Restless legs syndrome

Restless legs syndrome is characterised by uncomfortable sensations in the legs, which are worse during periods of inactivity or rest or while sitting or lying down.

Summary

• Restless legs syndrome is characterised by uncomfortable sensations in the legs.
• It gets worse during periods of inactivity or rest or while sitting or lying down.
• There is often a positive family history of the disorder.
• The sensations are described as: pulling, drawing, crawling, wormy, boring, tingling, pins and needles and prickly.
• It is a life-long condition for which there is no cure.

Description
Restless legs syndrome is characterised by uncomfortable sensations in the legs, which are worse during periods of inactivity or rest or while sitting or lying down. There is often a positive family history of the disorder.

Individuals affected with the disorder describe the sensations as pulling, drawing, crawling, wormy, boring, tingling, pins and needles, prickly, and sometimes painful sensations that are usually accompanied by an overwhelming urge to move the legs.

Sudden muscle jerks may also occur. Movement provides temporary relief from the discomfort. In rare cases, the arms may also be affected.

Symptoms may interfere with sleep onset (sleep onset insomnia). Research suggests that restless legs syndrome is related to periodic limb movement disorder (PLMD), another more common motor disorder, which causes interrupted sleep.

The symptoms often exhibit circadian rhythmicity in their peak occurrence during awakening hours.

Prognosis
Symptoms may gradually worsen with age, and their most disabling feature is the sleep onset insomnia they cause, which can be severe.

Treatment

• Treatment is symptomatic.
• Massage and application of cold compresses may provide temporary relief.
• Certain medications are effective in relieving the symptoms.
• Research suggests correction of iron deficiency may improve symptoms for some patients.

Reviewed by Dr Kevin Rosman, neurologist in sleep disorders, June 2010

To sleep, perchance... By Juliet Pitman

To sleep, perchance...

Sleep disorders leave one feeling exhausted and frustrated. We look at the many facets of this condition and how to treat them.

By Juliet Pitman

Narcolepsy, insomnia, sleep apnoea, restless leg syndrome. Apart from all having peculiar-sounding names, these conditions are all sleep disorders and, in a variety of different ways prevent their sufferers from feeling well-rested. If you’ve ever felt exhausted and in desperate need of sleep, imagine not being able to get to sleep, falling asleep unexpectedly or having severely disturbed sleep and you’ll have some idea of what it’s like to have a sleep disorder.

For sufferers, the road to treatment can be a long and frustrating one – but it’s a journey that starts with understanding the basics of sleep.

 

What is sleep?

The Morningside Sleep Centre in Johannesburg provides diagnosis and treatment for people with sleep and neurological disorders, and conducts research into sleep and neurological conditions. Lead by neurologist Dr Kevin Rosman, who has been Chairman of the Sleep Society of South Africa since 2002, the Centre’s literature describes sleep as “an active highly organised sequence of events and psychological conditions.”

Furthermore, sleep can be divided into two separate and distinctly different stages – non-rapid eye movement (NREM) sleep, which is further divided into four phases (1, 2, 3, 4) and rapid eye movement (REM) sleep. Your body cycles about 4 to 5 times during the night through NREM and REM sleep. The physiological differences of each stage are listed below

1. NREM Sleep: Around 75% of the time you are asleep is spent in the NREM state.

• Stage 1: this is the transitional phase just after you fall asleep during which time you can be easily awakened. It’s a short period.
• Stage 2: this phase accounts for almost half (45%) of NREM sleep and is characterized by a lack of eye movement and two kinds of brain waves called sleep spindles and K-complexes.
• Stage 3: this involves a deeper state of sleep and during this time the person will be difficult to wake. Around 12% of NREM sleep is made up of stage 3 sleep.
• Stage 4: this is very deep sleep and the final phase of NREM sleep. If you wake up during this time you may feel disorientated or very sleepy.

 

2. REM Sleep: most dreaming takes place in REM sleep, a period during which the brain blocks signals to the muscles to prevent you from being able to physically ‘act out’ your dreams. REM accounts for around 20 – 25% of your sleep.

Each of these phases is important but deep sleep possibly offers the most benefits. Studies of sleep deprived people show that the brain naturally attempts to recover deep sleep first and sleep experts know that the worst effects of sleep deprivation occur when people are deprived of deep sleep.

