A survey on the involvement of accident and emergency doctors in medicolegal work in Hong Kong

This study reports the results from a questionnaire survey on the pattern of medico-legal work undertaken by doctors working in Accident & Emergency Departments (ED) and their self-evaluation of competency in forensic medicine. A total of 155 questionnaires were returned with a response rate of 46%. Only 30% (46) respondents were fellows of the Hong Kong College of Emergency Medicine but 46% (71) had more than 6 years of experience working in the ED. Most of the requests for medical report came from police and insurance companies. Fellows had more experience writing reports on homicide, sexual assault and child abuse than non-fellows did. Nearly all fellows and three quarters (74%) of non-fellows had given evidence in courts of law. Physical assault was the commonest and sexual assault the least common experience. Most respondents had experience of attending district court (83%), followed by coroner inquest (67%), magistracy (66%) and high court (45%). Respondents were asked to rate themselves on their competence in various subject areas. It can be seen that respondents were less comfortable in areas like homicide, child abuse and sexual assault. On the job coaching by a senior seems to be the major mode of training. Both fellows (61%) and non-fellows (36%) favored some form of courses with a hands-on workshop element in future.     

Facilities for complainants of sexual assault throughout the United Kingdom

BACKGROUND: A sexual assault referral centre (SARC) is a model of service established to address the forensic and therapeutic needs arising following sexual assault. As yet, only a minority of urban areas in England are served by one, the rest of the United Kingdom (UK) being served by police victim examination suites. OBJECTIVE: To examine variations in service offered to complainants of sexual assault within the United Kingdom in 2005. METHODS: A purpose designed questionnaire sent to all areas of the United Kingdom. Data were received and analysed from 12 of 13 SARCs and 54 of 58 non SARC services. RESULTS: Very wide disparities in service, most marked between SARC and non SARC services. SARCs see a proportion of complainants from non-police sources. The non SARC services do not usually offer a forensic examination without police involvement, and a significant minority have so few doctors that they cannot provide a 24h rota for examinations. Inadequate numbers of forensic physicians are available for child examinations, and a robust service for 'acute child sexual assault' is virtually absent. Photodocumentation with appropriate safe storage is available in all SARCs, while 45% of non SARCs have no facility for photodocumentation. DNA contamination issues were perceived to be significant in many of non SARC services. Most non SARC services for adults do not provide baseline screening for sexually transmitted infection (STI) or offer prophylaxis against STIs. Follow up is by referral to local clinics which complainants may have to arrange themselves. Funded counselling is rare in the non SARCs with the exception of Yorkshire. CONCLUSION: In the non SARC services, lack of co-operative working with local health services, lack of equipment, and lack of 'in house' medical follow up arrangements is the norm. Many areas rely on the good will of a small number of doctors to provide a service without a rota.     

The use of HIV post-exposure prophylaxis in forensic medicine following incidents of sexual violence in Hamburg,Germany: a retrospective study

In Hamburg, Germany, the initiation of HIV post-exposure prophylaxis (HIV PEP) in cases of sexual violence is often carried out by forensic medical specialists (FMS) using the city’s unique Hamburg Model. FMS-provided three-day HIV PEP starter packs include a combination of raltegravir and emtricitabine/tenofovir. This study aimed to investigate the practice of offering HIV PEP, reasons for discontinuing treatment, patient compliance, and whether or not potential perpetrators were tested for HIV. We conducted a retrospective study of forensic clinical examinations carried out by the Hamburg Department of Legal Medicine following incidents of sexual violence from 2009 to 2016. One thousand two hundred eighteen incidents of sexual violence were reviewed. In 18% of these cases, HIV PEP was initially prescribed by the FMS. HIV PEP indication depended on the examination occurring within 24 h after the incident, no/unknown condom use, the occurrence of ejaculation, the presence of any injury, and the perpetrator being from population at high risk for HIV. Half of the HIV PEP recipients returned for a reevaluation of the HIV PEP indication by an infectious disease specialist, and just 16% completed the full month of treatment. Only 131 potential perpetrators were tested for HIV, with one found to be HIV positive. No HIV seroconversion was registered among the study sample. Provision of HIV PEP by an FMS after sexual assault ensures appropriate and prompt care for victims. However, patient compliance and completion rates are low. HIV testing of perpetrators must be carried out much more rigorously.     

The Cinderella section: room for improvement in the documentation and implementation of Section 136 of the Mental Health Act 1983

A questionnaire sent to all 43 police forces in England and Wales confirmed that there was a lack of understanding of the documentation issued by central government detailing section 136 of the Mental Health Act 1983. A survey of forensic physicians in England and Wales reveal that doctors providing medical care in police stations had insufficient knowledge of the Act.     

