The future of medium secure forensic psychiatry in Britain: a survey

The number of National Health Service (NHS) secure psychiatric beds is increasing. This survey asked forensic services about their plans for expansion. The survey indicated a large increase in medium secure provision over the next five years. The increase in the number of patients being detained in secure settings raises questions about whether there is in Britain an on-going process of 'reinstitutionalisation' of the mentally ill.     

Developing a strategic forensic science risk management system as a component of the forensic science system of systems

ABSTRACT

Over the last decade, reviews of the forensic science industry have addressed critical system failures and made recommendations for improvements to the industry. These reviews identify systemic risks and issues but they do not explicitly address the need for strategic risk and issue management systems to deal with the identified issues and to mitigate risks. Risk and issue management, along with quality management systems, are critical components of the forensic science ‘system of systems’, which describes forensic science as a supporting system in the larger criminal justice, law enforcement, intelligence, and military systems. The update of ISO 17,025:2017 General requirements for the competence of testing and calibration laboratories now includes a chapter on risk-based thinking. Furthermore, ISO 31,000 principle and guidelines for risk management was updated in 2018 and it is important for the forensic science industry to consider the updated ISO 17,025:2017 and ISO 31,000. In this paper, we discuss risk and issues management in relation to the forensic science system of systems. The purpose is to review the strategic risks identified in reviews of the forensic science industry to identify risk treatments to help to mitigate against critical system failure, such as miscarriages of justice.     

An audit of a specialist old age psychiatry liaison service to a medium and a high secure forensic psychiatry unit

The elderly prison population is increasing and there is a significant amount of unidentified psychiatric morbidity among elderly prisoners. A sizeable number of elderly subjects are referred to regional forensic units. These units are able to provide advice but are reluctant to admit frail, physically ill and vulnerable elderly into their unit because the ward environment is considered inappropriate for them. A sizeable number of inpatients in medium and high secure units are elderly. This paper is an exploratory audit of referrals from a medium and high secure forensic psychiatry unit to a specialist consultation-only liaison old age psychiatry service, which was specifically developed to service the forensic unit. The demographic and clinical characteristics of the patients seen by this specialist service were similar to elderly inpatients in medium and high secure units. All referrals were judged to be appropriate and new management advice was provided in all cases. Main reasons for referral included diagnostic advice, placement advice and treatment advice. Establishing a diagnosis of dementia was considered important because Alzheimer's disease and Lewy body dementia can be treated with cholinesterase inhibitors. Placement advice was the most difficult to provide because of paucity of residential and nursing homes able and willing to accept patients with a forensic history. There is a need for a comprehensive model of specialist forensic old age psychiatry service at a regional or supraregional level. A consensus needs to be reached on the exact configuration of such a service.     

Prevalence of HIV risk factors for individuals examined in clinical forensic medicine

Objective: to identify the prevalence of high-risk factors for infection with Human Immunodeficiency Virus (HIV) in individuals examined in clinical forensic medical practice and to determine opinions and attitudes about HIV in this patient group. Design: Anonymised questionnaire completed by consecutive individuals seen in clinical forensic medical practice. Setting: Police stations in London attended by Group IV forensic medical examiners. Subjects: 518 individuals examined in police stations (including prisoners and suspects, those detained in police custody, police officers and victims of crime). Results: 164 (31.7%) individuals did not respond to the questionnaire because of: 1) refusal (12.6%) 2) inability because of drugs and/or alcohol (11.4%) 3) mental illness/disorder (4.2%) or 4) language difficulties (3.5%). 28.4% of the respondents were in at least one of the 'high-risk' categories for HIV infection. 26.5% were intravenous drug misusers; 15% were prostitutes; 9.8% (or their sexual partners) had lived in Central or East Africa since 1977; 5.9% were male homosexuals and 0.5% were haemophiliacs. 5.1% were infected with HIV or had Acquired Immunodeficiency Syndrome (AIDS). Only 28.8% of individuals always used condoms in short-term sexual relationships. 44.4% of respondents believed that everyone should be tested for HIV. Conclusion: Over one-quarter of the respondents were in higher-risk groups for infection with HIV. Almost one-third could or would not respond. It is concluded that it is not possible to identify by questionnaire, individuals at higher risk of HIV infection in forensic medical practice. This reinforces the necessity of observing good clinical practice to reduce contamination risks in this work environment. It is clear that education about risks for HIV infection is still much needed.     

Taking chances: risk assessment and management in a risk obsessed society

Two earlier contributions to this journal on the topic of 'dangerous behaviour' are updated in the light of recent theoretical and practical developments in the assessment and management of risk in criminal justice and psychiatry. Such assessment and management need to be viewed against the background of current over-preoccupation with avoiding the hazards of daily living.     

The nature and management of aggressive incidents in a medium secure unit

The study describes and analyses incident reports over a three-year period in a medium secure unit. A low threshold of reporting was encouraged and substantial numbers of 'minor' incidents were reported. The frequency of incidents peaked in the evenings. The use of seclusion and manual restraint is reported and these were used more frequently where staff were the target of aggression.     