REM sleep is also important because it’s the period during which our brains process emotions, memories and stress. Although its function is not fully understood, it is believed to influence many things, from our ability to learn and develop new skills, to our ability to make proteins. If REM sleep is disrupted one night, your body will go through more REM the next to ‘catch up’.

 

How much is enough?

Your mother may have told you that a good night’s sleep was eight hours long, but the fact is that different people need different amounts of sleep. This may be because their body can operate on less sleep, or that they sleep more ‘effectively’ and are able to get maximum rest from less time spent sleeping. There is a misconception that older people need less sleep but this is not true; they often get less sleep but this is not because their body no longer needs as much. Children, on the other hand, definitely need more sleep than adults. If you were to look at averages, most adults need around 6 - 8 hours to function at their best. Experts suggest that the best way to determine how much sleep you naturally need.

     

When to sleep

Many things influence when we need to sleep and when we feel alert and awake. You may have heard of circadian rhythms. Dr Alison Bentley, head of the Wits Dial-a-Bed Sleep Laboratory describes what these are and how they influence sleep cycles in an article published in Science in Africa magazine: “These are our 24-hour body rhythms including changes in body temperature, plasma levels of various hormones and variables such as heart rate and blood pressure. These increase and decrease during the day and night.” She goes on to explain how simply changing the time you go to bed – for example going to bed in the morning and staying awake at night if you are a shift worker – does not mean your body will be ready to sleep or be wakeful when you want it to be. This also applies to travellers who are going to different time zones e.g. Australia which is nine hours ahead of us. “All the other rhythms need to be changed as well and that can take up to seven days to occur,” she explains.

The point is that sleep is complex, which is perhaps why sleep disorders are so difficult to understand and to treat.

 

Narcolepsy

Narcolepsy is probably one of the strangest sleep disorders. A chronic disorder caused by the brain’s inability to regulate sleep-wake cycles normally, it causes sufferers to experience urges to sleep, and in many cases to actually fall asleep, at various periods throughout the day. They typically remain asleep for a few seconds up to a few minutes, but in some cases can even be asleep for an hour or more.

In addition to falling asleep in this way during the day, people with narcolepsy can experience vivid hallucinations as well as brief periods of total paralysis during the onset of sleep or when they wake up. The cause of the disorder is unknown and at this time there no cure for it. In addition to antidepressant drug therapies, narcoleptics are treated using various behaviour strategies, such as taking short, regular naps during the day and improving the quality of sleep at night.

 

Restless legs syndrome

As its name suggests, Restless Legs Syndrome (RLS) is characterised by unpleasant sensations in the legs and an uncontrollable urge to move them when they are at rest in an effort to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs.

RLS is most noticeable in the evening and at night, and can severely disrupt sleep. Although its precise cause is not known, it is associated with low iron levels, end-stage kidney disease in people who are on dialysis and damage to the peripheral neurosystem. Pregnant women also often report experiencing RLS and certain medications, such as anti-nausea, anti-seizure and antipsychotic drugs, as well as some cold and allergy medications, may aggravate symptoms

Again, there is no cure for RLS, but there are drugs that can help to alleviate the symptoms. They include sedatives, pain relievers, anticonvulsants and dopaminergic drugs. In addition, the Restless Legs Syndrome Foundation suggests that sufferers have their iron and vitamin levels checked, remove alcohol and caffeine from their diet, change any medication that may be the cause and identify and try to avoid habits and activities that seem to make RLS symptoms worse.

 

Obstructive sleep apnoea

Described by the Morningside Sleep Centre as “a serious, potentially life-threatening condition that is far more common than is generally understood”, Obstructive Sleep Apnoea (OSA) is characterised by brief interruptions of breathing during sleep. It owes its name to the Greek word, apnoea, meaning “without breath”. The interruptions themselves are known as apnoeas and can last for 10 or more seconds. During this time the soft tissue at the back of the throat collapses, closing the airway. Breathing stops which in turn causes the brain to react by waking the person so that the airways can open again and breathing can resume.

Although sufferers are usually unaware of the process, they can be experiencing it hundreds of times a night, which makes restful sleep impossible. The excessive tiredness (even after what the person thought was a full night’s sleep) is one of the first signs of OSA. Loud snoring, followed by a gasp and then loud snoring again, is another common symptom. Experts at the Morningside Sleep Centre say, “Although the typical OSA patient is overweight, male, and over the age of 40, sleep apnoea affects both males and females of all ages and those of ideal weight.”

