Professional Documents
Culture Documents
M EDICINE
Professor CEDRIC KEITH SIMPSON CBE (1907-1985) MD (Lond), FRCP,
FRCPath, MD (Gent), MA (Oxon), LLD (Edin), DMJ. Keith Simpson was the first
Professor of Forensic Medicine at the University of London and undoubtedly
one of the most eminent forensic pathologists of the twentieth century. He spent
all his professional life at Guy's Hospital, and he became a household name
through his involvement in many notorious murder trials in Britain and over
seas. He was made a Commander of the British Empire in 1975. He was a superb
teacher, through both the spoken and the printed word. The first edition of this
book appeared in 1947 and in 1958 won the Swiney Prize of the Royal Society of
Arts for being the best work on medical jurisprudence to appear in the preceding
ten years.
Professor Simpson updated this book for seven further editions. Professor
Bernard Knight worked with him on the ninth edition and, after Professor
Simpson's death in 1985, updated the text for the tenth and eleventh editions.
Richard Shepherd updated Simpson's Forensic Medicine for its twelfth edition
in 2003. Jason Payne-James and Richard Jones have updated the 13th and this
edition.
W7
£/6
SIMPSON'S FORENSIC
M EDICINE
14th Edition
Edited by
Professor Jason Payne-James, l l m , m sc , f f f l m , f r c s ,
This book contains information obtained from authentic and highly regarded sources. W hile all reasonable efforts have been made
to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any
errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by indi
vidual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The
information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided
strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient s medical history, rel
evant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any
information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult
the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their
websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate
whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the
medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and
publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright
holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write
and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transm itted, or utilized in any
form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, m icrofilm ing, and
recording, or in any information storage or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copy-
right.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC
is a not-for-profit organization that provides licenses and registration for a variety o f users. For organizations that have been granted
a photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification
and explanation without intent to infringe.
Names: Payne-James, Jason (Forensic physician), editor. |Jones, Richard (Forensic pathologist), editor.
Title: Simpson’s forensic medicine / edited by Professor Jason Payne-James and Dr. Richard Jones.
O ther titles: Forensic medicine
Description: 14e. |Boca Raton : CRC Press, 2019. |Preceded by Simpson’s forensic medicine / Jason Payne-James
... [et al.]. 13th ed. c2011. |
Includes bibliographical references and index.
Identifiers: LCCN 2019014218| ISBN 9781498704298 (pbk.: alk. paper) |ISBN 9780367333195 (hardback : alk.
paper) |ISBN 9781315157054 (ebook)
Subjects: |MESH: Forensic Medicine
Classification: LCC RA1051 |NLM W 700 |DDC 614/.l-dc23
LC record available at https://lccn.loc.gov/2019014218
promulgation, adjudication and enforcement of rules. knowledge requiring expertise within a legal setting
There are many national variations but the basic pat (forensic medicine and forensic science) is most com
tern is often similar. The exact structure is frequently monly required. Criminal trials involve offences that
developed from, and thus determined by, the political are 'against the public interest'; these include offences
system, culture and religious attitudes of the country in against the person (e.g., murder, assault, grievous bodily
question. In England & Wales, the principal sources of harm, rape), property (e.g., burglary, theft, robbery), and
these laws are Parliament and the decisions of judges in public safety and security of the state (terrorism). In
courts of law. Criminal courts generally deal predomi these matters, the state acts as the voice or the agent of
nantly with disputes between the State and individual, the people. In continental Europe, a form of law derived
and the civil courts with disputes between individuals. from the Napoleonic era applies. Napoleonic law is an
Most jurisdictions will have a range of other legal bod 'inquisitorial' system and both the prosecution and the
ies that are part of these systems or part of the overall defence have to make their cases to the court, which
justice system (e.g., employment tribunals, asylum tri then chooses which is the more credible. Evidence is
bunals, mental health review tribunals and other spe often taken in written form as depositions, sometimes
cialist dispute panels) and such bodies may deal with referred to as 'documentary evidence'. The Anglo-
conflicts that arise between citizens and administrative Saxon model applies in England & Wales and in many
bodies, or make judgements in other disputes. All such of the countries that it has influenced in the past. This
courts, tribunals or bodies may, at some stage, require system is termed the 'adversarial' system. If an act is
input from medical and scientific professionals. considered of sufficient importance or gravity, the state
In England & Wales, decisions made by judges in the 'prosecutes' the individual. Prosecutions for crime in
courts have evolved over time and this body of decisions England & Wales are made by the Crown Prosecution
is referred to as 'common law' or 'case law'. The 'doc Service (CPS), who assess the evidence provided to them
trine of precedent' ensures that principles determined by the police. They must consider two main questions:
in one court will normally be binding on judges in infe (1) Is there enough evidence against the defendant?
rior courts. The Supreme Court of the United Kingdom is When deciding whether there is enough evidence to
the highest court in all matters under English and Welsh charge, Crown Prosecutors must consider whether evi
law, Northern Irish law and Scottish civil law. It is the dence can be used in court and is reliable and credible.
court of last resort and highest appeal court in the United Crown Prosecutors must be satisfied there is enough
Kingdom; however, the High Court of Justiciary remains evidence to provide a 'realistic prospect of conviction'
the highest court for criminal cases in Scotland. The against each defendant; and (2) Is it in the public inter
Constitutional Reform Act 2005 established (amongst est for the CPS to bring the case to court? A prosecution
other functions) a Supreme Court which assumed the will usually take place unless the prosecutor is sure that
judicial functions of the House of Lords, which were pre the public interest factors tending against prosecution
viously undertaken by the Lords of Appeal in Ordinary outweigh those tending in favour. Thus, even when there
(commonly called Law Lords). The Tong title' of the Act is sufficient evidence to justify a prosecution or to offer
further detailed the changes it enacted - 'An Act to make an out-of-court disposal, prosecutors must go on to con
provision for modifying the office of Lord Chancellor, sider whether a prosecution is required in the public
and to make provision relating to the functions of interest. The more serious the offence or the offender's
that office; to establish a Supreme Court of the United record of criminal behaviour, the more likely it is that a
Kingdom, and to abolish the appellate jurisdiction of the prosecution will be required in the public interest.
House of Lords; to make provision about the jurisdic In a criminal trial, it is for the prosecution to prove
tion of the Judicial Committee of the Privy Council and their case to the jury or the magistrates 'beyond reason
the judicial functions of the President of the Council; to able doubt'. This standard of proof was outlined in the
make other provisions about the judiciary, their appoint case of W oolmington v Director o f P ublic Prosecutions
ment and discipline; and for connected purposes'. Along [1935] AC 462 when Viscount Sankey, the then Lord
with the concept of Parliamentary Sovereignty is that the Chancellor, stated:
judiciary (the judges) are independent of state control,
although the courts will still be bound by statutory law. Throughout the web of the English C rim inal Law one
This separation is one that is frequently and increasingly golden thread is always to be seen that it is the duty of
the prosecu tion to prove the prisoner's guilt su bject to
tested by politicians and the media in particular.
what I have already said as to the d efence of insanity
and su b ject also to any statutory exception. If, at the
Criminal law end of and on the whole of the case, there is a reason
able doubt, created by the evidence given by either the
Criminal law is that law which addresses the relation prosecution or the prisoner, as to w hether the prisoner
ship between the state and the individual and as such killed the deceased with a m alicious intention, the
is probably the area in which medical and scientific prosecution has not made out the case and the prisoner
Legal systems I 3
is entitled to an acquittal. No m atter w hat the charge or seriously, the Family Court will deal with cases where
where the trial, the principle that the prosecu tion must the government (local councils, in practice) intervenes
prove the guilt of the prisoner is part of the com m on in a family to protect children from harm. That can lead
law of England and no attempt to w hittle it down can
to the children being taken into care and eventually
be en tertained .
adopted or placed with extended family. These cases
Nowadays, the burden of proof is often simplified to are ones where forensic practitioners are most likely to
being 'sure'. If that level cannot be achieved, then the be involved.
prosecution fails and the individual is acquitted. If the The Family Court also deals with the majority of
level is achieved then the individual is convicted and orders designed to protect people against domestic vio
a punitive sentence is applied. The defence does not
lence. The court may issue a 'non-molestation order'
have to prove innocence because any individual is pre instructing an individual not to contact, harass, threaten
sumed innocent until found guilty. Defence lawyers aim or be violent to another person or it can make an 'occu
to identify inconsistencies and inaccuracies or weak pation order' preventing someone from, for example,
nesses of the prosecution's case and can also present living in or returning to the family home. More complex
their own evidence. family cases may be dealt with the Family Division of
The penalties that can be imposed in the criminal the High Court which also deals with specific issues
system commonly include financial (fines) and loss of such as forced marriage and female genital mutilation.
liberty (imprisonment) and community-based sen The standard of proof in the civil setting is lower than
tences. A number of countries still permit corporal that in the criminal setting. In civil proceedings, the stan
punishment (beatings), mutilation (amputation of parts dard of proof is proof on the balance of probabilities - a
of the body) and capital punishment (execution). The fact will be established if it is more likely than not to have
World Medical Association has published a number of happened.
documents related to the involvement of healthcare pro In a decision of the Court of Appeal in Re (N) v Mental
fessionals in such occurrences, including the Medical Health Review Tribunal [2006] QB 468 it was stated that
there is only one single standard of proof in the civil sys
Ethics Manual.
In England & Wales, the lowest tier of court (in both tem but that the standard was flexible in its application:
civil and criminal cases) is the Magistrates' Court. These Although th ere is a single standard of proof on the bal
courts tend to deal with less serious crime and are lim an ce of probabilities, it is flexible in its application. In
ited in the punishments they can administer to those particular, the more serious the allegation or the more
found guilty. Lay (non-legal) magistrates (Justices of serious the consequences if the allegation is proved,
the Peace) sit in the majority of these courts advised by the stronger m ust be the evidence before the court will
a legally qualified justice's clerk. In some magistrates' find the allegation proved on the b a la n ce of probabili
ties. Thus, the flexibility of the standard lies not in any
courts a district judge will sit alone. The majority of
ad ju stm ent to the degree of probability required for
criminal cases appear in magistrates' courts. The Crown
an allegation to be proved (such that a m ore serious
Court sits in a number of centres throughout England allegation has to be proved to a higher degree of prob
& Wales and is the court that deals with more seri ability), but in the strength or qu ality of the evidence
ous offences, and considers appeals from magistrates' that w ill in practice be required for an allegation to be
courts. Cases are heard before a judge and a jury of 12 proved on the balance of probabilities.
people. Appeals from the Crown Court are heard in the
Court of Appeal Criminal Division. Special youth courts If the standard of proof is met, the penalty that can be
are utilised for those under 18 years of age (Figure 1.1). imposed by these courts is designed to restore the posi
tion of the successful claimant to that which they had
before the event, and is generally financial compensa
Civil law
tion (damages). In certain circumstances, there maybe
Civil law is concerned with the resolution of disputes a punitive element to the judgement.
between individuals. The aggrieved party undertakes The Magistrates' Court is used for some cases, but
the legal action. Most remedies are financial. All kinds the majority of civil disputes are dealt with within the
of dispute may be encountered, including those of County Court in the presence of a circuit judge. The
alleged negligence, contractual failure, debt, and libel High Court has unlimited jurisdiction in civil cases
or slander. The civil courts can be viewed as a mecha and has three divisions:
nism set up by the state that allows for the fair resolu
tion of disputes in a structured way. In England & Wales, • Chancery - specialising in matters such as com
the County Court is where trials for most civil cases are pany law;
held. The Family Court (and Family Division of the High • Fam ily - specialising in matrimonial issues and
Court) deal with all kinds of legal disputes to do with child issues and others as described above; and
children and the breakdown of relationships. Most • Queen's Bench - dealing with general issues.
4 I Principles of forensic practice
Figure 1.1 The structure of the court system in England & Wales.
In both civil and criminal trials, the person against Professional witness
whom the action is being taken is called the defendant;
the accuser in criminal trials is the state and in civil tri In 1924, Dr Graham Grant, a police surgeon (forensic
als it is the plaintiff. physician) in the East End of London, differentiated pro
fessional from expert witnesses in his book 'Practical
Forensic Medicine' (Figure 1.2a and 1.2b).
Doctors and other healthcare Little has changed. A professional witness is one
professionals and the law who gives factual evidence. This role is equivalent to a
simple witness of an event, but occurs when the doc
Doctors and other healthcare professionals may become
tor is providing factual medical evidence. For example,
involved with the law in the same way as any other pri
an emergency medicine physician may confirm that a
vate individual: they may be charged with a criminal
leg was broken or that a laceration was present and may
offence or they may be sued through the civil court.
report on the presentation and treatment given. A pri
A doctor may also be witness to a criminal act and may
mary care physician may confirm that an individual
be required to give evidence about it in court.
has been diagnosed as having epilepsy or angina. No
However, these examples will only apply to the
comment or opinion is generally given and any report
minority of professionals reading this book. For the
or statement deals solely with the relevant medical find
majority, it is the nature of their work which may result
ings on a factual basis.
in that individual providing evidence that may subse
quently be tested in court. Doctors (or other healthcare
professionals) may have one of two roles in relation to Expert witness
the court, either as a professional witness or as an expert An expert witness is one who expresses an opinion about
witness. The distinction between these roles may be medical or scientific matters in which they may not ini
blurred. tially have had direct involvement, but by virtue of their
Doctors and other healthcare professionals and the law I 5
It appeared that Rule 702 superseded Frye and in • An expert witness should make it clear when a
1993 this was confirmed in D aubert v Merrell Dow particular question or issue falls outside his area
Pharm aceuticals, Inc. 509 US 579 [1993]. This decision of expertise.
held that proof that establishes scientific reliability of • If an expert's opinion is not properly researched
expert testimony must be produced before it can be because he considers that insufficient data is
admitted. Factors that judges may consider were: available, then this must be stated with an indica
tion that the opinion is no more than a provisional
• Whether the proposition is testable. one.
• Whether the proposition has been tested. • In cases where an expert witness, who has prepared
• Whether the proposition has been subjected to a report, could not assert that the report contained
peer review and publication. the truth, the whole truth and nothing but the
• Whether the methodology technique has a known truth without some qualification, that qualification
or potential error rate. should be stated in the report.
• Whether there are standards for using the tech • If, after exchange of reports, an expert witness
nique. changes his views on a m aterial matter having
• Whether the methodology is generally accepted. read the other side's report or for any other reason,
such change of view should be communicated
The question as to whether these principles applied (through legal representatives) to the other side
to all experts and not just scientific experts was explored without delay and when appropriate to the court.
in cases and in 2000 Rule 702 was revised to: • Where expert evidence refers to photographs,
If scientific, technical, or other specialized knowledge plans, calculations, analyses, measurements,
w ill assist the trier of fact to understand the evidence survey reports or other similar documents, these
or to determ ine a fact in issue, a w itness qualified as must be provided to the opposite party at the same
an expert by knowledge, skill, experience, or train time as the exchange of reports.
ing, or education may testify thereto in the form of an
opinion or otherwise, provided that (1) the testimony is Another case further clarified the role of the expert
sufficiently based upon reliable facts or data, (2) the tes witness (Toulmin HHJ in Anglo Group pic v Winther
tim ony is the product of reliable principles and m eth Brown & Co. Ltd. [2000])
ods, and (3) the witness has applied the principles and
m ethods to the facts of the case. • An expert witness should at all stages in the pro
cedure, on the basis of the evidence as he under
Committee Notes of the Federal Rules also empha
stands it, provide independent assistance to the
sise that if a witness is relying primarily on experience
court and the parties byway of objective unbiased
to reach an opinion, then that witness must explain
opinion in relation to matters within his exper
how that specific experience leads to that particular
tise. This applies as much to the initial meetings
opinion.
of experts as to evidence at trial. An expert witness
In England & Wales, His Honour Judge Cresswell
should never assume the role of an advocate.
reviewed the duties of an expert in N ational Justice
• The expert's evidence should normally be con
C om pania Naviera SA v P rudential Assurance Co Ltd
[1993 2 Lloyd's Rep 68] (commonly known as 'the Ikarian fined to technical matters on which the court
Reefer' case) and identified the following key duties of will be assisted by receiving an explanation, or to
expert witnesses and their evidence: evidence of common professional practice. The
expert witness should not give evidence or opin
• Expert evidence presented to the court should be, ions as to what the expert him self would have
and should be seen to be, the independent product done in similar circumstances or otherwise seek
of the expert uninfluenced as to form or content by to usurp the role of the judge.
the exigencies of litigation. • The expert should cooperate with the expert(s) of
• An expert witness should provide independent the other party or parties in attempting to narrow
assistance to the Court by way of objective, unbi the technical issues in dispute at the earliest pos
ased opinion in relation to matters within his sible stage of the procedure and to eliminate or
expertise. place in context any peripheral issues. He should
• An expert witness in the High Court should never cooperate with the other expert(s) in attending,
assume the role of an advocate. without prejudice, meetings as necessary and in
• An expert should state facts or assumptions upon seeking to find areas of agreement and to define
which his opinion is based. precisely areas of disagreement to be set out in the
• An expert should not omit to consider material joint statement of experts ordered by the court.
facts which could detract from his concluded • The expert evidence presented to the court should
opinion. be, and should be seen to be, the independent
Evidence for courts I 7
product of the expert uninfluenced as to form or Recent cases within the United Kingdom emphasise
content by the exigencies of the litigation. the increasing scrutiny that experts are being subjected
• An expert witness should state the facts or assump to, which have sometimes resulted in suspension or
tions upon which his opinion is based. He should not criticism. In Pool v GMC [2014] EWHC 3791 a psychia
omit to consider material facts which could detract trist was found to have failed to restrict his opinion to
from his concluded opinion. areas in which he had expert knowledge and experience
• An expert witness should make it clear when a par and had neither requisite qualifications or experience
ticular question or issue falls outside his expertise. to act as an expert. In Squier v GMC [2016] EWHC 2739
• Where an expert is of the opinion that his conclu (Admin) the decision of a professional regulatory panel
sions are based on inadequate factual information was subject to rigorous review by the High Court. The
he should say so explicitly. court overturned the factual findings of the regulatory
• An expert should be ready to reconsider his opin panel in a 'shaken baby' case and also laid down guid
ion, and if appropriate, to change his mind when ance regarding the use of expert evidence. This guid
he has received new information or has consid ance set out the core duties of an expert when citing the
ered the opinion of the other expert. He should do works of others which are:
so at the earliest opportunity.
• The duty to explain that a hypothesis is controver
These points remain the essence of the duties of an sial.
expert within the English and Welsh jurisdiction. • The duty to provide to the court all material con
Further guidance is given in Kennedy v Cordia [2016] tradicting a controversial hypothesis.
UKSC 6 para 48 adopting Coopers (S Africa) v Deutsche • The duty to make all material available to other
G esellschaft [1976] 352 at 371 which states experts in the case when advancing a controver
sial hypothesis.
...exp ert's opinion represents his reasoned conclusion
• The duty to take all reasonable steps to verify
based on ce rta in facts or data, w hich are either com
m on cause, or established by his own evidence or that of
information provided.
som e other com petent witness. Except possibly where • The duty not to leave out relevant information.
it is not controverted, an expert's bald statem ent of his • The duty to take into account all material facts
opinion is not of any real assistance. Proper evaluation before them.
of the op in ion can only be undertaken if the process of • The duty to set out all material and literature relied
reason in g w hich led to the conclusion, including the upon in forming an opinion.
prem ises from which the reasoning proceeds, are dis
closed by the expert. This area of law will continue to evolve.
within the report that they know to be false. The state pre-booked holidays or other court commitments), but
ment makes reference to the relevant legislation. The this is not always successful. When notified that a court
effect of this declaration is to render the individual liable case in which you are a witness is going to take place, it is
for criminal prosecution if they have lied. A statement generally possible to agree a specific day on which your
provided when acting as a professional witness will be attendance is required. However, the court does have
based on the contemporaneous notes or records made the power to compel attendance even when you have
at the time of examination), and it is important that the other commitments. In this case, a witness summons
statement accurately reflects what was seen or done at may be issued. This is a court order signed by a judge or
the time. other court official that must be obeyed or the individual
A statement may be agreed by both defence and pros will be in contempt of court and a fine or imprisonment
ecution, negating the need for court attendance. If, for may result. Most courts and judges are reasonable, but
example, the defence do not accept the findings or facts it requires flexibility and as much notice as possible on
expressed, the doctor will be called to court to give live both sides.
(oral) evidence and be subject to examination, cross- Waiting to give evidence inevitably involves possible
examination and re-examination. delays and frustration, so it is sensible to take work to court
In civil proceedings a different official style may be so that some of the time is not wasted. Examples of reasons
adopted. In these cases, a sworn statement (an affida for last-minute changes in the need for court attendance
vit) is made before a lawyer who administers an oath or include factors such as a guilty plea being entered on the
other formal declaration at the time of signing. first day of the trial, or acceptance of a lesser charge, or the
In many countries, a statement in official form or a case being dropped because of disclosure failures.
sworn affidavit is commonly acceptable alone and per
sonal appearances in court are unusual. However, in Evidence in court
the system of law based on Anglo-Saxon principles, per
When called into court, each witness will undergo
sonal appearances are common in the criminal justice
some process in which they commit to telling the truth.
system and it is the testing by the defence and prosecu
'Taking the oath' or'swearing- in' requires, for those with
tion of the live evidence given in court (together with
religious beliefs, swearing on their respective holy book
written reports/statements made by that witness) that
(e.g., the New Testament, the Old Testament, the Quran)
may be particularly significant.
or a public declaration or affirmation that they will tell
If a case comes to trial, any statement or relevant evi
the truth. Regardless of how it is done, the effect of the
dence in the prosecution case must be disclosed to all
words is the same: once the oath has been taken, the wit
interested parties at the court; at present, the same prin
ness is liable for the penalties of perjury.
ciple of disclosure does not apply to all reports prepared
W hether called as a witness of fact, a professional
for the defence in a criminal trial. Thus, a defence team
witness of fact or an expert witness, the process of giv
may commission a report that is not helpful to the client's
ing evidence is the same.
defence. This does not have to be disclosed to the pros
In a criminal trial, whichever of the defence or pros
ecution team. Failure to disclose evidence by the police
ecution has called the witness will be the first to examine
or prosecution may fatally undermine the prosecution
them under oath. This is the 'examination in chief' and
case, and this subject is one that is of continuing rele
the witness will be asked to confirm the truth of the facts
vance. The format for reports in civil trials is different. In
in their statement(s). This examination may take the form
England & Wales, the Ministry of Justice publishes and
of one catch-all question as to whether the whole of the
updates a civil, criminal and family procedure rules and
statement is true, or the truth of individual facts may be
practice directions, and these are accessible online. It is
dealt with one at a time. If the witness is not an expert,
important to understand that, although these are pub
there may be questions to ascertain how the facts were
lished, practice sometimes varies from the published
obtained and the results of any examinations or ancillary
rules and directions and is updated regularly.
tests performed. If the witness is an expert, the question
ing may be expanded into the opinions that have been
Attending court expressed and other opinions may be sought.
If requested to appear as a witness for the court, it is the When this questioning is completed, the other law
duty of all to comply. Attendance at court by profession yers will have the opportunity to question the witness;
als is generally presumed without the need to resort to a this is 'cross-examination'. This questioning will test
formal summons from the court. Most courts now have the evidence that has been given and will concentrate
some form of witness liaison units that liaise with all on those parts of the evidence that are damaging to the
witnesses in a case, attempting (often unsuccessfully) lawyer's case. It is likely that both the facts and any opin
to ensure that the dates of any trial are convenient for all ions given will be tested.
witnesses. Court listing offices try to take into account The final part of giving evidence is the 're-examina
'dates to avoid' (e.g., clinics or operating sessions, tion'. The original lawyer has the opportunity to clarify
Healthcare professionals as witnesses in court 9
anything that has been raised in cross-examination but professionalism, but this decision must be a matter of
generally cannot introduce new topics. The rules of evi personal preference.
dence (what is and isn't admissible in front of a jury) are Evidence should also be given in a clear voice that is
hugely complex and frequently trials are interrupted to loud enough to reach across the court room. Take time in
discuss these and other legal points. responding and be aware that judges (and lawyers) will
The judge may ask questions at any time if he feels be writing the responses on paper or a laptop. Most wit
that by doing so it may clarify a point or clear a point of nesses will at some time have been requested to 'Pause,
contention, or if he thinks counsel are missing a point. please' to give time for the judge to complete notes.
The judge may allow the jury to ask questions. However, The witness should always answer the question
most judges will try to refrain from asking questions posed, not the one the witness believes should or
until the end of the re-examination. would have liked to have been asked. Questions should
be answered fully and then the witness should stop
and wait for the next question. Do not feel the need to
Healthcare professionals as fill the silence with an explanation or expansion of the
witnesses in court answer. If the lawyers want an explanation or expan
Any medicolegal report must be prepared and written sion of any answer, they will ask for it. Clear, concise
with care because it will either constitute the medical and complete should be the watchwords when answer
evidence on that aspect of a case or it will be the basis of ing questions.
any oral evidence that may be given in the future. Any A witness should also expect to have qualifications,
healthcare professional who does not, or cannot, sustain experience and opinions challenged. However, becom
the facts or opinions made in the original report while ing hostile, angry, flippant or rude as a witness does not
giving live evidence may, unless there are reasons for impress the court or the jury and is easily exploited by
the specific alteration in fact or opinion, find themselves counsel. Part of the role of the lawyers questioning is to
professionally embarrassed. Any medical report or state try and elicit such responses. The lawyers are in control
ment submitted to courts should always be reviewed by in the courtroom and they will very quickly take advan
the author prior to signing and submitting it to avoid fac tage of any witness who shows such emotions. A judge
tual errors (e.g., identifying the wrong site of an injury or will normally intervene if he feels that the questioning
sloppy typographical errors) and it is advisable to have it is unreasonable or unfair.
peer-reviewed by a colleague. However, any comments A witness must be alert to attempts by lawyers to
or conclusions within the report are based upon a set of circum scribe answers unreasonably: 'yes' or 'no' may
facts that surround that particular case. If other facts or be adequate for simple questions but they are simply
hypotheses are suggested by the lawyers in court dur not sufficient for most questions and, if told to answer
ing their examination, any witness must be prepared a complex question 'with a simple "yes" or "no" doctor',
to reconsider the medical evidence in the light of these he should decline to do so and, if necessary, explain to
new facts or hypotheses and, if necessary, should accept the judge that it is not possible to answer such a complex
that, in view of the different basis, the conclusions may question in that way.
be different. Prior to giving live evidence the doctor must The old adage of 'dress up, stand up, speak up and
refresh their memory of the case by reviewing the report shut up' is still entirely applicable and it is unwise to
and materials supplied. If, whilst giving evidence, the ignore such simple, appropriate and easy to follow
doctor does not know the answer to a question posed, or advice.
it is outside their range of experience, they should make Box 1.1 summarises key elements of how to be best
this clear and, if necessary ask the judge for guidance in prepared for court attendance.
the face of particularly persistent counsel.
Anyone appearing before any court in either role Preparation of medicolegal reports
should ensure that their dress and demeanour are com The diversity of uses of a report is reflected in the indi
patible with the role of an authoritative professional and viduals or groups that may request one: a report may be
respectful to the court. It is imperative that doctors and requested by the police, prosecutors, Coroners, judges,
others providing professional or expert witness evidence medical administrators, government departments, city
give their evidence in a clear, unbiased and dispassion authorities or lawyers of all types. The nature and the
ate manner. format of the report may vary in each setting. If unfamil
The oath or affirmation should be taken in a clear iar with the process always ask for a sample report in the
voice. Most courts are audio-recorded and microphones correct style. Many courts will have standard proforma
are placed for that purpose, not for amplifying speech. or procedural rules that will assist. Before agreeing to
In some courts, witnesses may be invited to sit, whereas write a report, it is essential to be sure that the author
in others they will be required to stand. Many expert (1) has the expertise to write such a report and (2) also
witnesses prefer to stand as they feel that it adds to their has the authority, permissions and consent to write such
10 I Principles of forensic practice
clarify whether or not a specific structure is required box. It is always embarrassing trying (and failing) to
and if so, follow it assiduously. For example, in the interpret your own handwriting in a witness box in front
civil justice system in England & Wales the process, of a judge and jury.
and how the evidence is dealt with, is described in Autopsy reports are a specialist type of report and
Part 35 of the Civil Procedure Rules which refers to may be commissioned by the Coroner, the police or any
experts and assessors and their roles. other appropriate person or body. Again, as with expert
A professional witness statement (one that simply reports, there are standardised protocols or proformas
reports facts found at examination) will be headed by (Box 1.2).
specific legal wording. The statement should include the The authority to perform the autopsy will replace the
full name of the practitioner, their age and their profes consent given by a live patient, and is equally impor
sional address. The reason for the examination should be tant. The history and background to the death will be
stated, and then the relevant history as recounted (e.g., obtained by the police or the Coroner's officer, but the
'he told me he was hit twice on the right forearm with a doctor should seek any additional details that appear
baseball bat'), the medical findings (e.g., two tramline to be relevant, including speaking to any clinicians
bruises, both 6 x 4 cm in size, purple in colour with asso involved in the care of the deceased and reviewing the
ciated swelling in the middle 1/3 of the ulnar bone with hospital notes. A visit to the scene of death in non-sus-
a possible fracture), and what treatment was given (e.g., picious deaths, especially if there are any unusual or
pain relief and referral for X-ray). The statement sum unexplained aspects, is advisable.
marises the personal involvement of the practitioner. A An autopsy report is confidential and should only be
professional witness statement simply reports facts. disclosed to the legal authority who commissioned the
Clarity and simplicity of expression make the whole examination. Disclosure to others, who must be inter
process simpler. Statements can be constructed along ested parties, may only be made with the specific per
the same lines as the clinical notes; they should be mission of the commissioning authority and, in general
structured, detailed (but not overelaborate - avoid com terms, it would be sensible to allow that authority to deal
plex medical and scientific terms unless absolutely nec with any requests for copies of the report.
essary, and where possible explain them) and accurate. Doctors must resist any attempt to change or delete
Do not include every single aspect of a medical history any parts of their report by lawyers who may feel those
unless it is relevant and consent has been given for its parts are detrimental to their case; any requests to
disclosure. A court does not need to know every detail, rewrite and resubmit a report with alterations for these
but it does need to know every relevant detail, and a good reasons should be refused. Persistent and inappropri
report will give the relevant facts clearly, concisely and ate pressure may require referral to the regulatory body.
completely, and in a way that someone without medical At times, lawyers, but more often police personnel, may
training can understand. sometimes need to be reminded or informed of the
The contemporaneous clinical notes maybe required duties of a healthcare professional which is to assist the
to support the statement and it is essential to ensure that court, not the relevant instructing body. Always seek the
all handwriting within such medical notes has been advice of the judge on matters arising that may result in
reviewed (and interpreted) prior to entering the witness potential breaches of these important duties.
Payne-James JJ, Bloomer JA. Court skills. In: Dalton M (ed). Forensic
Bibliography and information Gynaecology. Cambridge: Cambridge University Press; 2015.
sources Payne-James JJ, Newton MA, Bassindale C. Forensic sci
Anglo Group pic v Winther Brown & Co Ltd and others. [2000] All ence, forensic medicine and sexual crime. In: Radcliffe P,
ER (D) 294. Gudjonsson G, Heaton-Armstrong A (eds). Witness Testimony
Boccaccini MT, Brodsky SL. Believability of expert and lay wit in Sexual Cases. Oxford: Oxford University Press; 2016.
nesses: implications for trial consultation. Prof Psychol Res Pr Re (N) v Mental Health Review Tribunal [2006] QB468.
2002;33:384-388. Stark MM. Clinical Forensic Medicine: A Physician's Guide, 3rd edn.
Burton JL, Rutty GN (eds). The Hospital Autopsy: A Manual of New York: Humana Press; 2011.
Fundamental Autopsy Practice, 3rd edn. London: Hodder Toulmin HHJ in Anglo Group pic v Winther Brown & Co. Ltd.
Arnold; 2010. [2000]. http://www.bailii.org/ew/cases/EW HC/TCC/
Cooper J, Neuhaus IM. The 'hired gun' effect: assessing the effect 2000/127.html (Accessed 23 July 2019).
of pay, frequency of testifying and credentials on the percep Woolmington v Director of Public Prosecutions [1935] AC 462.
tion of expert testimony. Law Hum Behav 2000;24:149-171.
Court of Appeal in Re (N) v Mental Health Review Tribunal [2006]
QB 468.
Further general resources
Cramer RJ; Brodsky SL, DeCoster J. Expert witness confidence and Acting as a witness in legal proceedings. http://www.gmc-uk.
juror personality: their impact on credibility and persuasion org/guidance/ethical_guidance/21193.asp (Accessed 6 April
in the courtroom. J Am Acad Psychiatry Law 2009;37(1):63-74. 2019).
Crown Prosecution Service. Code for Crown Prosecutors, https:// Crown & Procurator Fiscal. Our role in investigating deaths.
www.cps.gov.uk/publication/code-crown-prosecutors http://www.copfs.gov.uk/investigating-deaths/our-role-in-
(Accessed 29 March 2019). investigating-deaths (Accessed 6 April 2019).
Daubert v Merrell Dow Pharmaceuticals, Inc. [1993] 509 US 579. Crown Prosecution Service. Disclosure manual, https://www.cps.
http://www.law.cornell.edu/supct/html/92-102.ZS.html gov.uk/legal-guidance/disclosure-manual (Accessed 6 April
(Accessed 29 March 2019). 2019).
Federal Rules of Evidence Article I. General provisions, Rule 702. Female Genital Mutilation: A guide for healthcare professionals.
https://www.law.cornell.edu/rules/fre/rule_702 (Accessed 29 https://www.england.nhs.uk/north/wp-content/uploads/
March 2019). sites/5/2016/01/fgm-hp-guide.pdf (Accessed 6 April 2019).
Freckelton I. A guide to the provision of forensic medical evi Guide to Coroner Services. Ministry of Justice. https://assets.
dence. In: Gall J, Payne-James JJ (eds) Current Practice in publishing.service.gov.uk/government/uploads/system/
Forensic Medicine. London: Wiley; 2011. uploads/attachment_data/file/363879/guide-to-coroner-
Freckelton I, Selby H. Expert Evidence: Law, Practice, Procedure and service.pdf (Accessed 6 April 2019).
Advocacy, 6th edn. Sydney: Lawbook Co; 2016. Mandatory reporting of child abuse and neglect. https://aifs.
Fryev United States, 293 F. 1013 (D.C.Cir. 1923). https://www.law.ufl. gov.au/cfca/publications/mandatory-reporting-child-abuse-
edu/_pdf/faculty/little/topic8.pdf (Accessed 29 March 2019). and-neglect (Accessed 6 April 2019).
House of Commons Debates, Volume 483, 29 January 1951 Mandatory reporting of female genital mutilation: procedural
(quote of Hartley Shawcross). information, https://www.gov.uk/government/publications/
National Justice Compania Naviera SA v Prudential Life Assurance mandatory-reporting-of-female-genital-mutilation-proce-
Co ('The Ikarian Reefer') [1993] 2 ULR 68,81-82. dural-information (Accessed 6 April 2019).
Lynch J. Clinical Responsibility. Oxford: Radcliffe Publishing; 2009. Part 35 of the Civil Procedure Rules, https://www.justice.gov.uk/
Ministry of Justice (England and Wales). Civil procedure rules. courts/procedure-rules/civil/rules/part35 (Accessed 6 April
http://w w w.justice.gov.uk/courts/procedure-rules/ 2019).
civil (Accessed 29 March 2019). The Forensic Science Regulator, https://www.gov.uk/govern-
Ministry of Justice (England and Wales). Criminal procedure ment/organisations/forensic-science-regulator (Accessed 6
rules, http://www.justice.gov.uk/courts/procedure-rules/ April 2019).
criminal (Accessed 29 March 2019). The judicial system of England & Wales: a visitor's guide.
Ministry of Justice (England and Wales). Family procedure rules. h ttp s ://w w w .ju d ic ia ry .u k /w p -c o n te n t/u p lo a d s /
http://w w w.justice.gov.uk/courts/procedure-rules/ 2016/05/international-visitors-guide-10a.pdf (Accessed 6
family (Accessed 5 April 2019). April 2019).
Ministry of Justice. Practice Direction 32: evidence https://www.
justice.gov.uk/courts/procedure-rules/civil/rules/part32/
pd_part32#evidence (Accessed 6 April 2019).
up
The Greek tradition of medical practice was epitomised It is commonly believed that all doctors (in the
by the Hippocratic School on the island of Kos around United Kingdom defined as a medical practitioner reg
400 BC and there the foundations of both modern medi istered by the General Medical Council) have taken the
cine and the ethical facets of the practice of that medi Hippocratic Oath. This is in fact not the case, although
cine were laid. What is now known as the Hippocratic some do, depending on where they trained, but the key
Oath was developed at and for those times, yet it remains principles espoused within the Oath lay the foundation
the basis of ethical medical behaviour today, even for what is broadly called 'medical ethics'. The principles
though some of the detail is now obsolete. Its endur of medical ethics have developed over several thousand
ing nature is a testament to its simple common sense years and continue to evolve and change, influenced by
and universal acceptance. The following is a generally society, the legal profession and the medical profession
accepted translation: itself. Most days in the media there will be a headline
news story with its basis in the interpretation of aspects
I sw ear by Apollo the physician and A esculapius and
of medical ethics, such as euthanasia, the death pen
Health and A ll-heal and all the gods and goddesses,
alty, torture and abortion. The laws governing the prac
that accord in g to my ability and judgem ent, I w ill keep
this O ath and th is stipulation - to hold him who taught
tice of medicine vary from country to country, but the
me this art, equ ally dear to me as my ow n parents, to broad principles of medical ethics are universal and are
m ake him p artn er in my livelihood: w hen he is in need formulated not only by national medical associations,
of money, to sh are m ine with him ; to consid er his fam but by international organisations such as the World
ily as my own brothers and to teach them this art, if they Medical Association (WMA).
14 The ethics of medical practice
GMC guidelines) or more generalised. The Nursing and Failure to comply with the Code may bring their fit
Midwifery Council (NMC) in the UK, which is the pro ness to practise into question. Box 2.4 gives a summary
fessional body for nurses, has its own Code. The Code of the main components of the NMC Code of perfor
presents the professional standards that nurses and mance standards and behaviours expected of registered
midwives must uphold in order to be registered to prac nurses and midwives.
tise in the UK. It is structured around four themes: The Health & Care Professions Council (HCPC) is
a body created by statute in England & Wales, which
1. Prioritise people regulates healthcare professionals (e.g., arts therapists,
2. Practise effectively biomedical scientists, chiropodists/podiatrists, clinical
3. Preserve safety scientists, dietitians, hearing aid dispensers, occupa
4. Promote professionalism and trust tional therapists, operating department practitioners,
16 I The ethics of medical practice
Table 2.1 Example Declarations of the World Medical Association (many have been revised and amended
in subsequent years)
1975 The Declaration ofTokyo Torture and other cruel and degrading treatment
or punishment
1981 The Declaration of Lisbon Rights of the patient
1983 The Declaration ofVenice Terminal illness
1983 The Declaration of Oslo Therapeutic abortion
1984 The Declaration of Sao Paolo Pollution
1987 The Declaration of Madrid Professional autonomy and self-regulation
2006 The Declaration of Ottawa Child health
2009 The Declaration of Delhi Health and climate change
2016 The Declaration ofTaipei (adopted by the 3rd WMA Research on Health Databases, Big Data and
General Assembly, Washington, DC, USA, October Biobanks
2002 and revised by the 67th WMA General Assembly,
Taipei, Taiwan, October 2016)
orthoptists, paramedics, physiotherapists, practitio p articip ants and to facilitate and prom ote ethical
ner psychologists, prosthetists/orthotists, radiogra research that is of potential benefit to p articip an ts, sci
phers, and speech and language therapists). The HCPC en ce and society.
was set up to protect the public and keeps a register of
The NHS Health Research Authority provides gover
health professionals who meet its standards for train
nance arrangements for research ethics committees,
ing, professional skills, behaviours and health. All of
most recently updated in 2018.
these professions have at least one professional title
Medical ethics as a subject is incorporated into
that is protected by law, including those shown above.
medical school curricula as the need for knowledge
This means, for example, that anyone using the titles
of such matters becomes increasingly important with
'physiotherapist' or 'dietitian' must be registered with
high-technology medicine creating clinical scenarios
the HCPC.
that may need to be assessed and interpreted by the
It is a criminal offence for someone to claim that they
courts. However medical ethics, like forensic medicine,
are registered with the HCPC when they are not, or to
although essential to safe and proper practice, is allot
use a protected title they are not entitled to use.
ted too little time in most medical schools and other
healthcare professions training.
Medical ethics in practice Examples of the type of subject that may be embraced
The formal role of ethics in contemporary health and in discussions on medical ethics might include:
social care has become much more clearly defined. One
• Patient autonomy and their right to refuse or
example of its practical application in the UK is the NHS
choose treatment.
Health Research Authority who has its own Research
• Non-maleficence - do no harm.
Ethics Service whose role is
• Beneficence - acting in the patient's best interests.
• Dignity.
to en able and support ethical research in the NHS. It
protects the rights, safety, dignity and w ellbeing of
• Honesty - providing informed consent.
research participants and has a duty to provide an effi • Justice - how healthcare is apportioned when
cient and robust ethics review service that m axim ises health and financial resources may be limited.
UK com petitiveness for health research and m axi
m ises the return from investm ent in the UK, while It is important for doctors and other healthcare
protecting participants and researchers. It protects professionals to be aware of these issues, even if
the rights, safety, dignity and w ellbeing of research they do not provide immediate answers to clinical
Medical ethics in practice I 17
m ^
dilemmas. Sometimes these factors conflict, for exam from informed consent to doctofr-doctor relationships.
ple, a Jehovah's witness declining a blood transfusion Often, law develops as a rfe^iibofrgtal^ic'and political
even though the doctor knows that death will ensue. debate on such issues. Breaches of medical ethical val
There are very few medical or healthcare activities ues (e.g., dishonesty, fraud, sexual assault) may result
that do not have some ethical considerations, varying in disciplinary processes and the sanctions that can
from research on patients to medical confidentiality, be applied by regulatory bodies are wide from giving
18 The ethics of medical practice
Source: Intim
ateexam
inationsandchaperones.
• Record that permission has been given for the
examination. 7"
So From General
• Offer the patient a chaperone (an impartial Medical Council, 2013. (https://www.gmc-uk.Org/-/
observer who should usually be a health profes media/documents/maintaining-boundaries-intimate-
sional, rather than a relative or friend, although examinations-and-chaperones_pdf-58835231.pdf).
Box 2.4 Summary of professional conduct standards for nurses and midwives
You must put the interests of people using or needing and accurate records; reflect and act on feedback
nursing or midwifery first and uphold the standards set you receive to improve your practice.
out in the Nursing & Midwifery Council Code. Action Preserve safety: make sure that patient and public
can be taken - including removal from the register - if safety is protected; work within the limits of your
you fail to do so. competence, exercising your professional 'duty
You must: of candour' and raising concerns immediately
Prioritise people: make their care and safety your whenever you come across situations that put
first concern and make sure that their dignity patients or public safety at risk.
is preserved and their needs are recognised, Promote professionalism and trust: be a m odel of
assessed and responded to; make sure that those integrity and leadership for others to aspire to;
receiving care are treated with respect, that their uphold the reputation of your profession at all
rights are upheld, and that any discriminatory times and display a personal commitment to the
attitudes and behaviours towards those receiving standards of practice and behavior set out in this
care are challenged. Code.
Practise effectively: assess need and deliver or
advise on treatment, or give help without too
much delay, and to the best of your abilities, on
Source:practiceandbeT
hahveiC
Adapted from
orodfoer:P
neurrfsoersm
aann
dcm
esidtaw
nidvaesr.dsof
Nursing
the basis of the best evidence available and best and Midwifery Council, 2015. (https://www.nmc.org.uk/
practice; communicate effectively, keeping clear standards/code/).
advice or warnings to erasure from the relevant regis seriousness with which each is viewed may vary in dif
ter and withdrawal of the licence to practice against the ferent parts of the world, as will the sanctions applied.
doctor found guilty of unethical practices. However, the World Medical Association defines quite
Although the spectrum of unethical conduct is wide, clearly, from a medical perspective, standards that
certain universally relevant subjects are recognised. The should be followed (see Box 2.1).
Confidentiality I 19
CONTENTS
Table 1 Statutory notifications of infectious diseases in the past 6 weeks with totals for the
current year compared with corresponding periods of the two preceding years
Table 2 Statutory notifications of infectious diseases for diseases for W EEK 2019/36 by PHE
Region, county, local and unitary authority including additional diseases notifiable from
6th April 2010
Registered Medical Practioner in England and Wales have a statutory duty to notify a Proper Officer of
the local authority, often the CCDC (Consultant in Communicable Disease Control), of suspected cases
of certain infectious diseases:
Notifications of infectious diseases, some of which are later microbiologically confirmed, prompt local
investigation and action to control the diseases. Proper officers are required every week to inform the
PHE (formerly the Registrar General) anonymised details of each case of each disease that has been
notified. PHE has responsibilty of collating the weekly returns from proper officers and publishing
analyses of local and national trends.
Figure 2.1 An example front page of the Public Health England weekly Notification of Infectious Disease
Report (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/830662/
NOIDS-weekly-report-week36-2Q19.pdf)
Confidentiality I 21
Health England weekly ‘Notification of Infectious purposes. These include disclosures for the administra
Diseases Report' illustrating a wide range of condi tion of justice, and for purposes such as financial audit
tions that registered medical practitioners in England and insurance or benefits claims. Anonymised infor
& Wales have a statutory duty to notify a ‘Proper Officers mation will usually be sufficient for purposes other
of the local authority' (who may be the Consultant in than the direct care of the patient and you must use it
Communicable Disease Control). in preference to identifiable information wherever pos
Certain government agencies or bodies may have sible. If you disclose identifiable information, you must
statutory power to access patients' records. Patients' be satisfied that there is a legal basis for breaching con
medical records and related personal information fidentiality. The patient must always be made aware of
may be required by regulatory bodies if there has the nature and extent of information being disclosed.
been a com plaint against a healthcare professional. The information disclosed must be unbiased, relevant
Courts may require access to m edical records when and limited to the needs expressed. The patient should
there is a concern that medical issues or conditions generally be offered the opportunity to see any report
might m aterially be relevant in a case. Information or disclosure prior to it being disclosed, unless poten
must be disclosed if it is required by statute, or if tially non-disclosable confidential information about
ordered by a judge or presiding officer of a court. It another person is contained within it.
is important to ensure that disclosure is required by
law and information should only be disclosed that is Disclosure in the public interest
relevant to the request. Patients should be informed Confidential medical care is recognised in law as being
about such disclosures, unless the purpose would be in the public interest. There may be a public interest in
undermined, for example, by prejudicing the preven disclosing information if the benefits to an individual or
tion, identification or prosecution of serious crime. society outweigh both the public and the patient's inter
If there is some ambiguity about the lawfulness of a est in keeping the information confidential. In particu
request and if disclosure is not consented to, then legal lar, in the forensic context, disclosure may be justified to
advice and advice from a medical defence organisa protect individuals or society from risks of serious harm,
tion or Caldicott guardian should be sought. The GMC such as from serious communicable diseases or serious
provides a framework about disclosing patients' per crime.
sonal information. In some circumstances, disclosing personal infor
mation without consent is justified in the public inter
Disclosing information with consent
est for important public benefits, other than to prevent
Certain patients may wish to withhold particular death or serious harm, if there is no reasonably prac
aspects of personal information, and unless other rea ticable alternative to using personal information. It
sons for disclosure apply this wish must be respected. If is always appropriate to seek advice in such circum
such a request might influence aspects of medical care, stances, for example from a Caldicott Guardian or a
it should be ensured that the patient is fully aware that medicolegal adviser from a medical defence organisa
withholding information may compromise that care. tion. In addition to risks of harm, there are more gen
Those who are provided with such information must eral areas where disclosure may be permissible in the
be reminded of their own duty of confidence. Clinical public interest and these can relate to areas such as
situations such as medical emergencies may mean that research, education and public health. The opportunity
information is passed without consent, and an explana to anonymise such information should always be taken
tion should later be given to the patient advising them if appropriate, although in many settings it may be pos
of the reasons for that disclosure. Disclosure may also sible to obtain consent. A decision to disclose must also
be permitted for audit if the patient is aware of that pos take into account the practicalities of obtaining con
sibility and they have not objected to it. sent in relation to the need for disclosure.
the details an d implications o f w hat is proposed. optimise care. Previously the standard test to measure
This is m ore important than how their consent is whether there has been a breach in their duty of care was
expressed or recorded. known as the Bolam test, which was introduced following
• Patients can give consent orally or in writing, or the landmark clinical negligence claim Bolam v Friern
they m ay imply consent by com plying with the pro Hospital M anagement Com m ittee 1957. The test expects
p osed exam ination or treatment, fo r example, by that standards of care have been followed in accordance
rolling up their sleeve to have their b loo d pressure with a responsible body of opinion, that is, the medical
taken. professional must demonstrate that they acted in a way
• In the case o f minor or routine investigations or that a responsible body of medical professionals in the
treatm ents, if you are satisfied that the patient same field would regard as acceptable or reasonable.
understands what you propose to do an d why, it is However, in the UK the law on informed consent has
usually enough to have oral or im plied consent. changed following a Supreme Court judgement. Doctors
• In cases that involve higher risk, it is important must now ensure that patients are aware of any 'material
that you get the patient's written consent. This is risks' involved in a proposed treatment, and of reason
so that everyone involved understands what was able alternatives, following the judgement in the case
explain ed an d agreed. Montgomery v Lanarkshire H ealth Board. This is a marked
• By law you must get written consent fo r certain change to the Bolam test. This test will no longer apply to
treatm ents, such as fertility treatm ent. You must the issue of consent, although it will continue to be used
fo llo w the laws and codes o f practice that govern more widely in cases involving other alleged acts of neg
these situations. ligence. In a move away from the 'reasonable doctor' to
the 'reasonable patient', the Supreme Court's ruling has
You should also get written consent fro m a patient if: outlined the new test: 'The test of materiality is whether,
• The investigation or treatm en t is com plex or in the circumstances of the particular case, a reasonable
involves significant risks. person in the patient's position would be likely to attach
• There m ay be significant con sequ en ces fo r the significance to the risk, or the doctor is or should reason
patient's employment, or social or personal life. ably be aware that the particular patient would be likely
• Providing clinical care is not the prim ary purpose to attach significance to it.' This decision enshrines in
o f the investigation or treatment. law principles that are already in the GMC’s guidance
• The treatm ent is part o f a research program m e or on consent. Consent may be given orally or in writing -
is an innovative treatment designed specifically fo r this is express or explicit consent. Consent may also be
their benefit. given implicitly, for example, by allowing blood pressure
• I f it is not possible to get written consent, fo r exam to be taken by removing clothing to give access to the
ple, in an emergency or if the patien t needs the arm. It is generally accepted that for higher risk or more
treatm en t to relieve serious p ain or distress, you complex procedures, if there is a risk to life or lifestyle,
can rely on oral consent. But you must still give the for research or in the criminal setting (e.g., the taking of
p atien t the information they w ant or n eed to m ake intimate samples such as penile or vaginal swabs) that
a decision. You must record the fa c t that they have written consent is appropriate. In some settings written
given consent, in their m edical records. consent is mandatory.
The responsibility for seeking consent is that of the
Recording decisions doctor undertaking the investigation or treatment.
Such a duty can be delegated if the person to whom it is
• You m ust use the patient's m ed ical records or a delegated is appropriately trained and has appropriate
consent fo rm to record the key elem ents o f your dis knowledge of the treatment or investigation proposed.
cussion with the patient. This shou ld include the
inform ation you discussed, any specific requests by
the patient, any written, visual or au dio informa
Young people, children and consent
tion given to the patient, an d details o f any deci Age is not necessarily a determining factor in the ability
sions that were made. to consent, although it is generally accepted that those
aged 16 years and older have the capacity to make deci
Patients with capacity to make decisions sions about treatment or care. Many children below the
Consent is a key concept of healthcare and it is expected age of 16 years may also have the capacity to understand
that all decisions about treatment and healthcare come and consider options. In the UK the GMC publishes guid
about as a result of collaboration between doctors and ance on making decisions in those aged under 18 years
patients. Consent should be based on trust, openness and and how capacity and best interests may be assessed. The
good communication. In the UK, doctors are expected capacity of children below the age of 16 years to consent
to work in partnership with their patients in order to to medical treatment depends on whether the child has
24 I The ethics of medical practice
achieved a sufficient understanding and intelligence to This test of competence is utilised in a number of
appreciate the purpose, nature, consequences and risks other jurisdictions.
of a particular treatment (including no treatment) and
has the ability to appraise the medical advice. Reference Patients without capacity to make
is made in England & Wales to Gillick competency and
the Fraser guidelines. Gillick competency and the Fraser decisions
guidelines refer to a legal case which looked specifically If patients are unable to make decisions for themselves,
at whether doctors should be able to give contraceptive the doctor must engage with those who are close to the
advice or treatment to under 16-year-olds without paren patient and with colleagues involved in the healthcare.
tal consent. They are now widely used to help assess In England & Wales decisions about those who lack
whether a child has the maturity to make their own deci capacity is governed by the Mental Capacity Act 2005
sions and to understand the implications of those deci (MCA). The MCA is intended to protect and empower
sions. Following an initial court case and then an appeal, people who may lack the mental capacity to make their
the case went to the House of Lords and the Law Lords own decisions about their care and treatment. It applies
(Lord Scarman, Lord Fraser and Lord Bridge) ruled in to people aged 16 and over. It covers a range of decisions
favour of the judgement delivered by Mr. Justice Woolf about everyday living (e.g., what to wear) and more seri
in the original case (Gillick v West Norfolk 1984): ous potentially life-changing decisions (e.g., having
major surgery). There is no specific group that lacks
...w hether or not a child is capable of giving the neces
capacity but examples of conditions which may have an
sary consent will depend on the child's m aturity and
understanding and the nature of the co n sen t required. effect include:
The child m ust be capable of m aking a reasonable
• Dementia
assessm ent of the advantages and disadvantages of the
treatm en t proposed, so the consen t, if given, can be
• Severe learning disability
properly and fairly described as true consen t. • Brain injury
• Mental health illness
The Fraser guidelines refer to the guidelines set out • Cerebrovascular accident
by Lord Fraser in his judgement of the Gillick case in • Unconsciousness caused by an anaesthetic or
the House of Lords (1985), which apply specifically to sudden accident
contraceptive advice. Lord Fraser stated that a doctor
could proceed to give advice and treatment: The presence of these or other health conditions
does not automatically mean that the individual lacks
'provided he is satisfied in the following criteria:
the capacity to make a specific decision, and the nature
• that the g irl (although under the age o f 16 years o f age) of capacity may vary dependent on the task (e.g., they
w ill understand his advice. may lack the ability to make financial decisions, but be
• th at he cannot persuade her to in form her parents or able to manage day-to-day tasks). The MCA assumed
to allow h im to inform the parents that she is seeking that every person has the capacity to make a decision
contraceptive advice.
themselves, unless it is proved otherwise; that wherever
• th at she is very likely to continue having sexual inter
possible, people should be assisted in making decisions;
course with o r without contraceptive treatment.
an unwise decision does not necessarily mean a per
• that unless she receives contraceptive advice or treat
m ent her physical or m ental health o r both are likely son lacks capacity; and if decision making on behalf of
to suffer. someone who lacks capacity you must act in their best
• th at her best interests require h im to give her contra interests. Additionally, treatment and care provided to
ceptive advice, treatment or both w ithout the parental someone who lacks capacity should be the least restric
consent .' tive of their basic rights and freedoms.
The Act sets out a 2-stage test of capacity:
In the same case Lord Scarman commented:
.. .it is not enough that she should understand the nature 1. Does the person have an impairment of their
of the advice which is being given: she m ust also have a mind or brain, whether as a result of an illness,
sufficient m aturity to understand w hat is involved or external factors such as alcohol or drug use?
2. Does the impairment mean the person is unable
and more generally on parents' versus children's
to make a specific decision when they need to?
rights:
...parental right yields to the child's right to m ake his Mental capacity can also fluctuate with time - some
own decisions when he reaches a su fficient under one may lack capacity at one point in time, but may be
standing and intelligence to be capable of m aking up able to make the same decision at a later point in time.
his own mind on the matter requiring decision. Whenever possible people should be allowed the time
Regulation of doctors and other professionals I 25
to make a decision themselves. The determination of all practising doctors in the UK, separate from the reg
capacity is made by determining whether the person is istration system. The GMC has legal powers designed to
able to: maintain the standards the public have a right to expect
of doctors. If a doctor fails to meet those standards, the
• Understand the decision to be made and the infor GMC acts to protect patients from harm - if necessary,
mation provided about the decision: the conse by seeking to remove the doctor from the register and
quences of making a decision must be included in removing their right to practise medicine.
the information given. Before the GMC can stop or limit a doctor's right to prac
• Retain the information: a person should be able tise medicine, it needs evidence of impaired fitness to prac
to retain the information given for long enough tise. Examples of such evidence include doctors who have
to make the decision - information can only be not kept their medical knowledge and skills up to date and
retained for short periods of time, it should not are not competent, have taken advantage of their role as a
automatically be assumed that the person lacks doctor or have done something wrong, are too ill, or have
capacity, for example, written information could not adequately managed a health problem to enable them
be used to assist a person's ability to retain it. to work safely. The GMC can also issue a warning to a doc
• Use that information in making the decision: a tor where the doctor's fitness to practise is not impaired but
person should be able to weigh up the advantages there has been a significant departure from the principles
and disadvantages of making the decision. set out in the GMC's guidance for doctors, Good Medical
• Communicate their decision: if a person cannot Practice. A number of sanctions are available. For example,
communicate their decision, for example, if they a warning will be disclosed to a doctor's employer and to
are unconscious, the Act specifies that they should any other enquirer during a 5-year period. A warning will
be treated as if they lack capacity. All efforts should not be appropriate where the concerns relate exclusively to
be made to help the person communicate their a doctor's physical or mental health.
decision before deciding they are not able to do so. Doctors (and other healthcare professionals) in the
UK have a 'professional duty of candour', and detailed
guidance as to how this ought to be achieved in practice
Regulation of doctors and other has been issued by the GMC. In essence, it is a duty to be
professionals honest with patients when things go wrong, and builds
on the recommendations made by Sir Robert Francis in
The General Medical Council the wake of the significant failures in the provision of
Regulation of the work of healthcare professionals is basic healthcare in Mid Staffordshire NHS Foundation
governed in many countries around the world by regula Trust hospital.
tory bodies that may have powers to assess the individ
ual's performance and work. In the UK, the regulatory
Legal framework for GMC fitness
body for registered medical practitioners (doctors) is the
General Medical Council (GMC). The Medical Act 1858 to practise procedures
established the General Council of Medical Education The legal framework for the Fitness to Practise proce
and Registration of the United Kingdom as a statutory dures is set out in the Medical Act 1983 and the Fitness
body. Subsequent Acts have refined this. Currently all to Practise Rules 2004. These are updated at frequent
the GMC's functions derive from a statutory require intervals. In particular these rules set timelines and
ment for the establishment and maintenance of a structure to the procedures.
register, which is the definitive list of doctors as provi The Medical Act gives the GMC powers and respon
sionally or fully 'registered medical practitioners'. The sibilities for taking action when questions arise about
GMC controls entry to the List of Registered Medical doctors' fitness to practise. The detailed arrangements
Practitioners ('the medical register'). The Medical Act for how these matters are investigated and adjudicated
1983 (amended) notes that, ‘The m ain objective o f the upon are set out in rules which have the force of law.
General Council in exercising their fu n ction s is to pro Procedures are divided into two separate stages:
tect, prom ote an d maintain the health an d safety o f the 'Investigation' and 'Adjudication'. In the investigation
public.' The GMC also regulates and sets the standards stage cases are assessed to determine whether they need
for medical schools in the UK, and liaises with other referral to the Medical Practitioners Tribunal Service
nations' medical and university regulatory bodies over (MPTS) for adjudication. The adjudication stage consists
medical schools overseas, leading to some qualifica of a hearing by a medical practitioner's tribunal.
tions being mutually recognised. It also regulates post Where the complaint raises questions about the doc
graduate medical education. Most recently the GMC is tor's fitness to practise, an investigation will commence
responsible for a licensing and revalidation system for and the complaint will be disclosed to the doctor and
26 I The ethics of medical practice
his/her employer/sponsoring body. This is intended to beyond the period initially set, the GMC will apply to
ensure that there is a complete overview of the doctor's the High Court (or the Court of Session in Scotland) for
practice and makes the information available to those permission to do so.
responsible for local clinical governance. Further infor The Fitness to Practise Panel hears evidence and
mation may be sought from the complainant, whose decides whether a doctor's fitness to practise is impaired.
consent will be needed to disclose the complaint to the Fitness to Practise hearings are the final stage of proce
doctor. dures following a complaint about a doctor.
The doctor is given an opportunity to comment on A Fitness to Practise Panel is composed of medi
the complaint. An investigation may need further doc cal and non-medical persons and normally comprises
umentary evidence from employers, the complainant three to five panelists. In addition to the chairman, who
or other parties, witness statements, expert reports on may be medical or non-medical, there must be at least
clinical matters, an assessment of the doctor's perfor one medical and one non-medical panelist on each
mance and an assessment of the doctor's health. panel. A legal assessor sits with each panel and advises
At the end of the investigation of allegations against on points of law and of mixed law and fact, including the
a doctor, the case will be considered by two senior procedure and powers of the panel. One or more spe
GMC staff known as case examiners (one medical and cialist advisers may also be present to provide advice to
one non-medical) who can conclude the case with no the panel in relation to medical issues regarding a doc
further action, issue a warning, refer the case to the tor's health or performance. The GMC is normally repre
Panel or agree undertakings. They must have in mind sented at the hearing by a barrister. The doctor is invited
the GMC's overarching objective of public protection to attend and is usually present and legally represented.
(including the protection of patients and maintaining Both parties may call witnesses to give evidence and if
public confidence in the profession) in considering they do so the witness may be cross-examined by the
whether there is a realistic prospect of establishing that other party. The panel may also put questions to the
a doctor's fitness to practise is impaired to a degree jus witnesses. The panels meet in public, except where they
tifying action on registration. Cases can only be con are considering confidential information concerning
cluded or referred to a Fitness to Practise Panel with the doctor's health or they are considering making an
the agreement of both a medical and non-medical case interim order.
examiner. If they fail to agree, the matter will be con Once the panel has heard the evidence, it must decide
sidered by the Investigation Committee, a statutory whether the facts alleged have been found proved and
committee of the GMC. A warning will be appropriate whether, on the basis of the facts found proved, the doc
if there is evidence to suggest that the practitioner's tor's fitness to practise is impaired and, if so, whether
behaviour or performance has fallen below acceptable any action should be taken against the doctor's registra
standards to a degree warranting formal censure by tion. If the panel concludes that the doctor's fitness to
the GMC, but does not warrant referral to a tribunal, practise is impaired, the following sanctions are avail
and action on registration is not necessary. A decision able: to take no action; to accept undertakings offered
may be made that, despite there being evidence that the by the doctor provided that the panel is satisfied that
practitioner's practice is impaired, no further action such undertakings protect patients and the wider pub
will be taken if that practitioner accepts undertakings lic interest; to place conditions on the doctor's registra
restricting future practice or behaviour, or to undergo tion; to suspend the doctor's registration; or to erase the
medical supervision or retraining, for example. doctor's name from the Medical Register, so that they
At any stage of the investigation a doctor may be can no longer practise. The process is summarised in
referred to an interim orders tribunal of the MPTS which Figure 2.2.
can suspend or impose conditions on a doctor's practice Doctors have a right of appeal to the High Court (Court
while the investigation continues. Cases referred to an of Session in Scotland) against any decision by a panel to
interim order tribunal are those where the doctor faces restrict or remove their registration. The GMC, and the
allegations of such a nature that it may be necessary Professional Standards Authority (which oversees and
for the protection of patients, or it may be in the public scrutinises nine healthcare regulatory bodies in the UK),
interest or in the interests of the doctor for the doctor's may also appeal against certain decisions if they consider
registration to be restricted whilst the allegations are the decision was too lenient. Any doctor whose name has
resolved. An interim orders tribunal may make an order been erased from the Medical Register ('the Register')
suspending a doctor's registration or imposing condi by a Fitness to Practise Panel can apply for their name to
tions upon a doctor's registration for a maximum period be restored to the Register. Doctors cannot apply to have
of 18 months. An interim orders tribunal must review their name restored to the Register until after a period
the order within 6 months of the order being imposed, of 5 years has elapsed since the date their name was
and thereafter, at intervals of no more than 6 months. erased. These processes were brought into sharp focus
If an interim orders tribunal wishes to extend an order in 2018 by the case of Dr Hadiza Bawa-Garba who had
Regulation of doctors and other professionals 27
C
cu
0
CL 5
S
CD M_:
>■£
C71 t—
q $
H1 u
^n
u CM
ra'-1
CD "O
<i q-
ll
> to
to Qj
Q. u
+-* O
1 s'I
u i/>
if 0)
I",
Q. c
l- J
2 I
to
$ <U
<L> J=
£ Ki
“■ 5
^ LO
ll £ u
3 Q
CL)
o _c
-O
re
+*
fN
3 fN
O
JQ as->
3
cn
u
<U
U d)
n
CT>
C
28 I The ethics of medical practice
been erased from the Register, despite recognised institu Francis R. Report of the Mid Staffordshire NHS Foundation Trust
tional failings at the time. Dr Bawa-Garba was convicted Public Inquiry, 2013. https://www.gov.uk/government/pub-
of gross negligence manslaughter following the death of lications/report-of-the-mid-staffordshire-nhs-foundation-
six-year-old Jack Adcock from sepsis. The MPTS decided trust-public-inquiry (Accessed 1 April 2019).
