Paediatric Brain Injury

Clinical basis for the opinion

Traumatic brain injury is a significant component of my consultant practice at Alder Hey Children's Hospital, a tertiary paediatric neurosurgical centre. I manage both operative and non-operative paediatric head injury, including extradural and subdural haematoma, depressed skull fracture and diffuse axonal injury.

Because that practice is current, opinion is informed by contemporary paediatric neurosurgical 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 and with regard to the resources and expertise reasonably available there.

Issues commonly in dispute

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

Delayed or missed diagnosis of intracranial injury

A common issue. The dispute usually concerns whether the presentation warranted imaging under the applicable guidance, whether the threshold for CT was correctly applied in a child, and whether neurosurgical referral should have been made earlier than it was.

Extradural haematoma

Presentation may include an initially well or apparently recovering period followed by neurological deterioration, and cases frequently turn on what was recorded during that period and whether deterioration was recognised. Outcome is strongly time-dependent, which makes causation arguments unusually sharp.

Subdural haematoma

Timing of recognition and evacuation, management of raised intracranial pressure, and whether transfer to a neurosurgical centre was arranged promptly. I do not currently accept instructions concerning suspected non-accidental injury.

Depressed skull fracture

Whether elevation was indicated, the timing of any operation, and the management of associated dural or cortical injury.

Adequacy of initial assessment and observation

Frequency and quality of neurological observations, use of paediatric early warning scores, escalation when observations deteriorated, and whether transfer to a neurosurgical centre was arranged appropriately.

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, and on prognosis so far as it can be addressed from the records.

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. 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

The material that most affects the quality of the opinion in this area is:

• Emergency department records including triage, observations and any imaging decision documentation
• All CT and MRI imaging with the formal radiology reports
• Ambulance and pre-hospital records
• Paediatric early warning score charts and nursing observations
• Neurosurgical records and operation notes
• PICU records where the child was ventilated
• Any transfer documentation between hospitals
• Witness statements from parents describing the injury and the child's condition

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.