Review of initiatives adopted for effective documentation of torture in a developing country

Effective documentation of torture is the key to successful interrogation and redress of torture victims. However the facilities available for such documentation to the forensic practitioners in less resourced countries are far from satisfactory. The emphasis on accurate and detailed documentation of examination findings of torture victims is currently necessary in Sri Lanka as the courts are relying heavily on medical reports for interrogation. In a situation where most of the torture victims are examined by unskilled medical officers who are not full time forensic practitioners, deficiencies of various degrees are commonly observed pertaining to depth of examination and documentation of examination findings. Therefore it was attempted in 2004, to introduce uniformity to existing documentation procedures by implementing Istanbul Protocol on island wide basis. However it was revealed that the adoption of the Istanbul Protocol could not be done as a whole in a short period due to variable degree of compliance from medical officers and further it need to be modified according to domestic requirements. The documentation of torture is a distinct multistage and multidisciplinary process. Therefore unless and until a cohesive collaboration is established between all disciplines concerned, a positive development on documentation process cannot be anticipated.     

Intentional burn injury: Assessment of allegations of self-infliction

This study investigates the question of whether there is evidence that suggests the possibility of self-infliction, or self-infliction by proxy, of burn injury among a group of asylum claimants in the UK who have attributed such injuries to torture, and how such evidence might be assessed. The question arose from the observations of doctors at the UK-based charity Freedom from Torture that increasing numbers of individuals from Sri Lanka who described a history of torture had suffered severe and disfiguring burn injuries from heated metal objects, and the suggestion from asylum decision-makers that in some cases such injuries could have been acquired deliberately by self-infliction or self-infliction by proxy rather than by torture as claimed. This suggestion has not been confined to Sri Lankan cases, but due to the large numbers of Sri Lankan asylum claimants referred to Freedom from Torture in recent years, including many with this type of injury, the case set for this study was drawn from this population. As many of these injuries are found to be on the back, where self-infliction would be extremely difficult, the possibility of self-infliction by proxy was specifically investigated.An observational data set was examined in detail, comprising medico-legal reports for Sri Lankans with heated metal object burn injuries documented in 2011–14 by the Medico-Legal Reports Service at Freedom from Torture. All had described detention in Sri Lanka since the end of the civil war in 2009. The study reviewed the documented evidence of these injuries alongside other physical and psychological evidence attributed to torture and relevant contextual factors documented in each case. Findings were compared with previous research on torture in Sri Lanka and patterns of injury identified in forensic medicine for both self-infliction and self-infliction by proxy. Thorough examination of the evidence found no indication in this data set to suggest the possibility of self-infliction or self-infliction by proxy and supported the view that, as indicated in the Istanbul Protocol, the overall conclusion on likelihood of torture should be made on evaluation of all the physical and psychological evidence over and above the scrutiny of an individual lesion.     

Statement on access to relevant medical and other health records and relevant legal records for forensic medical evaluations of alleged torture and other cruel,inhuman or degrading treatment or punishment

In some jurisdictions attempts have been made to limit or deny access to medical records for victims of torture seeking remedy or reparations or for individuals who have been accused of crimes based on confessions allegedly extracted under torture. The following article describes the importance of full disclosure of all medical and other health records, as well as legal documents, in any case in which an individual alleges that they have been subjected to torture or other forms of cruel, inhuman or degrading treatment of punishment. A broad definition of what must be included in the terms medical and health records is put forward, and an overview of why their full disclosure is an integral part of international standards for the investigation and documentation of torture (the Istanbul Protocol). The fact that medical records may reveal the complicity or direct participation of healthcare professionals in acts of torture and other ill-treatment is discussed. A summary of international law and medical ethics surrounding the right of access to personal information, especially health information in connection with allegations of torture is also given.     

Physical methods of torture and their sequelae: a Sri Lankan perspective

Methods of torture vary from country to country and sometimes within regions in the same country. Knowing torture methods used in a country or region assists in evaluating injuries, scars and other chronic sequelae of torture. Medical records of 100 victims of torture examined between 1998 and 2001 in the Judicial Medical Officer's Office in Colombo, Sri Lanka, were perused to gather data on torture methods used in Sri Lanka during that period. Altogether 68 methods of torture had been used on these victims. They included assault with blunt and sharp weapons, burns with lighted cigarettes, 'dry submarino', kicking, 'wet submarino', 'hanging', electric torture, 'falaka' and many more. However, only 18% of victims had any physical residual effects, highlighting the typical objective of torture, which is inflicting maximum pain without causing serious injury or death.     

