Richard Pyper

Congratulations on your recognition in the Lawyer Monthly Expert Witness Awards. How does this accolade reflect your contributions to the field of clinical negligence in obstetrics and gynaecology?

It is a great honour to receive this award, which recognises my work in the medicolegal field over 32 years, having written over 1200 reports on all aspects of clinical negligence in O&G. I am happy to say that, in most cases, my advice about whether a case will succeed or fail, has proved to be correct!

One cannot underestimate the importance of a thorough analysis of the medical records, which is the foundation of any case. I have devised a system to ensure that the available information is accessible from digital records.

Without a clear pathway through hundreds of pages, often duplicated, it would not be possible to achieve a clear and balanced view of the case. This is vital but inevitably time consuming.

An enthusiasm for detective work is required because adverse events can have multiple causes, including poor communication, poor teamwork, and inadequate staffing levels. In my experience, it is rare that an error by a single doctor is the sole cause of harm to a patient.

Having identified what went wrong, the expert has to form a decision as to whether the injury was avoidable due to clinical negligence, or whether it was an unavoidable complication of the treatment.

Sometimes the breach of duty is clear but, in other cases, there is a grey area between poor practice and negligence. These are serious decisions, which affect the success of a claimant's case and will impact the clinical and nursing staff working for the defendant hospital.

This is unrelated to the severity of the outcome for the claimant. Every day, many negligent errors occur in hospital but, fortunately, most have no consequences for the patients involved. On the other hand, a tragic event, such as a stillbirth, can seldom be predicted or prevented.

The insights gained from my medicolegal practice have led to an increased awareness of the issues concerning patient safety. I have served on several risk management committees in my hospital, which have recommended improvements in departmental protocols.

I also give regular lectures on the role of "human factors" in causing errors in diagnosis and treatment. It is so important for practitioners to understand the concepts that surround patient safety, such as recognising when a patient is unwell and asking for advice.

Improved protocols for the recognition of bowel and bladder injury in "low risk" procedures have been proposed.

With over 30 years of experience in writing expert reports on clinical negligence, how has the landscape of obstetrics and gynaecology evolved, and what key changes have you observed in medicolegal cases?

Many changes have taken place in Obstetrics and Gynaecology, especially in terms of the increase in subspecialisation. Whilst this can be regarded as a good thing, it has introduced areas of negligence where there has been insufficient appreciation of the patient as a whole.

When I started working as a consultant, I expected myself to be an expert in all areas of the speciality, including surgery for gynaecological cancer. Since then, with increasing subspecialisation, many consultants have developed limited areas of practice, with some doing only obstetrics and others only gynaecology.

The implication is that a consultant in O&G should only prepare medicolegal reports for the areas in which they practice and have expertise. However, generalist experience is still important, if patients have multiple problems, which do not fit into the pigeonhole of one subspeciality.

The process of consent for surgery and other treatments has changed completely over the last 30 years. The traditional practice would be for consultants to recommend the best treatment that they could offer for the patient's condition. There was also the concept that consultants would take overall responsibility for "their patients."

Currently, consultants are obliged to explain the benefits and risks of a range of different operations, as well as conservative options and no treatment. Patients should be given leaflets and be allowed to choose the option that suits their circumstances and lifestyle (as per the Montgomery judgement in 2015).

However, the process of consent is not straightforward. It has been shown that patients only remember 40% or less of what they are told in a consultation, so discussing multiple options makes becoming "fully informed" even more difficult.

Patients also have widely varying concepts of risk, with some refusing necessary surgery, even when told it is safe. Others seem determined to go ahead with surgery, even if they are warned of significant risks.

Many decisions about surgery are now made in "Multi-Disciplinary Team" (MDT) meetings, at which the patient is not present, comprising healthcare professionals, who have never met her, leading to risks of misunderstanding.

As a Consultant Obstetrician and Gynaecologist at Western Sussex Hospitals NHS Foundation Trust since 1992, how has your clinical practice informed your approach to medicolegal reporting?

My clinical training started in 1978, and I aimed for a "double qualification" in general surgery and O&G, which was common amongst the consultants that I worked for. Spending four years in general surgery and urology gave me invaluable experience of surgical techniques.