General Medical Council. Confidentiality: guidance for doctors.
she should be allowed to return to train and practise as a
Manchester: GMC, 2009. http://www.gmc-uk.org/guidance/
doctor after a year's suspension. The GMC had appealed
ethical_guidance/confidentiality.asp (Accessed 1 April 2019).
that MPTS decision. The GMC argued suspension was General Medical Council. Consent: patients and doctors mak
not sufficient and appealed the MPTS's sanction to the ing decisions together. Guidance for doctors. https://www.
Divisional Court of the Queen's Bench Division of the gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/
High Court. The Divisional Court held that the MPTS's consent (Accessed 1 April 2019).
decision was not consistent with, and did not respect, General Medical Council. 0-18 years: Guidance for all doctors.
the verdict of the jury that Dr Bawa-Garba's conduct was https://www.gmc-uk.org/ethical-guidance/ethical-guidance-
'truly exceptionally bad'. The Divisional Court considered for-doctors/0-18-years (Accessed 1 April 2019).
that the MPTS had been wrong to take into account that General Medical Council. Guidance to the GMC's Fitness to
there were systemic failings of the Hospital and that Dr Practise Rules 2004 (as amended) (2016). https://www.gmc-
uk.org/-/media/documents/DC4483_Guidance_to_the_FTP_
Bawa-Garba shared with others the responsibility for
Rules_28626691.pdf (Accessed 1 April 2019).
failings in the care and treatment of Jack. The Divisional General Medical Council. Fitness to practise statistics 2016.
Court concluded that, in view of the decision of the jury as https://www.gmc-uk.org/7media/documents/2016-fitness-
to Dr Bawa-Garba's personal culpability, the MPTS was to-practise-annual-statistics_pdf-71779372.pdf (Accessed 1
wrong to think that public confidence in the profession April 2019).
could be maintained by any sanction short of erasure General Medical Council. Good medical practice. https://www.
from the Medical Register. The Divisional Court, there gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/
fore, quashed the order of suspension of the MPTS and good-medical-practice (Accessed 1 April 2019).
substituted an order of erasure. Subsequently the Court General Medical Council. Openness and honesty when
of Appeal unanimously held that the Divisional Court things go wrong: the professional duty of candour.
https://w w w.gm c-uk.org/ethical-guidance/ethical-
was wrong to interfere with the decision of the MPTS. The
guidance-for-doctors/candour— openness-and-honesty-
Court of Appeal set aside the order of the Divisional Court
when-things-go-wrong (Accessed 1 April 2019).
that Dr Bawa-Garba should be erased from the Medical General Medical Council. Disclosing personal information: a
Register and restored the order of the Tribunal that she be framework, https://www.gmc-uk.org/ethical-guidance/ethi-
suspended from practice for 12 months subject to review. cal-guidance-for-doctors/confidentiality/disclosing-patients-
On 13 August 2018, the Court of Appeal overturned the personal-information-a-framework (Accessed 1 April 2019).
High Court's decision to remove Dr Bawa-Garba from the General Medical Council. Managing and protecting personal
medical register following the successful outcome of her information, https://www.gmc-uk.org/ethical-guidance/
appeal. ethical-guidance-for-doctors/confidentiality/managing-and-
Regulatory bodies for other healthcare professionals protecting-personal-information (Accessed 1 April 2019).
General Medical Council. Intimate examinations and chaperones,
in the UK follow a process similar to that of the GMC
2013. w w w .gmc-uk.org/7media/documents/maintaining-
when assessing the performance of practitioners. All
boundaries-intimate-examinations-and-chaperones_pdf-
publish regular updates of their fitness to practise find 58835231.pdf (Accessed 20 May 2019).
ings and the outcomes. Gillick v West Norfolk and Wisbech AHA [1986] AC 112. http://www.
bailii.org/uk/cases/UKHL/1985/7.html (Accessed 1 April 2019).
Health & Care Professionals Council. Fitness to Practice
Bibliography and information Annual Report 2018. https://www.hcpc-uk.org/resources/
reports/2018/fitness-to-practise-annual-report-2018/
resources (Accessed 3 June 2019).
Access to Health Records Act (1990). https://www.legislation.gov. Information Commissioner's Office. Guide to the General Data
uk/ukpga/1990/23/contents (Accessed 1 April 2019). Protection Regulation, https://ico.org.uk/for-organisations/
Bawa-Garba (Appellant) v General Medical Council (Respondent) guide-to-the-general-data-protection-regulation-gdpr/
[2018] EWCA Civ 1879. On appeal from: [2018] EWHC 76 (Accessed 1 April 2019).
(Admin). Lynch J. Health Records in Court. Oxford: Radcliffe Publishing; 2009.
Biggs H. Healthcare Research Ethics and Law: Regulation, Review Lynch J. Clinical Responsibility. Oxford: Radcliffe Publishing; 2009.
and Responsibility. London: Routledge Cavendish; 2010. McLean S. Autonomy, Consent and the Law. London: Routledge
BolamvFriern Hospital Management Committee [1957] 1 WLR 583. Cavendish; 2010.
British Medical Association (BMA) Medical ethics toolkits, https:// Mental Capacity Act 2005. https://www.legislation.gov.uk/
www.bma.org.uk/ethics (Accessed 17 April 2019). ukpga/2005/9/contents (Accessed 1 April 2019).
Dhai A, Payne-James J. Problems of capacity, consent Medical Practitioners Tribunal Service. https://www.mpts-uk.
and confidentiality. Best Pract Res Clin Obstet Gynaecol org/(Accessed 1 April 2019).
2013;27(1):59-75. Montgomery v Lanarkshire Health Board [2015] UKSC 11.
Further general resources I 29
NHS England. Confidentiality policy, 2018. https://www.england. UK Caldicott Guardian Manual. A manual for Caldicott
nhs.uk/wp-content/uploads/2016/12/confidentiality-policy- Guardians. 2017. https://assets.publishing.service.gov.uk/
v4.pdf (Accessed 6 April 2019). government/uploads/system/uploads/attachment_data/
NHS Health Research Authority. Research Ethics Service and file/581213/cgmanual.pdf (Accessed 2 April 2019).
Research Ethics Committees, https://www.hra.nhs.uk/about-us/ World Medical Association. WMA International code of medical
committees-and-services/res-and-recs/(Accessed 1 April 2019). ethics, https://www.wma.net/policies-post/wma-interna-
NHS Health Research Authority. Governance arrangements for tional-code-of-medical-ethics/ (Accessed 2 April 2019).
Research Ethics Committees, https://www.hra.nhs.uk/plan-
ning-and-improving-research/policies-standards-legislation/
governance-arrangement-research-ethics-committees/ Further general resources
(Accessed 1 April 2019). General Medical Council (GMC). https://www.gmc-uk.org/
Nursing and Midwifery Council. Openness and honesty when (Accessed 2 April 2019).
things go wrong: the professional duty of candour, https:// Health & Care Professions Council (HCPC). http://hpc-uk.org/
www.nmc.org.uk/globalassets/sitedocuments/nmc-publica- (Accessed 6 April 2019).
tions/openness-and-honesty-professional-duty-of-candour. Medical Act 1858. http://www.legislation.gov.uk/ukpga/Vict/21-
pdf (Accessed 2 April 2019). 22/90/enacted (Accessed 2 April 2019).
Nursing and Midwifery Council. Annual fitness to practise report Medical Act 1983. http://www.legislation.gov.uk/ukpga/
2016-2017. https://www.nmc.org.uk/globalassets/sitedocu- 1983/54/contents (Accessed 2 April 2019).
ments/annual_reports_and_accounts/ftpannualreports/ Nursing and Midwifery Council, https://www.nmc.org.uk/
annual-fitness-to-practise-report-2016-2017.pdf (Accessed 2 (Accessed 2 April 2019).
April 2019). Professional Standards Authority (PSA). https://www.
Pattinson SD. Medical Law and Ethics, 4th edn. London: Sweet & professionalstandards.org.uk (Accessed 2 April 2019).
Maxwell; 2014. World Medical Association (WMA). https://www.wma.net/
Payne-James JJ. Confidentiality and consent in police custody: (Accessed 2 April 2019).
general principles. J Forensic Leg Med 2018;57:66-72.
3 Medicolegal aspects of death
Box 3.1 Criteria for the diagnosis and confirmation o f death following
cardiorespiratory arrest
Simultaneous and irreversible onset of apnoea and ensuring an absence of a central pulse on palpation
unconsciousness in the absence of the circulation, fol and an absence of heart sounds on auscultation.
lowing 'full and extensive attempts' at reversal of any In a hospital setting, supplem entary 'evidence' of
contributing causes of cardiorespiratory arrest. death may be provided in the form of asystole on a
One of the following applies: continuous electrocardiogram (ECG) display, absence
of contractile activity using echocardiography or
• Criteria for not attempting cardiopulmonary
absence of pulsatile flow using direct intra-arterial
resuscitation (CPR) are fulfilled, or
pressure monitoring.
• CPR attempts have failed, or
Confirmation of the absence of pupillary responses
• Life-sustaining treatment has been withdrawn,
to light, of the corneal reflexes and any motor response
where a decision has been made that such treat
to supra-orbital pressure.
ment is not in the patient's best interest, or where
The time of death is recorded when these criteria
there is an 'advance decision' from the patient to
have been fulfilled.
refuse such treatment.
Source: Adapted from Academy of Medical Royal Colleges.
The person responsible for confirming death (2008). A Code of Practice for the Diagnosis and
observes the individual for a minimum of 5 minutes, Confirmation of Death. London.
Advances in resuscitation techniques in recent There is a spectrum of survival: some patients will
decades, for example in technologies such as ventila recover both spontaneous respiration and conscious
tion, and in the pharmacological support of the uncon ness, others will not regain consciousness but will regain
scious patient, result in the survival of patients who the ability to breathe on their own and some will regain
would otherwise have died as a result of direct cerebral neither consciousness nor the ability to breathe and will
trauma or of cerebral hypoxia from whatever cause. require permanent artificial ventilation to remain 'alive'.
Previously, brain-stem death would eventu
ally result in respiratory arrest causing myocardial Prolonged disorders of
hypoxia and cardiac arrest. A rtificial ventilation
interrupts that process and while ventilation is con consciousness
tinued, m yocardial hypoxia and cardiac arrest are Disorders of consciousness (DOC) include: coma,
prevented. vegetative state (VS), and m inim ally conscious state
Box 3.2 Criteria for the diagnosis o f death following irreversible cessation o f
brain-stem function (adults and children over the age of 2 months)
Absence of brain-stem reflexes: where arterial blood gas sampling confirms an
increase in PaC02 by more than 0.5 kPa above the
• Pupils are fixed and do not respond to changes in
starting level.
light intensity.
• Corneal reflex is absent. Brain-stem testing should be made by at least
• Oculovestibular reflexes are absent when ice-cold two medical practitioners, registered for more than 5
water is introduced into the ear canals. years, and who are competent in the interpretation of
• No motor responses within the cranial nerve dis such tests; at least one of these individuals must be a
tribution can be elicited by stimulation of any consultant.
somatic area. Ancillary investigations - cerebral angiography, per
• No cough reflex response to bronchial stimulation fusion and neurophysiological - may be appropriate in
by a suction catheter placed in the trachea down some circumstances; brain-stem tests cannot be per
to the carina. formed, for example, where there are extensive maxil
• No gag response to stimulation of the posterior lofacial injuries.
pharynx with a spatula.
Source: Adapted from Academy of Medical Royal Colleges.
• No spontaneous respiratory response following
(2008). A Code of Practice for the Diagnosis and
disconnection from the ventilator ('apnoea test'), Confirmation of Death. London.
32 | Medicolegal aspects of death
Box 3.3 Conditions necessary for the diagnosis and confirmation of death following
irreversible cessation ofbrain-stem function
Irreversible brain damage resulting from damage of Potentially reversible circulatory, metabolic and
known aetiology or, following continuing clinical obser endocrine disturbances have been excluded as the
vation and investigation, there is no possibility of a cause of the continuation of unconsciousness, includ
reversible or treatable underlying cause being present. ing hyperglycaemia or hypoglycaemia.
Potentially reversible causes of coma have been Potentially reversible causes of apnoea have been
excluded. excluded, for example the effects of neuromuscular
There is no evidence that the state is caused by blocking agents.
depressant drugs, for example narcotics, hypnotics or
tranquillizers; specific antagonists may need to be used.
Source: Adapted from Academy of Medical Royal Colleges.
Hypothermia as the cause of unconsciousness has (2008). A Code of Practice for the Diagnosis and
been excluded. Confirmation of Death. London.
(MCS). Following severe brain injury, many patients 12 months after traumatic brain injury or 3 months
progress through stages of coma, VS and MCS as they after non-traumatic brain injury. The UK RCP guide
emerge into a state of full awareness. However, some lines recommended a more cautious period of 6
will rem ain in a vegetative or m inim ally conscious months for non-traumatic brain injury. In light of the
state for the rest of their lives. The diagnosis, manage documented late recoveries, it is im portant to view
ment and lifelong (including end-of-life [EOL]) care the temporal definitions as probabilities. The US Task
of adults who have prolonged disorders of conscious Force emphasised that permanent VS refers to progno
ness (PDOC), persisting for more than 4 weeks fol sis and identifies the point after which recovery of con
lowing sudden onset profound acquired brain injury sciousness is 'highly improbable' but not impossible.
is a sensitive and complex area. In 2013, The Royal In such circumstances, the withdrawal of hydration
College of Physicians published 'Prolonged Disorders and assisted nutrition may be considered in the 'best
of Consciousness: National Clinical Guidelines, which interests' of the patient.
advise clinical and ethical standards of care for peo The first, and most significant case regarding the
ple with PDOC.' For the purposes of the guidelines, legality of such withdrawal of'life sustaining' treatment
the definitions in Table 3.1 are used to differentiate concerned Tony Bland, in 'persistent vegetative state'
between these states. following an accident at a football ground (Airedale
Based on a large cohort analysis the American NHS Trust v Bland). Since that case, in which permis
Academy of Neurology practice guideline recom sion to remove assisted feeding was granted, additional
mended that VS may be judged to be 'permanent' cases have sought to clarify the position following the
Coma A state of unrousable unresponsiveness, lasting more than 6 hours in which a person:
(Absent wakefulness and • cannot be awakened
absent awareness) • fails to respond normally to painful stimuli, light or sound
• lacks a normal sleep-wake cycle, and
• does not initiate voluntary actions.
Vegetative state (VS) A state of wakefulness without awareness in which there is preserved capacity for
(Wakefulness with spontaneous or stimulus-induced arousal, evidenced by sleep-wake cycles and a range of
absent awareness) reflexive and spontaneous behaviours.
VS is characterised by complete absence of behavioural evidence for self- or environmental
awareness.
Minimally conscious A state of severely altered consciousness in which minimal but clearly discernible
state (MCS) behavioural evidence of self- or environmental awareness is demonstrated.
(Wakefulness with MCS is characterised by inconsistent, but reproducible, responses above the level of
minimal awareness) spontaneous or reflexive behaviour, which indicate some degree of interaction with their
surroundings.
Tissue and organ transplantation I 33
enactment of the Human Rights Act 1998, the ‘right to the issues of consent for removal of organs for either
life' and the right not to be subjected to inhuman and research or transplantation under the Human Tissue
degrading treatment. Act where donors are deceased. It applies in England,
A recent judgement in the UK Supreme Court, the Wales and Northern Ireland, and is not affected by the
UK's highest court, has determined that legal permis Human Transplantation (Wales) Act 2013. The guidance
sion from the Court of Protection will no longer be is summarised in Figure 3.1.
needed to end life support for patients in a permanent The organs and tissues to be transplanted may derive
VS when relatives and doctors agree it should be turned from one of several sources, which are outlined below.
off {An NHS Trust a n d others v Y an d an other 2018). The
case related to a the 52-year-old financial analyst - Mr Y Homologous transplantation
who was in a PDOC. After suffering a cardiac arrest as a
result of coronary artery disease, experts agreed it was Homologous transplantation is the process by which
highly improbable that Mr Y would re-emerge into con tissue is moved between sites on the same body. For
sciousness and, even if he did, he would have profound example, skin grafts may be taken from the thigh to
cognitive and physical disability and would always be place on a burn site or bone chips from the pelvis may be
dependent on others. taken to assist in the healing of a fracture of a long bone.
Homologous blood transfusion can be used in certain
situations such as when there is a religious objection to
Tissue and organ transplantation the use of anonymously donated blood.
The laws relating to tissue and organ donation and
transplantation are dependent upon the religious and
ethical views of the country in which they apply. The Live donation
laws vary in both extent and detail around the world, In this process, tissue is taken from a living donor
but there are very few countries where transplanta whose tissues have been matched to, or are compat
tion is expressly forbidden and few religions that for ible with, those of the recipient. The most common
bid it - Jehovah's Witnesses are one such group; they example is blood transfusion but marrow transplan
also reject transfusion of donated blood. In the UK, the tation is now very common. Other live donations
Human Tissue Authority has issued guidance regarding frequently involve the kidneys as these are paired
Removal
of organ
SH TA
Human Tissue Authority
from
deceased
donor
The
Consent from the The Consent from the
' primary purpose
deceased donor* is primary purpose deceased donor* is :
for the removed organ
required to remove/ for the removed organ is required to remove/
is for research - the organ
store/use the organ . for transplantation use the organ for
for research v is not going to be
transplantation
^ ^ to n s p la n t e d ^ ^
Organ Organ
transplantation is transplanted
occurs and treatment (no planned research
is combined with ^ intervention) >
' V . research
Organ
* Consent in this case cannot be Recipient
means either the consent Treatment interventions being
transplanted consent is
of the donor, their researched can take place before or
required for
nominated representative after implantation of the removed
transplantation
or - in the absence of organ. The organ can be
either of th ese-th e sent for disposal or,
consent of a person in Health research involving patients is with valid consent
the most appropriate subject to approvals from relevant from the deceased
'qualifying relationship' bodies. donor*, stored and/
to the donor immediately or used for research
Note: Recipients of organs subjected to
before they died. More
research interventions must have given
guidance on this is
their consent to receive the organs.
available from the HTA.
Figure 3.1 Consent requirements for removal of organs for research or transplantation. (Adapted from HTA. Guidance
on consent for transplantation research where donors are deceased.)
34 I Medicolegal aspects of death
organs and live donors will, if the rem aining kidney is Cadaveric donation
healthy, m aintain their electrolyte and water balance
In many countries, cadaveric donation is the major
without problem.
source of all tissues for transplantation. The surgical
Most kidneys for transplant are derived from cadav
eric donation, but live donation is also possible and the techniques to harvest the organs are improving, as
long-term clinical results are better. The removal of are the storage and transportation techniques, but the
kidneys from cadavers must follow legal requirements, best results are still obtained if the organs are obtained
including the definition of death and consent. Kidney while circulation is present or immediately after cessa
donation by well selected living donors with good tion of the circulation. The aim is to minimise the 'warm
health coverage carries negligible risks. This can only ischaemic time'. Some organs (e.g., kidneys) are more
be ensured through rigorous selection procedures, resilient to anoxia than others and can survive up to 30
careful surgical nephrectomy and follow up of the minutes after cessation of cardiac activity.
donor to ensure the optimal management of untoward Cadaveric donation is now so well established that
consequences. The Transplantation Society adopted most developed countries have sophisticated laws to
a consensus statement on the care of the live kidney regulate it. However, these laws vary greatly: some
donor, prepared by a forum involving over 100 experts countries allow the removal of organs regardless of the
from more than 40 countries from around the world. wishes of the relatives, whereas other countries allow
This consensus statement addressed the responsibil for an 'opting-out' process in which organs can be taken
ity of communities for living donors. In particular, it for transplantation unless there is an objection from
defined the responsibilities of the transplant centre relatives. In the United Kingdom, Wales has enacted (in
which is charged, amongst other duties, with facili 2015) legislation - the Human Transplantation (Wales)
tating the long-term follow up of living kidney donors Act 2013 which permits an opt-out system of organ
and, if need be, their treatment, with identifying and donation, known as presumed consent. The act permits
tracking complications that may be important in defin hospitals to presume that people aged 18 or over, who
ing risks for informed consent disclosure (on the care have been resident in Wales for over 12 months, want
of the live kidney donor). The care of the live kidney to donate their organs at their death, unless they have
donor is often neglected in schemes where vulner objected specifically. That Act is in contrast to the law
able individuals are exploited and encouraged to sell still applicable in England, which relies on an opt-in
their kidneys by unscrupulous practitioners. Forced system; only those who sign the NHS Organ Donation
organ harvesting is a form of organ trafficking. On Register, or whose families agreed, are considered to
June 17th 2019, The China Tribunal Report concluded have consented to be organ donors. In the latter system,
'Forced organ harvestinghas been committed foryears the transplant team must ensure that the donor either
throughout China on a significant scale and that Falun gave active permission during life or at least did not
Gong practitioners have been one - and probably the object and that no close relative objects after death.
main - source of organ supply. The concerted persecu The statutory framework governing organ dona
tion and medical testing of the Uyghurs is more recent tion from the living and the dead for transplantation
and it may be that evidence of forced organ harvesting in England and Northern Ireland is embodied in the
of this group may emerge in due course. The Tribunal Human Tissue Act 2004 (with a similar framework in
has had no evidence that the significant infrastructure Scotland) - and the Human Tissue Authority has Codes
associated with China's transplantation industry has of Practice to be followed in such circumstances. Code
been dismantled and in the absence of a satisfactory F, 'Donation of solid organs and tissue for transplanta
explanation as to the source of readily available organs, tion' is the relevant one and emphasises that
concludes that forced organ harvesting continues ... donated organs and tissue must be used in accordance
until today (https://chinatribunal.com/final-judge- with the expressed wishes of donors, their nominated
ment-report/). It is also alleged that in some countries representatives, or their relatives, that donors and their
prisoners of conscience are killed for the purpose of relatives must be given the inform ation they need to be
removing one or more of their organs. The recipients able to m ake a decision that is right for them and that
of these harvested organs are citizens of that country those seeking consent should do so with sensitivity and
an appreciation of the particular circu m stan ces in each
or international transplant tourists who travel and pay
case. It also m eans that the dignity of the donor must be
substantial sums to receive trafficked organs.
respected at all times and that practitioners should work
A World Health Assembly Resolution acknowledged with proper skill, care and training, in accordance with
the risk of exploitation of live kidney donors and urged good practice and other relevant professional guidance.
Member States to
If an autopsy will be required by law for any reason, the
protect the poorest and vulnerable groups from tran s permission of the Coroner, Procurator Fiscal or other legal
plant tourism and the sale of tissue and organs. officer investigating the death must be obtained before
Cause of death determination and certification I 35
Figure 3.2 Sample of a Medical Certificate of Cause of Death (doctor's counterfoil omitted).
Cause of death determination and certification I 37
that is most important statistically and that is used to of relevant medical records and by making sure that
compile national and international mortality statistics. the family has the chance to raise any concerns. This
Doctors should not record the mode of death (e.g., independent review will make identifying malpractice
coma, heart failure) in isolation on the death certificate easier, provide opportunities for the NHS to learn and
but, if a mode is specified, it should be qualified by indi address system failures earlier.
cating the underlying pathological abnormality leading One of the recommendations was the introduc
to that mode of death. For example: tion of the new role of Medical Examiners (Medical
Reviewers in Scotland) in England & Wales. These are
la Congestive cardiac failure seniors who will scrutinise and confirm the cause of all
deaths that do not need to be investigated by a coroner
lb Essential hypertension before a medical certificate of cause of death (MCCD)
is issued (Figure 3.2). Reforms enabled in the Coroners
or
and Justice Act 2009, introduced Medical Examiners. In
la Coma April 2019 all acute hospitals in England & Wales began
lb Subarachnoid haemorrhage to establish Medical Examiner (ME) services. MEs are
involved after a death. In all cases not investigated by a
Ic Ruptured congenital aneurysm
coroner, the ME needs to address the following issues:
Some jurisdictions will allow specific causes of death • What did the person die from? (ensuring accuracy
that would not be allowed elsewhere. In the UK, it is of cause of death on the medical certificate)
acceptable in certain situations, i.e., if the patient is over • Does this case need to be reported to a coroner?
80 years of age, to record la : Old age'. The term 'frailty' (ensuring timely, accurate referral)
may also be included. • Are there any clinical governance concerns?
At the other end of the age range, the diagnosis of (ensuring the relevant authority is notified)
sudden infant death syndrome (SIDS) is now well estab
lished; unfortunately, the diagnostic criteria are seldom The ME addresses these issues by:
as well known and even less frequently are they applied • Carrying out a p roportionate review o f m edical
to the letter. records (focusing on the last hospital admission,
The utility of the second part of the death certifi selected investigation results, correspondence,
cate is perhaps questionable and has a tendency to be and interventions) - this is recorded on a form.
used as something of a 'dustbin' to record all, many • Discussing the case with the Q ualified Attending
or some of the diseases afflicting the patient at the Practitioner (QAPs) who will com plete the MCCD
time of death, regardless of their causative role in (the QAP will have completed a form which sum
that death. Guidance for doctors completing Medical marises the QAP's planned wording for the MCCD
Certificates of Cause of Death in England & Wales has - which will be discussed and agreed prior to com
been updated by the Office for National Statistics in pletion of the MCCD with the ME).
2018. Similarly, the Scottish Government produced • Interacting with bereav ed relatives to clarify
such guidance in 2014. whether they have any concerns or questions
In the UK, it has long been recognised that existing regarding the cause or circum stances of death,
arrangements for death certification are confusing, and review the MCCD.
provide inadequate safeguards, with no mechanism to
identify patterns, take action and learn from them. Currently this is a non-statutory process but it is
Dr Harold Shipman, a general practitioner, was able anticipated that a statutory service which will addi
to kill many patients because he relied on others hav tionally include oversight of all community and out-of
ing no reason to question or suspect malpractice when hospital deaths will be in place by 2021. International
he certified the causes of death. The system depends classifications of disease are now well established and
on the integrity of a doctor and there is no independent the WHO produced, with the full official name, the
oversight. In tern ation al Statistical Classification o f Diseases and
Inquiries into deaths and p ractices at Mid Related H ealth Problems. The short form, International
Staffordshire and Southern Health NHS Foundation Classification o f Diseases (ICD) is the international 'stan
Trusts showed that improved reporting and investiga dard diagnostic tool for epidemiology, health manage
tions could have prevented many unnecessary deaths. ment and clinical purposes'. ICD is the foundation for
A new system was proposed following a number of the identification of health trends and statistics glob
reviews (starting with that of Harold Shipman in 2003), ally, and the international standard for reporting dis
intended to introduce independent safeguards and eases and health conditions. ICD defines the universe
checks to highlight patterns, both through a review of diseases, disorders, injuries and other related health
38 I Medicolegal aspects of death
conditions, listed in a comprehensive, hierarchical fash Choi HJ, Yoon CH, Hyon JY; et al. Protocol for the first clinical trial to
ion that allows for: investigate safety and efficacy of corneal xenotransplantation
in patients with corneal opacity, corneal perforation, or impend
• Easy storage, retrieval and analysis of health infor ing corneal perforation. Xenotransplantation 2018;31:e12446.
mation for evidenced-based decision making. Coroners and Justice Act 2009. http://www.legislation.gov.uk/
• Sharing and comparing health information ukpga/2009/25/contents (Accessed 4 April 2019).
between hospitals, regions, settings and countries. Department of Health. Consultation on death certification
• Data comparisons in the same location across dif reforms, https://www.gov.uk/government/consultations/
ferent time periods. death-certification-reforms (Accessed 4 April 2019).
Department of Health. Death certification reforms: draft guid
Uses include monitoring of the incidence and prev ance for registered medical practitioners. https://www.
alence of diseases, observing reimbursements and gov.uk/government/uploads/system/uploads/attach-
resource allocation trends and keeping track of safety ment_data/file/506784/Draft_guidance_-_notification_of_
and quality guidelines. They also include the counting deaths_regulations_A.pdf (Accessed 4 April 2019).
Ethics Committee of the Transplantation Society. The consensus
of deaths as well as diseases, injuries, symptoms, rea
statement of the Amsterdam Forum on the Care of the Live
sons for encounter, factors that influence health status Kidney Donor. Transplantation 2004;78(4):491-492.
and external causes of disease. ICD can be used for both Freckleton I, Mendelson D (eds). Causation in Law and Medicine.
clinical diagnoses and death certificates. In this clas Aldershot: Dartmouth Publishing Company/ Ashgate
sification, each condition is given a four-digit ICD code, Publishing Limited; 2002.
which simplifies both data recording and data analysis General Medical Council. Consent: patients and doctors making
and allows information from many national and inter decisions together, http://www.gmc-uk.org/guidance/ethi-
national sources to be compared. The current version cal_guidance/consent_guidance_discussing_side_effects_
is ICD 10 and this will be superseded by ICD 11 in 2020. and_complications.asp (Accessed 4 April 2019).
A version of ICD 11 has been released in 2018 to allow General Medical Council. End of life care: certification, post-mor
tems and referral to a coroner or procurator fiscal. http://www.
preparations to be made prior to formal launch.
gmc-uk.org/guidance/ethical_guidance/end_of_life_certifica-
In some countries, doctors also have to record
tion_post-mortems_and_referral.asp (Accessed 4 April 2019).
the manner of death (e.g., homicide, suicide) on the Human Rights Act. 1998 http://www.legislation.gov.uk/
death certificate, as advocated by the World Health ukpga/1998/42/contents (Accessed 4 April 2019).
Organisation; however, in most Western countries Human Tissue Act 2004 C.30. http://www.legislation.gov.uk/
with an efficient medicolegal investigative system, ukpga/2004/30 (Accessed 4 April 2019).
the conclusion about the manner of death may be to Human Tissue Authority. Codes of practice and standards, https://
a legal officer, for example, the Coroner in England & www.hta.gov.uk/hta-codes-practice-and-standards-0
Wales, the Procurator Fiscal in Scotland or the Medical (Accessed 4 April 2019).
Examiner in some of the states of the USA. Chapter 4 Human Tissue Authority. Guidance on consent for transplantation
research where donors are deceased, https://www.hta.gov.uk/
expands on the role of the coroner in medicolegal
policies/ guidance-consent-transplantation-research-where-
death investigation.
donors-are-deceased (Accessed 5 August 2019).
McLean SA. Permanent vegetative state: the legal position.
Bibliography and information Neuropsychol Rehabil 2005;15:237-250.
Office for National Statistics' Death Certification Advisory Group.
sources Guidance for doctors completing medical certificates of
Academy of Medical Royal Colleges. 2008. A code of practice for cause of death in England and Wales. https://assets.publish-
the diagnosis and confirmation of death. London: Academy ing.service.gov.uk/government/uploads/system/uploads/
of Medical Royal Colleges, http://aomrc.org.uk/wp-content/ attachment_data/file/757010/guidance-for-doctors-com-
uploads/2016/04/Code_Practice_Confirmation_Diagnosis_ pleting-medical-certificates-of-cause-of-death.pdf
Death_1008-4.pdf (Accessed 4 April 2019). Padela Al, Duivenbode R. The ethics of organ donation, dona
Airedale NHS Trust v Bland (1993) AC789 at 898. http://www.bailii. tion after circulatory determination of death, and xenotrans
org/uk/cases/UKHL/1993/17.html (Accessed 4 April 2019). plantation from an Islamic perspective. Xenotransplantation
Amin L, Hashim H, Mahadi Z, et al. Determinants of stakehold 2018;25(3):1 —12.
ers' attitudes to xenotransplantation. Xenotransplantation Pattinson SD. Medical Law and Ethics, 4th ed. London: Sweet &
2018;22:e12430. Maxwell; 2014.
An NHS Trust and others v Yand another (2018) UKSC 46. Practice parameters: Assessment and management of patients
BBC. 1997. Dolly the sheep is cloned, http://news.bbc. in the persistent vegetative state. St Paul: American Academy
co.uk/onthisday/hi/dates/stories/february/22/new- of Neurology: Quality Standards Subcommittee, www.aan.
sid_4245000/4245877.stm (Accessed 4 April 2019). com/Guidelines/Home/GetGuidelineContent/83 (Accessed
BolamvFriern Hospital Management Committee [1957] 1 WLR582. 4 April 2019).
Chan JL, Miller JG, Singh AK, et al. Consideration of appropri Royal College of Pathologists. Medical examiners. https://www.
ate clinical applications for cardiac xenotransplantation. Clin rcpath.org/profession/committees/medical-examiners.html
Transpl 2018;29:e13330. (Accessed 4 April 2019).
Further general resources I 39
Royal College of Physicians. Prolonged disorders of conscious World Health Assembly. 2004. Transplantation. http://www.
ness: National clinical guidelines: Report of a Working Party. who.int/transplantation/publications/en/ (Accessed 4 April
https://www.rcplondon.ac.uk/guidelines-policy/prolonged- 2019).
disorders-consciousness-national-clinical-guidelines World Health Organisation (WHO). Medical certification of cause
(Accessed 4 April 2019). of death, https://apps.who.int/iris/handle/10665/40557
Shipman Inquiry: Archived at The National Archives, http:// (Accessed 8 April 2019).
webarchive.nationalarchives.gov.uk/20090808154959/http:// World Health Organisation (WHO). International statistical clas
www.the-shipman-inquiry.org.uk/home.asp (Accessed 4 sification of diseases and related health problems. ICD-10
April 2019). (10th Revision), http://apps.who.int/classifications/icd10/
Sia D, Moeini A, Labgaa I, Villanueva A. The future of browse/2016/en (Accessed 8 April 2019).
patient-derived tumor xenografts in cancer treatment. World Health Organisation (WHO). Online ICD-10 training tool.
Phormacogenomics 2015;16(14):1671 -1683. http://apps.who.int/iris/handle/10665/40557?locale=fr&mo
Skene L, Wilkinson D, Kahane G, Savulescu J. Neuroimaging and de=full (Accessed 4 April 2019).
the withdrawal of life-sustaining treatment from patients in
vegetative state. Med Law Rev 2009;17:245-261.
The Human Transplantation (Wales) Act 2013 (Consequential Pro Further general resources
vision) Order, http://www.legislation.gov.uk/uksi/2015/865/ Academy of Medical Royal Colleges (AMRC). http://www.aomrc.
article/3/made (Accessed 4 April 2019). org.uk (Accessed 4 April 2019).
TheTask Force. The MuItisocietyTaskforce report on PVS: medical World Health Organisation (WHO). ICD-10. http://apps.who.
aspects of the persistent vegetative state, Part 1 and 2. New int/classifications/icd10/browse/2016/en (Accessed 4 April
Eng J Med 1994;330:1499-1508,572-579. 2019).
United Nations. Manual on the effective prevention and inves
tigation of extra-legal, arbitrary and summary executions.
http://www.ohchr.org/Documents/Professionallnterest/
executions.pdf (Accessed 4 April 2019).
i Vi ol ence in society,
mM medicolegal investigation of
death and the autopsy
■ Introduction ■ The'Minnesota protocol'
■ Homicide and interpersonal violence ■ Exhumation
■ Medicolegal investigation of death ■ Bibliography and information sources
■ The autopsy ■ Further general resources
Box 4.1 Inequalities in death - violence and homicide as a public health problem
Analysis of age-adjusted homicide rates in the USA age 28 years, compared with 40 years, respectively),
shows a marked difference between white and black and were more likely to be stabbed or shot (compared
males (8.7 per 100,000, compared with 66.2 per 100,000, with homicide by hitting, kicking etc.). Twenty-five per
respectively). Age was the strongest predictor of homi cent of black victims were shot, compared with 6% of
cide rate, followed by the level of urbanisation. Rates white victims.
were significantly higher for both black and white men In the UK, analysis of the socioeconomic characteris
living in areas of low educational levels, or high levels of tics of homicide victims between 1981 and 2000 reveals
income inequality, and rates were significantly lower in that people living in the poorest 10% of areas were 4.5
areas with a low prevalence of crowded housing. times more likely to be murdered than those living in
In England & Wales, of the homicides recorded in the least poor 10% of areas between 1981 and 1985,
the three-year period ending in March 2013, 77% of and 5.7 times more likely to be murdered between
victims were white, and 11% were black. Census data 1996 and 2000.
reported the relative proportions of white and black A study in Scotland showed a marked inequality in
individuals to be 86%, and 3%, respectively. Black death from assault; between 2000 and 2002; a man
victims were therefore over-represented, and white under 65 years living in one of the most deprived areas
under-represented. Black males were over four times was nearly 32 times more likely to die due to an assault
more likely to be a victim of homicide than white males than if he had been living in one of the most affluent
(5.5 per 100,000 compared with 1.2 per 100,000). Black areas, and a woman of the same age was 35 times more
victims were also younger than white victims (average likely to die due to an assault.
increased importance of interpersonal violence in this Female victims in this category of homicide were
region compared with violence related to other criminal younger than other female homicide victims (41 years
activities (including gang-related violence). compared with 51 years).
In England & Wales, 96% of male homicide victims, Male victims of this sort of homicide in England &
and 87% of female victims, over 16 years of age were Wales were more likely to be killed with a sharp instru
killed by a man. ment than other male victims (60% compared with 38%),
whilst female victims of partner/ex-partner homicide
Global intimate partner and domestic were more likely to be killed by strangulation than other
female homicide victims (27% compared with 16%).
violence-related homicide Fifty-two per cent of all homicides in England &
Fourteen per cent of all homicide victims were killed Wales resulted from a quarrel, a revenge attack or a loss
by an intimate partner or a family member, with a of temper (rising to 61% where the principal suspect
global rate of 0.9 per 100,000. The rates were quite stable was known to the victim). Box 4.2 describes the extent
between regions, and over time, although the propor of non-fatal intimate partner violence in the UK and
tions of this type of homicide compared with the total globally.
homicides within a region varied (e.g. 28% of all homi
cides in Europe, compared with 8.6% of homicides in the Homicide mechanism
Americas). When the homicide rate was high in a region, Weapons played a significant role in homicide glob
the proportion of deaths related to, for example, other ally (Box 4.3); firearms were involved in 177,000 (41%)
criminal activities was more prevalent than in regions of homicides, 'other means' (including physical force/
with low homicide rates. blunt objects) accounted for just over one third of
Female victims were consistently higher in this type deaths, whilst sharp objects accounted for 24% of
of homicide. Of the 93,000 women killed in 2012, 47% deaths.
were killed by an intimate partner or family member. Firearms were involved in 66% of deaths in the
Regional variations included: 3300 deaths in Europe, Americas, whilst 'other means' predominated in Europe
200 in Oceania, and 19,700 in Africa. (54%), and Asia (47%).
Seventy-nine per cent of those homicide victims Sharp objects were most commonly used in the UK
killed by intimate partners were women. accounting for 35% of deaths in 2012-2013 in England
Female homicide victims in England & Wales were & Wales, and 38% in Scotland between 2003 and 2013.
more likely than male victims to have been killed by a There was no significant difference in the proportion
partner or ex-partner (45% compared with 4%). Global of deaths from this mechanism between the genders
studies report comparable data of between 40%-70%. in England & Wales.
42 I Violence in society, medicolegal investigation of death and the autopsy
The second most common method of killing in England Australia between 2008 and 2010 (that consumption
& Wales was 'kicking or hitting without a weapon' (20% of being by victim, perpetrator, or both).
the total), although there were gender differences present; This data gives a broad overview of the incidence,
25% of male homicide victims were killed by this method, demographics and means of homicide. As with much
whilst the second most common method of homicide in of the published data, it may be up to a decade behind
female victims was strangulation or asphyxiation (at 16%); the times and, when considering the current position, it
29 people were killed by a firearm. is always important to recognise that social trends and
Alcohol consumption was highly associated with geopolitical change can often dramatically influence
homicide; it preceded nearly 50% of homicides in these factors.
Adapted from Office on Drugs and Crime (UNODC). Global Study on Homicide 2013.
Medicolegal investigation of death I 43
Box 4.4 Proposed circumstances in which doctors in England & Wales would
be required to refer deaths to a coroner
There is no attending practitioner or the attending • The death may be related to a medical procedure
practitioner(s) is unavailable within a prescribed or treatment.
period. • The death may be due to an injury or disease
The death may have been caused by violence, received in the course of employment, or indus
trauma or physical injury, whether intentional or trial poisoning.
otherwise. • The death occurred whilst the deceased was in cus
The death may have been caused by poisoning. tody or state-detention, whatever the cause.
The death may be the result of intentional • The cause of death is unknown.
self-harm.
The death may be a result of neglect or failure of Source: Department of Health. Death Certification Reforms. Draft
care. guidance for registered medical practitioners, March 2016.
44 | Violence in society, medicolegal investigation of death and the autopsy
• Unlawful killing (which includes murder, man The clinical autopsy is performed in a hospital mor
slaughter, infanticide) tuary after consent for the examination has been sought
• Natural causes from, and granted by, the relatives of the deceased. The
• Open (i.e., there is insufficient evidence for any doctors treating the patient should know why their
other conclusion) patient has died and be able to complete a death cer
• Road traffic collision tificate even in the absence of an autopsy. These exami
• Stillbirth nations have been used in the past for the teaching of
• Suicide medical students and others, and for research, but have
been in decline worldwide for several decades.
There is an increasing trend, however, for the
The medicolegal autopsy is performed on behalf of
coroner to deliver a 'narrative conclusion' which is a
the State. The aims of these examinations are much
factual record of how, and in what circumstances, the
broader than those of the clinical autopsy; they aim to:
death occurred, and this is often used in those cases in
which the cause of death does not fit easily into any of • Identify the body.
the 'short-form' conclusions. Within the narrative con • Estimate the time of death.
clusion, the coroner may request an inquest jury (if the • Identify and document the nature and number of
inquest is held before a jury) to address specific ques injuries.
tions perceived to be of concern. • Interpret the significance and effect of the inju
ries.
The autopsy • Identify the presence of any natural disease.
• Interpret the significance and effect of the natural
The words autopsy, necropsy and post mortem exami
disease present.
nation are synonymous, although post mortem exami
• Identify the presence of poisons.
nation can have a broader meaning encompassing any
• Interpret the effect of any m edical or surgical
examination made after death, including an external
treatment.
examination. In general terms, autopsies are performed
for two reasons: clinical clarification and medicolegal Autopsies can, in theory, be performed by any doctor
purposes. but, ideally, they should be performed by a pathologist
Box 4.6 The diagnostic approach to the autopsy mirrors that familiar to clinicians
specifically trained to undertake such an examination. The autopsy should be performed in a mortuary with
The diagnostic process underpinning an autopsy mir adequate facilities (Figure 4.1).
rors that utilised in clinical medicine (Box 4.6). However, where there are no trained staff or no ade
Medicolegal autopsies are a specialised version of quate facilities, which can occur not only in some devel
the standard autopsy (described in detail in Box 4.7) oping countries but also in some so-called developed
and should be performed by pathologists who have countries that do not adequately fund their medicolegal
had the necessary training and experience in foren systems, non-specialist doctors may occasionally have
sic pathology, and who are aware of the need to guard to perform autopsies and histopathologists may have
against making the 'classic mistakes' and falling foul of to perform medicolegal autopsies. A poorly performed
the 'common medicolegal misconceptions' described in autopsy may be considerably worse than no autopsy at
Box 4.8. Box 4.9 lists the 'basic principles for best prac all; it is certainly worse than an autopsy delayed for a
tice' in forensic pathology identified by the Honorable short while to await the arrival of a specialist. The qual
Stephen Goudge who conducted an Inquiry into paedi ity of medicolegal autopsies for coroners in England &
atric forensic pathology in Ontario, Canada in 2007. Wales has previously been criticised in a report from
The autopsy I 47
Box 4.8 Moritz's 'classic mistakes in forensic pathology' and Petty's 'devil's dozen'
medicolegal misconceptions
The 'classic mistakes' to be avoided wherever possible: Only true and suspected homicide victims need
examination.
• Not examining the body at the scene of the crime The autopsy can properly be carried out without
(wherever possible). a 'history'.
• Misinterpreting post mortem changes. • Any pathologist is qualified (to perform a medico
• Being unaware of the objective of the medicolegal legal autopsy).
autopsy. • The autopsy always yields the cause of death.
• Performing an incomplete autopsy. • Poison is always detected by toxicologists.
• Failure to make an adequate examination and • The autopsy must be immediate.
description of external abnormalities. • The autopsy is over when the body leaves the
• Not taking adequate photographs of the evidence. autopsy room.
• Not exercising good judgement in the taking or • Embalming will not obscure the effects of trauma
handling of specimens for toxicologic examination. and disease.
• Permitting the body to be embalmed before per • The cause and manner of death are the only results
forming a medicolegal autopsy. of the autopsy.
• Confusing the objective with the subjective sec • The medicolegal autopsy is criminally or prosecu
tions of the written autopsy report. tion oriented.
• Permitting the value of the autopsy report to be
jeopardised by minor errors.
• All physicians are good death investigators. Source: Adapted from Petty CS.The devil's dozen. Popular
medicolegal misconceptions. South Med J 1971;64:819-823
• The tim e of death can be precisely determined by and Moritz AR Classica| mistakes in forensic patho|ogy.
the exam in ation of the body. Am J Clin Pathol 1956;26:1383-1397.
Box 4.9 The role of the forensic pathologist: Basic principles for best practice:
The Goudge Inquiry into paediatric forensic pathology in Ontario
1. To 'think truth' rather than 'think dirty'. To do so « Care in recording and preserving information
requires: received pre-autopsy, steps taken at autopsy,
• An independent and evidence-based approach and materials preserved after autopsy.
emphasising the importance of thinking • This transparency is necessary to ensure that
objectively. the pathologist's opinions can be properly
• Pathology evidence to be observed accurately reviewed and confirmed or challenged.
and followed wherever it leads. 4. The work of the forensic pathologist work at
• Guarding against confirmation bias (where evi autopsy must be understandable to the criminal
dence is sought or interpreted in order to sup justice system. The autopsy must be performed so
port a preconceived theory). that it can be described in clear and unambiguous
2. Remain independent of the coroner, police, pros language to lay people.
ecutors, and defence teams in order to discharge 5. Teamwork is fundamental to sound autopsy prac
responsibilities objectively, and in an impartial tice. Teamwork promotes excellence.
manner (independence). 6. The forensic pathologist's practices at autopsy
3. Autopsy findings must be independently review- must be founded on a commitment to quality.
able and transparent. This requires:
48 Violence in society, medicolegal investigation of death and the autopsy
Figure 4.1 Modern forensic autopsy facilities, including directional overhead lighting - with inbuilt video projection
and recording capability - to facilitate optimal forensic pathological examinations. (Courtesy of Richard Jones.)
Box 4.10 Quality and the medicolegal autopsy,: The main findings of the NCEPOD
report 'The Coroner's autopsy: do we deserve better?' (2006)
• 1 in 4 autopsy reports was poor/unacceptable The following types of case were poorly examined:
(26% of 1691 reports reviewed). • decomposed bodies
• Failure to do an external examination of the body • epilepsy cases
before evisceration by technicians occurred in one • deaths in the very elderly
third of mortuaries. The presence or absence of injury was not
• No examination of the brain was made in 1 in 7 well-recorded.
cases. There was poor communication between patholo
• A questionable cause of death was given in 1 in 5 gist and coroner in many cases.
cases. Microscopy was only performed in 19% of cases.
• The heart was poorly examined in cases in which a
cardiomyopathy might have been present.
Figure 4.4 Suicidal pistol contact head shot. Post mortem CT of head showing CT-dense deposits in subcutaneous tis
sues around entrance (A, see also photo with ample soot in a contact head shot). Skull defect of exit (B). Blood-dense
shapes in brain show hemorrhage along bullet track (C, straight/linear constellation) and blood inside ventricles (D).
(VRT, syngo via [Siemens Germany], segmented anatomy visualizer images. Images courtesy of the Virtopsy Team.)
The'Minnesota protocol' I 51
Box 4.11 The scope of The Minnesota Protocol on the investigation of potentially
unlawful deaths
1. The Minnesota Protocol aims to protect the right standards of professional ethics (Section III). It
to life and advance justice, accountability and provides guidance and describes good practices
the right to a remedy, by promoting the effec applicable to those involved in the investigative
tive investigation of potentially unlawful death or process, including police and other investigators,
suspected enforced disappearance. The Protocol medical and legal professionals and members of
sets a common standard of performance in inves fact-finding mechanisms and procedures (Section
tigating potentially unlawful death or suspected IV). While the Protocol is neither a comprehen
enforced disappearance and a shared set of prin sive manual of all aspects of investigations, nor a
ciples and guidelines for States, as well as for step-by-step handbook for practitioners, it does
institutions and individuals who play a role in the contain detailed guidelines on key aspects of the
investigation. investigation (Section V). A glossary is included
2. The Minnesota Protocol applies to the investiga (Section VI). Annexes (Section VII) contain anatom
tion of all 'potentially unlawful death' and, mutatis ical sketches and forms for use during autopsies.
mutandis, suspected enforced disappearance. For 4. States should take all appropriate steps to incor
the purpose of the Protocol, this primarily includes porate Protocol standards into their domestic
situations where: legal systems and to promote its use by relevant
a. The death may have been caused by acts or departments and personnel, including, but not
omissions of the State, its organs or agents, or limited to, prosecutors, defence lawyers, judges,
may otherwise be attributable to the State, in law enforcement, prison and military personnel,
violation of its duty to respect the right to life. and forensic and health professionals.
This includes, for example, all deaths possibly 5. With respect to armed groups, see Report of the
caused by law enforcement personnel or other UN Fact-Finding Mission on the Gaza Conflict,
agents of the state; deaths caused by para UN doc. A/HRC/12/48, 25 September 2009, para.
military groups, militias or 'death squads' sus 1836. OHCHR, Guiding Principles on Business and
pected of acting under the direction or with the Human Rights, UN doc. HR/PUB/11/04 (2011). 2005
permission or acquiescence of the State; and UN Basic Principles and Guidelines on the Right
deaths caused by private military or security to a Remedy and Reparation for Victims of Gross
forces exercising State functions. Violations of International Human Rights Law and
b. The death occurred when a person was Serious Violations of International Humanitarian
detained by, or was in the custody of, the State, Law (hereafter, UN Basic Principles and Guidelines
its organs, or agents. This includes, for exam on the Right to Remedy and Reparation).
ple, all deaths of persons detained in prisons, 6. The Protocol is also relevant to cases where the
in other places of detention (official and oth United Nations, armed non-State groups exer
erwise) and in other facilities where the State cising State or quasi-State authority, or business
exercises heightened control over their life. entities have a responsibility to respect the right
c. The death occurred where the State may have to life and to remedy any abuses they cause or
failed to meet its obligations to protect life. This to which they contribute. The Protocol can also
includes, for example, any situation where a guide the monitoring of investigations by the UN,
state fails to exercise due diligence to protect regional organizations and institutions, civil soci
an individual or individuals from foreseeable ety and victims' families, and can aid teaching and
external threats or violence by non-State actors. training on death investigations. States' Parties
d. There is also a general duty on the state to inves to relevant treaties may have specific obligations
tigate any suspicious death, even where it is not that go beyond the guidance set out in the pres
alleged or suspected that the state caused the ent Protocol. Although some States may not yet
death or unlawfully failed to prevent it. be in a position to follow all of the guidance set
3. The Protocol outlines States' legal obligations out within it, nothing in the Protocol should be
and common standards and guidelines relating interpreted in such a way as to relieve or excuse
to the investigation of potentially unlawful death any State from full compliance with its obligations
(Section II). It sets out the duty of any individual under international human rights law.
involved in an investigation to observe the highest
52 Violence in society, medicolegal investigation of death and the autopsy
Exhumation above, below and to the sides of the coffin and sub
mitted for toxicology. Additionally, samples should be
It is rare for a body to be removed from its grave for fur
taken of any fluid or solid material within the coffin;
ther examination; the most common reasons for exhu
these control samples may prove useful if any sugges
mation are personal, for example, if a family chooses to
tion of contamination is raised at a later date. The pro
move the body or if a cemetery is to be closed or altered.
cess must be as rigorous and meticulous as a forensic
In England & Wales a licence from the Ministry of Justice
post mortem.
must be applied for before exhumation can be done. Once
a licence is granted the correct site of the grave must be
determined from plans and records of the cemetery, as Bibliography and information
well as inscriptions on headstones. sources
In some countries with a low autopsy rate, for exam Academy of Medical Royal Colleges. Code of practice for the
ple Belgium, exhumations are more common, as legal diagnosis and confirmation of death, http://odt.nhs.uk/pdf/
arguments about an accident or an insurance claim, for code-of-practice-for-the-diagnosis-and-confirmation-of-
example, require an examination of the body to estab death.pdf (Accessed 5 April 2019).
lish the medical facts. Bolliger SA, Thali MJ, Ross S, et al. Virtual autopsy using imag
Logistics need to ensure that the body or human ing: bridging radiologic and forensic sciences: a review of the
remains are examined as quickly as possible. Thus, a virtopsy and similar projects. Eur Radiol 2008;18:273-282.
clear multiprofessional approach is required involving Bolliger SA, Filograna L, Spendlove D, et al. Post mortem imaging-
guided biopsy as an adjuvant to minimally invasive autopsy
amongst others the mortuary, the coroner, the patholo
with CT and postmortem angiography: a feasibility study. Am
gist, the police and everyone else with a legitimate
J Roentgenol 2010;195:1051-1056.
interest in the exhumation. Depending on the reason Burton JL, Rutty GN (eds). The Hospital Autopsy: A Manual of
and state of the burial or cremation site, there may be Fundamental Autopsy Practice, 3rd ed. London: Hodder
additional needs for other disciplines such as forensic Arnold; 2010.
anthropologists and forensic archaeologists. Burton J, Saunders S, Hamilton S. Atlas of Adult Autopsy Pathology
An examination of a body after exhumation is seldom Boca Raton: CRC Press; 2015.
as good as the examination of a fresh body, but it is sur Cameron P. Domestic violence among homosexual partners.
prising how well preserved a body may remain and how Psychol Rep 2003;93(2):410-416.
useful such an examination often is. It is almost impos Coroners and Justice Act 2009 C.25. http://www.legislation.gov.
uk/ukpga/2009/25 (Accessed 5 April 2019).
sible to predict how well preserved a body might be, as
Cubbin C, Pickle LW, Fingerhut L. Social context and geographic
there are so many confounding factors (Figure 4.6). The patterns of homicide among US Black and White males. Am
autopsy that follows an exhumation should be the same J Public Health 2000;90:579-587.
as that performed at any other time, and should be per Cummings PM, Trelka DP, Springer KM. Atlas of Forensic
formed by a trained forensic pathologist. All relevant Histopathology. New York: Cambridge University Press; 2011.
local protocols should be observed, and dependent on de Araujo EM, Costa Mda C, de Oliveira NF, et al. Spatial distribu
the reason for the exhumation, relevant samples (e.g., tion of mortality by homicide and social inequalities accord
for histology, toxicology) must be taken. ing to race/skin color in an intra-urban Brazilian space. BrazJ
In cases of possible poisoning, advice must be taken Epidemiol 2010;13(4):549-560.
Dettmeyer RB. Forensic Histopathology Heidelberg: Springer-
on the collection of other samples, such as soil from
Verlag; 2011.
DoH. Department of Health Guidance: Response to the Supreme
Court judgment: deprivation of liberty safeguards, https://
assets.publishing.service.gov.uk/government/uploads/sys-
tem/uploads/attachment_data/file/485122/DH_Consoli-
dated_Guidance.pdf (Accessed 5 April 2019).
DoH. Death Certification Reforms. Draft guidance for registered
medical practitioners, https://www.gov.uk/government/
uploads/system/uploads/attachment_data/file/506784/
Draft_guidance_-_notification_of_deaths_regulations_A.
pdf (Accessed 5 April 2019).
European Agency for Fundamental Rights. Violence against
women: an EU-wide survey. Main results, http://fra.europa.
eu/en/publication/2014/violence-against-women-eu-wide-
survey-main-results-report (Accessed 5 April 2019).
Figure 4.6 Removal of a coffin lid following an exhu Francisco RA, Evison MP, Costa Junior MLD, et al. Validation of
mation. Liquid mud covers the upper body following a standard forensic anthropology examination protocol by
leakage of the coffin lid as indicated by the arrow. measurement of applicability and reliability on exhumed and
(Reproduced with permission from Saukko P and archive samples of known biological attribution. Forensic Sci
Knight B. Knight's Pathology 4E, London, CRC Press, 2016.) Int 2017;279:241-250.
54 Violence in society, medicolegal investigation of death and the autopsy
Goudge ST. Inquiry into pediatric forensic pathology in Ontario. Petty CS. The devil's dozen: popular medicolegal misconcep
Ontario Ministry of the Attorney General 2008. https://www. tions. South MedJ. 1971;64:819-823.
attorneygeneral.jus.gov.on.ca/inquiries/goudge/report/ Pomara C, Karch SB, Fineschi V. Forensic Autopsy: A Handbook and
v1_en_pdf/Vol_l_Eng.pdf (Accessed 5 April 2019). Atlas. Boca Raton: CRC Press; 2010.
Home Office, The Forensic Science Regulator, Department of Registration of Births and Deaths Regulations 1987 No. 2088 (as
Justice, The Royal College of Pathologists. Code of Practice amended), http://www.legislation.gov.uk/uksi/1987/2088/
and Performance Standards for forensic pathology in contents/made (Accessed 5 April 2019).
England, Wales and Northern Ireland. G131 2012. https:// Shaw M, Tunstall H, Dorling D. Increasing inequalities in risk of
assets.publishing.service.gov.uk/government/uploads/sys- murder in Britain: trends in the demographic and spatial dis
tem/uploads/attachment_data/file/115698/code-practice- tribution of murder, 1981-2000. Health Place 2005;11:45-54.
forensic-pathology.pdf (Accessed 5 April 2019). United Nations. Manual on the effective presentation and inves
Jones R, Shepherd R. The role of the forensic pathologist. Faculty tigation of extra-legal, arbitrary and summary executions,
of Forensic and Legal Medicine 2017. https://fflm.ac.uk/wp- 1991 (The 'Minnesota Protocol'), http://www.ohchr.org/
content/uploads/2017/11/Role-of-Forensic-Pathologist-Dr-R- Documents/lssues/Executions/UNManual2015/Annex1_
Jones-and-Prof-R-Shepherd-November-2017.pdf (Accessed 5 The_UN_Manual.pdf (Accessed 5 April 2019).
April 2019). UN Office on Drugs and Crime (UNODC). Global study on
Leyland AH, Dundas R. The social patterning of deaths due to homicide 2013. United Nations publication, Sales No.
assault in Scotland, 1980-2005: population-based study. J 14.IV.1. http://www.unodc.org/documents/gsh/pdfs/
Epidemiol Community Health 2010;64:432-439. 2014_GLOBAL_HOMICIDE_BOOK_web.pdf (Accessed 5 April
Miller B, Irvin J. Invisible scars: Comparing the mental health of 2019).
LGB and heterosexual intimate partner violence survivors. J UN Women. Violence against women prevalence data: sur
Homosex 2017;64(9):1180-1195. veys by country, http://www.unwomen.org/en/what-
Mental Capacity Act. www.legislation.gov.uk/ukpga/2005/9/ we-do/ending-violence-against-women/facts-and-figures
contents (Accessed 20 May 2019). (Accessed 5 April 2019).
Ministry of Justice. Guide to coroner services and coroner inves Wheeler J, Anfinson K, Valvert D, et al. Is violence associated with
tigations: a short guide, https://www.gov.uk/government/ increased risk behavior among MSM? Evidence from a pop
publications/guide-to-coroner-services-and-coroner-inves- ulation-based survey conducted across nine cities in Central
tigations-a-short-guide (Accessed 5 April 2019). America. Glob Health Action 2014;7:24814.
Ministry of Justice. Coroners statistics annual 2018. https:// World Health Organisation. Global status report on violence pre
assets.publishing.service.gov.uk/government/uploads/ vention. http://www.who.int/violence_injury_prevention/vio-
system/uploads/attachment_data/file/800861/Coroners_ lence/status_report/2014/en/ (Accessed 5 April 2019).
Statistics_Annual_2018.pdf (Accessed 4 June 2019).
Ministry of Justice Coroners, Burials, Cremation and Inquiries
Team. Application for a licence for the removal of buried Further general resources
human remains (including cremated remains) in England & Burton JL, Saunders S, Hamilton S. Atlas of Adult Autopsy Pathology.
Wales, https://assets.publishing.service.gov.uk/government/ Boca Raton: CRC Press; 2015.
uploads/system/uploads/attachment_data/file/326818/ Burton JL, Rutty GN. The HospitalAutopsy: A Manual of Fundamental
application-exhumation-licence.pdf (Accessed 5 April 2019). Autopsy Practice, 3rd ed. London: Hodder Arnold; 2010.
Moritz AR. Classical mistakes in forensic pathology. Am J Clin Office for National Statistics, https://www.ons.gov.uk/ (Accessed
Pathol 1956;26:1383-1397. 5 April 2019).
National Confidential Enquiry into Patient Outcome and Death The Coroners' Society of England and Wales, http://www.coro
(NCEPOD). The coroner's autopsy: do we deserve better? ne rsociety.org.uk/ (Accessed 5 April 2019).
http://www.ncepod.org.uk/2006Report/introduction.html United Nations. The Minnesota Protocol on the Investigation of
(Accessed 5 April 2019). Potentially Unlawful Deaths (The Revised United Nations Manual
Office of National Statistics (ONS). Crime in England and Wales: on the Effective Prevention and Investigation of Extra-legal,
year ending March 2018. https://www.ons.gov.uk/people- Arbitrary and Summary Executions) 2017.
populationandcommunity/crimeandjustice/bulletins/cri- UN Women, http://www.unwomen.org/en/about-us
meinenglandandwales/yearendingmarch2018#statistici (Accessed 5 April 2019).
ans-comment (Accessed 5 April 2019).
Office on Drugs and Crime (UNODC). Global study on homicide
2013. United Nations publication, Sales No. 14.IV.1. (Available
at www.unodc.org/documents/gsh/pdfs/2014_GLOBAL_
HOMICIDE_BOOK_web.pdf).
S '
via glucose using oxidative phosphorylation and so ade In temperate conditions rigor can commonly be
nosine triphosphate (ATP) production from this process detected in the face between approximately 1 and 4
ceases and the secondary anoxic process takes over for hours after death and in the limbs between approxi
a short time but, as lactic acid is a by-product of anoxic mately 3 and 6 hours after death, with the strength of
respiration, the cell cytoplasm becomes increasingly rigor increasing to a maximum by approximately 18
acidic. In the presence of low ATP and high acidity, the hours after death. Once established, rigor can remain
actin and myosin fibres bind together and form a gel. for up to 2 days or so after death until autolysis and
The outward result of these complex cellular metabolic decomposition of muscle cells intervene and muscles
changes is that the muscles become stiff. However, they become flaccid again. These times are only very rough
do not shorten unless they are under tension. guidelines and can never be absolute.
