Dr Nusrat Mir

Dr Mir, could you explain your role as a Consultant Psychiatrist and an Expert Witness? What does a typical day look like for you?

I currently work as a NHS General Adult Psychiatrist leading a big Community Mental Health team in a deprived area of Sheffield. A typical day is varied and can include outpatient clinics, home visits, Mental Health Review Tribunals, and chairing Multidisciplinary team meetings. I also teach medical students and supervise Psychiatric trainees. I am very passionate about this. We have a duty to pass on our knowledge and experience to the next generation of doctors and Psychiatrists. We have to do this well as one day, we will inevitably have to pass on the baton to them. We might even need their expertise ourselves one day!

My Expert Witness work has, up to now, been done in the evenings and weekends though that is due to change as I will be going part-time in the NHS in September 2023. My appointments are face-to-face or virtual. I will typically see two or three cases an evening. There may also be a teleconference with a Barrister to do. The pandemic definitely changed how we work. We all had to adapt, myself included. It has meant that about 70% of my current Medico-legal examinations are virtual. This has not affected the quality of my reports and has made me more accessible to clients across the UK. Report dictation and checking are mainly done at weekends. I receive excellent administrative support from Parkhead Consultancy, Sheffield, who manage my private work.

Can you elaborate on your work concerning clinical negligence and personal injury cases? How do you approach these cases, and what role does your psychiatric expertise play?

I have dealt with all types of personal injury cases over the years. This has included anything from work-related incidents to unprovoked assaults and road traffic accidents. The latter remains the most common type of personal injury case I am instructed on. Clinical negligence cases have included delayed cancer diagnosis, surgical errors, and misdiagnosis of a life-threatening condition. I have a particular interest in Perinatal Psychiatry and birth trauma. As such, I have provided evidence on numerous perinatal cases of mismanaged pregnancy, stillbirth, traumatic instrumental delivery and retained products of conception, to name a few areas.

The common theme linking Personal injury and Clinical negligence is trauma, something Psychiatrists are well-trained in identifying at the emotional level. Being involved in a serious road traffic accident that leaves you paralysed or being told you have advanced breast cancer that was missed in its early stages on a mammogram two years earlier, may have significant psychological consequences. The role of the Psychiatric expert is vital in identifying and quantifying psychiatric injuries whose toll can be no less than that of physical injury. I am naturally passionate about ensuring that psychiatric injury is given its due in the Medico-legal setting, especially as in the NHS we have sadly still not achieved parity of esteem between physical and mental health.

How do you maintain objectivity and impartiality when providing your expert testimony?

One is neither a representative of the claimant nor the defendant but is an independent expert whose duty is always to the court. I never lose sight of this fact. For me, the key to maintaining impartiality and objectivity in expert testimony is holding true to the core ethical principles that guide medical practice. As doctors, we are trained to do no harm, respect patient autonomy and act fairly in all situations. This means fairness in clinical decision-making and fairness in expert testimony.

How do you handle situations where your professional opinion may not align with the perspective of the legal team that has retained you?

This comes back to knowing your duty is to the court, not to any other party. I remind myself that I am the Psychiatric Expert witness and could be cross-examined on the evidence I provide. I have to maintain integrity and be confident that I will be able to defend my opinion in court. Having said that, one has to keep a degree of humility. I have had the pleasure of working with many astute solicitors and barristers who have, at times, highlighted points in a case that has made me refine my opinion, only if it still makes clinical sense to me as a Psychiatrist.

Many of our readers will assume that being cross-examined in court is a stressful experience. Can you share any strategies you use to prepare and how you handle this pressure?

Cross-examination in court is indeed a stressful experience. I am lucky that my court appearances have been relatively few in number, as most of the cases I have prepared reports for have been settled before getting to that stage. I think the best strategy for any potentially stressful situation, such as cross-examination, is good preparation. That means ensuring that you know your own evidence inside out and being clear about the rationale for your opinions, as they will undoubtedly be challenged. That said, one should remain humble and human. Expert witness courses help, as does a good night’s sleep the night before a hearing.

Considering the workplace transformations due to the recent pandemic, have you observed an increase in cases related to occupational stress, and has this impacted your evaluation method?