On returning to O&G, I worked at several centres of excellence in London, including Queen Charlottes Hospital, the Chelsea Hospital for Women, Guy's Hospital, and ended as Senior Registrar at St Bartholomew's Hospital.

Thus, 14 years of clinical training with a broad experience of obstetrics and gynaecology was the foundation for starting medicolegal work in 1992.

On being appointed as a consultant at the age of 39, I joined a small team of 2 consultants responsible for 2,500 deliveries at Worthing Hospital and soon became Clinical Director for Women's and Children's services. This responsibility made me aware of the complexity of maintaining standards and improving services. For instance, shortage of staff and low standards of care continue to be major factors in medicolegal cases.

The more medicolegal reports I wrote, the clearer it became how important improved communication and teamwork were in avoiding negligent outcomes. Respecting all members of the team and listening to their concerns was vital for patient safety in the labour ward and theatre.

I have been involved in the development of many maternity protocols to improve the care of pregnant women but am aware of the difficulties in getting doctors and midwives to read the guidelines and put them in to practice, due to lack of time and opportunity for training.

Hospitals are complex organisations, and the care of a single patient is provided by many people during one admission. Each member of staff has the potential to cause a problem or prevent it and communication is vital, with failures causing harm to patients in many cases.

The operating theatre is the place that requires the most effective teamwork, and the contribution of each person is essential for safe surgery.
Awareness of the complexity of a patient's journey through the hospital system has informed my understanding of the process and my belief in a thorough analysis of the medical records to arrive at the opinion given in my reports.

Your special interests include urogynaecology and hysteroscopic surgery. How do these subspecialties enhance your expertise when providing opinions on complex clinical negligence cases?

Urogynaecology concerns treatment of women with pelvic organ prolapse and urinary incontinence and I took a special interest in this, when I was appointed to Worthing Hospital. With a large elderly population, there was a considerable workload in this field and a huge backlog of patients waiting for over two years for surgery. Performing three operating lists per week for two years, the waiting time was reduced to three months.

Surgery for stress incontinence has changed greatly over the last 40 years, with the open operation of colposuspension being the "gold standard procedure" from 1980 to 2000. After this, synthetic mid-urethral tapes, such as the TVT and TOT were introduced and appeared to be a minimally invasive procedure with superior results, so few patients chose major surgery.

However, with the passage of time, increasing problems with these TVT and TOT procedures became apparent, with some patients developing tape exposure and chronic pain. The use of these devices was suspended in 2018 until a parliamentary inquiry had concluded.

There are now a large number of claims involving the use of these mid-urethral tapes, as well as the use of mesh for vaginal repair, and this forms a significant part of my medicolegal practice. The issue of when consultants should have "known" about these complications and whether patients should have been warned about them is often the pertinent issue, which varies from case to case.

Pyper Medical Services has been instrumental in providing expert witness services. Can you tell us more about the company, its mission, and how it has grown under your leadership?

Pyper Medical Services (PMS) was founded in 2010 with a mission to offer accurate reports, which are fair to both claimants and defendants. The intention of PMS is always to assist lawyers and their clients by giving a clear explanation of the medical events with a balanced opinion about breach of duty and causation, as well as highlighting areas of uncertainty.

At that time, my offices were full of large ring binders containing paper records, which were often disorganised and difficult to use. Digital records have revolutionised medicolegal work but, early on, we had to invest considerable time and effort in IT. I pioneered novel software solutions for document handling and storage, and to organise the workload for expert witnesses.

The system ensures a smooth relationship with our customer base of lawyers, so that reports are delivered within the estimated turnaround time. Skilled office staff provide liaison and manage the invoices, allowing the experts more time to draft reports.

In 2014 with the medicolegal practice expanding, I stopped doing clinical obstetrics and worked on a gynaecology only contract.

In order to continue to provide high quality reports in obstetrics, my highly regarded colleague Ruth Mason, who is a Consultant Obstetrician, joined Pyper Medical Services in 2016.

Ruth undertook medicolegal training and gained the Cardiff University Bond Solon Expert Witness certificate. I acted as a mentor and oversaw her early reports. She now prepares 40 obstetric reports per year and has attended many coroner's inquests involving stillbirths and deaths of neonates. We are proud that she received an award for "Best Obstetric Expert Witness 2024 (UK)".