It is clear from the short discussion above that if mus It is best to test for rigor across a joint using very
cle glycogen levels are low, or if the muscle cells are acidic gentle pressure from one or two fingers only; the aim is
at the time of death as a result of exercise, the process of to detect the presence and extent of the stiffness, not to
rigor will develop faster. Electrocution is also associated 'break' it. If rigor is broken by applying too much force,
with rapidly developing rigor and this may be caused those muscle groups cannot reliably be tested again.
by the repeated stimulation of the muscles. Conversely, However, re-establishment of rigor mortis following
in the young, the old or the emaciated, rigor may be mechanical loosening also occurs with muscular rigid
extremely hard to detect because of the low muscle bulk. ity at re-establishment equalling, or even exceeding the
Rigor develops uniformly throughout the body but it degree observed before breaking.
is generally first detectable in the smaller muscle groups
such as those around the eyes and mouth, the jaw and Cadaveric rigidity
the fingers. It appears to advance down the body from
'Cadaveric rigidity' (also known as 'instantaneous rigor',
the head to the legs as larger and larger muscle groups
'kataleptische Totenstarre’, and 'sp asm e cadverique’) is
become stiffened. The only use of assessing the presence
said to represent the instantaneous post mortem onset
or absence of rigor lies in the estimation of the time of
of rigor mortis, the basis for which is the very occa
death. The key word here is 'estimation', as rigor is such
sional discovery of a body in an unusual position, or of
a variable process that it can never provide an accurate
items gripped firmly in the hand of the deceased before
assessment of the time of death. Extreme caution should
the 'expected' onset of rigor. Most cases are said to be
be exercised in trying to assign a time of death based on
related to individuals who are at high levels of emotional
the very subjective assessment of the degree and extent
or physical stress immediately before death and many
of rigor. Charts or tables that assign times since death
historic reports relate to battlefield casualties, but there
based on the assessment of rigor should be viewed with
are many reports of individuals recovered from rivers
great scepticism. On its own, rigor mortis has very little
with weeds or twigs grasped firmly in their hand (Figure
utility as a marker of the PMI because of the large num
5.1) or the finger of a suicidal shooting found tightly
ber of factors that influence it.
gripping the trigger. It has been argued, however, that
The chemical processes that result in the stiffening
the majority of historical accounts do not stand up to
of the muscles, in common with all chemical processes,
critical scrutiny, and that a more likely explanation is
are affected by temperature: the colder the temperature
the onset of rigor in an individual positioned such that
the slower the reactions and vice versa. In a cold body,
gravity does not cause the gripped object to fall, or con
the onset of rigor will be delayed and the length of time
strained in some way such as their unusual position is
that its effects on the muscles can be detected will be
maintained.
prolonged, whereas in a body lying in a warm environ
ment, the onset of rigor and its duration will be short.
It is also important to be aware of the micro-envi Post mortem hypostasis
ronment around the body when assessing rigor: a Cessation of the circulation and the relaxation of the
body lying in front of a fire or in a bath of hot water will muscular tone of the vascular bed allow simple fluid
develop rigor more rapidly than if it were lying outside movement to occur within the blood vessels. Post mor
in winter. When the post mortem cooling of a body is tem hypostasis or post mortem lividity (also known
extreme, the stiffening of the body may result from the as livor mortis or suggillation) are the terms used to
physical effects of cooling or freezing rather than rigor. describe the visual manifestation of this phenomenon.
This will become apparent when the body is moved to There is also filling of the dependent blood vessels.
a warmer environment (usually the mortuary) and the The passive settling of red blood cells under the influ
stiffening caused by cold is seen to disappear as the ence of gravity to blood vessels in the lowest areas of the
body warms. Continued observation may reveal that body is of forensic interest. This results in a pink, pur
true rigor then develops as the cellular chemical pro plish or bluish colour to these lowest areas and it is this
cesses recommence. colour change that is called post mortem hypostasis or
The early post mortem interval I 57
Figure 5.4 (a) Post mortem hypostasis pattern on the front of a body found face down on a bed. The linear marks are
formed by pressure from creases in a blanket. Pallor around the mouth and nose are caused by pressure against the
bed and do not necessarily indicate marks of suffocation, (b) Post mortem hypostasis in male who died face down
obliquely across an open drawer - causing the linear pallor across the upper right chest and neck, (c) 'Cherry red7
hypostasis on the back of the trunk in a case of fatal carbon monoxide poisoning.
bronze hypostasis. Again, these colour changes should diurnal variation), exercise, infection and the
be treated with caution, not overinterpreted, and taken menstrual cycle.
into account with all other findings at post mortem. • The second assumption is that it is possible to take
The presence of hypostasis can give an indication that post mortem body temperature readings and,
a body has been moved after death. For example, if a body using mathematical formulae, to extrapolate that
is found lying prone, but the hypostasis pattern is pres data and generate a reliable estimate of the time
ent on the deceased’s back, it is a reasonable assumption taken by that body to cool to that measured tem
that the body was originally positioned supine. Moving a perature.
body several times after death will also have an effect on • The third assumption is that the body has lain in
hypostasis. Even after the normal post mortem coagu a thermally static environment; this is generally
lation of the blood has occurred, movement of the red not the case and even bodies lying in a confined
blood cells, although severely reduced, still continues. domestic environment may be subject to the
This continued ability of the red blood cells to move is daily variations of the central heating system,
important because changes in the position of a body while the variations imposed on a body lying
after the initial development of hypostasis will result in outside are potentially so great that no sensible
redistribution of the hypostasis and examination of the 'average' can be achieved.
body may reveal two overlapping patterns.
• The first assumption is that the body temperature Figure 5.5 The sequence of major changes after death
was 37°C at the time of death. However, many in a temperate environment. Note that the core body
factors affect body temperature in life, including temperature does not show a fall for the first hour or so.
variation throughout any 24-hour period (i.e., The times are only rough estimates.
Other post mortem changes I 59
Many other variables and factors also affect the rate This green colour is but an external marker of the pro
of cooling of a body (Box 5.1) and together they show found changes that are occurring in the body as the gut
why any trained forensic practitioner will be reluctant bacteria find their way out of the bowel lumen into the
to make any pronouncement on a specific time of death abdominal cavity and the blood vessels.
based on the body temperature alone. The blood vessels provide an excellent channel
through which the bacteria can spread with some ease
Other post mortem changes throughout the body. Their passage is marked by the
decomposition of haemoglobin which, when present in
As the PMI increases, the body undergoes additional
the superficial vessels, results in linear branching pat
changes that reflect tissue 'breakdown', autolysis and
terns of variable discoloration of the skin that is called
progressive decomposition/putrefaction.
'marbling' (Figure 5.6b). Over time, generalised skin
Decomposition/putrefaction discolouration occurs and, as the superficial layers of
the skin lose cohesion, blisters or large bullae contain
In the cycle of life, dead bodies are usually returned, ing red or brown putrefaction fluid form (sometimes
through reduction into their various components, to gas filled) in many areas (Figure 5.6c and d). When
the chemical pool that is the earth. Some components these burst, the contents are released and the skin
will do this by entering the food chain at almost any sloughs off.
level - from ant to tiger - whereas others will be reduced In temperate climates particularly, considerable
to simple chemicals by autolytic enzymatic processes gas formation in soft tissues and body cavities is com
built into the lysosomes of each cell. mon and the body begins to swell, with bloating of the
The early changes of decomposition are important face, abdomen, breasts and genitals (Figure 5.7). The
because they may be mistaken for signs of violence or body rapidly becomes unidentifiable. The increased
trauma. internal pressure causes the eyes and tongue to pro
Decomposition results in liquefaction of the soft tis trude and forces blood-stained fluid up from the lungs
sues over a period of time, the appearance of which, and which often Teaks out' of the mouth and nose as 'purge
the rate of progress of which, is a function of the ambient fluid'. Such fluid is frequently misinterpreted by those
temperature: the warmer the temperature, the earlier the inexperienced with decomposition-related changes as
process starts and the faster it progresses. In temperate representing injury-associated haemorrhage. The post
climates the process is usually first visible to the naked mortem appearance can be misleading in many cases,
eye at about 3-4 days as an area of green discoloration of with wrong assumptions being made, for example
the right iliac fossa of the anterior abdominal wall. This about body habitus and ethnic origin.
'greening' is the result of the extension of the commensal The role of insects and other animals may be signifi
gut bacteria through the bowel wall and into the skin, cant in accelerating the decomposition process; domes
where they decompose haemoglobin, resulting in the tic animals and other predators are not excluded from
green colour. The right iliac fossa is the usual origin as this process. As decomposition continues, soft tissues
the caecum lies close to the abdominal wall at this site, liquefy; however, some organs are relatively resistant to
but then can extend throughout the body (Figure 5.6a). putrefaction and may be identifiable for many months.
These include the prostate and the uterus and the ten
dons and ligaments. Eventually, skeletalisation will be
Box 5.1 Examples of factors affecting complete and, unless the bones and teeth are destroyed
the rate of cooling o f a body by larger animals, they may remain for years.
No reliable 'timetable' for decomposition can be
• Mass of the body.
constructed because environmental factors may favour
• Mass/surface area.
enhanced or delayed decomposition, and such factors
• Body temperature at the time of death.
• Site of reading of body temperature(s).
will generally be unknown to those investigating the
death.
• Posture of the body: extended or curled into a
fetal position.
Box 5.2 identifies some of the factors that influence
decomposition rates.
• Clothing: type of material, position on the
body - or lack of it.
Immersion and burial
• Obesity: fat is a good insulator.
• Emaciation - lack of muscle bulk allows a body Immersion in water or burial will slow the process of
to cool faster. decomposition. Casper's Law (or Ratio) states that: if all
• Environmental temperature. other factors are equal, then, when there is free access
• Winds, draughts, rain, humidity. of air, a body decomposes twice as fast than if immersed
in water and eight times faster than if buried in earth.
60 I The appearance of the body after death
Figure 5.6 (a) Greening of upper chest wall, (b) Marbling seen in blood vessels in the chest wall. The marbling
represents decomposition changes within the blood vessels, (c) Skin slippage and fluid collection following decompo
sition. (d) Blisters and bullae evident - early decomposition.
Adipocere
Adipocere is a chemical change in the body fat, which is
hydrolysed to a waxy substance with a texture similar
to soap. The need for water means that this process is
most commonly seen in bodies found in wet conditions
(i.e., submerged in water or buried in wet ground) but
this is not always the case and some bodies from dry
vaults have been found to have adipocere formation,
presumably the original body water being sufficient to
allow for the hydrolysis of the fat (Figure 5.11a and b).
Figure 5.8 Disposition of a body floating in water. In the early stages of formation, adipocere is a pale,
Typically, the head and limbs hang down, resulting in rancid, greasy semi-fluid material with a most unpleas
superficial injuries to the head/face, back of the arms and ant smell. As the hydrolysis progresses, the mate
hands, knees and top of the feet. rial becomes more brittle and whiter and, when fully
formed, adipocere is a grey, firm, waxy compound that
maintains the shape of the body. The speed with which
and the river, lake or sea bed uneven (Figure 5.8). Often adipocere can develop is variable; it would usually be
such damage must be distinguished from pre-death, expected to take weeks or months, but it is reported to
pre-immersion trauma. Figure 5.9 shows the forehead have occurred in as little as 3 weeks. All three stages of
of a male immersed for 7 days in a tidal river. Most of the adipocere formation can coexist and they can also be
appearance relates to contact with the river bed. Trauma found with areas of mummification and putrefaction if
was excluded as this was a witnessed immersion. the conditions are correct.
The first change that affects the body in water is the loss
of epidermis. Gaseous decomposition progresses and the
bloated body is often, but not always, lifted to the surface Mummification
by these gases, most commonly at about 1 week but this A body lying in dry conditions, either climatic or in a
time is extremely variable. Marine predators are often as microenvironment, may desiccate instead of putrefy -
active as animals found on land and they can cause exten a process known as mummification (Figure 5.12a and
sive damage (Figure 5.10). Exposure to water can, in some b). Mummified tissue is dry and leathery and generally
cases, predispose to the formation of adipocere, but this brown in colour. It generally occurs in the absence of
is unusual unless a body lies underwater for many weeks. bacterial or insect influence. It is most commonly seen
The effects and the timescale of the changes following in warm or hot environments such as desert and leads
burial are so variable that little can be said other than bur to the spontaneous mummification of bodies buried
ied bodies generally decay more slowly, especially if they in the sand in Egypt. However, it is not only bodies
are buried deep within the ground. Many factors including from hot dry climates that can be mummified, as the
the level of moisture in the surrounding soil and acidity of
the soil will significantly alter the speed of decomposition.
Figure 5.11 (a) Adipocere formation. Following burial for 3 years, w axy adipocere forms a shell around the skeleton of
this infant, (b) Advanced adipocere formation after 2.5 years in a grave. Exhumation due to exclusion of an acciden
tal death (fall) in a bathtub, ([a] Adapted from Simpson's 13th ed Fig. 5.11b; [b] From Saukko P and Knight B, Knight's
Forensic Pathology, 4th ed., Chapter 2. CRC Press. London. 2015.)
Figure 5.12 (a) Mummification. The skin is dry and leathery following recovery from a locked room for 10 weeks,
(b) Mummification of the hand, ([a] Reproduced with permission from Saukko P and Knight B. Knight's Pathology 4E,
London, CRC Press, 2016.)
Estimation of the post mortem interval I 63
with regard to determining the location and presence enzyme and electrolyte levels elsewhere in the body,
of biological materials such as semen, blood or hair. remain as interesting research tools but none has been
Electronic temperature probes allow the use of other widely accepted in routine case work as they have not
orifices, including the nose and ear, for temperature yet been proved to be valid.
taking, although it must be accepted that these loca
tions are unlikely to register the same temperature as Other techniques used in estimating or
the deep rectum or the liver.
The most widely recognised means of estimating the
corroborating PMI
time of death with temperature is Henssge's nomogram Forensic entomology has an im portant role in estab
(see Box 5.3). Crucially, the 95 per cent accuracy claimed lishing time of death, but as with other methods the
for this method is, at best, only 2.8 hours on either side accuracy and limitation of such determinations must
of the most likely time (a total spread of over 5.5 hours). be understood. Forensic entom ologists can deter
Henssge's nomogram relies on three measurements mine a probable time of death - in the region of days
- body temperature, ambient temperature and body to months - from examination of the populations and
weight - and lack of accuracy in any one of these will stages of development of the various insects that invade
substantially degrade the final result. Corrective factors a body. The use of insects to estim ate PMI requires
can be applied to allow for clothing, air movement and/ knowledge of the insect's life cycle, the relationship of
or water (Table 5.1). Whilst the use of the nomogram is the insect to the remains, and the relationship of the
advocated by forensic pathologists in some jurisdictions, remains to the habitat in which they are discovered.
it has enjoyed limited acceptance in the UK, and realisti Insects pass through a number of distinct stages dur
cally it should be accepted that the results it provides are ing their life cycle. For example, a female blowfly in the
an indicator of a range of time of death and actual time of family C alliphoridae arrives at the body and deposits
death may still lie outside the range provided. eggs in body openings associated with the head, anus,
Indeed, the need to record the ambient temperature and genitals, or in wounds. Following hatching, larvae
poses one of the major problems because of fluctuating or maggots feed on the decomposing tissues. There are
temperatures at the scene. The first police officers or three larval stages, with a moult (an instar) in between
scientists at the scene should always be encouraged to each stage. Once the maggot is fully developed, it
take the ambient temperature adjacent to the body and ceases to feed and moves away from the remains before
to record the time that they made their measurement. pupariation. The puparium is an inactive stage during
This, however, may give rise to concerns about inter which the larval tissues are reorganised to produce the
pretation of physical findings (dependent on how and adult winged fly (Figure 5.15a and b). The time from
by what route the temperature is taken). Occasionally egg laying through the instars to pupation varies from
meteorological data sources can assist in providing such species to species and the ambient temperature, but
information. with the relevant expertise a PMI can be determined
In the past various ‘rules of thumb' have been used to from these data.
calculate the time of death from the body temperature Other animals, both large and small, will arrive to
but like most 'rules of thumb' they are not derived from feed on the body, with the species and the rapidity of
any evidence base and should be considered as simple their arrival depending on the time of year and the envi
guesswork, and not to be used in forensic practice. ronment. The examination of buried bodies or skeletal
Additionally, the perceived temperature of the body remains may require the combined specialist skills of
to touch is mentioned in court as an indicator of the time the forensic pathologist, an anthropologist, an odon-
of death; this assessment is so unreliable as to be useless tologist and an entomologist.
and is even more so if the pathologist is asked to com Analysis of gastric contents - other than for toxicolog-
ment upon the reported observations of another person. ical purposes - may assist in an investigation, but cannot
The UK Forensic Science Regulator, which sets quality reliably be used to accurately determine time of death
standards for the provision of forensic science services, although it may provide an indicator within a 6 hour or
has issued guidance on the application of post mortem so timeframe (see Box 5.4). The presence or absence, and
cooling methods to the estimation of time since death nature (if present), of gastric contents may be very useful
and unambiguously states that the pathologist must in terms of corroborating accounts of witnesses. Review
make clear to the investigator that the accuracy of the of such evidence generally requires full retention of gas
estimate cannot be determined, and that it should not tric contents, analysis by a forensic scientist, interpreta
be used to define the period in which death occurred. tion by a forensic physician or gastroenterologist, and
Various other methods have been researched in as review of pre-death medical records and post mortem
yet unsuccessful attempts to find a technique to deter findings. In some cases, plant analysis can provide a reli
mine time of death. Biochemical methods, includ able estimation for skeletal remains dating, when tradi
ing vitreous humour potassium levels and changes in tional techniques are not applicable. Forensic botany is a
Estimation of the post mortem interval I 65
, r orrectWefactors------
A
M
B
i
E
N
T
°C
r -10
10
15
KILOGRAM
15
This nomogram is for ambient temperatures up to proportionally adjusted by corrective factors of the
25°C. Permissible variation of 95% (+ /- h). The Henssge real body weight, giving the corrected body weight by
nomogram expresses the death-time (t) as follows: which, the death-time is to be read off. Factors above
1.0 may correct thermal isolation conditions and fac
tors below 1.0 may correct conditions accelerating the
%3 ~T-~rTambient = 125 exp (Bt) “ 25 exp (5Bt);
*ambient
' •*- heat loss of a body.
B = -1.281 5 (kg--625) + .0284
How to read off the time of death
The nomogram is related to the chosen standard; Connect the points of the scales by a straight line accord
that is, a naked body extended lying in still air. Cooling ing to the rectal and the ambient temperature. It crosses
conditions differing from the chosen standard may be the diagonal of the nomogram at a specific point.
(Continued)
66 I The appearance of the body after death
Box 5.3 (Continued) The rectal temperature: Time o f death relating nomogram
Draw a second straight line going through the No strong fever or general hypothermia.
centre of the circle, below left of the nomogram, and No uncertain3 severe changes of the cooling con
the intersection of the first line and the diagonal. The ditions during the period between the time of
second line crosses the semicircle of the body weight death and examination (e.g., the place of death
and the time of death can be read off. The second line must be the same as where the body was found).
touches a segment of the outermost semicircle. Here • No high thermal conductivity of the surface
can be seen the permissible variation of 95%. beneath the bodyb.
Figure 5.15 (a) Maggot infestation of a body recovered from heated premises approximately 2 weeks after death.
Forensic entomology may assist in estimating post mortem interval (PMI) in such cases, (b) Maggot infestation below
skin surface - note also mummification of fingertips.
Box 5.4 Gastric contents and the post mortem interval: The 'Truscott Case'
In 1959, a 12-year-old girl, Lynne Harper, was found must have died between V/2 and 2 hours after her last
dead in woodland in Ontario, Canada. She had been meal had finished, a time period in which Steven was
strangled and sexually assaulted. A 14-year-old boy, thought to have had 'exclusive opportunity' to kill her.
Steven Truscott, was convicted of her murder and sen Her body was found two days after her disappear
tenced to death, although this was later commuted to ance, and the environmental conditions in the area had
life imprisonment. His conviction was quashed in 2007, been hot and damp. Evidence of decomposition, how
following a second 'Reference' to the Court of Appeal. ever, was lacking raising the possibility that she had
Whilst there appeared to be agreement amongst been killed at a later time than was suggested by the
the expert witnesses at trial, and at subsequent appeal crown.
hearings, that Lynne had died as a result of strangula It was recognised on appeal that gastric empty
tion (a ligature fashioned out of her blouse), there was ing times were subject to variation precluding its use
intense controversy regarding the pathological assess as a reliable factor in the assessment of time of death,
ment of the post mortem interval. although it might assist an investigation in other ways,
The Crown case was that, due to the presence of such as confirming that death occurred after a particu
recognisable food particles (vegetable matter and lar meal was eaten.
possibly meat) within the stomach contents, Lynne
newer discipline that includes many subdisciplines such Belsey SL, Flanagan RJ. Post mortem biochemistry: current appli
as palynology (including mycology), anatomy, dendro cations. J Forensic Leg Med 2016;41:49-57.
chronology, limnology and ecology and its role is likely Brown A, Marshall TK. Body temperature as a means of estimat
to continue to develop in the future. ing time of death. Forensic Sci 1974;4:125-133.
Burger E, Dempers J, Steiner S, Shepherd R. Henssge nomogram
In all cases of determination of PMI, it is for the foren
typesetting error. Forensic Sci Med Path 2013;9:615-617.
sic practitioner to advise the justice system of the limits
Cartozzo C, Singh B, Boone E, Simmons T. Evaluation of DNA
of each technique. extraction methods from waterlogged bones: a pilot study.
Forensic Sci 2018;63(6):1830-1835.
Biblography and information Cook GT, MacKenzie AB. Radioactive isotope analyses of skeletal
materials in forensic science: a review of uses and potential
sources uses. IntJ Legal Med 2014;128(4):685-698.
Alberti F, Gonzalez J, Paijmans JLA, et al. Optimized DNA sam Crostack C, Sehner S, Raupach T, Anders S. Re-establishment of
pling of ancient bones using Computed Tomography scans. rigor mortis: evidence for a considerably longer post mortem
Mol Ecol Resour. 2018;18(6):1196-1208. time span. IntJ Legal Med 2017;131(4):1039-1042.
Amendt J, Richards CS#Campobasso CP, et al. Forensic ento Donaldson AE, Lamont IL. Biochemistry changes that occur after
mology: applications and limitations. Forensic Sci Med Path death: potential markers for determining post-mortem inter
2011;7:379-392. val. PLOS ONE 2013;8(11):e82011.
68 I The appearance of the body after death
Faris AM, Wang HH, Tarone AM, Grant WE. Forensic entomology: Marshall TK. The use of body temperature in estimating the time
evaluating uncertainty associated with postmortem interval of death and its limitations. Med Sci Law 1969;3:178-182.
(PMI) estimates with ecological models. J Med Entomol 2016; Marshall TK, Hoare FE. Estimating the time of death J Forensic Sci
53:1117-1130. 1962;7:56-81,189-210,211-221.
Forensic Science Regulator/Royal College of Pathologists. The Miller Coyle H, Lee CL, Lin WY, et al. Forensic botany: using plant
use of time of death estimates based on heat loss from the evidence to aid in forensic death investigation. Croat Med J
body. FSR-G-211 Issue 1 2014 https://www.gov.uk/govern- 2005;46(4):606-612.
ment/publications/time-of-death-estimations (Accessed 5 Pirch J, Schulz Y, Klintschar M. A case of instantaneous rigor? IntJ
April 2019). Legal Med 2013;127:971-974.
Goff L. Forensic entomology. In: Resh VH, Carde RT (eds). Schrag B, Uldin T, Mangin P, et al. Dating human skeletal
Encyclopedia of Insects, 2nd ed. Burlington, MA: Elsevier; 2009, remains using 90Sr and 210Pb: case studies. Forensic Sci Int
381-386. 2014;234:190.e1 -190.e6.
Gondek AT, Boessenkool S, Star B. A stainless-steel mortar, pestle Sher J. 'Untilyou are dead': Steven Truscott's Long Ride into History
and sleeve design for the efficient fragmentation of ancient Toronto: Vintage Canada; 2002.
bone. Biotechniques 2018;64(6):266-269. Shirley NR, Wilson RJ, Jantz LM. Cadaver use at the University
Haglund WD, Sorg MH (eds). Forensic Taphonomy: The Post of Tennessee's Anthropological Research Facility. Clin Anat
mortem Fate of Human Remains. Boca Raton, FL: CRC Press; 2011;24:373-380.
1997. Shkrum MJ, Ramsay DA. Forensic Pathology of Trauma. Totowa:
Hawksworth DL, Wiltshire PE. Forensic mycology: the use of fungi Humana Press, Inc.; 2007.
in criminal investigations. ForensicSciInt 2011 ;206:1. Simpson K. The case against Steven Truscott in Canada. Medico-
Henssge C. Death time estimation in case work. I. The rec Legal J 1968;36:58-71.
tal temperature time of death nomogram. Forensic Sci Int Truscott (Re), 2007 ONCA 575 Court of Appeal for Ontario tran
1988;38:209-236. script, http://www.cbc.ca/news2/background/truscott/
Lancia M, Conforti F, Aleffi M, et al. The use of Leptodyctium pdf/20070NCA0575.pdf (Accessed 5 April 2019).
riparium (Hedw.) Warnst in the estimation of minimum post Singh R, Sharma S, Sharma A. Determination of post-burial interval
mortem interval. J Forensic Sci 2013;58(Suppl 1):S239-S242. using entomology: a review.J Forensic Leg Med 2016;42:37-40.
Legge CM, Payne-James JJ, Puntis JWL, Short SL. Post mortem
gastric content analysis: its role in determining time since
death. In: Gall JAM, Payne-James JJ (eds). Current Practice in Further general resources
Forensic Medicine, Volume 2. Chichester: Oxford Editorial Payne-James JJ, Byard RW. Encyclopedia of Forensic & Legal
Office; 2016. Medicine. 4 volumes, 2nd ed. Oxford: Elsevier; 2015.
Madea B. Estimation of the Time Since Death, 3rd ed. London: CRC Saukko P, Knight B. Knight's Forensic Pathology, 4th ed. London:
Press; 2016. CRC Press; 2015.
6 Death from natural causes
Figure 6.2 Myocardial infarction, (a) Macroscopic appearance of acute left-ventricular myocardial infarction,
(b-d) Microscopic appearance of myocardial infarction with early necrosis (b), organisation including residual haemo-
siderin-laden macrophages and fibroblasts (c), and extensive replacement fibrosis (d). (Courtesy of Richard Jones.)
• Communication with the families. epidemic. Regular physical activity is associated with
• A multidisciplinary approach including cardioge- lower blood pressure, reduced cardiovascular risk, and
netic counselling. cardiac remodelling. While exercise and hypertension
can both be associated with the development of left ven
Hypertensive heart disease tricular hypertrophy (LVH), the cardiac remodelling from
hypertension is pathological with an associated increase
Long-standing hypertension can result in cardiac
in myocyte hypertrophy, fibrosis, and risk of heart failure
remodelling, manifested by left ventricular hypertrophy
and mortality, whereas LVH in athletes is generally non-
(and cardiomegaly). Although the 'normal heart weight'
pathological and lacks the fibrosis seen in hypertension.
(approximately 400 g for the average male) is dependent
on body size/weight, an enlarged heart predisposes an
individual to chronic myocardial hypoxia and electri Aortic stenosis
cal instability which, when combined with a trigger, can Aortic stenosis is a disease that classically affects older
result in a fatal arrhythmia. Some authors consider a individuals with calcified tricuspid aortic valves, but
heart weight of greater than 500 g to represent an inher may also be seen in younger people who have a congen
ently unstable heart. Hypertensive heart disease fre ital bicuspid aortic valve. It is the most common form
quently coexists with coronary artery atherosclerosis, of valvular heart disease. Angina, exertional syncope
increasing the potential for the development of fatal and heart failure are key symptoms indicating a need
arrhythmias at times of cardiovascular 'stress'. There are for intervention. The accompanying myocardial hyper
regional and ethnic variations in the incidence of such trophy is similar to that caused by hypertension - lead
diseases but in general the global burden of hyperten ing to LVH - which may, in some cases, produce heart
sion is rising and accounts for substantial morbidity weights of over 700 g.
and mortality. Lifestyle factors such as diet and physical In aortic stenosis, myocardial perfusion is worsened
inactivity contribute to this burden, further highlighting by the narrow valve, which results in a lower pressure at
the need for prevention efforts to curb this public health the coronary ostia and hence in the coronary arteries.
72 Death from natural causes
Gastrointestinal system
The main causes of sudden death in the gastrointesti
nal system are predominantly vascular in nature; severe
bleeding from a gastric or duodenal peptic ulcer can be
fatal in a short time, although less catastrophic bleed
ing may be amenable to emergency medical/surgical/
Figure 6.11 Fatal pulmonary thromboembolism. endoscopic intervention (Figure 6.13a). Bleeding from
(a) Thrombus which has formed in life has broken away oesophageal varices as a result of portal hypertension
from the peripheral circulation to be transported in the from any cause has a significant mortality that increases
bloodstream to this lung, where it has lodged in, and after a first event (Figure 6.13b).
occluded, a pulmonary vein. Note how the thromboem- Mesenteric thrombosis and embolism, often related
bolus protrudes from the cut end of the occluded blood to aortic or more generalised atherosclerosis, may result
vessel (*). (b) Microscopic appearance, ([a] From Burton J, in infarction of part of the small or large intestine. The
Saunders S, Hamilton S. Atlas o f Adult Autopsy Pathology. diagnosis may be unclear and a rapid but not sudden
Boca Raton: CRC Press 2015 (Fig 4.37b, page 96) death is likely if the infarction remains undiagnosed.
with permission.) Intestinal infarction owing to a strangulated hernia,
or obstruction owing to torsion of the bowel as a con
become lodged in smaller-calibre pulmonary blood ves sequence of adhesions, can also be rapidly fatal (Figure
sels where they interfere with pulmonary function and 6.14a and b).
lead to myocardial ischaemia and cardiac arrest. Peritonitis, following perforation of a peptic ulcer,
Even without any risk factors some PEs occur unex diverticulitis or perforation at the site of a colonic
pectedly in normal, ambulant people who have reported tumour for example, can be fatal if not treated (Figure
no clinical symptoms. This sometimes makes establish 6.15) and even when treated has a significant mortality.
ing the causal relationship between death and an injuri Often these conditions present as sudden death
ous event difficult. For the purposes of civil law (where because of failure to seek medical assistance early after
the standard of proof for causation is 'on the balance of symptom onset, by which time the effects of sepsis are
probabilities') the embolism can often be linked to the overwhelming.
trauma, but in a criminal trial in which a higher stan
dard of proof ('beyond reasonable doubt') is required,
it may be much harder to demonstrate a causal link Gynaecological conditions
between the two events. When a female of childbearing age is found deceased,
Other rare causes of sudden death in the respiratory a complication of pregnancy must be considered to be
system (excluding bronchial asthma which is covered the most likely cause of death until other causes have
78 I Death from natural causes
been excluded. Abortion is a particular risk in countries in high-income countries is 1 in 3300, compared to 1 in 41
where legal abortion is not available. in low-income countries. UK evidence suggests a mortal
A ruptured ectopic pregnancy, usually in a Fallopian ity rate of ~ 8 .5/100,000 during pregnancy or shortly after
tube, is another serious obstetric emergency that can childbirth of which heart disease was the most significant
result in death from intraperitoneal bleeding unless figure, contributing to 2/100,000. There is an international
rapidly treated by surgical intervention (Figure 6.16).
Maternal deaths (occurring during pregnancy or
within 12 months of parturition in the UK) can be clas
sified into 'direct' deaths (caused by diseases specifically
related to pregnancy, such as pulmonary thromboem
bolism, pre-eclampsia, obstetric haemorrhage, amniotic
fluid embolism, acute fatty liver of pregnancy or ectopic
gestation), 'indirect' deaths (from pre-existing disease
exacerbated by pregnancy such as congenital heart dis
ease or a cardiomyopathy) or 'coincidental' deaths.
From 1990 to 2015, the global maternal mortality
ratio declined by 44 per cent - from 385 deaths to 216
deaths per 100,000 live births, according to UN data. This
gives an average annual rate of reduction of 2.3 per cent.
Almost all maternal deaths can be prevented, as evi Figure 6.15 Peritonitis. Note the fibrinous deposits on
denced by the huge disparities found between the richest the surface of loops of intestines.
and poorest countries. The lifetime risk of maternal death (Courtesy of Richard Jones.)
Deaths from asthma and epilepsy
resulting in a temporary disturbance of motor, sen 500 sudden and unexpected deaths in epileptics each
sory or mental function. There are many types of sei year in the UK where the precise cause of death is not
zures, depending primarily on what part of the brain identified. Such deaths have been classified as Sudden
is involved. The term epilepsy says nothing about the Unexpected Death in Epilepsy (SUDEP), defined as a
type of seizure or cause of the seizure, only that the ‘sudden unexpected, witnessed or unwitnessed, non-
seizures happen again and again. Seizures that have traumatic and non-drowning death in epilepsy, with
no known underlying cause may be called primary or or without evidence of a seizure, and excluding docu
idiopathic epilepsy. A seizure may start as a partial, mented status epilepticus, where post mortem exami
or focal, seizure, involving the face or arm. Then the nation does not reveal a toxicological or anatomic
muscular activity spreads to other areas of the body. cause of death' (Figure 6.18). The rate of sudden death
Healthy people may have seizures under certain cir in epilepsy may be >20 times the incidence rate of sud
cumstances. If the seizures have a known cause, the den death in the total population of the same age.
condition is referred to as secondary or symptomatic The mechanism of death in such cases is uncertain,
epilepsy. Some of the more common causes include but may be related to a seizure-induced arrhythmia,
the following: head injuries; toxic chemicals or drugs seizure-mediated inhibition of respiratory centres or a
of abuse; alcohol or benzodiazepine withdrawal; and complication of anti-epileptic treatment. Post mortem
stroke. There may be specific reasons why a person findings in SUDEP are non-specific (e.g., pulmonary
with epilepsy may die (e.g., drowning as a result of a oedema and congestion) and the utility of the presence of
seizure while swimming), but there are approximately a tongue injury in diagnosing a seizure is controversial.
f
Spread to respiratory Spread to cardiovascular
Spread to midbrain
centres in medulla centres in medulla
i i — 1 I
Ascending arousal Respiratory Serotonin neuron
system inhibition nuclei inhibition inhibition
Loss of
arousal
PGES Hypoventilation/
Apnoea
Predisposing
factors Cardiac autonomic
neuron dysfunction
Prone/face
down
! Congenital
Sleep/Sleep Arrhythmias/ LQTS
apnoea Asystole
Intrinsic Intrinsic cardiac
pulmonary dysfunction
dysfunction SUDEP/death
Figure 6.18 Pathophysiological mechanisms underlying sudden unexpected death in epilepsy (SUDEP). SUDEP often
results from a generalised tonic-clonic seizure, which leads to inhibition of specific midbrain and medulla-mediated
effects via an unknown pathway. Other factors shown may predispose these patients to SUDEP. (Abbreviations:
LQTS, long QT syndrome; PGES, postictal generalised EEG suppression). (From Dlouhy BJ, Gehlbach BK, Richerson GB.
Sudden unexpected death in epilepsy: basic mechanisms and clinical implications for prevention. J Neuro Neurosurg
Psych 2016; 87:402-413; Fig. 3 page 408.)
Bibliography and information sources I 81
Neuropathological examination of the brain is Friedman M, Manwaring JH, Rosenman RH, et al. Instantaneous
important in order to exclude the presence of a lesion and sudden deaths: clinical and pathological differentiation
capable of providing an explanation for seizure activity, in coronary artery diseaseJ/\m Med Assoc 1973;225:1319-1328.
(e.g., non-recent brain injury; arteriovenous malforma Hegde SM, Solomon SD. Influence of physical activity on hyper
tion; tumour). At present, the pathogenesis is considered tension and cardiac structure and function. CurrHypertensRep
2015;17(10):77.
to be multifactorial. Potential neuroimaging biomarkers
Hill SF, Sheppard MN. Non-atherosclerotic coronary artery
have been identified but as yet these remain as research, disease associated with sudden cardiac death. Heart
rather than clinicopathological tools. 2010;96:1084-1085.
Hinkle LE Jr, Thaler HT. Clinical classification of cardiac deaths.
Bibliography and information Circulation 1982;65:457-464.
Izumi C. Asymptomatic severe aortic stenosis: challenges in diag
sources nosis and management. Heart 2016;102(15):1168-1176.
Arbustini E, Dal Bello B, Morbini P, et al. Plaque erosion is a major Jones R. The last page: aortic dissection. Med Sci Law 2013;53:
substrate for coronary thrombosis in acutemyocardial infarc 59-60.
tion. Heart 1999;82:269-272. Kaur BP, Lahewala S, Arora S, et al. Asthma: hospitalization trends
Arbustini E, Narula N, Tavazzi L, et al. The MOGE(S) classifica and predictors of in-hospital mortality and hospitaliza
tion of cardiomyopathy for clinicians. J Am Coll Cardiol tion costs in the USA (2001-2010). Int Arch Allergy Immunol
2014;64(3):304-318. 2015;168(2):71 —78.
Bhattacharyya S, Hayward C, Pepper J, Senior R. Risk stratification Leadbeatter S. Extracranial vertebral artery injury: evolution of a
in asymptomatic severe aortic stenosis: a critical appraisal. Eur pathological illusion? Forensic Sci Int 1994;67:33-40.
Heart J 2012;33(19):2377-2387. Libby P. Current concepts of the pathogenesis of the acute coro
Brown RD Jr, Broderick JP. Unruptured intracranial aneurysms: nary syndromes. Circulation 2001;104:365-372.
epidemiology, natural history, management options, and Lombardi R, Betocchi S. Aetiology and pathogenesis of hyper
familial screening. Lancet Neurol 2014;13(4):393-404. trophic cardiomyopathy. Acta Paediatr Suppl 2002;91 (439):10—14.
Burton J, Saunders S, Hamilton S.Atlas ofAdult Autopsy Pathology. Martin CA, Huang CL, Matthews GD. The role of ion channelopa
Boca Raton: CRC Press, 2015. thies in sudden cardiac death: implications for clinical prac
Caforio AL, Pankuweit S, Arbustini E, et al. European Society of tice. Ann Med 2013;45(4):364-374.
Cardiology Working Group on Myocardial and Pericardial Maternal, Newborn and Infant Clinical Outcome Review
Diseases. Current state of knowledge on aetiology, diag Programme. Saving lives, improving mothers' care, https://
nosis, management, and therapy of myocarditis: a position www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/
statement of the European Society of Cardiology Working MBRRACE-UK%20Maternal%20Report%202017%20-%20
Group on Myocardial and Pericardial Diseases. Eur Heart J Web.pdf (Accessed 01 May 2019).
2013;34(33):2636-2648, 2648a-2648d. Millward-SadlerGH. Pathology of maternal deaths. In: Kirkham N,
Certification of Death (Scotland) Act 2011. http://www.legislation. Shepherd N (eds). Progress in Pathology 2003, Vol 6. London:
gov.uk/asp/2011/11/pdfs/asp_20110011_en.pdf (Accessed 1 Greenwich Medical Media; 2003,163-185.
May 2019). Nashef L. Sudden unexpected death in epilepsy: terminology and
Challa VR, Moody DM, Bell MA. The Charcot-Bouchard aneu definitions. Epilepsia 1997;38(Suppl 11):S6-S8.
rysm controversy: impact of a new histologic technique. J Nielsen JD. The incidence of pulmonary embolism during deep
Neuropathoi Exp Neurol 1992;51 (3):264-271. vein thrombosis. Phlebology. 2013;28(Suppl 1):29-33.
Cohle S, Suarez-Mier MP, Aguilera B. Sudden death resulting from Ottaviani G, Buja LM. Anatomopathological changes of the car
lesions of the cardiac conduction system. Am J Forensic Med diac conduction system in sudden cardiac death, particularly
Pathol 2002;23(1):83-89. in infants: advances over the last 25 years. Cardiovasc Pathol
Dlouhy BJ, Gehlbach BK, Richerson GB. Sudden unexpected 2016;25(6):489-499.
death in epilepsy: basic mechanisms and clinical implications Pankuweit S, Luers C, Richter A, et al. German Competence
for prevention. J Neurol Neurosurg Psych 2016;87:402-413. Network Heart Failure. Influence of different aetiologies on
Drago F, Merlo G, Rebora A, Parodi A. Syphilitic aortitis and its clinical course and outcome in patients with dilated cardio
complications in the modern era. G Ital Dermatol Venereol myopathy. EurJ Clin Invest 2015;45(9):906-917.
2018;153(5):698-706. Ptaszek LM, Kim K, Spooner AE, et al. Marfan syndrome is associ
Eefting D, Ultee KH, Von Meijenfeldt GC, et al. Ruptured AAA: ated with recurrent dissection of the dissected aorta. Ann
state of the art management. J Cardiovasc Surg (Torino) Thorac Surg 2015;99(5):1616-1623.
2013;54(1 Suppl 1):47-53. Saetre E, Abdelnoor M. Incidence rate of sudden death in epi
Ellis SP Jr, Szabo CA. Sudden unexpected death in epilepsy: inci lepsy: a systematic review and meta-analysis. Epilepsy Behav
dence, risk factors, and proposed mechanisms. Am J Forensic 2018;86:193-199. pii: S1525-5050(18)30448-7.
Med Pathol 2018;39(2):98-102. Sidebotham HJ, Roche WR. Asthma deaths: persistent and pre
Fernandez-Falgueras A, Sarquella-Brugada G, Brugada J, et al. ventable mortality. Histopathology 2003;43:105-117.
Cardiac channelopathies and sudden death: recent clinical Soilleux EJ, Burke MM. Pathology and investigation of potentially
and genetic advances. Biology (Basel) 2017;6(1):7. hereditary sudden cardiac death syndromes in structurally
Fornes P, Lecompte D, Nicholas G. Sudden out-of-hospital coro normal hearts. DiagHist 2008;15:1-26.
nary death in patients with no cardiac history: an analysis Stather PW, Sidloff DA, Rhema IA, et al. A review of current report
of 221 patients studied at autopsy. J Forensic Sci 1993;38: ing of abdominal aortic aneurysm mortality and prevalence
1084-1091. in the literature. Eur J Vase Endovasc Surg 2014;47(3):240-242.
82 Death from natural causes
Te Riele AS, Hauer RN. Arrhythmogenic right ventricular dyspla Wilhelm M, Bolliger SA, Bartsch C, et al. Sudden cardiac death in
sia/cardiomyopathy: clinical challenges in a changing disease forensic medicine: Swiss recommendations for a multidisci
spectrum. Trends Cardiovasc Med 2015;25(3):191—198. plinary approach. Swiss Med Wkly 2015;145:w14129.
Tomson Tf Nashef L, Ryvlin P. Sudden unexpected death in epi World Health Organisation. Strategies towards end
lepsy: current knowledge and future directions. Lancet Neurol ing preventable maternal mortality (EPMM). 2015.
2008;11:1021-1031. h ttps://apps.w ho.int/iris/bitstream /handle/10665/
UNICEF. Maternal mortality, https://data.unicef.org/topic/mater- 153544/9789241508483_eng. pdf;jsessionid=92DAF49DA73A
nal-health/maternal-mortality/(Accessed 1 May 2019). 70417CF038BC29D157D0?sequence=1
Wang T, Zhao J, Yuan D, et al. Comparative effectiveness of open
surgery versus endovascular repair for hemodynamically
stable and unstable ruptured abdominal aortic aneurysm.
Medicine (Baltimore) 2018;97(27):e11313.
7 Deaths and injury in infancy
Injuries in the deceased child ankles and knees, may be evidence of gripping by an
adult. Bruises on the face, ears, lips, neck, lateral thorax,
Post mortem in children anterior abdomen, buttocks and thighs require an expla
The post mortem examination of a child is a specialised nation, as these sites are less likely to be injured in child
procedure that must be carried out by a pathologist with hood falls (Figures 7.7-7.9). In very general terms, bruises
specific training and experience in paediatric autopsy over soft tissue areas in non-mobile infants, bruises that
pathology. In many jurisdictions, dedicated perinatal carry an imprint of an implement and multiple bruises of
and paediatric pathologists make these examinations uniform shape are suggestive of some forms of physical
in regional specialist centres. abuse.
Full radiological skeletal surveys precede the physi The explanation given by the carers of how each
cal examination of the body, and evidence of old or bruise came to be present on the child must be docu
recent fractures usually results in a medicolegal autopsy mented with great care. This is because frequently an
to exclude assault. The need for detailed documenta interpretation may be required comparing the injuries
tion during the autopsy is similar to that involved in documented with a variety of explanations in cases of
adult autopsies, and the procedure progresses from possible NAI.
an inspection of the surface of the body to the internal
organs in a similar manner. Skeletal injury
The procedure is adapted to take account of develop- Currently in the UK the Royal College of Radiologists
ment-specific differences between children and adults; recommends that imaging should always include skel
the presence of incomplete skull bone fusion, and rem etal survey in children under two years of age and skele
nants of the fetal circulation, for example. A detailed tal survey and CT head scan in children under one year.
description of the perinatal and paediatric autopsy Figure 7.10 shows the recommended images to be taken
is beyond the scope of this book, and the interested in suspected physical abuse of children.
reader is directed to specialist texts listed at the end of Children who are older than one year and have exter
this chapter. nal evidence of head trauma and/or abnormal neuro
It is essential that as much information (including logical symptoms or signs should also have a CT head
accounts of all witnesses, pre-existing medical records, scan. Skeletal surveys may occasionally be indicated in
and school records) be reviewed. When a child dies or older children and may include those with communi
is seriously harmed as a result of abuse or neglect, a cation or learning difficulties who are unable to give a
review is conducted to identify ways that profession full history or those where there is clinical suspicion of
als and organisations can improve the way they work bony injury.
together to safeguard children and prevent similar inci Healing fractures (representing previous traumatic
dents from occurring again. Each UK nation has its own episodes) can be visualised by radiological means
terminology and guidance for carrying out and sharing although histological assessment post mortem is more
the learning from the reviews. Cases that meet the cri precise.
teria set out in the relevant guidance are reviewed by Rib fractures are rarely accidental in children. They
multi-agency panels. may occasionally be associated with birth trauma, but
In England, Child Death Overview Panels (CDOP) in general they are a feature of the application of sub
are tasked with collecting and reviewing information stantial force. One particular pattern that may be seen
about each child death with a view to identifying: any on X-ray or at autopsy comprises areas of callus on the
case giving rise to the need for a review mentioned in posterior ribs, often lying in a line adjacent to the verte
Regulation 5(l)(e) of the Local Safeguarding Children brae, and giving a 'string-of-beads' appearance. This pat
Board Regulations 2006; any matters of concern affect tern is interpreted as indicating an episode or episodes of
ing the safety and welfare of children; and any wider forceful squeezing of the chest by adult hands. The pos
public health or safety concerns arising from a particu sibility that such posterior rib fractures can be caused by
lar death or from a pattern of deaths. The Government cardiopulmonary resuscitation (CPR) is thought unlikely
publishes a series of standardised forms recording data on biomechanical grounds, as such fractures occur as a
about child deaths. Figures 7.5 and 7.6 show examples. result of anterior-posterior compression during 'squeez
Form A is used for notification of a child death and Form ing' of the chest. Anterolateral rib fractures as a conse
B4 for Sudden Unexpected Death in Infancy. quence of CPR are rare. The discovery of rib fractures in
an infant who has undergone CPR without underlying
Bruising bone disease or major trauma warrants a full child pro
The features of bruises that are important can be summed tection investigation (Figure 7.11a and b).
up as site, age and pattern. Bruising of the arms and legs, A skull fracture is a marker of significant force
especially around the upper arms, forearms, wrists, applied to the head, and skull fractures are common in
Child abuse I 89
Child’s Details
Address
Postcode
Name of school/nursery
Death details:
Date of death / /
Suspected cause of
death
Case Management:
Y/ N/NK
Is there to be a Joint Agency Response?
Y/ N/ NK
Death discussed with the medical examiner?
Y/ N/NK
Death to be investigated by Coroner?
Y/ N/ NK
Post mortem examination?
Notification Details:
Please outline the circumstances leading to notification. Also include if any other
review is being undertaken (e.g. internal agency review); and whether any immediate
action is being taken as a result of this death.
The place where the child is believed to have died regardless of where death was confirmed. Where a child is
brought in dead from the community and no signs of life were recorded during the resuscitation, the place of death
should be recorded as the community location; where a child is brought in to hospital following an event in the
community and is successfully resuscitated, but resuscitation or other treatment is subsequently withdrawn, the place
of death should be recorded as the location within the hospital where this occurs
V Lead
Agency Name and contact details Professional
(only one
tick is
required)
Comm unity
Paediatrician
Local Paediatrician/
Neonatologist
Tertiary Paediatrician/
Neonatologist
O ther local or tertiary
specialists
GP
M idwife
Health Visitor
School Nurse
O bstetrician
Police - Collision
Investigation Unit or
Child Protection
Children's Social Care
Nursery/School
College/Or Local
Education Authority
Others (list all agencies
known to be involved)
Referral details
Date of referral / /
Name of referrer
Agency
Address
Tel Number
F o r m B 4 - S u d d e n u n e x p e c t e d d e a t h in in fa n c y
C D O P Id e n tifie r (U n iq u e i d e n t i f y i n g n u m b e r ) .....................................................................
Family:
This baby:
B. Circumstances of Death:
Had any signs of illness been identified in the baby in last 24 hours by the family,
carers or professionals? Y □ N □ Not Known □
Time from when the baby was last seen/heard to be alive and being found dead:
□ 10 minutes
□ 10 minutes-1 hour
□ 1-2 hours
□ 2-4 hours
□ 4-6 hours
□ Not known
Time of day found dead:
□ 24.00-06.00
□ 06.00-12.00
□ 12.00-18.00
□ 18.00-24.00
□ Not known
Immediately before being found dead or collapsed was the child thought to be:
□ Awake
□ Asleep
□ Not known
□ Car seat
□ Sofa (alone)
□ Floor
If sharing a sleep surface with another person who was that person?
□ Mother
□ Father
□ Both parents
□ Sibling
□ Other (please specify)
□ Not known
If sharing a bed/other sleeping place with another person had that person taken
the following in the past 8 hours:
Did the child have a dummy when put down for last sleep? Y □ N □ Not Known □
If sharing a sleep environment with another person was there any evidence of
overlying? Y □ N □ Not Known □
Was resuscitation attempted when the child was found? Y □ N□ Not Known □
□ 1-2 hours
□ 2-6 hours
□ 6-24 hours
□ >24 hours
□ Not known
Who attended?
Police Y □ N□ Not Known □
GP Y □ N□ Not Known □
What was the cause of death as ascribed by the local case review meeting?
1a
1b
1c
2
GP YD N□ Not Known □
Were the parents/family offered the opportunity to meet with one or more of the
professionals after the case review meeting?
GP YD N□ Not Known □
fatal cases of physical child abuse. They are not always present and basal fractures are uncommon (Figure 7.12)
associated with brain injury although up to one-third and some fractures may be caused in settings other
may be. Abusive skull fractures are more likely to be than assault, such as birth trauma (Figure 7.13).
multiple, comminuted, bilateral or cross sutures. Less Skull fractures from falls may occur from relatively
often, fractures of the occipital or frontal bones are low heights, with studies suggesting that a head-first fall
98 I Deaths and injury in infancy
Figure 7.7 Multiple 'fingertip7bruises on the front Figure 7.9 Ear bruising in an infant raises the possibility
of the trunk in an abused infant. (Reproduced with of NAI. Radiology revealed multiple rib fractures.
permission from Saukko P and Knight B. Knight's
Pathology 4E, London, CRC Press, 2016.)
Head injuries
from 0.9 m onto a concrete surface had a high likelihood Head injuries are the most frequent cause of death in
of fracture. Even a fall from that height onto a carpeted child abuse and, even when they are non-fatal, they may
surface has a significant risk of fracture. Skull fractures result in severe and permanent neurological disability.
in dead children can be caused by a fall from a height 'Shaken Baby syndrome' (SBS) has been the sub
that is below 0.9 m, from a seat, a chair or a mattress, ject of intense controversy; the diagnosis has in the
for example, but the incidence of a fracture decreases past depended on the triad of subdural haemorrhage
with decreasing height and is, therefore, dependent on (SDH), retinal haemorrhage (RT) and encephalopathy.
the nature of the impacting surface and of the fall. Falls The hypothesis correlating the triad with shaking as the
from furniture onto the floor can cause skull fractures injurious mechanism has been hotly contested, and has
in children and low-height falls can occasionally cause been extensively reviewed in pathological, clinical and
fatal head injury. legal communities. There is no doubt that infants do suf
fer abusive injury at the hands of their carers, and that
impact and shaking can cause physical effects, but it is
now generally agreed that the finding of the 'triad' alone
should not lead to an automatic assumption that it was
caused by NAI. Thus, as for all forensic cases, it is essen
tial to be aware of all the evidence and relevant factors
before coming to any opinions about the causation.
Whether from direct blows or from 'shaking', it is
clear that if sufficient force is applied to the head of a
child, brain injury can occur, and that injury carries
with it a substantial risk of disability or death. The
terms 'Abusive Head Trauma' (AHT) and 'Inflicted
Head Injury' (IHI) have gained wider appeal, and allow
the clinico-pathological and radiological findings to
Figure 7.8 Fingertip grip marks to left buttock and lower be emphasised. In summary, the diagnosis of IHI or
back of infant. It is rare for grip marks and finger marks to accidental trauma (AT) in infants is based on clinical,
show distinct patterns of four fingers and a thumb. radiological and/or ophthalmological findings such as
Child abuse I 99
• AP ch e st (to include the sh o u ld e rs) and both obliques (o bliq ues to in clu d e all ribs, left and right, 1 -1 2 )
• AP a b d o m en and pelvis
• C o n e d lateral elbow
• C o n e d lateral wrist
• C o n e d lateral elbow
• C o n e d lateral wrist
Lo w er lim b s, w h e re possible:
________ • DP foot______________________________________________________________________________________________________________________________
• Chest AP and both obliques (to include the shoulders and all ribs, left and right, 1-12).
SDH, encephalopathy, RH, and signs of impact. Each following the death of a child suspected of being
case must be considered in its own context before con abused. A recent study has described the presence
clusions are reached. of 'cherry hemorrhages' (isolated, elevated circular
bleeds, typically in the equatorial retina), and 'peri-
macular ridges' (elevated, circular retinal folds with a
Ocular injuries
canopy of internal limiting membrane [ILM]) in asso
The significance of ocular lesions - such as RH, reti- ciation with ILM tears in AHT. Survivors had optic
noschisis and orbital content haemorrhage - is a fur nerve atrophy and macular ganglion cell loss, and the
ther area of controversy in the medical and scientific study authors thought that infants under 16 months
community. All children suspected of being physically of age were particularly susceptible to damage from
abused should have their eyes examined by an oph vitreomacular traction by rotational and/or acceler-
thalmologist, and the eyes should be examined as an ation-deceleration forces. It is essential that a multi
integral component of the post mortem examination professional team review all aspects of findings in the
100 Deaths and injury in infancy
Oral injuries
Lips may be bruised or abraded by impacts or pressure to
the face and, if the child is old enough to have teeth, the
inner side of the lips may be bruised, abraded or lacerated
by contact with the tooth edges. Tooth patterned marks
may be seen. A torn frenulum (frenum) inside the lip is
an occasional finding and this may be caused by a tan
gential blow across the mouth or by an object, typically
a feeding bottle, being rammed forcibly into the mouth
between lip and gum (Figure 7.15a and b). The current
evidence indicates that a child with a torn frenum should
undergo a full child protection evaluation but, if no other
injuries nor any social concerns are identified, this find
ing alone is not diagnostic of physical abuse. The intraoral Figure 7.13 Depressed skull fracture. Not all infant skull
hard and soft tissue should be examined in all suspected fractures are non-accidental in origin; instrumentation
abuse cases, and a dental opinion sought where abnor and manual dis-impaction from the birth canal led to this
malities are found. fracture.
Child abuse 101
Figure 7.14 Retinal haemorrhages, (a) Macroscopic post mortem appearance and (b) microscopy showing widespread
haemorrhage within multiple layers of the retina, (i) Vitreous body; (ii) retinal pigment epithelium, ([b] Reproduced
from Keeling J and Busuttil A. Paediatric Forensic Medicine and Pathology. London: Hodder Arnold, 2008.)
fist or foot, and blows from the front can compress the chemicals (e.g., from acid). Some thermal injuries can
duodenum, the jejunum or the mesentery between the be accidentally sustained, but others reflect a degree
skin of the abdominal wall and lumbar spine. This com of neglect (e.g., a child pulling a saucepan full of boil
pression crushes the soft tissues and may even result in ing water from the top of a cooker or from an oven).
transection or perforation of the bowel, resulting in peri Different burns have different patterns and character
tonitis and shock (Figure 7.16b). Crushing or rupturing of istics. Cigarette burns from firm contact with the skin
the mesentery may lead to intra-abdominal bruising or are commonly depigmented, circular or oval deep
to frank intraperitoneal or retroperitoneal haemorrhage. partial thickness burns, 5-10 mm in diameter, with a
The liver is relatively large in a child and the liver pigmented rim. The differential diagnosis of such burn
edge is palpable below the costal margin. It can be rup scars includes dermatological conditions such as impe
tured by direct blows to the abdomen. Splenic injuries tigo, and vaccination scars.
are rare in physical child abuse because of its relatively Human bites are common in child abuse and can be
protected anatomical site (Figure 7.17). multiple. They must be differentiated from bites from sib
lings, other children or even domestic pets. Swabs from a
new possible bite site should be taken as soon as possible,
Other injuries as DNA of the perpetrator may be recovered. If there is
Other injuries in physical child abuse include burns doubt about whether a mark or injury does represent
and human bites. There are a range of means of caus a bite, a forensic odontologist should be asked to pro
ing burns/thermal injury including the application of vide an opinion. The forensic odontologist may be able
heated metal objects or lighted cigarettes to the skin, to compare the bite with a suspected biter's dentition,
forced immersion in hot water, and contact with some although this aspect of their practice is controversial,
Figure 7.15 (a) Torn frenum due to forced bottle feed to mouth; (b) Bruising to upper lip (with intact frenum) caused
by same mechanism, ([a] Reproduced from Keeling J and Busuttil A. Paediatric Forensic Medicine and Pathology.
London: Hodder Arnold, 2008.)
Deaths and injury in infancy
Urinary
bladder
Urethra
Anterior abdominal
wall
Intestine
and has suffered from severe criticism in the USA, where Child sexual abuse
conclusive matches have been shown to be erroneous, Despite increased awareness of the nature and extent of
leading to several high-profile exonerations. sexual abuse in children it remains a worldwide prob
Accidental injury in children occurs far more often lem. Data as to its extent is difficult to interpret as it is
than acts of child physical abuse. However, it can be likely that there is increased reporting. In the UK it is
extremely difficult to distinguish between them. All believed that up to 1 in 20 may have experienced some
healthcare professionals who work with or assess children form of sexual abuse as a child according to current defi
must always bear in mind the possibility of child abuse. nitions (Box 7.2).
Complaints of non-recent and current abuse con GroRe Ostendorf AL, Rothschild MA, Muller AM, Banaschak S. Is the
tinue to emerge at individual and institutional level. lung floating test a valuable tool or obsolete? A prospective
It is essential that the assessment, diagnosis and autopsy study. Int J Legal Med 2013;127(2):447-451.
management of child sexual abuse is undertaken with Hajiaghamemar M, Lan IS, Christian CW, et al. Infant skull
fracture risk for low height falls. Int J Legal Med 2019;
a multidisciplinary approach involving healthcare pro
133(3):847-862.
fessionals, families, social care agencies and where rel
Haynes RL. Biomarkers of Sudden Infant Death Syndrome (SIDS)
evant, law enforcement agencies. risk and SIDS death. In: Duncan JR, Byard RW (eds). Sudden
Infant and Early Childhood Death: The Past, the Present and the
Bibliography and information Future. Adelaide: University of Adelaide Press; 2018.
Infant Life (Preservation) Act 1929 C.34. http://www.legislation.
sources gov.uk/ukpga/Geo5/19-20/34 (Accessed 8 April 2019).
A Local Authority v S [2009] EWHC 2115 (Fam). http://www.fami- Infanticide Act 1938 C.36. http://www.legislation.gov.uk/ukpga/
Iylawweek.co.uk/site.aspx?i=ed53850 (Accessed 8 April 2019). Geo6/1-2/36/section/1 (Accessed 8 April 2019).
Ballard JL, Khoury JC, Wedig K, et al. New Ballard Score, Kellogg ND. American Academy of Pediatrics Committee on
expanded to include extremely premature infants. J Pediatr Child Abuse and Neglect. Evaluation of suspected child
1991;119(3):417-423. physical abuse. Pediatrics 2007;119:1232-1241.
Barbet JP, Houette A, Barres D, Durigon M. Histological assess Kemp AM, Butler A, Morris S, et al. Which radiological investiga
ment of gestational age in human embryos and fetuses. Am tions should be performed to identify fractures in suspected
J Forensic Med and Pathol 1988;9:40-44. child abuse? Clin Radiol 2006;61:723-736.
Births and Deaths Registration Act 1953 c.20. http://www.legislation. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal frac
gov.uk/ukpga/Eliz2/1-2/20/contents (Accessed 8 April 2019). tures in child abuse: systematic review. Br Med J 2008;337
Bilo RAC, Robben SGF, van Rijn RR. Forensic Aspects of Paediatric :a1518.
Fractures: Differentiating Accidental Trauma from Child Abuse. Kempe CH. Paediatric implications of the battered baby syn
Berlin: Springer-Verlag; 2010. drome. Arch Dis Child 1971;46(245):28-37.
Breazzano MP, Unkrich KH, Barker-Griffith AE. Clinicopathologi- Kempe CH, Silverman FN, Steele BF, et al. The battered-child syn
cal findings in abusive head trauma: analysis of 110 infant drome. JAMA 1962;181:17-24.
autopsy eyes. Am J Ophthalmol 2014;158(6):1146-1154.e2. Kroll ME, Quigley MA, Kurinczuk JJ, et al. Ethnic variation in
Busuttil A, Keeling JW. Paediatric Forensic Medicine and Pathology. unexplained deaths in infancy, including sudden infant
London: Hodder Arnold; 2009. death syndrome (SIDS), England and Wales 2006-2012:
Caffey J. Multiple fractures in the long bones of infants suf national birth cohort study using routine data. J Epidemiol
fering from chronic subdural hematoma. Am J Roentgenol Community Health 2018;72(10):911-918. pii: jech-2018-210453.
1946;56:163-173. Lee AC, Panchal P, Folger L, Whelan H, Whelan R, Rosner B,
Choudhary AK, et al. Consensus statement on abusive head Blencowe H, Lawn JE. Diagnostic Accuracy of Neonatal
trama in infants and young children. Pediatr Radiol 2018;48(8): Assessment for Gestational Age Determination: A Systematic
1048-1065. Review. Pediatrics 2017 Dec;140(6). pii: e20171423. doi: 10.1542/
D'Arcy TJ, Hughes SW, Chiu WS, et al. Estimation of fetal lung peds.2017-1423. [Epub 2017 Nov 17.]
volume using enhanced 3-dimensional ultrasound: a new Maguire S, Hunter B, Hunter L, et al. Diagnosing abuse: a system
method and first result. Br J Obstet Gynaecol 1996,103(10): atic review of torn frenum and other intra-oral injuries. /\rcA?
1015-1020. Dis Child 2007;92:1113-1117.
Domestic Violence, Crime and Victims Act 2004 C.28. http:// Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of
www.legislation.gov.uk/ukpga/2004/28/contents (Accessed bruising in childhood which are diagnostic or suggestive of
8 April 2019). abuse? A systematic review. Arch Dis Child 2005;90:182-186.
Elinder G, Eriksson A, Hallberg B, etal.Traumatic shaking: The role Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises
of the triad in medical investigations of suspected traumatic accurately in children? A systematic review. Arch Dis Child
shaking. /Acfa Paec//afr 2018;107(Suppl 472):3-23. 2005;90:187-189.
Faller-Marquardt M, Poliak S, Schmidt U. Cigarette burns in foren Maguire S, Mann M, John N, et al. Does cardiopulmonary resus
sic medicine. Forensic Sci Int 2008;176:200-208. citation cause rib fractures in children? A systematic review.
Fleming PJ, Blair PS, Pease A. Sudden unexpected death in Child Abuse Negl 2006;30:739-751.
infancy: aetiology, pathophysiology, epidemiology and pre Maguire S, Pickerd N, Farewell D, et al. Which clinical features dis
vention in 2015. Arch Dis Child 2015;100(10):984-988. tinguish inflicted from non-inflicted brain injury? A system
Franke I, Pingen A, Schiffmann H, et al. Cardiopulmonary resus atic review. Arch Dis Child 2009;94:860-867.
citation (CPR)-related posterior rib fractures in neonates and Malcolm AJ. Examination of fractures at autopsy. In: Rutty GN
infants following recommended changes in CPR techniques. (ed). Essentials of Autopsy Practice: New Advances, Trends and
Child Abuse Negl 2014;38(7):1267-1274. Developments. London: Springer-Verlag; 2008,23-44.
Goudge ST. Inquiry into paediatric forensic pathology in Ontario Meservey CJ, Towbin R, McLaurin RL, et al. Radiographic char
Report 2008. www.attorneygeneral.jus.gov.on.ca/inquiries/ acteristics of skull fractures resulting from child abuse. Am J
goudge/policy_research/pdf/Limits_and_Controversies- Roentgenol 1987;149:173-175.
CORDNER.pdf (Accessed 8 April 2019). Nguyen A, Hart R. Imaging of non-accidental injury: what is clini
Gray B, Tester DJ, Wong LC, et al. Noncardiac genetic predis cal best practice? J Med Radiat Sci 2018;65(2):123-130.
position in sudden infant death syndrome. Genet Med Office for National Statistics. Characteristics of birth 1, England
2019;21 (3):641 -649. and Wales, 2013. http://webarchive.nationalarchives.gov.
