What I Do - The Expert in Clinical Microbiology

First, I must declare my hand - I do not belong to the EWI or to any other "expert" societies - I joined the EWI at its foundation but only for a year. Their aims are laudable and they offer an excellent service but it is not for me.

I was first instructed as a microbiology expert while still working as a consultant at St Thomas' Hospital, running the clinical infection service and doing much of the teaching. It was something of a baptism by fire as the case, which involved gentamicin toxicity, went to Court and, to make matters worse, it was a split trial. After this I was asked to do many more cases and, although I did the work in the evenings and at weekends, I found most of it very interesting and I learned a huge amount from other experts, particularly those in other specialities than microbiology and from barristers. After doing this for about five years I retired from St Thomas' but continued to teach on the course for the membership of the Royal College of Surgeons (MRCS). I had a huge backlog of medicolegal cases and thought that when I finally got through them the requests would dry up but this did not happen. Indeed, not only have instructions continued, but they have increased. In marked contrast to my NHS life, I conclude that I am instructed because I am a competent expert. I found it profoundly depressing that in the NHS it does not matter if you are incompetent or indeed absent, the remuneration is the same. I have been instructed by almost 300 different solicitors and my claimant/defendant split is about 60/40 but this varies from year to year. I have been a single joint expert, involved as an expert in a GMC and, later Home Office hearing and two murder cases. Speaking at medicolegal meetings resulted in an increase in enquiries; I suspect that solicitors write down my name as "useful".

Assessing the medical documents, and there may be many lever arch files, takes several hours and I make it an absolute rule to read every word on every page. Often important nuggets of information are hidden in a nursing care plan or other notes. On the day I can no longer be bothered to do this, I will stop at once. Then there is the report to prepare and I find that most take at least a day to write. In general medicolegal work is much more exacting than being a clinical microbiologist in the NHS.

My working life has been spent dealing with the problems of infection in patients. Though based in the laboratory, I have accumulated a mass of experience relevant to medicolegal work. Throughout my career I have kept detailed records of patients with a large variety of infections and all cases of bacteraemia and meningitis. These data were computerised many years ago and continue to this day by my successors. Now it is extremely easy to keep abreast of new developments in microbiology with PubMed maintained by the US National Library of Medicine and the like, and reviews such as the expensive but excellent American UpToDate publication. Previously, I just kept a huge, and carefully catalogued, mass of literature references.

Administrative lessons learnt

Fees and all that

My career has been working for the NHS and a Medical School and, although I often advised colleagues on infections in their private patients, I never submitted accounts for my services. One cardiac surgeon, whose sternal and other infections I sorted out, used occasionally to give me lunch at the Garrick. This may sound incredibly naive and meant that when I entered the real world of writing expert reports and attending conferences with counsel, I had no idea that quite often the solicitors involved would not settle my accounts for many months. Had it

not been for the excellent advice of a streetwise neurosurgeon, I would not have known how to address this problem - I do now! The question of appropriate fees is also interesting; bodies such as the MDU and BMA provide guidelines but I find it easier to check with other experts and I have received unfailingly helpful guidance from orthopaedic surgeons. As my fees have never been queried, my conclusion is that I am not at the greedy end of the spectrum.

Occasionally I am asked to provide an "overview" of a case for which only the "relevant pages" of the documents are sent. This might be termed a "cheap" overview, for that is the intention, and the case will usually be one with a conditional fee agreement (CFA). Whilst in such cases, I am reluctantly prepared to wait for payment, I never accept what I refer to as "filleted" documents.

As of May 2007 medicolegal experts have had to register for VAT, something I had tried not to think about. My husband, who was a chairman of the VAT tribunal, constantly nagged me but even though HM Customs and Excise have sent me several impenetrable brochures on the subject, it is quite beyond me to fill in the required forms. It is one more thing to do, so I turned to my accountant.

Availability

As a consultant, I never had a secretary but fortunately, by courtesy the NHS, I became computer literate some years ago. Thus, I am self-sufficient and now employ no one save for the intermittent and expensive services of a computer geek. Thanks to mobile phones and the ubiquitous e-mail, it is quite possible to keep in touch. Most recently, while living in a tent at 14,500ft on a horse-riding holiday in Peru, I was telephoned by a solicitor at 5am local time!