Consistent with: what doctors say and jurors hear

While there is an extensive body of literature regarding the factors that influence how juries interpret medical expert statements, there is limited empirical evidence regarding the effects of word choice. The term ‘consistent with’ is widely used in legal proceedings and expert witness statements, so it is important to understand what this term means to a jury. The aim of this research is to understand how potential jurors interpret the phrase ‘consistent with’ in a forensic medical context. Potential jurors were recruited for a survey containing three mock vignettes where the doctor stated that the injury was ‘consistent with’ either self-inflicted injury, accidental injury, or injury by a third party. Participants were asked what the doctor meant, using a range of options taken from the United Nations’ Istanbul Protocol definitions of medico-legal terms used to describe lesions caused by torture. The results from 151 surveys indicate there was no consistent interpretation of the phase within each vignette or between vignettes. This research demonstrates that the phrase ‘consistent with’ can be interpreted in a variety of ways: caution is therefore required when using this expression in legal proceedings. Further research regarding the best choice of terms to use in court is required.     

Folter

During the past decades international rules against every form of torture have been established based on the United Nations (UN) “Declaration of Human Rights” from 1948. Torture is defined in the “Convention against torture and other cruel, inhuman or degrading treatment or punishment: United Nations Convention against Torture” from 1987. Muslim nations also consented to the “Cairo Declaration on Human Rights in Islam” from 2000. In 1999 a manual that came known as the “Istanbul protocol” was submitted to the UN High Commission for Human Rights and contains details on how to perform a thorough physical examination of torture victims taking all body regions into account. Different types of torture are described as well as injuries due to torture and additionally the participation of physicians involved in abuse and torture is dealt with.     

Medico legal and ethical aspects of surrogacy; A case report of a tragic maternal death from Sri Lanka

A case report from Sri Lanka on surrogacy leading to a tragic maternal death; medico-legal and ethical aspects.Surrogacy, with multiple ethical and legal issues associated with it, is practised worldwide. Although regulations are not available in Sri Lanka, we report a woman who had a tragic death as a complication of surrogate pregnancy.The body of a young mother with four living children was brought for autopsy examination. According to the documents provided, there was a controversy about the deceased's identity. A woman volunteered to show a pillow trapped in her abdomen, simulating a pregnancy. By surrogacy, her husband's sperm were inseminated in this woman's uterus artificially according to a contract.She was diagnosed and managed for pregnancy-induced hypertension in the second trimester. At 36 weeks of gestation, she was admitted to the hospital in labour. On admission, she was icteric with elevated blood pressure. A cesarean section delivered a baby, and it was noted that she had an abruption of the placenta. She developed a postpartum haemorrhage following delivery, and resuscitation failed, resulting in her death. She had elevated liver enzymes and low serum proteins before death. Autopsy findings included intense icterus, congested lungs, global ischemic changes in the myocardium, pale kidneys and fatty soft yellow liver.This case discusses many unanticipated legal and ethical issues related to surrogate pregnancy, especially in a lack of regulations regarding the practice and relatively cheap medical expenses.     

Physical assessment of tortures: Interobserver analysis of medico-legal degrees of consistency based on the Istanbul protocol

The Istanbul Protocol section on medicolegal evaluation delineates the guidelines for the correct management of the physical examination and the methods of assigning the degrees of consistency. Considering that most cases exhibit highly heterogeneous lesions, the examiner is forced to rely on his own experience, and their evaluation may be very subjective. The purpose of this work is to understand how subjective such an evaluation may be and whether the “experience” factor, interpreted as years dedicated to this profession and the number of cases evaluated, is statistically significant. To this end, a survey containing eleven cases of pre-evaluated asylum seekers was sent to thirty Italian clinical forensic practitioners. The participants were invited to assign a degree of consistency to each case according to the Istanbul Protocol guidelines, besides answering a few questions regarding their professional record. The doctors were divided into groups based on the number of cases evaluated and the experience collected expressed in years, and then interobserver analysis was performed. Results showed that the Fleiss’ Kappa coefficient acquired significant values when attention was turned to the sub-samples composed of more experienced participants. Therefore, the introduction of appropriately trained health professionals – “experts in migrations and torture” – could lower the risks of misinterpretation and make the assessment as reproducible as possible.     

