Hydrocephalus & Shunt Complications

Clinical basis for the opinion

Hydrocephalus management forms a core part of my day-to-day consultant practice at Alder Hey Children's Hospital. I undertake CSF diversion procedures including ventriculoperitoneal shunting, endoscopic third ventriculostomy and shunt revision surgery. Before my current appointment I was a consultant in both paediatric and adult neurosurgery at Sheffield Teaching Hospitals (2024–2025).

Because that practice is current, my opinion is informed by contemporary hydrocephalus management, while the standard of care applied is that which applied at the material time, judged in the clinical setting in which the care was actually given.

I am a Sub-Investigator on ENLIVEN-UK, the national randomised trial of neuro-endoscopic lavage for neonatal intraventricular haemorrhage, recruiting, operating on and following up trial patients at Alder Hey. I was also a collaborator on BASICS, the multicentre randomised trial comparing antibiotic and silver shunts with standard shunts in preventing shunt infection, published in The Lancet in 2019.

Issues commonly in dispute

Instructions in this area most often turn on one of the following.

Delayed diagnosis of shunt malfunction

A common issue. Shunt malfunction presents variably in children, and the dispute usually concerns whether the presenting symptoms and signs — headache, vomiting, drowsiness, changes in a child's behaviour reported by a parent — should have prompted imaging and neurosurgical referral earlier than they did, and what the outcome would have been had they done so. In young adults the same dispute arises in emergency departments and adult services, where a long-standing shunt may not be recognised as the likely cause of the presentation.

Shunt infection

Questions arise over the adequacy of peri-operative measures, the timeliness of diagnosis once infection was suspected, the choice between externalisation, removal and antibiotic treatment, and the management of ventriculitis and its sequelae.

Timing and appropriateness of revision

Whether revision was indicated, whether it was performed sufficiently promptly, and whether the operative strategy adopted was one that a responsible body of paediatric neurosurgeons would have chosen.

Endoscopic third ventriculostomy

Patient selection is the usual issue: whether ETV was an appropriate alternative to shunting given the aetiology and the child's age, how the risk of late failure was assessed and communicated, and whether post-operative surveillance was adequate.

Complications of CSF diversion surgery

Over-drainage, subdural collections, catheter migration, abdominal complications of the distal catheter, and loculated or multi-compartment hydrocephalus arising from repeated intervention.

What can and cannot be addressed

Instructions are accepted on a records and papers basis. Opinion is therefore provided on breach of duty and causation — whether the care fell below a reasonable standard, and whether any such failure caused or materially contributed to the injury alleged.

Claimants are not examined, so condition and prognosis reports that depend on examination are a separate instruction — in paediatric neurosurgical claims usually to a paediatric neurologist, neurorehabilitation physician or paediatrician. Where a case requires both, instructing solicitors generally instruct separately for the breach and causation issues and for condition and prognosis.

Opinion is confined to paediatric neurosurgical practice and to young adults with hydrocephalus that began in childhood. Normal pressure hydrocephalus, idiopathic intracranial hypertension and hydrocephalus arising for the first time in adulthood fall outside this scope. Matters turning principally on neuroradiological interpretation, paediatric neurology or neurorehabilitation are better directed to an expert in the relevant field, and will be identified as such at the enquiry stage rather than after papers have been sent.

Records that assist

For hydrocephalus cases specifically, the material that most affects the quality of the opinion is:

• The complete neurosurgical record, including all previous shunt operations and revisions
• Operation notes for the index procedure and any prior CSF diversion
• All cross-sectional imaging and the formal radiology reports
• Shunt series and any programmable valve settings
• Emergency department, general paediatric or adult medical records for the presentation in question, and any transition clinic correspondence
• Nursing observations and any early warning score charts
• The patient's or parents' account, where a witness statement exists

If material appears to be missing this is raised before work begins rather than qualified in the report.

Basis of instruction

Instructions are accepted from claimant and defendant solicitors, from insurers, and as a single joint expert. Reports are prepared in accordance with Part 35 of the Civil Procedure Rules, Practice Direction 35 and the Civil Justice Council's Guidance for the Instruction of Experts in Civil Claims, and carry a statement of truth and the expert's declaration of duty to the court.

Reports are typically prepared within four to six weeks of receipt of all relevant papers. Answering Part 35 questions, taking part in experts' discussions and joint statements, and attending conference with counsel are all within scope.