Delayed diagnosis of a childhood brain tumour is among the most frequently litigated allegations in paediatric practice, and among the hardest to opine on. Early symptoms are common and non-specific; the question is rarely whether they were present but whether their pattern, persistence or progression should have prompted imaging sooner.

Clinical basis for the opinion

Paediatric neuro-oncology is a subspecialty area of my current practice at Alder Hey, where I am a member of the neuro-oncology multidisciplinary team. My operative practice covers the range of paediatric CNS tumours, including posterior fossa tumours, craniopharyngiomas, pineal region tumours and high-grade gliomas.

I have published as first author on the surgical management of pineal region tumours, and as a co-author on paediatric pineoblastoma outcomes and on open Ommaya reservoir placement in craniopharyngioma. I co-authored the chapter Pediatric-Like Brain Tumors in Adults to Advances and Technical Standards in Neurosurgery. My fellowship at SickKids Toronto provided further exposure to complex oncological practice.

Issues commonly in dispute

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

Delayed diagnosis

A frequent issue. Opinion usually addresses whether the recorded combination of symptoms and signs crossed the threshold for imaging under the applicable guidance, how long the tumour is likely to have been present, and — critically — whether earlier diagnosis would have altered the surgical options, the extent of resection achievable and, so far as it can be addressed from the records, subsequent outcome.

Surgical decision-making and operative planning

Whether the approach taken was one a responsible body of paediatric neurosurgeons would have chosen, the balance struck between extent of resection and neurological preservation, and whether staged surgery or biopsy was the appropriate strategy.

Posterior fossa tumours

Management of associated hydrocephalus, the timing of CSF diversion relative to resection, and posterior fossa syndrome including its recognition and counselling.

Craniopharyngioma

Management strategy, endocrine and visual consequences, the adequacy of consent given the known morbidity, and long-term surveillance.

Operative complications

New neurological deficit, CSF leak, infection, and the adequacy of postoperative recognition and management.

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:

The complete oncology and neurosurgical record
All imaging from first presentation onwards, with formal radiology reports
Primary care records covering the period before diagnosis, which usually determine the delayed-diagnosis issue
Operation notes and histopathology, including molecular characterisation where performed
Multidisciplinary team meeting records and treatment plans
Ophthalmology and endocrine records where relevant
Oncology treatment records including radiotherapy and chemotherapy

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.

Paediatric Brain Tumours