With over two decades of hands-on experience in neonatal intensive care, Dr. Michael Munro brings a rare combination of clinical leadership, academic research, and expert witness insight to the complex world of perinatal medicine. As a consultant neonatologist and co-author of Medical Negligence and Childbirth, he has played a pivotal role in shaping neonatal care practices, including the development of family-focused transitional care models and the design of Aberdeen's state-of-the-art Baird Family Hospital.
In this interview, Dr. Munro shares his perspective on the evolving challenges of expert witness work in cases involving neonatal injury, the critical role of clear and balanced testimony in court, and the importance of multidisciplinary insight in determining causation and liability. His grounded, evidence-based approach offers a compelling look into the intersection of medicine, law, and ethics in one of healthcare's most sensitive fields.
With over two decades of experience as a consultant neonatologist, what initially drew you to this field, and how has your role evolved over the years?
Neonatal intensive care is a very hands on specialty with multiple resuscitations occurring on a daily basis; a challenge which I have always enjoyed. I continue to participate in neonatal transport around Scotland and the UK and whilst again challenging at times, is very rewarding in terms of outcomes that can be achieved.
Over my career, the focus of the neonatal team has evolved from pure clinical care, becoming more holistic and embracing developmental care. Developmental care acknowledges the impact of the environment and interactions on a baby's development. To promote better care we have developed a new form of neonatal care (known as transitional care) whereby the mother and baby are kept together even though the baby has medical needs, promoting bonding and the family unit.
My role has evolved from being a junior member of a large neonatal team, to leading the team. Over the last 10 years, I have had the opportunity to lead the design and construction of a state-of-the-art women's hospital containing a level 3 neonatal unit in Aberdeen. We have created a hospital that focuses on all aspects of neonatal care and promotes family, hence the name of the hospital; the Baird Family Hospital.
You have served as an expert witness in legal cases involving neonatal care and medical negligence. What are the key challenges in providing expert reports and testimony in such cases?
Obviously maintaining impartiality and independence is vital, as is not straying out with my field of expertise. A lot of the cases I have been involved with are not specifically neonatal in nature, rather they are perinatal meaning that obstetrics and midwifery opinion are equally as vital.
As a neonatologist I am often tasked to determine causation of an injury that may not have occurred in the neonatal period. It can be challenging to opine on causation in a birth injury case when as a neonatologist I do not participate in delivering any antenatal or intrapartum care.
In addition, there is often neuroimaging involved and whilst neonatologists commonly have experience of point of care ultrasound imaging, it takes an expert neuroradiology opinion to interpret CT and MRI scans. Genetic testing evolves at rapid pace and often has relevance as does metabolic testing.
The unique challenge for the expert neonatolgist is being able to acknowledge, understand and bring together coherently all of these strands in order to determine causation.
Medical negligence cases involving newborns can be particularly complex. What are the most common issues that arise in litigation related to neonatal care?
With regards medical negligence involving newborns, damage from avoidable hypoglycaemia (low blood sugar) is one of, if not, the commonest cause of neonatal litigation in the NHS. Despite highlighting this fact in a paper published in the British Medical Journal in 2017, litigation involving brain damage from neonatal hypoglycaemia remains common in my experience. Failure to follow protocols and a lack of knowledge appears to remain the underlying root cause.
More recently, I have been involved in multiple cases regarding the causation of autism. With the incidence of autism estimated to have risen by over 700% between 1998 and 2018 in the UK, it is no surprise that claims with regard to autism and birth injury are increasingly commonplace.
You co-authored the book Medical Negligence and Childbirth. How has this experience shaped your approach to expert witness work?
As a neonatologist I participate in regular follow up of our neonatal graduates. It has become apparent to me that whilst asphyxiated and preterm babies may escape the development of cerebral palsy, they are at high risk of developing behavioural and cognitive problems. These tend to present later in life, are less well studied and not as readily acknowledged but can be equally as devastating to the child and their family; autism being a prime example.
Witnessing this has sparked my interest in autism and its link to events in the perinatal period, hence me authoring one of the chapters in this book specifically about autism and its causation. In writing that chapter I spent a long time trawling the scientific and non-scientific literature, collating the theories and evidence surrounding the aetiology of autism. Put simply, the aetiology is split between genetic and environmental factors. The experience has emphasised to me just how broad the expert's knowledge has to be, how medical thinking and understanding is ever evolving and how vital it is for the expert witness to keep
up to date.
Neonatal resuscitation is a critical aspect of newborn care, and you have been a leader in this field. How do you assess whether medical professionals have met the appropriate standard of care in emergency situations?
