Mr Stephen E Mccabe, FRCS, FFAEM

1st Report

Re:

20th November 2007

McCabeMedicoLegal Limited

Mr Stephen E McCabe MBChB FRCS FCEM

Consultant in Emergency Medicine

Telephone and Fax 01452 814 553 Email:

Website:

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MEDICAL REPORT

IN RESPECT OF:

Name of Patient

Stephen E McCabe FRCS FCEM

Consultant in Emergency Medicine

SEM/

1st Report

Re:

20th November 2007

MEDICAL REPORT

CLAIMANT DETAILS

Name:

Date of Birth:

Address:

Occupation:

Time off work:

Date of Incident:

Materials relied upon:

Date of Examination:

Clinic Venue:Winfield Private Hospital, Gloucester

Instructing Party:

Our Ref:SEM/

This is a report to the Court upon the history of the injuries sustained by the claimant, his/her treatment, condition and prognosis.

Stephen E McCabe FRCS FCEM

Consultant in Emergency Medicine

SEM/

1st Report

Re:

20th November 2007

SUMMARY CV of MR STEPHEN E McCABE FRCS FCEM

I have been a fully accredited Accident & Emergency Consultant since 1988 and am currently Senior Consultant in Accident & Emergency Department at Gloucester Royal Hospital.
I am a Founding Fellow of the Faculty of Accident & Emergency and a Fellow of the Royal Colleges of Glasgow and Edinburgh.
I am an Examiner for the final College Exam (FCEM)
Medico-legal work has been a major interest over the last 15 years, attending training seminars on Woolf reports, giving expert evidence in court and report preparation in general.
My medico-legal work has involved the preparation of approximately 500-700 reports a year, joint statements with colleagues, pre-trial negotiations and giving expert witness evidence in the High Court and the Court of Appeal. The latter includes being cross-examined by Michael Mansfield QC in the Court of Appeal.
I was trained in general surgery and orthopaedics in Glasgow and in A&E on the Bristol rotation. During the latter I undertook training attachments in neurosurgery, plastics and burns at Frenchay Hospital, Paediatrics at the Bristol Children’s Hospital and further Orthopaedic training in Taunton and Bristol.
My work at Gloucester Royal Hospital includes interests in major trauma, head and neck injuries, resuscitation, sports and soft tissue injury.
Neck injuries constitute the majority of cases in my personal injury practice.
I have published widely on trauma, fractures and emergency medicine, and am a referee for papers for the Journal of A&E Medicine.
I was the sole author of a review chapter on ‘Neck Injuries’ in a CD-ROM for personal injury lawyers, principally entitled ‘MedicoLegal Solutions – Personal Injury and Criminal Trauma’ (Medicolegal Publications).
I was involved in the national launch of the ‘Whiplash Book’ for patients and the ‘Whiplash (WAD) Training Pack’ for professionals at the Royal Society of Medicine in January 2003.
Recently published a doctors guide to writing reports on neck and back injuries on Doctors.net, the UK’s largest online resource for doctors education entitled “ Excellence in preparing medicolegal reports “
I am currently collaborating with Prof.M.Cooke in the national “MINT” trial of physio vs. standard treatment in Neck Injuries with over 300 patients recruited thus far (Spring 2007).
My Department sees an average of 60 new patients a month with neck injuries sustained in road traffic collisions.

Stephen E McCabe FRCS FCEM

Consultant in Emergency Medicine

SEM/

1st Report

Re:

20th November 2007

1SUBSTANCE OF REPORT

The report is prepared on the basis of instructions received from instructing solicitors by letter dated 22nd November 2006. In preparing the report I have relied upon information provided by NAME OF PATIENT during enquiry and examination at the Winfield Hospital as well as the materials listed.

2DETAILS OF INCIDENT

2.1Name of patient described a slipping incident as she was entering a marquee on the 15th July 2005, falling forwards onto her outstretched hands and face. Her hands and face fell onto a gravelled car park surface. She became increasingly aware of severe pain in her wrist over the next few hours. She describes the pain as 10 out of 10 arising from her right wrist.

3HOSPITAL TREATMENT

3.1She attended the Emergency Department at the Great Western Hospital in Swindon at about 1.46pm. She gave the above history and was immediately given a combination of Co-codamol and Brufen tables for pain. X-Rays of the right wrist are available on CD. They demonstrate a displaced fracture of the proximal third of the scaphoid.

4SUBSEQUENT PROGRESS

4.1When she was first seen in the Fracture Clinic the decision was made that she would benefit from internal fixation.

4.2Arrangements were made on three occasions in the next week or so for her to come in for the operation but on three occasions it was cancelled. This almost certainly arose because of bed availability problems.

4.3She was eventually admitted on the 28th July 2005 and underwent a Herbert Screw internal fixation under general anaesthetic.

