Injured in Jail the need for gathering medical evidence

Margaret Stark LLM, MSc, MB BS, FFFLM, FACLM, FRCP, DGM, DMJ, DAB

Director, CFMU, NSW Police Force

Adjunct Professor Sydney Medical School

Aims today

• Outline the “Gold Standard” for medical evidence in injury documentation

• Discuss the interpretation of the injuries seen

• Present the current guidelines for taking forensic specimens (NSW)

Duty of care

• Assessment of the patient (immediate triage: history, examination, investigation as required)

• Referral to hospital for investigation/treatment

• Reporting requirements ethical/mandatory

• Full documentation and expert interpretation

Baha Mousa death: Army doctor Derek Keilloh struck off

BBC News England 21 December 2012

http://www.bbc.co.uk/news/uk-england-20809692

• Iraqi detainee died in British Army Custody

• Mousa had 93 injuries

• Dr Keilloh was aware of the injuries but failed to report them, supervised a failed resuscitation attempt

• ‘The doctor did not do enough to protect his patients, the other detainees, from further mistreatment breaking a “fundamental tenet” of the medical profession.’

• Public Inquiry and MOD paid £2.83m in compensation to families involved

Dr Brain Alderman

MPTS Panel Chairman

“Your misconduct is fundamentally incompatible with continued registration”

Medical Practitioners Tribunal Service

http://www.mpts-uk.org/about/1520.asp

Best evidence

• The documentation of injuries by clinical examination by a suitably qualified practitioner in the field of clinical forensic medicine

• Within an agreed timeframe

• Clear contemporaneous notes that can be interpreted by other doctors – the defence expert if necessary

• Supported by body maps and photographs

• Expert interpretation as to causation

Quality of evidence

• Variable quality of evidence obtained in ED/GP as the focus is on treatment and there is not enough time to document injuries to the standard required for the Criminal Justice System (CJS)

Types of Injuries (often mixed picture)

• Abrasions - scratch abrasions, friction abrasions, patterned abrasions

• Bruises • Lacerations • Incised wounds • Self-inflicted injuries • Defensive injuries • Resulting from strangulation • Burns

From the history

• How was the injury sustained? – Use open ended questions – Record critical components verbatim

• Factors that limit the provision of a full & accurate account – Pain & circumstances of the interview – Impaired mental function, psychological factors and fictitious

• What time was the injury sustained? • Weapon(s) used? • Handedness of victim and suspect • Use of drugs or alcohol – analgesic effects • Previous history (e.g., skin disease, liver disease) • Regular medication (e.g., aspirin, anticoagulants, steroids) • Has the injury been treated?

Abrasions

• An abrasion is a superficial injury of the skin that is produced by a combination of pressure & movement applied simultaneously to the skin

Abrasions

• Show exact site of the trauma

• Differentiate between the sub-categories of abrasions – Scratch abrasion - contact with fingernails, sticks or a pin

– Friction abrasion - grazes, gravel rashes and carpet burns

– Patterned abrasion

• Consider the causation for each sub-category

• Possible evidence or soiling within the abrasion

Bruises

• Bruising is produced by blunt pressure of sufficient force to cause leakage of blood from blood vessels (veins, venules & small arteries) beneath or within the skin

Selected sub-types of bruises

• ‘Love bites’ (suction bruise) • ‘True’ bite-mark bruise (teeth) • ‘Grip’ bruises (fingertips)

– Upper arms – Face or trunk – Inner thighs – Neck

• ‘Tramline’ bruises (linear object) • Wrist bruises (restraint) • Shoulder bruises (restraint) • Arm & leg bruises (assault v fall) • Upper inner thigh bruises (assault v fall)

Misinformation about bruises

• The age of a bruise cannot be determined with any degree of accuracy

• Colour of a bruise may be effected by a number of factors including colour perception

• The site of bruising is not necessarily the site of the trauma - tracking

• The shape of the bruise does not necessarily reflect the shape of the causative implement.

• The size of the bruise is not necessarily a reflection of the amount of force received.

The extent of bruises

• Diseases (alcoholism, liver disease, coagulation disorders, hypertension)

• Drugs (aspirin, anticoagulants, steroids)

• Site of trauma (tissue vascularity, near to bone, type & texture of tissues)

• Condition of tissues (elderly, infants)

• Treatment

• Time

Lacerations

• A laceration is a ragged or irregular tear or split in the full thickness of skin and possibly the subcutaneous tissues that is produced by blunt trauma.

