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So I'm just gonna introduce uh two of our main speakers. Uh Doctor Hernan Soma who is trained in gastro hematology and completed a low degree as a registrar, worked for MDU for 16 years and she completed um and she's now head of advisory services. She was working as a clinical hepatologist until last year. And we have uh also Professor Viz of who is a senior upper gi laparoscopic endoscopic and robotic practicing surgeon for the last 24 years. He's an educationist and trainer at regional National and International Fora. He's actively involved in a LSG B IBB U GSS, AU GI S and Tu Gss and is the current president of Bu Gss and trustee of TT U GSS. He leads the MC H post grad surgical specialties program and been practicing medical legal work sparingly over the last two decades. He will lead the first legal mock trial for us today in Assay 2024. Thank you very much, Professor. No, great, welcome everybody. And um it's my pleasure to introduce this session. Um Professor has a really interesting mock trial for you to come up on the theme of clinical negligence and I'll try and introduce really briefly some of the key concepts in this area. Um It was really great to talk to many of you on the, on the MDU stand today. And I know you're curious in this area. Now we're gonna talk about the top thing here. A civil claim. That's what a clinical negligence claim is about. And the outcome is simply payment of compensation or not to a claimant doctors work in a much more complex medicolegal landscape than that these days, particularly in the UK. Um And the sorts of things we see at the MDU can amount for something that's relatively straightforward, such as a patient complaint to something really serious like a criminal investigation or a regulatory or GMC investigation. Um So, you know, this is a complex area and you're dealing with um a small part of that today that said clinical negligence is important. There are significant numbers of claims notified to NHS RESOLUTION in the NHS each year. It amounts to around 1.5% of the NHS budget much higher in certain specialities. A much greater proportion of say the budget spent in neurosurgery is spent compensating patients than that 1.5%. So it is important in terms of the scenario, you'll see for somebody to be successful in making a clinical negligence claim. They have to demonstrate that the person that they're suing essentially owed them a duty of care that's relatively straightforward in the doctor and patient relationship. We do owe our patients a duty of care that there was a breach of that duty and that's judged to the standard of a reasonable professional. And they also have to show that harm resulted. The importance of that is say, for example, your regulator, the GMT might be concerned simply if you make poor decisions and have a near miss. Whereas in this sort of setting, a claimant can only secure compensation if something has been done to not an appropriate standard and cause them harm. Now, what standard are doctors he held to? Now, this is a really old case in relation to use of muscle relaxant during an EC T procedure. Um but this statement um is still probably good law in a very basic sense. It's more nuanced than that in various areas, but essentially a doctor won't be held to be negligent if they acted in accordance with practice accepted as proper by a responsible body of medical opinion and the language in this, you'll see it's from 1957 you know, so it's held up for quite a long time. Now, that doesn't mean you have to do it in a way that everybody agrees with people are uh can descend from that and that is where debate can happen in these areas. But you've got to have a body of medical opinion that can sustain logical analysis that's supported by a responsible body. Now, this has changed a little bit in so far as it relates to consent. Most of you will have heard of the Montgomery case, a relation, uh an obstetric case in relation to shoulder dystasia touching on the issue of consent. And the kind of little headline from that is that doctors are under a duty to declare material risks to patients, pa things that patients would reasonably worry about. Now that you may say, well, we do that already. The really legally important part of Montgomery was that it moved consent from away from a test that relied on a responsible body of medical opinion to a patient focused test. It's what would a reasonable patient want to know rather than what would a reasonable doctor disclose. Again. Things are always a little bit more complicated than that. And in this uh 2023 case, it was kind of helpful and reassuring to doctors in so far as it did not suggest that we've got a duty to discuss options for treatment that are theoretically possible, but ones we think are not appropriate or irrelevant, um that, you know, this was a case in relation to myocarditis. We're not under a duty to discuss that. So I've left you there with concepts of what a claim is about, is about the payment of compensation. And so damages are worked out in very straightforward ways. The calculations can be complicated and, and extensive. But essentially there are damages for pain suffering