DNS-Laborstrategie zur Identifizierung von Katastrophenopfern

More than 400 samples from 101 Tsunami victims from Sri Lanka were sent to our laboratory. Barcoded sampling kits were used to collect 2 swabs from internal body regions, a 4 cm piece of long bone and 2 teeth, which were all shipped on ice. A high throughput DNA extraction and STR analysis procedure for the swabs was developed in order to provide STR profiles within 24 h. For the skeletal remains and teeth a highly sensitive DNA extraction procedure was applied Both processes included electronic accessioning to maintain the numbering system of the DVI team in Sri Lanka and data exchange via Interpol and Plass Data software. DNA profiling of swabs was successful in 42% of the cases. For the remaining cases skeletal remains had to be typed and produced useful results in 65% for teeth and in 94% for bone. A sufficient profile was obtained from each victim, so the overall success rate was 100%. Until now DNA matching procedures in Innsbruck facilitated by using DNAVIEW software enabled DNA-based identification of 24 victims from 9 countries.     

Implementing Istanbul Protocol standards for forensic evidence of torture in Kyrgyzstan

The Kyrgyz government declared a policy of “zero tolerance” for torture and began reforms to stop such practice, a regular occurrence in the country's daily life. This study presents the results of 10 forensic evaluations of individuals alleging torture; they represent 35% of all criminal investigations into torture for the January 2011–July 2012 period. All individuals evaluated were male with an average age of 34 years. Police officers were implicated as perpetrators in all cases. All individuals reported being subjected to threats and blunt force trauma from punches, kicks, and blows with objects such as police batons. The most common conditions documented during the evaluations were traumatic brain injury and chronic seizures. Psychological sequelae included post-traumatic stress disorder and major depressive disorder, which was diagnosed in seven individuals. In all cases, the physical and psychological evidence was highly consistent with individual allegations of abuse. These forensic evaluations, which represent the first ever to be conducted in Kyrgyzstan in accordance with Istanbul Protocol standards, provide critical insight into torture practices in the country. The evaluations indicate a pattern of brutal torture practices and inadequate governmental and nongovernmental forensic evaluations.     

Scars of torture: a Sri Lankan study

Interpretation of scars of torture is not an easy task as our understanding of evolution of scars of different methods of torture is still in its infancy. The objectives of this study were to produce the features of a typical scar of a few selected methods of torture and determine their characteristic distribution. To achieve this, 100 medico-legal records of victims of torture examined at the Judicial Medical Officer's Office, Colombo between 1998 and 2001 were perused. Scars caused by seven selected methods of torture were taken into consideration. They were, assault with both non-pliable and pliable blunt objects, cigarette burns, burns with heated solid objects and molten plastic, ligature application with different forms of suspension and cuts with sharp objects. Total number of scars analyzed in this study was 1846, which included 740 scars of non-pliable blunt weapons, 182 of pliable blunt weapons, 102 of ligature, 59 of molten polythene, 55 of heated objects and 82 of razor blades and knives. Typical scars of each method of torture and their characteristic distribution were determined.     

Examination for the late physical after effects of torture

This paper describes the experience of doctors at the Medical Foundation for the Care of Victims of Torture, London, in documenting torture as recounted by survivors, mostly refugees from one of 63 countries, and in writing medico-legal reports to support their asylum claims. More than 2000 new patients are seen each year and 500 reports written. Few patients are seen in the acute phase; many not until 10 years following their torture. Patterns of torture practised in different countries are described, with the resulting physical signs. Methods of history-taking and examination are discussed, with emphasis on the detection of subtle forms of torture, recognition of deception and encouragement of full disclosure.     

Torture by excision and ingestion of the ear helix

The forensic medical documentation of torture is important to the legal disposition of cases of alleged crimes against humanity perpetrated on civilian populations. Most injuries that have been attributed to torture are not 'aietologically specific' of torture, and take the form of blunt impact trauma and thermal injuries that are consistent with, but not diagnostic of, alleged torture. In this case report, excision of the helix of the pinna and subsequent forced ingestion of the amputated segment is described in the context of torture.     

Modellprojekt zur Implementierung eines medizinischen Kompetenzzentrums für Gewaltopfer in Hamburg

A medico-legal competence centre for victims of violence was established in Hamburg in 1998 where a low threshold of intervention is provided. Victims who come to the Competence Centre to have their injuries documented are not required to report the offence to the police. A forensic documentation of injuries as well as the securing of biological evidence is available for free. The service is expanded to provide victims not just with the possibility of further examination by the appropriate departments of the University Hospital Hamburg-Eppendorf, but also with in- house psychological support. In 2003, 1071 victims of violence were examined (62% females, 38% males, about 21% with foreign nationality). The underlying history was violence in intimate partnerships in 26.5% of the cases, sexual violence in 17.7%, robbery in 6.1%, and other categories of non-intimate violence in 30.5% (history unknown in 15%). The project analyses the provision of care and legal aid for acute cases and thereby contributes to an improvement in the situation of victims of violent crime by connecting existing services in the public health system in Hamburg.     