• Distinguishing features of a laceration compared to an incised wound e.g. edges or margins of the wound will be irregular, abraded, crushed or bruised.

• Foreign materials or hairs may be detected in the wound.

Incised wounds

• These are sharply cut injuries from knives, glass or another object with a cutting edge.

• Incised wounds have regular clean edges and bleed profusely with structural damage below the skin.

• An incised wound is a full thickness cut of the skin

• There are two types of incised wound:

– Slash wound - this is defined as an incised wound that is longer than it is deep. It may be deeper at its entry point and the wound edges may gape.

– Stab wound - this is defined as an incised wound that is deeper than it is wide.

Features of stab wounds

• Scissors will frequently produce double wound directed towards each other.

• Glassing (or bottling) – frequently ragged, multi-shaped injuries (some straight & some curved), abrasions & bruising are unusual.

• Meat forks – abraded if the shaft is blunt, the distance between the two puncture site may not correlate with measurements of the fork.

• Screw driver – abraded edges due to skin being pulled down into the wound (the screw driver being relatively blunt).

Self-inflicted injuries

• The wounds tend to be very superficial.

• There are usually multiple wounds and grouped together.

• The wounds may show symmetry and are often parallel.

• The wounds tend to be of similar depth and severity

• There is a pre-selection of certain sites (forearm, face, neck, upper chest, abdomen and thighs).

• Vital structures or sensitive area tend to escape injury (eyes, lips, mouth and nipple).

• The injury must be at accessible sites to self-infliction.

• Lack of corresponding clothing defects

• Tentative wounds may be present within the grouping of suicidal wounds.

Defensive Injuries

• May occur in blunt and sharp force injuries • Occur when individuals attempt to defend

themselves and are a natural reaction to assault • The old, young, intoxicated, and those already

impaired by an assault may not be able to defend themselves

• May see injuries e.g. bruises on the backs of the forearms, or incised wounds on hands as attempts are made to grab a knife from an attacker

Strangulation

• Often no signs

• Petechiae alone non specific

• Red Flags

– Loss of consciousness

– Trouble swallowing

– Change in voice

– Loss of control of bladder &/or bowels

Body diagrams (FFLM website)

• http://fflm.ac.uk/librarydetail/4000095

• Series of body diagrams

– one page adult

– separate areas (adult)

– paediatric

Forensic Photography

• The aim is to represent the subject as true to life as possible

• Provides a permanent record of the injury

• Consider colour reproduction (colour chart)

• Size of injury (use a scale)

• Consider site and orientation of the injury

Disclaimer re Photographs

• “Interpretation of injuries from photographs should be treated with caution as the quality of the final image depends upon a number of factors such as the skill of the photographer, lighting, exposure, colour and other factors in the printing process.”

Istanbul Protocol for Interpreting Injuries

• Not consistent: could not have been caused by the trauma described;

• Consistent with: the lesion could have been caused by the trauma described but it is non-specific and there are many other possible causes;

• Highly consistent: the lesion could have been caused by the trauma described and there are few other possible causes;

• Typical of: this is an appearance that is usually found with this type of trauma; and

• Diagnostic of: this appearance could not have been caused in any way other than that described

Evidence-Based

Forensic Sampling

The nature of the [sexual] act?

The timing of the [sexual] act?

Behaviour since the assault?

Evidence-Based Forensic Sampling

Locard’s Principle:

“Every contact leaves a trace!”

Where?

• Appropriate venue – security, privacy

• Decontamination procedures need to be in place

• Decontamination Kit (NSW Police Force) now available

Possible Specimens for DNA Testing

• Buccal swab

• Skin swabs

• Fingernail swabs

• Hair – head/pubic

• Vaginal

• Anal

• Penile

Toxicology

• Blood 48 hours

• Urine 48 hours maybe longer

• Hair (4-6 weeks after ingestion of drug)

Skin swabs

• Purpose of technique to obtain traces of ‘foreign’ DNA without ‘swamping’ it with the examinee’s DNA

• Single swabbing technique required in NSW with a DAMP swab used lightly to pick up any foreign DNA left on surface

Advice for non-forensic practitioners

• Keep detailed contemporaneous clinical notes

• Describe what you see

• Get advice later if not sure re interpretation

• Seek expert help to produce expert certificate

Conclusions

The Forensic Practitioner has a

• Duty of care to complainants and suspects

• Duty to obtain the best evidence for the criminal justice system as a whole

Thank you

Questions?

Contact

Tel: 9265 4401

Fax: 9265 4496

FSGCFMU@police.nsw.gov.au