The epidemiology of sexual assault of older female nursing home residents,in Victoria Australia,between 2000 and 2015

Sexual assault is the least acknowledged, detected, and reported type of assault against nursing home residents. Nursing home staff are responsible for reporting suspected allegations to the police, who will contact a clinical forensic examiner to conduct a forensic medical examination.This study examined the epidemiology of sexual assaults of older women (aged 65 years and older) residing in nursing homes in Victoria, Australia, between 2000 and 2015, whose alleged incidents were referred to a clinical forensic examiner for a forensic medical examination. A retrospective analysis of alleged sexual assaults reported to the Clinical Forensic Medicine Unit at the Victorian Institute of Forensic Medicine between 1 January 2000 and 31 December 2015 was conducted.The study identified 28 forensic medical examinations performed for alleged sexual assault. The alleged victims frequently had cognitive impairments; injuries were infrequent; and alleged victims were cooperative. The forensic medical examiner responded within 72 h of reporting; and frequently noted limitations to physical examinations of the alleged victim.The actual number of sexual assaults during this period may be masked by under-reporting and, lack of identification by nursing home staff.There are many unresolved issues including: incidence, levels of reporting, nature of investigations, responses required to assist the victim, and the interventions needed to prevent sexual assault. Better data is vital. This data should be standardized, validated, reliable, and gathered prospectively across Australia and internationally.     

Near miss incidents in police custody suites in London in 2003: a feasibility study

INTRODUCTION: Potentially preventable deaths in police custody include those which involve illicit drugs, alcohol and deliberate self-harm. Near miss incidents (NMI) that did not result in death have a crucial role in understanding risk factors in custody. Such research has not previously been undertaken. A program of research has been developed to study NMI, in order to better identify those at risk in police custody. For the purposes of this research, NMI have been defined as 'an unplanned and unforeseeable or unforeseen event that could have resulted, but did not result, in human death or may have resulted in injury or other adverse outcomes'. It was intended that the definition although broad, would not include simple accidents (e.g. slipping on urine in a cell) or trivial injury. AIMS AND METHODS: The two aims of the study are (a) to determine whether it is realistic to attempt to assess NMI with the intention of identifying information of use in enhancing detainee care and (b) to assess how frequently NMIs occur and whether there are specific patterns. Pilot interviews were conducted with three forensic physicians practising in London, UK to create a structured questionnaire for all forensic physicians working in London. The questionnaire provided the basis of a retrospective recall survey of all forensic physicians working in London as Forensic Medical Examiners. The questionnaire was designed to assess the numbers of NMI, patterns in occurrence and relevant learning points within the previous 6 months. A covering letter, background questionnaire (exploring the background of the medical practitioner), copies of the survey, and reply paid envelopes were sent to each Forensic Medical Examiner (n=134) in London, contracted to provide forensic medical services for the Metropolitan Police Service. Data about all incidents were anonymized. RESULTS: Ninety six (73%) Forensic Medical Examiners responded. Of these 18% were Principal grade, the remainder were Senior (24%), Standard (35%) and Assistant (23%). Thirty eight NMI were reported by 27 Forensic Medical Examiners (of all levels). The initial reason for police contact was recorded as alcohol (n=8), theft and robbery (n=7), warrants (n=4), violence (n=3), traffic violations (n=2) and single cases of drugs, murder and immigration offences. Of the main perceived cause of each NMI, illicit drugs were involved in 12/38, alcohol in 17/38, deliberate self-harm in 11/38, issues concerning searches, checks or rousing in 8/38, failure of inter-agency communications in 5/38, and possible resource issues in 4/38. In a number of cases more than one factor was involved. CONCLUSIONS: The information established about NMI is broadly consistent with documented patterns of deaths in police custody in England and Wales which supports the validity of the data. The next stage of this research will be a prospective six month study in which NMI will be analysed in order to learn lessons which may be utilised to attempt to prevent potentially avoidable deaths in police custody.     