There are 2 main neonatal resuscitation courses accessible to the neonatologist; the Newborn Life Support (NLS), a UK course, and the larger world wide Neonatal Resuscitation Program (NRP). Both make it absolutely clear that provider validation does not guarantee competency. Both the NLS and the NRP acknowledge that becoming competent in resuscitation is not simply undertaking their course, rather it is the safe application of the course principles under expert supervision ensuring competency is achieved.
From personal experience the only way to ensure competency in trainee neonatologists, involved in acute resuscitation and intensive care, is to have them undertake the NRP or NLS and then be accompanied/supervised by senior neonatal team members to ensure that they apply the techniques in resuscitation appropriately. Hot debriefs are vital and to be encouraged, along with feedback to the junior doctors' clinical and educational supervisors regarding progress.
Simulation training increasingly has a role to play and the computer mannequins are now realistic enough to allow very effective simulation in all aspects of neonatology. Participation in regular simulation sessions is essential in the training and assessment of junior doctors in emergency situations.
Your research on brain perfusion and injury provides valuable insights into neonatal care. How does scientific evidence influence the legal assessment of causation in cases involving newborn injury?
Having large amounts of scientific data to back one's opinion is obviously very helpful when determining causation; the challenge, however, is that we rarely have absolutely conclusive scientific data that lacks any ambiguity.
In cases of brain injury resulting in long-term neurodevelopmental impairment, the current state-of-the-art neuroimaging techniques can, at times, offer very limited or inconclusive information with regards to causation.
Take autism as an example, we currently have no brain imaging techniques (including conventional MRI scanning) that are able to reliably diagnose autism. In other words a normal conventional brain MRI does not rule out that the patient has autism and cannot give any information as to how they acquired autism. This is somewhat at odds with that fact that conventional brain MRI can sometimes evidence that perinatal asphyxia occurred and there are multiple scientific studies that have found that perinatal asphyxia significantly increases the risk of developing autism. Newer MRI techniques such as 3D volumetric MRI, Diffusion Tensor Imaging (DTI) MRI, functional MRI (fMRI), and Magnetic Resonance Spectroscopy (MRS) may eventually be able to diagnose autism, particularly when coupled with artificial machine learning. Until then, science has a long way to go, particularly with regards the ability of brain imaging to determine causation of long term neurodevelopmental problems. Until it progresses, we will have to rely on scientific epidemiological studies to inform the legal assessment of causation in some cases of neurodevelopmental delay.
What role does an expert witness play in helping courts understand complex medical issues in neonatal cases, and how do you ensure your testimony is clear and accessible?
Helping the courts navigate complex neonatal medical issues is obviously vital but not without its challenges. One must prepare a detailed report that presents findings in a clear, structured manner and that is accessible to the court with no medical background.
Whilst referencing one's opinion with medical papers and text is useful, a lot of scientific papers are challenging to understand and explaining medical terminology and the medical abbreviations commonly used is vital. I have found that coming up with analogised examples found in everyday life can assist the court greatly and consideration of examples that might help is a useful exercise pre testimony.
Scientific papers are increasingly laden with statistical information particularly meta-analysis and it is imperative that the expert fully understands the statistics being presented before imparting to the court what the statistics actually mean. I personally have, on occasion, consulted with statistician colleagues to ensure that I have correctly understood the statistics contained in a paper before giving testimony.
What advice would you give legal professionals working on neonatal medical negligence cases to ensure they effectively utilize expert witness testimony?
One common issue it the provision of case records. As a neonatologist I often get asked whether I require the maternal obstetric records. Without them it makes preparing an opinion impossible. The resuscitation record, for instance, is vital and is often part of the maternal record. The antenatal history is essentially the newborn's past medical history.
I am regularly asked to comment on matters which are out of my field of expertise and are the remit of obstetric or midwifery staff expert opinion. In a case of alleged intrapartum asphyxia causing brain injury, whilst causation would typically be established by the neonatologist, an obstetric expert opinion will likely be required to determine liability. Both neonatal along with obstetric /midwifery expert opinion are vital in these cases.
I have, on occasion, been invited to become initially involved in cases after the personal injury summons has been issued, with only obstetric evidence obtained up to that point. Whilst causation and liability may have been identified by the obstetrician, it is not unusual to find additional breaches of duty of care in the neonatal period that have not been identified and a neonatologist can lend weight to both causation and liability. Emphasising that both neonatal and obstetric /midwifery expert opinion are required ideally prior to any personal injury summons being issued.