 

Insomnia

At some period in their lives, most people have experienced insomnia, or the inability to fall or stay asleep. The condition is so common that it affects one third of the population each year, and around 10% of adults are regular insomniacs. It can last for days, months or even years and sufferers experience extreme fatigue, lethargy, concentration difficulties, poor memory, irritability and a depressed mood as a result.

The causes of insomnia vary widely and include psychological factors such as stress and depression, the use of stimulants such as alcohol and caffeine, keeping erratic hours and environmental factors such as too much noise or light. Many people find that once they’ve experienced a bout of insomnia, they become hyper-vigilant and are unable to fall asleep precisely because they are focusing on the fact that they won’t.

Treatment for insomnia takes many forms. If the problem is acute, your doctor may prescribe sleeping tablets, but many of these are potentially habit-forming and don’t offer a sustainable long-term solution. Natural non habit-forming over-the-counter remedies can provide relief. They include herbal remedies such as chamomile, valerian root, kava kava, lemon balm, passionflower, lavender, and St. John’s Wort. Some people have found essential aromatherapy oils to be of benefit. The ones most commonly used include lavender, jasmine, clary sage, and chamomile. Your homeopath might recommend you try Belladonna, Nux vomica, Hyoscyamus or Chamomilla, depending on your condition and the reasons underlying your insomnia. Relaxation techniques such as yoga and meditation can also be very helpful. 

A New Pill for Jet Lag? EBEN HARREL

Lifestyle - A New Pill for Jet Lag?

EBEN HARREL

Is there a medical condition more emblematic of the modern age than jet lag? Dislocated and deadened, the sleep-starved traveler wanders through meetings or tourist sites in a somnambulant haze. Now an experimental drug promises to reset the body's internal clock and banish jet lag zombies for good - and, surprise, it comes in a pill.


The drug, tasimelteon, works by mimicking the effects of the naturally occurring hormone melatonin, which has long been identified as the regulator of the body's sleep and wake patterns. In Phase II and III clinical trials of 450 people who were subjected to simulated jet lag in a sleep laboratory (participants were forced to go to bed at 6 p.m. and wake up at 2 a.m.), a team from Brigham and Women's Hospital in Boston found that the new drug restored near normal sleep the first night it was used. In one arm of the study, participants taking a high dose of the drug actually fell asleep more quickly than usual. In another part of the study, pill-takers' sleep efficiency - the percentage of bed-time spent sleeping - remained unchanged after experiencing jet lag, while their counterparts who received placebos slept 19% less. (See TIME's photos of the history of land speed record)


Melatonin, which is available over the counter in pill form, is a known treatment for jet lag, but the substance can't be patented, leading drug companies like Vanda Pharmaceuticals, the maker of tasimelteon, to rush to develop drugs that imitate it. Dr. Irshaad Ebrahim, medical director of the London Sleep Centre, says the recent study, published Dec. 2 in the journal The Lancet, confirms what experts already know. "I'm not sure this adds anything. Melatonin itself can be quite effective on its own. So, of course, something that mimics melatonin would show promising results," he says.


Still, a melatonin-emulator may offer some utility, Dr. Ebrahim says. Currently in the United States and many other countries, melatonin can be purchased easily as a health supplement, but supplements are unregulated and vary in quality and strength, making it difficult for consumers to receive a consistent dose.


In the interim, Dr. Ebrahim says, sleep experts have developed more reliable - albeit more complicated than popping a pill - methods of altering the body's natural melatonin production, which may help some of the 100 million people who take international flights from the U.S. each year, and the millions more who live in a perpetual state of jet lag due to night-shift work. One strategy is to use light-dark exposure, which helps cue the body's circadian rhythm. British Airways, for example, offers a "jet-lag calculator" that applies research into bright-light therapy to advise passengers when to sit in a pitch-black room and when to seek bright light after a flight.


Melatonin, as well as its analogs, have the added advantage of being less addictive and safer than other sleep-inducing medications. (The current study reported no immediate adverse effects of tasimelteon, though participants were not examined the following day.) In recent years, the popular prescription sleep aid Ambien, for example, has been linked to a range of bizarre sleepwalking incidents, including air rage. In a high-profile case in London in 2002, REM guitarist Peter Buck was cleared of assault and drunkenness charges stemming from his destructive rampage aboard a British Airways flight, after successfully claiming that his Ambien pill - combined with several glasses of wine - caused "non-insane automatism," which rendered him unable to control his actions.