104 I D eaths and injury in infancy
Sexual offences:
Terminology of injury
Words to describe injury or harm are used non-spe- • Penetrative
cifically by lay persons and non-forensic healthcare • Non-penetrative (both with or without extra-gen
professionals. In a legal setting, the use of a particular ital injury)
word may have a specific meaning that can influence
the nature of the charge and the penalties or sentence Injury and the law
related to an offence. In England & Wales, murder and manslaughter are two
One frequent error in English-speaking jurisdictions of the offences that constitute homicide. Manslaughter
is the use of the word 'laceration' in the context of a cut can be committed in one of three ways:
to the skin. In the forensic setting, as discussed below,
a laceration is a split or tear in the skin caused by blunt 1. Killing with the intent for murder but where a
impact. If the word laceration is used wrongly in court partial defence applies, namely loss of control,
or in written evidence to describe a cut caused by a knife diminished responsibility or killing pursuant to
(an incised wound) this may have implications with a suicide pact.
regard to the credibility of the witness. 2. Conduct that was grossly negligent given the risk
Each jurisdiction will have its own specific legal of death, and did kill, is manslaughter ('gross
classification of injury or wounding, and again the use negligence manslaughter').
of such terms may have its own particular relevance. 3. Conduct taking the form of an unlawful act
Forensic practitioners must be familiar with such clas involving a danger of some harm, that resulted
sifications in their own jurisdiction (and others if they in death, is manslaughter ('unlawful and danger
also practise elsewhere) in order to assist the courts in ous act manslaughter').
106 Assessment classification and documentation of injury
The term 'involuntary manslaughter' is commonly maximum prison sentence of 5 years. The key element
used to describe a manslaughter falling within (2) and of this offence is the causing of grievous bodily harm or
(3) while (1) is referred to as Voluntary manslaughter'. wounding but without having had the intent to do so.
The crime of murder is committed, where a person: of
sound mind and discretion (i.e., sane); unlawfully kills Section 47
(i.e., not self-defence or other justified killing); any rea This section of the Act creates the offence of assault
sonable creature (human being); in being (born alive occasioning actual bodily harm. It encompasses those
and breathing through its own lungs - R anee v Mid- assaults that result in substantial injuries, typically
Downs Health Authority (1991) 1 All ER 801 and AG Ref requiring a degree of medical treatment for the victim
No 3 o f 1994 (1997) 3 All ER 936; under the Queen's Peace; and provides the penalty to which a person is liable on
with intent to kill or cause grievous bodily harm (GBH). conviction of that offence on indictment. A periorbital
In the England & Wales jurisdiction a 'wound' (used haematoma with a superficial laceration after a punch,
in the colloquial setting interchangeably with 'injury') or a broken tooth, are the types of injury that could be
has a specific legal meaning: a wound is an injury that considered a Section 47 assault.
breaks the continuity of the skin. There must be a divi
sion of the whole skin structure and not merely a division
of the cuticle or upper layer. A bruise (or subcutaneous Non-fatal violence-related injury in
rupture of blood vessels) is not a wound as the skin is not
England and Wales
broken. A broken bone is not (legally) a wound, unless it
is a comminuted fracture. A variety of sources is available for information on non-
The Offences Against the Person Act 1861 which has fatal (and fatal) violence-related injury. The Violence
been amended over the years, sets out a range of offences and Society Research Group based at Cardiff University
for which an individual, in England & Wales, can be in Wales reports on Emergency Department atten
prosecuted when that individual is alleged to have dances for violence-related injuries each year via the
caused injury to another person. This statute excludes National Violence Surveillance Network. These data
homicide and sexual offences (which are covered by the are available online and are continuously updated, as
Sexual Offences Act 2003). are the Office for National Statistics data for crime in
The language used in a law whose origins go back England & Wales which include data for all types of
almost one and half centuries can sometimes be difficult violent crime. Figures published in 2018 showed a rise
to understand. The main offences relevant to injury assess in the number of offences (n = 40,147) involving knives
ment by forensic practitioners are found in the follow or sharp instruments (a 16% increase compared with
ing sections of the Offences Against the Person Act 1861. 2017) and provisional NHS data showed admissions for
assaults involving a sharp instrument increasing by 14
Section 18 per cent for England. There had been a rise of 2 per cent
in recorded offences involving firearms (n = 6492). The
Section 18 of the Offences Against the Person Act 1861 number of homicides recorded by the police showed a
created the offences of wounding and causing grievous fourth consecutive rise, increasing by 12 per cent com
bodily harm, with intent to cause grievous bodily harm, pared with 2017 after a long-term decline (n = 736).
or to resist arrest. It is punishable with life imprison
ment. The specific wording of the offence is: How does the body respond to injury?
W hosoever shall unlawfully and maliciously by When an injury is sustained, tissue damage is accompa
any means whatsoever wound or cause any griev
nied by a disturbance of cellular function, and the host
ous bodily harm to any person ... with in te n t... to do
inflammatory response is initiated, resulting in cascade
s o m e ... grievous bodily harm to any person, or with
intent to resist or prevent the lawful apprehension or
of tightly regulated physiological and behavioural pro
detainer of any person, shall be guilty of felony, and cesses which have evolved to rapidly destroy or isolate
being convicted thereof shall be liable ... to be kept in the cause of the disturbance, remove damaged or dead
penal servitude for life .... tissue, and restore normal function.
Damaged or dead cells express molecules
The key element of this offence is the intent to cause
(Damage-Associated Molecular Patterns (DAMPs),
grievous bodily harm. Types of injury would include
and 'Alarmins') that are recognised by cells of the immune
stabbings or shootings, but may also include trying to
system - principally neutrophils and monocytes/macro
poison or infect a person.
phages - which produce chemicals (cytokines and che-
mokines) which recruit more immune cells to the injured
Section 20
area, and thereby create a cytotoxic environment which
This section creates the offences of wounding and aims to kill invading pathogens. However, this process
inflicting grievous bodily harm. They are less serious also causes further cellular/tissue damage. The blood
than the offences created by Section 18 and carry a clotting system is also activated to stop bleeding at the site
Non-fatal violence-related injury in England and Wales 107
of injury, and vascular alterations take place to facilitate • The n atu re an d severity o f the injury(s) (the
the delivery of immune cells to the injury location. 'trauma load'): some injuries (such as decapita
The outcome of the host response to trauma depends tion) are obviously incompatible with life, and
on the nature and the severity of the injurious insult, severe injury to vital organs such as the brain and
the presence of pathogens and the extent of the body's heart can be rapidly (but not invariably) fatal.
physiological response(s). An efficient and effective • The m echanism o f injury: the nature of the transfer
coordinated localised response leads to resolution of the of energy to a vital organ can influence survivabil
inflammatory environment, healing/repair of damaged ity (a low-energy penetration by a knife might be
tissue, and restoration of normal function. survivable, for example, if emergency medical and
These processes assist in the microscopic 'ageing' surgical care is provided rapidly, whilst a higher
of injuries which is reliant on the recognition of, and energy gunshot wound to the same organ might
subjective assessment of, the nature and extent of the lead to a rapid death).
inflammatory response to trauma, and of the healing • The rapidity with which emergency m edical care is
processes that may have followed. provided, an d the availability o f m odern trauma
Severe (or multiple) insults, lead to an exaggerated, care/intensive care facilities: if the injury is sus
systemic (throughout the body) inflammatory response, tained in a rural location - poorly served by pre
which can set the scene for major organ dysfunction, hospital personnel - or the injurious event is
organ failure and death. unwitnessed, potentially survivable injuries can
Modern pre-hospital trauma care, advanced trauma become fatal.
life support-based resuscitation, and 'damage-control • The age an d health status o f the injured person:
surgery' aim to minimise the adverse physiological con increasing age influences the survivability of
sequences of trauma, and sustain life for long enough individuals sustaining multiple rib fractures fol
to enable that injured person to receive artificial organ lowing blunt force chest impact in a road traffic
support in an intensive care unit and definitive surgi collision, for example, and pre-existing cardiac or
cal repair. Trauma management has traditionally been respiratory disease tends to reduce the ability of
aimed at preventing the so-called 'triad of death': meta the body to maintain vital functions in the face of
bolic acidosis, hypothermia and coagulopathy (abnor a traumatic insult.
mal blood clotting), thought to be caused by a complex • The body's physiological respon se to injury:
interaction between the physiological responses to medical/surgical intervention, and infection/
trauma and haemorrhage, environmental factors, and sepsis.
resuscitation/surgical interventions.
The following factors may all influence whether the The significance of physiological complexity and the
trauma sustained is likely to have a fatal outcome: host response to injury is considered in Box 8.1.
Figure 8.2 (a) Visible swelling to the right side of face and eyelids after repeated punches, (b) Periorbital haematoma
(black eye) caused by direct impact from fist, (c) Diagrammatic representation of potential bleeding and tracking sites
after direct impact to nose or orbital region (1) around globe, (2) beneath skin and scalp anatomical planes, (3) intra
cranial. Each can result in visible bruising if tracked via tissue planes or via bone fractures.
Types of injury 109
Bruises
Figure 8.3 (a) Bruising (contusion) to thigh (a) following Bruises are discolouration of the skin surface caused
direct blunt force (fall between iron girders); (b) shows by leakage of blood from damaged blood vessels, often
resolution of bruising 5 days after injury as seen in 8.3a; small-diameter vessels such as venules or arterioles,
(c) bruising to scrotum and penis after direct kicks with into underlying tissues. The degree, nature and colour
shod foot. (Courtesy of Jason Payne-James.) of the bruise is, in part, related to the colour of the over-
lying skin. Bruising is most commonly seen in the skin,
but it can also occur in the deeper tissues, including
110 Assessment, classification and documentation of injury
it)
Compression may produce petechiae at the level of, Figure 8.9 Extensive bruising following tissue planes and
or above, the compressing force (e.g., in ligature stran contours, one week after multiple blunt force impacts
gulation, or by crushing/chest compression in a crowd). to (a) head and (b) face (neck was spared impacts).
Bruises evolve and can 'migrate'. The effects of grav (Courtesy of Jason Payne-James.)
ity and anatomical tissue planes are two of the factors
that may determine how the position of a bruise might during a stamp or a kick (Figure 8.10a-c). The depth
change (Figure 8.9). Thus, the presence of a bruise in one of such bruises can only be confirmed at post mortem
place does not always imply that the blunt impact was examination.
applied at that particular site. Some superficial bruises Certain types of blunt injury commonly cause evi
(often called intradermal bruises), caused by leak dentially useful patterns. Single patterned bruises may
age of blood confined to the epidermis and the upper indicate the nature of the impacting object. 'Tramline'
strata of the dermis, can remain in the position in which (or 'tram-track' or 'railtrack') bruises (Figure 8.11) are
the impact occurred, and 'patterned' bruises, which those caused by impacts from longitudinal, generally
reproduce the nature of the object that caused them, cylindrical or rod-like, objects (where blood is forced
often have such an 'intradermal' element. Intradermal laterally from the point of impact, rupturing blood ves
bruises are often associated with diffuse compression sels either side of the impacting object) and shoeprint
forces such as pressure from a car tyre or from a shoe bruises may be seen from stamp injuries (Figure 8.12).
112 Assessment classification and documentation of injury
Tramline bruises
Compression
______________________________________ /
Figure 8.11 (a) Tramline bruise caused by impact from cylindrical firm object (in this case, a police baton), (b) Tramline
bruise to right hip region caused by impact from broom handle, (c) Creation of parallel bruises with central sparing by
impact from cylindrical object - 'tramline', 'tramtrack' or 'railtrack' bruises, ([a & b] Courtesy of Jason Payne-James.)
interpreting 'new' bruises when a post mortem exami scuff (brush) abrasions (very superficial abrasions, with
nation has been performed. no bleeding, Figure 8.17) and point or gouge abrasions
(deeper linear abrasions caused by objects such as metal
Abrasions nails, often with bleeding; Figure 8.18).
An abrasion (or graze) is a superficial injury involving As the epidermis does not contain blood vessels,
(generally) outer layers of skin without penetration of superficial abrasions might not bleed, but the folded
the full thickness of the epidermis. They are caused nature of the junction between the dermis and the epi
when there is contact between a rough surface and dermis, and the presence of loops of blood vessels in the
the skin, often involving a tangential 'shearing' force dermal folds, will mean that deep abrasions have a typi
(Figure 8.14). They can also be caused by crushing of the cal punctate or spotty appearance. Deeper abrasions
skin when the force is applied vertically down onto the may therefore bleed, resulting in subsequent scabbing
skin. Bites and the grooved, often parchmented, abra and possible scarring.
sion found in hanging, can cause typical 'crush' abra The size, shape and type of abrasion depends upon
sions (Figure 8.15). the nature of the surface of the object which contacts the
The appearance of abrasions always represents the skin, its shape and the angle at which contact is made.
exact contact area (unlike bruises) and the nature of the Contact with the squared corner of an object (e.g., a
abrasion itself may assist in determining the direction of brick) could result in a linear abrasion, whereas contact
the contact from the blunt, abrasive object, or the direc with one face of the same object will cause a larger area
tion of the body when making contact. A variety of abra of'brush' abrasion.
sions have been described including scratches (linear Contact with a rough surface, such as a road, espe
abrasions, e.g., caused by fingernails; Figure 8.16a-c), cially when associated with the higher levels of force
Assessment, classification and documentation of injury
Figure 8.16 (a) Multiple fingernail scratches with wheal reaction and superficial abrasions, (b) Deeper abrasions
caused by fingernails, (c) Large abrasions caused when climbing over brick wall whilst being pursued by police dog.
([a & b] Courtesy of Jason Payne-James.)
Lacerations
A laceration is a 'split or tear' in the skin caused by blunt
force compressing or stretching the skin, or applying
a shear force to it. Lacerations often extend through
the full thickness of the skin and, depending on the
anatomical site, can bleed profusely (e.g., the scalp).
Because the skin is composed of many different tis
sue types, some of the more resilient tissues will not
be damaged by the forces that split the weaker tissues.
This is what enables a distinction to be made between
Figure 8.19 Deep and extensive abrasion ('gravel rash') an open wound apparently made by a blunt object and
caused by contact with road surface after motorcycle one made by a sharp object. Those most resilient tis
accident. sues are often nerves, fibrous bands of fascial planes
and, sometimes, at the base of the laceration, an occa
that include colour standards are also available (e.g., sional medium-sized elastic blood vessel. These struc
Forensigraph®). tures are seen to extend across the defect in the skin
Scaled photographs of injuries are also essential and are often referred to as 'bridging fibres'. The same
to allow subsequent comparison to be made between blunt force causing such a laceration may also cause
those injuries and scaled photographs of 'suspected irregular splits, bruising and abrasion at the margins
injury causing implements or surfaces'. Many differ of the wound (Figure 8.21). These features are generally
ent injury causing objects have been identified in this absent in sharp force injuries.
way, such as car radiator grills, the tread of escalator Lacerations are most common where the skin can
steps, plaited whips (see Box 8.2) and the lines from be compressed between the applied force and underly
floor tiles. ing bone (e.g., over the scalp, face, elbows, knees, and
Figure 8.20 (a) Directional scuff - note raised skin layers on left side of abrasion: yellow arrow indicates direction
of abrasive movement; red arrow indicates line of terminal epidermal tags, (b) Direction of tangential force can be
determined by position of raised epidermal skin layers, ([a] Courtesy of Jason Payne-James.)
Types of injury 117
Box 8.2 Patterned injuries and the forensic pathologist - R v V Neville Heath 1946
The body of Marjorie Gardiner was discovered in bed for grouping, was found on the whip. When the pathol
in a hotel in London, England, in June 1946. Her ankles ogist, Keith Simpson, examined that whip, he thought
were bound by a handkerchief and her left arm lay that the pattern of the weave 'corresponded in fine
diagonally under her back to lie close to the right wrist, detail' with the marks on the body, saying 'it is identical,
and the wrists appeared to have been tied, although no in my view, and the mark of the tip corresponds with
restraint was present. Heavy bloodstaining was pres the projecting metallic tip'.
ent at the scene and, on releasing the ankle bindings, a Heath was charged with murder (and that of a simi
large amount of blood issued from her vagina. lar murder in Bournemouth), and found guilty. He was
At autopsy, blunt force injuries were present on executed in October 1946.
the face and lower jaw, and there were 17 patterned Comparisons and overlays of scaled photographs of
injuries to the trunk and breasts which appeared as the patterned injuries with scaled photographs of the
stippled intradermal bruises with abrasion, having implement would be made in modern investigations,
parallel linear components and diamond-shaped in order to see whether the whip could be excluded
intervening components, and a rounded 'end'; they as having caused the patterned injury, and the whip
had the appearance of having been caused by a flex would also be examined by forensic scientists for fin
ible cane or whip, having a patterned surface. There gerprints and DNA (of the assailant and victim) in order
were bite marks to the breasts, and the vagina was to allow the jury to decide whether or not the whip has
lacerated. caused the injuries, and who had wielded it. The bite
A search of Heath's belongings revealed a leather marks would have been examined and compared with
riding whip with a hard tip; human blood, insufficient Neville Heath's own dentition.
Skin
■Bone
Figure 8.21 (a) Laceration to ear following impact with baseball bat - note irregularity of laceration and associated
swelling bruising masked by dry blood, (b) Mechanism of causation of laceration. (Courtesy of Jason Payne-James.)
118 Assessment, classification and documentation of injury
shins). They are very rare (unless severe force has been
applied) over the soft, fleshy areas of the body such as
the buttocks, breasts and abdomen.
The margins of a laceration are usually ragged; how
ever, if a thin, regular, object inflicts an injury over a
bony area of the body, the wound caused may look very
sharply defined and can be mistaken for an incised
injury. Careful inspection of the margins will reveal
some crushing or tearing and bruising, and examina
tion of the inner surfaces of the wound will reveal the
presence of bridging fibres.
The shape of the laceration (e.g., linear, curvilinear
or stellate) rarely reflects the nature of the impacting
object (unless accompanied by other patterned blunt
force injury).
When significant tangential blunt force is applied to
the skin, for example owing to the rolling or grinding
action of a vehicle wheel, the laceration may be hori
zontal and result in a large area of separation of skin
from the underlying tissues (often called 'flaying' or
'degloving').
Incised, slash and stab wounds surface. A surgical operation wound is an example of an
Incised wounds are caused by objects with a sharp or incised wound. There is an artificial distinction between
cutting edge, often a knife but other examples include a stab and slash wound in forensic terms.
shards of glass, broken glass and bottles, the edges of A stab wound is (like a slash wound) caused by a sharp
pieces of broken pottery or ceramics, or the edge of a implement and is generally said to have penetrated the
broken tin can (Figure 8.23). The edges of the wound will body deeper than its length on the skin surface. A stab
give some indication as to the sharpness of the weapon wound can, however, be quite shallow if its progress
causing it. A sharp-edged object/implement will leave into the body is impeded, for example by the presence
no bruising or abrasion of the wound margins. Careful of bone or cartilage, in which case its depth may not
inspection of the depths of the wound will reveal that exceed its length on the skin surface. Classifying such
no bridging fibres are present because the cutting edge a wound as a stab is relatively straightforward in the
divides everything in its passage through the skin and deceased, but in the living (1) the depth of the wound
underlying tissues. may not be accessible and (2) if it has been recorded at
Incised wounds, by their nature, are only life-threat all, the measurement of the skin surface wound may be
ening if they penetrate deeply enough to damage a blood inaccurate.
vessel of significant size. Thus, incised wounds over the Forensic pathologists may also have the advan
wrist or neck, where major arteries lie in more superfi tage of being able to determine the direction of such
cial tissues, can prove fatal. An incised wound caused wounds. The direction or depth of a wound in the liv
by an object sweeping or moving across the skin surface ing may not be clear (or indeed recorded at all) when
is sometimes referred to as a 'slash' wound or a 'slice' interpreting medical or operative notes in survivors of
wound (Figure 8.24). In contrast, a stab wound is caused stab injuries. This lack of detail may be aggravated by
by a motion down through (rather than across) the skin the move from open to laparoscopic surgery. However,
Types of injury I 119
Figure 8.23 (a) Sutured incised wound across right side of head and face, (b) Incised wound to neck caused by use of
knife, (c) Irregular incised wounds after broken bottle slashed twice across back of head and neck, (d) Glass broken on
impact near upper left nose. Sutured. Multiple satellite superficial shard cuts. (Courtesy of Jason Payne-James.)
imaging techniques (CT, US and MRI) may all provide • The geometry of the knife, including the radius of
detailed wound track length information, and if such the blunt edge at the tip.
information is not recorded in the clinical notes, it • The sharpness of the 'cutting edge' of the imple
may be determinable by further review of the imaging. ment.
The depth of the injury and its direction are of great • The nature of the force applied: stabbing incidents
importance when considering different accounts of are usually dynamic, involving complex relative
causation of stab wounds and so the more information movements between victim and assailant.
recorded at the time of treatment, the more helpful it • W hether clothing has been penetrated: some
can be to the justice system. items of clothing, such as thick leather jackets,
Any weapon with a point or tip can cause a stab may offer significant resistance to penetration.
wound; the edge of the blade does not need to be • Whether bone has been injured: skin offers little
sharp. For example, a ballpoint pen or a screwdriver resistance to penetration by a sharp knife, but
can cause stab injuries. Stab-like wounds may also injury to bone tends to suggest that a greater
be caused by other (relatively) blunt objects such as force has been used to in flict the wound.
car keys. For penetration of the skin to occur, a vari Significant penetration of bone may also dam
ety of factors determine how much force is required, age the knife.
including:
Once a knife or other sharp implement has pen
• The sharpness of the tip of the weapon: this is often etrated the skin, subcutaneous tissues (except bone)
the most important factor and the sharper the tip, offer little further resistance to deeper penetration and,
the easier it is to penetrate the body. to an assailant, it may appear that the rest of the weapon
120 Assessment, classification and documentation of injury
Box 8.3 Examples of features to consider which can influence the appearance o f a
possible stab wound
A slit-like wound will distort, after removal of the Provided that clothing has not intervened, skin
weapon, because of the action of elastic fibres present adjacent to the stab wound may be bruised and/
in the skin. If the fibres are orientated at right angles to or abraded as a consequence of forcible contact
the skin surface wound, it will be pulled outwards and between the skin and, for example, the hilt/blade
get shorter and wider; if they run parallel to the skin sur guard of a knife, or the 'knife-wielding' hand of the
face wound, it will be pulled lengthways and the edges assailant.
will tend to close and the wound elongate slightly. The depth of a wound within the body may be
Even if the edges of the wound are gently pushed greater than the length of the blade if a forceful stab is
together, the resulting defect is rarely the exact size as inflicted. This is because the abdomen and, to a lesser
the knife. extent, the chest, and other soft tissues can be com
The dimensions of the wound on the skin surface pressed by the force of the knife hilt or knife-wielding
and depth of the wound also depend on the shape/con hand against the skin.
figuration of the blade and how deeply it was inserted. A blunt object such as a screwdriver or 'spike' will
Movement of the knife in the wound, as a conse tend to indent, split and bruise the skin on penetra
quence of relative movement between the assailant tion. Different types of screwdriver can cause different
and victim, may cause the wound to be enlarged. If the patterns of injury, for example 'cross-head' or 'Phillips'
knife is twisted or rotated within the body, an irregu- screwdrivers can cause very distinctive cruciate skin
larly-shaped, or even triangular, skin surface wound surface wounds.
may be result. Unusually shaped stab wounds may be caused by
Many knives have only one cutting edge; the other implements less commonly encountered in stabbing
being blunt. This design may be reproduced in the assaults; scissors, for example, may cause a 'Z-shaped'
wound where one wound apex is sharp or 'V'-shaped, skin surface injury, while chisels may cause rectangular
while the other is blunt, or rounded. The blunt wound shaped stab wounds. When such injuries are encoun
apex may 'split' at each side, an appearance commonly tered, it is important to consider unusual causative
referred to as a 'fishtail'. implements.
reflect the pattern of the sole of the shoe which may lead
to identification of the assailant.
Bite injuries
A bite mark can be described as a mark caused by
teeth alone, or by teeth in combination with other
mouth parts. Biting is a dynamic process and bite
marks can be complex injuries. Bites can be human
or animal.
Bite damage can be caused by a mixture of cutting -
predominantly from the incisor teeth - and tearing
when teeth clamp down on skin and other tissue.
The appearance of bite marks made by human teeth/
mouths can vary significantly from there being little
to no visible injury, to reddening, swelling, bruising,
abrasions/cuts and substantial skin and tissue loss.
In some cases, the pattern of individual teeth marks
is very clear as these leave an imprint or impression
at the site of injury.
Bite marks may be seen in all crimes of violence
including sexual assaults, child and elder abuse, and
also on the sports field.
Bite marks may be found on almost any surface of
the body; specific sites are associated with specific
forms of assault (Figure 8.28a-c). The neck, breasts and
shoulders are often bitten in a sexually motivated attack,
while in child abuse bites to the arms and the buttocks
are common.
A forensic odontologist should review any possible
bite marks when confirmation of identity of the biter is
required. There have, however, been many judicial con
cerns about the practice of bite mark-suspect dentition
comparisons by forensic odontologists, and even the
ability of forensic practitioners to reliably recognise that
an injury is, in fact, a human bite mark.
Despite these concerns, it is essential that forensic
practitioners, and all healthcare professionals caring for
the vulnerable, consider whether the injury that they are
examining could be a bite mark so that the injured area
can be swabbed for DNA recovery, and so that it may be
photographed with a scale by a trained forensic photog
rapher.
Defence injuries
In situations of assault and attack it is a normal reflex to
protect oneself. In many instances, that reflex inevita
bly results in the individual being assaulted sustaining
injury, albeit whilst potentially reducing the extent of
injury that might otherwise have been sustained.
When a knife or a stabbing implement is directed at Figure 8.28 (a) Human bite with tissue loss to the right
an individual, the head and face may be protected by ear. (b) Bite mark with bruising, skin lifts and teeth
raising the hands and arms to cover the head and face. marks to chest, (c) Bite causing tissue loss to chin - no
The hand may attempt to grab or deflect a weapon. The identifiable teeth marks are evident.
arms and hands sustain injuries but the head, face and (Courtesy of Jason Payne-James.)
Survival after injury 123
Torture
Article 3 of the European Convention on Human Rights
states that no-one shall be subjected to torture or to
Figure 8.31 (a) Multiple linear burn marks (caused by inhumane or degrading treatment or punishment.
heated knife blade applied to the skin) - note healed Unfortunately, such treatment and punishment is still
lesions between acute lesions, (b) Multiple incised widely found throughout the world.
wounds to forearm caused by a male with a psychotic The International Committee of the Red Cross uses
episode harming himself with a knife blade. definitions for torture and other forms of ill-treatment
(Courtesy of Jason Payne-James.) which are: torture consists of severe pain or suffering,
whether physical or mental, inflicted for such purposes
as obtaining information or a confession, exerting pres
sure, intimidation or humiliation; cruel or inhumane
(synonymous terms) treatment consists of acts which
cause serious pain or suffering, whether physical or
mental, or which constitute a serious outrage upon indi
vidual dignity. Unlike torture, these acts do not need to
be committed for a specific purpose; and humiliating
or degrading (synonymous terms) treatment consists of
acts which cause real and serious humiliation or a seri
ous outrage upon human dignity, and whose intensity is
such that any reasonable person would feel outraged; ill-
treatment is not a legal term, but it covers all the above-
mentioned acts.
Forensic physicians and pathologists may be asked
to assess individuals claiming torture or other forms
of ill-treatment and human rights abuse. Such assess
ments can be complex and it may be necessary to assess
and interpret physical findings for which there may be
a number of explanations. The doctor's role is to assess
these findings impartially. In order to make an assess
Figure 8.32 Multiple new incised wounds with smaller ment for physical evidence of torture a structured exam
and more superficial tentative injuries (arrowed). ination must take place, which involves the history, the
(Courtesy of Jason Payne-James.) medical history and then the physical examination.
126 Assessment, classification and documentation of injury
Table 8.1 Some characteristics that may be associated with self-inflicted injury
The physical examination must involve systematic • Beating of the soles of the feet (falanga, falaka or
examination of the skin, face, chest and abdomen, mus bastinado; Figure 8.33).
culoskeletal system, genitourinary system and the central • Amputation (Figure 8.34).
and peripheral nervous systems. Specific examination • Positional torture - e.g., cheera (legs stretched
and evaluation are required following specific forms of apart) or Parrot's Perch (wrists tied over knees -
torture which include: beatings and other blunt trauma; a pole placed under the knees).
beatings of the feet; suspension; other positional torture; • Suspension - e.g., Palestinian hanging (arms and
electric shock torture; dental torture; asphyxiation; and wrists tied and elevated behind the back; Figure
sexual torture, including rape. Specialised diagnostic 8.35), which can result in disruption of shoulder
tests can be used to assess damage (e.g., radiological joint complexes and subsequent deformity.
imaging, nerve conduction studies). • Electrical burns (Figure 8.36).
The history taking should include direct quotes • Wet submarino - immersing the victim's head in
from the victim, establishment of a chronology, where a container full of water until the person almost
possible backing it up, for example, with old medical drowns.
records and photos. A summary of detention settings • Dry submarino - placing the victim's head inside
and abuses, must be obtained with details of the condi a plastic bag until nearly suffocated.
tions within those settings and methods of torture and
ill-treatment. Attention must also be paid to, and may Each of these may have short- and long-term sequelae.
require specialist assessment of, the psychological sta It is extremely important to recognise that there
tus of the victim. Specific torture techniques that may may be no physical evidence of torture. Where scars or
be described include: marks are present it is important, for the credibility of
Documentation of injury or marks of injury 127
Forensic pathologists may be dependent on avail (e.g., ForensiDoc®). Such documentation will ensure
able information, from police, from witnesses, from that the opportunity for proper interpretation is max
medical records, from family and many other sources imised. Thus, any clinical notes should: record the
to determine what may or may not have caused fatal appropriate history; record accurately and clearly all
injury. Forensic physicians dealing with the injured findings - positive and negative; record legibly; sum
living person may be able to get a history directly from marise findings with clarity; use consistent terminol
that person, but may not have access to other materi ogy; and interpret within the limits of your experience.
als. If it is possible to take a history, then the relevance If the healthcare professional is not able to interpret
of each factor listed below should be considered: findings then this should be stated clearly in any report.
There is frequently an 'evidence gap' for those who
• When did the injury or injuries happen?
are seriously injured, and who require immediate
• Have they been treated (e.g., at hospital or at home)?
resuscitation and immediate surgery or ventilation,
• Are there any pre-existing illnesses (e.g., skin
when compared with those with relatively minor inter
disease)?
personal assaults, where the complainant can give a
• Are there any pre-existing (but unrelated) sites of
full account and injuries can be documented, and the
injury?
deceased, who will have a full post mortem examina
• Does the individual take any regular physical
tion carried out by a forensic pathologist. The need to
activity which puts them at risk of injury (e.g., at
save life and stabilise the critically injured is the prior
work, or whilst participating in contact sports)?
ity, rather than the need to document injury accurately,
• Is the person taking regular medication (e.g., anti
or to retrieve crucial evidence, and lack of forensic skills
coagulants, steroids)?
mean that often hugely important evidence (e.g., nature
• What is the handedness of the complainant and
of injury or important trace materials) is lost. There is
suspect?
a clear argument for those involved in the care of the
• Were drugs and/or alcohol used?
severely or critically injured to have access to forensic
• What weapon or weapons was/were used (if still
physicians who can (with the consent of the clinical
available)?
teams) gather evidence at the earliest opportunity.
• What clothing was worn?
Forensic pathologists must document and record
Most of this information should be easily obtainable all injuries identified at post mortem examination in
from the history and documented in the contemporane detail, sufficient to enable subsequent review of their
ous medical notes. findings, and to demonstrate the reliability of their con
The following characteristics should be recorded clusions in any legal forum.
wherever possible for each injury identified:
Forensic photography
• Location (anatomical - measure distance from
landmarks) Forensic photography is a specialised area embracing a
• Presence of pain or tenderness range of imaging techniques that allow best presentation
• Reduced mobility/altered function of visually relevant evidence in an appropriate format. The
• Nature of injury (e.g., bruise, laceration, abrasion) principles are straightforward, and ensure that interpre
• Size (measure, do not estimate. Use a ruler or a table images are retained. Photographic techniques have
scale - which could include a colour standard e.g., included the use of ultraviolet, infrared and polarised light
Forensigraph®) photography, which have been said to enhance or identify
• Shape items or injuries of interest. Data are somewhat lacking as
• Colour to the utility of these techniques which in general enhance
• Orientation or show features which may not ordinarily be visible to the
• Possible age (is it consistent with account?) naked eye. Caution should be used when reviewing such
• Causation (is it consistent with account?) images. An essential element of forensic photography is
• Handedness (of complainant and suspect) data management of images and how these are appropri
• Time (that injury was caused) ately stored, reproduced and shared. Forensic practitio
• Transientness (has it changed in appearance?) ners need to work closely with forensic photographers to
ensure that the relevance of images taken is best suited
The recording of such information in the clinical set to the requirements of the evidential and court process.
ting should ideally be in three forms: first in a written All forensic practitioners should consider undertaking
form, appropriately describing the injury; second as a training in forensic photography. Poor-quality imaging
hand-drawn body diagram; and third, ideally, to sup is now unacceptable and it is appropriate that those most
plement the first two, in digital image form. There are skilled in producing robust evidence are used to provide it
some Apps which can record all this type of information for courts and other agencies. Guidelines are available on
and data (via tablet or smartphone) which can generate best practice. Boxes 8.5 and 8.6 describe 2D and 3D pho
immediate reports summarising all such information tography of patterned injuries in more detail.
Documentation of injury or marks of injury I 129
Bibliography and information Bolliger SA, Kneubuehl BP, Thali MJ, et al. Stabbing energy and
force required for pocket-knives to pierce ribs. Forensic Sci
sources Med Pathol 2016;12(4):394-398.
Adams VI, Flomenbaum MA, Hirsch CS. Mechanisms of death. Byard RW, Gehl A, Tsokos M. Skin tension and cleavage lines
In: Spitz WU (ed). Spitz and Fisher's Medicolegal Investigation (Langer's lines) causing distortion of ante- and post mortem
of Death, 4th ed. Springfield, Illinois: Charles C Thomas; 2006. wound morphology. Int J Legal Med 2005;119:226-230.
Annaidh AN, Cassidy M, Curtis M, et al. A combined experimental Chadwick EK, Nicol AC, Lane JV, Gray TG. Biomechanics of knife
and numerical study of stab-penetration forces. Forensic Sci stab attacks. Forensic Sci Int 1999;105:35-44.
Int 2013;233(1 —3):7—13. Como JJ, Bokhari F, Chiu WC, et al. Practice management guide
Annaidh A, Cassidy M, Curtis M, et al. Toward a predictive assess lines for selective nonoperative management of penetrating
ment of stab-penetration Forces. Am J Forensic Med Pathol abdominal traumaJ7rac//7?a 2010;68(3):721-733.
2015;36(3):162—166. Critchley M. The Trial of Neville George Clevely Heath. Notable
Blackwell SA, Taylor RV, Gordon I, et al. 3D imaging and quanti British Trials Series. London: William Hodge & Co., Ltd.; 1951,
tative comparison of human dentitions and simulated bite 77-83.
marks, Int J Legal Med 2007;121:9-17. Deodhar AK, Rana RE. Surgical physiology of wound healing: a
Bleetman A, Hughes Lt H, Gupta V. Assailant technique in knife review. J Postgrad Med 1997;43:52-56.
slash attacks. J Clin Forensic Med 2003;10:1-3. Ertan T, Sevim Y, Sarigoz T, et al. Benefits of CT tractography in
Bleetman A, Watson CH, Horsfall I, Champion SM. Wounding pat evaluation of anterior abdominal stab wounds. Am J Emerg
terns and human performance in knife attacks: optimising Med 2015;33(9):1188-1190.
the protection provided by knife resistant body armour.JClin European Convention on Human Rights, Article 3. http://www.hri.
Forensic Med 2003;10:243-248. org/docs/ECHR50.html#C.Art3 (Accessed 8 April 2019).
Bogert JN, Harvin JA, Cotton BA. Damage control resuscitation J Evans S, Jones C, Plassmann P. 3D imaging in forensic odontol
Intensive Care Med 2016;31:177-186. ogy, J Vis Commun Med 2010; 33:63-68.
Bibliography and information sources I 131
Evans S, Jones C, Plassmann P. 3D imaging for bite mark analysis. Jones R. Complexity in forensic pathology. Forensic Sci Int
Imaging Sci J 2012; 61:1-9. 2015;257:e38-43.
Evans S, Baylis S, Carabott R, et al. Focusing on the future: survey Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: typi
results on the image capture of patterned cutaneous injuries. cal and atypical features. IntJ Legal Med 2000;113:259-262.
J Forensic Leg Med 2014;24:7-11. Karger B, Rothschild MA, Pfeiffer H. Accidental sharp force fatali
Evans S, Baylis S, Carabott R, et al. Guidelines for photography of ties: beware of architectural glass, not knives. Forensic Sci Int
cutaneous marks and injuries: a multi-professional perspec 2001;123:135-139.
tive. J Vis Commun Med 2014;37(1— 2):3—12. Karlsson T. Homicidal and suicidal sharp force fatalities in
Flora G, Tuceryan M, Blitzer H. Forensic bite mark identifica Stockholm, Sweden: orientation of entrance wounds in
tion using image processing methods. In: Proceedings of the stabs gives information in the classification. Forensic Sci Int
2009 ACM symposium on Applied Computing (SAC), Honolulu, 1998;93:21-32.
Hawaii, USA, March 9-12 2009;903-907. Keel M, Trentz O. Pathophysiology of polytrauma. Injury
Freeman AJ, Senn DR, Arendt DM. Seven hundred seventy-eight 2005:36:691-709.
bite marks: Analysis by anatomic location, victim and bitter Kemp AM, Maguire SA, Nuttall D, et al. Bruising in children who
demographics, type of crime, and legal disposition .J Forensic are assessed for suspected physical abuse. Arch Dis Child
Sci 2005;50:1436-1443. 2014;99(2):108-113.
Fry WR, Smith RS, Schneider JJ, Organ CH Jr. Ultrasonographic Knight B. The dynamics of stab wounds. Forensic Sci 1975;6:249-
examination of wound tracts. Arch Surg 1995;130(6):605—607. 255.
Gall J, Payne-James JJ. Injury interpretation: possible errors and Langlois NE, Gresham GA. The ageing of bruises: a review and
fallacies. In: Gall J, Payne-James JJ (eds). Current Practice in a study of the colour changes with time. Forensic Sci Int
Forensic Medicine. London: Wiley; 2011. 1991;50:227-238.
Gall J, Payne-James JJ, Goldney RD. Self-inflicted injuries and Large M, Babidge N, Nielssen O. Intracranial self-stabbing. AmJ
associated psychological profiles. In: Gall J, Payne-James Forensic Med Pathol 2012;33(1):13-18.
JJ (eds). Current Practice in Forensic Medicine. London: Wiley; Lenz A, Franklin GA, Cheadle WG. Systemic inflammation after
2011 . trauma. Injury 2007;38(12):1336-1345.
Gando S, Otomo Y. Local hemostasis, immunothrombosis, and Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of
systemic disseminated intravascular coagulation in trauma bruising in childhood which are diagnostic or suggestive of
and traumatic shock. CritCare 2015;19:72. abuse? A systematic review. Arch Dis Child 2005;90:182-186.
Green MA. Stab wound dynamics: a recording technique Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises
for use in medico-legal investigations. J Forensic Sci Soc accurately in children? A systematic review. Arch Dis Child
1978;18:161-163. 2005;90:187-189.
Hainsworth SV, Delaney RJ, Rutty GN. How sharp is sharp? Maguire S, Mann M. Systematic reviews of bruising in relation
Towards quantification of the sharpness and penetration to child abuse - what have we learnt: an overview of review
ability of kitchen knives used in stabbings. Int J Legal Med updates. Evid Based Child Health 2013;8(2):255-263.
2008;122(4):281 -291. Marsh N. Injury photography: is it more than skin deep? Journal
Henn V, Lignitz E. Kicking and trampling to death: pathological of Homicide and Major Incident Investigation 2010;6(2):45-55.
features, biomechanical mechanisms, and aspects of victims Martin-de-Las-Heras S, Tafur D. Comparison of simulated human
and perpetrators. ln:Tsokos M {ed). Forensic Pathology Reviews dermal bitemarks possessing three-dimensional attributes to
Volume I.Totowa: Humana Press Inc.; 2004. suspected biters using a proprietary three-dimensional com
Higashitani K, Kondo T, Sato Y, et al. Complete transection of the parison. Forensic Sci Int 2009;190:33-37.
pancreas due to a single stamping injury: a case report. IntJ Munang LA, Leonard PA, Mok JY. Lack of agreement on colour
Legal Med 2001;115(2):72-75. description between clinicians examining childhood bruis
Horsfall I, Prosser PD, Watson CH, Champion SM. An assess ing. J Clin Forensic Med 2002;9:171-174.
ment of human performance in stabbing. Forensic Sci Int Nguyen HS, Oni-Orisan A, Doan N, Mueller W.Transnasal penetra
1999;102:79-89. tion of a ballpoint pen: case report and review of literature.
Hughes VK, Ellis PS, Langlois NE. The perception of yellow in World Neurosurg 2016;96:611.e1-611 .e10.
bruises. J Clin Forensic Med 2004;11:257-259. O'Callaghan PT, Jones MD, James DS, et al. Dynamics of stab
Hunt AC, Cowling RJ. Murder by stabbing. Forensic Sci Int wounds: force required for penetration of various cadaveric
1991;52:107-112. human tissues. Forensic Sci Int 1999;104:173-178.
International Forensic Expert Group. Statement on access to rel Ong BB. The pattern of homicidal slash/chop injuries: a 10 year
evant medical and other health records and relevant legal retrospective study in University Hospital Kuala LumpurJC//n
records for forensic medical evaluations of alleged torture and Forensic Med 1999;6:24-29.
other cruel, inhuman or degrading treatment or punishment. Ormstad K, Karlsson T, Enkler L, et al. Patterns in sharp force fatali
Torture 2012;22(Suppl 1):39-47. ties: a comprehensive forensic medical study. J Forensic Sci
Jaffe FA. Petechial haemorrhages. A review of pathogenesis. AmJ 1986;31:529-542.
Forensic Med Pathol 1994;15:203-207. Oudshoorn BY, Driscoll HF, Dunn M, James D. Kinetic and kine
Johansen RJ, Bowers CM. Digital Analysis of Bite Mark Evidence matic analysis of stamping impacts during simulated rucking
(Using Adobe® Photoshop®), 1st ed. Forensic Imaging Services: in rugby union. J Sports Sci 2018;36(8):914—919.
Santa Barbara, California, USA. 2000. Payne-James JJ. Rules & scales used in measurement in the foren
Jones R. Wound and injury awareness amongst students and sic setting. Forensic Sci Med Pathol 2012. doi: 10.1007/s12024-
doctors. J Clin Forensic Med 2003;10:231-234. 012-9320-7.
132 I Assessment, classification and documentation of injury
Payne-James JJ, Hawkins C, Bayliss S; Marsh N. Quality of Simpson K.The Heath Case. R - v - Neville George Clevely Heath.
photographic images for injury interpretation: room for Police J 1947;20:266-274.
improvement? Forensic Sci Med Pathol 2012. doi: 10.1007/ Simpson K. Neville Heath and the diamond weave whip. In: Simpson
si 2024-012-9325-2. K. 40 Years of Murder. London: Harrap Ltd.; 1978,103-112.
Payne-James JJ, Hinchliffe JA. Injury assessment, documentation Sivarajasingam V, Read S, Svobodova M, et al. Injury resulting
and interpretation. In: Stark MM (ed). Clinical Forensic Medicine, from targeted violence: an emergency department per
3rd ed. New Jersey: Humana Press; 2011. spective. Crim BehavMent Health 2018;28(3):295-308.
Payne-James JJ, Hawkins C, Baylis S, Marsh NP. Quality of photo Spitz WU. Blunt force injury. In: Spitz WU (ed). Spitz and Fisher's
graphic images provided for injury interpretation: room for Medico-legal Investigation of Death: Guidelines to theApplication
improvement? Forensic Sci Med Pathol 2012;8:447-450. of Pathology to Crime Investigation, 3rd ed. Springfield: Charles
Payne-James JJ. Rules and scales used in measurement in the C Thomas Publishers; 1993.
forensic setting: measured - and found wanting! Forensic Sci Sweet D, Lorente M, Lorente JA, et al. An improved method to
Med Pathol 2012;8:482-483. recover saliva from human skin: the double swab technique.
Payne-James JJ. Injury, fatal and nonfatal: blunt force injury. In: J Forensic Sci 1997;42:320-322.
Payne-James J, Byard RW (eds). Encyclopedia of Forensic and Thali MJ, Braun M, MarkwalderTH, et al. Bite mark documentation
Legal Medicine, 2nd ed. Oxford: Elsevier; 2016,166-172. and analysis: the forensic 3D/CAD supported photogramme-
Payne-James JJ. Injury, fatal and nonfatal: sharp and cutting-edge try approach. Forensic Sci Int 2003;135:115-121.
wounds. In: Payne-James J, Byard RW (eds). Encyclopedia of Thoresen SO, Rognum TO. Survival time and acting capa
Forensic and Legal Medicine, 2nd ed. Oxford: Elsevier; 2016, bility after fatal injury by sharp weapons. Forensic Sci Int
244-256. 1986;31:181-187.
Payne-James JJ, Beynon J, Nuno Vieira D. Assessment of physical Tsukamoto T, Chanthaphavong RS, Pape H-C. Current theories on
evidence of torture or cruel, inhuman and degrading treat the pathophysiology of multiple organ failure after trauma.
ment during visits to places of detention. In: Payne-James JJ, Injury 2010;41:21-26.
Beynon J, Nuno Vieira D (eds). Monitoring Detention, Custody, United Nations Office on Drugs & Crime. Global Study on
Torture and Ill-treatment. A Practical Approach to Prevention and Homicide 2013. https://www.unodc.org/gsh/ (Accessed 8
Documentation. Boca Raton: CRC Press; 2017. April 2019).
Pentone A, Innamorato L, Introna F. Dying transfixing his own Vanezis P, West IE. Tentative injuries in self stabbing. Forensic Sci
heart: a rare case of suicide by stabbing. Am J Forensic Med Int 1983;21:65-70.
Pathol 2013;34(4):318-320.
Pilling ML, Vanezis P, Perrett D, Johnston A. Visual assessment
of the timing of bruising by forensic experts. J Forensic Legal Further general resources
Med 2010;17:143-149. Faculty of Forensic & Legal Medicine. PICS Working Group:
Pretty IA. Development and validation of a human bitemark Guidelines on photography. 2017. PICS Working Group
severity and significance seal e.J Forensic Sci 2007;52:687-691. Guidelines on photography.
Rutty GN. Bruising: concepts of ageing and interpretation. In: https://www.cps.gov.uk/legal-guidance/homicide-murder-and-
Rutty GN (ed). Essentials ofAutopsy Practice. London: Springer- manslaughter (Accessed 8 April 2019).
Verlag; 2001. http://www.cardiff.ac.uk/violence-research-group/research-
Sexual Offences Act 2003 c42 http://www.legislation.gov.uk/ projects/national-violence-surveillance-system (Accessed 8
ukpga/2003/42/contents (Accessed 8 April 2019). April 2019).
Shah M, Galante JM, Scherer LA, Utter GH.The utility of laparoscopic Offences Against the Person Act 1861. http://www.legislation.
evaluation of the parietal peritoneum in the management of gov.uk/ukpga/Vict/24-25/100/contents (Accessed 8 April
anterior abdominal stab wounds. Injury 2014;45(1):128—133. 2019).
Sheasby DR, MacDonald DG. A Forensic classification of distor Payne-James JJ, Beynon J, Nuno Vieira D. Monitoring Detention,
tion in human bite marks. Forensic Sci Int 2001;122:75-78. Custody, Torture and Ill-treatment: A Practical Approach to
Sheets HD, Bush PJ, Bush MA. Bitemarks: distortion and covaria Prevention and Documentation. Boca Raton: CRC Press; 2017.
tion of the maxillary and mandibular dentition as impressed Payne-James JJ, Byard RW (eds). Encyclopedia of Forensic & Legal
in human skin. Forensic Sci Int 2012; 223:202-207. Medicine, 2nd ed. 4 volumes. London: Elsevier; 2016.
9 Ballistic injuries
The term 'lethality' itself is a complex issue and Shotguns, commonly used in the sport, hunting and
although case law exists (Moore v G ooderham [1960] 3 farming sectors, are long-barrelled, smooth-bore fire
All E.R. 575), only a court can decide whether any par arms that are used to discharge cartridges that usually
ticular weapon is a 'firearm' for the purposes of the Acts. contain a number of shot. These guns may have single
There are two main types of firearm: those with or double barrels, commonly 26-30 inches (66-76 cm)
smooth barrels, which fire groups of pellets or shot, and in length; the double-barrelled weapons are arranged
those with grooved or rifled barrels, which fire single pro either 'side by side' or 'over and under'. The length of the
jectiles or bullets. Both of these types of weapon rely upon barrel makes handling and concealing shotguns dif
the detonation of a solid propellant to produce the gases ficult and so it is not uncommon for the barrels to be
134 I Ballistic injuries
Rifled firearms
Shot This group of firearms usually fire one bullet at a time
through a barrel that has had a number of spiral grooves
Wad cut into the bore. The resultant projections, referred to
as 'lands', engage with the bullet and impart gyroscopic
Powder
spin that produces a more stable and accurate trajec
charge tory. Rifled weapons fall into two main groups: hand
guns and rifles.
Brass head Revolvers and pistols are short-barrelled hand guns.
Revolvers contain a rotating cylinder into which car
Primer
tridges are manually loaded. Pistols, or semi-automatic
Figure 9.1 Shotgun cartridge structure: (a), image of a hand guns, usually contain a magazine enclosing the
shotgun cartridge; (b), diagram of structure of typical cartridges located within the grip. The firearm is dis
cartridge. charged when the cocked firing pin, or striker, impacts
on to the primer cup in the base of the cartridge by pull
ing the trigger. The main difference in the two types of
shortened for criminal activities. This shortening of the firearm is the method of operation (Figure 9.2).
barrel has little impact on the effectiveness of the gun, In the revolver, the cylinder rotates to align a new
especially over short to middle distances. A shotgun cartridge with the firing pin and the barrel, which is
generally has an effective range of about 30-50 m. achieved by either pulling the trigger (double action)
The cartridges for shotguns (Figure 9.1) consist of a or by manually cocking the hammer and subsequently
metal base, or head, containing a central primer cap, pulling the trigger (single action). The fired cartridge
supporting a cardboard or plastic tube containing the cases remain in the gun until they are manually
propellant charge and the shot, which is closed by a thin unloaded.
disc or a crimp at the end of the tube. The shot may be In a pistol, the forces generated each time a cartridge is
contained within a plastic wad or there may be discs of discharged are used to recycle the weapon, which involves
felt, cork or cardboard, acting as wads above and below extracting and ejecting the fired cartridge case, resetting
the shot. The plastic wads open into a petal-shape the firing mechanism and loading a new cartridge from
in flight and may themselves contribute to an injury, the magazine into the chamber. For semi-automatic
especially at close range. weapons this occurs each time the trigger is pulled.
Shotgun cartridges are designated according to the Rifles are long-barrelled weapons that are designed to
size of the individual shot contained within and can accurately fire projectiles at targets at a much greater dis
vary significantly in number depending on the shot tance than revolvers or pistols. Rifles have been designed
size (typically 6-850 in number for a 12-bore cartridge). to use many different types of operating mechanism,
There are also cartridges that contain a single heavy ranging from single shot bolt-action rifles to fully auto
projectile, commonly referred to as a 'slug'. The types of matic gas-operated assault rifles, some of which are
wound produced by a shotgun will be dependent on the capable of firing in excess of 700 cartridges per minute.
Figure 9.2 Revolvers and pistols, (a) Heckler & Koch USP (Universal Service Pistol), Germany, 1993. Calibre 9 mm para-
bellum. (b) Ruger GP-100, USA, 1987. Calibre .357 Magnum.
Firearms injuries I 135
Firearms injuries
Injuries sustained from discharge of firearms can origi
nate from the smoke, flame and gases of combustion
(as well as the projectile). These exit the barrel, together
with portions of unburned, burning and burnt pro
pellant and other items such as wadding and plastic
containers for the pellets. These items and particles
will usually follow the projectile(s), but in some guns
they may also precede them. The distance they will
travel from the end of the muzzle is extremely variable,
depending mainly on the type of weapon and the type
of propellant. They can also escape from small gaps
around the breech and will soil hands or clothing close
to the breech at the time of discharge. The presence,
location and distribution of such items and particles
may have substantial evidential value in the forensic
investigation of a shooting incident, and determining
who fired or handled the weapon (see Box 9.1).
SUDJlLJLIL tnt ^r
~ t -j n rrTTTT
. 6 . 5 4 3 2
•V:: .Q- O o © 1 (b )
Figure 9.4 Variation in appearance of a shotgun wound at Figure 9.6 Firm contact entrance wound just above the
increasing range of discharge: (a)/1(a), split wound from umbilicus from a twelve-bore shotgun. Clothing pre
contact over bone; (b)/1(b), usual round contact wound; vented soot soiling, but minor peripheral abrasions were
2, close but not contact range up to approximately 30 cm caused by impact of a belt. Gas expansion in the disten
(variable); 3, 'rat hole' (scalloped) wound from 20 cm sible abdomen has prevented skin splitting at the wound
to approximately 1 m (variable); 4, satellite pellet holes edges. (Reproduced with permission from Saukko P and
appearing over approximately 2 m; 5, spread of shot Knight B. Knight's Pathology 4E, London, CRC Press, 2016.)
increases, central hole diminishes; 6, uniform spread with
no central hole over approximately 10 m. All these ranges
may usually be recovered from the wound track. The tis
vary greatly with barrel choke, weapon and ammuni
sues along the wound track may be blackened and the
tion. (Reproduced with permission from Saukko P and
surrounding tissues are said to be pinker than normal
Knight B. Knight's Pathology 4E, London, CRC Press, 2016.)
supposedly as a result of the carbon monoxide contained
within the discharge gases creating carboxyhaemoglo-
Contact wounds are created when the gun muzzle bin. As with most colour descriptions in forensic medi
abuts the skin and usually results in a circular entrance cine, the theory is not always clearly backed up by the
wound that approximates the size of the muzzle (Figures findings.
9.5 and 9.6). The wound edge will be regular and often A close discharge, within a few centimetres of the
has a clean-cut appearance with no individual pellet skin surface, will also produce a wound with a similar
marks apparent. Often there will be smoke soiling of at appearance, but as for the muzzle gases can escape,
least some of the margin of the wound. There may be a there will be no muzzle mark (Figure 9.7). More smoke
narrow, circular rim of abrasion around some or all of soiling can occur, and burning of skin, with singe
the entrance wound, caused when the gases of the dis ing and clubbing of melted hairs, may be seen around
charge enter through the wound and balloon the tissues the wound (Figure 9.8). Powder 'tattooing' of the skin
upwards so that the skin is pressed against the muzzle. around the entry wound may be evident. This tattoo
If the discharge was over an area supported by bone, ing results from burnt and burning flakes of propellant
the gases cannot disperse as readily as they would in causing tiny burns on the skin and cannot be washed
soft, unsupported areas such as the abdomen, and the off. As with contact discharges, wads will often be found
greater ballooning of the skin results in splits (lacera in the wound track.
tions) of the skin, which often have a radial pattern. In At intermediate ranges (between 20 cm and 1 m),
contact wounds, any wadding or plastic shot containers there will be diminishing smoke soiling and burning of
S* ■
, 4
+ •
/ ' ; 1
away from the wound track itself. The cavitation effect common ways in which the gas is compressed. The sim
may be exacerbated by the radial stretching of tissues plest method employs the compression of a spring which,
creating a temporary wound cavity. when released, moves a piston along a cylinder; more
The importance of an adequate description of gun powerful weapons use repeated movements of a lever
shot wounds at autopsy is illustrated very well by the to pressurise an internal cylinder. The third type has an
ongoing controversy surrounding the death of US internal cylinder which is 'charged' by connecting it to a
President John F Kennedy in 1963 (Box 9.2), and sub pressurised external source. The barrel of an air weapon
stantial tissue damage and loss, and unknown other may or may not be rifled; the more powerful examples
factors (e.g., direction of wound track, distance from have similar rifling to ordinary handguns and rifles.
weapon) all impact on the extent to which reliability The energy of the projectile will depend mainly on
can be placed on the conclusions drawn. This, how the way in which the gas is compressed: the simple
ever, does not appear to prevent people coming up with spring-driven weapon is low powered, while the more
their own theories, in which speculation and general complex systems can propel projectiles with the same
assumptions play a large part. energy, and hence at approximately the same speed, as
many ordinary handguns.
The injuries caused by the projectiles from air weap
Air weapons, unusual projectiles ons will depend upon their design, but entry wounds
and other weapons from standard pellets are often indistinguishable from
those caused by standard bullets in that they have a
Air guns and rifles defect with an abrasion rim. The relatively low power of
Air weapons rely upon the force of compressed air to pro these weapons means that the pellet will seldom exit,
pel the projectile, usually a lead or steel pellet although but if it does do so, a typical exit wound with everted
darts and other projectiles may be used. There are three margins will result.
Air weapons, unusual projectiles and other weapons 141
S ig h t
(s t y le v a rie s )
S e rv in g
Stock
S ig h t
b r id g e
weapon must be present at the scene, although it may be fatal, as is demonstrated by the cases described in
at a distance from the body because it may have been cat Box 9.4. It is most likely that severe damage to the brain,
apulted away from the body by the gun recoil, or by move heart, aorta and any number of other vital internal
ment of the individual if death was not instantaneous. organs will lead to rapid collapse and death; however,
The deceased's DNA or fingerprints should be present many forensic practitioners will have seen cases of sur
on the weapon (unless gloves were worn). Suicidal gun vival (sometimes long-term) following a contact dis
shot injuries are most commonly in the 'sites of election', charge of a firearm into the head.
which vary with the length of the weapon used.
Both long-barrelled and short-barrelled weapons
can be used in the mouth, below the chin, on the front Evidence recovery
of the neck, the centre of the forehead or, more rarely, In the living, all efforts must be directed to saving life but,
the front of the chest over the heart. Discharges into the if at all possible, the emergency medicine specialist, and
temples are almost unique to handguns and are usu surgeon, should make good notes of the original appear
ally on the side of the dominant hand, but this is not an ances of the injuries and preferably take good-quality
absolute rule. People rarely shoot themselves in the eye images of any entry or exit wounds before any surgical
or abdomen or in inaccessible sites such as the back. It cleaning or operative procedures are performed. Intra-
is unusual for females to commit suicide with guns and operatively it is useful to record the nature and direction
females are rarely involved in firearms accidents. of possible wound tracks, and their length. Any foreign
If suicide can be ruled out by the range of discharge, objects such as wads, bullets or shot, and any skin removed
by absence of a weapon or by other features of the injury from the margin of a firearm wound during treatment,
or the scene, a single gunshot injury could be either should be carefully preserved for the police. The presence
accident or homicide. Multiple firearm wounds strongly of a forensic physician at the time can be helpful in ensur
suggest homicide. However, there have been a number ing that appropriate documentation is made, for presenta
of published reports of suicidal individuals who have tion at a later stage in court. Ideally, the police should be
fired repeatedly into themselves even when each wound contacted (with the individual's consent) should surgical
is potentially fatal. The distinction between homicide, intervention be required so that a 'chain of custody' for
suicide and accident can sometimes be extremely dif evidence can be established.
ficult and a final conclusion can only be reached after a Those arrested for possible involvement in firearms
full medicolegal investigation. offences will need detailed examination and taking of
It is as unwise to state that a gunshot wound, as with samples, including skin and hand swabs, and nasal
any other sort of injury, must have been immediately samples, to identify any firearms residue. Standardised
144 I Ballistic injuries
and approved processes should be applied to all these vicinity solely from the effects of the wave of high pres
forms of trace evidence collection. sure and hot gases striking the body. A minimum pres
The same general rules apply to the post mortem sure of about 700 kPa (100 lb/inch2) is needed for tissue
recovery of exhibits. The skin around the wounds may damage in humans. There will also be pressure effects
be swabbed for powder residue if this is necessary, but upon the viscera and these effects are far more damag
the retention of wounds themselves is no longer consid ing where there is an air-fluid interface, such as in the air
ered to be essential. Swabs of the hands of the victim passages, the lungs and the gut. Rupture and haemor
should be taken. The pathologist must ensure that accu rhage of these areas represent the classical blast lesion.
rate drawings and measurements of the site, size and Blast injuries can be categorised as primary to qua
appearance of the wound are obtained and that distant ternary injuries. Primary injuries result from the effect
and close-up photographs are taken of each injury with of transmitted blast waves on gas-containing structure
an appropriate scale in view. (e.g., thorax); secondary injuries result from the impact
In many countries, all firearm wounds, whether or of airborne debris; tertiary injury results from transpo
not they are fatal, must be reported to the police, irre sition of the entire body due to blast wind or structural
spective of the consent of the injured individual. The collapse, and quaternary injuries make up the remain
UK General Medical Council advises, having reiterated der, including burns. Quinary blast injuries have also
the duty of confidentiality, 'the police should usually be been proposed: the clinical consequences of post-deto
informed whenever a person presents with a gunshot nation environmental contamination such as bacteria.
wound. Even accidental shootings involving lawfully Although the primary effect of blast is large, in
held guns raise serious issues for the police about, for most cases many more casualties, fatal and otherwise,
example, firearms licensing'. are caused by secondary and tertiary effects of explo
sive devices, especially in the lower-powered terrorist
Blast injuries bombs. These effects include:
Armed conflict and terrorist activity lead to many deaths • Burns - directly from the near effects of the explo
from explosive devices. Domestic and international sion and secondarily from fires started by the
terrorist activity is now present in many countries and bomb.
therefore there has been an increase in the experience • Missile injuries from parts of the bomb casing,
of medical personnel in the assessment and treatment of contents or shrapnel or from adjacent objects.
blast (explosive) injuries. They may derive from a number • Peppering by small fragments of debris and dust
of sources including improvised explosive devices (IEDs), propelled by the explosion (Figure 9.20).
car bombs and suicide bombers. The nature of the explo • Various types of injury owing to collapse of struc
sive device may alter the nature of injury, and the position tures as a result of the explosion.
or activity of the individual (e.g., in a vehicle, on foot) at • The body impacting against other structures or
the relevant time may also have substantial influence on objects.
injury and outcome. Experience with IEDs has resulted • Injuries and death from vehicular damage or
in substantial research and drivers for revised coding of destruction, such as decompression, intrusion
injury such as the Military Combat Injury Scale. of occupant space, fire and ground impact of
In military bomb, shell and missile explosions, the bombed aircraft and crash damage to cars, trucks,
release of energy may be so great that death and disrup and buses.
tion from blast effects occur over a wide area. In con
trast, terrorist devices, unless they contain very large
amounts of explosive, are generally of less power and
the pure blast effects are far more limited. However,
the locations in which such devices are often detonated
maybe within relatively confined spaces (e.g., subways
and buses), influencing the subsequent pattern of injury
caused. The energy generated by an explosion decreases
rapidly as the distance from the epicentre increases.
When an explosion occurs, a chemical interaction
results in the generation of huge volumes of gas, which
are further expanded by the great heat that is also gener
ated. This sudden generation of gas causes a compres
sion wave to sweep outwards; at the origin, this is at
many times the speed of sound. Figure 9.20 Multiple abrasions and lacerations caused
The pure blast effects can cause either physical frag by flying debris projected in a bomb blast. (Courtesy of
mentation or disruption of those within the immediate Professor T K Marshall, Queens University, Belfast.)
Mass disasters 145
Mass disasters
Most mass disasters are now either natural disasters
or terrorist and criminal events. For the non-specialist
doctor at the scene of a mass disaster of any kind, the
first consideration is the treatment of casualties, for
which the first, and often most testing, role is on triage.
Those faced with triaging patients in mass disasters are
faced with a number of practical and ethical decisions.
Box 9.5 illustrates the widely accepted colour-code sys
tem used to categorise disaster victims in the field. The
Figure 9.21 Massive disruption of the body of an 'expectant' category can be the most challenging for
individual who had constructed an explosive device. caregivers from an ethical and emotional standpoint.
(Courtesy of Richard Jones.) In 2017, the World Medical Association (WMA) revised
its Statement on Medical Ethics in the Event of Disasters.