4.4She was discharge the following day and followed up in the Out Patient clinic by the Orthopaedic surgeons. The wrist was mobilised freely without plaster post-operatively.

4.5 Despite the free mobilisation she developed substantial stiffness in the first few weeks after the operation. She describes her hand as being extremely swollen in the first few weeks.

4.6She experienced pins and needles in the little and ring fingers and occasional shooting pains around the base of the ring finger of her right hand in the first three to four weeks following the operation. The later symptoms resolved thereafter.

4.7When she was reviewed in March 2006 she reported continuing aching around the wrist and there was some continuing tenderness. X-Rays at that stage in March 2006 showed that the fracture line was still visible although probably 50% healed.

4.8A further review in September 2006 revealed improvement in the X-Ray appearance such that the fracture line was only now barely visible on the X-Rays that are available to me from September 2006.

5ONGOING SYMPTOMS ARISING FROM THE ACCIDENT

5.1There are no residual symptoms from the grazing injuries to the hands, to the face and jarring injuries to both shoulders.

5.2There continues to be discomfort and weakness in the right wrist in association with a scaphoid fracture. The discomfort is mostly low grade scoring 2 out of 10 on the pain scale. She rarely takes pain killers now. She did take pain killers between the time of the injury and Christmas 2005.

5.3She attended the physiotherapist on six occasions between September and December 2005 with some considerable benefit.

5.4There remains low grade discomfort in the hand however, and she is acutely aware of persistent weakness of grip for a variety of tasks requiring adequate grip strength of her largely dominant right hand are affected by her weak grip. Activities such as opening jars, driving or pushing or lifting heavy objects are associated with weakness and discomfort.

6PAST MEDICAL HISTORY

6.1patient has a long history of low back pain over the last four or five years. There is a letter from the GP in June 2005 suggesting that her back pain had recently been increasing and deteriorating and she was referred back to the Orthopaedic surgeon. She has undergone further MRI scanning of her back which reveals bulging discs at the L4/5 and L5/S1 level. These two discs have almost certainly been bulging for several years. They were almost certainly responsible for the symptoms she had treated by choroidal epidural injection a few weeks ago in an attempt to control her deteriorating pattern of low back pain.

6.2There was a short period after the fall when her low back pain was exacerbated but there has been an overall pattern of deteriorating back pain over the last two years that precedes and pre-dates this fall.

7OCCUPATIONAL LOSSES

7.1patient is job title and place of work. She was unable to return to work for a period of nine weeks.

7.2When she did return to work she still had difficulty in using the keyboard or the mouse and a colleague did a lot of the typing for her. She still gets an ache in her wrist if she uses the mouse too much,

7.3She has difficulty in shaking hands with people who call to visit the Principal. She has difficulty carrying anything heavy in her right hand. She tells me that even a cup of coffee might be too much for her to carry if she had to go any distance or up and down stairs. She tends to carry things like coffee in her left hand now, not her right hand.

7.4She drives about 8 miles to and from work on a daily basis. She was unable to drive at all for the first nine weeks after the fall. She continues to find driving painful, particularly holding the steering wheel for manoeuvres such as reversing or parking. She took the decision to change to an automatic car in the aftermath of the fall and I would support that decision entirely.

8SOCIAL AND DOMESTIC DIFFICULTIES

8.1She lives alone normally but fortunately her son was in the summer break from University and managed to find a job locally. He came home and lived with his mother during the crucial first two to three months following her surgery when she was largely unable to do the majority of household tasks. Tasks such as hoovering, cooking, cleaning and ironing were all extremely difficult as she did not have very much use of her right hand in the first two months after surgery.

8.2She has a small garden which she was unable to tend in the first months after the operation.

8.3She was largely housebound for the first nine weeks as she was unable to drive. She cancelled a walking holiday in September 2005.

9SPORTS AND HOBBIES

9.1She regularly goes to the gym and undertakes Pilates and aerobics. She had great difficulty in doing anything in the first three months after the operation. She continues to have difficulty with tasks such as press-ups or floor activities where she has to put any pressure on the right wrist.

10EXAMINATION

10.1I examined name of patient on the 18th December 2006 at the Winfield Hospital when she gave a straight forward, honest impression.

10.2Examination was largely confined to the right wrist. There are no residual cosmetic abnormalities resulting from the grazing injuries to the hands or chin and there is a full range of movements to the shoulder.

10.3The right wrist demonstrates continuing dramatic weakness of gripping activities in particular. Full gripping activities were tested with a sphygmomanometer cuff device. Maximal repetitive grip with the right hand was 40 to 45% of maximal levels achieved with the right hand using this same 5 squeeze test. Maximal single grip strength was 40 to 45% lower in the right hand than in the left hand.

10.4There is full preservation of mobility.

10.5The anatomical snuff box is non tender. The wrist joint is stable.