and loss of amenity. So essentially for the, the the harm caused and the disability that results perhaps, and they're called general damages. Special damages are often much greater and they relate to what the knock on consequences of that are. So, say, for example, in a neurosurgical claim, if somebody is paralyzed and they're a young person and they have a long loss of earnings claim for the course of their working life. They need a lot of help and support at home adaptations, nursing care, etcetera. All of those will go into the settlement. The really important point I want to make is it's not a punishment for the severity of the error. It's all about what those costs are. So I'm gonna hand over now, you're gonna see a scenario. Um And I think it's focused to be fair on, on what amounts to a breach of duty. The duty of care point is fairly straightforward. You have to think when you're thinking about this, what harm was caused, what damages might be due. Think about the role of experts you'll see talking about the case here. And I think the other thing I'd want to say is think about if you were defending this particular case, if you were a lawyer, would you take it to trial? And remember, court cases for clinical negligence are extremely rare, rough, less than 5% of cases are litigated, the vast majority are discontinued or settled before they get to that point. And that's because there's a lot of work that goes on before things get to trial. You'll be often involved and asked to write a report, et cetera. But it's very rare that you'd actually be called to court for a case such as this. So I'll leave you with that reassurance over to the team. Ok, good afternoon. All. Thank you doctor for the interrupted part from M and thank you Chase. And I'm grateful for a, to give the opportunity to hold the first legal mock trial, at least in the history of a and I'm sure all of you would go through this act, which is better dramatized on actually a real patient, fictitious name, fictitious dates and of course, fictitious characters. Uh So you can sort of witness that obviously. Yeah. Uh uh given the type of conference, it's my duty to just elude briefly about the uh the, the patient and also a few of you probably may not be aware of just the commonly used legal terms. So in UK, we use a claimant, it's a person who in instigates the litigation. Although in different countries, they use different names including pursuer, plaintiff, et cetera. But for this conversation today, for this act, so we just use the term claimant, the person who is accused of is the defendant, which again is not too dissimilar in the majority of the countries, especially in the Western societies from the point of civil law when a judge declares a compensation or whatever or, or a punishment. Usually it's always on the balance of argument and counter argument and on the balance of probabilities. So that's that term has not changed, at least in the, in the British Society over the last 100 years. We just, I would be repeating this again for a typical claim to be successful is a tripod of three things, duty of care, breach of the duty, the harm cause as a result, these three things would be taken into account in the eyes and minds of judiciary and then they will come out and draft our judgment again. We just read it and uh uh from um from the previous speaker and very important, I want to just repeat it from Bol's statement more than in 1957. He is not guilty of negligence. If he has acted in accordance with a practice accepted as proper by a responsible body of medical men killed in that particular act as an orthopedic surgeon. If you do an appendectomy, you may be capable, but that's questionable. So it's simple things. But at the end of the day, it is not the capability, but it's also what you are tasked for in a given scenario. So this is uh as I said, a real patient but fictitious name. I'm delighted to introduce this case summary on MP with a retired Pleasant Lady, borderline fitness who presents um with reflux problem with hydraemia, she develops after about 15 years, what we call a Barrett's changes, which basically this is the stomach. That's the esophagus, recurrent acid coming up can change the lining. And it's called Barrett's. Obviously general surgeons or ga trainees may be aware of it, but this is a precancerous condition. At least in the Western society, we advise all these patients to have three or five yearly endoscopic examination as a surveillance because it's precancerous because of last 10 years, huge demand and capacity issues. All these surveillance endoscopies are subcontracted in various other hospitals. This poor patient lands up in a hospital called Moon Hospital and that's where this incident occurs. And I'm going to sort of summarize what happened to the patient again at the end, I don't want her to go into details at this juncture. So this patient attends the Moon hospital for uh elective planned surveillance endoscopy because she was detected to have a precancerous condition called Barrett's. So I was involved in this case and these are not my questions. The solicitor who asked me to give uh expert report, asked me to report back to them and trying to