Situations like Buck's may make this new research all the more attractive. Better yet, consider the case of Sarah Krasnoff, probably the world's most extreme jet-lag sufferer. In 1971, caught up in a custody dispute over her teenage grandson, Krasnoff learned that she was not subject to custody laws in the sky. That summer, she made about 160 continuous flights between New York and Europe with her grandson. By the end of the summer, Krasnoff, 74, collapsed and died of a heart attack.

Managing insomnia in shift workers

Issued by: Jenni Newman Public Relations

Some of the most significant industrial accidents in human history - the Exxon Valdez incident, the Chernobyl disaster, the Three Mile Island accident and the Challenger Space Shuttle crash - were caused by human error as a result of fatigue.

The human, environmental and financial implications of these disasters have been considerable, and have been long remembered.

What these disasters also have in common is that all have been attributed to fatigue. People working shifts will be able to relate to the excessive sleepiness than can occur either when working night shifts, or working double shifts. Jet lag presents similar feelings of excessive sleepiness. In a nutshell shift work throws out your body clock and is a well-known risk factor for insomnia.

Referred to as circadian rhythm sleep disorder, shift-work type, but more commonly known as shift-work disorder, this particular manifestation of insomnia can have serious implications: nurses, doctors, ambulance drivers - all are professions which rely on shift work, and their capacity to make life and death decisions on the spot. Sleep deprivation can lead to poor decisions being made. In fact, neurologist and sleep expert Dr Kevin Rosman says that people who have been awake for 17 hours straight function as if they have a blood alcohol level of 0.05%, the legal blood alcohol limit in South Africa. Stay awake for a further two hours, and you are functioning with the equivalent of a 0.08% blood alcohol level. “The most dangerous time to be on our roads is at 3am, as people are driving home incredibly tired after a long day at work followed by an evening out,” says Dr Rosman. “Traffic accidents in South Africa are all too common, and a huge number of these accidents are related to fatigue. When tired, people tend to respond rapidly, but the response isn't always the right one.”

Of particular concern for Dr Rosman are the long hours truck and bus drivers are expected to undertake here in South Africa. “People can fall asleep in three seconds without warning. You simply can't beat fatigue, you will succumb to it eventually. Winding down windows and putting up the music only delays the inevitable if you are suffering from extreme sleep fatigue.”

But there are ways to address the challenges inherent in shift-work disorder. The focus of most interventions is to optimise the natural sleep-wake cycle. “Shift-workers often don't have a problem falling asleep, their problem is staying asleep. They need to sleep better, and for longer, so that they wake up feeling refreshed - irrespective if it is day or night - and then to stay awake.”

First and foremost, shifts need to be properly structured, with speed of shift rotation, direction of rotation and even shift length and time playing a significant role in minimising the negative consequences of shift-work disorder. Short-acting sleeping agents such as sleeping pills can be hugely beneficial in facilitating a higher quality of sleep. People working longer shifts can benefit from a one hour nap - even a 10 minute power nap can be invigorating. Night shift workers should wear dark goggles when going home to avoid exposure to sunlight (the retinal cells of the eye will pick up the stimulus of the sun and suppress melatonin which encourages wakefulness). “Of equal importance is the understanding and compassion of family members and friends who must realise that, even though a shift worker is home during the day, it does not mean he or she can now do the shopping or look after the children. They need to sleep for their own safety, and for that of others.”

There are also people who are more suited - and less suited - to working shifts. People over 40 or who have pre-existing sleep problems, gastrointestinal disorders, need a rigid sleep schedule or conditions to sleep well, or are ‘morning' people, should generally avoid shift work. Conversely, ‘night owls' and people suffering from delayed sleep phase disorder may adapt to shift work very well.