Continuing education programme - Victorian Institute of Forensic Medicine

With the increasing requirement of the courts for forensic experts to engage in ongoing education, a continuing education programme (CEP) was developed in the field of clinical forensic medicine at the Victorian Institute of Forensic Medicine in 1996. This programme has been described and was initially established to provide a means of education for the contracted forensic medical officers who provide forensic services to the police via the Institute throughout the State of Victoria. Owing to the sparsity of the population and the considerable distances between forensic practitioners, the CEP was designed to cater for individuals who are working alone: in effect, a distance education programme. Forensic pathologists expressed interest in the programme and it was subsequently modified to include forensic pathology cases. Currently, the programme caters for both clinicians and pathologists, and takes the form of four to five cases with related questions which are circulated several times per year. The cases include a mixture of both challenging and ordinary procedural types that may present to practitioners working in either clinical forensic medicine or forensic pathology, or both. The areas covered include: * injury interpretation * procedural matters in relation to adult and child sexual and physical assault * pharmacology/toxicology interpretation of findings * medico-legal issues (e.g. confidentiality, consent, etc.) * issues relating to alcohol and drugs * traffic medicine * clinical and legal aspects of sudden natural death * suspicious deaths * suicide * interpretation of findings at autopsy * fitness for interview * fitness to plead * psychiatric issues * general clinical medical issues. The presentation of each case includes relevant and appropriate details/findings and may include photographs. A series of questions follow which are answered in either short answer or multiple-choice format. The answers are returned and are correlated by a review panel of forensic physicians and pathologists, and a commentary with the response outcomes is distributed to all those involved. This also includes pertinent references. The cases presented here and in subsequent issues are selected from this programme.     

Forensic entomology in research and practice: an overview of forensic experts’ perceptions and scientific output in Brazil

Given the growing demands for standardization of procedures for collection, preservation, and identification of insect specimens, this study aimed to identify how forensic entomology is used in Brazil and the perceptions of professionals involved in this process. We conducted: (1) bibliometric survey of the scientific production of forensic specialists from 2001 to 2020; (2) questionnaire applied to forensic professionals to verify their perceptions about the use of entomological evidence in practice. An increase in publications on Forensic Entomology was noticed in the last 5 years, mainly in the South and Northeast regions. Of the 82 respondents to the questionnaire, 62.8% deal with cadavers at least once a week, but 89.0% of the professionals who examine cadavers weekly find less than 10.0% colonized by insect larvae. Using entomological evidence to estimate PMI was mentioned by only 36.6% of the professionals. Most respondents stated no procedures related to collecting, handling, or identifying necrophagous insects in their daily practice. Regarding the chain of custody, 64.6% said they were aware of the changes in the regulations involving the collection and maintenance of forensic evidence. We emphasize the importance of collaboration between scientists at universities and crime scene examiners. Although the use of entomological evidence in criminal investigations in Brazil is still scarce, a growing interest in this area can be detected among forensic experts.

     

Child abuse examination enquiry

OBJECTIVE: To determine how police surgeons in the United Kingdom performed examinations of child abuse victims because wide variations in protocols and procedures have been reported. METHOD: Practising members of the Association of Police Surgeons were requested to complete an enquiry form. Replies were anonymous and subjects covered included gender, work area, training, procedures and protocols for joint examinations with paediatricians and the use of digital or instrument examinations in alleged penetrative sexual abuse. RESULTS: Of all those eligible, 47.7% had responded. Males made up 74.7% of respondents. Published guidelines were followed by 85.3% and 69.8% used purpose-built examination suites while 8.8% still used police station facilities. Procedures for joint examinations were working satisfactorily, according to 79.2% of respondents who also considered that the forensic physician should take the lead role in examinations. Clinical findings were recorded on a prepared aide memoire by 35.2%. Colposcopes were used by 3.4% while 23.3% of respondents considered that a colposcope should be used but cost was an inhibiting factor. CONCLUSIONS: Reported variations in procedures and protocols in examining child abuse victims were confirmed. More discussion and liaison between agencies concerned is required and a firm commitment to the paramountcy of the child's interests is needed.     

Policy considerations of human immunodeficiency virus (HIV) infection in U.S. Naval aviation personnel

This article reviews the available medical data that form the basis for the U.S. Navy's policy on aeromedical disposition of Human Immunodeficiency Virus (HIV) seropositive flyers. Following a brief review of military HIV antibody testing and clinical evaluation, this article addresses the main issue in the Navy's aeromedical disposition policy--the subtle neurologic sequelae of HIV infection or HIV encephalopathy. Following a review of the available knowledge of HIV involvement in the nervous system, the aeromedical considerations that form the basis of Navy policy of permanently grounding without waiver all HIV seropositive flyers is discussed.     

HIV preventive medicine services and public health interventions: the Bethesda experience

A basic Public Health approach to the Human Immunodeficiency Virus (HIV) epidemic has been considered by many to be the most appropriate initial strategy against the spread of this infection. Comprehensive Preventive Medicine services were implemented at Naval Hospital Bethesda, which utilized a sexually transmitted disease (STD) model and included: counseling and education; sexual contact interviews and spouse evaluations; Blood Bank Look Back tracking of donated blood; reporting of notifiable diseases; and screening of transfusion recipients, STD cases, and other at-risk populations. This coordinated approach is highly efficient and capable of evaluating the increasing numbers of HIV-positive individuals.     