10.6There is an ugly, somewhat lumpy, bright purple 5 cm scar over the dorsum of the wrist travelling in a vertical direction. The scar is non tender but is easily visible from a distance of 5 to 10 yards.

11CONCLUSION

In a slipping incident on the 15th July 2005 it is consistent with the mechanism reported, that patient sustained the following injuries:

1multiple superficial grazes to the hands and chin

2minor jarring injuries to the shoulder

3fractured scaphoid bone in the right wrist requiring fixation, ongoing grip weakness.

There were no major psychological impacts.

12COMMENTS AND PROGNOSIS

12.1A period off work as a secretary and PA was, I would suggest, entirely reasonable.

12.2Maximal pain level was experienced on the day of the injury when the pain was described as 10 out of 10 on the pain score. Until the wrist was immobilised and plastered there was a period of sleep disturbance which was maximal in the first week following the fall but there was occasional sleep disturbance in the next three to four weeks.

12.3There was substantial swelling of the hand in the first three to four weeks after the operation.

12.4The operation consisted of the placement of a compression screw device called a Herbert Screw across the fracture between the proximal and distal poles of the scaphoid bone. Check X-Rays revealed that the operation has largely been successful given that there is now 70 to 80% disappearance of the fracture line on most recent X-Rays in September 2006. In other words the majority of the fracture has united and scaphoid bone is now stable.

12.5The low grade dull aching discomfort in the wrist is common place in the first two years after surgery of this nature. I expect the low aching to improve substantially over the next twelve months to only occasional levels.

12.6The persisting and quite profound weakness of right handed grip strength in a largely right hand dominant lady is of some concern. The only solution to the problem of persisting weakness is repeated and prolonged exercising over, I would suggest, the next twelve months. Over that period I would predict that up to 80% of former pre-operative grip strength can be returned. It is however, in my experience, unlikely any more than 80% of grip strength to return after an operation of this nature.

12.7No further surgery is anticipated. I expect the fracture to have completely united within the next six to twelve months.

12.8The screw should remain in place ad-infinitum.

12.9I do not anticipate that there would be any further benefit from physiotherapy. name of patient is well motivated and will, I believe, undertake the exercises regularly and on a daily basis over the next twelve months with good effects.

12.10I would entirely support the decision to change from a manual car to an automatic in order to make holding the steering wheel with both hands much more practical and avoid the twisting and turning manoeuvre using one hand that accompanies driving a car with a manual gear box.

12.11In the long-term I would anticipate no major difficulties with her continued employment as a PA.

12.12I do anticipate any surgery in the long-term.

12.13I anticipate considerable improvement in her ability to undertake virtually all tasks with her right hand over the next twelve months with continued rehabilitation.

12.14There should be no accelerated propensity to arthritis in the wrist.

Stephen E McCabe FRCS FCEM

Consultant in Emergency Medicine

SEM/

1st Report

Re:

20th November 2007

EXPERTS DECLARATION

I understand that my overriding duty is to the Court, both in preparing reports and in giving oral evidence. I have complied with and will continue to comply with that duty.

I am aware of the requirements of Part 35 and practice direction 35, the protocol for instructing experts to give evidence in civil claims and the practice direction on pre-action conduct.

I have set out in my report what I understand from those instructing me to be the questions in respect of which my opinions as an expert are required.

I have done my best in preparing this report, to be accurate and complete. I have mentioned all matters that I regard as relevant to the opinions I have expressed. All of the matters on which I have expressed an opinion lie within my field of expertise.

I have drawn to the attention of the Court all matters, of which I am aware, which might adversely affect my opinion.

Wherever I have no personal knowledge, I have indicated the source of factual information.

I have not included anything in this report which has been suggested to me by anyone, including those instructing me, without forming my own independent view of the matter.

Where, in my view, there is a range of reasonable opinion, I have indicated the extent of that range in the report.

At the time of signing the report I consider it to be complete and accurate. I will notify those instructing me if, for any reason, I subsequently consider that the report required any correction or qualification.

I understand that this report will be the evidence that I will give under oath, subject to any correction or qualification I may make before swearing to its veracity.

I have not entered into any agreement where the amount of payment of my fee is in any way dependant on the outcome of the case.

I confirm that I have made clear which facts and matters referred to in this report are within my own knowledge and which are not. Those that are within my own knowledge I confirm to be true. The opinions I have expressed represent my true and complete professional opinions on the matters to which they refer.

Stephen E McCabe MBChB FRCS FCEM

Consultant in Emergency Medicine

Date: 10 January 2XXX

Stephen E McCabe FRCS FCEM

Consultant in Emergency Medicine

SEM/

1st Report

Re:

20th November 2007

Stephen E McCabe FRCS FCEM

Consultant in Emergency Medicine

SEM/