The investigation of the scene of an explosion is a The key points are summarised in Box 9.6.
huge and technically complex exercise with a number The International Committee of the Red Cross and
of factors to be considered, including triaging to pre other bodies have provided advice on the appropriate
serve life and evacuating casualties, whilst concurrently and dignified management of the dead which is con
attempting to establish and maintain a crime scene (or sidered to be one of the three key pillars of humani
scenes) for the identification, sampling and preserva tarian response to disaster. The investigation of the
tion of evidence. causes of death, the causes of the incident (such as a
Full assessment of both the living and the dead bomb), and the identification of the dead, are specialist
following an explosion is essential, with careful operations involving individuals from a wide variety of
documentation of the sites and sizes of all injuries. professional backgrounds, including those with exper
Multiprofessional teams including forensic patholo tise in the provision of emergency mortuary accom
gists, forensic physicians, forensic scientists, forensic modation, pathologists, dentists, the police and the
anthropologists, forensic odontologists and crime usual state agencies responsible for sudden death; in
scene investigators are required to ensure the integ England & Wales this is the Coroner. A team of patholo
rity and proper interpretation of evidence. For the gists, assisted by police officers and mortuary staff, and
deceased, post mortem radiology is essential, in order backed up by dental and radiological facilities, inspects
to identify unexploded ordinance, and items com each body and records all clothing, jewellery and per
prising components of the explosive device, which sonal belongings still attached to the bodies. The body,
may assist in determining its source. Identification or body part, is then carefully examined for every aspect
of deceased individuals is important, not only from a of identity, including sex, race, height, age and personal
moral and ethical standpoint for families, but also to characteristics. All these details are recorded on stan
enable the relevant medicolegal authority to discharge dard forms and charts and the information is sent back
their responsibilities. The identification of suicide to the identification teams, who can compare this post
bombers, whose bodies are frequently extensively dis mortem information with ante mortem information
rupted following the explosion, can be extremely chal obtained from others including relatives, friends and
lenging, particularly if previously unknown to security work colleagues. A post mortem examination is usually
services (Figure 9.21). performed to determine the cause of death, retrieve any
Box 9.5 Triage Levels and Colour Coding to categorise disaster victims in the field
• Red Triage Tag ('Immediate' or T1 or Priority 1): Black Triage Tag ('Expectant' or No Priority):
Patients whose lives are in immediate danger and Patients who are either dead or who have such
who require immediate treatment. extensive injuries that they cannot be saved with
• Yellow Triage Tag ('Delayed' or T2 or Priority 2): the limited resources available.
Patients whose lives are not in immediate danger
and who will require urgent, not immediate, medi
cal care. Source: A d a p te d from Kennedy K, A g h ab ab ia n RV, G a n s
• Green Triage Tag ('Minimal' or T3 or Priority 3): L, Le w is CP. Triage: te ch n iq u e s and a p p lica tio n s in
Patients with minor injuries who will eventually d e c isio n m ak ing . Ann Em erg M ed 1996;28(2):136-144.
require treatment.
Ballistic injuries
Box 9.6 (Continued) Recommendations from the WMA Statement on Medical Ethics
in the Event o f Disasters (2017)
respect the often emotional and politicised atmo personal damages to which physicians might be
sphere surrounding disaster situations. Any and all subject when working in disaster or emergency
media, especially filming, must only occur with the situations. This should also include life and disabil
explicit consent of each patient who is filmed. With ity coverage for physicians who die or are harmed in
regard to social media use, physicians must adhere the line of duty.
to these same standards of discretion and respect
The WMA requests that governments
for patient privacy.
• Ensure the preparedness of healthcare system to
Duties of paramedical personnel
serve in disaster settings.
• The ethical principles that apply to physicians • Share all information related to public health
in disaster situations should also apply to other timely and accurately.
healthcare workers. • Accept the participation of demonstrably quali
fied foreign physicians, where needed, without
Training
discrimination on the basis of factors such as
• The WMA recommends that disaster medicine affiliation (e.g., Red Cross, Red Crescent, ICRC, and
training be included in the curricula of university other qualified organizations), race, or religion.
and post-graduate courses in medicine. • Give priority to the rendering of medical services
over anything else that might delay necessary
Responsibility treatment of patients.
• The WMA calls upon governments and insurance
companies to cover both civil liability and any
foreign objects that, for example, may be related to an Haag LC. Base deformation of full metal-jacketed rifle bullets as
explosive device, and to seek any further identifying fea a measure of impact velocity and range of fire. Am J Forensic
tures, such as operation scars and prostheses. Med Pathol 2015;36(1):16-22.
Karger B, Billeb E, Koops E, Brinkmann B. Autopsy features rel
evant for discrimination between suicidal and homicidal
Bibliography and information gunshot injuries. IntJ Legal Med 2002;116:273-278.
Karger B, Bratzke H, Grass H, et al. Crossbow homicides. IntJ Legal
sources Med 2004;118(6):332-336.
Agu CT, Orjiaku ME. Management of a nail impalement injury to Kennedy K, Aghababian RV, Gans L, Lewis CP. Triage: tech
the brain in a non-neurosurgical centre: a case report and niques and applications in decision making. Ann Emerg Med
review of the literature. IntJ Surg Case Rep 2016;19:115-118. 1996;28(2):136-144.
Bilukha 00, Leidman EZ, Sultan AS, Jaffar Hussain S. Deaths due to Knudsen PJT. Ballistic trauma: overview and statistics. In: Payne-
Intentional Explosions in Selected Governorates of Iraq from James JJ, Byard RW (eds). Encyclopedia of Forensic & Legal
2010 to 2013: prospective surveillance. Prehosp Disaster Med Medicine, 2nd ed. Elsevier; 2016.
2015;30(6):586-592. Kolomeyer AM, Shah A, Bauza AM, et al. Nail gun-induced
Breitenecker R. Shotgun wound patterns. Am J Clin Pathol open-globe injuries: a 10-year retrospective review. Retina
1969;52:258-269. 2014;34(2):254-261.
Dana SE, DiMaio VJM. Gunshot trauma. In: Payne-James JJ, Busuttil Krukemeyer MG, Grellner W, Gehrke G, et al. Survived crossbow
A, Smock W (eds). Forensic Medicine: Clinical and Pathological injuries. Am J Forensic Med Pathol 2006;27(3):274-276.
Aspects. London: Greenwich Medical Media; 2003,149-168. Lawnick MM, Champion HR, Gennarelli T, et al. Combat injury cod
DiMaio VJM. Bloody bodies and bloody scenes. In: DiMaio VJM. ing: a review and reconfiguration. J Trauma Acute Care Surg
Gunshot Wounds: Practical Aspects of Firearms, Ballistics and 2013;75(4):573—581.
ForensicTechniques, 2nd ed. Boca Raton: CRC Press; 1999,254. Ling SN, Ong NC, North JB. Eighty-seven cases of a nail gun
Fackler ML. Wound ballistics: a review of common misconcep injury to the extremity. Emerg Med Australas 2013;25(6):
tions. J Am Med Assoc 1988;259:2730-2736. 603-607.
Fowler KA, Dahlberg LL, HaileyesusT, Annest JL. Firearm injuries Loder RT, Farren N. Injuries from firearms in hunting activities.
in the United States. PrevMed 2015;79:5-14. Injury 2014;45(8):1207-1214.
General Medical Council 2017. Confidentiality: reporting Maiden N. Ballistics reviews: mechanisms of bullet wound
gunshot and knife wounds, https://www.gmc-uk.org/ trauma. Forensic Sci Med Pathol 2009;5(3):204-209.
ethical-guidance/ethical-guidance-for-doctors/confidenti- Marri MZ, Bashir MZ. An epidemiology of homicidal deaths due
ality—reporting-gunshot-and-knife-wounds/reporting-gun- to rifled firearms in Peshawar Pakistan. J Coll Physicians Surg
shot-and-knife-wounds#paragraph-4 (Accessed 8 April 2019). Pak 2010;20(2):87-89.
148 | Ballistic injuries
Marshall TK. Deaths from explosive devices. Med Sci Law Thali MJ, Kneubuehl BP, Dirnhofer R, Zollinger U. The dynamic
1976;16:235-239. development of the muzzle imprint by contact shot: high
Mathews ZR, Koyfman A. Blast Injuries. J Emerg Med speed documentation utilizing the 'skin-skull-brain model'.
2015;49(4):573-587. Forensic Sci Int 2002;127:168-173.
Mehta A, Khosa F. Firearms, bullets, and wound ballistics: an Volgas DA, Stannard JP, Alonso JE. Ballistics: a primer for the sur
imaging primer. Injury 2015;46(7):1186-1196. geon. Injury 2005;36:373-379.
Milroy CM, Clark JC, Carter N, et al. Air weapon fatalities. J Clin Weinberger SE, Hoyt DB, Lawrence HC, et al. Firearm-related injury
Pathol 1998;51:525-529. and death in the United States: a call to action from 8 health
National Archives. President John F Kennedy assassination records professional organizations and the American Bar Association.
collection, https://www.archives.gov/research/jfk (Accessed 3 Ann Intern Med 2015;162(7):513-516.
June 2019). Wilber CG. Medicolegal Investigation of the President John F.
Payne-James JJ. Restraint techniques, injuries, and death: impact Kennedy Murder. Springfield: Charles C Thomas Publisher;
rounds. In: Payne-James J, Byard RW (eds). Encyclopedia of 1978.
Forensic and Legal Medicine, 2nd ed. Vol. 4. Oxford: Elsevier; Yeh DD, Schecter WP. Primary blast injuries: an updated concise
2016,130-134. review. World J Surg 2012;36(5):966-972.
PBS. Cold Case JFK. NOVA (aired 13/11/2013). https://www.www.
pbs.org/wgbh/nova/video/cold-case-jfk (Accessed 3 June
2019).
Further general resources
Rosenfeld JV, Bell RS, Armonda R. Current concepts in penetrat CPS. Guidance on Firearms, https://www.cps.gov.uk/legal-guid-
ing and blast injury to the central nervous system. World J ance/firearms (Accessed 8 April 2019).
Surg 2015;39(6):1352-1362. Firearms Act 1968. http://www.legislation.gov.uk/
Santucci RA, Chang YJ. Ballistics for physicians: myths about ukpga/1968/27/contents (Accessed 8 April 2019).
wound ballistics and gunshot wounds. J Urol 2004,171:1408- Police & Crime Act 2017 http://www.legislation.gov.uk/
1414. ukpga/2017/3/part/6/crossheading/firearms/enacted
Saukko P, Knight B. Gunshot and explosion deaths. In: Saukko P, (Accessed 8 April 2019).
Knight B (eds). Knight's Forensic Pathology, 4th ed. Boca Raton: International Committee of the Red Cross. Management of dead
CRC Press; 2016,241-275. bodies after disasters: a field manual for first responders.
Singleton JA, Gibb IE, Bull AM, et al. Primary blast lung injury prev https://www.icrc.org/en/publication/0880-management-
alence and fatal injuries from explosions: insights from post dead-bodies-after-disasters-field-manual-first-responders
mortem computed tomographic analysis of 121 improvised (Accessed 8 April 2019).
explosive device fatalities. J Trauma Acute Care Surg 2013;75(2 World Medical Association. WMA statement on medical ethics in
Suppl 2):S269-S274. the event of disasters, https://www.wma.net/policies-post/
Smith S. Voluntary acts after a gunshot wound of the brain. Police wma-statement-on-medical-ethics-in-the-event-of-disas-
J 1943;16:108-110. ters/ (Accessed 8 April 2019).
Thali MJ, Kneubuehl BP, Zollinger U, Dirnhofer R. A study of the
morphology of gunshot entrance wounds, in connection
with their dynamic creation, utilising the 'skin-skull-brain'
model. Forensic Sci Int 2002,125:190-194.
Regional injuries and
10 patterns of injury
■ Introduction ■ C h e st in juries
■ Head injuries ■ A b d o m en
■ Neck injuries ■ B ib lio g ra p h y a n d inform ation so u rces
■ Spinal injuries ■ Fu rth er g e n e ra l resources
Intracranial haemorrhage
The clinical significance of any space-occupying lesion
within the cranial cavity is the effect that the resultant
raised intracranial pressure has on brain structure and
function.
Intracranial bleeding, which in effect creates a
space-occupying lesion, is the cause of many deaths
and disability following head injury, often as a result of
delayed or missed diagnosis. Bleeding can compress the
brain and, if it continues for sufficient time, and in suffi
cient quantity, can raise the pressure within the cranial
cavity. As the intracranial pressure increases, blood flow Figure 10.4 Depressed skull fracture, with rounded
to the brain decreases and, if the intracranial pressure contours in the centre of the image, closely replicating
reaches a point where it equals or exceeds arterial blood the dimensions of a round-headed hammer. Additional
pressure, the blood flow to the brain will cease. fracture lines also seen. (Courtesy of Richard Jones.)
152 I Regional injuries and patterns of injury
Periosteum
Scalp
Thicker
outer table
Emissary vein
Diploe
Dura
Thinner inner
table
Cortical vein
Meningeal
Cerebral artery
artery
Venous sinus
Pia mater
Arachnoid
granulation
Arachnoid
mater
Subarachnoid
space Brain
Falx
________ J
Figure 10.5 Anatomy of the blood vessels and structures related to cranial bones in diagrammatic form.
Two main types of haemorrhage within the skull but begin to turn brown after several days; microscopi
cavity, each resulting in haemorrhage in different tis cally, haemosiderin can be identified with Peris' stain
sue planes, are extradural and subdural haemorrhage. (Figure 10.8). Older subdural collections (chronic sub
Extradural haemorrhage is associated with damage to dural haematoma) maybe enclosed in gelatinous 'mem
the meningeal artery, particularly the middle menin branes', which can harden into a firm rubbery capsule
geal artery, in its course in the temporal bone (Figure in extreme cases. Such old collections of subdural blood
10.6a and b). Damage to this vessel leads to arterial are most commonly seen in the elderly, whose cerebral
bleeding into the extradural space. As the blood atrophy allows space for the formation of the haematoma
accumulates, it separates the dura from the overlying without apparent significant clinical effect. Chronic
skull and forms a haematoma (a collection of blood). subdural haematomas are also seen in those prone to
Arterial bleeding is generally rapid, and the develop frequent falls, such as those with alcohol dependencies.
ment of the haematoma will result in a rapid displace Occasionally, subdural haemorrhages may be present for
ment of the brain and the rapid onset of symptoms. many months or even years before diagnosis, which can
Extradural haemorrhages may present in the clinical be difficult because of the often non-specific neurologi
setting with head trauma followed by a Tucid period' cal changes. Spontaneous subdural haemorrhages can
of half an hour or more, before sudden, rapid dete occur without trauma (although there may be underly
rioration occurs. Rarely, extradural haemorrhage can ing pathology such as sepsis, bleeding diathesis or vas
develop as a result of venous bleeding from damaged cular malformation).
perforating veins or dural sinuses, in which case the The effects of both extradural and subdural haem
development of symptoms will be slower. orrhages are essentially the same: they can act as
The second most important cause of traumatic intra space-occupying lesions compressing the brain and,
cranial haemorrhage is damage to the communicating as discussed below, and at their most severe, can cause
veins as they cross the (potential) 'subdural space', caus internal herniation (e.g., through the tentorium cer-
ing subdural haemorrhage (Figure 10.7). This venous ebelli, or the foramen magnum - 'coning'). There may
damage is not necessarily associated with fractures of also be resultant traumatic brain contusion and swell
the skull. In many instances, particularly in the very ing, which compounds the clinical deterioration and
young and the very old, there may be no apparent pre can hasten a fatal outcome in the absence of medical
vious history or evidence of any trauma to the head. and neurosurgical intervention.
These venous injuries are associated with rotational or
shearing forces that cause the brain to move relative to Traumatic subarachnoid haemorrhage
the inner surface of the skull; this motion is thought to Small areas of subarachnoid haemorrhage are common
stretch the thin-walled veins, causing them to rupture. where there has been direct trauma to the brain, either
The venous bleeding lies in the subdural space. Recent from an intrusive injury, such as a depressed skull frac
subdural haemorrhages are dark red in colour and shiny, ture, or from movement of the brain against the inner
Head injuries I 153
Dura
Arachnoid
Haematoma
Figure 10.6 Extradural haemorrhage. Schematic repre Most basal subarachnoid haemorrhages are non-
sentation (a) of the formation of an extradural haemor traumatic in origin and arise from the spontaneous
rhage and autopsy appearance (b) of a large right-sided, rupture of a berry aneurysm of one of the arteries in the
temporoparietal, extradural haemorrhage associated circle of Willis. In the deceased, particular care must be
with deep scalp bruising at the site of impact. There taken to exclude this natural cause, and special autopsy
was a linear skull fracture on the right passing through dissection techniques are required to evaluate the
the middle meningeal artery. (Reproduced with permis integrity of the vertebral arteries.
sion from Saukko P and Knight B. Knight's Pathology 4E,
London, CRC Press, 2016.)
Figure 10.10 (a) Schematic representation of the effects of brain swelling and 'internal herniation' caused by raised
intracranial pressure, (b) Transtentorial herniation in brain trauma. Compression of the medial temporal lobes against
the tentorium edges has caused bilateral haemorrhagic necrosis (arrows). Haemorrhagic infarcts in the left temporal
lobe (asterix) followed compression of the left posterior cerebral artery, and there is slight midline shift to the right (of
the vertical white line).
Head injuries I 155
Axonal injury
The terminology of axonal injury is in flux. However, dif
fuse axonal injury (DAI) is one of the most common and
important pathological features of TBI. Neuronal axons Figure 10.11 Microscopy of axonal injury. The immunohis
in the white matter of the brain appear to be particu tochemical staining of (3-amyloid precursor protein ((3-APP)
larly vulnerable to injury due to mechanical loading of demonstrates axonal injury in white matter (corpus cal
the brain during, for example, blunt impact head injury. losum). Discrete axonal swellings and 'axonal retraction
Traumatic DAI has been found in all severities of TBI bulbs' can be visualised following traumatic brain injury if
and is even thought to underlie concussion associated the injured person survived for some hours after sustain
with mild head injury. The transmission of mechani ing their head injury. (Courtesy of Richard Jones.)
cal energy following blunt impact head injury, which
may be accompanied by rotational head movement phenomena including hypoxia-ischaemia (Figure 10.11).
and acceleration/deceleration forces, damages axonal Progressive axonal injury, resulting in the formation of
processes. Traumatic DAI encompasses mechanical axonal retraction 'bulbs', can easily be recognised by
disruption of axonal cytoskeletal components as well silver staining techniques after some 12 hours following
as subsequent physiological abnormalities that follow axonal injury, and subsequently on routine haematoxylin
disturbances of function. The clinical manifestation of and eosin (H&E) staining.
DAI ranges from confusion and concussion to cognitive It has been recognised for many decades that some
dysfunction and persistent coma. Recent research has boxers developed the disabling progressive neurode
highlighted links between TBI and the development of generative 'punch drunk syndrome' (called dementia
neurodegenerative disorders - such as Alzheimer's dis pugilistica). Repetitive mild TBI led to the abnormal
ease - later in life. accumulation of another protein in the brain - tau - and
When the brain is subjected to the forces described recent research has identified neurofibrillary tangles
above, traumatic injury to axons within the brain sub and neuropil threads containing this protein in distri
stance can occur as a consequence of 'shearing' effects butions different to those seen in other neurodegen
because of the differential movement of the various com erative diseases, prompting the description of a new
ponents of the brain which move in different ways, or at entity - Chronic Traumatic Encephalopathy (CTE). CTE
different speeds, relative to each other. This shearing can has been described in the brains of American Football
cause contusions and lacerations deep within the sub players, military personnel exposed to explosive blasts
stance of the brain, and differential movement of com and, most recently, soccer players (from 'heading the
ponents of the brain results in damage at the interface football').
between those structures.
The shearing effects are also identifiable on micros
copy, where damage to axons can be visualised with the Coup and contrecoup injuries
aid of special staining techniques. These changes have A coup injury to the brain is one that occurs at the site of
been termed traumatic axonal injury which, when pres primary impact, when deformation of the skull contacts
ent at multiple sites throughout vulnerable areas of the the underlying brain. The site of scalp injury will gener
cerebral hemispheres and brain-stem, may be described ally approximate the site of brain injury. Such a coup
as diffuse traumatic axonal injury. Axonal injury takes injury to the brain is often represented by localised sub
a variable time to develop, or at least to become appar arachnoid haemorrhage and cortical surface contusion
ent under the microscope, and in cases of immediate or with, or without, laceration.
very rapid death following brain injury the microscopic In a 'moving head injury', such as might be expe
changes may not be identifiable. 0-amyloid precursor rienced following a fall onto the back of the head, for
protein ((3-APP) takes part in the axoplasmic transport example, impact causes the skull to stop moving sud
system and accumulates at sites of interruption of axo denly, while movement of the brain continues momen
plasmic flow. Where there has been survival for sev tarily before also stopping. As a consequence of such
eral hours, immunohistochemical staining for (3-APP relative movement, and the effects of deceleration
may identify injured axons, although interpretation of forces acting on the skull and the cranial contents, a
such staining may be problematic, given that this stain distinctive pattern of head/brain injury can be recog
also highlights axonal injury caused by non-traumatic nised (Figure 10.12a and b).
156 I Regional injuries and patterns of injury
Scalp injury
(fracture)
brain dam age
May suffer
se co n d a ry fracture
Figure 10.13 Contrecoup contusions on the inferior-
Tem p oral and surface of the brain. (Courtesy of Richard Jones.)
frontal con tu sion
Immediate • decapitation
• brainstem disruption
Very rapid • diffuse cerebral vascular injury
• traumatic basal subarachnoid haemorrhage
• severe diffuse traumatic axonal injury
Rapid • diffuse traumatic axonal injury
• cerebral substance disruption
• haemorrhage: e.g., external from scalp wounds; internal via injured cerebral
vessels (including into nose/throat/lungs)
Delayed • mass effect of intracerebral haemorrhage with internal cerebral herniation
• global brain swelling (oedema) with raised intracranial pressure and internal
herniation
• hypoxic-ischaemic encephalopathy
• cerebral infarction
• infection: meningitis; pneumonia (aspiration or hypostatic following
intubation/mechanical ventilation)
• post-traumatic epilepsy
Remote (long delay post injury) • post-traumatic epilepsy
• post-traumatic dementia (pugilistica)/chronic traumatic encephalopathy (cte)
• infection as a complication of persistent vegetative (or minimally conscious)
state:'bed sores', pneumonia, renal tract infection etc.
presence of arterial injury capable of explaining blood estimated by bystanders. Sometimes the spinal injuries
patterns such as 'arterial spray' or 'arterial rain' at the are more subtle and at post mortem it is only after care
scene of a suspicious death and venous injury raising ful dissection that damage to the upper cervical spine
the possibility of death having been caused by cardiac and, in particular, disruption of the atlanto-occipital
air embolism. joint will be revealed.
The application of pressure to the neck, whether it For the survivors of trauma, spinal injuries may have
be manual or by means of a ligature, and the pattern of some of the most crucial long-term effects because the
injury seen in such a scenario, is considered separately spinal cord is contained within the spinal canal and
in Chapter 11. there is little, if any, room for movement of the canal
before the cord is damaged. The sequelae of spinal
damage will depend upon the exact anatomical site and
Spinal injuries mechanism of injury.
The spine is a complex structure with interlocking but The type of injury to the spine will depend upon
mobile components often described as having anterior, the degree of force and the angle at which the spine is
middle and posterior 'sub-columns'. Damage to one of struck. A column is extremely strong in compression
the sub-columns is unlikely to result in instability: if and, unless the force applied is so severe that the base
the middle column is damaged then the likelihood of of the skull is fractured, vertically applied forces will
instability, neural damage is increased, and if all three generally result in little damage if the spine is straight.
columns are involved then fracture-dislocations and Angulation of the spine will alter the transmission of
spinal cord damage is expected. The spine is designed to force and will make the spine much more susceptible to
flex to a great extent but lateral movement and extension injury, particularly at the site of the angulation.
are more limited. The spine is very commonly injured Force applied to the spine may result in damage to
in major trauma such as road traffic collisions or falls the discs or to the vertebral bodies. The other major
from a height, and severe injury with discontinuity is components of the vertebrae - the neural arches and the
easily identified. The history of the event (e.g., the height transverse processes - are more likely to be injured if the
fall distance) is often very important in predicting the direction of the force of the trauma is not aligned with the
potential injury patterns, but distances may be poorly spine.
158 I Regional injuries and patterns of injury
Abdomen
The anatomy of the abdominal cavity plays a major
role in determining the type of injuries that are found.
The vertebral column forms a strong, midline, verti
cal structure posteriorly, and blunt trauma, especially
in the anterior/posterior direction, may result in com
pression of the organs lying in the midline against the
vertebral column. This compressive injury may result
in substantial blunt force injury to intra-abdominal
organs, including bruising (or even transection) of the
duodenum or jejunum, rupture of the pancreas, rupture
of the liver, and disruption of omentum and mesentery
(Figures 10.16 and 10.17).
The forces generally required to cause these inju
ries in an adult are severe and they are commonly
encountered in road traffic collisions. In an otherwise
healthy adult, it would be unusual but not impossible
for a simple punch to the abdomen to cause significant
intra-abdominal injuries, but kicks and stamps are
commonly the cause of major trauma. The kidneys and
Figure 10.15 Multiple rib fractures (a) following a road
the spleen are attached only by their hila and are sus
traffic collision. There were many 'flail' segments (b)
ceptible not only to direct trauma but also to rotational
and fractures rib ends pierced the underlying lung (c).
and shearing forces that may result in avulsion from
([a & c] Courtesy of Richard Jones.)
their vascular pedicles. Blunt trauma to the spleen is
sometimes associated with delayed rupture leading to
Penetrating injuries of the chest, whether caused by
sharp-force trauma (stab wounds) or gunshot wounds,
may result in damage to any of the organs or vessels
within the thoracic cavities. The effect of the penetra
tion will depend mainly upon which organ(s) or vessel(s)
are injured. Penetration of the chest wall can lead to the
development of pneumothorax, haemothorax or a com
bination (haemopneumothorax).
Damage to the lungs can also result in the develop
ment of pneumothoraces, and damage to the intratho- Figure 10.16 Mesenteric bruising and laceration follow
racic blood vessels will result in haemorrhage, which ing blunt force trauma in a road traffic collision.
160 I Regional injuries and patterns of injury
Adams JH, Mitchell DE, Graham Dl, Doyle D. Diffuse brain dam
age of immediate impact type: its relationship to 'primary
brain-stem damage' in head injury. Brain 1977;100:489-502.
Adams JH; Doyle D, Ford I, et al. Diffuse axonal injury in head
injury: definition, diagnosis and grading. Histopathology
1989;15:49-59.
Bathe Rawling L. Fractures of the skull. Lecture 1. Lancet
1904;163:973-979.
Beks RB, Reetz D, de Jong MB, et al. Rib fixation versus non
operative treatment for flail chest and multiple rib fractures
after blunt thoracic trauma: a multicenter cohort study. EurJ
Trauma Emerg Surg 2018. doi: 10.1007/s00068-018-1037-1.
Blumbergs P, Reilly P, Vink R. Trauma. In: Love S, Louis DN, Ellison
DW (eds). Greenfield's Neuropathology, 8th ed. London:
Hodder Arnold; 2008,733-832.
Figure 10.17 Multiple lacerations of the liver following Carey S, Carr M, Ferdous K, et al. Accuracy of height estimation
blunt force abdominal trauma in a road traffic collision. among bystanders. West J Emerg Med 2018;19(5):813—819.
(Courtesy of Richard Jones.) Case M. Head trauma: neuropathology. In: Payne-James KK, Byard
RW (eds). Encyclopedia of Forensic and Legal Medicine 2nd ed.
haemorrhage and possibly death some hours or even Oxford: Elsevier; 2016.
days after the injury. Pancreatic trauma can cause fatal Changa AR, Vietrogoski RA, Carmel PW. Dr. Harrison Martland and
pancreatitis or peritonitis, although sometimes may the history of punch drunk syndrome. Brain 2018;141:318-321.
lead to the development of a pseudocyst, with little or Chrysou K, Halat G, Hoksch B, et al. Lessons from a large trauma
no short-term or long-term sequelae. Once diagnosed center: impact of blunt chest trauma in polytrauma patients:
the successful treatment of these conditions may be still a relevant problem? Scand J Trauma Resusc Emerg Med
2017;25(1):42.
conservative or surgical. The best opportunity of sur
Davceva N,Sivevski A, Basheska N.Traumatic axonal injury: a clini
vival for many of these conditions is immediate assess
cal-pathological correlation .J Forensic Leg Med 2017;48:35-40.
ment, diagnosis and resuscitation. Dawson SL, Hirsch CS, Lucas FV, Sebek BA. The contrecoup
Abdominal injuries in children may have the same phenomenon: reappraisal of a classic problem. Hum Pathol
causes, but the forces required to cause them will be 1980;11:155-166.
considerably reduced, and the slower compressive forces Denis F. Spinal instability as defined by the three column
associated with squeezing of the abdomen during abuse spine concept acute spinal trauma. Clin Orthop Relat Res
may also result in the injuries described above. The pos 1984;189:65-76.
sibility of intra-abdominal injuries being caused by CPR Dunn LT, Fitzpatrick MO, Beard D, Henry JM. Patients with a head
is also one that is raised in court, but such instances of injury who 'talk and die' in the 1990s.J Trauma 2003;54:497-502.
Geddes JF. What's new in the diagnosis of head injury? J Clin
injury to either solid or hollow intra-abdominal organs
Pathol 1997;50:271-274.
in adults or children are very rare.
Geddes JF, Vowles GH, Beer TW, Ellison DW. The diagnosis of
Penetrating injuries to the abdomen can be the result diffuse axonal injury: implications for forensic practice.
of either gunshots or sharp-force trauma. The effects of Neuropathol Appl Neurobiol 1997;23:339-347.
these injuries will depend almost entirely on the organs Geddes JF,Whitwell HL, Graham Dl. Traumatic axonal injury: prac
and vessels involved in the wound track. A penetrat tical issues for diagnosis in medico-legal cases. Neuropathol
ing injury to the aorta, or inferior vena cava, can result Appl Neurobiol 2000;26:105-116.
in severe haemorrhage and may produce rapid death. Geisenberger D, Huppertz LM, Buchsel M, et al. Non-traumatic
Peritonitis from a ruptured bowel or stomach may not be subdural hematoma secondary to septic brain embolism:
recognised until too late, by which time overwhelming a rare cause of unexpected death in a drug addict suffer
sepsis will have developed. The presence of peritonitis, ing from undiagnosed bacterial endocarditis. Forensic Sci Int
2015;257:e1-e5.
and blood clots at post mortem are both factors which
Gennarelli TA, Thibault LE. Biomechanics of acute subdural hae
may give indications of how long before death intra matoma. J Trauma 1982;22:680-685.
abdominal trauma had occurred. Gentleman SM, Roberts GW, Gennarelli TA, et al. Axonal injury:
a universal consequence of fatal closed head injury? Acta
Bibliography and information Neuropathol 1995;89:537-543.
Graham Dl, Lawrence AE, Adams JH, et al. Brain damage in
sources non-missile head injury secondary to high intracranial pres
Abdel-Aziz H, Dunham CM. Effectiveness of computed tomogra sure. Neuropathol Appl Neurobiol 1987;13:209-217.
phy scanning to detect blunt bowel and mesenteric injuries Graham Dl, Smith C, Reichard R, et al. Trials and tribulations of
requiring surgical intervention: a systematic literature review. using (3-amyloid precursor protein immunohistochemistry
Am J Surg 2018. pii: S0002-9610(18)30123-5. doi: 10.1016/j.amj- to evaluate traumatic brain injury in adults. Forensic Sci Int
surg.2018.08.018. 2004;146:89-96.
Further general resources 161
Gurdjian ES. Cerebral contusions: re-evaluation of the mecha Mulcahy MJ, Chaganti J, Dower A, Al-Khawaja D. Spontaneous
nism of their development. J Trauma 1976;16:35-51. acute arterial subdural hematoma. World Neurosurg
Gurdjian ES, Webster JE, Lissner HR. The mechanism of skull frac 2018;110:403-406.
ture.JNeurosurg 1950;7:106-114. Munro D, Merritt HH. Surgical pathology of subdural hematoma.
Hampson D. Facial injury: a review of biomechanical studies Arch Neurol Psychiatry 1936;35:64-78.
and test procedures for facial injury assessment. J Biomech Ommaya AK, Grubb RL Jr, Naumann RA. Coup and contre-coup
1995;28:1-7. injury: observations on the mechanics of visible brain injuries
Hein PM, Schulz E. Contrecoup fractures of the anterior cranial in the rhesus monkey. JNeurosurg 1971;35:503-516.
fossae as a consequence of blunt force caused by a fall. Acta Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuro
Neurochir (Wien) 1990;105:24-29. pathology of adult and paediatric head injury. Br JNeurosurg
Heinzelman M, Platz A, Imhof HG. Outcome after acute extra 1992;16:220-242.
dural haematoma, influence of additional injuries and Parry NG, Moffat B, Vogt K. Blunt thoracic trauma: recent
neurological complications in the ICU. Injury 1996;27: advances and outstanding questions. Curr Opin Crit Care
345-349. 2015;21 (6):544-548.
Hill CS, Coleman MP, Menon DK. Traumatic axonal injury: mech Prakash A, Harsh V, Gupta U, et al. Depressed fractures of skull: an
anisms and translational opportunities. Trends Neurosci institutional series of453 patients and brief review of literature.
2016;39(5):311-324. Asian J Neurosurg 2018;13(2):222-226.
Jiang 0, Asha SE, Keady J, Curtis K. Position of the abdominal Preuss J, Padosch SA, Dettmeyer R, et al. Injuries in fatal cases of
seat belt sign and its predictive utility for abdominal trauma. falls downstairs. Forensic Sci Int 2004;141:121-126.
Emerg Med Australas 2019;31(1):112-116. Ramsay DA. Deaths: trauma, head and spine. In: Payne-James KK,
Johnson VE, Stewart W, Smith DH. Axonal pathology in traumatic Byard RW (eds). Encyclopedia of Forensic & Legal Medicine, 2nd
brain injury. Exp Neurol 2013;246:35-43. ed. Elsevier; 2016.
Joseph B, Khan M, Jehan F, et al. Improving survival after an Reichard RR, Smith C, Graham Dl. The significance of beta-APP
emergency resuscitative thoracotomy: a 5-year review of the immunoreactivity in forensic practice. Neuropathol Appl
Trauma Quality Improvement Program. Trauma Surg Acute Neurobiol 2005;31:304-313.
Care Open 2018;3(1):e000201. Rizen A, Jo V, Nikolic V, Banovic B.The role of orbital wall morpho
Kordzadeh A, Melchionda V, Rhodes KM, et al. Blunt abdominal logical properties and their supporting structures in the etiol
trauma and mesenteric avulsion: a systematic review. EurJ ogy of'blow out' fractures. Surg Radiol Anat 1989;11:241-248.
Trauma Emerg Surg 2016;42(3):311-315. Romero Tirado MLA, Blanco Pampin JM, Gallego Gomez R. Dating
Le Count ER, Apfelbach CW. Pathologic anatomy of traumatic frac of traumatic brain injury in forensic cases using immunohis-
tures of cranial bones. J Am Med Assoc 1920;74:501-511. tochemical markers (I): Neurofilaments and (3-amyloid precur
Lee MC, Haut RC. Insensitivity of tensile failure properties of sor protein. Am J Forensic Med Pathol 2018;39(3):201 -207.
human bridging veins to strain rate: Implications in biome Salia SM, Mersha HB, Aklilu AT, et al. Predicting dural tear in com
chanics of subdural hematoma .J Biomech 1989;22:537-542. pound depressed skull fractures: a prospective multicenter
Lindenberg R, Freitag E. The mechanism of cerebral contusions: correlational study. World Neurosurg 2018; 114:e833-e839.
a pathologic-anatomic study. Arch Pathol 1960;69:440-469. Saukko P, Knight B. Gunshot and explosion deaths. In: Saukko P,
Ling H, Morris HR, Neal JW, et al. Mixed pathologies including Knight B (eds). Knight's Forensic Pathology, 4th ed. Boca Raton:
chronic traumatic encephalopathy in retired association foot CRC Press; 2016,241-275.
ball (soccer) players. Acta Neuropathol 2017;133:337-352. Slaar A, Fockens MM, Wang J, et al. Triage tools for detecting
MacFarlane MP, Glen TC. Neurochemical cascade of concussion. cervical spine injury in pediatric trauma patients. Cochrane
Brain Inj 2015;29:139-153. Database Syst Rev 2017;12:CD011686. doi: 10.1002/14651858.
Margulies SS, Thibault LE, Gennarelli TA. Physical model simu CD011686.pub2.
lations of brain injury in the primate. J Biomech 1990;23: Vogel AM, Zhang J, Mauldin PD, et al. Variability in the evalu-
823-836. tion of pediatric blunt abdominal trauma. Pediatr Surg Int
McKee AC, Stein TD, Nowinski CJ, et al. The spectrum of disease 2019;35(4):479-485. doi: 10.1007/s00383-018-4417-z. [Epu b 2018].
in chronic traumatic encephalopathy. Brain 2013;136:43-64. Yoganandan N, Pintar FA, Sances A, et al. Biomechanics of skull
McKee AC, Cairns NJ, Dickson DW, et al. The first NINDS/ NIBIB fracture. J Neurotrauma 1995;12:659-668.
consensus meeting to define neuropathological criteria for Zingg T, Agri F, Bourgeat M, et al. Avoiding delayed diagnosis of
the diagnosis of chronic traumatic encephalopathy. Acta significant blunt bowel and mesenteric injuries: can a scoring
Neuropathol 2016;131:75-86. tool make the difference? A 7-year retrospective cohort study.
Mez J, Daneshvar DH, Kiernan PT, et al. Clinicopathological eval Injury 2018;49(1):33—41.
uation of chronic traumatic encephalopathy in players of
American football. JAm Med Assoc 2017;318:360-370.
Milroy CM, Whitwell HL. Difficult areas in forensic neuropathol Further general resources
ogy: homicide, suicide or accident. In: Whitwell HL (ed). Ellison de D, Love S, Chimelli LMC, et al. Neuropathology, 3rd ed.
Forensic Neuropathology. London: Arnold; 2005,124-134. Oxford: Elsevier Mosby; 2012.
Pressure to the neck
11 and asphyxia deaths
■ In trod uction ■ O b stru ctio n or occlusion of th e a irw a ys
■ Classificatio n of asphyxia ■ Pressure to the chest or a b d o m e n
■ P h a se s and signs of'asphyxia' ■ B ib lio g rap h y and in form ation s o u rce s
■ Ty p e s of m echanical asphyxial m e ch a n ism s ■ Fu rth e r gen eral resources
Figure 11.1 Classification of asphyxia in forensic contexts. (Adapted from Sauvageau A, Boghossian E. 2010,
Classification of asphyxia: the need for standardisation.)
Asphyxia
Failure in supply of Failure to transfer oxygen Failure of transport of oxygen Failure of cells to take up Complex cases/
adequate amounts of from the environment into due to a breakdown in supply oxygen (e.g., cyanide combined mechanisms
oxygen (e.g., due to the blood (e.g., external/ or uptake, or a problem with impeding cellular utilisation (e.g., drowning and
displacement of internal obstruction in blood flow due to local vascular of oxygen by damaging hanging: combined
environmental oxygen by smothering, choking and compression reducing cerebral enzyme systems - chemical venoarterial occlusion,
other gases; consumption hanging; extrinsic/intrinsic blood flow (e.g., hanging and asphyxia) upper airway
of oxygen without compromise of thoracic cage strangulation) obstruction from lifting
replacement; confinement function in mechanical/ of the tongue, and
in sewers etc.) traumatic asphyxia or chest tracheal compression
wall trauma; and reduced
etc.)
oxygen binding capacity of
the blood in carbon monoxide
toxicity)
Figure 11.2 Classification of asphyxia by pathophysiological mechanism. (Adapted from Byard 2011, Commentary on
Sauvageau.)
164 I Pressure to the neck and asphyxia deaths
Research into the pathophysiology of asphyxia con • Congestion and oedema of the face.
tinues, and has been assisted by attempts to analyse • Cyanosis (blue discolouration) of the skin of the
the sequence of events depicted in documented filmed face.
recordings made by individuals who have hung them • Right heart congestion and abnormal fluidity of
selves. Agonal sequences of movements have been the blood.
described, together with timings of their appearance
(see Table 11.2). However, none of these signs is specific to 'asphyxia'
(however defined). Ambroise Tardieu was convinced that
The 'classic signs of asphyxia' were traditionally
petechiae (Tardieu spots) were pathognomonic of suffo
described as:
cation, but they are not. They may be frequently seen, for
• Petechial haemorrhages in the skin of the face and example, in those dying from congestive cardiac failure
in the lining of the eyelids. deaths. Raised intravascular pressure in blood vessels
Phases and signs of'asphyxia' I 165
the absence of pressure applied to the neck, can breath- The external signs of manual strangulation (Figure 11.7)
hold in static apnoea settings for more than 10 minutes. can include bruises and abrasions on the front and sides
Historic animal experiments indicated the potential for of the neck, and the lower jaw; the pattern of skin sur
their survival up to 14 minutes following obstructive face injuries is often difficult to interpret because of the
asphyxiation. dynamic nature of an assault, and the possibility of the
repeated re-application of pressure during strangula
tion. These signs are often florid in the survivor and may
Strangulation be more pronounced in the fatality where death has not
Manual strangulation is used to describe the applica been immediate. It is generally not possible to reliably
tion of pressure to the neck using the hands (although determine which of an assailant's hands caused a par
some would add forearms/limbs), and is a relatively ticular set of injuries or how much pressure must have
common mode of homicide, particularly where there is been exerted by an assailant during the process of stran
disparity between the sizes of the assailant and victim. gulation based on the injury pattern (as was illustrated
Pressure to the neck and asphyxia deaths
Petechiae
Ear bleed
Congestion
Nose bleed
Petechiae
Bruises, abrasions
and fingernail m arks
Ligature mark
Figure 11.7 Potential signs of strangulation when cardiac arrest is delayed and circulation persists.
in the 'Barleycorn Public House Murder', described in level of the constricting ligature, and there is usually a
Box 11.3). Bruises caused by fingertip pressure (rounded ligature mark on the neck at the site of constriction. This
or oval-shaped bruises up to approximately 2 cm in size) mark may be formed by a combination of compression
and fingernail scratches (linear or crescent-shaped and abrasion of the skin, and often reflects the nature
abrasions, imprints or skin breaches) may be seen, the of the ligature itself, sometimes replicating the pattern
latter being made either by the assailant or the victim of the ligature. Precise documentation (including mea
(Figure 11.8). surement and scaled photography) of any pattern visible
Ligature strangulation may be homicidal, suicidal within a ligature mark, may enable comparison to be
or accidental and involves the application of pressure made with putative ligature in that case at a future date.
to the neck by an item capable of constricting the neck, Ligatures that are wide, or of a soft, non-abrasive mate
for example, a scarf, a neck-tie, a belt, a pair of tights, or rial, however, may leave very little evidence of compres
cable tie (Figure 11.9). There is frequently a clear demar sion on the skin of the neck, or even injury to underlying
cation of congestion, cyanosis and petechiae above the structures, because of pressure dispersal.
Hanging
Figure 11.10 Layered in situ dissection of the anterior neck Hanging describes suspension of the body by the neck.
structures is essential in order to evaluate injuries follow Any material capable of forming a ligature can be used
ing pressure to the neck. Such dissection must be carried for hanging. The pressure of the ligature on the neck is
out following 'drainage' or 'decompression' of the blood produced by the weight of the body; it is not necessary
vessels in the neck to avoid artefactual haemorrhage. for the body to be completely suspended, with the feet
Figure 11.13 Partial parchmented ligature mark with • Evid ence of solo sexual activity,
sparing to left side of neck at site of suspension.• Private or secure location.
172 I Pressure to the neck and asphyxia deaths
Geserick G, Krocker K, Wirth I. Tardieu's spots and asphyxia: a litera Reay DT, Eisele JW. Death from law enforcement neck holds. Am
ture study. Article in German. Arch Kriminol 2010;226(5-6): J Forensic Med Pathol 1982;3:253-258.
145-160. Rose A. Chapter 15. In: Lethal Witness. Gloucestershire: Sutton
Gill JR, Ely SF, Hua Z. Environmental gas displacement: three Publishing; 2007.
accidental deaths in the work place. Am J Forensic Med Pothol Rossen R, Kabat H, Anderson JP. Acute arrest of cerebral circula
2002;23:26-30. tion in man. Arch Neurol Psychiatry 1943;50:510-528.
Gilson T, Parks BO, Porterfield CM. Suicide with inert gases. Am J Sauvageau A, Boghossian E. Classification of asphyxia: the need
Forensic Med Pathol 2003;24:306-308. for standardization.-/ Forensic Sci 2010;55:1259-1267.
Greenwood RJ, Dupler DA. Death following carotid sinus pres Sauvageau A, Laharpe R, King D, et al. Agonal sequences in 14
sure. JAm Med Assoc 1962;181:605-609. filmed hangings with comments on the role of the type of
Harm T, Rajs J. Types of injuries and interrelated conditions of suspension, ischaemic habituation, and ethanol intoxication
victims and assailants in attempted and homicidal strangula on the timing of agonal sequences. Am J Forensic Med Pathol
tion. Forensic Sci Int 1981;18:101-103. 2011;32:104-107.
Hlavaty L, Sung L. Strangulation and its role in multiple causes of Sauvageau A. Current reports on autoerotic deaths: five persis
death. Am J Forensic Med Pothol 2017;38(4):283-288. tent myths. Curr Psychiatry Rep 2014;16:430.
Hillsborough Independent Panel. The report of the Hillsborough Schmunk GA, Kaplan JA. Asphyxial deaths caused by automo
Independent Panel. HMSO. https://assets.publishing.service. bile exhaust inhalation not attributable to carbon monoxide
gov.uk/government/uploads/system/uploads/attachment_ toxicity: study of 2 cases. Am J Forensic Med Pathol 2002;23:
data/file/229038/0581.pdf (Accessed 30 April 2019). 123-126.
Humble JG. The mechanism of petechial haemorrhage forma Schrag B, Vaucher P, Bollmann MD, Mangin P. Death caused by
tion. Blood 1949;4:69-75. cardioinhibitory reflex cardiac arrest: a systematic review of
Ikeda T, Tani N, Aoki Y, et al. Effects of postmortem positional cases. Forensic Sci Int 2011;207:77-83.
changes on conjunctival petechiae. Forensic Sci Med Pathol Schrag B, Mangin P, Vaucher P, Bollmann MD. Death caused by
2019;15(1):13—22. cardioinhibitory reflex: what experts believe. Am J Forensic
Jones R. Complexity in forensic pathology. Forensic Sci Int Med Pathol 2012;33:8-12.
2015;257:38-43. Sep D, Thies KC. Strangulation injuries in children. Resuscitation
Khokhlov VD. Pressure on the neck calculated for any point along 2007;74:386-391.
the ligature. Forensic Sci Int 2001;123:178-181. Shields LB, Corey TS, Weakley-Jones B, Stewart D. Living victims
Lasczkowski G, Risse M, Gamerdinger U, Weiler G. Pathogenesis of strangulation: a 10-year review of cases in a metropolitan
of conjunctival petechiae. Forensic Sci Int 2005;147:25-29. community. Am J Forensic Med Pathol 2010;31(4):320-325.
Le Blanc-Louvry I, Papin F, Vaz E, Proust B. Cervical arterial injury Simpson K. Murder at the John Barleycorn, Portsmouth. Police J
after strangulation: different types of arterial lesions .J Forensic 1947;20:18-26.
Sci 2013;58(6):1640-1643. Simpson K. Deaths from vagal inhibition. Lancet 1949;1:558-560.
Lebreton-Chakour C, Godio-Raboutet Y, Torrents R, et al. Manual Simpson K. 40 Years of Murder. London: Harrap Ltd; 1978.
strangulation: experimental approach to the genesis of hyoid Smith S. Mostly Murder. London: Granada Books; 1984.
bone fractures. Forensic Sci Int 2013;228(1 —3):47—51. Swann HG, Brucer M. The cardiorespiratory and biochemical
Linkletter M, Gordon K, Dooley J. The choking game and events during rapid anoxic death; obstructive asphyxia. Tex
YouTube: a dangerous combination. Clin Pediatr (Phila) Rep Biol Med 1949;7:593-603.
2010;49(3):274-279. Verma SK. Pediatric and adolescent strangulation deaths.
Maxeiner H, Brockholdt B. Homicidal and suicidal ligature stran J Forensic Leg Med 2007;14:61 -64.
gulation: a comparison of the post-mortem findings. Forensic Wright RK, Davis J. Homicidal hanging masquerading as sexual
Sci Int 2003;137:60-66. asphyxia. J Forensic Sci 1976;21:387-389.
Mcquown C, Frey J, Steer S, et al. Prevalence of strangulation in Zatopkova L, Janik M, Urbanova P, et al. Laryngohyoid frac
survivors of sexual assault and domestic violence. AmJ Emerg tures in suicidal hanging: a prospective autopsy study with
Med 2016;34(7):1281-1285. an updated review and critical appraisal. Forensic Sci Int
Mitchell JR, Roach DE, Tyberg JV, et al. Mechanism of loss of 2018;290:70-84.
consciousness during vascular neck restraint. J Appl Physiol
2012;112(3):396-402.
Payne-James JJ. Asphyxia: clinical findings. In: Payne-James JJ, Byard Further general resources
RW (eds). Encyclopedia of Forensic and Legal Medicine, 2nd ed. Payne-James JJ, Byard RW. Encyclopedia of Forensic and Legal
Oxford: Elsevier; 2016;246— 251. Medicine, 2nd ed. Oxford: Elsevier; 2016.
Puschel K,Turk E, Lach H. Asphyxia-related deaths. Forensic Sci Int
2004;144:211-214.
Heat, cold and electrical
12 trauma
■ Introduction ■ Electrical injury
■ Injury caused by heat ■ Bibliography and information sources
■ Cold injury (hypothermia) ■ Further general resources
Scalds
The general features of scalds are similar to those of
burns, with erythema and blistering, but charring
of the skin is only found when the liquid applied is
extremely hot, for example, with molten metal. The
Figure 12.1 The extensiveness of burns on a body recov
pattern of scalding will depend upon the way in which
ered from a fire may be varied. This individual had sec
the body has been exposed to the fluid: immersion
ond and third degree burns after dousing himself with
into hot liquid results in an upper 'fluid level', whereas
petrol before setting himself on fire (self-immolation).
poured, splashed or scattered droplets of liquid result
Note the molten and singed hair, carboxyhaemoglobin
in scattered punctate areas of scalding. Runs or streams
levels may be low in rapid flash petrol fires leading to dif
of hot fluid will leave characteristic areas of scalding.
ficulties in assessing vitality at the time of the fire.
These will generally flow under the influence of grav
ity and this can provide a marker to the orientation or
broken down into 18% for anterior components and 18% position of the victim at the time the fluid was moving
for the back. The anterior aspect of the trunk can further (Figure 12.4). This maybe useful for corroboration when
be divided into chest (9%) and abdomen (9%). The upper two different accounts of how the injury was sustained
extremities total 18% and thus 9% for each upper extrem are given.
ity. Each upper extremity can further be divided into If only small quantities of hot liquid hit the skin,
anterior (4.5%) and posterior (4.5%). The lower extremities cooling will be rapid, which will reduce the amount of
Box 12.7 A practical classification of burns related to extent of tissue dam age
Very superficial burns, for example, those caused by are damaged and the burn is very painful. New
sunburn, may simply cause reddening with mild epithelium grows quickly and the burn heals in
blistering that may occur after 12-18 hours. After 10-14 days with little or no scarring.
5-10 days the damaged layers of cells peel off Deep partial-thickness burns are often less painful as
without residual scarring. nerve endings are destroyed and scarring is likely
Partial-thickness burns destroy the whole of the epi to be marked if the wound is allowed to heal spon
dermis and possibly part of the next cellular layer: taneously without skin grafting.
the dermis. Full-thickness burns destroy all skin elements and may
Superficial partial-thickness burns result in fluid pro require substantial reconstructive surgery because
duction which lifts off the dead epidermis forming of the potential for incapacitating scarring.
blisters and subsequently scabs. Sensory nerves
Injury caused by heat I 179
Figure 12.2 (a) The 'Rule of Nines', (b) Lund and Browder Burns Chart.
damage done to the skin. However, if clothing is soaked in toddlers who pull kettles and saucepans down upon
by hot fluid, the underlying skin may be badly affected, themselves by grabbing the handle of the vessel.
as the fabric will retain the hot liquid against the skin Scalds are also seen in child physical abuse and are
surface. Scalding is seen typically in industrial settings the most common intentional thermal injury in chil
where steam pipes or boilers burst. It may also be seen dren. In a systematic review of the medical literature,
several characteristics of the history and burn injury
were associated with a significantly higher perceived
likelihood of abuse, including children with reported
inflicted injury, absent or inadequate explanation,
hot water as agent, immersion scald, a bilateral/sym
metric burn pattern, TBSA >10%, full thickness burns,
and concurrent injuries. Accidental scalds (e.g., from
hot beverages/liquids being pulled off a cooker) are
predominantly spill injuries from flowing liquid, char
acterised by scalds with irregular margins and burn
Pathophysiological consequences
of thermal injury
Tissue exposed to burn or scald trauma elicits an acute
inflammatory response, leading to increased capillary
permeability at the injured site; tissue fluid loss associ
ated with thermal injury can be severe enough to cause
dehydration, electrolyte disturbance and hypovolaemic
shock and, if the burn area exceeds 20% of the TBSA, the
release of systemic inflammatory mediators which may
lead to acute lung injury and multiple organ dysfunc
tion/failure. Burned skin provides no protection against
infection, increasing the risk of sepsis in survivors.
Exposure to heat/hyperthermia
Hyperthermia, a condition where the core body tem
perature is greater than 40°C (100°F), occurs when heat
is no longer effectively dissipated, leading to exces
sive heat retention. Its development may be associated
with those who have taken prescribed drugs including
some anti-psychotics and those who have taken illicit
stimulants including cocaine and amphetamine and
some novel psychoactive substances. These appear to
elevate metabolic rate/heat production or reduce sweat
ing. It may also occur in those with medical conditions
(e.g., hyperthyroidism), or in those who are resisting
restraint. It may occur in those exposed to high ambi
ent temperatures (heat stroke) and has a high risk of
mortality or morbidity, which can occur in the young
and fit (exertional heat stroke) as well as the elderly and
infirm (non-exertional heat stroke). Other examples
may include children trapped in hot cars. Exertional
heat illness is recognised within military training pro
grammes. Autopsy findings in such cases are non-spe-
cific but can include diffuse petechial haemorrhages of
serosal membranes and lung congestion as well as fea
tures in keeping with 'shock' and multiple organ failure
in those who survive for a short period, if resuscitative
measures are ineffective.
Children have a high body surface-to-weight ratio necrosis following microvascular injury and thrombo
and lose heat rapidly. In some cases of deliberate neglect sis (Figure 12.17).
or careless family circumstances, infants may be left in Hypothermia may cause behavioural abnormali
unheated rooms in winter and suffer hypothermia. ties that can lead to death-scene findings that appear
In an unrefrigerated body, the finding of indistinct suspicious. Paradoxical undressing is a phenomenon
red or purple skin discolouration over large joints, that describes the finding of partially clothed, or naked,
such as the elbows, hips or knees (and in areas of skin individuals in a setting of lethal hypothermia. The
in which such discolouration cannot be hypostasis)
raises the possibility of hypothermia and is found in
approximately 50 per cent of presumed hypothermia
deaths (Figure 12.15). The nature of such discoloura
tion ('frost erythema') is not completely understood,
but may reflect capillary damage and plasma leakage;
microscopy reveals no red blood cell extravasation, dis
tinguishing it from bruising.
Classically, haemorrhagic gastric lesions (Wisch-
newsky spots) may be seen in hypothermia deaths. It
has been hypothesised that cooling of the body in the
setting of cold ambient temperatures primarily leads
to circumscribed haemorrhages of the gastric glands
in vivo or in the agonal period. Subsequently, due to
autolysis, erythrocytes are destroyed and haemoglobin
is released. Following exposure to gastric acid, haemo
globin is hematinised, leading to the typical blackish-
brownish appearance of Wischnewsky spots seen at
gross examination (Figure 12.16). Like Tardieu spots
and asphyxia, Wischnewsky spots are not specific to
hypothermia as they are identical to those lesions seen
in some deaths following sepsis and shock, as well as in
cases of alcohol misuse.
Other gastrointestinal lesions sometimes found in
deaths caused by hypothermia include haemorrhagic
erosions and infarction in the small bowel (because of Figure 12.15 (a) Pinkish discolouration over the large
red blood cell 'sludging' and submucosal thrombosis), joints in fatal hypothermia, (b) When a partially-clothed
and haemorrhagic pancreatitis with fat necrosis. body is found outdoors, caution is needed in order
Cold injury to the extremities may be severe enough to exclude foul play. This scene, however, illustrates
to cause frostbite, which reflects tissue injury that hypothermia-related disrobing ('paradoxical undressing')
varies in severity from erythema to infarction and and the so-called 'hide and die' phenomenon.
Electrical injury I 187
the electric field, but similar appearances can occur in Bibliography and information
purely thermal burns. Metallisation of the skin may be a
marker of electrocution. The use of a scanning electron sources
microscope equipped with an Energy Dispersive X-Ray Adato B, Dubnov-Raz G, Gips H, et al. Fatal heat stroke in chil
Spectroscopy (EDS) probe may allow the detection and dren found in parked cars: autopsy findings. Eur J Pediotr
the identification of the metals embedded in the skin 2016;175(9):1249-1252.
and their evaluation in the context of the ultrastructural Adekoya N, Nolte KB. Struck-by-lightning deaths in the United
States. J Environ Health 2005;67(9):45-50,58.
morphology, and assist in diagnosis.
Arturson MG. The pathophysiology of severe thermal injury. J
Burn Care Rehabi11985;6:129-146.
Death from lightning Ayoub C, Pfeifer D. Burns as a manifestation of child abuse and
neglect. Am J Dis Child 1979;133:910-914.
Hundreds of deaths occur each year from atmospheric Bright FM, Byard RW. Extremes of temperature: hypothermia.
lightning, especially in tropical countries. A lightning In: Payne-James JJ, Byard R (eds). Encyclopedia of Forensic
strike from cloud to earth may involve property, animals and Legal Medicine, Volume 2, 2nd ed. Oxford: Elsevier; 2016,
or humans. Huge electrical forces are involved, produc 486-495.
ing millions of amperes and phenomenal voltages. Some Busche MN, Gohritz A, Seifert S, et al. Trauma mechanisms, pat
of the lesions caused to those who are struck directly terns of injury, and outcomes in a retrospective study of 71
or simply caught close to the lightning strike are purely burns from civil gas explosions J Trauma 2010;69:928-933.
Cheah AKW, Kangkorn T, Tan EH, et al. The validation study on a
electrical, but other injuries will be from burns or from
three-dimensional burn estimation smart-phone application:
the explosive effects of a compression wave of heated air accurate, free and fast? Burns Trauma 2018;6:7.
leading to ruptured tympanic membranes, pulmonary Cherrington M, Olson S, Yarnell PR. Lightning and Lichtenberg
blast injury and muscle necrosis/myoglobinuria. Many figures. Injury 2003;34:367-371.
bizarre appearances may be found, especially the par DeGroot DW, MokG, Hathaway NE. International classification of
tial or complete stripping of clothing from the victim, disease coding of exertional heat illness in U.S. army soldiers.
which may arouse suspicions of foul play. Severe burns, Mil Med 2017;182(9):e1946-e1950.
fractures and gross lacerations can occur, along with the D'Souza AL, Nelson NG, McKenzie LB. Pediatric burn injuries
well-known magnetisation or even fusion of metallic treated in US emergency departments between 1990 and
objects in the clothing. The usual textbook description is 2006. Pediatrics 2009;124:1424-1430.
Dutta B. Lichtenberg figure and lightning. Indian J Dermatol
of Tern- or branch-like' patterns on the skin, the so-called
2016;61(1):109-111.
Lichtenberg figure (Figure 12.21) but others claim that Esen Melez i, Arslan MN, Melez DO, et al. Manner of death deter
such marks are not seen, although if they have seen the mination in fire fatalities: 5-year autopsy data of Istanbul City.
image in Figure 12.21, it is unlikely they would disagree. Am J Forensic Med Pathol 2017;38(1):59-68.
Red streaks following skin creases or sweat-damped Ferrari LA, Giannuzzi L. Assessment of carboxyhemoglobin,
tracks are more likely, although many bodies are com hydrogen cyanide and methemoglobin in fire victims: a
pletely unmarked. novel approach. Forensic Sci Int 2015;256:46-52.
Gaudio FG, Grissom C. Cooling methods in heat stroke. J Emerg
Med 2016;50(4):607-616.
Kauvar DS, Wolf SE, Wade CE, et al. Burns sustained in combat
explosions in Operations Iraqi and Enduring Freedom (OIF/
OEF explosion burns). Burns 2006;32:853-857.
Lund CC, Browder NC. The estimation of areas of burns. Surg
Gynaecol Obstet 1944;79:352-358.
Madea B,Tsokos M, Preu(3 J. Death due to hypothermia. ln:Tsokos
M (ed). Forensic Pathology Reviews, Volume 5.Totowa: Humana
Press; 2008,3-21.
Maquire S, Moynihan S, Mann M, et al. A systematic review of
the features that indicate intentional scalds in children. Burns
2008;34:1072-1081.
McCance KL, Huether SE. Pathophysiology. The Biologic Basis for
Disease in Adults and Children, 6th ed. St Louis: Mosby Inc.; 2009.
Miller SF, Finley RK, Waltman M, Lincks J. Burn size estimate reli
ability: a study. J Burn Care Rehabil 1991;12(6):546—559.
Moore RA, Burns B. Rule of nines. [Updated 2018 Jul 25]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2018.
Figure 12.21 The 'Lichtenberg figure' and lightening Moritz AR, Henriques FC. Studies of thermal injury II. The relative
fatalities. Note the fern-like branching pattern of skin importance of time and surface temperature in the causation
discolouration particularly on the upper right chest. of cutaneous burns. Am J Pathol 1947;23:695-720.
Heat, cold and electrical trauma
Nixdorf-Miller A, Hunsaker DM, Hunsaker JC 3rd. Hypothermia Stroop R, Schone C, Grau T. Incidence and strategies for pre
and hyperthermia medico-legal investigation of morbidity venting sustained hypothermia of crash victims during
and mortality from exposure to environmental temperature prolonged vehicle extrication. Injury 2019;50(2):308-317. pii:
extremes. Arch Pathol Lab Med 2006;130:1297-1304. S0020-1383(18)30626-0.
Odell M. Electric shocks and electrocution: clinical effects and Suominen PK, Vallila NH, Hartikainen LM, et al. Outcome of
pathology. In: Payne-James JJ, Byard RW (eds). Encyclopedia drowned hypothermic children with cardiac arrest treated
of Forensic and Legal Medicine, 2nd ed. Oxford: Elsevier; 2016. with cardiopulmonary bypass. Acta Anaesthesiol Scand
Pawlik MC, Kemp A, Maguire S, et al. Children with burns referred 2010;54:1276-1281.
for child abuse evaluation: burn characteristics and co-exis- Tsokos M, Rothschild MA, Madea B, et al. Histological and irmmu-
tent injuries. Child Abuse Negl 2016;55:52-61. nohistochemical study of Wischnewsky spots in fatal hypo
Pincus JL, Lathrop SL, Briones AJ, et al. Lightning deaths: a retro thermia. Am J Forensic Med Pathol 2006;27(1):70-74.
spective review of New Mexico's cases, 1977-2009.J Forensic Visona SD, Chen Y, Bernardi P, et al. Diagnosis of electrocution:
Sci 2015;60(1):66-71. the application of scanning electron microscope and energy-
Roeder RA, Schulman Cl. An overview of warrelated thermal inju dispersive X-ray spectroscopy in five cases. Forensic Sci Int
ries. J Craniofac Surg 2010;21:971-975. 2018;284:107-116.
Rothschild MA. Lethal hypothermia: paradoxical undressing and Williams B, Deaton T, Galarneau M, et al. Fatal and non-fatal elec
hide-and-die syndrome can produce very obscure death trocution injuries at U.S. marine corps forward medical facili
scenes. In: Tsokos M (ed). Forensic Pathology Reviews, Volume ties during operation enduring freedom and operation iraqi
1. Totowa: Humana Press; 2004,263-272. freedom. Mil Med 2017;182(9):e2017-e2023.
Ruas F, Mendonga MC, Real FC, et al. Carbon monoxide poisoning Wills S. Extremes of temperature: hyperthermia. In: Payne-James
as a cause of death and differential diagnosis in the forensic JJ, Byard R (eds). Encyclopedia of Forensic and Legal Medicine,
practice: a retrospective study, 2000-2010. J Forensic Leg Med Volume 2,2nd ed. Oxford: Elsevier; 2016,476-485.