answer these three questions was the endoscopies performed to an adequate standard in the moon hospital? Obviously, that's fictitious name. What actions were taken when this uh Barrett's metaplasias further towards the cancer stage, which is called dysplasia and also what were the implications if appropriate action were taken? These are three questions they asked. And now it's the time for the real mock trial. So I'm going to sort of change our tack. And I'm delighted to introduce uh five actors from neurosurgical specialty to plastic surgical trainee to orthopedic trainee to general surgical trainee. It's the true representation of asset. And uh now I've invite Doctor AA which is enacted by Doctor Soho as the defendant please on the stage. And it's my pleasure to invite Miss Miss Beta Clement's barrister acted by Pfizer. Next is Mis mister theta lead endoscopy nurse and also he is the endoscopy assistant as well. Please come to the stage. Next one is different. And barrister Mr Cars trainee Nathan Walker, please under the stage last but not least Miss Gamma, the senior endoscopy and endoscopies and a qualified gastroenterologist works at Sun hospital, acted by Dr Lola. So myself, I'm going to change to Mr AOTA the judge, but I'll be walking around. I also I'll be moving the slides for your information. Ok. Uh So we're going to uh start the trial and um in any uh western society, um the first part of the trial is examination in chief. So first two acts are uh revolves around what we call examination in chief. So now I'll call upon defendant barrister Mr Cost to Inju Mr the over to thank you. Thank you very much. So I just wanted to ask the first question is if you could please explain your current role in employment details. Yes. Um I'm Mister the, I'm the lead endoscopy nurse. Um What was the details? Yeah. Ok. How long have you been in that role for? I've been in the role for six years. And how often have you worked with the defendant in question regularly? Probably at least once a week. And how over, how long had that been? Uh I've known them for five years. Five years. Ok. Ok. Could you describe the event? Um And what happened on that day? Um Yeah, of course. So, um the endoscopy um was what we call a failed endoscopy. Um and routinely when this happens we book an appointment. Um and everything was pretty routine like that. Ok. Ok. Do you recall um any sort of untoward events on the day? Did it, did things go smoothly? Could you just describe that a bit more for us? Yeah, absolutely. So it was a very regular day. Um Things ran smoothly, usual sort of busines in general. But um yeah, it wasn't anything untoward. You don't think there was anything untoward. Yes. And what do you think of the defendant as a practitioner? Um Just an amazing person, you know, genuinely got on really well, um couldn't think of anything wrong at all. So when, when you say compare him to other endoscopist that you work with, where would you kind of place him among his colleagues? Probably like number one, number one. And, and that's, and And how about that? Compared to other endoscopist you've worked with elsewhere? Because, um, you, we're working for a long time, as you said. Yeah, absolutely. Um, still number one, number one. So, so clearly, yeah, clearly a very good endoscopist. Ok. Yeah. In your best opinion, do you consider him to be competent for the job that, uh, that he has? Yeah, wholeheartedly. And is that view shared amongst your colleagues? I know you said that you're the lead nurse endoscopist. But what about other colleagues that you work with? Has anybody else mentioned? Don't really, you know, talk about very much. Yeah. Ok. Ok. Thank you for that. I've got no further questions. Thank you. Ok. Now, II invite uh again, Mister K different barrister to interrogate doctor Alpha. The dependent, please. Thank you. So Dr Alpha. And I was wondering if you could just please confirm your full name and role just for the jury and the judge, my name is so Alpha and I'm one of the trainees, but I'm an independent practitioner in performing endoscopy for a whole range of conditions hospital. Thank you. Could you give us a little bit of a background about your training and where you're up to? Yeah. So as part of my training, we have to regularly go through procedures first under supervision with consultants and then gradually independent progress, you get regularly audited as does the rest of the endoscopist at the hospital. And I've done all this very well and I'm now thought to be independent. I've got to that stage, but I have yet to secure a consultant post. And therefore I'm still in training. But despite still being in training, you've got quite a lengthy experience in qualification. Could you tell me a little bit more about your both your undergraduate and postgraduate qualifications that makes you, you know. So my, my undergraduate qualifications were Oxford where I did medical school, I went straight from Oxford into foundation years where I did rotations in gastroenterology and general surgery where I had regular exposure to endoscopy. And then I went into surgical training and then specialty training. And during all of this, I had regular exposure to endoscopy