The use of an alcometer in clinical forensic practice

Forensic physicians are at times required to provide a professional opinion on a person's degree of intoxication through alcohol, particularly with regard to fitness for interview by the police. Inherent to these assessments is an estimation of the blood alcohol concentration (BAC). Most forensic physicians rely on taking a history regarding recent alcohol consumption and a clinical assessment to estimate the BAC. We report a study in which the BAC of 118 detainees was estimated and compared with the BAC measured by an alcometer. Our estimations were accurate in 66% of cases. Most errors resulted from underestimating the BAC. Additionally, we attempted to determine fitness for interview using a single measurement of the BAC without a clinical assessment. 19% of those who were assessed as unfit for interview had a BAC of less than the UK legal limit for driving (currently 80 mg%) and 37% considered fit, had a BAC above that level. We conclude that the routine use of alcometers would enhance the practice of forensic medicine but could not replace its role in the assessment of levels of alcohol intoxication.     

The assessment of 3D printer technology for forensic comparative analysis

ABSTRACT

Three-dimensional (3D) printing technology is a layer-by-layer building tool that uses a variety of engineering processes and materials. It has many applications in the automobile, medical, aerospace and fashion industries, as well as for the 3D-printing hobbyist. Currently, there are seven main types of 3D printers, which can be categorized according to the engineering process used. Cost reductions and the increased quality of personal 3D printers are making them more affordable and accessible to organizations and individuals for potential criminal purposes. This review is an assessment of 3D printer engineering features and the materials used. This is crucial in understanding the potential application and development of forensic techniques to identify a printer source, and in the comparison of printed materials that may have been used in alleged criminal activity.     

The role of direct multiplanar high resolution CT in the assessment and management of orbital trauma

Basic anatomic research has resulted in the discovery of an intricate intraorbital connective tissue system involved in normal eye movements, and in combination with the development of the direct triplane high-resolution CT technique, this research has dramatically improved the treatment of orbital trauma. On the basis of clinical and CT evaluation, four causes of motility impairment after orbital trauma are now recognized and permit patient-tailored treatment methods.     

喉返神经实时监测技术在高风险、复杂甲状腺术中临床应用价值

目的探讨喉返神经监测技术在高风险、复杂甲状腺手术中的应用及临床价值。方法回顾性分析自2015年5月至2016年12月行甲状腺手术的167例患者临床资料,包括巨大结节性甲状腺肿(包括胸骨后甲状腺肿)、桥本氏甲状腺炎、术前疑为甲状腺癌、再次甲状腺手术、术前声音嘶哑、甲状腺功能亢进以及甲状旁腺肿瘤等术中喉返神经显露困难、易损伤者。其中,喉返神经实时监测组76例,术中探查喉返神经129根;常规显露组91例,术中探查喉返神经132根。比较两组喉返神经损伤率、术中出血量、低钙血症发生率、淋巴漏发生率、住院时间及总住院费用。结果喉返神经实时监测组、常规显露组,喉返神经损伤发生率分别为2.3%(3/129)、10.6%(14/132),两组间比较,差异有统计学意义(P<0.01);暂时性喉返神经损伤发生率分别为1.6%(2/129)、9.1%(12/132),两组间比较,差异有统计学意义(P<0.01);永久性喉返神经损伤发生率分别为0.8%(1/129)、1.5%(2/132),两组间比较,差异无统计学差异(P>0.05)。两组患者术后低钙血症发生率、术后淋巴漏发生率、术中出血量及住院时间比较,差异无统计学差异(P>0.05)。喉返神经实时监测组、常规显露组,总住院费用分别为(17 428.96±5 303.00)元、(14 031.74±3 503.00)元,两组间比较,差异有统计学意义(P<0.01)。结论在高风险、复杂甲状腺术中,喉返神经实时检测可降低暂时性喉返神经损伤率,但住院费用偏高。对永久性喉返神经损伤率、出血量、住院时间、术后低钙血症发生率、术后淋巴漏发生率无明显影响。     

The interaction of death, sorcery and coronial/forensic practices within traditional indigenous communities

The investigation of death in traditional indigenous communities often involves 'men of high degree' performing rituals and procedures to ascertain whether sorcery has been involved. If this is the case then the perpetrator must be identified and suitable retribution or compensation sought. In Central Australia investigations into such deaths occur in 'sorry camps' which consist of temporary meeting camps distant from facilities and amenities. Delays in the issuing of autopsy reports may unnecessarily prolong the time that tribal members have to spend in these camps, and wording of standard autopsy reports may not assist tribal concerns over matters such as sorcery. An initiative in South Australia, following discussions with Aboriginal elders in the Anangu Pitjantjatjara tribal lands, has been to issue a one page provisional report as soon as possible after completion of the autopsy, listing the likely cause of death. This is sent to Aboriginal authorities through local health clinics. In addition, a statement that 'no sticks, stones, bones or other foreign objects were found within the body that would implicate another person in the death' is also included to inform tribal members that no physical evidence of magical interference with the body has been detected. Relatively minor alterations in standard forensic/coronial reporting practices may significantly assist certain groups whose cultural requirements may be under-appreciated and incompletely understood by investigating authorities.     