That’s an interesting question. The sudden change in working patterns due to the pandemic inevitably brought additional stress into our lives. However, I have to say that I personally have not seen that translated into increased cases of occupational stress coming my way. This is perhaps surprising.

What I have seen and continue to see is clinical negligence and personal injury cases being impacted negatively by pandemic-related issues. These have been mostly due to social distancing restrictions. For example, clients who have been hospitalised following a serious road traffic accident, had a traumatic postnatal complication or delayed cancer diagnosis, have had to face hospital admission and treatment on their own. Social isolation has always been an important causal factor in Psychiatry, but the pandemic took it to new levels.

As part of Peak Medico-legal Services, you offer psychiatric medico-legal reports. Can you walk us through the process of creating these reports and ensuring their accuracy and comprehensiveness?

That’s right, Medico-legal report writing is the bread and butter of my Expert witness work. The first stage is the triaging of instructions from solicitors, which come to me via Parkhead Consultancy. I will read through the instruction letter, check if it falls within my area of expertise and consider whether there are any conflicts of interest.

Appointments are then arranged face-to-face or virtually with the claimant. I set aside enough time for this in order to get as detailed a history as possible. One is only as good as one’s information in Psychiatry, and this helps to prepare a comprehensive report. Time is also important for the reason that claimants will have suffered trauma of some type. Their lives may have been turned upside down through no fault of their own. They may be seeking justice, but they also need to be heard. A listening ear is therapeutic.

As well the examination of the claimant, one, of course, needs to go through the documentation relating to the case with a fine-tooth comb, looking for relevant information to be factored into the report. Once it has been dictated and typed, I check the report for any errors and reflect upon whether the solicitor’s instructions have been fully addressed. When I am happy with it, the report is sent off to the instructing party.

How do you maintain confidentiality and professionalism while dealing with sensitive mental health information in your practice?

As doctors, the importance of confidentiality is drilled into us repeatedly during our long years of medical training, and rightly so. As Psychiatrists, we are in a very privileged position, one in which patients, in their most vulnerable states, open up to us about the most intimate and sensitive things that they may have never told anyone else. This can only happen if we are trusted by our patients, and maintaining confidentiality is at the core of building trust. Empathy is also important during Psychiatric consultations as it helps to build rapport and shows that active listening is taking place.

Consultations take place where privacy can be assured. It also goes without saying that all written documentation is dealt with in accordance with GDPR Regulations, with confidential data being disposed of appropriately at the end of a legal case.

Lastly, could you share any standout experiences or cases that have particularly shaped your career as a Consultant Psychiatrist and Expert Witness?

About eight years ago, I was instructed on a tragic case in Northern Ireland in which a lady of a professional background had smothered her newborn baby son to death. I was instructed by her solicitor to examine her and provide a Psychiatric opinion on her state of mind at the time of the fatal incident. I travelled to Belfast to examine her, where she had been imprisoned.

It was very clear to me that the lady had suffered from Postpartum Psychosis, a rare but devastating sudden-onset Psychiatric disorder that occurs within six weeks of childbirth. In this case, it had been characterised by a severely depressed mood and delusional thinking, the lady having been convinced that she needed to ‘save’ her child from the very evil world he had been born into. When it went to court, my independent evidence was factored into the sentencing as the Judge’s verdict, in the end, was one of manslaughter as opposed to murder.

For me personally, this was a landmark case in my Medico-legal career as up until then, I had only ever been instructed on General Adult Psychiatric cases, not on Perinatal ones. I have since been instructed on numerous perinatal claims, particularly clinical negligence, and continue to receive instructions on a regular basis.

In terms of experiences that have helped to shape my Expert Witness career, I would say that invitations to present to the legal community have been very important. It has been an honour to be invited by lawyers to speak at their meetings as well as by charities such as Action against Medical Accidents (AvMA). I presented a webinar entitled ‘Medico-legal issues in Perinatal Psychiatric Injury’ for AvMA in 2020, which was aimed at Clinical Negligence lawyers. It was very rewarding to offer a specialist Psychiatric perspective on medico-legal issues at the interface between Medicine and Law, two great professions of the world. It offered me an excellent networking opportunity too.