demonstratetherightexpertisetocommentoncausation
ProvidingEvidence
• Persuasionrequiresevidence• Peer-reviewedliterature• Guidelines• Textbooks• Relyonexperienceifthatisthebestevidence– butexplain
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ProvidingEvidence:CautionaryTale1
NasirHussainvBradfordTeachingHospitalNHSFoundationTrust2011
'Althoughtherewasagooddealofliteratureonthesubject…MrMdidnotrelyonanyofthat…Heonlyreferredtoittodismisstheliteraturealtogether…Insteadhesoughttorelyonhisownexperiencewhich,becauseitwasbothcontradictoryandundocumented,couldnotbethesubjectofmeaningfulresearchorcommentbythedefendant'sexperts’.
ProvidingEvidence:CautionaryTale2
• Hirtenstein andAnother2014.• “MrC'svaluationapproacheffectivelyinvolvedputtingtheavailableinformationintoablackboxfromwhichafigureemergedbasedentirelyonhisgutfeel.• Theproblemwithavaluationbeingpronouncedexcathedrainthiswayisthatitisnotcapableofbeingtestedorsubjectedtoanyrationalscrutiny.• Itamountstosaying,'Trustme,Iamanexpertvaluer…’• Experts'opinions,iftheyaretobeaccordedanyweight,needtobesupportedbyatransparentprocessofreasoning.”
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Conflictsoffact
• Beopen-mindedaboutwhichfactualaccountiscorrect:leavefindingsoffacttothejudge• Whereyoucanexpressaviewonthefacts:• Basedonyourexpertiseandexperience,onesetoffactsisimprobableorlessprobable
Maintainobjectivity
• Thedutyofimpartiality• Adutytothecourt• The‘usefultestofindepence’• TheExpertWitnessInstitute’schecklist(seeAppendix1)• Thereality– mostexpertsarepartisantoadegree• Consideralltheevidencebeforeforminganopinion• Ifthereisarangeofopinionsummariseitandexplainwhyyoureachedyourview
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Maintainobjectivity:cautionarytales…
• TheDefensiveexpert:EdwardLifesciencesvBostonScientific,2017• 'IregrettosaythatinthecourseoflisteningtoProfM,Iformedtheimpressionthathehasalsodevelopedwhatmightberegardedasanexpertiseingivingevidence.• ProfMwasextremelycarefulingivinghisanswers.• IincreasinglytooktheviewthatthiswasbecausehisfirstprioritywastoavoidsayinganythingthatmightdamageBoston'scase.'• Incontrast:'IfoundDrBtobeanexcellentwitness.Hegaveclearanddirectanswerswithoutunduedelaywhereverhewasableto.'
Maintainobjectivity:cautionarytales…
• Theexpertwhoknewaparty:EXPvBarker2017
• Thejudge:'myconfidenceinDrM'sindependenceandobjectivityhasbeenverysubstantiallyundermined'.• Theexpertwassocompromisedthatthedecisionwhethertoadmithisevidencewasfinelybalanced.• ItwasadmittedbutthejudgerejecteditandpreferredtheClaimant'sexpert.
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Theexpertwhoknewaparty:Thefaut vJohnson2017
• 'Inthespecialistfieldinissuetherearearelativelysmallnumberofsurgeons…InsuchcircumstancesthereisahighprobabilitythatwhenoneofthisselectgroupisinstructedtoactasanexpertinacaseheorshemayknowoftheDefendanteitherpersonallyorbyrepute.ThiswasthecaseofMrGinrelationtoMrJ
Theexpertwhoknewaparty:Thefaut vJohnson2017• …itismyviewthatMrGwouldhavebeenfarbettertogetoutintheopenhispersonalknowledgeofMrJ.AconcisebutaccurateandcomprehensiveparagraphinhisreportsettingoutthebarefactsofhisknowledgeofMrJwouldhavesufficed.Thiswouldhavetakenmuchofthestingoutofthecrossexaminationwhichdid,Iamboundtosay,leaveMrGfeelingandsoundingdefensive.Theissuehereistheappearanceofbias.'
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Maintainobjectivity:cautionarytales…
• Ruffell vLovatt 2018• Painmanagementexpertheavilycriticised.Hisevidencewassoflaweditwasrejectedonanycontentiouspoint.• Failedtoreadthemedicalrecordswhichwereinconsistentwithhisconclusion:neithercarefulnorforensicallythorough• Thisledhimtoputtingforward‘severalplainlyabsurdconclusions’
Maintainobjectivity:cautionarytales
• Dismissiveofotherexpertsintermswhichwere‘atbestoff-handandatworserude’• Dogmatic:‘rigidlyheldopinions’• ‘Displayedalackofbalanceandjudgment’
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Maintainobjectivity:cautionarytales…
• Theadvocate• Judge:'IsharedMrGibson'sconcernsaboutthemannerinwhichProfW'sevidencewasgiven;heusedtheverb"submit"andreferredtohis"argument"whengivinghisoralevidence'.