2014;24:1-6. Wick R, Gilbert JD, Simpson E, Byard RW. Fatal electrocution in
Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates adults: a 30-year study. Med Sci Law 2006;46:166-172.
of probability of death from burn injuries. New Engl J Med Yigit M, Tanrikulu N, Turkdogan KA, Yigit E. Pathognomonic
1998;338:362-366. symptom associated with lightning strike: Lichtenberg figure.
Schimmel J, George N, Schwarz J, et al. Carboxyhemoglobin lev J Pak Med Assoc 2015;65(2):218-219.
els induced by cigarette smoking outdoors in smokers J Med Yankelson L, Sadeh B, Gershovitz L, et al. Life-threatening events
Toxicol 2018;14(1):68— 73. during endurance sports: is heat stroke more prevalent than
Selvaggi G, Monstrey S, Van Landuyt K, et al. Rehabilitation of arrhythmic death? JAm Coll Cardiol 2014;64(5):463-469.
burn injured patients following lightning and electrical
trauma. NeuroRehabilitation 2005;20:35-42.
Shkrum MJ, Ramsay DA. Forensic Pathology of Trauma: Common Further general resources
Problems for the Pathologist. Totowa: Humana Press; 2007. Payne-James JJ, Byard RW (eds). Encyclopedia of Forensic and Legal
Strassle PD, Williams FN, Napravnik S, et al. Improved survival of Medicine, 2nd ed. Oxford: Elsevier; 2016.
patients with extensive burns: trends in patient characteris
tics and mortality among burn patients in a tertiary care burn
facility, 2004-2013.J Burn Care Res 2017;38(3):187-193.
;
Post mortem artefact and fragments/limbs may become detached and lost due to
decomposition and movement of the body in water.
immersion
Bodies immersed in water may be subject to movement
from tidal flow, wind and waves and come into con Pathological diagnosis of drowning
tact with sand/silt, rocks, piers and other underwater Pathophysiology of drowning
objects, all of which cause injury to the skin and under
Drowning is a complex phenomenon embracing a range
lying structures (Figure 13.3). Specific injury patterns
of psychological, physical, clinical and pathological
may be identified. For example, contact of a body with
mechanisms. Some of these relate to the upper airway
moving propeller blades classically leads to deep 'chop'
being out of the water, and others relate to the upper
wounds and/or lacerations and sometimes traumatic
airway being underwater. Immersion in water causes
amputation. Artefactual post mortem injuries produced
an interplay between cardiorespiratory responses to
in such circumstances must be differentiated from ante
skin and deep body temperature, including cold shock,
mortem injuries suggestive of assault.
physical incapacitation, and hypovolaemia, as precur
Other artefactual injuries characterised by immer
sors of collapse and submersion. These are combined
sion include damage to the body by marine life (e.g.,
with the diving response, autonomic processes, fear of
shark, alligators, fish, crustaceans, molluscs and insects;
drowning, upper airway reflexes, water aspiration and
Figure 13.4). As the post mortem interval increases,
swallowing, emesis, and electrolyte disorders. The out
come is determined by a mixture of cardiac, pulmonary,
and neurological insults. Regardless of the composition
of water/fluid, drowning, the process of experiencing
respiratory impairment from submersion in a liquid,
may also result in pulmonary surfactant insufficiency/
damage, pulmonary oedema, alveolitis, hypoxaemia
and metabolic acidosis. In addition, as the popularity of
water-based sports advances, specific conditions such
as swimming-induced pulmonary oedema are being
recognised.
As time in cold water continues, so does the likelihood
of hypothermia (core body temperature <35°C). As hypo
thermia develops, cognitive function becomes impaired
Figure 13.3 Post mortem injuries predominantly to the increasing the risks of (1) poor decision-making and (2)
back of the hand of a body recovered from a shallow aspiration of water.
river. Such injuries are likely to have been caused by Drowning reflects a combination of the physical
contact against the river bed. presence of water within the respiratory system (caus
ing a mechanical asphyxia) and fluid and electrolyte
changes which vary according to the medium (sea vs
fresh water) in which immersion has occurred.
Fresh water is hypotonic compared with blood plasma
and, when inhaled, is rapidly absorbed into the blood
stream, causing transient (but probably clinically irrel
evant) electrolyte dilution and hypervolaemia. It results
in alveolar collapse/atelectasis because of changes in
the surface tension properties of pulmonary surfactant,
resulting in intrapulmonary (left to right) shunts.
Seawater is generally three times more hyperosmolar
than blood plasma, and following inhalation the hyper
osmotic seawater can result in serious effects to the
lung and alveoli. These effects may be predominantly
categorised into insufficiency of pulmonary surfactant,
blood-air barrier disruption, inflammation, oxidative
Figure 13.4 Post mortem injuries caused by marine stress, autophagy and apoptosis. Aspiration of fresh or
creature predation. This body was recovered from the sea water therefore leads to systemic hypoxaemia caus
sea and the circular skin defects are likely to have been ing myocardial depression, reflex pulmonary vasocon
caused by crustaceans such as crabs. striction and altered pulmonary capillary permeability,
Immersion and drowning
increasing the likelihood of the development of a fatal Co-stimulation of both diving and cold shock
arrhythmia. Cardiac arrest has also been documented responses may precipitate arrhythmias including atrial
following entry of water into the nose. fibrillation and those associated with drug-induced pro
The cold shock response, which is initiated by periph longed QT intervals.
eral subcutaneous receptors, causes respiratory effects
(inspiratory gasp and uncontrolled hyperventilation, The role of alcohol and drugs in
respiratory alkalosis and cerebral hypoxia) and cardio
vascular effects (tachycardia, increased cardiac output, drowning
hypertension and 'heart strain' potentially leading to Alcohol and drugs are often frequently found in the
cardiac irritability and ventricular fibrillation), which blood of drowning victims and their contribution to the
appear temperature dependent. death may be difficult to determine, but there is a strong
association between substance use and 'fall-related' determining if a body recovered in water was due to
cases; concussive head injuries may be exacerbated by drowning or not. In particular, a diatom database of the
alcohol, with immersion/submersion contributing to a rivers, seas, and lakes is essential as is collection of a
fatal outcome. Vasodilation from alcohol and other sub water sample from the putative site of drowning to allow
stances may initiate and worsen hypothermia. The use a rigorous comparison of the diatom species in water
of alcohol and drugs may encourage risk-taking behav and biological samples. It must be emphasised however
iour. Additionally, a person intoxicated through alcohol that the interpretation of diatom testing remains con
(or other drugs) has a reduced ability to respond appro troversial, as diatoms have been found to be ubiquitous
priately and may be hampered by confusion, ataxia and in food and the environment, have been found in non
incoordination as a direct result of the substance use. drowning deaths and have been absent in confirmed
cases of drowning. The use of diatomology in the foren
sic diagnosis of drowning must currently be used with
Other investigations in bodies caution and in the light of available evidence, but may
recovered from water be useful to corroborate other findings.
Strontium (Sr) concentration in tooth samples has
been used for the diagnosis of seawater drowning, and
Bibliography and information
research continues on this. Although there are no other
specific reliable biochemical markers for drowning, sources
there has been some promising research into utilising Azaparren JE, Vallejo G, Reyes E, et al. Study of the diagnostic
lung-body weight (LB) ratio with post mortem vitreous value of strontium, chloride, haemoglobin and diatoms in
humor sodium and chloride (PMVSC) to diagnose salt immersion cases. Forensic Sci Int 1998;91:123-132.
water drowning when the immersion time is less than 1 Bierens JJLM, Lunetta P, Tipton M, Warner DS. Physiology of
hour. Additionally, the use of real-time polymerase chain drowning: a review. Physiology 2016;31:147-166.
Cihan E, Hesdorffer DC, Brandsoy M, et al. Dead in the water:
reaction (PCR) assays with TaqMan probes to differenti
epilepsy-related drowning or sudden unexpected death in
ate freshwater from marine bacterioplankton have been
epilepsy. Epilepsia 2018;59(10):1966-1972.
shown to assist in the diagnosis of drowning. This will Coelho S, Ramos P, Ribeiro C, et al. Contribution to the deter
continue to be an area of important research but inter mination of the place of death by drowning: a study of dia
pretation may be complicated by uncertainties about the toms' biodiversity in Douro river estuary. J Forensic Leg Med
nature of drinking water/human microbiomes. 2016;41:58-64.
Copeland AR. An assessment of lung weights in drowning cases:
Diatoms the Metro Dade County experience from 1978 to 1982. AmJ
Forensic Med Pathol 1985;6:301 -304.
Diatoms are microscopic organisms present in sea and Datta A, Tipton MJ. Respiratory responses to cold water immer
fresh water, and have a siliceous capsule that survives sion: neural pathways, interactions, and clinical consequences
acid digestion in the laboratory (Figure 13.7). The pres awake and asleep .J Appl Physiol 2006;100:2057-2064.
ence of diatoms in the lung tissues, internal organs Fortes FJ, Perez-Carceles MD, Sibon A, et al. Spatial distribution
and bone marrow is considered by some to be sup analysis of strontium in human teeth by laser-induced break
portive evidence in the diagnosis of death by drown down spectroscopy: application to diagnosis of seawater
drowning. Int J Legal Med 2015;129(4):807—813.
ing. Quantitative diatom analysis in the lung tissues,
Golden FS, Tipton MJ, Scott RC. Immersion, near drowning and
combined with the diatom analysis of the drown
drowning. BrJAnaesth 1997;79:214-225.
ing medium, may provide supportive evidence in Hsieh WH, Wang CH, Lu TH. Bathtub drowning mortality among
older adults in Japan. Int J Inj Contr Saf Promot 2019;26(2):
151-155.
Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for
uniform reporting of data from drowning: the Utstein style.
Resuscitation 2003;59:45-57.
Jin F, Li C. Seawater-drowning-induced acute lung injury: from
molecular mechanisms to potential treatments. Exp TherMed
2017;13(6):2591-2598.
Kanthem RK, Guttikonda VR, Yeluri S, Kumari G. Sex determina
tion using maxillary sinus .J Forensic Dent Sci 2015;7(2):163—167.
Karhunen PJ, GoebelerS, Winberg 0,Tuominen M.Time of death
of victims found in cold water environment. Forensic Sci Int
2008;176(2-3):e17-22.
Kaur PP, Drummond SE, Furyk J. Arrhythmia secondary to cold
water submersion during helicopter underwater escape
Figure 13.7 Diatoms from lake water. training. Prehosp Disaster Med 2016;31 (1):108—110.
Further general resources I 197
Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis Royal College of Pathologists. Guidelines on Autopsy Practice:
Child 2011;96:5-8. Autopsy for Bodies Recovered from Water. London: RCP, 2018.
Lee DH, Park JH, Choi SP; et al. Clinical characteristics of elderly Rutty GN, Bradley CJ, Biggs MJ, et al. Detection of bacterioplank-
drowning patients. Am J Emerg Med 2018;37(6):1091 -1095. ton using PCR probes as a diagnostic indicator for drowning:
Lukaszyk C, Mittal S, Gupta M, et al. The impact and understand the Leicester experience. Leg Med (Tokyo) 2015;17(5):401 —408.
ing of childhood drowning by a community in West Bengal, Sarode GS, Sarode SC, Choudhary S, et al. Dental records of
India, and the suggested preventive measures J Acta Paediatr forensic odontological importance: maintenance pattern
2019;108(4):731 -739. among dental practitioners of Pune city. J Forensic Dent Sci
Lunetta P. Autopsy findings: drowning and submersion deaths. 2017;9(1):48.
In: Payne-James JJ, Byard RW (eds). Encylopedia of Forensic and Saukko P, Knight B. Immersion deaths. In: Knight's Forensic
Legal Medicine, Volume 1,2nd ed. Oxford: Elsevier; Academic Pathology 4th ed. Boca Raton: CRC Press; 2016,399-413.
Press, 2005,315-322. Smith R, Ormerod JOM, Sabharwal N, Kipps C. Swimming-
Lunetta P, Penttila A, Sajantila A. Circumstances and macropatho- induced pulmonary edema: current perspectives. Open
logic findings in 1590 consecutive cases of bodies found in Access J Sports Med 2018;9:131-137.
water. Am J Forensic Med Pathol 2002;23:371-376. Suzuki T. Suffocation and related problems. Forensic Sci Int
Lunetta P, Smith GS, Penttila A, Sajantila A. Unintentional drown 1996;80:71-78.
ing in Finland 1970-2000: a population-based study. IntJ Tester DJ, Medeiros-Domingo A, Will ML, Ackerman MJ.
Epidemiol 2004;33:1053-1063. Unexplained drowning and the cardiac channelopathies: a
Modell JH, Davis JH. Electrolyte changes in human drowning molecular autopsy series. Mayo Clin Proc 2011 ;86:941 —947.
victims. Anesthesiology 1969;30:414-420. Tipton MJ. The initial responses to cold-water immersion in man.
Modell JH, Moya F. Effects of volume of aspirated fluid dur Clin Sci 1989;77:581-588.
ing chlorinated fresh water drowning. Anesthesiology Tipton MJ, Collier N, Massey H, et al. Cold water immersion: kill or
1966;27:662-672. cure? Exp Physiol 2017;102:1335-1355.
Modell JH, Bellefleur M, Davis JH. Drowning without aspiration: is Tobin JM, Rossano JW, Wernicki PG, et al. Dry drowning: a distinc
this an appropriate diagnosis? J Forensic Sci 1999;44:1119-1123. tion without a difference. Resuscitation 2017;118:e5-e6.
Morild I. Pleural effusion in drowning. Am J Forensic Med Pathol Tse R, Garland J, Kesha K, et al. Combining postmortem vitreous
1995;16:253-256. sodium and chloride and lung-body ratio in aiding the
Necas P, Hejna P. Eponyms in forensic pathology. Forensic Sci Med diagnosing saltwater drowning. Am J Forensic Med Pathol
Pathol 2012;8(4):395—401. 2018;39(3):229-235.
Orlowski JP. Drowning, near-drowning, and ice-water submer van Beeck EF, Branche CM, Szpilman D, et al. A new definition
sions. Pediatr Clin North Am 1987;34:75-92. of drowning: towards documentation and prevention of
Pajunen T, Vuori E, Lunetta P. Epidemiology of alcohol-related a global public health problem. Bull World Health Organ
unintentional drowning: is post-mortem ethanol production 2005;83:853-856.
a real challenge? InjEpidemiol 2018;5(1):39. Vincenzi FF. Drug-induced long QT syndrome increases the risk
Peden AE, Barnsley PD, Queiroga AC. The association between of drowning. Med Hypotheses 2016;87:11-13.
school holidays and unintentional fatal drowning among Williams VF, Oh GT, Stahlman S. Update: Accidental drownings
children and adolescents aged 5-17 years. J Paediatr Child and near drownings, active component, U.S. Armed Forces,
Health 2019;55(5):533-538. 2013-2017. MSMR 2018;25(9):15-19.
Peden AE, Franklin RC, Leggat P. Preventing river drowning Zhao J, Ma Y, Liu C, et al. A quantitative comparison analysis of
deaths: lessons from coronial recommendations. Health diatoms in the lung tissues and the drowning medium as an
PromotJAustr 2018;29(2):144-152. indicator of drowning. J Forensic Leg Med 2016;42:75-78.
Peden AE, Franklin RC, Pearn JH. Unintentional fatal child drown
ing in the bath: a 12-year Australian review (2002-2014).
Paediatr Child Health 2018;54(2):153-159.
Further general resources
Reijnen G, van de Westeringh M, Buster MC, et al. Epidemiological Payne-James JJ, Byard RW. Encyclopedia of Forensic and Legal
aspects of drowning and non-fatal drowning in the waters of Medicine. Oxford: Elsevier; 2016.
Amsterdam. J Forensic Leg Med 2018;58:78-81.
14 Identification of the living
and the dead
■ Introduction ■ Age estimation in the living
■ Methods of identification ■ Bibliography and information sources
■ Identity of decomposed or skeletalised remains ■ Further general resources
■ Mass disasters
photographs and location. Additional techniques such elements of forensic science) that the use of DNA should
as gait analysis or facial profiling from CCTV can be use be considered as another piece of the jigsaw in the over
ful when other features cannot be used, although their all puzzle of solving crime and identifying unknown
accuracy is less consistent. individuals.
Comparison of DNA profiles with assumed or known
family members or against known databases can ensure
DNA profiling a person's identity is established. If these comparisons
The specificity of individual DNA profiles means that cannot be done, other tests must be used.
from a statistical point of view it can be considered spe As forensic DNA analysis continues to progress,
cific to any given individual. identifying, extracting and amplifying smaller and
The molecule of DNA has two strands of sugar and smaller amounts of genetic material, so the risks of
phosphate molecules that are linked by combinations contamination from other sources increase. Crime
of four bases, adenine, thymine, cytosine and gua and mass disaster scenes have great potential for cross
nine, forming a double helix structure. Only about 10 contamination and standard operating procedures to
per cent of the molecule is used for genetic coding (the avoid contamination must always be in place to mini
active genes), the remainder being 'silent'. In these mise this risk. Appropriate protective clothing must be
silent zones, there are between 200 and 14,000 repeats worn to prevent the investigators obscuring any rel
of identical sequences of the four bases. Sir Alec Jeffreys evant DNA by their own material being inadvertently
found that adjacent sequences were constant for a shed from exposed skin, or by sneezing, or perhaps
given individual and that they were transmitted, like even by touching. In many jurisdictions, it is now a
blood groups, from the DNA of each parent. The statis requirement for all those involved in the identification,
tical analysis of DNA identification is extremely com collection and analysis of samples to provide exclusion
plex and it is important that any calculations are based DNA samples in the same way as exclusion fingerprints
upon the DNA characteristics of a relevant population were once provided.
and not upon the characteristics of a 'standard' popu
lation somewhere else in the world. Forensic genetics Examination of dental structures
developed from protein-based techniques and brought Forensic odontology is one of the most important
with it the term 'DNA fingerprinting', this being based specialties available to establish or confirm identity
on restriction fragment length polymorphisms (RFLPs) of unknown bodies whether in isolation, after terror
of high-molecular-weight DNA. Development of ana ist events, in mass graves or after natural disasters.
lytical techniques resulted such as the amplification The success of such identification is very dependent
of much smaller short tandem repeat (STR) sequences on access to ante mortem records from general den
using the polymerase chain reaction (PCR) which soon tal practitioners. Pre-existing (ante mortem) dental
replaced RFLP analysis and became standard in genetic records and charts and radiographic images can be
identification. STR multiplexes are now available which compared with examination of the dentition of the
simultaneously amplify up to 30 STR loci from as little as deceased (Figure 14.1). If these are not immediately
15 cells or fewer. The huge volume of information asso available an odontologist will construct dental charts
ciated with the great range of observed STR genotypes of bodies whose identity remains unknown or uncon
allows for genetic individualisation (with the exception firmed despite a police investigation, so that, should
of identical twins). dental information become available at a later date,
Unlike before, there is now no need to match blood the two sets of records may be then be compared. The
with blood, and semen with semen, as all the DNA in essence of the identification by dentition is compari
one individual's body must of necessity be identical. son. This implies that the dental chart has to be com
Buccal swabbing permits simple sampling of a sus pared with, and found to match, a chart whose origins
pect. A suspect in any crime leaving cells or biological are known (Figure 14.2). Unfortunately, studies suggest
fluids at a scene leaves proof of their presence at the that the recording of accurate dental charts by general
scene. The continued ability to analyse smaller and dental practitioners is sometimes inadequate.
smaller amounts of DNA and to recover and analyse The forensic odontologist is of prime importance in
historical samples means that many old crimes can mass disasters where trauma is likely to make visual
be investigated (or reinvestigated) and there is now a identification impossible. The great advantage of den
considerable number of individuals being found guilty tal identification is that the teeth are the hardest and
of a crime decades later as a result of DNA advances. most resistant tissues in the body and can survive total
Additionally, and some might argue more impor decomposition and even severe fire, short of actual cre
tantly, there is a considerable body of those who were mation and thus DNA samples (e.g., from teeth pulp)
incorrectly convicted, being exonerated, as a result of which can be collected by the forensic odontologist can
these newer techniques. It is important (as with most be stored for future analysis (Figure 14.3).
Identification of the living and the dead
Figure 14.1 Identification from the teeth: post mortem X-rays (outlined in red) are compared with ante mortem radi
ography which, in this case shows a good match. (From Saukko P, Knight B. Knight's Forensic Pathology. 4th ed. Boca
Raton: CRC Press, 2016 [Fig. 26.8].)
Figure 14.4 Preserving fire-damaged teeth at the scene. A forensic odontologist applies cold cure acrylic liquid to
teeth (a), which sets and helps protect the teeth during transportation to the mortuary (b).
Box 14.2 Issues arising following the discovery of apparently human remains
Are the remains actually bones? What was the age of the person at death?
Sometimes objects such as stones, plastic models or This will require a multiprofessional approach utilising
even pieces of wood are mistaken by the public or the skills of the forensic pathologist, anthropologist,
police for bones: the anatomical shape, character and odontologist and radiologist, each contributing to the
texture may not always be obvious to someone who is overall picture.
medically trained, but in most cases will be.
What was the height (stature) of the person?
Are the remains human? The head to heel measurement of even the newly
deceased is rarely the same as the person's standing
This isa more difficult question to answer. Differentiating
height in life, owing to a combination of factors, including
human from animal bones is not always easy. A foren
muscle relaxation and shrinkage of intervertebral discs.
sic pathologist or forensic physician should be able to
If a whole skeleton is present, an approximate height
identify almost all of the human skeleton, although
can be obtained by direct measurement but, because of
phalanges, carpal and tarsal bones can be extremely
a range of factors (e.g., changes in joint spaces, articu
difficult to positively identify as human because some
lar cartilage) this can only be an approximation. If only
animals have extrem ity bones with features similar
some bones are available, calculations can be made
to the human hand and wrist. Identifying the source
from established tables, of which there are many. Height
of fragmented or burned/cremated bones generally
can be estimated from a range of long bones including
requires the skill of a forensic anthropologist or com
the humerus, ulnar and femur. Other bones such as the
parative anatomist.
sternum have also been used in this setting.
Do the remains represent one or more bodies (is there What is the ancestry of the deceased?
co-mingling of body parts)?
This is a very complex area of much controversy and sits
Clearly, if there are two intact skulls or two intact left firmly within the realm of anthropologists whose main
femurs then specific expertise is not required. If there focus lies within the field of craniometries.
is no obvious duplication, it is important to examine
each bone carefully to assess whether the sizes and Can a personal identity be discovered?
appearances match. Excluding the possibility of co- The previous criteria can assign bones broadly to vari
mingling of skeletal remains is the realm of the forensic ous groups of age and sex but putting a name to the
anthropologist. individual depends, as does all identification, upon hav
ing reliable, corroborative ante mortem data. There are
What is the biological sex? occasions when foreign bodies such as bullets or other
There is a vast anthropological literature on these metallic fragments may be found embedded in the skel
matters with norms established for a range of popu eton; these may either relate to the cause of death or
lations. The skull and the pelvis offer the best informa may simply be an incidental finding. Sometimes these
tion on sexing; although the femur and sternum can can assist in identification. Surgical or other implant
provide assistance. There are, however, many studies procedures (e.g., pacemakers, arthroplasty implants,
which explore these and other structures including implantable defibrillators) have a unique reference
the maxillary sinus volume, and the nature of teeth number which may identify the maker; these and other
and the size of the patella. It is im portant to attempt unique medical data are often useful in establishing
to determine the sex of each of these structures and identity, and can frequently be seen after radiological
not to rely on the assessment of just one. Examination imaging and tracked, following referral to the implant
by a forensic anthropologist or anatomist is vital. manufacturer, to the named patient.
An emergency or major incident may result in fatali process involves bringing together ante mortem and
ties. Disaster victim identification (DVI) is the interna post mortem information to make a positive identi
tionally accepted term for the processes and procedures fication by scientific means in a dignified manner,
for recovering and identifying deceased people and taking into account the needs of the investigation pro
human remains in multiple fatality incidents. The cess, the needs of the bereaved and the needs of the
204 I Identification of the living and the dead
community. Within the UK, the National Disaster Victim purposes. This also requires that the practitioner has a
Identification Unit coordinates the national capability realistic understanding of the variation expressed by
of the police service to respond to mass fatality inci the human form and the extrinsic and intrinsic factors
dents in the UK. The team works with police services, that may affect any age estimation process.
government departments, local authorities and other Four main means of age estimation are available,
agencies to do this. The Coroner in England & Wales (or and the more of these that are used the more likely
Procurator Fiscal in Scotland), is responsible for chair it is that the result of the examination will correlate
ing the Identification Commission, where the identity of well with the chronological age of the individual.
the deceased is confirmed. It is the Coroner's responsi Underestimation of age is unlikely to raise any issue in
bility to establish the deceased's identity and how, when relation to an infringement of human rights (as younger
and where the death occurred. They have the power to: persons tend to be treated more advantageously in the
take lawful possession and control of deceased persons legal process) but an over-estimation of age can have
or human remains from when the death is reported adverse effects. It is essential that the final estimation
until all enquiries are complete; authorise removing the is robust and conveys a realistic range within which
deceased from their place of death to a mortuary; and the chronological age is most likely to occur. As yet,
authorise a post mortem examination. Body recovery the use of DNA for age estimation is not a feature of the
teams will identify the deceased wherever they may be legal process. Any element of doubt must result in an
found. They will then be photographed before they are increased range of possibilities. It is not possible in any
moved to assist any criminal investigation and to assist circum stance to ascertain with certainty whether an
the Coroner in establishing cause of death. At the mor individual is 20 or 21 years of age. An assessment of 20
tuary, any personal items will be retrieved. These will be years ranges from a specific calendar date (birthday) to
used as indicators of the potential identity of the person. a date that is 364 days beyond that date and only one
Investigators will then go with a family liaison officer to day short of the assessment of an age of 21 years. The
recover items that could assist the identification, such as means of assessment that should be used now to esti
personal items from the deceased's home that may yield mate age in the living are:
fingerprints or DNA, or their dental records from their
dentist. Once identification evidence has been collected
• Social and psychological evaluation: This
this will be presented to the Identification Commission
requires evaluation by a highly trained clinician
which will decide if it meets the standards required to
or social work practitioner.
confirm identity. Further evidence may need to be col
• External estimation of age: This evaluation must
lected. If identity reaches the standard of proof required
be undertaken by a qualified clinician (a forensic
then the evidence will then inform an inquest into the
physician, or a paediatrician for the child and geri
death.
atrician for the elderly; examination by more than
one practitioner maybe appropriate).
• Skeletal estimation of age: This investigation can
Age estimation in the living not be undertaken visually and therefore relies
For the deceased, investigation of identity and age is on technology to assist the process (exposure to
generally undertaken by order of, and with the con much of the relevant technology has risk from ion
sent of, legal authorities, for example, the Coroner in ising radiation and can only be undertaken with
England & Wales. informed consent).
In the living, other constraints apply. The essential • Dental estimation of age.
element of any age estimation procedure is to ensure
that it complies with, and fulfils, all local and/or Certain aspects of each of these means of assessment
national legal and ethical requirements. All practitio are well recognised. External estimation of age should
ners, clinical or forensic, must take full responsibility use Tanner staging to assess child maturity (Figure
for their actions in relation to the human rights of the 14.5). Skeletal estimation will assess hand/wrist radio
subject undergoing investigation. It is essential that the graphs in the first instance, which are compared against
practitioner, clinical or forensic, undertaking the esti standards previously published. A visual intraoral
mation is experienced in the interpretation and presen inspection will inform the practitioner as to the stage
tation of data emanating from the investigation. They of emergence and loss of the dentition and is particu
must have a current and extensive understanding of the larly useful for age evaluation in the pre-pubertal years.
limitations of their investigation both in relation to the Pubertal and post-pubertal individuals will, however,
physical technology available to them and to the nature require a radiographic investigation subject to their
of the database to which they will refer, for comparison local regulatory guidelines and statute.
Bibliography and information sources I 205
J larger testes
/ i i
nipple contour
separation
( f \
coarsens,
starts to
curl
commeneces at
this stage
iy j
projects, areola
v l) follows breast
contour)
Flecker H. Roentgenographic observations of the times of Prajapati G, Sarode SC, Sarode GS, et al. Role of forensic odontol
appearance of epiphyses and their fusion with the diaphyses. ogy in the identification of victims of major mass disasters
JAnat 1933;67:118-164. across the world: a systematic review. PLOS ONE 2018;13(6):
Freire-Aradas A, Phillips C, Lareu MV. Forensic individual age e0199791.
estimation with DNA: from initial approaches to methylation Parson W. Age Estimation with DNA: from forensic DNA finger
tests. Forensic Sci Rev 2017;29(2):121 -144. printing to forensic (epi)genomics: a mini-review. Gerontology
Gilsanz V, Rati b 0. FlandBoneAge:A Digital Atlas of Skeletal Maturity. 2018;64(4):326-332.
Berlin: Springer; 2005. Pyle SI, Waterhouse AM, Greulich WW. A Radiographic Standard of
Gleiser I, Hunt EE Jr. The permanent mandibular first molar; Reference for the Growing Hand and Wrist. Cleveland: The Press
its calcification, eruption and decay. Am J Phys Anthropol of Case Western Reserve University; 1971.
1955;13:253-284. Rani SU, Rao GV, Kumar DR, et al. Age and gender assessment
Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of through three-dimensional morphometric analysis of maxil
the Hand and Wrist. Stanford: Stanford University Press; 1959. lary sinus using magnetic resonance imaging .J Forensic Dent
Hackman L, Black SM. Age estimation in the living. In: Payne- Sci 2017;9(1):46.
James JJ, Byard R. (eds). Encyclopedia of Forensic and Legal Ritz S, Schutz HW, Peper C. Postmortem estimation of age at
Medicine, Volume 1.2nd ed. Oxford: Elsevier; 2016,34-40. death based on aspartic acid racemization in dentin: its appli
Hampikian G, Peri G, Lo SS, et al. Case report: coincidental inclu cability for root dentin. Int J Leg Med 1993;105:289-293.
sion in a 17-locus Y-STR mixture, wrongful conviction and Rivers E. Children: Stages of growth and development. In: Payne-
exoneration. Forensic Sci Int Genet 2017;31:1 -4. James JJ, Byard RW (eds). Encyclopedia of Forensic and Legal
Hampikian G, West E, Akselrod O. The genetics of innocence: Medicine, 2nd ed. Oxford: Elsevier; 2016,539-557.
analysis of 194 U.S. DNA exonerations. Annu Rev Genomics Roberts G, Lucas V, McDonald F. Age estimation in the living:
Hum Genet 2011;12:97-120. dental age estimation - theory and practice. In: Payne-James
Jeffreys AJ. The man behind the DNA fingerprints: an interview JJ, Byard R (eds). Encyclopedia of Forensic and Legal Medicine,
with Professor Sir Alec Jeffreys. Investig Genet 2013;4(1):21. Volume 1,2nd ed. Oxford: Elsevier; 2016,41-69.
Jeffreys AJ, Wilson V, Thein SL. Hypervariable minisatellite regions Royal College of Paediatrics and Child Health. The Health Of
in human DNA. Nature 1985;314:67-73. Refugee Children: Guidelines For Paediatricians. London: Royal
Kaplowitz PB, Oberfield SE. Reexamination of the age limit for College of Paediatrics and Child Health; 1999.
defining when puberty is precocious in girls in the United Saks MJ, Albright T, Bohan TL, et al. Forensic bitemark identifi
States: implications for evaluation and treatment. Drug and cation: weak foundations, exaggerated claims. J Law Biosci
Therapeutics and Executive Committees of the Lawson Wilkins 2016;3(3):538—575.
Pediatric Endocrine Society. Pediatrics 1999;104:936-941. Saraf A, Kanchan T, Krishan K, et al. Estimation of stature from
Kranioti EF, Garcia-Donas JG, Can IO, Ekizoglu O. Ancestry esti sternum: exploring the quadratic models. J Forensic Leg Med
mation of three Mediterranean populations based on cranial 2018;58:9-13.
metrics. Forensic Sci Int 2018;286:265, e1-265.e8. Saunders E. The Teeth, a Test of Age, Considered with Reference to
Kvaal SI, Kolltveit KM, Thompsen IO, Solheim T. Age determination the Factory Children, Addressed to the Members of Both Houses
of adults from radiographs. Forensic Sci Int 1995;74:175-185. of Parliament. London: Renshaw; 1837,1-2.
Liu S, Mi Z, Langenburg GM, Wu J. Accuracy and reliability of Schaefer M, Black SM, Scheuer L. Juvenile Osteology: A Laboratory
feature selection by Chinese fingerprint examiners. Forensic and Field Manual. London: Elsevier; 2009.
Sci Res 2017;2(4):203-209. Scheuer JL, Black SM. The Juvenile Skeleton. London: Academic
Liversidge HM, Molleson Tl. Developing permanent tooth length Press; 2004.
as an estimate of age. J Forensic Sci 1999;44:917-920. Schmeling A. Age estimation in the living: imaging and age
Liverpool City Council (R, on the application of) v. London Borough estimation. In: Payne-James JJ, Byard R (eds). Encyclopedia
of Hillingdon [2008] EWHC 1702 (Admin). https://www. of Forensic and Legal Medicine, Volume 1, 2nd ed. Oxford:
casemine.com/judgement/uk/5a8ff72a60d03e7f57ea900e Elsevier; 2016, 70-78.
(Accessed 1 May 2019). Schmeling A, Olze A, Reisinger W, Geserick G. Age estimation
Marshall WA. Growth and sexual maturation in normal puberty. of living people undergoing criminal proceedings. Lancet
Clin Endocrinol Metab 1975;4:3-25. 2001;358:89-90.
Marshall WA, Tanner JM. Variations in pattern of pubertal changes Schmeling A, Grundmann C, Fuhrmann A, et al. Criteria for age
in girls. Arch Dis Child 1969; 44:291-303. estimation in living individuals. Int J Leg Med 2008;122:457-
Marshall WA, Tanner JM. Variations in the pattern of pubertal 460.
changes in boys. Arch Dis Child 1970;45:13-23. Schmidt S, Muhler M, Schmeling A, et al. Magnetic reso
Menendez Garmendia A, Sanchez-Mejorada G, Gomez-Valdes nance imaging of the clavicular ossification. Int J Leg Med
JA. Stature estimation formulae for Mexican contemporary 2007;121:321-324.
population: a sample based study of long bones. J Forensic Shrestha R, Acharya J, Shakya A, Acharya J. Searching for kin
Leg Med 2018;54:87-90. amidst tragedy-disaster victim identification operations for
Murphy RE, Garvin HM. Morphometric Outline analysis of US Bangla Flight 21l.JForensic Sci. 2019;64(3):824-827.
ancestry and sex differences in cranial shape. J Forensic Sci Simpson EK. Anthropology: morphological age estimation. In:
2018;63(4):1001-1009. Payne-James JJ, Byard RW (eds). Encyclopedia of Forensic and
Page M, Taylor J, Blenkin M. Reality bites: a ten-year retrospec Legal Medicine, 2nd ed. Oxford: Elsevier; 2016,189-195.
tive analysis of bitemark casework in Australia. Forensic Sci Int Smith S. The Sydney Shark case'. In: Smith S. Mostly Murder.
2012;216(1 -3):82-87. London: Panther books; 1984.
Further general resources I 207
Solheim T. A new method for dental age estimation in adults. van der Linden FPGM, Duterloo HS. The Development of the
Forensic Sci Int 1993;59:137-147. Human Dentition: An Atlas. Hagerstown: Harper and Row;
Tabasum Q, Sehrawat JS, Talwar MK, Pathak RK. Odontometric sex 1976.
estimation from clinically extracted molar teeth in a North von Wurmb-Schwark N, Preusse-Prange A, Heinrich A, et al. A
Indian population sample. J Forensic Dent Sci 2017;9(3):176. new multiplex-PCR comprising autosomal and y-specific
Tanner JM. Foetus into Man: Physical Growth from Conception to STRs and mitochondrial DNA to analyze highly degraded
Maturity London: Open Books; 1978. material. Forensic Sci Int Genet 2009;3(2):96-103.
Tanner JM, Whitehouse RH. Clinical longitudinal standards for Wadhwani S, Shetty P, Sreelatha SV. Maintenance of antemortem
height, weight, height velocity, weight velocity and stages dental records in private dental clinics: knowledge, attitude,
of puberty. Arch Dis Child 1976;51:170-179. and practice among the practitioners of Mangalore and sur
Tanner JM, Whitehouse RH, Healy MJR. A New System for rounding areas. J Forensic Dent Sci 2017;9(2):78-82.
Estimating Skeletal Maturity from the Hand and Wrist, with Wheeler MD. Physical changes of puberty. Endocrinol Metab Clin
Standards Derived from a Study of2,600 Healthy British Children. North Am 1991;20:1-14.
Paris: Centre International de I'Enfance; 1962. Wittwer-Backofen U, Gampe J, Vaupel JW. Tooth cementum
Tanner JM, Whitehouse RH, Marshall WA, et al. Assessment of annulation for age estimation: results from a large known
Skeletal Maturity and Prediction of Adult Height (TW2 Method), age validation study. AmJPhysAnthropol 2004;123:119-129.
2nd ed. London: Academic Press; 1975.
Tanner JM, Healy MJR, Goldstein H, Cameron N. Assessment of
Skeletal Maturity and Prediction of Adult Height (TW3 Method). Further general resources
London: W.B. Saunders; 2001. Black S, Aggrawal A, Payne-James JJ. Age Estimation in the Living.
Thompson TJU. Anthropology: cremated bones. In: Payne-James London: Wiley; 2010.
JJ, Byard RW (eds). Encyclopedia of Forensic and Legal Medicine, Bowers CM. Forensic Dental Evidence: An Investigator's Handbook,
2nd ed. Oxford: Elsevier; 2016,177-182. 2nd ed. Amsterdam: Academic Press; 2011.
Todd TW. Atlas of Skeletal Maturation. St Louis: C.V. Mosby; 1937. College of Policing. Civil emergencies: disaster victim identi
Torimits S, Makino Y. Anthropology: Stature estimation from the fication. https://www.app.college.police.uk/app-content/
skeleton. In: Payne-James JJ, Byard RW (eds). Encyclopedia of civil-emergencies/disaster-victim-identification/dvi-roles-
Forensic and Legal Medicine, 2nd ed. Oxford: Elsevier; 2016, and-responsibilities/(Accessed 1 May 2019).
221-226. Royal College of Paediatrics & Child Health. Refugee and unac
Ubelaker DH. Human Skeletal Remains: Excavation, Analysis and companied asylum seeking children and young people.
Interpretation. Washington, DC: Smithsonian Institute Press; https://www.rcpch.ac.uk/topic/refugee (Accessed 01 May
1978. 2019).
Ulery BT, Hicklin RA, Roberts MA, Buscaglia J. Interexaminer varia
tion of minutia markup on latent fingerprints. Forensic Sci Int
2016;264:89-99.
15 Restraint and control
techniques
■ Use of force ■ Irritant sprays
■ Conflict resolution ■ Impact rounds
■ 'Empty hands': unarmed restraint ■ Dogs
■ Handcuffs ■ Conducted energy devices
■ Batons ■ Bibliography and information sources
• Use of force
• Conflict resolution
• 'Empty hand': unarmed restraint
• Handcuffs
• Batons
• Irritant sprays
• Impact rounds
Figure 15.1 Scleral haemorrhage 2 hours after
• Dogs
neck compression in a restraint setting.
• Conducted electrical energy devices/weapons
(Courtesy of Jason Payne-James.)
• Spit guards (or spit hoods, or bite guards)
for signs of injury. Examination for petechiae is manda
the injured person may need further clarification by tory in the skin of the head, neck, face, ears and scalp,
direct communication with the restraining personnel the intraoral mucosa and the eyes (Figure 15.1). Clothing
concerned. Review of available CCTV, body worn video can be grabbed in a scuffle and the tightening, ligature
or video recordings recorded on phones and broadcast effect of this can cause linear or patchy type bruising
on social media by members of the public may all assist around the neck.
in the proper determination of the facts in these cases. Positional asphyxia is a term that describes respi
ratory impairment as a consequence of the position
'Empty hands': unarmed restraint in which a person finds themselves, including whilst
A variety of arm locks and holds, pressure-point control being restrained. It can occur as a result of the indi
and knee and elbow strikes may be used. If excessive vidual being held down and being unable to maintain
force is used, either directly by the officer or as a result adequate respiratory movement either because of the
of the restrained person moving, joints such as the wrist, chest and/or the diaphragm being splinted, for exam
elbow or shoulder can be strained to varying degrees. ple, because law enforcement/security personnel are
Other soft tissue injuries may be found. kneeling on the chest and thorax. The risk of death is
Neck hold and neck restraints (sometimes known further heightened by lying prone (face down), being
as vascular neck restraint or sleeper holds) are avoided handcuffed behind the back, being unable to change
by many law enforcement agencies, as there is a real, position, obesity, respiratory or cardiac disease, and
unpredictable risk of serious injury or fatality from struggling against restraint.
neck compression. If an individual is restrained in such
a hold the neck and head should be examined carefully Handcuffs
Three main means of handcuffing individuals exist: tra
ditional handcuffs with two wrist pieces connected by a
Box 15.1 Conflict resolution: Factors short chain; rigid cuffs whereby the two wrist pieces are
affecting the behaviour o f an connected by a bar and cannot move in relation to each
other; and plasticuffs, in effect, larger-size cable ties
individual and how an officer which are easy to store and easy to apply but less secure
responds than the first two types. The fixed connecting bar of the
• Presence of an imminent danger rigid handcuffs allows controlled application of force
• Comparative ages across the wrist to gain control. Once applied, simple
• Sex and size pressure against the wrist allows the single bar of the
• Strength cuffs to release over the top of the wrist and close with
• Skills a ratchet mechanism. If the individual is noncompliant
• Specialist knowledge and continues moving, the handcuffs can progressively
• Presence of drugs or alcohol tighten causing increasing pain and potentially increas
• Mental state ing the risk of neurological and skin damage. A num
• Relative position of disadvantage ber of injuries may be caused by handcuff application.
• Injury Soft tissue injuries may be produced by movement of
• Number of individual's involved the wrist within the handcuff, movement of the hand
• Whether weapons are present cuff on the wrist or by the handcuff being too tight. The
• Officer's overall perception of the situation commonest injuries are blunt force injuries of redden
ing, abrasions and bruising, particularly to the radial
210 Restraint and control techniques
(a)
Source: Adapted from McGorrigan J, Payne-James JJ. Irritant sprays: clinical effects and management Recommendations
for Healthcare Professionals (Forensic Physicians, Custody Nurses and Paramedics). Faculty of Forensic & Legal
Medicine, 2017.
projectiles are intended to impact on the ground prior consist of a single, long round, or several shorter ones
to hitting the subject, dissipating the energy in advance. fired concurrently. One additional group is the 'beanbag
The projectiles are frequently irregular cylinders made projectile' which consists of a tough fabric bag filled with
from rubber, plastic, wood or foam, and can be as large compliant material (Figure 15.7). Baton rounds have two
as the full-bore diameter of the launcher. Projectiles may roles: public order and as another alternative to the use
Conducted energy devices 213
Dogs
Trained dogs from law enforcement agencies are capa
ble of restraining and detaining individuals who need to
be controlled. In some cases, dogs bite. Bites all require
medical assessment as there may be, dependent on the
site and degree of injury, a risk of infection, neurological
Figure 15.7 Bean bag round. Figure 15.8 (a) TASER® X2 and (b) barbs.
(Courtesy of Jason Payne-James.) (Courtesy of Jason Payne-James.)
214 I Restraint and control techniques
Armstrong EJ. Distinctive patterned injuries caused by an Hardwicke J, Satti U. Facial burns after exposure to CS spray. Inj
expandable baton. Am J Forensic Med Pathol 2005;2: Extra 2006;37(3):133—134.
186-188. Han JS, Chopra A, Carr D. Ophthalmic injuries from a Taser. CJEM
Blain PG. Tear gases and irritant incapacitants. 1-chloroacetophe- 2009;11:90-93.
none, 2-chlorobenzylidene malononitrile and dibenz[b,f]- Ho JD, Dawes DM, Bultman LL, et al. Respiratory effect of pro
1,4-oxazepine. Toxicol Rev 2003;22(2):103—110. longed electrical weapon application on human volunteers.
Bleetman A, Steyn R, Lee C. Introduction of the Taser into British Acad Emerg Med 2007;14:197-201.
policing. Implications for UK emergency departments: an Ho JD, Dawes DM, Reardon RF, et al. Human cardiovascular
overview of electronic weaponry. Emerg Med J 2004;21(2): effects of a new generation conducted electrical weapon.
136-140. Forensic Sci Int 2011 ;204:50-57.
Bozeman WP, Hauda WE, Heck JJ, et al. Safety and injury pro Horton D, Burgess P, Rossiter S, Kaye W. Secondary contamination
file of conducted electrical weapons used by law enforce of emergency department personnel from o-chlorobenzyl-
ment officers against criminal suspects. Ann Emerg Med idene malononitrile exposure. Ann Emerg Med 2005;45:655-
2009;53(4):480-489. 658.
Bui ET, Sourkes M, Wennberg R. Generalized tonic-clonic seizure Hughes D, Maguire K, Dunn F, et al. Plastic baton round injuries.
after a Taser shot to the head. CMAJ 2009;180:625-626. Emerg Med J 2005;22:111-112.
Carron P-N, Yersin B. Management of the effects of exposure to Karagama YG, Newton JR, Newbegin CJ. Short-term and
tear gas. BMJ 2009;338:1554-1558. long-term physical effects of exposure to CS spray. JRSM
Chan TC, Vilke GM, Neuman T, Clausen JL. Restraint position and 2003;96:172-174.
positional asphyxia. Ann Emerg Med 1997;30:578-586. Karaman E, Erturan S, Duman C, et al. Acute laryngeal and bron
Chariot P, Ragot F, Authier FJ, et al. Focal neurological compli chial obstruction after CS (o-chlorobenzylidenemalononitrile)
cations of handcuff application. J Forensic Sci 2001;46(5): gas inhalation. EurArch Otorhinolaryngol 2009;266(2):301-304.
1124-1125. Kennedy KM, Payne-James JJ, Payne-James GJ, Green P. The use
Chute DJ, Smialek JE. Injury patterns in a plastic (AR-1) baton fatal of spit guards (also known as spit hoods) by police services in
ity. Am J Forensic Med Pathol 1998;19(3):226— 229. England, Wales and Northern Ireland: to prevent transmission
Committees on Toxicity, Mutagenicity, and Carcinogenicity of of infection or another form of restraint? J Forensic Leg Med
chemicals in food, Consumer Products, and the Environment, 2019;66:147-154.
1999. Statement on 2-chlorobenzylidene Malononitrile (CS) and Khonsari R, Arzul L, Lefevre F, Vincent C. Severe facial rubber bul
CS Spray. London: Department of Health. let injuries in France. J Craniomaxillofac Surg 2008;36(Suppl
CookAA. Handcuff neuropathy among U.S. prisoners of war from 1):S116.
Operation Desert Storm. Mil Med 1993;158(4):253-254. Kobayashi M, Mellen PF. Rubber bullet injury: case report with
Davey A, Moppett IK. Postoperative complications after CS spray autopsy observation and literature review. Am J Forensic Med
exposure. Anaesthesia 2004;59(12):1219-1220. Pathol 2009;30(3):262-267.
de Brito D, Challoner KR, Sehgal A, Mallon W. The injury pattern Kroll MW. Physiology and pathology of Taser® electronic control
of a new law enforcement weapon: the police bean bag. Ann devices. J Forensic Leg Med 2009;16:173-177.
Emerg Med 2001 ;38(4):383-390. Maguire K, Hughes DM, Fitzpatrick MS, et al. Injuries caused by
DOMILL. Defence Scientific Advisory Council Sub-Committee on the attenuated energy projectile: the latest less lethal option.
the Medical Implications of Less- Lethal Weapons: Statement Emerg Med J 2007;24(2):103-105.
on the Medical Implications of Use of the Taser X26and M26 Mahajna A, Aboud N, Harbaji I, et al. Blunt and penetrating
Less- Lethal Systems on Children and Vulnerable Adults. 2012. injuries caused by rubber bullets during the Israeli-Arab
Emson HE. Death in a restraint jacket from mechanical asphyxia. conflict in October, 2000: a retrospective study. Lancet
CMAJ 1994;151:985-987. 2002;359(9320):1795-1800.
Euripidou E, MacLehose R, Fletcher A. An investigation into McGorrigan J, Payne-James JJ. Irritant sprays: clinical effects and
the short term and medium term health impacts of per management: recommendations for healthcare profession
sonal incapacitant sprays: a follow up of patients reported als (Forensic Physicians, Custody Nurses and Paramedics).
to the National Poisons Information Service. Emerg Med J Faculty of Forensic & Legal Medicine, 2017. https://fflm.
2004;21:548-552. ac.uk/wp-content/uploads/2018/08/lrritant-sprays-Dr-J-
Forrester MB, Stanley SK. The epidemiology of pepper spray McGorrigan-and-Dr-J-Payne-James-December-2017.pdf
exposures reported in Texas in 1998-2002. Vet Hum Toxicol (Accessed 01 May 2019).
2003;45(6):327-330. Ng W, Chehade M. Taser penetrating ocular injury. Am J
Ghaleb SS, Elshabrawy EM, Elkaradawy MH, Nemr Welson N. Ophthalmol 2005;139(4):713-715.
Retrospective study of positive physical torture cases in Cairo O'Brien AJ, McKenna BG, Thom K, et al. Use of Tasers on people
(2009 & 2010). J Forensic Leg Med 2014;24:37-45. [Epub 2014]. with mental illness; a New Zealand database study. Int J Law
Grant AC, Cook AA. A prospective study of handcuff neuropa Psychiatry 2011;34(1):39—43.
thies. Muscle Nerve 2000;23(6):933-938. Olivas T, Jones B, Canulla M. Abdominal wall penetration by a
Gross M, Regev E, Hamdan K, Eliashar R. Penetrating rubber bul police "bean bag". Am Surg 2001;67(5):407-409.
let into the ethmoid sinus: should the bullet be removed? Parkes J. Sudden death during restraint: a study to measure the
Otolaryngol Head NeckSurg 2005;133(5):814—816. effect of restraint positions on the rate of recovery from exer
Haileyesus T, Annest JL, Mercy JA. Non-fatal conductive energy cise. Med Sci Law 2000;40:39-44.
device-related injuries treated in US emergency depart Payne-James J, Sheridan B, Smith G. Medical implications of the
ments, 2005-2008. InjPrev 2011;17:127-130. Taser. £A4J2010;22:340.
216 I Restraint and control techniques
Payne-James JJ, Rivers E, Green P, Johnston A. Trends in less-lethal Sheridan SM, Whitlock RIH. Plastic baton round injuries. BrJOral
use of force techniques by police services in England &Wales. Surg 1983;21 (4):259— 267.
Forensic Sci Med Pathol 2014;10(1):50—55. Smith J, Greaves I. The use of chemical incapacitant sprays: a
Payne-James JJ, Smith G, Rivers E, et al. Effects of incapacitant review. J Trauma 2002;52(3):595-600.
spray deployed in the restraint and arrest of detainees in the Southward RD. Cutaneous burns from CS incapacitant spray. Med
Metropolitan Police Service Area, London, UK: a prospective Sci Law 2001 ;41(1):74-77.
study. Forensic Sci Med Pathol 2014;10(1):62—68. Stone DA, Laureno R. Handcuff neuropathies. Neurology
Pinaud V, Leconte P, Berthier F, et al. Orbital and ocular 1991 ;41 (1):145—147.
trauma caused by the Flash-Balls: a case report. Inj Extra Strote J, Range Hutson H. Taser use in restraint-related deaths.
2009;40(9):172-174. Prehosp Emerg Care 2006;10(4):447-450.
Pollanen MS, Chiasson DA, Cairns JT, Young JG. Unexpected Strote J, Walsh M, Angelidis M, et al. Conducted electrical weapon
death related to restraint for excited delirium: a retrospective use by law enforcement: an evaluation of safety and injury. J
study of death in police custody and in the community. CMAJ Trauma 2010;68(5):1239-1246.
1998;158:1603-1607. Sutter FK. Ocular injuries caused by plastic bullet shotguns in
Pudiak CM, Bozarth MA. Cocaine fatalities increased by restraint Switzerland. Injury 2004;35(10):963-967.
stress. Life Sci 1994;55:379-382. Suyama J, Panagos PD, Sztajnkrycer MD, et al. Injury patterns
Reay DT, Eisele JW. Death from law enforcement neck holds. Am related to use of less-lethal weapons during a period of civil
J Forensic Med Pathol 1982;3(3):253-258. unrest. J Emerg Med 2003;25(2):219-227.
Reay DT, Holloway GA Jr. Changes in carotid blood flow pro VanMeenen KM, Lavietes MH, Cherniack NS, et al. Respiratory and
duced by neck compression. Am J Forensic Med Pathol cardiovascular response during electronic control device
1982;3(3):199-202. exposure in law enforcement trainees. Front Physiol 2013;4:78.
Rehman TU, Yonas H, Marinaro J. Intracranial penetration of a Varma S, Holt PJ. Severe cutaneous reaction to CS gas. Clin Exp
Taser dart. Am J Emerg Med 2007;25:733. Dermatol 2001;200(26):248-250.
Rezende-Neto J, Silva FD( Porto LB, et al. Penetrating injury to the Viala B, Blomet J, Mathieu L, Hall AH. Prevention of CS tear
chest by an attenuated energy projectile: a case report and gas eye and skin effects and active decontamination with
literature review of thoracic injuries caused by "less-lethal" Diphoterine: preliminary studies in 5 French Gendarmes. J
munitions. World J Emerg Surg 2009;26:4-26. Emerg Med 2005;29:5-8.
Ritchie A. Plastic bullets: significant risk of serious injury above Vilke GM, Sloane CM, Suffecool A, et al. Physiologic effects of
the diaphragm. Injury 1992;23(4):265-266. the TASER after exercise. Acad Emerg Med 2009;16:1-7.
Roberts A, Nokes L, Leadbeatter S, Pike H. Impact characteristics Wahl P, Schreyer N, Yersin B. Injury pattern of the Flash-Ball, a less-
of two types of police baton. Forensic Sci Int 1994;67(1):49-53. lethal weapon used for law enforcement: report of two cases
Roggla G, Roggla M. Death in a hobble restraint. CMAJ 1999;161:21. and review of the literature. J Emerg Med 2006;31(3):325-330.
Ross DL. Factors associated with excited delirium deaths in police Walter RJ, Dennis AJ, Valentino DJ, et al. TASER X26 discharges in
custody. Mod Pathol 1998;11:1127-1137. swine produce potentially fatal ventricular arrhythmias. Acad
Ross EC. Death by restraint: horror stories continue, but best Emerg Med 2008;15:66-73.
practices are also being identified. Behav Flealth Tomorrow Watson K, Rycroft R. Unintended cutaneous reactions to CS
1999;8:21-23. spray. Contact Dermatitis 2005;53(1):9-13.
SACMILL. Scientific Advisory Committee on the Medical Weir E. The health impact of crowd control agents. CMAJ
Implications of Less- Lethal Weapons: Statement on the 2001 ;164(13):1889-1890.
Medical Implications of Use of the TASER X2 Conducted Worthington E, Nee Patrick A. CS: exposure: clinical effects and
Energy Device System. 2016. management. JAccid Emerg Med 1999;16:168-170.
Scott TF, Yager JG, Gross JA. Handcuff neuropathy revisited. Zipes DP. Sudden cardiac arrest and death associated with
Muscle Nerve 1989;12(3):219-220. application of shocks from a TASER electronic control device.
Shambhu S, Kurtis R. Allergic contact dermatitis due to CS spray. Circulation 2012;125:2417-2422.
EMJ 2011;28(4):345.
Sheridan RD, Payne-James JJ. TASER®: clinical effects and man
agement of those subjected to TASER® discharge. Faculty of
Forensic & Legal Medicine, 2017.
16 Police custodial healthcare
mechanisms for reducing and avoiding unwanted out (which may include regulatory, employment and crimi
comes. All countries should collect robust data regard nal courts or tribunals). The Independent Office for
ing deaths and harm related to police custody but this is Police Conduct (IOPC) publishes data on deaths related
not currently the case. Any death in state custody should to police contact in England & Wales. In 2017-2018 in
be investigated independently and thoroughly and any England & Wales, there were the following number of
acts of commission or omission that contributed to the fatalities in each category of police related death: 29 road
death should be identified and dealt with appropriately traffic fatalities; four fatal police shootings; 23 deaths in
(a)
For each item, w rite in th e num ber that best describes th e patient's signs or symptom. Rate on ju st the apparent relationship to opiate withdraw al.
For example: If heart rate is increased because the patient w as jogging just prior to assessment, the in creased pulse rate would not add to th e score.
Buprenorphine Induction:
Enter scores at tim e zero, 30 minutes after first dose, 2 hours after first dose, etc. Tim es of O bservation:
Sweating: O ver Past 1/2 Hour not Accounted for by Room Temperature or Patient Activity
Pupil Size
I 0 = pupils pinned or normal size for room light • 2 = pupils moderately dilated
j 1 = pupils possibly larger than normal for room light • 5 = pupils so dilated that only the rim of the iris is visible j
Anxiety or Irritability
0 = none • 2 = patient obviously irritable/anxious
1 = patient reports increasing irritability or • 4 = patient so irritable or anxious that pat ticipation
anxiousness in the assessm ent is difficult
Gooseflesh Skin
0 = skin is sm ooth • 5 = prom inent piloerection
J
3 = piloerection of skin can be felt or hairs standing up on arms
5-12 = Mild
Total score
13-24 = Moderate
25-36 = Moderately Severe
O bserver's initials
More than 36 = Severe Withdrawal
(b)
This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67
(see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal.
Figure 16.1 (Continued) (b) Assessment of alcohol withdrawal. (Reproduced from Sullivan JT et al. Assessment of
alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for alcohol scale [CIWA-Ar]. B rJ Addict
1989;84:1353-1357.)
Deaths and harm in police custody I 221
(a)
Self Assessment
Have you had or are you receiving any treatment for this? Yes □ No 0 Other □
Are you taking or supposed to be taking any medication for these injuries? Yes □ No 0 Other □
If the person has or claims to need medication for a heart condition, diabetes, epilepsy or other comparable serious condition the
advice of a Health C are Professional MUST be sought as soon as possible.
Have you had or are you receiving any treatment for this? Yes □ No 0 Other □
Are you taking or supposed to be taking any medication for this? Yes □ No 0 Other □
Have you consumed alcohol/taken any drugs (prescribed or otherwise) or solvents within the Yes 0 N oD Other □
last 24 hours?
Stopped drinking 3am and had a bit of cocaine at about lam and some cannabis
Are you:
Dependent on alcohol? Yes □ No 0 Other □
Figure 16.2 Example Risk Assessment Proforma for Detainees in Police Custody.
(Continued)
222 I Police custodial healthcare
Do you wish to see or be contacted by an Independent Drug/Alcohol Referral Scheme Worker? Yes □ No 0 Other □
Do you have any allergies, specific dietary needs or religious dietary needs? Yes □ No 0 Other □
Are there any other issues that might affect you whilst you are in custody or anyone that depends Yes □ No 0 Other □
on you, who may be affected by your detention?
(If any o f the answers to the above questions are affirmative the Custody Officer must consider completing a Detained Person s medical
form and contacting a Health Care Professional)
Figure 16.2 (Continued) Example Risk Assessment Proforma for Detainees in Police Custody.
(Continued)
or following police custody; 57 apparent suicides follow a breath alcohol measurement. Missing a serious injury
ing police custody; and 170 other deaths following police can result in a fatal outcome. This principle, however,
contact that were independently investigated. Figure is a key issue in care and requires not only an initial
16.3 illustrates the number of fatalities following deaths awareness, but the need for appropriate monitoring
in police custody and following police contact from (e.g., rousing to ensure there has been no deterioration
2004 to 2018 in England & Wales. Figure 16.4 shows the in conscious level) so that treatable, potentially fatal
primary cause of death in custody - England & Wales - injuries are not missed. Failure to recognise high-risk
1998/9 to 2008/9. patients remains a common problem, in particular for
Work has been done worldwide by those involved in healthcare professionals who have little experience in
healthcare in custody settings to look at the nature and custodial medicine, and deaths or harm outcomes that
causes of deaths in custody and there are similarities could have been avoided may result in severe penalties
between many of these studies, irrespective of juris to those who have failed in their duties. Complaints
diction. Sometimes the studies focus on all deaths in about healthcare professionals to their respective regu
custody (e.g., in police custody, prison custody, secure latory bodies appear to be increasing.
mental health units) and others solely on police settings. Specific issues may arise which require an aware
Detainees may be arrested for drink/drug driving ness of local trends and behaviours. Often these relate
offences after road traffic collisions (RTCs) and are taken to drug use (either due to the nature of the drug taken
to a police station. It is crucial that proper medical assess or the means by which it was administered). Anthrax
ment is undertaken of such individuals, being aware of (caused by Bacillus anthracis) is rare in the UK but was
all the factors of any collision (e.g., type of impact, use identified in injecting drugs misusers. Ultra-potent
of seat belts, deployment of airbags, whether extraction opioids (e.g., fentanyl and carfentanil) are now widely
of the detainee was required, what the speed at impact available, and detainees (and police and healthcare
was, etc.) so that serious underlying injury is not missed professionals caring for them) may be at risk of expo
whilst the police procedures are being undertaken. This sure to these potent narcotics necessitating guidance
ensures that risk factors over and above the use of alco for scene safety and force protection from medical
hol and/or drugs are taken into account, and in particu directors. The availability of novel psychoactive sub
lar the risk that substance misuse is masking significant stances (NPS) with many different modes of action and
clinical conditions; a full clinical examination remains clinical effects often makes assessment difficult. Rare
essential. Particular attention should be paid to drink- medical conditions may also be responsible for deaths
drivers who have refused, or were not able to complete, in police custody.
Deaths and harm in police custody I 223
(b)
Appears to have taken or be under the influence o f alcohol, drugs, or any other substance? Yes □ No 0 Unknown □
3. Reflect any information obtained from the above in your careplan and consider HCP.
Officers who have applied any use of force must be directed to complete the "Use of Force” E-Form via intranet "Form s”
Record here details of injury / observation AND what advice or treatment given
First time in custody? (If Yes, explain custody processes and cell facilities) Yes □ No 0 Unknown □
(If any of the answers to the above questions are affirmative the Custody Officer must consider completing a Detained Person’s medical
form and contacting a Health Care Professional)
Observations
□ Detainee to be visited
Figure 16.2 (Continued) Example Risk Assessment Proforma for Detainees in Police Custody.
Cruel, inhuman and degrading to cruel, inhuman and degrading treatment or torture.
Such issues may be disclosed by the detainee, or may be
treatment and torture
established during the clinical assessment. Often those
The healthcare professional working in custodial set who have fled oppressive regimes may come into con
tings should be aware that this is often an opportunity tact with criminal justice or immigration systems. The
to identify and assist those who have - either during the healthcare professional should always be in a position
current period of detention, or previously - been subject to ask appropriate questions and refer to appropriate
224 Police custodial healthcare
Figure 16.3 Total number of deaths in police custody or following police custody in the UK from 2004 to 2018.
agencies or personnel if such issues are identified. The Excited delirium syndrom e
Istanbul Protocol (described in Chapter 8) provides the
Unexpected deaths periodically occur in individuals
means to ensure that such allegations can be properly
held in police custody. These decedents have usually
investigated. Appropriate enquiry or awareness may
had significant physical exertion associated with vio
identify individuals who have been trafficked or sub
lent and/or bizarre behaviour, have been restrained by
ject to forced marriage or female genital mutilation
the police, and often have drug intoxication. An autopsy
(FGM - described in Chapter 17). The relevance of such
in such cases may not provide a satisfactory explana
issues will be dependent on the jurisdiction in which the
tion for the cause of death, and these deaths may then
healthcare professional is working.
/ / *///tft/////*
V y " W // * * 4 / /
Figure 16.4 Primary cause of death in custody in England & Wales from 1998/9 to 2008/9. (Adapted from the
Independent Police Complaints Commission. Death in or following police custody: an examination o f the cases 1998/99-
2008/09. IPCC, London, 2010.)
Prevention of death and harm in police custody 225
be attributed to the excited delirium syndrome (ExDS), Faculty of Forensic and Legal Medicine and the Royal
or an 'acute behavioural disturbance'. The pathogen College of Emergency Medicine have produced guide
esis of excited delirium syndrome/acute behavioural lines on management in police custody of acute behav
disturbance-associated deaths is likely to be multifac ioural disturbance.
torial and includes a variety of factors such as positional
asphyxia, hyperthermia, drug toxicity, and/or catechol Prevention of death and harm in
amine-induced fatal arrhythmias.