Uneventful recovery from suicidal hanging: a case report

Although hanging accounts for a considerable number of suicidal deaths in Sri Lanka, on rare occasions the victims survive. A few cases have been reported in the literature where victims survived after varying periods of unconsciousness. It has been observed that death does not necessarily result from hanging, provided the victim is brought down promptly and resuscitated actively and vigorously. This paper focuses on an unusual case of a 39-year-old male who survived after resuscitation, without any adverse neurological outcome, after a suicide attempt by hanging.     

The impact of major occupational injuries on professional reintegration. A Portuguese medico-legal contribution

Occupational injuries represent an enormous economic impact for victims, respective families, involved institutions and all the community due to professional outcomes. Thus, it is of the utmost importance that medico-legal personal injury assessment and the posterior follow-up of these victims, may allow their concrete damage repair, considering the victims' needs fulfilment and professional reintegration, whenever possible. The main objective of this study is to reflect on the role that legal medicine can play in promoting the professional reintegration of victims of major occupational accidents through the analysis of occupational injuries cases considering the medico-legal examinations performed. A retrospective study was conducted using medico-legal major occupational injuries cases (Partial Permanent Disability ≥40%). Data were collected from two medico-legal assessment moments: (a) personal injury assessment homologated by a labour court 4.8 years on average after occupational injury; (b) medico-legal follow-up for needs and/or Partial Permanent Disability adjustments performed 18.9 years on average after occupational injury. The final sample includes 103 cases. The results showed that in major occupational accidents, permanent long-term outcomes were principally associated with neurological (62.1%) and orthopaedic (52.4%) sequelae. Permanent professional damage parameters assigned by the labour court included Partial Permanent Disability (23.3%), Permanent Absolute Disability for Regular Work (41.7%) and Permanent Absolute Disability for Any Work (35%). Three-dimensional methodology is helpful in predicting Partial Permanent Disability and Permanent Absolute Disability for Any Work. However, three-dimensional methodology did not reveal correlations with Permanent Absolute Disability for Regular Work, and currently 65% of the victims who were considered able to work by the labour court are not professionally active. Thus, these major cases deserve a more detailed medico-legal approach based on concrete information about the professional reality of each victim, especially cases with an eventual Permanent Absolute Disability for Regular Work. Medico-legal Injury Assessment must be based on concrete aspects of the victim's professional reality and not only on permanent disability tables. This calls for an articulation between all institutions working with the victim of occupational injuries and legal medicine to promote recovery and the necessary measures to assure professional rehabilitation.     

Klinische Rechtsmedizin

In the context of intimate partner violence, a medico-legal expert’s assessment is not routinely requested. However, a more intensive integration of medico-legal expertise into existing network structures—groups which have been installed in the community to improve the safety protection and care of victims of intimate partner violence—would be of great benefit. Each of the institutions in such networks should be informed of what forensic expertise entails and the services this field can offer to help guarantee optimal care. Medico-legal medicine should provide this information in direct contact with the different professions within the networks (police, courts, victim aid centres) and also approach health care providers (doctors, nurses, psychotherapists and health sector trainees). In addition, it is necessary to make it broadly known that forensic physicians can be consulted for injury assessment, physical examinations and documentation of violence-induced injuries.     

Tsunami disaster victim identification in Sri Lanka: legal aspects

Natural hazards amounting to disasters have almost become an endemic phenomenon during past decades throughout the globe, particularly affecting less resourced countries. The capabilities of the affected nations are stretched to the maximum in most of the disasters, thereby exposing deficiencies at various levels of the disaster mitigation mechanisms. A key factor identified through the human experience of all previous disaster scenarios is the requisite of effective and integrated local, national and regional disaster management mechanisms. The national and regional legal framework in this context can supplement disaster management enormously by drafting and implementing practical legislation which can be activated in disaster situations to co-ordinate the relief missions and minimize the damage. Thus, the existing legal systems and legislation at national and regional levels should be modified accordingly to yield proper disaster management policies. However, many less resourced countries are still lacking functional disaster management mechanisms in local legislation and are consequently highly vulnerable to heavy casualties in disasters. Sri Lanka is a typical example of a state which had an ineffective disaster management mechanism, not strengthened by legislation, when the Asian tsunami struck the country in December 2004, despite having frequently been affected by natural and man-made hazards during the past three decades. The net effect was total disarray in disaster victim identification, leading to drastic and irreparable consequences.     

Practice of clinical forensic medicine in Sri Lanka: Does it need a new era?

Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms.