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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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