Expert Witness Journal Issue 64 December 2025 - Flipbook - Page 10
this role has provided a unique vantage point from
which to observe recurring patterns in clinical care—
insights that have proven invaluable when preparing
expert witness reports for clinical negligence cases.
carefully to maintain transparency, impartiality,
and trust in the death certi昀椀cation process.
This article aims to explore how the role of ME
enhances the quality and credibility of expert
witness work in clinical negligence cases. Drawing
on my experience as a Transplant Surgeon and
Medical Examiner, I examine how the skills
developed through case scrutiny—such as ethical
awareness, pattern recognition, and objective
analysis—translate into more robust, balanced, and
legally sound expert reports.
The dual role of a transplant surgeon and ME
presents a unique ethical consideration, especially
in cases where organ donation is being considered.
In my clinical surgeon role involved in organ
retrieval, there is a potential con昀氀ict when certifying
a death that may lead to donation. The ME system
is built on the principle of independent scrutiny,
and guidance from NHS England and the Royal
College of Pathologists explicitly states that Medical
Examiners must not review deaths of patients they
have treated or where they have a vested interest (1,
2). In organ donation scenarios, this means that an
ME who is also part of the retrieval team must recuse
themselves from certifying the death to preserve
impartiality and public trust. The ethical framework
for donation after circulatory death (DCD) also
highlights the importance of separating clinical care
from donation decisions to avoid any perception of
undue in昀氀uence (3). Maintaining this boundary is
essential not only for legal compliance but also for
ensuring that families feel con昀椀dent in the integrity
of the process. In practice, this requires clear local
protocols and transparency about roles, particularly
in time-sensitive donation pathways. Holding insight
into both the clinical and logistical aspects of organ
donation o昀昀ers a valuable perspective on the ethical
principles underpinning the process—particularly
around consent, timing, and separation of roles.
This dual understanding helps maintain objectivity
and reinforces the importance of transparency
and fairness in decision-making. These attributes—
ethical awareness, impartiality, and clarity—are
directly transferable to expert witness report
writing, where the ability to assess complex clinical
scenarios with balanced judgment is essential to
validating credibility.
The Medical Examiner Role in Practice
As an ME, I have reviewed numerous deaths across
surgical and medical specialties, and several
recurring themes consistently emerge—each with
signi昀椀cant implications for clinical negligence
analysis.
Delays in recognition of deterioration are among
the most common.
In one anonymised case, a patient with sepsis
showed early signs of organ dysfunction, but these
were not escalated due to fragmented handovers
and reliance on outdated observations. The delay
in initiating critical care contributed to a poor
outcome, highlighting the importance of timely
clinical vigilance.
Documentation and communication failures also
feature prominently.
In another case, a postoperative patient deteriorated
overnight, but the escalation plan was not clearly
documented, and nursing sta昀昀 were unsure whom
to contact. The lack of clarity in the notes and
absence of a documented ceiling of care led to
delayed intervention and ultimately death. These
failures not only compromise patient safety but also
complicate retrospective analysis and legal review.
In addition to the ethical considerations, holding
dual roles as a transplant clinician and Medical
Examiner o昀昀ers unique advantages in fostering a
robust multidisciplinary team (MDT) approach.
Transplant clinicians routinely collaborate with a
wide array of specialists—intensivists, anaesthetists,
radiologists, microbiologists, and theatre teams—
creating a dynamic and highly integrated network
that enhances patient care. This breadth of access
often surpasses that of other specialties, enabling
more comprehensive clinical insights and decisionmaking. However, this collaborative strength also
highlights the risks of working in isolation. In cases
where deaths are reviewed without input from
relevant experts or an MDT framework, there is
potential for missed nuances in clinical reasoning
or oversight in complex cases. Ensuring consistent
communication across specialties remains a
challenge, and the dual role must be navigated
EXPERT WITNESS JOURNAL
Missed opportunities in care escalation often
stem from unclear responsibilities or assumptions
between teams.
In a case involving a complex renal patient, early
signs of 昀氀uid overload were noted but not acted
upon due to uncertainty over whether nephrology or
general medicine was leading care. This ambiguity
delayed appropriate management and contributed
to the patient’s decline.
These examples underscore the importance of
systemic awareness and clinical scrutiny—skills
honed through ME work and directly applicable to
expert witness practice. Recognising these patterns
allows for a more informed and balanced assessment
of breach of duty and causation in medico-legal
reports.
7
DECEMBER/JANUARY 2025-2026