and I've done, I think about 67 years in it now, so sufficiently experienced in it. I've got accreditation from the body that regularly reviews us every, every six months and I'm on the JMC register. Ok. So not only have you got both procedural qualifications, but you've also got academic experience. Is that fair to say that that is? Yes. Ok. And you already mentioned about accreditation just to make it clear. So everybody's aware. Are you fully jag accredited, which is the, the advisor on Gastroscopy? Yes, that's the body I was referring to. No. Ok. And can you explain how you comply er annually with kind of CPD points, uh any conferences that you might attend where you know, asset may be one of them, for example. Yeah, so I regularly attend the Asset conference every year. It's one of the best highlights of my academic journey. Um In addition, I regularly present at endoscopy conferences. I have a budding research career looking into techniques, potentially how we should not always follow the guidelines. Word for word because potentially, you know, it doesn't take into individual patient benefits and weaknesses and it's just kind of done on the average patient and how we should be more patient centric approach and often present this and it's often be viewed by other colleagues and other doctors as the right way forward. So kind of a reasonable body would suggest exactly. Ok. Ok. So you mentioned that you had between six or seven years of experience in performing endoscopies. How many endoscopies do you perform kind of per year? Roughly? So I've got an endoscopy list every week and out of a year, I probably attend 40 of them and in each endoscopy list of about four or five patients. So I'm looking at 160 to 200 endoscopies per year. And where are you up to with your annual appraisals and revalidation? My consultant says I am fully independent in this procedure. They are now, I would say quite reluctant to help me unless there's something very, very difficult going on and they're very trusting with what I do and I send my reports regularly to be double checked. Ok, so you sound quite thorough in what you do. That's what I understand my consultants think of me. And obviously, we know just so everybody's aware, we have you were telling me earlier about the training process and how you get feedback from colleagues in a more formal way. Could you tell everybody about that and what the feedback has been both from, like you mentioned, consultants, also other members of staff. So as part of my annual appraisal, I have to get feedback from across the board, not just consultants but really valuable colleagues across the table that you've heard from the endoscopy nurse. We often work very closely together. In addition, I work with various other associate specialists and I regularly show them what I've done, ask for Theresa, have a sit down once a month just to go through what I've done any cases, any learning points and I talk them through exactly how I do the procedure and any images that were potentially saved from that procedure. Given I frequently take images when I can, when the image, when the equipment's functioning of everything that's going on. And as part of um getting that bit of feedback from people, often people tend to write things down only that you were mentioning before. Could you just highlight some of the words that were perhaps used to describe how you are as a practitioner? You've already heard some kind words being said about me? I think that's often, I don't want to blow my own trumpet. But I often said to the best trainee they've ever had in the unit for this, they've often said academically gifted, really good use of patient centric approach. Er and not a Maverick. Thank you. Thank you very much. I've got no further questions, your honor. Thank you. Just move on. Now, this part of the examination, we technically we call it as cross examination and now I invite be the claimant barrister to interrogate the endoscopy nurse, please. So um Mr the for the documentation purposes, can you state your name and your role, please? Yeah, sure. So I'm Mr the, I'm the lead endoscopy nurse. Ok. And what does that involve doing on a day to day basis? Um So I've got quite an important role and very busy and very stressed. I've got a whole clinic to run a whole list to run. So appreciate that. I really appreciate it in addition to that the appointments and hang out with the amazing doctors like, ok, and how many people work alongside you? It's probably about six of us, but I do six people's work and they do one. So yeah, so can you please educate me on how your appointment system works? Yeah. So um basically we we have referrals in and um and then you triage those referrals and then you make the appointments based on whatever you triaged. Um and then during the list, whatever the findings are from the endoscopy you, you then uh make appointments accordingly. So if there's a need to follow up and that kind of stuff, then it's a really smooth automated kind of process. It's really good. OK. Six people working in your unit. Do you think that the work is appropriated distributed among the staff? It is. But like I said, you know, I'm basically as good as