Issued on behalf of sanofi aventis

Editorial contact
Natalie Jackson
Tel: +27 11 772 1061
Cell: +27 82 449 9984
Email: nataliej@jnpr.co.za

[17 Nov 2008 07:54]

Car Crash MVA from Apnoea

1
REGINA
-VCOLIN
WRIGHTON
NOTE
1. The Crown – after detailed and anxious consideration of this case - propose to
offer no evidence against the Defendant. In view of the severity of the charge and the
issues raised, I propose to set out the matter in some detail.
2. The facts are undisputed – on the 8th August 2006 this Defendant was responsible
for the death of Joseph Tobias Tweddell, known as ‘Toby’. He was born on the 4th
July 1981. Toby’s parents are both alive, as are his brother and sister and he was due
to be married to Jenny Crisp. They had been together since they were 19 years old,
and she described Toby as intelligent and charismatic; they were both in good
employment, having recently returned from a lengthy period of travelling, and they
were looking forward to life together. The victim impact statements from Mr. and
Mrs. Tweddell and Miss Crisp are heart rending. In view of what I say later, Mr.
Tweddell’s remarks are mature and prescient –
I don’t know whether Toby’s death was an accident or a crime…whatever the
outcome…the driver who ran into the back of Toby caused his death and I imagine
this is a life sentence for any driver; any sentient human being would surely carry the
burden of remorse for such an event for the rest of their lives…I want to reach out
beyond this driver to all those future drivers who may kill someone. Road death is a
blind spot of our society…if 20 people die in a train crash it is a national disaster, yet
(statistically) that many people die on our roads every 2 days throughout the year.
2
3. So far as the facts are concerned, the Defendant was behind the wheel of his 35
tonne lorry at the Liverpool end of the M62 motorway approaching the rocket
interchange, at about 8.30 a.m. The lorry appeared to drift onto the hard shoulder of
the M62, then back onto the inside and middle lane. There was no alteration in the
lorry’s speed, which later tachograph tests showed was a constant – governed – 56
mph. There was no evidence of braking. There was a build up of stationary traffic on
the motorway, and the lorry crashed into the rear of the first stationary vehicle, a
Toyota Hilux. The force of the impact caused the line of vehicles to crush together;
one witness described the scene ‘as if a bomb had gone off’.
Tragically, the Nissan Micra being driven by the deceased was forced into the rear of
a Ford pickup vehicle. Mr. Tweddell was freed from the wreckage by the emergency
services, but he had suffered catastrophic injuries and he died in hospital at around
2.00 p.m. on the 8th August 2006.
4. The Defendant escaped any significant injury. He dismounted from his cab, and
then tried to get back in it. He said to a paramedic (page 37) who attended at the scene
‘What have I done…how am I going to live with myself’. The paramedic checked his
blood pressure, pulse, pupils and blood saturation and stated ‘none of the results
indicated anything wrong with him’. During the journey to Whiston he was
remorseful and in shock. At Whiston there is conflicting evidence of his behaviour,
varying from blasé to distressed. When the Defendant was examined by Doctor
Rostron he said that he had very little memory of the crash, that he didn’t know if he
had lost consciousness. He was described as upset and anxious and said ‘why did it
happen’. His employer collected him from the hospital. Significantly, when asked by
the police about the Defendant’s driving, his employer, Mr. Jackson, described him as
professional, pleasant and conscientious about his work. When the police interviewed
the Defendant, in November 2006, he claimed that he must have blacked out at the
wheel. Evidence excluded the condition of the vehicle from contributing to the crash,
and the Defendant’s mobile telephone telephone records have been examined, and
exclude any such activity leading up to the impact.
5. The Defendant pleaded not guilty at the plea and case management hearing herein
on the 25th May 2007. A medical defence was flagged at that stage, but with no
3
supporting evidence. In anticipation of such a report the Crown Prosecution Service,
on my advice, undertook two enquiries;-
a. We obtained copies of the Defendant’s general practitioner records, and
b. Retained a ‘sleep expert’, Professor Horne; he is the author of a paper ‘Falling
asleep at the wheel: observations and guidelines for police forces’. His concluding
remarks are ‘usually, little can be gained by asking drivers involved in sleep related
crashes whether they remember being sleepy or fell asleep. Such information is most
unreliable, especially if obtained more than a few hours after the crash. Evidence in
support of this type of crash has to depend on more objective information’
6. Subsequently, the defence expert evidence was received, a report from Dr.