Recommending other experts

Solicitors sometimes asked me to recommend experts, and not only microbiology experts. To my cost, I have learned never to recommend anyone without having personally seen at least one of their medicolegal reports; it is not a good idea to recommend people who are very good doctors and nice people or even ones friends. I keep a list of all the "good" experts I encounter in a variety of specialities, not only microbiology, and also of those to avoid. Some solicitors have even asked which barristers they should to go to! Maybe I have a future as some sort of agent.

Trials

Legal colleagues tell me that only about 1% of medicolegal cases actually go to Court. It seems to me an expensive lottery and best avoided. This means that I have only been in Court on about eight occasions. However, trials are always booked and I am already getting bookings for 2009, for which I do not even have a diary. Much of 2008 is back to back trials, some running concurrently. I used to avoid trials dates when organising holidays but I now adopt a much more cavalier approach. One rarely is one told until rather late in the day that a trial is going ahead and sometimes one is not even informed that it will not take place. Some years ago I went to the Court in Cardiff, only to find the Court door locked and a clerk told me that the case had settled; no one had bothered to let me know.

Range of cases

There is hardly a clinical specialty on which microbiology does not impinge, including general practice. I have been involved with orthopaedic surgeons, plastic surgeons, vascular surgeons, neurosurgeons, colorectal surgeons, general surgeons - do any of these remain? - ENT surgeons, ophthalmologists, gynaecologists and obstetricians and physicians of all varieties as well as paediatricians and neonatologists.

I am not enamoured of the personal injury lawyers and once made a fatal error of speaking at one of their meetings, which resulted in a rash of enquiries. Occasionally, however, they provide some interesting work, as when a client who has usually had some sort of major accident, appears to have deteriorated as a result of a sojourn in hospital.

The last few years have seen me instructed by solicitors who act for people who travel to sunny climes and get gastroenteritis. I used to think that diarrhoea was part of travel - travel broadens the mind but loosens the bowels - but now they sue the travel companies and sometimes in large numbers; a recent case involved 78 people who had an unfortunate experience in the Dominican Republic. Never in my wildest dreams did I imagine that last year I would spend a whole day in Court in Birmingham discussing Salmonella enteritidis in scrambled eggs served in a dodgy hotel in Corfu!

Some common microbiological themes

I have lost count of the huge number of cases of infection with methicillin-resistant Staphylococcus aureus (MRSA) I have done, and I turn down many, especially those in which the solicitor's letter refers to the MRSA virus! The public, educated by the media, tend to think that if they acquire MRSA in hospital, compensation is virtually automatic. This is, of course, far from the case. Notwithstanding the MRSA case of an infected hip replacement that succeeded on the basis of contravention of the COSHH regulations (Kitty Cope v Bro Borgannwg NHS Trust), it is actually difficult to prove that the acquisition, as opposed to the management, of an MRSA infection has been negligent; in very few of the cases that I have done has this been the case. The most glaring example of negligent acquisition is when a patient is screened for MRSA before admission to hospital, is found positive, no none notices and an elective operation goes ahead with the inevitable consequences. When assessing the acquisition of MRSA, it is vital to obtain data on numbers of MRSA on the relevant ward(s) at the relevant time and also to obtain the Minutes of the Infection Control Committee meetings. The latter usually provide useful information - most recently an acknowledgement of a bed occupancy of over 100%! Post-operative MRSA infections were until recently the prerogative of NHS hospitals but now the private sector is not immune.

Methicillin-sensitive Staphylococcus aureus (MSSA)

There is a common misapprehension amongst some doctors that MSSA are much more benign microbes than MRSA. Whilst many strains of MRSA are undoubtedly very aggressive bacteria, MSSA can also be virulent pathogens and they cause numerous community and hospital-acquired infections. The essential difference, when considering acquisition, is that some 25-30% of normal healthy people in the community are carriers of MSSA, community carriage of MRSA is most unusual; it is still a hospital microbe. I was interested to note that many newspapers who recently reported the large award to Lesley Ash, referred to the MSSA that caused the infection as a variant of MRSA!

Clostridium difficile

Not until last year was I involved with a case of Clostridium difficile infection. Undoubtedly there has been a huge increase in such cases, some fatal, and a major factor has been the arrival of the hypervirulent O27 strain which can cause devastatingly severe infection. I have even had two cases of hapless patients who acquired not only C. difficile but MRSA as well.