all of them if not six times, but you are quite stressed too. Yeah. Hence I'm stressed. Yeah. Ok, because you are good because, yeah, I'm really good. Yeah. Ok. Anyway, so in short, you are on top of your game. Is that what you are saying? Of course. Yeah, of course. Yeah, great stuff. Moving on. How long have you worked with doctor? Um, so I've known him for five years and worked with him for as long as that. And you think he is an amazing doctor top notch? Yeah. So in regards to the Endoscopies, has there been instances where Dr has not been able to complete the procedure and he just abandoned it? No, no, no, of course not. He's, he's great. He, he finishes everything and you know. Yeah, even when the stomach is full with food residue. No. Well, that, that's unsafe. So that, that doesn't count, you know, it's obvious. So if a doctor has abandoned the scope for any reason, so what is the policy for rescheduling? Yeah. So, um, if the scope is abandoned for various reasons. Um Then there's a, there's a new appointment that's made, it's usually in the little follow up plan and then we go based on that, you know, I can't make those decisions, you know, you understand. Yeah, so, so you can't make this decision. So who does make this decision? So that, that comes from the doctor and, and that's, that's what we read, you know, so it will be written up in the endoscopy report so that a new appointment needs to be made. Yeah. Yeah. Ok. So in this particular incident in question, did Dr Alpha wrote his follow up plan in the endoscopy report? Um I, you know what, I can't remember funnily enough. I've got a very cloudy memory about that. So I know you are very stressed, stressed, you wouldn't remember. Ok. So if it's a standard practice, is it a standard practice that after an abandoned procedure, you would just reschedule it? Yeah. So if it is a standard practice and Dr didn't even mention it, why was all of this not prompted? Ok. No more questions. You're all right. Thank you. Thank you. So the uh uh part two of cross examination now invite uh Clemen Barer to question uh Mr uh uh um uh with defendant doctor Alpha, please. Ok. For the purpose of documentation. Could you please state your name, role and place of work, please? As I've said before, my name is Soham Alpha. I am a senior trainee at the Moon hospital and I regularly perform endoscopies. Ok. And how long have you been working in your current role as a senior trainee? Uh, for a few years? But overall I've got about 67 years of experience in this. And is your unit jagged to it? Yes. It, you've already heard from one of our really accomplished nurses. Of course, they follow everything. Yeah, I heard it from the stressful nurse. Yeah, I did. Uh You are also jagged. Did it? Yes. Ok. So could you please tell me why this patient was referred to you? The referral history was a bit hazy. They said some indigestion, some stomach acid. I presumed it was dyspepsia and looking through their previous notes, they've had 44 endoscopies before that showed Barrett's esophagus. So I just assumed it was the Barretts esophagus anyway. So it was just a routine routine endoscopy. Yeah. Yeah. So a routine endoscopy for Barrett's esophagus. Will that include biopsies if the patient has been prepared adequately? But unfortunately, whoever referred them, as I said, was a bit hazy and I don't think they properly got the patient ready for such a complex procedure. Ok. Um What was the A sa grade for this patient? The anesthetist wasn't involved in this case and that's not something that we typically do. It's called an anesthetic. It's called the an anesthetic scoring system for a reason. So from my point of view, it was an ASA one but, but I understand talking to a colleague, they're actually ASA two and the patient was comfortable during the procedure. You've heard that I'm skilled, I would of course make my patients comfortable. So, what was your post procedure plan? Um So given they were inadequately prepared, they had a stomach full of food. As in, they'd just eaten right before they came. There was no chance to get a proper view down in any further than the esophagus. And that, that's not how you perform a proper endoscopy. I couldn't in good faith say I performed a proper endoscopy. I do recognize it was right before Christmas though. And I did tell everyone, everyone was really busy on Christmas holidays. We only had one nurse performing the role of six people that we probably should reschedule another appointment and to do it as soon as possible when everyone's back, but one person doing the job of six things get lost them. But did you document that? Um I usually as a senior registrar these days, um, dictate and expect other people to, to note down what I'm saying that that's an oversight on my part. Ok. And how long after the first procedure, the patient came back for the second one to no fault of my own. It took two months. Ok. Is that the correct length of time? Is that the usual one? I have a lot of patients and I lost track of what had happened with this one. Surely due to the, as you've heard, the high volumes. If I had a more manageable practice, I'm sure I would have noticed that this was beyond guidelines. Ok. So