Evaluation of forensic medical history taking from the child in cases of child physical and sexual abuse and neglect

BackgroundSuspected child physical abuse, sexual abuse and neglect are not uncommon presentations. As part of the assessment of these cases, a forensic medical history may be taken. This forensic history is used not only to determine the steps necessary to address the child's wellbeing but also to direct the forensic examination. Currently, there is no clear consensus on whether or not a forensic medical history should consistently be considered an integral element within the paediatric forensic evaluation. This study examines the value derived by the medical practitioner taking a forensic medical history rather than relying on hearsay evidence when a child presents for an assessment.MethodsA retrospective review of paediatric cases seen by the Victorian Forensic Paediatric Medical Service (VFPMS) between 2014 and 2015 was undertaken. 274 forensic case reports were reviewed and the data was entered into an Excel spread sheet and analysed using chi squared tests within STATA^®.ResultsWith increasing age of the child, a forensic medical history is significantly more likely to be taken. Additional information is made available to the medical practitioner what would otherwise have been provided if the medical practitioner relied only on the interview conducted by the police. Discrepancies observed between the official third parties (police or child protection) report of what a child has said and what the child says to the medical practitioner decrease with age, as do discrepancies observed between the child's version of events and a third party's (eg. parents, caregivers, friends) version of events.ConclusionsThe study showed that by taking a forensic medical history from the child additional information can be obtained. Further, that there is a value in the examining medical practitioner taking a forensic medical history from children in cases of child physical and sexual abuse and neglect.     

The potential for the use of personal computers in clinical forensic medicine

This paper describes the use of a personal computer in clinical forensic medicine. It shows how a database can be easily created, updated for each new case by unqualified personnel, and then used to provide statistical data with a minimum resource input, without the need for great computer expertise. Databases will only recognise exactly identical abbreviations. Once created they can cross-reference data and provide individually tailored statistics. Registration with the Data Protection Agency is required in the UK in order to hold personal information on file. The results of 2201 cases entered on the database of one forensic physician show high levels of drug and alcohol abuse co-existing with unemployment and homelessness. 53% of individuals brought to police stations as a place of safety (under Section 136 of the Mental Health Act 1983) were in need of admission to a psychiatric hospital. 12% of those individuals were of no fixed abode. The potential for a national database linking forensic physicians on a national basis, pooling their data thereby creating a powerful statistical tool is clear.     

Challenges experienced by service providers in the delivery of medico-legal services to survivors of sexual violence in Kenya

While much discussion has been devoted to defining the standards of care required when offering services to survivors of sexual violence, much less attention has been given to procedures for evidence collection to allow the successful prosecution of perpetrators. In Kenya there are no comprehensive guidelines that outline the roles of the survivor, the community, health care workers, and the police with regard to the handling of forensic evidence, a deficit that contributes to delays in prosecuting, or even a failure to prosecute sex offenders. This study examines some of the obstacles in Kenya to the adequate handling of forensic evidence in sexual violence cases. It was based on in-depth interviews with respondents drawn from health facilities, police stations, civil society organizations and with the Government Chemist in three Kenyan provinces. The study's objective was to examine the existing policy requirements regarding the maintenance of an evidence chain by the health and criminal justice systems, and how effectively they are being implemented. The findings indicate that the quality of the evidence obtained by the health care workers was often deficient, depending on the time elapsed before the rape survivor reports to the health facility; the equipment available at the health facility; the age of the survivor; and the level of knowledge of the service provider regarding the types of evidence to be collected from survivors of sexual violence.     

Appraisal by Year Six French medical students of the teaching of forensic medicine and health law

Legal medicine is a cross-sectional specialty in which medico-legal situations very frequently combine with routine medical practice. A total of 132 students in the last year of the second cycle of medical studies (Year 6) replied anonymously and voluntarily to a questionnaire corresponding to the topics in the curriculum for the national ranking examination: law relating to death and the dying, examination of assault victims, medical malpractice liability rules, writing death certificates, respect of medical confidentiality and the principles of medical deontology. The most frequently cited activities of the forensic physician were autopsy (87.9%), writing certificates (75.8%) and consultations with victims of violence (60.6%). Students did not often come into contact with a medico-legal situation during Years 2-6 of medical studies. Assiduity in attending lectures was low. Students preferred the standard textbooks available in specialized bookshops. They were severe in their appraisal of their own competence at the end of the second cycle, and did not feel ready to examine a corpse (95.5%) or to examine victims of assault (92.4%). Knowledge of the law and of the risks of medical practice was felt to be inadequate by 60.5% of students, and of the writing of a medical certificate by 56.8%. Training medical students in this field is a major challenge in view of the limited number of teaching hours and the need to acquire increasingly specialized knowledge. Complementary initiatives appear to be necessary, such as partnership with other clinical specialties which are frequently confronted with medico-legal situations.     