Pulakal. He narrates that the Defendant would feel tired most days, and used to take a
20-30 minute sleep during the day. If he felt sleepiness coming on when driving, he
would pull over and take a short nap to refresh himself before continuing his trip
(page 3 of report). He mentioned this on two occasions to his g.p., who the consultant
said ‘provided reassurance.’ The Defendant thought no more about cat-napping
because this is common practice among truck drivers. Examination of the gp records
shows the following important entries-
29th March 2005 – he contacted the surgery for assistance, when he stopped driving
owing to buttock pain. He actually telephoned the surgery from his lorry because of
his inability to carry on driving. The doctor saw him and prescribed tablets and rest.
Later entries show treatment for a skin condition and sciatica, and waking at night
with chest pain.
23rd May 2006 – he is noted as ‘feeling tired all the time.’ The doctor organised blood
tests, to investigate potential diabetes and thyroid problems, which were negative.
26th July 2006 – a skin infection and a note ‘feeling a little unwell last week and
sleepy? due to brewing infection.’ He was given antibiotics.
4
The notes of his attendance on the 8th August state ‘? Blackout…denies previous
episodes with blackout but just tired episodes.’
Dr. Pulakal’s report (page 4) shows that the Defendant scored in the abnormal range
so far as a so-called ‘sleepiness scale test’ is concerned. This is a subjective test,
reliant on a patient’s answers. Verification of an abnormal sleep pattern is gained
from objective tests, known as an oximetry test and a monitored sleep study; this
latter study monitored by polysomnography. The results showed poor quality sleep
and frequent but short periods of awakening (page 5). The expert’s opinion is that
the sleep study findings - with clinical features of obesity, heavy snoring, witnessed
apnoeic episodes, nocturnal choking, unrefreshing sleep and excessive daytime
sleepiness - confirms a diagnosis of moderate obstructive sleep apnoea.
‘Sleep apnoea’ is marked by obstruction of the upper airway during sleep. This causes
pauses or breaks in a person’s breathing, preventing air from entering the lungs and
forcing the person to wake briefly to reinitiate breathing before falling asleep again.
The person is unaware of this and the interruption to breathing can happen hundreds
of times a night…during the apnoea people come out of the deep sleep and wake
momentarily or sleep lightly. The period of wakefulness is so brief that even though it
may happen hundreds of times a night, a person will not remember it. As far as they
are concerned, they have had an uninterrupted good night’s sleep but are unrefreshed,
continue to feel excessively tired during the day and wonder why they are tired.
Worringly, the expert quotes that in the UK about 300,000 middle-aged men suffer
from this syndrome – obstructive sleep apnoea - but more than 80% remain
undiagnosed and untreated. He states that this sleep disorder remains among the most
under diagnosed and under treated medical conditions and ‘awareness among the
public and within the medical profession is low.’
At the time of the crash, the Defendant was about a stone heavier than when he was
examined – he would have been about 20 stone – which would have led to more
severe apnoea. The expert cannot of course say exactly what happened, but comments
(page 12) – patients with sleep disorders may not be as aware of impending sleep,
unlike the healthy population…patients with obstructive sleep apnoea are often only
aware of the severity of the sleepiness retrospectively. At page 14 of the report he
says that many gps do not think about sleep apnoea as a possible cause for tiredness in
5
the first instance. ‘I would not have expected for all doctors to think about the
possibility of sleep apnoea in this given situation.’ He knows of many patients making
multiple visits to their surgeries and hospitals before a diagnosis is made.
7. Professor Horne has been abroad, and the Crown took advice on this report from
Doctor Irshaad Ebrahim, a consultant neuropsychiatrist in sleep disorders at St.
Thomas Hospital, London. He reviewed relevant papers and Dr. Pulakal’s report and
agreed with the conclusion. He also told me that in a survey he conducted of several
hundred lorry drivers in South Africa, 25% of them were suffering from a medical
sleep disorder. Following a telephone conference, he submitted the following
addendum;-
-----Original Message-----
From: Ian Harris
To: Centre Administrator
Sent: Sat Sep 29 14:31:08 2007
Subject: RE: Colin Wrighton Medical report from Dr. Irshaad Ebrahim
Dear Dr. Ebrahim,
Thank you for your report and assistance. As discussed, can you confirm for me the following details,
following our discussions;-
1. That you have no reason to doubt the accuracy and integrity of the tests conducted by Dr. Pulakal,
and that there is no point in the prosecution seeking an adjournment of the case so that you can conduct