UseofMedicalRecords
• Importantevidencebutnottheonlysource• Absenceofevidenceisnotevidenceofabsence• Usepaginatedbundleandgivepagenumber• Pasteinextracts?• Besensitive• Protectdata
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Therelationshipwithyourlawyer:timings
•Minimisingdelay:theslowprocess• Pre-issuedelays• Limitationpressures• Courtdeadlinesandsanctions
Therelationshipwithyourlawyer:responsiveness•Qualityofresponse•Phonecallorletter•Charges
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Therelationshipwithyourlawyer:consistency• Theweather-vaneexpert• Thinkthroughyourconclusionscarefullyattheoutset• Avoidputtingyourselfinapositionwhereyouneedtochangethem• Impactonclient• Impactoncosts• Impactonfuturework
• Butdon’tbeobstinateifyoudo
Anothercautionarytale…
• SmithvTescoPLCandRoyalFreeLondonNHSFoundationTrust.• Thejudgeonanexpert’slate-advancedtheory:• 'Thelateradvancementofthisopinionis,inmyview,veryunsatisfactoryandifaliveissueshouldhavebeenconsideredatamuchearlierstage…• Itdefeatsthepurposeofexchangeofexpertevidenceandjointdiscussionsbetweenexpertsifexpertsraisenewtheoriesshortlybeforetrial'.
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Therelationshipwithyourlawyer:handlingtheclient• Ensureclientsaretreatedwellduringconsultations• Takeintoaccountwhattheysayinpersonandintheirstatement– showthatyouhavereadit• Dealwithconflictsofevidencesensitively•Wordreportstactfully:bearinmindthatclientwillreadthem
Costs:Funding• CFAs:• Paidifwin• Writtenoffiflose(ouch!)• Clientscontributetocostsfromdamages
• LegalAid• Limitedavailability• Statutorycharge
• Tightfinancialconstraintseverywhere• Budgets• Assessment
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Costs
• Implications:
• Asteerattheoutsetsavescosts
• Latechangesofviewcanbecommerciallydisastrousforsolicitors.
Costs:Proportionality
• Thecourts’objective:dealingwithcasesjustlyandatproportionatecost(CPR1)• Constraintsonrecoverablecosts• Avoidunnecessarywork:helpkeepcostsdown• Estimatecostscarefully
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Costs:FixedFees
• Anexistingregimeforlowervaluepersonalinjuryclaims• Thefutureofcivillitigation• Aregimefor(claimant)clinicalnegligenceclaimsupto£25,000?(fornow)• Difficultiesforclinicalnegligence:complexityandvalue
TheClaimsProcess:Pre-Issue
Establishthefacts:
RecordsStatement
InstructexpertBreachofdutyCausationCandP
LetterofclaimResponse(4months)
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TheClaimsProcess:Pre-Issue
Admission:Negotiate(withoutprejudice)andsettle
Denial/can’tsettleTestevidenceinconference
Conferenceswithcounsel
•Whenconferencestakeplace• Howlong?• Purposeofconferences• Importanceofpreparation• Byphoneorinperson?
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TheClaimsProcess:Post-Issue
Serviceofclaim
ServiceofDefence
(2months?)
Proceduralhearing
(4months?)
Exchangeofstatements
Exchangeofexpert
evidenceonliability
TheClaimsProcess:Post-Issue
Furtherdisclosure:
C+PevidenceFinancialloss
Discussionofexperts ADR
Pretrialconference Trial
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Understandingthelanguage
• Afewwordstogetright:• Claimant(notPlaintiff)• Claimform(notWrit)• Statementsofcase(ParticularsofClaimandDefence)• NottobeconfusedwithWitnessStatements
TheimportanceofplainEnglish
• Becrystalclear• Uselanguagenon-medicscanunderstand• Thejudgeneedstounderstandandprobablywon’tknowmuchaboutmedicineormedicallaw
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TheCivilProcedureRules1998
Questionstoexperts(CPR35.6)
• Theothersidecanputwrittenquestionstoyou• Notcommonlyused• Questionsmustbeproportionate(yoursolicitorcanguideyou)• Theycanonlybeputonce• Theymustbeputwithin28daysofserviceofyourreport• Thecourtcanstillpermitlaterquestions(orthepartiescanagree)
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Questionstoexperts(CPR35.6)
• Theymustbeforclarification– notnewevidence•Unlessthepartiesagreeorthecourtordersotherwise• Youranswersbecomepartofyourreport• Letyourinstructingsolicitorconsiderthedraft
Questionstoexperts(CPR35.6)
• Thepartyinstructingyoupays(notthepartyaskingquestions)• Sanctionsforfailuretocomplywith35.6:• Disallowanceofyourevidence• Disallowanceofyourfeesfromtheotherparty
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Therighttoaskfordirections:CPR35.14
• Therighttoask• Noticetobothparties• Thisisrarelyused• Normallyunnecessary- yourinstructingsolicitorwillguideyou• Difficulttoimaginewhyyouwouldaskthecourt
Discussionsofexperts:CPR35.12
• Thecourt‘may’directadiscussionofexperts(anditwill)• Akeystageinthelitigation• Preparingtheagenda• Focusontheissues• Clarification,notcross-examination• Expertsusuallyaskedtocontributetotheagenda
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Discussionsofexperts:CPR35.12
• Contentsoftheagenda:• Reminderoflegaltests• Listofdocumentsconsidered• Questions
• Discussionnormallybyphone• Doitatagoodtime(notwhendinnerisbeingserved)• Bewarethebully• Preparationiskey• Noobligationtoresolvetheissues
Discussionsofexperts:CPR35.12
• Preparingthejointstatement• Recitequestions• Explainanswers• Makesureyourviewsarefairlyrepresented
• Don’tbeoutgunnedbylonganswers• Avoidtomuchto-ingandfro-ing
• Don’tsenddrafttoyoursolicitorforapproval• Explainanychangesofmindcarefully• Discussionsarewithoutprejudice
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ExpertWitnessTrainingDayOxford
10th May2019
PaulSankey