The clinical management of substance misusers in police custody -- a survey of current practice

Large numbers of substance misusers are seen in police custody. Their management remains a significant part of a forensic physician's workload. Substance misuse, including alcohol, is a factor in a substantial number of deaths in custody. Guidelines have been produced on the acceptable minimum standards for assessment and treatment. The aims of this study were to determine the current attitudes and practice of forensic physicians to see whether there had been any change in practice since their publication. The results suggest that the majority of respondents had read the guidelines. However, there were still considerable variations in practice and circumstances where the minimum standards were not being achieved. Whilst 90% of respondents felt confident in dealing with substance misusers, many commented that further information on specific drugs and further training on management of substance misusers would be beneficial.     

Patterns of illicit drug use of prisoners in police custody in London, UK

AIMS AND METHODS: The aims of the study were to explore the current characteristics of drug misusers seen in police custody and identify trends or changes that have taken place in the last decade. A prospective, anonymised, structured questionnaire survey was undertaken of consenting consecutive, self-admitted illicit drug users seen by forensic physicians in police custody within the Metropolitan Police Service in London, UK in 2003. RESULTS: 30% of detainees were dependent on heroin or crack cocaine. Drug users (n=113) were studied in 2003. 95.4% completed the questionnaire. 82% were male, 18% female. Mean age was 28.5 y (range 18-49). 80% were unemployed; significant mental health issues (e.g., schizophrenia) were present in 18%; 15% had alcohol dependence; heroin was the most frequently used drug (93%); crack cocaine -- 87%; mean daily cost of drugs -- heroin GBP 76 (range 20-240), crack GBP 81 (range 20-300). >50% users inject crack and heroin simultaneously. 56% used the intravenous route; 25% had shared needles; 100% had accessible sources of clean needles; 6.4% were hepatitis B positive; 42% were aware of hepatitis prophylaxis; hepatitis C positive -- 20.2%; 3.6% were HIV positive. Mean length of time of drug use was 7.5 y (range 1 month -- 20 years); 82% had served a previous prison sentence; 54% had used drugs in prison; 11% had used needles in prison; 3% of users stated they had started using in prison. 38% had been on rehabilitation programs; 11% had been on Drug Treatment and Testing; Orders (DTTO); 32% had used the services of Drug Arrest Referral Teams in police stations; 10% were in contact with Drug Teams at the time of assessment. CONCLUSIONS: In the last decade, there appears to be a substantial increase in the prevalence of drug use in this population -- particularly of crack cocaine. Treatment interventions are either not readily available, or not followed through. In very general terms, the illicit drug use problem appears to have significantly worsened in the population seen in police custody in London, UK, in the last decade although there is evidence that health education and harm reduction messages appear to have had some positive effects.     

Knowledge,attitude, and practice of forensic practitioners during COVID-19 pandemic in Arab countries

COVID-19 pandemic burdens forensic practice worldwide. The experience of crisis management is a lesson learned that guides future preparedness for similar casualties. Thus, the present study takes an in-depth look at the knowledge, attitude, and practice of forensic practitioners during the COVID-19 pandemic in the Arab world. A comprehensive questionnaire was adopted in compliance with optimum international standards for the management of deaths during the pandemic. The survey was electronically distributed in 13 Arab countries. The responses were received from 29 forensic practitioners from 11 countries. Total median knowledge, attitude, and practice scores of respondents constituted 37.9%, 74%, and 36.8% of optimum scores respectively. Regarding knowledge, better scores are related to risk assessment and routes of exposure to Coronavirus, whereas, least scores were related to ventilation and negative pressure system. Most of the participants had a positive attitude, 85.2% were concerned about proper management of COVID-19 deaths, and 77.8% trusted the decisions of their teams. Considering practice, better scores are related to forensic staff competence, whereas, least scores were related to the implementation of ideal safety measures. Participants described the management process as useful (52%), reliable (35%), high quality (21%), and cost-effective (17%), however, they expressed challenges as staff infection, limited resources, and infrastructure issues. This survey guides readjusting of procedures and future preparedness for similar disasters in the Arab world. This research adopted a questionnaire that could be used in initial and periodic assessments in any medicolegal institute worldwide. Also, it could support infrastructure projects and disaster management plans.