your own examination.
2. That the sleep study and oximetry tests are totally objective.
3. That in response to the question "should the defendant have been driving", your view/opinion is
that he did the right thing, he went to his gp and had no advice not to drive.
4. That a lot of general practitioners fail to recognise or are ignorant of sleep apnoea, and thus fail to
refer potential sufferers for consultations.
5. That your advice to the crown prosecution service would be to 'drop the case'.
I look forward to your reply - an acknowledgment by e-mail agreeing the above points will be
sufficient,
Again, many thanks for your help and expertise,
Kind Regards,
Ian Harris
Exchange Chambers
Liverpool
0151 236 7747
From: Irshaad Ebrahim [Irshaad.Ebrahim@londonsleepcentre.com]
Sent: 29 September 2007 15:01
6
Ian
Thank you for your email. Your recollection of my views is accurate and I confirm this now by email.
Dr Irshaad Ebrahim MBChB MRCPsych
The London Sleep Centre
137 Harley Street
London
W1G 6BF
Tel: +44 20 77250523
Fax: +44 20 77250524
8. Archbold describes the defence (2007, chapter 32 –22) in this way, in driving
cases –
In an ordinary case, once it has been proved that the defendant was in the driving
seat of a moving car, there is prima facie an obvious and irresistible inference that he
was driving it. No dispute or doubt will arise on that point unless and until there is
evidence tending to show that by some extraordinary mischance he was rendered
unconscious or otherwise incapacitated from controlling the car. If he lapses into a
coma, is stunned by a blow on the head or attacked by a swarm of bees, it can be said
that he is no longer driving. If he falls asleep it is a question of fact whether driving in
the circumstances was reckless: Hill v. Baxter[1958] 1 Q.B. 277,42 Cr.App.R. 51,
DC. If his loss of control results from an epileptic fit, a defence of automatism will be
tantamount to a plea of insanity: R. v. Sullivan [1984] A.C. 156, HL; R. v. Burgess
[1991] 2 Q.B. 92,93 Cr.App.R. 41, CA. Similarly, if the loss of control is due to a
hyperglycaemic episode caused by diabetes: R. v. Hennessy 89 Cr.App.R. 10, CA…
The defence of automatism ought not to be considered at all until the defence has
adduced at least prima facie evidence: Hill v. Baxter, ante. Once a proper foundation
is laid for automatism, the matter becomes at large and must be left to the jury. The
legal burden comes into play and requires that the jury be satisfied beyond
reasonable doubt that the act was a voluntary act: Bratty v. Att.-Gen. for Northern
Ireland[1963] A.C. 386, HL.
Bratty was followed by the Court of Appeal in later cases; the Crown in this case
cannot medically contradict the defence expert evidence, thus on a balance of
probability the defence is established, and I cannot satisfy a jury so that they can be
sure that the Defendant was not suffering from sleep apnoea.1 Legally, I cannot
negative non-insane automatism beyond reasonable doubt. The police accident
1 R v Burns 58 Cr.App. R 364 (see Archbold 2007, 17-86.
7
reconstruction expert – a very experienced officer – Paul Hulme (exhibit pages 11)
stated, in November 2006 ‘…the movement of the lorry drifting across lanes and the
driver failing to apply the brakes would give extremely strong support to the fact that
the driver has either suffered a medical condition such as a black-out or he has
simply fallen asleep.’ The decision has been taken by the application of the criminal
burden and standard of proof.
9. It was on Friday last, the 28th September that the decision was taken, in the light
of all of the facts that this case should not proceed to trial. An initial view that the
Defendant should not have been driving because he had previously complained of
sleepiness was dealt with by Dr Ebrahim as set out earlier. There is no evidence from
any witness or other driver that the Defendant’s driving had previously given any
cause for concern owing to his tiredness, and he himself was of the view that catnapping
was part and parcel of his work since it is common practice. Thus an
alternative possible route to proving dangerous driving wasn’t evidentially available.
Although the decision and responsibility rests on me, as Trial Counsel, I was ably
assisted by Mr. Hopkins, my instructing solicitor, his caseworker Mr. Challinor, and
the investigating officer Sergeant Sue Allen. At my request the family liaison officer
Constable Nolan also attended the conference, and the family have been consulted. A
copy of this note will be provided to all concerned.
10. If this case stimulates wider public and medical appreciation about sleep
disorders, then perhaps some positive factors can emerge from such a senseless waste
of a human life. I end as I began by citing Mr. Tweddell senior who calls for more
education about driving and the causes of road death in the hope that other parents
won’t have to go through his family’s suffering in future cases.
Ian Harris
Exchange Chambers
Liverpool
30/09/2007