on the second procedure, what were the findings? Uh, it, it didn't line up with any previous findings. Um, it suggested that potentially it wasn't just Barrett's esophagus but something cancerous, but it didn't line up with any previous findings. So II wasn't totally happy that what I'd found was true because I'm a trainee and a consultant had done the previous one. So I II wasn't confident. Did you take biopsies this time? I did. Yes. And what were the results? You said something about dysplasia? Can you please tell, what is it? So the initial findings were suggestive of dysplasia, which means it could be cancerous. Did the patient know about these results? I didn't want to worry them in case I was wrong. Ok. So in short, you didn't tell the patient and the patient was also lost to the follow up. Yes. Um Do you refer these patients to the MDT? Because it's a precancerous thing? And you cannot take a decision. Of course, your consultant can, but you can refer the patient to the MDT O. You can't, I am given access rights to refer patients to MDT S. I wasn't confident in this diagnosis. Do you know what the guidelines are to refer them to the MDT? Yeah. Ok. No further questions Thank you very much. Thank you for that. So, uh the last part of uh the Q and A as a part of cross examination, I'll invite uh uh the claimant barrister uh sorry uh to intricate Doctor Gamma. Ok. Um Could you please state your name role and the hospital you work in currently? I'm Doctor Gamma. I'm a consultant, gastroenterologist at the Sun Hospital. And how long you have been working in your unit? Um as a consultant for 13 years now, 13 years. And of course, you would be jagged today. Yeah. So can you tell me why this patient was referred to you? They were just sent to me as routine follow up. OK. And the findings when you scoped this patient. So actually the classifications were c naught M two barretts with no active information. There was a five cm hiatus hernia, but there was also an eight mill discrete lesion paris classification of Paris two. Um So I took multiple biopsies of this lesion that I'd identified um sent it away to the lab for urgent analysis. OK. And uh when the analysis came back, what did it show? It showed high grade dysplasia with at least intramural adenocarcinoma? Ok. And was the patient, these findings were related to the patient? Yes. So we arranged for the patient to come back urgently and we explained the results with the patient's family to explain what was going to happen next, which was of course, that I referred them to the MDT. Ok. And so what are the guidelines, at what point the patients are referred to the MDT? Once you have any signs of high grade dysplasia, any signs of dysplasia, they're referred to the MDT where they could have some investigations. Ok. Um, so in your opinion, would the treatment have been altered if this referral was made like six months ago or at the time of previous scope? So according to the literature, um untreated, high grade dysplasia can become an invasive carcinoma in 20 to 50% of patients. So we have, so we've already identified, we had a missed opportunity to offer the patient an MDT and an endoscopic um assessment and some therapy. So in my opinion, on balance of the probabilities, looking at the literature, I'd say probably over 50 per cent chance that the patient would have been cured if they'd been referred to the MDT and had the removal and the therapy in 2044. I rest my case with you, your honor. Thank you all. So you heard the story and obviously, you know, this is more of a journey of this patient in the eyes and minds of the defendant side as well as the claimant side. So through this intro, I hope you agree with me that, you know, we are able to sort of answer these three questions. The first question is, was the endoscopy performed to adequate standard of care in a timely fashion. Obviously, you know, it's below par competency was uh questionable because there was so much of variation between 1st and 2nd endoscopy by Doctor Alpha. And also there was admin, you know, uh uh delaying the second endoscopy. And the second one was what actions were taken once high grade dysplasia was diagnosed and non referral to MDT resulted in no further discussion, no investigations, patient was actually given an and and again, that delayed at least 6 to 7 months before patient went to the Sun Hospital to have another endoscopy by Dr Gamma. So what would have been outcome? So we discussed it basically. So any dysplastic lesion which is much more precancerous can become cancerous 20 to 50% of the time. And unfortunately, at least at the time of third endoscopy in this episode, at Sun Hospital demonstrated some precancerous two cancerous changes. So the judgment by myself is Mr Ayo is read as follows. Doctors and medical personnel do amazing work daily basis with the intention of improving health of millions of patients. But mistakes do happen in this case on the balance. Witnessing the trial, scrutinizing the correspondence, scrutinizing the legal reports. I confirmed that the substandard endoscopy assessments by Doctor Alpha in the Moon hospital. And in action, once the diagnosis of high grade dysplasia caused