Rahila Khan joined PMS in 2018. She is a consultant obstetrician, who completed a Fellowship in Maternal Fetal Medicine at the University of Connecticut and has expertise in high-risk pregnancy. Following an Expert Report Writing course with Inspire MediLaw, I provided further training and supervision in the legal aspects of preparing reports. Her services are now much in demand, and she prepares over 40 reports per year for both claimants and defendants.

Jim English is a consultant gynaecologist specialising in laparoscopic surgery, who previously worked as an O&G consultant in Worthing. He has an international reputation for complex laparoscopic surgery for endometriosis. After Expert Witness training with Inspire MediLaw, he joined PMS in 2022 to provide reports on the injuries occurring during laparoscopic surgery, which has largely replaced open abdominal surgery. Like all PMS experts, his caseload has increased to a 4 month turnaround time.

Pyper Medical Services holds regular team meetings to improve efficiency, including communication with solicitors, organisation of workload and IT issues.

We also have a lively series of expert meetings where a case is presented, or an outside speaker sought to discuss various aspects of our medicolegal practice. I am glad to say that PMS has a stable and dedicated set of staff who are all fascinated by and committed to Expert Witness work.

You have trained and mentored many colleagues in the field. What do you see as the most important aspects of developing the next generation of expert witnesses in obstetrics and gynaecology?

Most consultants have excellent knowledge of their speciality and good clinical experience. However, they do not "think like lawyers" and need training to appreciate what is legally relevant to a case, as well as anticipating the questions that the solicitors need to be answered!

There are many pitfalls: appreciating the difference between "failing to provide best practice" and "breach of duty" is vital. Furthermore, national guidance about "best practice" changes with time and an incident 10 years ago cannot be judged by current standards.

The causation of some medical problems is obvious but, often, with chronic pain and other ongoing symptoms, the mechanism is unclear and the cause uncertain. This is not what litigation lawyers like to hear, but it is the expert's duty to explain the complexities and put them into the context of the case.

Maintaining impartiality and objectivity is crucial in clinical negligence cases. How do you ensure that your reports and testimony remain unbiased, even in highly contentious cases?

PMS experts always try to prepare the same report, whether we are instructed by claimants or defendants. The "facts" of a case are distilled from the medical records into the chronology section and should be the same in each type of report.

Opinion sections are more likely to vary, but the opposing expert will have had a similar training and be familiar with the same NICE or RCOG guidelines. It is likely that other experts will reach similar conclusions, and it is a matter of drilling down on the pertinent details of the case.

Many single joint expert reports have been written and there is an increased responsibility to be fair and accurate, with no opposing expert to pick up details or challenge our opinions.
From 2011 to 2013, I was instructed to prepare 90 single joint expert reports for a group litigation by 400 women, involving a urogynaecologist in the North of England. This was done to the satisfaction of both the claimants' and defendants' solicitors, who appreciated my impartial approach and thoroughness. Both sides continued to instruct me in other cases, resulting in a significant expansion in my medicolegal practice at that time.

What role does continuous professional development play in your practice, and how do you stay updated with the latest advancements in obstetrics and gynaecology to inform your expert reports?

To remain accredited as a medical practitioner registered with the General Medical Council, all our experts must maintain a comprehensive continuing educational process.

Hence it is vital to participate in the RCOG continuing medical education program and attend formal meetings relevant to my speciality. Drafting reports requires regular reviewing of national guidelines and research of the literature about the matters at hand.

There are also several excellent medicolegal courses, run by lawyers, which provide updates on any changes in the law and new precedents.

Discussion with my colleagues in PMS is always interesting and we hold "Expert meetings," including outside speakers on a regular basis.

Conferences with solicitors and barristers provide ongoing feedback on points of law and the progress of similar cases, which informs our caseloads and approach to the work.

Looking ahead, what are your aspirations for Pyper Medical Services, and how do you plan to continue contributing to the field of medicolegal expertise while supporting your colleagues in their professional development?

My aspirations are for PMS to continue to provide reports of the highest quality about clinical negligence in O&G. We are only slowly expanding the number of experts in order to maintain standards, as well as the fertile environment we share at PMS. We provide funding for medicolegal courses and training, as well as holding "In House" meetings with our experts, along with providing continuous technical, administrative, and managerial backup, organised by our excellent office manager, Alayne Fawkes.