外周插管中心静脉导管在CT增强检查中的应用分析

目的探讨外周插管中心静脉导管(Power PICC SOLO Catheter,Power PICC SOLO)在增强CT(CECT)风险防范中的应用。方法选取我院化疗患者90例,按照随机数字表法分为观察组和对照组,两组均45例,其中对照组实施经外周静脉留置针注入对比剂行CECT检查,观察组经外周插管中心静脉导管进行CECT检查,观察两组患者不良事件发生率、检查期间相关时间、图像质量评分。结果观察组不良事件发生率与对照组差异无统计学意义(P> 0.05);观察组自检查室到开展CT、CT结束后处理通路、总耗时低于对照组,观察组图像质量好于对照组(P<0.05)。结论在增强CT检查中实施外周插管中心静脉导管,能够减少反复穿刺疼痛,缩短检查时间,具有重要临床意义。     

Muscle cramping in athletes--risk factors, clinical assessment, and management

Exercise associated muscle cramping (EAMC) is defined as a painful, spasmodic, and involuntary contraction of skeletal muscle that occurs during or immediately after exercise. There is a high lifetime prevalence of EAMC in athletes, specifically in endurance athletes. The most important risk factors for EAMC in athletes are a previous history of EAMC, and performing exercise at a higher relative exercise intensity or duration, when compared with normal training and participating in hot and humid environmental conditions. The diagnosis of EAMC is made clinically, and the most effective immediate management of EAMC is rest and passive stretching. The key to the prevention of EAMC is to reduce the risk of developing premature muscle fatigue.     

The role of the forensic pathologist in quality assurance and safety of patient care

During this past half century, there has been remarkable increase in the role of forensic pathologists and medical examiners in the determination of cause and manner of deaths in health care facilities and investigations of quality of patient care. Autopsy data are an essential part of this quality assurance (QA) program in patient care, especially in trauma centers' QA programs. Forensic pathologists participate in evaluating appropriateness of patient care where death occurs during or following therapeutic and diagnostic procedures. Continuous quality improvement programs now extend into data sharing in child and elder abuse, monitoring of defective medical devices and consumer products which contributed to deaths. In recent years, forensic pathologists are increasingly requested directly by family members to conduct private autopsies to provide independent opinions as to quality of patient care. Thus forensic pathologists are contributing expertise to an ever widening circle of influence in prevention of unnecessary deaths with quality assurance programs and peer review processes.     

Altitude-related hypoxia: risk assessment and management for passengers on commerical aircraft

BACKGROUND: Individuals with pulmonary and cardiac disorders are particularly at risk of developing hypoxemia at altitude. Our objective is to describe the normal and maladaptive physiological responses to altitude-related hypoxia, to review existing methods and guidelines for preflight assessment of air travelers, and to provide recommendations for treatment of hypoxia at altitude. DATA SYNTHESIS: Falling partial pressure of oxygen with altitude results in a number of physiologic adaptations including hyperventilation, pulmonary vasoconstriction, altered ventilation/perfusion matching, and increased sympathetic tone. According to three guideline statements, the arterial pressure of oxygen (PaO2) should be maintained above 50 to 55 mm Hg at all altitudes. General indicators such as oxygen saturation and sea level blood gases may be useful in predicting altitude hypoxia. More specialized techniques for estimation of altitude PaO2, such as regression equations, hypoxia challenge testing, and hypobaric chamber exposure have also been examined. A regression equation using sea level PaO2 and spirometric parameters can be used to estimate PaO2 at altitude. Hypoxia challenge testing, performed by exposing subjects to lower inspired FIO2 at sea level may be more precise. Hypobaric chamber exposure, the gold standard, mimics lower barometric pressure, but is mainly used in research. CONCLUSION: Oxygen supplementation during air travel is needed for individuals with an estimated PaO2 (8000 ft) below 50 mmHg. There are a number of guidelines for the pre-flight assessment of patients with pulmonary and/or cardiac diseases. However, these data are based on small studies in patients with a limited group of diseases.     

The minor child's degree of autonomy and the measures taken to protect him or her within the health care sector in Belgium

The necessity of taking into account the interest and opinion of the child was recently emphasized in the Belgian Constitution. The Belgian Act of August 22nd, 2002 on Patients' Rights introduced an important innovation concerning the minor child, in that the latter has since been authorized to exercise his or her patients' rights autonomously, as far as he or she is considered able to reasonably appreciate his or her interests. In some areas, the Belgian legislature has made certain reservations. For example, the minor child has no right to ask for euthanasia; several bills have been proposed in order to recognize it in some circumstances, but they have not been passed. Similarly, activities relating to medically assisted reproduction are not available to the minor, except in cases where there are medical indications. Finally, it might be relevant for the Belgian legislature to enact more specific protective provisions for the child participant in clinical trials.