Generally, the forensic medical community has clas police custody
sified patients who presented with altered sensorium and Any episode of death or harm in police custody is a trag
aggressive agitated behaviour, and a combination of other edy. It is a tragedy for families of the deceased, but it can
symptoms including 'superhuman' strength, diaphore also be hugely disruptive and traumatic for any of those
sis, hyperthermia, propensity to break glass, attraction who have been involved in the arrest, care and health
to light or lack of willingness to yield to overwhelm care assessment of that person. Adequate training of
ing force, who then died with a positive drug screen for law-enforcement personnel in relation to restraint plays
sympathomimetic agent, and no other anatomical cause a vital role in preventing deaths in custody. Concepts
of death, as an 'Excited Delirium' (or acute behavioural such as ExDS (or acute behavioural disturbance),
disturbance-associated) death. In recent years, it has and the potential dangers of vascular restraint holds,
become increasingly clear that many patients with this assist officers in making appropriate restraint deci
constellation of symptoms and signs have been man sions. Understanding the broad principles of positional
aged in emergency departments for decades and in only asphyxia, such as how some positions and some indi
a minority of cases is the outcome fatal. Law enforcement viduals are more prone to respiratory compromise, and
and emergency medical services (EMS) in the USA have that kneeling on someone's back may increase the risk of
many years of experience of dealing with ExDS patients. death, means that some potentially fatal situations are
Individuals with ExDS (or acute behavioural disturbance) avoided. Such training in 'use of force' tactics needs to
most frequently come to the attention of police, forensic include an understanding of the effects, and complica
physicians and emergency departments because of the tions, of less-lethal weapons and personal protection
associated violent, agitated, and erratic behaviour. These systems including batons, irritant sprays and conducted
out-of-hospital ExDS (or acute behavioural disturbance) energy devices. Different means of providing healthcare
subjects have traditionally been transported to custody for detainees exist across the world. Some are compa
and survived, transported to the hospital and survived, rable (or aim to be comparable) to healthcare for the
or have a sudden cardiac arrest with death ensuing. If non-detainee (e.g., UK, France, Netherlands) whilst
death occurs, a forensic autopsy is required. When the others have lower, or less consistent, standards of pro
outcome is fatal, forensic pathologists may, in the absence viding healthcare for detainees. The standards of the
of other apparent causes of death, typically rule that death healthcare professionals are key, as certain skills may
is a consequence of excited delirium, although the use of be needed in general medical problems, but with a great
this diagnostic 'label' is not currently preferred in the UK. emphasis on mental health and substance misuse. All
Instead, a 'narrative' style cause of death is given, iden countries should have minimum standards of training
tifying those factors thought to be most important. The and qualification for healthcare professionals working
concept of excited delirium remains controversial, but has with detainees in police custody. Over recent years sub
become a matter of increasing concern for forensic and stantial advances have been made in setting standards
emergency physicians and other primary care health pro for short-term custodial healthcare in a variety of ways
fessionals as many work with policing agencies respon in different countries. It is essential that any practitioner
sible for the policy and procedures used in the field. has knowledge of, and is trained in, aspects of mental
Forensic physicians and healthcare practitioners who health, drug and alcohol misuse, medical law and eth
encounter such individuals are generally supportive of ics, forensic sampling and police process in addition to
this diagnosis as a means to identify the at-risk patient. basic training. Police or law-enforcement officers tasked
The key practical element in care of the detained with the care of detainees must also have training in
(or about to be detained) individual is to differentiate order to identify those patients at risk. Non-medical
between an aggressive individual who is trying to avoid factors, such as the use of CCTV to monitor those iden
arrest, and an individual with ExDS (or an acute behav tified as being at risk of self-harm, and the availability
ioural disturbance). Such an individual represents a of ligature knives, should an individual gain access to a
medical emergency and requires immediate trans ligature, are common-sense ideas that should be widely
port to a medical facility with full resuscitation and life disseminated (see Figure 16.6). Life signs monitoring
support capability. A Special Panel Review of Excited devices are available for use in police cells but are not
Delirium produced a simple 'aide memoire' to assist substitutes for appropriate staffing with appropriately
in making this crucial diagnosis (Figure 16.5). The UK trained and qualified healthcare professionals. Training
Police custodial healthcare
Figure 16.5 Excited delirium syndrome pocket card (front and back) for law enforcement and EMS providers created
by the work of the National Institute of Justice Technology Working Group (TWG) on Less-Lethal Devices (Reproduced
by permission of NIJ).
of all those who come into contact with or are respon Dorn T, Ceelen M, Buster M, Stirbu I, et al. Mental health and
sible for, the care of detainees in basic or immediate life healthcare use of detainees in police custody. J Forensic Leg
support or cardiopulmonary resuscitation should be Med 2014;26:24-28.
compulsory. Continuous professional development and Dyer C. Former police doctor is suspended after a death in cus
update training is essential so that lessons learnt can tody. BMJ 2014;348:g2302.
Fablet D, Chariot P. Children detained in French police cells. J
be applied to day-to-day practice, in order to maximise
Paediatr Child Health 2018;54(7):788-792.
recognition of healthcare issues and minimise the risks Faculty of Forensic & Legal Medicine. Role of the healthcare
of death or harm as an outcome. professional. Faculty of Forensic & Legal Medicine, London,
2012. https://fflm.ac.uk/wp-content/uploads/document-
Bibliography and information store/1367330032.pdf (Accessed 15 May 2019).
Faculty of Forensic & Legal Medicine. FFLM Quality Standards
sources in Forensic Medicine. Faculty of Forensic & Legal Medicine,
Aasebo W, Orskaug G, Erikssen J. Deaths in Norwegian police cells London, 2016. https://fflm.ac.uk/wp-content/uploads/2014/04/
from 2003 to 2012. TidsskrNorLaegeforen. 2014;134(3):291-294. Quality-Standards-in-Forensic-Medicine-February-2016.pdf -
Aasebo W, Orskaug G, Erikssen J. Can deaths in police cells be (Accessed 15 May 2019).
prevented? Experience from Norway and death rates in other Faculty of Forensic & Legal Medicine. FFLM Quality Standards for
countries. J Forensic Leg Med. 2016;37:61-65. Nurses and Paramedics - General Forensic Medicine (GFM).
Beaufrere A, Belmenouar O, Chariot P. Elderly arrestees in police London, 2016. https://fflm.ac.uk/publications/fflm-quality-
custody cells: implementation of detention and medical deci standards-for-nurses-and-paramedics-general-forensic-
sion on fitness to be detained. Forensic Sci Int 2014;241:15-19. medicine-gfm/ (Accessed 15 May 2019).
Beaumont G. Anthrax in a Scottish intravenous drug user. Faculty of Forensic & Legal Medicine. The role of the indepen
J Forensic Leg Med. 2010;17(8):443-445. dent forensic physician. Faculty of Forensic & Legal Medicine,
Bucke T, Teers R, Menin S, et al. Near Misses in Police Custody: A London, 2014. https://fflm.ac.uk/wp-content/uploads/docu-
Collaborative Study with Forensic Medical Examiners in London. mentstore/1391519170.pdf (Accessed 14 May 2019).
London: IPCC, 2008. Faculty of Forensic & Legal Medicine. Acute behavioural dis
Buster M, Dorn T, Ceelen M, Das K. Detainees in Amsterdam, a tar turbance (ABD): guidelines on management in police
get population of the Public Mental Health System? J Forensic custody. Faculty of Forensic & Legal Medicine, London
Leg Med. 2014;25:55-59. 2019. https://fflm.ac.uk/wp-content/uploads/2019/05/
British Medical Association (BMA). Safeguarding vulnerable AcuteBehaveDisturbance_Apr19-FFLM-RCEM.pdf
adults: a toolkit for general practitioners. October 2011. FernandoT, Byard RW. Positional asphyxia without active restraint
https://www.bma.org.Uk/-/media/files/pdfs/practical%20 following an assault. J Forensic Sci 2013;58(6):1633-1635.
advice%20at%20work/ethics/safeguardingvulnerableadults. Fruchtnicht W. Medical examination of fitness for police cus
pdf (Accessed 15 May 2019). tody in two large German towns. IntJ Legal Med 2012;126(1):
Celeen M, Dorn T; Buster M, et al. Health-care issues and health 27-35.
care use among detainees in police custody. J Forensic Leg Gahide S, Lepresle A, Boraud C, et al. Reported assaults and
Med 2012;19:324-331. observed injuries in detainees held in police custody. Forensic
Chariot P, Briffa H, Lepresle A, et al. Fitness for detention in police Sci Int 2012;223:184-188.
custody: a practical proposal for improving the format of Gerardin M, Guigand G, Wainstein L, et al. Evaluation of problem
medical opinion. J Forensic Leg Med 2013;20:980-985. atic psychoactive substances use in people placed in police
Chariot P, Lepresle A, Lefevre T, et al. Alcohol and substance custody. J Forensic Leg Med 2017;49:24-32.
screening and brief intervention for detainees kept in Gill J, Koelmeyer TD. Death in custody and undiagnosed central
police custody: a feasibility study. Drug Alcohol Depend neurocytoma. Am J Forensic Med Pathol 2009;30(3):289-291.
2014;134:235-241. Hall CA, Kader AS, Danielle McHale AM, et al. Frequency of signs
Chariot P, Baufrere A, Denis C, et al. Detainees in police custody of excited delirium syndrome in subjects undergoing police
in the Paris, France area: medical data and high-risk situations use of force: Descriptive evaluation of a prospective, consec
(a prospective study over 1 year). Int J Legal Med 2014;128: utive cohort. J Forensic Leg Med 2013;20(2):102—107.
853-860. Hall C, Votova K, Heyd C, et al. Restraint in police use of force
Clement R, Gerardin M, Vigneau Victorri C, et al. Medical, social events: examining sudden in custody death for prone and
and law characteristics of intoxicant's users medically exam not-prone positions. J Forensic Leg Med 2015;31:29-35.
ined in police custody. J Forensic Leg Med 2013;20:1083-1086. Hannan M, Hearnden I, Grace K, Bucke T. Death in or following
Coulton S, Newbury-Birch D, Cassidy P, et al. Screening for alcohol police custody: an examination of the cases 1998/99-2008/09.
use in criminal justice settings: an exploratory study. Alcohol London: IPCC; 2010.
2012;47(4):423-427. Havis S, Best D, Carter J. Concealment of drugs by police detain
DeViggiani N. A clean bill of health? The efficacy of an NHS com ees: lessons learned from adverse incidents and from 'rou
missioned outsourced police custody healthcare service. J tine' clinical practice J Clin Forensic Med 2005;12:237-241.
Forensic Leg Med 2013;20:610-617. Heide S, Henn V, Kleiber M, Dressier J. An avoidable death in
Dhai A, Payne-James J. Problems of capacity, consent and confi police custody? Am J Forensic Med Pathol 2010;31 (3):261 -263.
dentiality. Best Pract Res Clin Obstet Gynacol 2013;27(1):59—75. Heide S, Kleiber M, Hanke S, Stiller D. Deaths in German police
Dorn T, Ceelen M, Buster M, Das K. Screening for mental illness custody. EurJ Public Health 2009;19:597-601.
among persons in Amsterdam police custody. Psychiatr Serv Heide S, Chan T. Deaths in police custody. J Forensic Leg Med
2013;64(10):1047-1050. 2018;57:109-114.
228 I Police custodial healthcare
Heide S, Chariot P, Green P, et al. Healthcare and forensic medical Payne-James JJ. Care in police custody: United Kingdom. In:
aspects of police detainees, suspects and complainants in Payne-James JJ, Byard RW (eds). Encyclopedia of Forensic and
Europe. J Forensic Leg Med 2018;57:58-65. Legal Medicine, 2nd ed. Oxford: Elsevier, 2016,744-756.
Independent Office for Police Conduct. Deaths during or follow Payne-James JJ. Healthcare and forensic medical services in
ing police contact. Statistics for England & Wales 2017/2018. police custody: to degrade or to improve? Clin Med (Lond).
London 2018. https://policeconduct.gov.uk/sites/default/ 2017;17(1):6—7.
files/Documents/statistics/deaths_during_following_ Payne-James JJ, Beynon J, Nuno Vieira D. Assessment of physical
police_contact_201718.pdf (Accessed 15 May 2019). evidence of torture or cruel, inhuman and degrading treat
Jamieson RJ. Methadone and heroin use: a survey of prisoners in ment during visits to places of detention. In: Payne-James JJ,
police custody. J Forensic Leg Med 2011 ;18:233. Beynon J, Nuno Vieira D (eds). Monitoring Detention, Custody,
Jones R. Complexity in forensic pathology. Forensic Sci Int Torture and Ill-treatment: A Practical Approach to Prevention and
2015;257:e38-43. Documentation. Boca Raton: CRC Press, 2017.
Kennedy KM, Green PG, Payne-James JJ. Complaints against Payne-James JJ, Green PG, Green N, et al. Healthcare issues of
health-care professionals providing police custodial and detainees in police custody in London, UK. J Forensic Leg Med
forensic medical/health-care services and sexual offence 2010;17(1):11-17.
examiner services in England, Wales and Northern Ireland. Payne-James JJ, Rivers E, Green P, Johnston A. Trends in less-lethal
Med Sci Law 2017;57(1):12-32. use of force techniques by police services within England and
Lefevre T, Denis C, Marchand C, et al. Multiple brief interventions Wales: 2007-2011. Forensic Sci Med Pathol 2014;10(1):50-5.
in police custody: the MuBIC randomized controlled study Payne-James JJ, Smith G, Rivers E, et al. Effects of incapacitant
for primary prevention in police custody. Protocol and pre spray deployed in the restraint and arrest of detainees in the
liminary results of a feasibility study in the Paris metropolitan Metropolitan Police Service area, London, UK: a prospective
area, France .J Forensic Leg Med 2018;57:101-108. study. Forensic Sci Med Pathol 2014;10(1):62—8.
Lepresle A, Mahindhoratep TS, Chiadmi F, et al. Police custody Payne-James JJ, Stark MM, Butler B, Seymour C. So you want a
following drink-driving: a prospective study. Drug Alcohol career in forensic and legal medicine? Br J Hosp Med (Lond).
Depend 2012;126(1-2):51-4. 2018;79(3):C38-C41.
Less-Lethal Devices Technology Working Group. Special Panel Rekrut-Lapa T, Lapa A. Health needs of detainees in police cus
Review of Excited Delirium. NIJ Weapons and Protective tody in England and Wales; literature review. J Forensic Leg
Systems Technologies Center. 2011. https://www.justnet.org/ Med 2014;27:69-75.
pdf/ExDS-Panel-Report-FINAL.pdf (Accessed 15 May 2019). Sondhi A, Williams E. Health needs and co-morbidity among
Lindon G, Roe S. Deaths in police custody: a review of the inter detainees in contact with healthcare professionals within
national evidence. Research Report 95. Home Office. London, police custody across the London Metropolitan Police
October 2017. https://assets.publishing.service.gov.uk/ Service area. J Forensic Leg Med 2018;57:96-100.
government/uploads/system/uploads/attachment_data/ Southall P, Grant J, Fowler D. Police custody deaths in Maryland, USA:
file/655710/Deaths_in_police_custody_A_review_of_the_ an examination of 45 casesJForensic Leg Med 2008;15:227-230.
international_evidence.pdf Stark MM, Payne-James JJ. Provision of clinical forensic medical
Lorin de la Grandmaison G, Houssaye C, Bourokba N, Durigon M. services in Australia: a qualitative survey 2011/12. J Forensic
Frequency of traumatic lesions alleged by victims of assault Leg Med 2014;21:31-7.
during police custody. J Forensic Legal Med 2007;14:364-367. Stark MM, Payne-James JJ. People can die from opiate with
Lynch MJ, Suyama J, Guyette FX. Scene safety and force protec drawal. Med Sci Law 2017;57(2):103.
tion in the era of ultra-potent opioids. Prehosp Emerg Care Sturgiss EA, Parekh V. The work forensic physicians with police
2018;22(2):157—162. detainees in the Canberra City Watchhouse. J Forensic Leg
McArdle DJ, Howie RS, Harle RA. Two cases of benign pneu Med 2011;18:57-61.
momediastinum in patients with psychosis who had Unal V, Ozgun Onal E, ^etinkaya Z, imali M, et al. Custody and
been restrained in police custody. Aust N Z J Psychiatry prison deaths autopsied in Istanbul between 2010 and 2012.
2017;51(4):412-413. J Forensic Leg Med 2016;39:16-21.
McKinnon I, Grubin D. Health screening in police custody. Vilke G, Payne-James JJ, Karch SB. Excited Delirium Syndrome:
J Forensic Leg Med 2010;17:209-212. redefining an old diagnosis. J Forensic Leg Med 2012;19:7-11.
Noga HL, Walsh EC, Shaw JJ, Senior J. The development of a Vilke GM, Payne-James JJ. Excited Delirium syndrome: aetiology,
mental health screening tool and referral pathway for police identification and treatment. In: Gall JAM, Payne-James JJ (eds).
custody. Eur J Public Health 2015;25(2):237-242. Current Practice in Forensic Medicine, Vol 2. Chichester: Wiley, 2016,
Ogloff J, Warren L, Tye CB, et al. Psychiatric symptoms and his 97-114.
tories among people detained in police cells. Soc Psychiatry
Psychiatr Epidemiol 2011;46(9):871 —880. Further general resources
Otahbachi M, Cevik C, Bagdure S, Nugent K. Excited delirium,
restraints, and unexpected death: a review of pathogenesis. Faculty of Forensic & Legal Medicine. Resources https://fflm.
Am J Forensic Med Pathol 2010;31 (2):107-112. ac.uk/resources/publications/ (Accessed 13 August 2019).
Payne-James JJ, Byard RW. Encyclopedia of Forensic and Legal
Payne-James J. Clinical risk and detainees in police custody.
Medicine, 2nd ed. Oxford: Elsevier, 2016.
Clinical Risk 2010;16:56-60.
Payne-James J. Confidentiality and consent in police custody: Payne-James JJ, Beynon J, Nuno Vieira D. Monitoring Detention,
general principles. J Forensic Leg Med. 2018;57:66-72. Custody, Torture and Ill-treatment. A Practical Approach to
Prevention and Documentation. Boca Raton: CRC Press, 2017.
Payne-James J, Sheridan B, Smith G. Medical implications of the
Taser. BMJ 2010;22(340):c853. Stark MM, Payne-James JJ, Scott-Ham M. Symptoms and Signs of
Substance Misuse, 3rd Ed. Boca Raton: CRC Press, 2014.
Il 7
Sexual assault, genitoanal
injury and female genital
mutilation
■ Introduction ■ Medical findings after sexual contact
■ Examination requirements ■ Care after sexual assault
■ Definitions and the law ■ Female genital mutilation
■ Intimate partner violence ■ Bibliography and information sources
■ Medical assessment ■ Further general resources
■ Evidential samples and documentation of findings
Box 17.1 Key elements o f offences under the Sexual Offences Act 2003
(England & Wales)
Section 1: Definition of the act of'rape' • (A) does not reasonably believe that (B) consents.
• A person guilty of an offence under this section is
A person (A) commits an offence [of rape] if:
liable, on conviction on indictm ent, to imprison
• He intentionally penetrates the vagina, anus or ment for life.
mouth of another person (B) with his penis
• (B) does not consent to the penetration, and Section 3: Definition of'sexual assault'
• (A) does not reasonably believe that (B) consents. A person (A) commits an offence if:
• A person found guilty of rape under this section
• He intentionally touches another person (B)
is liable, on conviction on indictment, to imprison
• The touching is sexual
ment for life.
• (B) does not consent to the touching and
Section 2: Definition of the offence of'assault • (A) does not reasonably believe that (B) consents.
by penetration' A person guilty of an offence under this section is liable:
A person (A) commits an offence if:
a. On summary conviction, to imprisonment for a
• He intentionally penetrates the vagina or anus of term not exceeding 6 months or a fine not exceed
another person (B) with a part of his body or any ing the statutory maximum, or both
thing else b. On conviction or indictment, to imprisonment for
• The penetration is sexual a term not exceeding 10 years.
• (B) does not consent to the penetration and
Medical assessment 231
me by_____________________________________________________________________________________________________________________
I understand that the forensic examination will include (delete if not applicable)
c) Taking of notes, photographs/videos/digital images for recording and evidential purposes (including
second opinions from medical experts and peer review). I have been told that any sensitive photographs,
videos and/or digital images will be stored securely and only be made available to other non-medical
persons on the order of a judge;
d) I understand and agree that the doctor/nurse may provide a statement/report for the police;
e) I understand and agree that a copy of the medical notes may be given to professionals involved in the
case (eg police or lawyers) and may be used in a court;
g) I agree to the use of my anonymised photographs/videos/digital images/medical notes for audit and
research;
h) I have been advised that I may halt the examination at any time.
Figure 17.1 Consent to history, examination and report. (From the Faculty of Forensic & Legal Medicine pro forma
for adult female and male forensic sexual assault examination, [https://fflm.ac.uk/wp-content/uploads/2014/04/
Proforma-for-ADULT-female-and-male-forensic-sexual-assault-examination-JULY-2010.pdf].)
and equipment to be used for the examination should if an examination under anaesthetic for vaginal or anal
be carried out using suitable cleaning agents, pre- and injuries is necessary, the sexual offence examiner or
post-examination. forensic physician should be present at that examina
In some cases, the need for urgent medical care tion with the treating doctors to take relevant samples.
because of injury overrides the immediate need for a The sexual offence examiner must explain the
sexual assault examination. Healthcare aspects have nature, purpose and process of the assessment, in order
priority. Wherever possible, examinations should be that consent is fully informed and that chaperones
undertaken at the earliest opportunity in order to ensure are used when appropriate. An assessment for sexual
best opportunities for evidential sampling. For example, assault requires a detailed history and examination. The
232 I Sexual assault, genitoanal injury and female genital mutilation
history of the alleged assault from the complainant is an might yield trace evidence including the DNA of that
extremely important part of the assessment, as it assists alleged assailant.
in ensuring the best opportunities for evidence recovery. The genito-anal examination may be undertaken
For example, apart from genito-anal assault or penetra by naked eye or, depending on the available facilities,
tion, sites where there has been licking, kissing or biting with the assistance of specialist lighting, magnification
may allow DNA recovery. The examiner should ensure or colposcopes. Examination of a female complainant
that they record the briefing details from the referring (dependent in part on the history) will record the pres
police team, and then compare those details with the ence of any abnormalities or the absence of any findings
account of the complainant themselves confirming or in the following anatomical sites: thighs, buttocks and
amending it as necessary. Discrepancies may become perineum; pubic area; pubic hair; labia majora; labia
very significant at a later stage of any legal proceed minora; clitoris; posterior fourchette; fossa navicularis;
ings. Apart from a general medical history, detail of the vestibule; hymen; urethral opening; vagina and cervix.
full history of events and any specific physical contacts For the male (suspect or complainant) the buttocks,
must be identified (e.g., penis to mouth, mouth to geni thighs, perineum, anus, perianal area, testes, scrotum
talia, penis to anus, penis to vulva/vagina, ejaculation, and penis (including shaft, glans and coronal sulcus)
object/implement penetration of mouth/vulva/vagina/ will be examined.
anus, kissing/licking/biting/sucking/spitting). Recent
drug and alcohol intake must be recorded in as much Evidential samples and
detail as possible, and this may be relevant in terms of
ability to recall events appropriately or if there is a pos documentation of findings
sibility of drugs or alcohol having been administered in Appropriate samples in sexual assault will assist in
possible cases of drug-facilitated sexual assault. Specific determining the nature of sexual contact, the gender
questions are also asked about events after the assault and possibly identity of the assailant and possible links
as these may affect subsequent findings or recovery of with other offences. Samples that may be required
evidence. Such questions include 'Since the assault have include buccal swabs (for DNA), blood (for drugs and
you... noted pain... noted bleeding... brushed teeth... alcohol), urine, hair (head and pubic), nails and swab
passed urine... defaecated... douched?' A full medical samples from body orifices, mouth, ears, nose and geni
history must include past medical history, past surgical talia, including vulva, vagina, cervix, penis, anal canal
history, past gynaecological history, menstrual history and rectum. Appropriate sample kits, assembled with
and past psychiatric history so that, if necessary, any appropriate quality control, for particular areas of the
influence of these on examination findings can be con body should be used wherever possible (Figure 17.3)
sidered. Previous sexual history should not generally be Sampling must conform to agreed protocols and a clear
relevant, but it is important to enquire sensitively about chain of custody established. The Faculty of Forensic &
recent sexual activity before the alleged assault and Legal Medicine provides guidance as to sampling and
sexual activity after the assault. The appropriateness an example of guidance for some samples is shown
of the need for this information is still subject to some in Figure 17.4. This guidance is updated regularly and
debate. Based on this history, an appropriate examina as with all published guidance, practitioners should
tion can be undertaken to collect appropriate evidential ensure that they are using the most recent version.
samples. Figure 17.2a-d shows the specifics of informa Table 17.1 summarises the type of sample and what
tion that should be sought from the complainant. may be achieved from analysis of such a sample. In all
The nature of the examination of the adult in sexual cases if uncertain, confirm with forensic science labo
assault cases is determined in part by the history elic ratories (1) the type of specimen required and (2) how
ited, in that certain points may direct an examiner to it should be stored to ensure optimum preservation.
areas of particular interest. The following should always Samples should be taken in the light of the known his
be documented: weight, height (and Body Mass Index), tory and accounts of events. If there is any doubt whether
general appearance, skin abnormalities of changes (e.g., a particular sample may be relevant it is better to take
scars, tattoos, piercing) and appearance of the hair (e.g., a sample and retain it for later analysis. In the case of
dyed, shaved). a suspect the doctor should advise the police investiga
A standard general physical examination will be car tors regarding samples as legal requirements will need
ried out and a detailed physical, external examination to be observed in order to appropriately request samples.
which identifies injury or abnormality. The absence of Control swabs may be required, depending on local lab
injury and abnormality is also recorded. This examina oratory protocols and standard operating procedures.
tion will be documented on body diagrams and images The persistence of evidentially relevant materials is
of abnormalities should be taken. The external exami variable and advice should be sought from a forensic
nation will focus on those areas likely to have been in scientist or forensic toxicologist if uncertain whether
physical contact with an alleged assailant and which it is appropriate to take a sample. In general, foreign
Evidential samples and documentation of findings I 233
Mouth to (details)
NOT KNOWN / NO / YES
genitalia/anus?
Digit to (details)
NOT KNOWN / NO / YES
vulva/vagina/anus?
(details)
Penis into mouth? NOT KNOWN / NO / YES
(details)
Penis into anus? NOT KNOWN / NO / YES
Object to (details)
NOT KNOWN / NO / YES
vulva/vagina/anus?
(details)
Injuries? NO / YES
(details)
Ano-genital bleeding? NO / YES
(details)
Weapon used? NOT KNOWN / NO / YES
(details)
Damage to clothing? NO / YES
Figure 17.2 (a) Details of Assault from the Complainant. (From the Faculty of Forensic & Legal Medicine pro forma for
adult female and male forensic sexual assault examination [https://fflm.ac.uk/wp-content/uploads/2014/04/Proforma-
for-ADULT-female-and-male-forensic-sexual-assault-examination-JULY-2010.pdf].)
[Continued)
Sexual assault, genitoanal injury and female genital mutilation
(specify)
Changed clothes
(sites)
Self harm
C ircle.
Figure 17.2 (Continued) (b) Details of Assailant(s) and Post Assault events. (From the Faculty of Forensic & Legal
Medicine pro forma for adult female and male forensic sexual assault examination [https://fflm.ac.uk/wp-content/
uploads/2014/04/Proforma-for-ADULT-female-and-male-forensic-sexual-assault-examination-JULY-2010.pdf].)
(Continued)
Evidential samples and documentation of findings I 235
Abdominal pain
Urinary symptoms
eg dysuria, frequency,
haematuria, incontinence, UTI
Genital symptoms
Bowel symptoms
eg soreness, pain on
defaecation, discharge, bleeding,
change in bow el habit,
incontinence, pruritis, injuries
Figure 17.2 (Continued) (c) Direct Questions to be asked of complainant. (From the Faculty of Forensic & Legal
Medicine pro forma for adult female and male forensic sexual assault examination [https://fflm.ac.uk/wp-content/
uploads/2014/04/Proforma-for-ADULT-female-and-male-forensic-sexual-assault-examination-JULY-2010.pdf].)
(Continued)
Sexual assault, genitoanal injury and female genital mutilation
Dates and times of other relevant sexual activity within the previous 10 days ___________________________________
Have any illicit drugs been used by/administered to the subject within 4 days of the examination?
Are any other substances suspected of having been used by/administered that could be relevant to the offence?
Figure 17.2 (Continued) (d) Sexual History: Drug and Alcohol Use in Relation to Assault. (From the Faculty of Forensic
& Legal Medicine pro forma for adult female and male forensic sexual assault examination [https://fflm.ac.uk/wp-con-
tent/uploads/2014/04/Proforma-for-ADULT-female-and-male-forensic-sexual-assault-examination-JULY-2010.pdf].)
Medical findings after sexual contact I 237
_QJ
cn
Figure 17.4 Recommendations for the collection of forensic specimens from complainants and suspects, 2019. (From Faculty of Forensic & Legal Medicine.)
QJ
C71
• C: "Q
n-c O
J
ro
CL
1 = Ero
1-o
QJ
_QJ
S
ra1 o
cn
JO
:1 E-e
rxo o
-o rt3
I QJ TD
5
— oi c= . QJ I-M i
> • ra ra E
■S
" Q.S IT, -Q
;|§
O -—
■— u ra £
!L; lQ^J !•<o
’ ^ QJ -Cl - o
.• QJ •=■ C
I -9 £ > ^ E^ -5 E q5 O ^ 1-5
Cl ^ e 2! : QJ = 5 E---Q"J I I— QJ i/I QJ QJ
.>.2> r—a'
E 3 E i
«-<-> •— QJ QJ
I C O --QJ QJ
LO * ‘S ^ c qj a __ QJ Q— Q p - 3 L Q IC
S c 8
3 I fU STO£c- 3
e
<U •ra
—^ ro c:c QJ ro <r-o» cc ro
•— > E a) r QJ ro
* -“= sfi
erora t oj
CO I a. cl IS it
7T 7T ra q_ cl iS LO 2 t CL CL i S £
"O
C ■QJo ■-r (U
>
- QJ
(V •F,"0 ^ ra -O (JrT'3= u.
C ^ > QJ ° - d O
vo o t;
r» QJ Qj
ro
>— ro >"o
qj
Itg
+-» ■— 3 y i, ex.
; O _ ^ QJ I o ra
L_j -£
q QZ
J *-
ro °o S:
So 2□ ro E S
> O QJ QJ
C s » ;
QJ
W u o ° QJ §■£ E 2 c ro q j
CD l■bi? l 2i a;f— -• - >< E ?| “ s
QJ • ^ - > '
ra *o ro > ra :E
QJ c cl to = _£= Qj QJ S 2 QJ cE
^ -o
j- ro q j - c ; E x
_c -C ro I.E frofoj l-E qo c -t; E 2
i s SJ t/» 1/1 O > « E ^ :S CL QOJ ‘cn
QJ QJ
CL . o QJ Si ~ TD "O
£)0 3 " ° c c § fi £ | 'a 2 >
o ra (_i >. .ra
-Cl QJ Q.
E I -= r- \s\ QJ — ro 1 1 .5 _£ ro c l ^ ra -5 o
o cn o to Q ro > . y
^ >- Q.
qj
o
c-> ■<
g= e ro £ . §- .E TS -E * ^-S
-O CL o ro ro
g -qj5 1ro J 2 S-l -S^e ^
t qj - c - o - ^ < O O 5
^ oJ-g 5 £ g ro
E .;£> _E_QJ cn <y ,_
III
-£= O QJ
(_) v_» QJ .‘t i
o o o o E ro qj
g c r * - .E’TE w | ra Q <- > -d S
E
E -o ^ j
H i ro ro o .
=ra"u
roJj^ °q] S
> «S ai ~ -K <=P : QJ ro qj ^
= TO fU QJ ^ x ^^ ^ & ^ Q-c .t ^ =o _c E
oo o x i t ai.E - cr = fD ■n n
C u,
—
-- O -
QJ ro o
"> "^ro o crE ■*—* ro
C 2 ^ qj 9J 3 qj ro rora c qj ro
q—j . - oJ ~ cn E
'
..a u r a «I o -t5 -ti — QJ
■— C (n ^ ^ 2
<1> -, o >• a» S Q> S' = ■
P : = ,?o «,
"ct
ro w q j > ~ ~
|E c-o ro-° c ~ I * QJ E
•-«-»
B — — - o ro i 2
at ro Q) o 2“ QJ ‘ 12 ro ro ^ ^ -O 1/1rQo
J qj 2 ^
Q- CL^2
i O ra 3 1 - 0 QJ
S i i QJ O
I 2 2 >*£«£ c ts = c QJ „ •S s = t: = S | oPI F qj
Please ensure you have read the instructions on page 1 before referring to the table.
a> ■ j° f o 0w QJ -£=
* - ru ■CT ^
sj '5 -. O
_QJ > =1 i 5|
_QJ ^ E
3 O ^O - cn
QJ 2 ^ ro
Q l r=5 S ^ .E -c i sl?| ^ O > >.
QJ c• •n -o
CL QJ "I 5 ro
to o “ l ^ I ' 5 o TO_ -O ^
o
E ? ° r a g 'w r
■E QJ W = 3 CLC c
QJ fU
- E5^i
QJ _E
E| .t; w 3 ro E S"-E
c? £ 1/1-° ra o ct E Si J= -1= 5{ E
co E S: = ra n. > c
'>/■> o o $ j=
D U a S i t : o ^□
CL ^
QJ
i =
r5 2 £ 3 .E--
1 -E-P _= o .!=!
i .—
= ^-1 E 3 -iD Q§J 2i "J>
C 3 wn > C* UJ
a>
t_ QJ
O
vZl TD
I “O C
1 C O
QJ c
QJ Q J ~
- t
CL
ZD ra TO■£E
O "to
c(T3"O
ro•c—E
fO n
°
QJ
i ■="S ^s ^ C= > -
c j§ C QJ^
Cl
.2 5 I —
I
e
-
"B * - - o
qj ~ c •£ flj P r E ^ QJ
t s i
•qj=i— sy 3 >-
qj -E
—
dl u
rg
| S o | a ;o 0u J,S
C
O -D
QJ nOJ
w q>js I j - s r "c
"o J ro cu -c - x > ro QJ^ -°g Ero
VJ I— ^
I a jS -g £ E| < c: s <^
Z
^
m i- —
Q .— .E . ro
ill - S '5 o ra .E
|-8:s-S-§ £ X uq >
^ >
QJ
cn
cn
*t= ^
-o
t=
c .E 2
qj
=> j= _E _
ro
= r" c 3-5S £3 ^ c =
QJ
1—
* TOv> ® >*•= QJ I
I C
QJ
g.
P
-O
2
01 r- .£ =
C
o -5 I "S ra2 m"0'^ E § u.
ro ‘-o
^ >• cri
2
i -2/o -S ^ sg l-Q&p ero QJ «0
^ -c _ o ro
- ‘S QJ ^
IS ) On
O S 8J ° SP 3 m
o >■- 2 >«CL C -°
£o 5^ QJ '> 2i ^ -5 ro 55 3 «! e S3 2 S q35 S C
O QJ ’i^ ^ c - o £ I-—=, sO QJ
5
I CJ I 1 S lc
QJ 0 _ c
CO QJ q : x : ■£ aQJ 2ro .E^ID
io
"O ro
C >
a; I <U3 5
£o 1 3 E 5Sro
.■
»^ o w
E re 'T = ~
i: ^a ”Tc3 ?_S. ^^ g
^ E -§E^^ IQ. -S
o *«- 3 .E 6 M ° e p •-
§ s XI O O c
5 m Qi
%a.™ CL = o Aj 2 g -g
o- o E ^?
Q£ I \SI — vO O
Fem ale genital m u tilatio n I 239
Table 17.1 Type of sample taken and what may identified by analysis
Sample type What may be Identified by analysis
of FGM (i.e., it does not apply where a woman aged 18 Faculty of Forensic & Legal Medicine of the Royal College of
or over discloses she had FGM when she was under 18). Physicians. Quality standards in forensic medicine & qual
Complying with the duty does not breach any confiden ity standards for nurses and paramedics, www.fflm.ac.uk/
tiality requirement or other restriction on disclosure wp-content/uploads/2016/11/Quality-Standards-for-Nurses-
and-Paramedics-General-Forensic-Medicine-May-2016.pdf
which might otherwise apply The duty is a personal duty
(Accessed 16 May 2019).
which requires the individual professional who becomes
Faculty of Forensic & Legal Medicine of the Royal College of
aware of the case to make a report; the responsibility Physicians. Operational procedures and equipment for medi
cannot be transferred. The only exception to this is if the cal rooms in police stations & operational procedures and
professional is aware that another individual from the equipment for medical facilities in victim examination suites
same profession has already made a report; there is no or Sexual Assault Referral Centres (SARCs). https://fflm.ac.uk/
requirement to make a second report. The first success wp-content/uploads/2016/01/0perational-procedures-and-
ful prosecution for FGM was achieved in the UK in 2019. equipment-for-medical-facilities-in-victim-examination-
suites-or-SARCs-Dr-M-Stark-Jan-2016.pdf (Accessed 16 May
2019).
Bibliography and information Faculty of Forensic & Legal Medicine of the Royal College of
Physicians. Recommended equipment for obtaining forensic
sources samples from complainants and suspects, https://fflm.ac.uk/
Abedr-Rahman H, Salameh HO, Salameh RJ, et al. Role of foren publications/recommendations-recommended-equipment-
sic medicine in evaluating non-fatal physical violence against for-obtaining-forensic-samples-from-complainants-and-sus-
women by their husbands in Jordan. J Forensic Leg Med pects/ (Accessed 16 May 2019).
2017;49:33-36. Faculty of Forensic & Legal Medicine of the Royal College
Anderson SL, Parker BJ, Bourgignon CM. Changes in genital injury of Physicians. Quality Standards for doctors undertaking
patterns over time in women after consensual intercourse. J Paediatric Sexual Offence Medicine (PSOM). https://fflm.
Forensic Leg Med 2008;15:306-311. ac.uk/wp-content/uploads/2017/06/Quality-Standards-for-
Bartels S, Kelly J, Scott J, et al. Militarized sexual violence in South doctors-undertaking-PSOM-Dr-Cath-White-and-Prof-lan-
Kivu, Democratic Republic of Congo. J Interpers Violence Wall-April-2017.pdf (Accessed 10 May 2019).
2013;28(2):340-358. Faculty of Forensic & Legal Medicine of the Royal College of
Bechtel LK, Holstege CP. Criminal poisoning: drug facilitated Physicians. Recommendations for the examination of female
sexual assault. Emerg Med Clin North Am 2007;25:499-525. suspects of sexual assault, https://fflm.ac.uk/wp-content/
Beck AJ, Harrison PM. Sexual victimization in state and federal pris uploads/2018/01/Recommendations-for-the-examination-
ons reported by inmates. Bureau of Justice Statistics Special of-female-suspects-of-sexual-assault-Dr-M-Stark-Jan-2018.
Report; 2007. pdf (Accessed 10 May 2019).
Beh P, Payne-James JJ. Adult sexual assault. In: Gall J, Payne-James Faculty of Forensic & Legal Medicine of the Royal College of
JJ (eds). Current Practice in Forensic Medicine. London: Wiley; Physicians. Recommendations for the collection of forensic
2011,95-118. specimens from complainants and suspects. https://fflm.
Brown C. Rape as a weapon of war in the Democratic Republic ac.uk/wp-content/uploads/2018/01/Recommendations-for-
of the Congo. Torture 2012;22(1):24—37. the-collection-of-forensic-specimens-from-complainants-
Burger C, Olson M, Dykstra D, et al. What happens at the 72 hour and-suspects-FSSC-Jan-2018.pdf (Accessed 10 May 2019).
mark? Physical findings in sexual assault cases when victims Faculty of Forensic & Legal Medicine of the Royal College of
delay 2009 reporting. Ann Emerg Med 2009;54:S93. Physicians. Care of suspects of sexual assault in police cus
Castro CA, Kintzle S, Schuyler AC, et al. Sexual assault in the mili tody. https://fflm.ac.uk/wp-content/uploads/2018/09/Care-of-
tary. Curr Psychiatry Rep 2015;17(7):54. Suspects-of-Sexual-Assault-in-Police-Custody-FFLM-Aug-2018.
Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV pdf (Accessed 10 May 2019).
post-exposure prophylaxis in victims of sexual assault: Faculty of Forensic & Legal Medicine of the Royal College of
a systematic review and meta-analysis. Sex Transm Infect Physicians. Recommendations for the collection of forensic
2012;88(5):335—341. specimens from complainants and suspects. https://fflm.
Coulter RWS, Mair C, Miller E, et al. Prevalence of past-year ac.uk/publications/recommendations-for-the-collection-
sexual assault victimization among undergraduate stu of-forensic-specimens-from-complainants-and-suspects-3/
dents: exploring differences by and intersections of gen (Accessed 16 May 2019).
der identity, sexual identity, and race/ethnicity. Prev Sci Forensic Science Regulator Guidance. DNA anticontamination -
2017;18(6):726-736. forensic medical examination in sexual assault referral cen
Crane J. Interpretation of non-genital injuries in sexual assault. tres and custodial facilities https://assets.publishing.service.
Best Pract Res Clin Obstet Gynaecol 2013;27(1):103-111. gov.uk/government/uploads/system/uploads/attachment_
Crawford-Jakubiak JE, Alderman EM, Leventhal JM, AAP data/file/540116/207_FSR_anti-_contam_SARC__ Custody.
Committee on Child Abuse and Neglect, AAP Committee Issue1.pdf (Accessed 10 May 2019).
on Adolescence. Care of the adolescent after an acute sexual Gallion HR, Dupree LJ, Scott TA, Arnold DH. Diagnosis of
assault. Pediatrics 2017;139(3) e20164243. Trichomonas vaginalis and adolescents evaluated for pos
Department of Homeland Security. Standards to prevent, detect, sible sexual abuse: a comparison of the InPouch TV culture
and respond to sexual abuse and assault in confinement method and wet mount microscopy. J Pediatr Adolesc Gynecol
facilities: final rule. FedRegist 2014;79(45):13099-13183. 2009;22:300-305.
242 I Sexual assault, genitoanal injury and female genital mutilation
Grossin C, Sibille I, de la Grandmaison GL, et al. Analysis of 418 Mason F, Lodrick Z. Psychological consequences of sexual
cases of sexual assault. Forensic Sci Int 2003;131:125-130. assault. Best Pract Res Clin Obstet Gynaecol 2013;27(1):
Guy KM. Mai-Mai militia and sexual violence in Democratic 27-37.
Republic of the Congo. Int J Emerg Ment Fleolth 2014;16(2): McCall-Hosenfeld JS, Freund KM, Liebschut JM. Factors associ
366-372. ated with sexual assault and time to presentation. PrevMed
Hakkanen-Nyholm H, Repo-Tiihonen E, Lindberg N, et al. Finnish 2009;48:593-595.
sexual homicides: offence and offender characteristics. McCauley J, Ruggiero KJ, Resnick HS, et al. Forcible, drug-facil-
Forensic Sci Int 2009;188:125-130. itated and incapacitated rape in relation to substance use
Hall JA, Moore CB. Drug facilitated sexual assault: a review. J problems: results from a national sample of college women.
Forensic Leg Med 2008;15:291 -297. Addict Behav 2009;34:458-462.
Hensley C, Koscheski M, Tewksbury R. Examining the character Mellins CA, Walsh K, Sarvet AL, et al. Sexual assault incidents
istics of male sexual assault targets in a Southern maximum- among college undergraduates: prevalence and factors asso
security prison. Jlnterpers Violence 2005;20(6):667-679. ciated with risk. PLOSONE 2017;12(11):e0186471.
Hilden M, Schei B, Sidenius K. Genitoanal injury in adult female Muriuki EM, Kimani J, Machuki Z, et al. Sexual assault and HIV
victims of sexual assault. Forensic Sci Int 2005;154:200-205. postexposure prophylaxis at an urban african hospital. /A/OS
Home Office. Mandatory Reporting of Female Genital Patient Care STDS 2017;31 (6):255-260.
Mutilation. Procedural information 2015. https://assets. Norfolk GA. Accidental anal intercourse: does it really happen? J
publishing.service.gov.uk/government/uploads/system/ Clin Forensic Med 2005;12:1-4.
uploads/attachment_data/file/573782/FGM_Mandatory_ O'Connor M. Sexual violence in armed conflict: the least con
Reporting_-_procedural_information_nov16_FINAL.pdf demned of war crimes. J Law Med 2014;21 (3):528-542.
(Accessed 16 May 2019). Office for National Statistics. Sexual offences in England and
Ingemann-Hansen O, Sabroe S, Brink O, et al. Characteristics of Wales: year ending March 2017. Analyses on sexual offences
victims of assaults of sexual violence: improving inquiries and from the year ending March 2017 Crime Survey for England
prevention. J Forensic Leg Med 2009;16:182-188. and Wales and crimes recorded by police https://www.
Jones JG, Worthington T. Genital and anal injuries requiring surgi ons.gov.uk/peoplepopulationandcommunity/crime-
cal repair in females less than 21 years of age. J PediatrAdolesc andjustice/articles/sexualoffencesinenglandandwales/
Gynecol 2008;21:207-211. yearendingmarch2017#main-points (Accessed 10 May 2019).
Jones JS, Dunnuck C, Rossman L, et al. Significance of toluidine Okonkwo JEN, Ibeh CC. Female sexual assault in Nigeria. In tJ
blue positive findings after speculum examination for sexual Gynaecol Obstet 2003;83:325-326.
assault. Am J Emerg Med 2004;222:201-203. Omuodo DO. Initiatives. Uganda: female genital mutilation
Jones JS, Rossman L, Diegel R, et al. Sexual assault in post meno among the Sabiny.AfrLink 1995;14—15.
pausal women: epidemiology and patterns of genital injury. Palmer CM, McNulty AM, D'Este C, Donovan B. Genital injuries
Am J Emerg Med 2009;27:922-929. in women reporting sexual assault. Sex Health 2004;11:55-59.
Kelly DL, Larkin HJ, Cosby CD, Paolinetti LA. Derivation of Payne-James JJ, Roger DJ. Drug facilitated sexual assault,
the Genital Injury Severity Scale (GISS): a concise instru 'ladettes' and alcohol.JRSocM ed 2002;95:326-327.
ment for description and measurement of external female Payne-James JJ. Sexual offenses: injuries and findings after sexual
genital injury after sexual intercourse. J Forensic Leg Med contact. In: Payne-James JJ, Byard RW (eds). Encyclopedia of
2013;20(6):724-731. Forensic and Legal Medicine, 2nd ed. Oxford: Elsevier; 2016,
Kelly DL, Larkin HJ, Paolinetti LA. Intra- and inter-rater agree 280-285.
ment of the Genital Injury Severity Scale. J Forensic Leg Med Payne-James JJ, Newton MA, Bassindale C. Forensic sci
2017;52:172-180. ence, forensic medicine and sexual crime. In: Radcliffe P,
Kelly-Hanku A, Kawage T, Vallely A, et al. Sex, violence and HIV Gudjonsson G, Heaton-Armstrong A (eds). Witness Testimony
on the inside: cultures of violence, denial, gender inequal in Sexual Cases. Oxford: Oxford University Press; 2016.
ity and homophobia negatively influence the health out Payne-James JJ. Sexual assault in detention. In: Payne-James JJ,
comes of those in closed settings. Cult FleaIth Sex 2015;17(8): Beynon J, Nuno Vieira D (eds). Monitoring Detention, Custody,
990-1003. Torture and Ill-treatment. A Practical Approach to Prevention and
Kumar T, Sampsel K, Stiell IG. Two, three, and four-drug regimens Documentation. Boca Raton: CRC Press; 2017.
for HIV post-exposure prophylaxis in a North American sex Peel M, Mahtani A, Hinshelwood G, Forrest D. The sexual abuse
ual assault victim population. Am J Emerg Med 2017;35(12): of men in detention in Sri Lanka. Lancet 2000;355:2069-2070.
1798-1803. Regueira-Dieguez A, Perez-Rivas N, Munoz-Barus Jl, et al. Intimate
Langenderfer-Magruder L, Walls NE, Kattari SK, et al. Sexual victim partner violence against women in Spain: A medico-legal and
ization and subsequent police reporting by gender identity criminological study.J Forensic Leg Med 2015;34:119-126.
among lesbian, gay, bisexual, transgender, and queer adults. Richters J, Butler T, Schneider K, et al. Consensual sex between
Violence Viet 2016;31(2):320-331. men and sexual violence in Australian prisons. Arch Sex Behav
MacLeod KJ, Marcin JP, Boyle C, et al. Using telemedicine to 2012;41(2):517-524.
improve the care delivered to sexually abused children in Riggs N, Houry D, Long G, et al. Analysis of 1076 cases of sexual
rural, underserved hospitals. Pediatrics 2009;123:223-228. assault. Ann Emerg Med 2000;35:358-362.
Maguire M, Goodall E, Moore T. Injury in adult female sexual Rossman L, Jones JS, Dunnuck C, et al. Genital trauma associated
assault complainants and related factors. EurJObstetGynecol with forced digital penetration. Am J Emerg Med 2004;22:101-104.
Reprod Biol 2009;142:149-153. Saliu A, Akintunde B. Knowledge, attitude, and preventive prac
Masho SW, Odor RK, Adera T. Sexual assault in Virginia: a popula tices among prison inmates in Ogbomoso prison at Oyo State,
tion study. Women's Health Issues 2005;15:157-166. South West Nigeria. Int J Reprod Med 2014;2014:364375.
Further general resources I 243
Saltzman LE, Basile KC, Mahendra RR, et al. National estimates Wolff N, Jing Shi. Contextualization of physical and sexual assault
of sexual violence treated in emergency departments. Ann in male prisons: incidents and their aftermath .J Correct Health
Emerg Med 2007;492:10-17. Care 2009;15(1):58—77.
Santos JC, Neves A, Rodrigues M, Ferrao P. Victims of sexual Yap L, Richters J, Butler T, et al. The decline in sexual assaults in
offences: medico-legal examinations in emergency settings. men's prisons in New South Wales: a "systems" approach. J
J Clin Forensic Med 2006;13:300-303. Interpers Violence 2011;26(15):3157-3181.
Schilling S, Deutsch SA, Gieseker R, et al. Improving HIV post Zawati HM. Impunity or immunity: wartime male rape and sexual
exposure prophylaxis rates after pediatric acute sexual torture as a crime against humanity. Torture 2007;17(1):27-47.
assault. Child Abuse Negl 2017;69:106-115. Zilkens RR, Phillips MA, Kelly MC, et al. Non-fatal strangulation in
Schneider K, Richters J, Butler T, et al. Psychological distress and sexual assault: a study of clinical and assault characteristics
experience of sexual and physical assault among Australian highlighting the role of intimate partner violence. J Forensic
prisoners. Crim Behav Ment Health 2011;21(5):333—349. Leg Med 2016;43:1-7.
Sexual Offences Act 2003. http://www.legislation.gov.uk/ Zilkens RR, Smith DA, Kelly MC, et al. Sexual assault and general
ukpga/2003/42/contents (Accessed 10 May 2019). body injuries: a detailed cross-sectional Australian study of
Seyller M, Denis C, Dang C, et al. Intimate partner sexual assault: 1163 women. Forensic Sci Int 2017;279:112-120.
traumatic injuries, psychological symptoms, and perceived
social reactions. Obstet Gynecol 2016;127(3):516-526. Further general resources
Sommers MS, Zink T, Baker RB, et al. The effects of age and eth
nicity on physical injury from rape. J Obstet Gynecol Neonatal Payne-James JJ, Newton MA, Bassindale C. Forensic sci
Nurs 2006;35:199-207. ence, forensic medicine and sexual crime. In: Radcliffe P,
Stephens T, Cozza S, Braithwaite RL. Transsexual orientation in Gudjonsson G, Heaton-Armstrong A (eds). Witness Testimony
HIV risk behaviours in an adult male prison. Int J STD AIDS in Sexual Cases. Oxford: Oxford University Press; 2016.
1999;10(1):28—31. UN Entity for Gender Equality and the Empowerment of
Sturgiss EA, Tyson A, Parekh V. Characteristics of sexual assaults in Women (UNWOMEN). Violence against women prevalence
which adult victims report penetration by a foreign object J data: surveys by country, http://www.endvawnow.org/
Forensic Leg Med 2010;17:140-142. uploads/browser/files/vawprevalence_matrix_june2013.pdf
Sugar NF, Fine DN, Eckert LO. Physical injury after sexual (Accessed 10 May 2019).
assault: findings of a large case series. Am J Obstet Gynecol UN Office on Drugs and Crime. HIV/AIDS prevention, care, treat
2004;190:71-76. ment and support in prison settings: a framework for an
Tsai AC, Eisa MA, Crosby SS, et al. Medical evidence of human effective national response, 2006. https://www.unodc.org/
rights violations against non-Arabic-speaking civilians in pdf/HIV-AIDS_prisons_July06.pdf (Accessed 16 May 2019).
Darfur: a cross-sectional study. PLoSMed 2012;9(4):e1001198. UN Office on Drugs and Crime. HIV prevention, treatment and
UNICEF Female Genital Mutilation/Cutting: A Global Concern. care in prisons and other closed settings: a comprehen
New York: UNICEF; 2016. sive package of interventions, 2013. https://www.who.int/
US Department of Justice. Justice Department releases final rule to hiv/pub/prisons/interventions_package/en/ (Accessed 13
prevent, detect and respond to prison rape. http://www.justice. August 2019).
gov/opa/pr/justice-department-releases-final-rule-prevent- UN Third Committee of the UN General Assembly. UN Standard
detect-and-respond-prison-rape (Accessed 10 May 2019). Minimum Rules for the Treatment of Prisoners (the Nelson
White C. Genital injuries in adults. Best Pract Res Clin Obstet Mandela Rules), 2015. https://www.un.org/en/events/mande-
Gynaecol 2013;27(1):113-130. laday/mandela_rules.shtml (Accessed 16 May 2019).
Safeguarding and protection
18 of children and vulnerable
J
adults
■ Introduction ■ Neglect and emotional abuse
■ Child abuse and neglect ■ Fabricated or induced illness in children
■ Definitions ■ Management of child abuse
■ Legislation in England &Wales ■ Safeguarding vulnerable adults
■ Safeguarding children and young people ■ Elder abuse
■ Physical abuse ■ Bibliography and information sources
■ Sexual abuse ■ Further general resources
The Act used the term 'harm' to describe the effects to support children living with relatives, family, friends
of ill-treatment and poor care leading to injury, impair and foster families, or sometimes, especially for older
ment of health or development of a child. The term 'sig young people, in children's homes and units. The quality
nificant harm' was used to determine the severity of the of life of such children is of major concern and should
ill-treatment and is the threshold for compulsory inter be assessed. In the UK, the Children's Commissioner
vention in child protection cases. All police services publishes the 'Stability Index' which provides an annual
within the UK should now have specialist Child Abuse measure of the stability of the lives of children in care.
Investigation Units tasked with investigating suspected
cases of child abuse.
Physical abuse
Physical abuse takes many forms. Children are prone to
Safeguarding children and young injury as a result of accident and play and sports, and the
type and site of injury will relate to those factors as well
people as their age and mobility. Deciding whether an injury
In response to a number of high-profile deaths of chil represents an accident or physical abuse can be chal
dren, the Children Act 2004 imposed a duty on local lenging. A number of systematic reviews provide practi
authorities to establish Local Safeguarding Children tioners with a reliable evidence base to assist in making
Boards, which have overall responsibility for deciding diagnoses of physical abuse. (See Boxes 18.1-18.6 which
how relevant organisations work together to safeguard summarise some of these findings.)
and promote the welfare of children in their areas. The prevalence, number and location of bruising
Where statutory child protection proceedings have relates to motor development. Non-abusive bruises tend
been initiated, then a local authority social care worker to be small, sustained over bony prominences, and found
is tasked with taking the lead in supporting and safe on the front of the body (Figure 18.1a and b). In children
guarding the child. Serious case reviews are undertaken alleged to have been subject to abuse, bruising is com
when a child dies or is seriously injured, and abuse or mon. Certain parts of the body are particularly vulner
neglect are known or suspected to be factors in the able. Significantly more children with physical abuse
death. They are carried out under the auspices of Local had bruises, and had significantly more sites affected.
Safeguarding Children Boards so that lessons can be The odds of a physically abused child having bruising to:
learned locally. Children in care are children who are buttocks/genitalia, left ear, cheeks, neck, trunk, front of
'looked after' by a local authority under the Children thighs and upper arms were significantly greater than
Act 1989 and Social Services and Wellbeing Act 2014. in children where abuse was excluded. Petechiae, lin
The term Tooked-after children' is utilised in both stat ear or bruises with distinct pattern, bruises in clusters,
ute and guidelines. Looked-after children are those additional injuries or a child known to social services for
that are given accommodation away from their families previous child abuse concerns were significantly more
at the request of their parent and those in care as the likely in physical abuse. Figure 18.2 shows areas on the
result of a Care Order. The Looked-after Children ser body where bruises were significantly more likely to
vice is responsible for children who cannot, for what occur in a child with confirmed physical abuse than in
ever reason, live with their families. The service aims one where physical abuse was excluded.
Box 18.2 The main systematic review findings relating to thermal injury in
infants and children
Changing trends indicate that scalds and non-scald samples. Notably, there is no evidence to support
burns are equally common among children now, partly the lack of splash marks as an indicator of abusive
contributed to by a rise in contact burns due to hair scalds, which may be due to newer taps producing
styling devices, such as hair straighteners. aerated water, where individual droplets are not
sufficiently hot to cause a scald.
• High-quality comparative data of scalds suggests • Abusive non-scald burns lack high-quality com
that those due to abuse are more likely to be caused parative studies, thus precise distinguishing fea
by hot water (rather than beverages), immersion tures are harder to define. Contact burns are the
rather than pull-over or spill injuries, and to involve most common intentional and unintentional burn,
the lower limbs, buttocks or perineum. although children have been subject to caustic,
• They may also involve the hands and forearms flame and irradiation burns.
('glove and stocking' injuries), are usually bilateral • Characteristics of abusive contact burns include
but may involve a single limb. Characteristically, a clearly demarcated edge, present on the back,
they will have clear upper margins, and equal shoulders or buttocks, may be multiple and occur
depth of burn, as opposed to accidental injuries ring across the age span. The pattern of the burn
which usually have an irregular margin and typi may facilitate matching to the object that was the
cally involve the deepest burn at initial point of source of the heat.
contact (e.g., hand/arm), becoming more super • Identification of burns due to being microwaved
ficial as the cooling liquid travels down the body. include characteristic sparing of the subcutane
• Co-existent injuries can include fractures, other ous fat beneath burned epidermis and dermis, and
cutaneous injuries, prior burns and research sug below the fat layer, significantly burned muscle
gests these children may show toxicology evi with no nuclear streaming.
dence of exposure to illicit substances on hair
Box 18.3 The main systematic review findings relating to abdominal injuries
in infancy and childhood
• Abusive abdominal injuries are predominantly injuries are extremely rare in childhood, predomi
blunt trauma (the exception being the insertion nantly resulting from high-impact collisions or
of long embroidery needles into the liver/caecum/ crush injury. Duodenal injuries sustained include
rectum, also described as being inserted into the intramural haematomas, perforation or transec-
brain of infants). tions, the latter being more common in abuse
• Solid and hollow organ injuries appear equally than other causes; typically, trauma was between
common, but hepatic injury may be underes the 3rd and 4th part of the duodenum.
timated due to children's capacity to compen • The range of pancreatic injuries are similar, with a
sate for subcapsular haematomas and the lack high fatality rate among abused children. Further
of explicit sensitivity and specificity of screening intrabdominal injuries include hepatic, splenic,
with liver enzymes. renal, adrenal trauma, or gastric/colonic or blad
• Key characteristics distinguishing abusive abdom der rupture, or chylous ascites many, but not all,
inal injuries is the young age of the patients, with of whom had associated injuries including rib frac
mean age of 3 years in contrast to the mean age tures or head injury.
of unintentional injuries being 7 years, although • It is notable that abdominal bruising was fre
abusive duodenal injury may occur throughout quently absent, even in the presence of liver tran
childhood. section, the reason for which is postulated to be
• No child less than two years of age has been that the impact is absorbed by the viscera, thus no
described with a duodenal injury from acciden bruise is evident externally.
tal mechanisms. Both duodenal and pancreatic
248 I Safeguarding and protection of children and vulnerable adults
Box 18.4 The main systematic review findings relating to infant and childhood
abusive head trauma (AHT)
• The spectrum of injuries seen in AHT includes although both types of intracranial haemorrhage
intracranial, cutaneous and possibly cervical liga are equally likely to be present in non-abusive
mentous injury. head trauma.
• There may be associated fractures, such as rib or • Extradural haemorrhage (EDH) is strongly associ
metaphyseal, although the presence of skull frac ated with non-abusive head trauma.
tures is more commonly associated with non-abu- • With increasing sophistication in neuro-imaging,
sive head trauma. it is apparent that hypoxic ischaemic injuries in
• The predominant intracranial association is sub association with SDH are strongly associated with
dural haemorrhage (SDH), typically multiple, bilat AHT.
eral, and which may be interhemispheric, over the • Cerebral oedema and shear injury are also asso
convexities or in the posterior fossa. SDH may be ciated with AHT, but intra-parenchymal injury is
accompanied by subarachnoid haemorrhage, equally likely in abusive or non-abusive injury
Box 18.5 The main systematic review findings relating to spinal injuries in
infancy and childhood
Some of the most exciting new research evidence with posterior fossa SDH. It is not yet clear whether
relates to the pattern of ligamentous cervical these are due to tracking of blood through the
injury seen in association with AHT. subdural space, or are the result of trauma to the
In the live child, these will only be identified if spine itself in association with AHT. Children who
magnetic resonance imaging (MRI) includes short exhibit significant cervical trauma, including frac
T1 inversion recovery (STIR) sequences, which are tures or anterolisthesis, tend to be young infants
not routinely performed. with co-existent AHT. In contrast, those children
The presence of nuchal, interspinous, posterior sustaining thoraco-lumbar injuries, including
atlanto-axial, posterior atlanto-occipital and cap vertebral compression fractures (often multiple),
sule ligamentous injury was seen only in infants dislocations, subluxations or ligamentous injury,
with spinal trauma, not in those undergoing spi tend to be older, with a mean age of 16 months,
nal imaging for medical reasons, and were sig and may present with or without symptoms.
nificantly more common amongst those with AHT Co-existent AHT is more common in the youngest
than those with direct trauma to the cervical spine. infants, but may still be present in the toddlers,
Spinal cord injury per se is rare, although spinal and rib and limb fractures are also common co
SDH extending throughout the spine to the lum existent injuries.
bosacral area is now well recognised in association
of children will provide no information. Examination characteristics may indicate both neglect and emo
of a pre-pubertal girl alleging vaginal penetration some tional abuse, for example, age-inappropriate social
months earlier may have value. A male alleging historic skills (e.g., inability to use knife and fork), bedwet
anal penetration with immediate pain and bleeding at ting and soiling, inability to self-dress, smoking, drug
the time may have persistent scarring. Review of medi and alcohol misuse, sexual precocity and absenting
cal records of the individual at the time of the allega from school. Certain features associated with possible
tions may provide helpful supportive evidence. neglect may be evident during assessment and physi
The interpretation of physical signs found after cal examination and include unkempt child, ill-fitting
genito-anal assessment is a very difficult and complex or absent items of clothes, dirty or uncut nails, local skin
area. Most complainants of child sexual abuse have no infections/excoriations and low centiles for weight and
genito-anal abnormalities when examined after alleged height. However, some of these features may be seen in
sexual abuse. It is essential that precise and consistent normal, non-abused children. There may be a failure
terminology is used in the description of abnormality to thrive. There may be considerable geographical and
and injury so that abnormal findings are clearly under cultural differences in the manifestation of such abuse.
stood (Box 18.7). The presence of certain infections may Certain groups of children are at particular risk of
have relevance in sexual abuse enquiries. The impli emotional abuse such as unplanned or unwanted chil
cations of these findings must be determined with an dren, looked-after children, children of the 'wrong'
understanding of the context of presentation and a sex, children with behavioural issues and children in
detailed awareness of current research findings, and unstable or chaotic family settings. In the UK, emotional
may require additional expertise, for example, from abuse is most prevalent in 5 to 15-year-olds. Every prac
genitourinary medicine or virology specialists. titioner should be aware of the particular risks and how
to identify matters of concern.