preventable delay in receiving the right treatment in the right time. The likelihood of cure means complete endoscopic excision of this nodule would have enhanced the cure by more than at least 50% following this endoscopic complete excision. Most patients advised just a radio frequency therapy not an operation to ablate rest of the barrett segment. Sadly, this was not the case in in MP. So it's insupportable to reassure the patient to go on to just medication in the form of antacids. Once you establish the diagnosis of high grade dysplasia, this has to be regarded as completely missed opportunity of cure that later resulted in invasive early cancer patient received subsequent toxic chemotherapy that is not without side effects. So in summary, I would award the claimant final $50,000 best deal cost the case ends. Ok. I'm just going to become a ok. Coming back to my my real out. Ok. So in short, you, you learned how this goes on, you know, a smart endoscopies senior are training is very, very good at these procedures, probably just a misjudgment or or missed opportunity. And and uh you know, a established endoscopy unit at the Moon hospital resulted in a dysplastic lesion going on to invasive cancer on a 71 year old, resulting in a huge amount of psychological trauma, physiological trauma, physical trauma. And this patient went on to develop various complications. As a little came, I don't want to go into details, but she all few of them include, she developed pulmonary embolism and also stricture due to radiotherapy. So again, going back to the constraints of typical pain, uh a claim which includes duty of care, you can answer yourselves, breach of that duty and the harm caused as result. So I'm sure you agree with me that all these can be ticked in this particular case when we give any reports, you know, there is a format which we have to follow in a causation report, which is the first or second report followed by the last but not, but one when it goes to the High Court of Justice where we have to submit all these in the legal terms and explain to the solicitors to the uh and subsequently to the judge. So that's us. And thank you for being here and I'm going to sort of sign out and invite any questions. Um And can I ask uh to come on to the di as well? Uh Please, thank you. And I would uh please join with me to uh applaud the actors here. So, uh they, they were spontaneous and uh you know, we went through a bit of rehearsals uh every night after nine, around 89 pm or 8 p.m. So there you go. So, uh thank you again. Yeah, uh go to yourselves for any questions, please fire away in the novel character. I've got a very quick question for you. What is from your perspectives when it comes to the legal side of things is apologizing to a patient for a mistake that's happened, admitting culpability and how is that used in sort of a medical legal aspect in terms of a clinical case such as this, there is statutory protection for the fact that an apology does not amount to an admission of liability. Now, of course, there may be cases say such as this where you've got fairly clear expert evidence that look, there was a clear breach of duty here that you know, whether you apologize or not, that's, that's going to be difficult to defend. The thing I would say about apologies though is that if you're giving an apology, give a proper apology, don't say I am sorry if you feel that or the worst thing I've probably read is I'm sorry for the inconvenience of you having been delayed with cancer, diagnosed with cancer. You know, that give a proper apology if you feel that something is unreasonable and there is no need to apologize, give an explanation. So, you know, and do that with reference to an external source. So they're not just having to believe you. If someone says I should have had this procedure done at this time, you'll say, well, I know you'll naturally feel like that because you've had a given diagnosis and we're really sorry that you've had that diagnosis. But I can set out here why we took the approach we did and why that is supported by authoritative guidance or the specific circumstances in your case, any comments most important along with what he said is documentation, timeliness and having a third person in the room chaperone or somebody, you know, it's very, very important. It just um harmonize the whole atmosphere. So besides uh what's that? Forgot any other questions? Yeah. Yep. Thanks very much for that. That it was brilliant. Um Quite a broad question. So I guess post pandemic there have been in certain specialties, a huge amount of missed cancers by means of not having the resource to scope people or image people or just get people to outpatient clinic. Um Have you seen a rise in litigation following that? And how's it dealt with, do the hospital sort of get out of it because, oh, it's COVID that's happened. And how does that work? And then sorry part two is um with regards to missed tumors. Uh I know in colorectal, the literature around tumor growth rate is really replete. Um And so how do you go about advising on whether or not something was missed because the tumor has grown in time? I don't know about the numbers. I don't know about m statistics but going back to part one, no doubt, partly because of the fear of COVID, partly because of non existent medical services during the pandemic has resulted in upstaging of various cancers. I deal with the esophagus and stomach like in a few of you deal with colorectal and others. So certainly it has upstaged. Um But at least to, to, to to ourselves. It's a multifactorial. It's very difficult to say if the patient doesn't come and seek my help, I can't do the majority of scenarios where we are, we are seen no doctor, I was afraid or whatever. So, so it has not resulted in the eyes, at least in the world o cancer in litigation as such. But certainly in the MDT, for example, if I see 100 patients, 30 to 35 would go for under knife. Now we are seeing less than 20. That's kind of the same thing. I can't speak of, you know, other specialities and I do share similar information. Uh So yeah, I think it's an interesting question. The, um we know, don't we from the data out there that given the number of cancers diagnosed during that period, that there will be plenty out there that haven't been diagnosed? I think in terms of what view a court would take of the impact of the pandemic that will depend on a, a case by case basis, you know, if the actions were taken were reasonable in that context and were supportable with expert evidence, then then that's, that's a defense to some degree, you know, if it's an NHS case, then obviously those are dealt with by NHS resolution and II certainly can't speak for them, but they may take a policy view on what they do with those cases. And by that, I might mean to say, look, we will still compensate people who were disadvantaged because of the pandemic. Um So I think that's a really interesting question. The other thing is, is, it's really, it's impossible to know where the, what the impact of that is because there's, you know, although there's a, a thing called a limitation period of three years, so somebody has to bring a claim within three years of the date. They know that they've suffered harm, um, to come through the system. These things take quite some time, you know. So, so that's the first thing, the other thing, the point you made about tumor growth rates is a really interesting one because in a situation like this where you've got a clear breach of duty, like in this scenario on the biopsies. Well, actually, if you were defending that and to be honest, I think that's the sort of case that would be settled. Well, before litigation, the thing you may be looking for is that causation point in that, is it simply true that had the biopsies been taken, there would have been a better outcome, you know. So II think that's and essentially the way the court will look at that is look at expert evidence. If there's conflicting expert evidence, they will hear the evidence and pick one frankly. That's, that's how it will work out. And you may well not agree with how the court has looked at that evidence, but that is how the findings of fact work got time for one final question from the floor. Thanks just to lead on from what you mentioned there about documentation. This has briefly alluded to in the case as well. It's fairly common practice that you observe for one person to ask another person to document their advice and sometimes their review or their involvement in a case. Where does that leave people medical legally? And is that considered appropriate practice in this kind of setting? So I if I take that one, that there's obviously a, you know, there's various requirements, particularly regulatory one that you keep adequate records. Now, if you ask somebody else to make those records, that's in effect, a delegation of your duty, isn't it? And it's up to you then to know that they're competent to take that record and to, you know, to, to make it to an appropriate standard. So I guess you're still accountable for that decision to delegate. And I know that you'll have had experiences of having a 20 minute conversation with a patient and somebody's written, continue in the record as, as that. So it, it's kind of, you know, you still are responsible for that. I guess the other thing is to talk about the status of medical records in a process like this, the records are evidence. Now, they're pretty good evidence. Um But it, it, it is, you know, you in a case like this, you would be saying, well, actually that's what's written. But, and if it's within time, you can recollect to say, look, this is what I recall happened and you might have other sources of evidence to back that up. The problem. The real disadvantage is is that these claims can come in a long time after the events, you'll have seen thousands of patients. This will be something that is burned in the memory of the patient. And it's, you know, the question of whose account will be believed? You'll have a strong bias towards the patient's account in that setting for those reasons if, if it's not clearly documented. Yeah, thank you. So, any further questions last from anybody? Thank you very much for that. That was a fantastic session taking us through a mock trial there. So can I just have another round of applause for all of our members up on stage there? Thank you.