Neglect and emotional abuse
Childhood experiences, both positive and negative, Fabricated or induced illness in
have a tremendous impact on future violence victimi
sation and perpetration, and lifelong health and oppor
children
tunity. As such, early experiences are an important Fabricated or induced illness (previously known as
public health issue. Much of the foundational research Munchausen syndrome by proxy or factitious disorder
in this area has been referred to as Adverse Childhood by proxy) takes place when a caregiver elicits healthcare
Experiences (ACEs). As the implications of ACEs are on the child's behalf in an unjustified way It is a term
better recognised, research is identifying associations used to describe a relatively rare behavioural disor
with features later in life such as non-suicidal injuri der affecting a child's primary caregiver, typically the
ous behavior. Additionally, a number of behavioural mother. The carer presents a false history or appear
ance of illness for their child to healthcare profession
als. Examples of how illness can be claimed, fabricated
or induced include manipulation of required drug regi
Box 18.7 Features that m ay be seen in mens (e.g., in diabetics), suffocation and administration
sexual abuse of noxious substances (e.g., salt). Injury maybe caused
to ears and eyes initiating otorhinolaryngological and
Genital erythema/redness/inflammation
ophthalmological repeat referral. Such approaches
Oedema may result in the child presenting, or being presented
Genital bruising repeatedly to healthcare professionals with a range of
Genital abrasions
often inexplicable or puzzling symptoms. The motives
behind such behaviour are unclear, but psychiatric,
Hymenal transections mental health or attention-seeking problems may be
Hymenal clefts and notches associated with such behaviour. Management of the
Labial fusion perpetrator is largely dependent on their capacity to
acknowledge the abusive behaviour and collaborate
Vaginal discharge in pre-pubertal girls
with helping agencies.
Anal/perianal erythema
Perianal venous congestion Management of child abuse
Anal/perianal bruising
The management of child abuse will depend on the
Anal fissures, lacerations, scars and tags type of abuse or abuses experienced and many other
Reflex anal dilatation factors such as their health, and where they are living.
Every jurisdiction will have its own legal requirements,
Elder abuse I 253
Relationship:
• Dependence of perpetrator on the victim
Source: Adapted from Sethi et al., 2011 - individual risk factors
in bold represent those with strong evidence, the
(financial, emotional, accommodation) others are considered to be potential risk factors, or are
• Long-term history of difficulties in the relationship contested in the literature.
having witnessed an incident of physical abuse by other British Medical Association. Children & Young People Toolkit.
members of staff. BMA London.http://www.bma.org.uk/support-at-work/eth-
The WHO estimates that at least 4 million people over ics/children/children-and-young-people-tool-kit (Accessed
60 years of age experience elder abuse in Europe in any 1 May 2019).
Care Act 2014 c.23. http://www.legislation.gov.uk/ukpga/2014/23
one year, with 2500 homicides due to maltreatment. The
(Accessed 1 May 2019).
estimated prevalence of elder maltreatment in Europe is
Children Act 1989 c.41. http://www.legislation.gov.uk/
3% (0.4% for the UK), although it may be as high as 25% for ukpga/1989/41/contents (Accessed 1 May 2019).
'vulnerable adults requiring care', and 'even higher' for Children Act 2004 c.31. http://www.legislation.gov.uk/
nursing and residential home residents. Risk factors for ukpga/2004/31/notes/contents (Accessed 1 May 2019).
elder abuse and maltreatment can be seen in Box 18.8. Children's Commissioner. Stability Index 2018. Overview and
As with child abuse, extreme vigilance is required so findings, https://www.childrenscommissioner.gov.uk/wp-
that episodes of abuse in the elder population are not content/uploads/2018/05/Childrens-Commissioners-2018-
missed or ignored. Stability-lndex-Overview.pdf (Accessed 1 May 2019).
Choi YJ, O'Donnell M, Choi HB, et al. Associations among elder
abuse, depression and PTSD in South Korean older adults. Int
Bibliography and information J Environ Res Public Flealth 2018;15(9). e1948.
Davis P, Murtagh U, Glaser D. 40 years of fabricated or induced
sources illness (Fll): where next for paediatricians? Paper 1: epidemiol
American Academy of Pediatrics. Section on Radiology. ogy and definition of Fll. Arch Dis Child 2019;104(2):110—114.
Diagnostic Imaging of child abuse. Pediatrics 2009;123:1430- Domestic Violence, Crime and Victims Act 2004 c.28. http://
1435. www.legislation.gov.uk/ukpga/2004/28/contents (Accessed
American College of Radiology. ACR-SPR practice parameter for 1 May 2019).
skeletal surveys in children, Revised 2016. https://www.acr. Donald T. Children: emotional abuse. In: Payne-James JJ, Byard
org/-/media/ACR/Files/Practice-Parameters/Skeletal-Survey. RW (eds). Encyclopedia of Forensic and Legal Medicine, Volume
pdf (Accessed 1 May 2019). 1,2nd ed. London: Elsevier; 2016,467-473.
Arab-Zozani M, Mostafazadeh N, Arab-Zozani Z, et al.The preva Drake SA, Pickens S, Wolf DA, Thimsen K. Improving medicole
lence of elder abuse and neglect in Iran: a systematic review gal death investigative gaps of fatal elder abuse. J Elder Abuse
and meta-analysls.J Elder Abuse Negl 2018;30(5):408-423. Negl 2018;30:1-10.
Bass C, Glaser D. Early recognition and management of fabricated Drinkwater J, Stanley N, Szilassy E, et al. Juggling confidentiality
or induced illness in children. Lancet 2014;383(9926):1412- and safety: a qualitative study of how general practice clini
1421. cians document domestic violence in families with children.
Beh P, Payne-James JJ. Adult sexual assault. In: Gall J, Payne-James BrJ Gen Pract 2017;67(659):e437-e444.
JJ (eds). Current Practice in Forensic Medicine. London: Wiley; English A. Mandatory reporting of human trafficking: potential
2011 . benefits and risks of harm./MM J Ethics 2017;19(1):54—62.
Bibliography and information sources I 255
Faculty of Forensic & Legal Medicine. Quality standards for Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of
doctors undertaking Paediatric Sexual Offence Medicine bruising in childhood which are diagnostic or suggestive of
(PSOM). https://fflm.ac.uk/wp-content/uploads/2017/06/ abuse? A systematic review. Arch Dis Child 2005;90:182-186.
Quality-Standards-for-doctors-undertaking-PSOM-Dr- Maguire SA, Williams B, Naughton AM, et al. A systematic review
Cath-White-and-Prof-lan-Wall-April-2017.pdf (Accessed 1 of the emotional, behavioural and cognitive features exhib
May 2019). ited by school-aged children experiencing neglect or emo
Gallion HR, Dupree LJ, Scott TA, Arnold DH. Diagnosis of tional abuse. Child Care Health Dev 2015;41 (5):641 —653.
Trichomonas vaginalis and adolescents evaluated for pos Marc B, Barthes A. Children: physical abuse. In: Payne-James JJ,
sible sexual abuse: a comparison of the InPouch TV culture Byard RW (eds). Encyclopedia of Forensic and Legal Medicine,
method and wet mount microscopy. JPediatrAdolescGynecol Volume 1,2nd ed. London: Elsevier; 2005,513-527.
2009;22:300-305. Mawar S, Koul P, Das S, Gupta S. Association of physical problems
Girardet RG, Lemme S, Biason TA, et al. HIV post-exposure pro and depression with elder abuse in an urban community of
phylaxis in children and adolescents presenting for reported North India. Indian J Community Med 2018;43(3):165—169.
sexual assault. Child Abuse Negl 2009;33:173-178. McTavish JR, Kimber M, Devries K, et al. Mandated reporters'
HM Government. Working Together to Safeguard Children. A experiences with reporting child maltreatment: a meta
guide to inter-agency working to safeguard and promote synthesis of qualitative studies. BMJOpen 2017;7(10):e013942.
the welfare of children. https://assets.publishing.service. Meinck F, Fry D, Ginindza C, et al. Emotional abuse of girls in
gov.uk/government/uploads/system/uploads/attachment_ Swaziland: prevalence, perpetrators, risk and protective fac
data/fi Ie/729914/W orking_Together_to_Safeguard_ tors and health outcomes. J Glob Health 2017;7(1):010410.
Children-2018.pdf (Accessed 1 May 2019). Ministry of Justice. Achieving best evidence in criminal proceed
Ho GWK, Chan ACY, Chien WT, et al. Examining patterns of adver ings guidance on interviewing victims and witnesses, and
sity in Chinese young adults using the Adverse Childhood guidance on using special measures, https://www.cps.gov.
Experiences-lnternational Questionnaire (ACE-IQ). Child uk/sites/default/files/documents/legal_guidance/best_evi-
Abuse Negl 2019;88:179-188. dence_in_criminal_proceedings.pdf (Accessed 1 May 2019).
Jackson AM, Kissoon N, Greene C. Aspects of abuse: recogniz Mudrick NR, Smith CJ. Mandatory reporting for child protection
ing and responding to child maltreatment. Curr Probl Pediatr in health settings and the rights of parents with disabilities.
Adolesc Health Care 2015;45(3):58-70. Disabil Health J 2017;10(2):165-168.
Jenny C. Committee on Child Abuse and Neglect. Evaluating National Research Council. Elder mistreatment: abuse, neglect and
infants and young children with multiple fractures. Pediatrics exploitation in an ageing America. The National Academies
2006;118:1299-1303. Press, Washington DC. http://www.nap.edu/catalog.
Jin J. Screening for intimate partner violence, elder abuse, and php?record_id=10406 (Accessed 1 May 2019).
abuse of vulnerable adults. JAMA 2018;320(16):1718. Nicoletti A. Teens and drug facilitated sexual assault. J Pediatr
Jones JG, Worthington T. Genital and anal injuries requiring surgi Adolesc Gynecol 2009;22:187.
cal repair in females less than 21 years ofag e .J Pediatr Adolesc Offiah AC, Hall CM. Observational study of skeletal surveys in
Gynecol 2008;21:207-211. suspected non-accidental injury. Clin Radiol 2003;58:702-705.
Jones JS, Rossman L, Hartman M, Alexander CC. Anogenital inju Office of the Public Guardian. Safeguarding Policy 2015. https://
ries in adolescents after consensual sexual intercourse. Acad www.gov.uk/government/publications/safeguarding-policy-
Emerg Med 2003;10:1378-1383. protecting-vulnerable-adults/sd8-opgs-safeguarding-policy
Keller E, Santos C, Cusack D, et al. European Council of Legal (Accessed 4 February 2019).
Medicine guidelines for the examination of suspected elder Palusci VJ, Cox EO, Shatz EM, Schultze JM. Urgent medical assess
abuse. IntJ Leg Med 2019;133(1):317-322. ment after child sexual abuse. Child Abuse Negl 2006;30:
Kellogg N. American Academy of Pediatrics Committee on Child 367-380.
Abuse and Neglect. The evaluation of sexual abuse in chil Payne-James J, Rogers DJ. Drug facilitated sexual assault,
dren. Pediatrics 2005;116:506-512. 'ladettes' and alcohol. J Royal Soc Med 2002;95:326-327.
Kemp A, Maguire SA, Nuttall D, et al. Bruising in children who Payne-James JJ, Newton MA, Bassindale C. Forensic sci
are examined or suspected child abuse. Arch Dis Child 2014;2: ence, forensic medicine and sexual crime. In: Radcliffe P,
108-113. Gudjonsson G, Heaton-Armstrong A (eds). Witness Testimony
Kempe CH, Silverman FN, Steele BF, et al. The battered-child syn in Sexual Cases. Oxford: Oxford University Press; 2016.
drome.J Am Med Assoc 1962;181:17-24. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: global situ
Krug EG, Dahlberg LL, Mercy JA, et al. (eds). World report on vio ation, risk factors, and-prevention strategies. Gerontologist
lence and health. Geneva: World Health Organisation; 2002. 2016;56 Suppl 2:S194-205.
https://www.who.int/violence_injury_prevention/violence/ Prosser I, Maguire S, Harrison SK, et al. How old is this fracture?
world_report/en/ (Accessed 15 August 2019). Radiological dating of fractures in children: a systematic
Lachs MS, Pillemer K. Elder abuse. The Lancet 2004;364:1263- review. Am J Roentgenol 2005;184:1282-1286.
1272. Rees P, Al-Hussaini A, Maguire S. Child abuse and fabricated or
Magill J, Yeates V, Longley M. Review of In safe Hands. A review induced illness in the ENT setting: a systematic review. Clin
of the Welsh Assembly Government's guidance on the pro Otolaryngol 2017;42(4):783-804.
tection of vulnerable adults in Wales. Welsh Institute for Royal College of General Practitioners. Safeguarding Children
Health and Social Care 2010. https://gov.wales/docs/dhss/ Toolkit for General Practice http://www.rcgp.org.uk/clinical-
publications/100914insafehandsreviewen.pdf (Accessed 1 and-research/resources/toolkits/the-rcgp-nspcc-safeguarding-
May 2019). children-toolkit-for-general-practice.aspx (Accessed 1 May 2019).
256 I Safeguarding and protection of children and vulnerable adults
Royal College of Paediatrics and Child Health. The physical Van den Bruele AB, Dimachk M, Crandall M. Elder abuse. Clin
signs of child sexual abuse: an evidence-based review and GeriatrMed 2019;35(1):103-113.
guidance for best practice, https://www.rcpch.ac.uk/shop- Valeina S, Krumina Z, Sepetiene S, et al. J Fabricated or induced
publications/physical-signs-child-sexual-abuse-evidence- illness presenting as recurrent corneal lesions, cataracts, and
based-review (Accessed 1 May 2019). uveitis. Pediatr Ophthalmol Strabismus 2016;53:e6-e11.
Royal College of Paediatrics and Child Health. Child protection Wan Y, Chen R, Ma S, et al. Associations of adverse childhood
evidence, https://www.rcpch.ac.uk/key-topics/child-protec- experiences and social support with self-injurious behaviour
tion/evidence-reviews (Accessed 1 May 2019). and suicidality in adolescents. BrJPsychiatry 2019;214(3):146—
Royal College of Paediatrics and Child Health and Royal College of 152.
Ophthalmologists. Abusive head trauma and the eye in infancy. Wang M, Sun H, Zhang J, Ruan J. Prevalence and associated fac
London, UK: Royal College of Ophthalmologists. https://www. tors of elder abuse in family caregivers of older people with
rcophth.ac.uk/wp-content/uploads/2014/12/2013-SCI-292- dementia in central China: cross-sectional study. IntJGeriatr
ABUSIVE-HEAD-TRAUMA-AND-THE-EYE-FINAL-at-June-2013.pdf Psychiatry 2019;34(2):299-307.
(Accessed 1 May 2019). Watkeys JM, Price LD, Upton PM, Maddocks A. The timing of
Royal College of Paediatrics and Child Health, Faculty of Forensic medical examination following an allegation of sexual abuse:
and Legal Medicine. Guidelines on paediatric forensic exami is this an emergency? Arch Dis Child 2008;93:851-856.
nations in relation to possible child sexual abuse. Lavenham: Welsh Government. Safeguarding. http://gov.wales/topics/
Lavenham Group; 2012. http://fflm.ac.uk/wp-content/ health/socialcare/safeguarding/?lang=en (Accessed 1 May
uploads/documentstore/1352802061.pdf (Accessed 8 2019).
December 2018). White C, McLean I. Adolescent complainants of sexual assault:
Royal College of Radiologists. Standards for radiological inves injury patterns in virgin and non-virgin groups.JClin Forensic
tigations of suspected non-accidental Injury: joint docu Med 2006;13:172-180.
ment produced in collaboration with the Royal College of Young A, Grey M, Abbey A, et al. Alcohol-related sexual assault
Paediatrics and Child Health. London: RCR; 2008. https:// victimization among adolescents: prevalence, characteristics
www.rcr.ac.uk/audit/skeletal-surveys-non-accidental-injury and correlates. J Stud Alcohol Drugs 2008;69:39-48.
(Accessed 1 May 2019). Young JC, Widom CS. Long-term effects of child abuse and
Schilling C, Weidner K, Brahler E, et al. Patterns of childhood neglect on emotion processing in adulthood. Child Abuse
abuse and neglect in a representative german population Negl 2014;38(8):1369-1381.
sample. PLOSONE 2016;11(7):e0159510.
Sethi D, Wood S, Mitis F, et al. European report on prevent
ing elder maltreatment. Geneva: WHO; 2011. http://www.
Further general resources
euro.who.int/__ data/assets/pdf_file/0010/144676/e95110. British Medical Association. Child protection: a toolkit for doc
pdf?ua=1t (Accessed 1 May 2019). tors. 2010.
Sexual Offences Act 2003. http://www.legislation.gov.uk/ British Medical Association. Adult Safeguarding Ethics Toolkit
ukpga/2003/42/contents (Accessed 1 May 2019). https://www.bma.org.uk/advice/employment/ethics/adult-
Social Care Institute for Excellence (SCIE). The Care Act: safe safeguarding-ethics-toolkit (Accessed 1 May 2019).
guarding adults http://www.scie.org.uk/care-act-2014/safe- Payne-James JJ, Byard RW. Encyclopedia of Forensic and Legal
guarding-adults/(Accessed 1 May 2019). Medicine, 2nd ed. Oxford: Elsevier; 2016.
Social Services and Well-being (Wales) Act 2014 anaw 4. http:// Radcliffe P, Gudjonsson G, Heaton-Armstrong A (eds). Witness
www.legislation.gov.uk/anaw/2014/4/contents (Accessed Testimony in Sexual Cases. Oxford: Oxford University Press;
1 May 2019). 2016.
Sommers MS, Zink T, Baker RB, et al. The effects of age and eth Royal College of Radiologists. Standards for radiological inves
nicity on physical injury from rape. J Obstet Gynecol Neonotol tigations of suspected non-accidental injury: joint docu
Nurs 2006;35:199-207. ment produced in collaboration with the Royal College of
Swinson S, Tapp M, Brindley R, et al. An audit of skeletal surveys Paediatrics and Child Health. London: RCR; 2008. https://
for suspected non-accidental injury following publication www.rcr.ac.uk/audit/skeletal-surveys-non-accidental-injury
of the British Society of Paediatric Radiology guidelines. Clin (Accessed 1 May 2019).
Radiol 2008;63:651-656. World Health Organisation (WHO) International Network for the
Tonmyr L, Mathews B, Shields ME, et al. Does mandatory report Prevention of Elder Abuse (INPEA). Missing voices: views of
ing legislation increase contact with child protection? A legal older persons on elder abuse. Geneva: WHO; 2002. http://
doctrinal review and an analytical examination. BMC Public apps.who.int/iris/bitstream/handle/10665/67371/WHO_
Health 2018;18(1):1021. NMH_VIP_02.1.pdf?sequence=1 (Accessed 1 May 2019).
Tozzo P, Picozzi M, Caenazzo L. Munchausen Syndrome by Proxy:
balancing ethical and clinical challenges for healthcare pro
fessionals. Ethical consideration in factitious disorders. Clin Ter
2018;169(3):e129-e134.
19 Transportation medicine
Table 19.1 Drug levels permitted by law when driving a motor vehicle in the UK
benzoylecgonine 50
cocaine 10
delta-9-tetrahydrocannabinol (cannabis) 2
ketamine 20
methylamphetamine 10
methylenedioxymethamphetamine (MDMA) 10
6-monoacetylmorphine (heroin) 5
clonazepam 50
diazepam 550
flunitrazepam 300
lorazepam 100
methadone 500
morphine 80
oxazepam 300
temazepam 1,000
Separate approach (to balance its risk) Threshold limit in blood (jxg/L)
amphetamine 250
4. Medical consultation
Consultation commenced at____________ . hours Alcohol intake and times in last 24 hours _
Epilepsy_______________________________________________________ ________________________________________________________________
Prescribed
OTC medicines
Non-prescribed
Figure 19.1 (a) and (b) Impairment tests for 'driving under the influence' cases. (Taken from Faculty of Forensic & Legal
Medicine. Proforma - Section 4 RTA Assessment [England, Nl and Wales], 2016.) (Continued)
Transportation medicine
5. Medical examination
Examined in presence of_______________ Specimen of handwriting.
General demeanour____________________
State of clothing _
______________________________________________________________ Breath.
______________________________________________________________ Mouth.
Other abnormal findings (F5, F6, F7, F8 from the PIT may be repeated)
Eye examination
Use this gauge or a 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5
printed laminate card _ ^ A ^ ^
.............., 9 * t 9 f 9 9 9 t V V
Visual acuity
Visual fields
Horizontal gaze nystagmus
Vertical gaze nystagmus
Lack of smooth pursuit
Figure 19.1 (Continued) (a) and (b) Partial proforma for assessments (alcohol & drugs) under England & Wales
road traffic legislation. These pages identify the relevant medical consultation and examination details.
(Taken from the Faculty of Forensic & Legal Medicine 'Assessments (alcohol & drugs) under the RTA - 2019'
[https://fflm.ac.uk/wp-content/uploads/2019/08/Section4_RTAform_Jun19.pdf].)
Personal transport and road traffic injuries 261
Figure 19.2 (a) A pedestrian struck by the front of a car may be projected forwards or lifted onto the vehicle; (b) 'bum
per injuries' including a compound fracture of the right lower leg, and laceration of the left shin probably following
primary impact to this pedestrian's right leg. ([b] Reproduced with permission from Saukko P and Knight B. Knight's
Pathology 4E, London, CRC Press, 2016.)
Figure 19.3 At speeds of over 23 kph (15 mph) a pedestrian can be 'scooped up' onto a car, suffering head injuries on
impacting the windscreen. They may then fall off sideways or, at higher speeds, be thrown over the roof. (Reproduced
with permission from Saukko P and Knight B. Knight's Pathology 4E, London, CRC Press, 2016.)
Even in the absence of skull fracture, traumatic externalised, internal organs may be ruptured and
brain damage, including traumatic axonal injury, is there may be fractures of the spine. Compression of the
frequently observed in fatally injured pedestrians. This chest may result in multiple rib fractures, causing a 'flail
occurs as a consequence of the rotational, deceleration chest'. The rotation of the wheel may strip off large areas
forces produced when the rapidly moving head is sud of skin and subcutaneous tissue; this is called a 'flaying
denly stopped at impact, leading to 'shearing' injuries injury' (Figure 19.4). On occasion, patterned injuries are
to the brain and its coverings. Fractures of the spine, recognised on the skin surface bearing the characteris
especially in the cervical and thoracic segments, may tics of tyre-treads (Figure 19.5).
lead to cord damage. Fractures of the limbs are common
but, apart from those of the legs that are associated with
the primary impact sites, they are somewhat unpredict
able because of random 'flailing' of the limbs following
primary impact.
When an adult is struck by a larger vehicle, for exam
ple a van, a 4 x 4, a sport utility vehicle (SUV), truck or
lorry, or when a small child is struck by any vehicle, the
typical lower limb primary contact injury site tends to
be 'higher up' (pelvis, abdomen, chest or head). It is
likely that the victim will make contact with more of
the front of the vehicle or be projected along the line of
travel of the vehicle and 'run-over'.
'Run-over' injuries are relatively unusual and the Figure 19.4 Pedestrian leg injury from a rotating
effects are variable, depending on the area of the body wheel resulting in 'flaying' of the skin. (Reproduced
involved, the weight of the vehicle and the surface area with permission from Saukko P and Knight B. Knight's
of the contact. The skull may be disrupted and the brain Pathology 4E, London, CRC Press, 2016.)
Personal transport and road traffic injuries 263
Vehicle occupants
Most road traffic collisions involve the front, or the front
corners, of the vehicle and a high percentage of impacts
are against either another vehicle or a stationary object.
This type of impact rapidly decelerates the vehicle. Less
commonly, the vehicle is hit from behind, causing an
'acceleration' impact. The least common impacts are
side impacts and 'roll-overs'.
Many countries have legislation regarding the
requirement to wear seat belts, both in the front and
back of moving vehicles.
Figure 19.6 shows 2011 data which identify those
countries with seat belt legislation.
Substantial evidence of seat belt efficacy has been
shown by several studies, and it is widely recommended
that motor vehicle occupants use properly-fitted seat
belts. However, some countries with national seat belt
laws permit various exemptions which may lower use
rates. Unrestrained front-seat occupants in a vehicle
subjected to rapid deceleration during a collision will
continue to move forwards as the vehicle decelerates
Figure 19.5 Intradermal bruising reflecting the pattern of around them, and will impact those parts of the vehi
a vehicle tyre tread. Note that the bruising is in the 'val cle that are in front of them. The degree of injury sus
leys' and not the 'hills' in the tread. Scaled photographic tained by the occupant is very much dependent on the
documentation of such a patterned injury will allow vehicle's speed at the moment of impact, its deforma
future comparisons to be made between it and the tread tion properties and the structure of the part (or parts)
pattern of a suspect vehicle. (Courtesy of Richard Jones.) of the vehicle being impacted by the occupant (Box 19.1,
Figures 19.7-19.9).
Where the risk of pedestrian and other road-related The unrestrained rear-seat passenger is also liable to
fatalities and serious injuries has been treated as a pub injury through either deceleration or acceleration. The
lic health and social issue, educating the public, par injuries, in general, may not be as severe as those caused
ticularly children and young people, has resulted in a to the front-seat occupants. In a deceleration impact, the
significant reduction in pedestrian and other fatalities. rear-seat passengers will be thrown against the backs of
Figure 19.6 The State of Seat belt Legislation Worldwide. (Courtesy of the World Health Organisation.)
264 I Transportation medicine
Cervical spine
injury
Face and
■ Comprehensive
| Comprehensive/no standard
■ Not comprehensive/no law
g§ Data not available
■ Not applicable
Figure 19.11 Map showing which countries have motorcycle helmet laws and helmet standards in 2013. (Courtesy of
the World Health Organisation. The State of Seatbelt Legislation Worldwide https://www.who.int/gho/road_safety/
legislation/seat_belt/en/)
Aviation incident-related injury and fatalities I 267
and bridges crossing them are a common site for suicide A careful search for unusual injuries inconsistent
attempts and there have been many initiatives to try and with the setting, and examination for a vital response
reduce the incidence of this type of suicidal behaviour. to the severe blunt force injuries, should be made, as
It is important to remember that railway employees may homicides may be concealed by staging the scene, with
be considerably affected by rail deaths and they should the deceased being placed on the rail track in an attempt
be provided with appropriate support and counselling. to conceal the true cause of death.
Medically, there is nothing specific about railway Railway workers may be injured or killed by falling
injuries except the frequency of very severe mutila under, or by being struck by, moving rolling stock or by
tion. The body may be in many pieces and soiled by axle being trapped between the buffers of two trucks while
grease and dirt from the wheels and track, and local uncoupling or coupling the rolling stock. The injuries
vegetation. Where passengers fall from a train at speed, associated with the squeezing between rolling stock are
multiple injuries caused by repeated impacts and roll often those of a flail chest, with or without evidence of
ing may be seen, often with multiple abrasions from traumatic asphyxia (See also Chapter 11).
contact with the coarse gravel of the railway line bal
last. It is generally very difficult to be able to determine Aviation incident-related injury and
the sequence of events because of the severe damage to
the body. fatalities
Suicides on railways fall into two main groups: those Aviation incidents can be divided into two main
who lie on the track (sometimes placing their neck groups: those which involve the crew and the large num
across a rail so that they are decapitated) and those bers of passengers of a modern, commercial aircraft,
who jump in front of a moving train from a platform, and those which involve the occupants of small, rela
bridge or other structure near to the track. Jumping from tively slow, light aircraft. Additional, but much smaller,
a moving train is much less common. The injuries pres groups include those involving ultralight aircraft and
ent will depend on the exact events, but they are usually paragliders. More recently consideration has been given
extensive and severe when there has been contact with a to injuries sustained by impact from unmanned aircraft
moving train, although they may be localised with black systems (drones). Skull fractures and ocular globe rup
soiling at the crushed decapitation or amputation site if tures have been reported.
the individual has lain across the track (Figure 19.12). Large aircraft are pressurised and, if the integrity of
There is a risk of secondary injury if survival occurs the cabin is breached, there can be rapid decompression
where other factors such as electrified lines are pres and the passengers may suffer barotrauma. If the defect
ent. On electrified lines, an additional cause of suicidal in the cabin is large enough, victims may exit through
or accidental injury or death is present in the form of the defect and fall to their death. When an aircraft hits
electric shock from either a live rail or overhead power the ground, the results will depend on the rapidity of
lines. The voltage in these circuits is high, often in the transfer of the forces, and this is dependent on the speed
region of 600 V. Death is rapid and often associated with of the aircraft and the angle of impact. If the forces are
severe burns at the points of contact or earthing (see very severe, all passengers may be killed by deceleration
also Chapter 12). injuries and by multiple trauma owing to loss of integ
rity of the fuselage.
In lesser impacts, the results may be similar to those
of motor vehicle crashes, although the forces are usually
greater and the injuries sustained are proportionately
more severe. The usual lap-strap seat belt offers little
protection in anything but the most minor accident. Fire
is one of the greatest hazards in air crashes and accounts
for many deaths.
In light and ultralight aircraft crashes, the velocity,
and hence the forces, may be less than in large com
mercial aircraft, but they are still often fatal. In some
cases, the pilot may be separated from the aircraft and
without a parachute the injuries are those that would
be expected with a fall from a substantial height. The
investigation of air accidents is a task for specialist
medical personnel, who are often available from the
Figure 19.12 Traumatic amputation of the right arm and national air force or from a civil authority. There should
bruising of the face and chest in a pedestrian struck by a always be a full autopsy on the pilot or suspected pilot,
passing train. with full microscopic and toxicological examination to
268 I Transportation medicine
exclude natural disease, intoxication by drugs and alco musculoskeletal and back injuries recorded. Kitesurfing
hol, and carbon monoxide toxicity. These findings will is a relatively new sport and kite surfers are at risk of
be included in the overall assessment of the incident injury in a number of ways. Research has shown that
which will include consideration of the activities prior the injury rates may be influenced by the nature of the
to the incident and the condition and performance of kitesurf equipment used.
the aircraft. Motor-powered vessels may cause injury from explo
sion or fire, and those in the water may sustain injury
from rotating propellers.
Marine fatalities Commercial vessels may cause their own specific
Fatalities in the marine setting embrace a range of problems, such as asphyxiation in storage tanks or falls
marine-specific and general injury types. The range of from heights. Most of these scenarios are of an indus
activities include commercial diving, recreational div trial/occupational nature and may involve potential
ing, use of powered water sport bikes, sailing, motor breaches of health and safety legislation. In the UK, the
cruising and commercial marine transport (e.g., oil Marine Accident Investigation Branch (MAIB) examines
tankers, container ships, passenger vessels). The likeli and investigates all types of marine accidents, involving
hood of dying in a marine environment is enhanced by UK ships worldwide, and other ships in UK territorial
not wearing appropriate safety gear. In the recreational waters, and publishes regular reports on its findings.
setting, fatalities occur when individuals fall from ves Marine life may also cause injury. In the US since
sels and drown, or succumb to hypothermia, or cannot the 1900s, there have been ~ 5000 shark attacks of
be recovered back on board. which ~1200 were fatal. Fatalities were associated with
Physical injuries in recreational sailing are wide swimming, boating, three or more bites, limb loss or
spread and examples include those of suffering direct tiger shark attack. The most common attacks involved
trauma (e.g., to the head or neck following uncontrolled bites to the legs or arms with limb loss occurring in 7%
gybe; Figure 19.13), loss of digits or limbs when caught up of attacks.
in winches or anchor cable, limb or skull fractures from The majority of transportation injuries and fatalities,
direct impact from flailing blocks, and friction burn whether related to air, sea or land would be reduced if
injury from uncontrolled rope movement. Drowning appropriate public health and education messages were
may occur from being trapped after inversion of the given and reinforced to the public. Many are avoidable,
vessel (see also Chapter 13). Between 2000 and 2011, the and many are predictable.
US Coastguard reported 271 sailing-related fatalities
and 841 injuries. Falls overboard and capsizing were Bibliography and information
the most common fatal accidents. Operator inattention,
inexperience, and alcohol use were common prevent sources
able factors contributing to fatal and non-fatal injury. Bardon C, Mishara BL. Development of a comprehensive pro
Changes in the way in which established sports are gramme to prevent and reduce the negative impact of rail
undertaken or the introduction of new sports, may way fatalities, injuries and close calls on railway employees. J
introduce new or different patterns of injury. Rowing Occup Rehabil 2015;25(3):557-568.
has had a growth in popularity, particularly open- Baumbach SF, Stawinski T, Schmitz D, et al. Influence of kite
surf equipment on injury rates. J Sports Med Phys Fitness
water and coastal rowing. This may affect the pattern of
2018;58(10):1482-1489.
Bhatti JA, Razzak JA. Railway associated injuries in Pakistan. IntJ
Inj Contr SafPromot 2010;17:41 -44.
Boniface K, McKay MP, Lucas R, et al. Serious injuries related to
the Segway® personal transporter: a case series. Ann Emerg
Med 2011;57:370-374.
Campolettano ET, Bland ML, Gellner RA, et al. Ranges of injury risk
associated with impact from unmanned aircraft systems. Ann
BiomedEng 2017;45(12):2733-2741.
Chao T-C, Lau G, Eng-SweeTeo C. Falls from a height: the pathol
ogy of trauma from vertical deceleration. In: Mason JK,
Purdue BN (eds). The Pathology of Trauma, 3rd ed. London:
Arnold; 2000,313-326.
Chung LK, Cheung Y, Lagman C, et al. Skull fracture with efface-
ment of the superior sagittal sinus following drone impact: a
case report. Childs NervSyst 2017;33(9):1609-1611.
Clark JC, Milroy CM. Injuries and deaths of pedestrians. In: Mason
Figure 19.13 Abrasion of neck caused by mainsheet dur JK, Purdue BN (eds). The Pathology of Trauma, 3rd ed. London:
ing uncontrolled gybe whilst sailing. Arnold; 2000,17-29.
Bibliography and information sources 269
Conroy C, Hoyt DB, Eastman AB, et al. Motor vehicle-related car Moran D, Bose D, Bhalla K. Impact of improving vehicle front
diac and aortic injuries differ from other thoracic injuries. J design on the burden of pedestrian injuries in Germany, the
Trauma 2007;62:1462-1467. United States, and India. Traffic Inj Prev 2017;18(8):832-838.
Corporate Manslaughter and Corporate Homicide Act 2007 c.19. Moskowitz EE, Siegel-Richman YM, Hertner G, Schroeppel T. Aerial
http://www.legislation.gov.uk/ukpga/2007/19/contents drone misadventure: a novel case of trauma resulting in
(Accessed 20 May 2019). ocular globe rupture. Am J Ophthalmol Case Rep 2018;10:
Cullen SA, Drysdale HC. Aviation accidents. In: Mason JK, Purdue 35-37.
BN (eds). The Pathology of Trauma, 3rd ed. London: Arnold; Murphy GK. Death on the railway. J Forensic Sci 1976;21:218-226.
2000,300-312. National Highway Traffic Safety Administration. Recent trends in
Deaner RM, Fitchett VH. Motorcycle trauma. J Trauma 1975; motorcycle fatalities. Ann Emerg Med 2002;39:195-197.
15:678-681. Niebuhr T, Junge M, Rosen E. Pedestrian injury risk and the effect
Delouche S, Ballesteros C, Flores D, et al. WalkSafe keeps walking of age. Accid Anal Prev 2016;86:121-128.
for 15 years: a program review. Am J Public Health 2018:e1-e3. Nikolic S, Atanasijevic T, Mihailovic Z, et al. Mechanisms of aortic
Faculty of Forensic & Legal Medicine. Proforma - Section 4 RTA blunt rupture in fatally injured front-seat passengers in fron
Assessment (England, Nl and Wales), https://fflm.ac.uk/pub- tal car collisions: an autopsy study. Am J Forensic Med Pathol
lications/pro-forma-section-4-rta-assessment-england-ni- 2006;27:292-295.
and-wales/ (Accessed 20 May 2019). Obafunwa JO, Bulgin S, Busuttil A. Medico-legal considerations
Feltracco P, Barbieri S, Galligioni H, et al. A fatal case of ana of deaths from watersports among Caribbean tourists. JClin
phylactic shock during paragliding. J Forensic Sci. 2012;57(6): Forensic Med 1997;4:65-71.
1656-1658. Ostrom M, Eriksson A. Natural death while driving. J Forensic Sci
Forsberg R, Bjornstig U. One hundred years of railway disasters 1987;32:988-988.
and recent trends. Prehosp Disaster Med 2011;26(5):367—373. Penttila A, Lunetta P. Transportation medicine. In: Payne-James
Garry E, Donnelly J, Heffernan S, et al. Further reductions in J, Busuttil A, Smock W (eds). Forensic Medicine: Clinical and
road-related deaths and injuries in Irish children. Ir Med J Pathological Aspects. London: Greenwich Medical Media;
2018;111(4):728. 2003,525-541.
Goonewardene SS, Baloch K, Porter K, et al. Road traffic collisions- Pourmand A, Liao J, Pines JM, Mazer-Amirshahi M. Segway®
case fatality rate, crash injury rate, and number of motor Personal Transporter-related injuries: a systematic literature
vehicles: time trends between a developed and developing review and implications for acute and emergency care. J
country. Am Surg 2010;76:977-981. Emerg Med 2018;54(5):630-635.
Graham JW. Fatal motorcycle accidents. J Forensic Sci 1969;14: Ricci JA, Vargas CR, Singhal D, Lee BT. Shark attack-related injuries:
79-86. epidemiology and implications for plastic surgeons. J Plast
Havarneanu GM, Burkhardt JM, Paran F. A systematic review of the Reconstr Aesthet Surg 2016;69(1):108-114.
literature on safety measures to prevent railway suicides and Rosenkrantz KM, Sheridan RL. Trauma to adult bicyclists: a
trespassing accidents. AccidAnalPrev 2015;81:30-50. growing problem in the urban environment. Injury 2003;34:
Hefny AF, Eid HO, Abu-Zidan FM. Pedestrian injuries in the United 825-829.
Arab Emirates. IntJInj ContrSafPromot 2015;22(3):203-208. Roston AT, Wilkinson M, Forster BB. Imaging of rib stress frac
Hitusugi M, Takatsu A, Shigeta A. Injuries of motorcyclists and tures in elite rowers: the promise of ultrasound? Br J Sports
bicyclists examined at autopsy. Am J Forensic Med Pathol Med 2017;51(14):1093-1097.
1999;20:251-255. Ryan KM, Nathanson AT, Baird J, Wheelhouse J. Injuries and fatali
Hubele N, Kennedy K. Forward collision warning system impact. ties on sailboats in the United States 2000-2011: an analysis
Traffic Inj Prev 2018;19(sup2):S78-S83. of US Coast Guard Data. Wilderness Environ Med 2016;27(1):
Karger B,Tiege K, Buhren W, DuChesne A. Relationship between 10-18.
impact velocity and injuries in fatal pedestrian-car collisions. Sato Y, Oshima T, Kondo T. Airbag injuries: a literature review in
IntJ Leg Med 2000;113:84-88. consideration of demands in forensic autopsies. Forensic Sci
Liu BC, Ivers R, Norton R, et al. Helmets for preventing Int 2002;128:162-167.
injury in motorcycle riders. Cochrane Database Syst Rev Saukko P, Knight B. Transportation injuries. In: Saukko P, Knight
2008;1 :CD004333. B (eds) Knight's Forensic Pathology, 4th ed. Boca Raton: CRC
Lukaschek K, Baumert J, Erazo N, Ladwig KH. Stable time pat Press; 2016,277-297.
terns of railway suicides in Germany: comparative analysis Schmidt P, Haarhoff K, Bonte W. Sudden natural death at the
of 7,187 cases across two observation periods (1995-1998; wheel: a particular problem of the elderly? Forensic Sci Int
2005-2008). BMC Public Health 2014;14:124. 1990;48:155-162.
Matsui Y, Oikawa S, Sorimachi K, et al. Association of impact Schulze W, Richter J, Schulze B, et al. Injury prophylaxis in para
velocity with risks of serious injuries and fatalities to pedes gliding. BrJ Sports Med 2002;36(5):365-369.
trians in commercial truck-pedestrian accidents. Stapp Car Semeraro D, Passalacqua NV, Symes S, Gilson T. Patterns of
Crash J 2016;60:165-182. trauma induced by motorboat and ferry propellers as illus
Mcllvain C, Hadiza G, Tzavaras TJ, Weingart GS. Injuries associ trated by three known cases from Rhode Island .J Forensic Sci
ated with hoverboard use: a review of the National Electronic 2012;57(6):1625-1629.
Injury Surveillance System. Am J Emerg Med 2018;37(3):472- Sevitt S. The mechanisms of traumatic rupture of the thoracic
477. pii: S0735-6757(18)30484-4. aona.BrJ Surg 1977;64:166-173.
Milroy CM, Clark JC. Injuries and deaths in vehicle occupants. In: Shang S, Otte D, Li G, Simms C. Detailed assessment of pedestrian
Mason JK, Purdue BN (eds). The Pathology of Trauma, 3rd ed. ground contact injuries observed from in-depth accident
London: Arnold; 2000,1-16. data. Accid Anal Prev 2018;110:9-17.
270 Transportation medicine
Shkrum MJ, McClafferty KJ, Green RN, et al. Mechanisms of aor Thornton JS,Vinther A, Wilson F,etal. Rowing injuries: an updated
tic injury in fatalities occurring in motor vehicle collisions. J review. Sports Med 2017;47(4):641-661.
Forensic Sci 1999;44:44-56. Toro K, Hubay M, Sotonyi P, Keller E. Fatal traffic injuries among
Shkrum MJ, McClafferty KJ, Nowak ES, German A. Driver and pedestrians, bicyclists and motor vehicle occupants. Forensic
front seat passenger fatalities associated with air bag Sci Int 2005;151:151-156.
deployment. Part 2: a review of injury patterns and inves Transport and Works Act 1992 c.42. http://www.legislation.gov.
tigative issues. J Forensic Sci 2002;47:1035-1040. uk/ukpga/1992/42/contents (Accessed 20 May 2019).
Siegel JH, Smith JA, Tenebaum N, et al. Deceleration energy Vanlaar W, Mainegra Hing M, Brown S, et al. Fatal and serious
and change in velocity on impact: key factors in fatal versus injuries related to vulnerable road users in Canada. J Safety
potentially survivable motor vehicle crash (mvc) and aortic Res 2016;58:67-77.
injuries (Al): the role of associated injuries as determinants of World Health Organisation. The State of Seatbelt Legislation
outcome. Annu Proc Assoc AdvAutomot Med 2002;46:315-338. Worldwide, https://www.who.int/gho/road_safety/legisla-
Silla A, Luoma J. Main characteristics of train-pedestrian fatalities tion/seat_belt/en/ (Accessed 20 May 2019).
on Finnish railroads. AccidAnolPrev 2012;45:61-66. World Health Organisation. Map showing which countries have
Smith TG 3rd, Wessells HB, Mack CD, et al. Examination of the motorcycle helmet laws and helmet standards in 2013. www.
impact of airbags on renal injury using a national databaseJ who.int/gho/road_safety/legislation/situation_trends_
Am Coll Surg 2010;211:355-360. motorcycle_helmet/en (Accessed 20 May 2019).
Swan KG, Swan BC, Swan KG. Deceleration thoracic injury. Zettas JP, Zettas P,Thanasophon B. Injury patterns in motorcycle
J Trauma 2001;51:970-974. accidents. J Trauma 1979;19:833-836.
Thali MJ, Braun M, Bruschweiler W, Dirnhofer R. Matching tire Zivot U, Di Maio VJ. Motor vehicle-pedestrian accidents in adults:
tracks on the head using forensic photogrammetry. Forensic relationship between impact speed, injuries and distance
Sci Int 2000;113:281-287. thrown. Am J Forensic Med Pathol 1993;14:185-186.
Thali MJ, Braun M, Aghayev E, et al. Virtopsy: scientific docu
mentation, reconstruction and animation in forensic:
individual and real 3D data based geo-metric approach
including optical body/object surface and radiological CT/
MRI scanning. J Forensic Sci 2005;50:428-442.
20 Torture and cruel, inhuman
and degrading treatment
■ Introduction ■ The Istanbul Protocol
■ Definitions ■ Bibliography and information sources
■ Investigation ■ Further general resources
and effects, of different types of torture. Interpretation of so (see also Chapter 17). It is also essential to distinguish
findings must be balanced and non-biased, and requires between acute (recent) injury and old injury which may
appropriate knowledge of published information which be manifest as marks or scars, and to distinguish between
should be interpreted critically in the light of documented injury, marks and scars that are due to ill-treatment,
findings. Numerous publications have explored the and those that are caused by other factors (e.g., culture,
nature and patterns of ill-treatment and torture, allow employment, sports and accident). The phrase 'absence
ing regional and geographical differences to be reviewed. of visible evidence of maltreatment is not evidence of
Many methods of ill-treatment and torture methods absence of maltreatment' is appropriate, which is why
(including sensory deprivation - isolation/blindfolding, the assessment must be as thorough and complete as the
beating - fists, sticks, truncheons, whipping - electric circumstances allow. Figures 20.1-20.5 provides some
cords, rape, suspension, falaka, electric shocks, sharp example of visible evidence of maltreatment or torture
force injury, burning) are used. The objective interpreta (see also Chapter 8).
tion of findings is crucial, to best assist the complainant
of ill-treatment, so that the evidence is accepted as being
accurate by whichever body (e.g., prison, court, tribunal,
judge) is going to rely on it in their deliberations. This is
important because, although the accounts for marks or
scars given by victims may be true, they can sometimes
be false. If false, this may be as a result of an intention to
mislead the examiner and courts, poor recall, or misin
terpretation due a variety of causes (e.g., mental health
issues). The body adjudicating on the medical assessment
will find it easier to accept findings and conclusions if the
examiner is clearly seen to be independent and unbiased.
The methods used may leave minimal or no evidence, Figure 20.2 Amputation of digit (right thumb). Note neat
and any injuries that are produced may heal without scars suggesting involvement of someone with medical
visible evidence. This has particular relevance to sexual skills.
assault, where penetrative sexual contact only has vis
ible evidence in a minority of cases, and that acute injury
(whether to anus or vagina) often heals within 72 hours or
Figure 20.1 Multiple tramline bruises from whipping Figure 20.4 Scarring to penile shaft from cigarette
with an electrical cable. burns.
274 I Torture and cruel, inhuman and degrading treatment
Kuehler BM, Childs SR. One stop multidisciplinary pain clinic for Prip K, Persson AL. Clinical findings in men with chronic pain after
survivors of torture. Pain Monag 2016;6(5):415—419. falanga torture. Clin J Pain 2008;24:135-141.
Lunde I, Ortmann J. Prevalence and sequelae of sexual torture. Raghavan SS. Cultural considerations in the assessment of
Lancet 1990;336:289-291. survivors of torture. J Immigr Minor Health 2019;21(3):586-595.
Lustig SL( Kureshi S, Delucchi K, et al. Asylum grant rates follow Sanders J, Schuman MW, Marbella AM. The epidemiology of tor
ing medical evaluations of maltreatment among political ture: a case series of 58 survivors of torture. Forensic Sci Int
asylum applicants in the United StatesJ Immigr Minor Health 2009;189:e1-e7.
2008;10(1):7—15. Savnik A, Amris K, Rogind H, et al. MRI of the plantar structures
Marsh N. The photography of injuries. In: Gall J, Payne-James JJ of the foot after falanga torture. Eur Radiol 2000;10:1655-1659.
(eds). Current Practice in Forensic Medicine. Oxford: Wiley; 2011, Taylor B, Carswell K, Williams AC. The interaction of persistent
159-190. pain and post-traumatic re-experiencing: a qualitative study
Meana JJ, Morentin B, Idoyaga Ml, Callado LF. Prevalence of sexual in torture survivors. J Pain Symptom Manage 2013;46(4):
torture in political dissidents. Lancet 1995;345:1307. 546-555.
Moisander PA, Edston E. Torture and its sequel: a compari Thomsen AB, Eriksen J, Smidt-Nielsen K. Chronic pain in torture
son between victims from 6 countries. Forensic Sci Int survivors. Forensic Sci Int 2000;108:155-163.
2003;137:133-140. Torp-Pedersen S, Matteoli S, Wilhjelm J, et al. Diagnostic accuracy
Moreno A, Grodin MA. Torture and its neurological sequelae. of heel pad palpation: a phantom study. J Forensic Leg Med
Spinal Cord 2002;40:213-223. 2008;15:437-442.
Morentin B, Idoyaga Ml, Callado LF, Meana JJ. Prevalence and Tsai AC, Eisa MA, Crosby S, et al. Medical evidence of torture
methods of torture claimed in the Basque Country (Spain) and other human rights violations in Darfur. PLoS Med
during 1992-3. Forensic Sci Int 1995;76:151-158. 2012;9(4):e1001198.
Morgan E, Wieling E, Hubbard J, Kraus E. The development United Nations. Istanbul Protocol: Manual ofthe effective investiga
and implementation of a multi-couple therapy model with tion and documentation of torture and other cruel, inhuman or
torture survivors in the Democratic Republic of the Congo. degrading treatment or punishment, 2004. https://www.ohchr.
J Marital Fam Ther 2018;44(2):235-247. org/Documents/Publications/training8Rev1en.pdf
Payne-James JJ. Rules &scales used in measurement in the foren Unuvar U, Ulas H, Fincanci SK. Diagnosis of torture after 32 years:
sic setting. Forensic Sci Med Pathol 2012;8(4):482-483. assessment of three alleged torture victims during the 1980
Peel M, Hughes J, Payne-James JJ. Post inflammatory hyper- military coup in Turkey. Forensic Sci Int 2014;244:e42-47.
pigmentation following torture. J Clin Forensic Med 2003;10: Wenzel T, Mirzaei S, Nowak M. Assessment of sequelae of torture
193-196. for refugees in host countries. Lancet 2016;387(10020):746.
Perera C, Verghese A. Implementation of Istanbul protocol for Williams A de, Pena CR, Rice ASC. Persistent pain in survivors
effective documentation of torture: review of Sri Lankan per of torture: a cohort study. J Pain Symptom Manage 2010;40:
spectives .J Forensic Leg Med 2011;18(1):1—5. 715-722.
Perera P. Physical methods of torture and their sequelae: a Sri
Lankan perspective. J Forensic Leg Med 2007;14:46-50.
Perez-Sales P, Morentin B, Barrenetxea O, Navarro-Lashayas Further general resources
MA. Incommunicado detention and torture in Spain, Part Payne-James JJ, Beynon J, Nuno Vieira D. Monitoring Detention,
II: Enhanced credibility assessment based on the Istanbul Custody, Torture and Ill-treatment: A Practical Approach to
Protocol. Torture 2016;26(3):8-20. Prevention and Documentation. Boca Raton: CRC Press; 2017.
Principles of forensic
21 science and crime scene
investigation
■ What is forensic science? ■ Blood pattern analysis
■ Locard's exchange principle ■ Damage assessment
■ Scene examination ■ Fingerprints
■ Evidence recovery ■ Footwear
■ Chain of custody ■ Trace evidence
■ Sample analysis ■ Bibliography and information sources
Box 2h 7 Locard's exchange principle Box 21.2 Does the 'CSI effect' exist?
T h e truth is that none can act with the inten The American TV crime drama 'CSI: Crime Scene
sity induced by criminal activities without Investigation' aired in the USA for the first time in
leaving multiple traces of his passing. [...] The 2000, and became popular worldwide. The portrayal
clues I want to speak of here are of two kinds: of forensic science and forensic scientists was highly
Sometimes the perpetrator leaves traces at stylised for dramatic effect; forensic science was the
a scene by his actions; sometimes, alterna 'star of the show'. Soon after its appearance, how
tively, he picked up on his clothes or his body ever, the media started to refer to the 'CSI effect' to
traces of his location or presence/* describe the alleged adverse effects of the portrayal
of forensic science in the drama on the expecta
'Wherever he steps, wherever he touches,
tions of jurors in the criminal justice system, which
whatever he leaves, even without conscious
favoured defendants in cases where forensic evi
ness, will serve as a silent witness against him.
dence was absent, or where there were uncertainties
Not only his fingerprints or his footprints, but
or ambiguities in the forensic evidence presented
his hair, the fibers from his clothes, the glass
to them. Although some commentators question
he breaks, the tool mark he leaves, the paint
whether the 'CSI effect' is real, the potential effect of
he scratches, the blood or semen he deposits
misrepresentation of forensic science in the popu
or collects. All of these and more, bear mute
lar media has important implications for the way in
witness against him. This is evidence that does
which the forensic science community in general,
not forget. It is not confused by the excite
and forensic practitioners individually, communicate
ment of the moment. It is not absent because
the utility, reliability and limitations of forensic evi
human witnesses are. It is factual evidence. dence in legal proceedings.
Physical evidence cannot be wrong, it cannot
perjure itself, it cannot be wholly absent. Only
human failure to find it, study and understand
it, can diminish its value/1
Evidence recovery
At a scene, however large or small, once items of forensic
interest are found, they are recorded appropriately and
assigned an affidavit or exhibit number. They are usually
given the initials of the person responsible for the item
being 'seized' (very often an exhibits officer) followed by
a sequential number, for example 'JDM.l'. The item is
usually photographed before being removed carefully,
so as not to disturb the relevant evidence, and pack
aged. There are a number of different types of packag
Figure 21.2 Sealed and labelled weapon tube
ing that can be used for different items. Paper sacks are
containing a bloodstained knife.
used for clothing because, if the item is slightly damp,
(Courtesy of Manlove Forensics Ltd.)
this allows moisture to pass through. Plastic bags can be
used for items such as cigarette ends. Plastic tubes that
item and the time and date of seizure. The label is then
screw together are used for sharp items such as knives or
signed by the person who seized the item (Figure 21.3).
screwdrivers; these are known as weapons tubes (Figure
See Box 21.4 to learn more about what the work of a
21.2). Cardboard boxes can also be used for such items
forensic scientist entails.
with plastic ties to secure the item in place.
If there is no exhibit label integral with the bag, a
separate label will need to be filled out and secured to Chain of custody
the packaging containing the item. This contains details Once an exhibit has been created, each time it is trans
describing the item, its origin, the person seizing the ferred from one place to another the details need to be
Box 21.3 The discovery o f modified human remains at a scene: The 'acid bath
murders'
The complete disposal of a dead body, leaving no trace Haigh told police 'Mrs. Durand-Deacon no lon
for forensic experts to effect an identification of the ger exists. She has disappeared completely, and no
remains, has proved elusive for many murderers; Haigh trace of her can ever be found. I have destroyed her
planned to evade justice for the murder of Olive Durand- with acid ... how can you prove murder if there is no
Deacon in 1949 by dissolving her body in sulphuric acid. body?'. He describes having shot her through the back
Examination of yellow, greasy sludge-soaked earth of the head - there were blood stains on a wall in the
from his workshop in Crawley West Sussex, England, workshop in keeping with the scenario - and putting
revealed dentures, human gallstones, most of a left her body in a 40-gallon drum, returning over the fol
foot, fragments of human bone, part of a plastic hand lowing day to empty the drum's contents outside the
bag, and a lipstick case top. workshop before adding more acid. He pleaded guilty
At trial, the forensic pathologist, Keith Simpson, to murder but his defence was that he was insane at the
stated that he considered that the human remains time of the killing. A psychiatrist called for the Defence
belonged to a single person, and that a pelvic bone frag admitted that Haigh knew that what he did was pun
ment had female characteristics, the better-preserved ishable by law, and he was convicted and executed.*
bones showed 'senile change', and that the bones were
of an 'elderly woman'. The damage to the remains could Source: Simpson K. The acid-bath murder(s). R vJohn George
have been caused by immersion in sulphuric acid. He Haigh. The Police Journal 1950;23:190-202; Lord
could not determine cause of death. Mrs. Durand- Dunboyne. The trial of John George Haigh (The acid bath
murder). Notable British Trials Series. William Hodge & Co.
Deacon's dentist confirmed that the dentures were hers.
Ltd., London UK 1939 (138-140).
Sample analysis 279
Box 21.4 A typical day in the life o f a senior forensic scientist in the UK
As a senior 'reporting' forensic biologist I manage appropriately, and to ensure that a full interpretation
between 10 and 20 cases on a typical day, including and evaluation of the findings can be undertaken in
sexual assaults, homicide, assaults, and often a 'cold due course.
case' where new techniques can be employed on Once the examination of the exhibits in a case has
original exhibits/samples in order to detect a histori begun, I view the items in question in conjunction
cal, unsolved crime. At any time during the day routine with the forensic examiner making the initial examina
work can be interrupted by requests to deliver urgent tion under my supervision. In a suspected homicide
reports, give advice or attend a scene or a court. this may require the examination of an exhibit, such
On any given day, the cases I am dealing with are as a weapon or items of clothing, for the presence of
likely to be at different stages and require different bloodstaining. A visual examination of the item is made
tasks to be undertaken at any time. One of the first using varied light sources and, if necessary, low-power
tasks of the day I undertake as a priority is to set a strat microscopy in order to detect microscopic traces of
egy for any new case I am allocated. I receive a submis blood, supplemented by presumptive chemical testing
sion form from the police that gives a summary of the of stains of interest.
circumstances surrounding an incident, a list of the Depending on the case, some exhibits may require
exhibits submitted and a request detailing what the an examination for the presence of hairs, saliva, fae
police aim to prove by the examination of the items ces or urine, and joint examinations may be necessary
submitted. I review the information and the examina where the presence of other types of trace evidence
tion request and, if necessary, contact the police for requires consideration by another forensic specialist.
any further information or for additional exhibits that When the initial examinations have been under
I believe are necessary to undertake the examination taken, I examine the items myself, and review and
(Continued)
280 Principles of forensic science and crime scene investigation
Box 21.4 (Continued) A typical day in the life o f a senior forensic scientist in the UK
confirm the initial findings made by the forensic exam regarding the circumstances of the incident as known
iner. I will then make key decisions to progress the at that time. Often the information provided at the
case, such as the selection of relevant blood/body fluid early stage of the investigation will be limited, and that
stains for DNA profiling analysis, or the interpretation from witnesses may be incorrect, so keeping an open
of the nature and distribution of any blood present in mind when interpreting the scene is essential.
order to comment as to how the blood was deposited At many scenes involving the discovery of a body, I
on the item. For example, in a case where it is alleged a will initially work closely with a Home Office Pathologist
person was kicked or stamped upon, I may be able to and Crime Scene Investigators to ensure that relevant
comment as to whether the nature and distribution of trace evidence is recovered from the body, and that
bloodstaining on an assailant's footwear is indicative of any blood patterns are observed and documented
the wearer having kicked or stamped on an individual. I with the body in situ. Depending on the type of scene,
may need to assess the presence of any textile damage I may work closely with other experts. For instance, in
to a garment, for example, to determine if a garment cases where an attempt has been made to conceal a
had been cut or torn, and I may have to establish if any murder by setting fire to the scene, I will work closely
stab cuts are present and establish if a particular imple with the expert in fire investigation in order to examine
ment could have caused damage to a garment. the scene in a coordinated, sequential manner so that
A great deal of time is spent reviewing analytical no potential evidence is compromised or overlooked.
results and compiling reports or statements for court, On completion of the scene examination, I 'debrief'
as well as reviewing other scientists' strategies, reports the crime scene manager and/or the investigating offi
and statements. Such peer review is essential for qual cer on my interpretation of the bloodstain patterns at
ity assurance purposes, and forms part of the formal the scene, and offer advice as to which exhibits ought
quality assurance system in which forensic scientists in to be submitted to the forensic science laboratory as a
my organisation operate (including the accreditation priority to assist the investigation.
standards for laboratories - ISO 17025 - and for crime The police will normally submit key exhibits in rela
scene investigation - ISO 17020). tion to the scene to be examined immediately in order
Once all the examinations and analyses are com to assist in the charging of a suspect or to identify an
pleted in a case, I write an evidential statement or a assailant if the case is undetected. This will require the
report detailing the findings and offer any interpreta examinations and any DNA profiling tests undertaken
tion if possible. Reports are initially sent to the police to be completed within 48 hours of submission to the
informing them of the results obtained, however, if laboratory. One of the most satisfying aspects of my job
the case proceeds to trial an evidential statement will is obtaining a DNA profile from a sample and obtain
need to be provided, providing a full evaluation of the ing a match on the National DNA Database, allowing
findings, documenting the continuity of exhibits, and the police to apprehend an assailant for a violent crime
containing explanations of the techniques employed in who until then was unknown to the investigation.
the case. In some cases, the version of events given by Periodically, I am required to attend court to
the victim and suspect may differ, and I may be able to give evidence in a trial, which involves travelling to
offer an opinion in my statement as to whether or not a court which is usually in the region in which the
the scientific findings offer scientific support in favour crime occurred. When giving expert forensic science
of one of the versions of events over the other. evidence, I will be expected to explain complex scien
Every six weeks I will be on call 24 hours a day for tific methods and evidence in 'layman's terms' to the
one week in order to respond immediately to any court, and I can expect to be subjected to cross exam i
request to attend a crime scene, which may be indoors nation by the defence in which I may have to consider
or outdoors. The request will usually require the inter alternative hypotheses for my findings or robustly
pretation of bloodstain patterns at the scene in order defend my interpretation and conclusions.
to shed light on the events that led to the death of
Andrew Parry BSc (Hons)
the individual(s) and to offer advice on the recovery of
Senior Reporting Forensic Scientist
trace evidence at the scene. Prior to entering the crime
Cellmark Forensic Services
scene, I will usually attend the police station where the
Abingdon, UK
investigation is being run, and will be 'briefed' by the
(h ttp://www.cellmorkforensics.co.uk/)
police crime scene manager or the investigating officer
Sample analysis 281
that pair with a complementary chain to produce the The loci that are amplified vary in the number of
double helix. One chromosome of each pair is inherited repeats that are commonly encountered and so a range
from the mother and the other from the father. DNA in size and thus molecular weight exists. The sample is
is also present in mitochondria, which are organelles subjected to capillary electrophoresis in a genetic analy
located in the cell cytoplasm; this latter DNA is inherited ser across a high potential difference. This means that
through the maternal lineage. the low molecular weight alleles pass through the cap
Currently, the most common type of DNA profiling illaries and are detected more rapidly than those of a
utilises the fact that there are short regions, normally higher molecular weight. As each of the STR alleles have
consisting of between three to five nucleotides in length, been tagged with a fluorescent dye, they are detected
repeated a variable number of times along a chromo as they pass a laser detector. The time of detection,
some. These are called short-tandem repeats (STRs). calibrated against a molecular weight standard, and
They are generally believed to be non-coding and are the particular dye label enables a range of STRs to be
conserved from generation to generation. The number of analysed in the same sample. As each allele passes the
repeats gives the name to the STR variant (the allele) on laser, it registers as a peak in intensity of the fluorescent
the chromosome and varies between individuals. The dye. This is translated into an electropherogram (EPG)
range of variation is relatively low and, individually, which represents a DNA profile as a series of peaks along
each allele occurs quite commonly (generally between a graphical line (Figure 21.4).
5 per cent and 40 per cent of the population). A person If a profile has been obtained from a crime scene
can have the same (homozygous) or different STR alleles sample such as a blood stain, it can then be compared
(heterozygous) at each region (locus) that is analysed. with a reference sample, often a mouth (buccal) swab,
The power of DNA analysis is realised when one con from an individual believed to be connected to the case,
siders that currently sixteen different loci are analysed, or a match searched for on a DNA database. If DNA pro
giving a total of 32 alleles plus an indication of the sex files do not match then they could not have come from
of the individual in a collection referred to as DNA17. the same person. Conversely, if the crime scene profile
matches at every locus then the DNA could have come
from the reference person. Only identical twins would
How is a DNA profile obtained? share the same profile. If a large number of loci have one
A sample that is taken for analysis undergoes several or more alleles in common, however, then the analyst
steps before a DNA profile can be obtained. The first is may suspect that the profile comes from a close relative
to extract the DNA from the cellular matrix. Different of the identified individual instead.
chemical processes may need to be used in order to Once a matching profile has been identified a statistic
recover the DNA: for example, a ground tooth would can be provided as to the likelihood of the match in com
receive very different treatment from that of a cigarette parison with a hypothesised unrelated person. The more
end. incomplete a sample profile is (a partial profile) the more
Following this, the amount of DNA within the sample people may be expected to match by chance. The way in
is estimated. In forensic samples, the concentration of which the statistics are calculated relies on an assump
DNA is often very low and measured in nanograms per tion of independence between loci; most STRs are on dif
microlitre (ng/i^l). This stage is necessary so that the cor ferent chromosomes or far enough apart to assume this.
rect amount of the extracted sample is used for the next This independence allows the frequency of the alleles
stage (amplification) to ensure an optimum chemical at each locus to be multiplied across all the loci. Even
concentration for maximum sensitivity. The scientist if many of the individual matching alleles are common
will normally amplify around 0.5 to 1 ng of the DNA in the population, the likelihood of some other person
(aiming for a minimum of 0.2 ng, roughly the rough providing the same profile decreases rapidly with each
equivalent of around 30 cells). added locus. It is estimated that the probability of any
Amplification is carried out using the polymerase other person unrelated to an identified person sharing
chain reaction (PCR), which uses a thermostable enzyme- the same profile will be less than one in one billion.
catalysed reaction over a number of cycles in which the Box 21.5 illustrates some significant historic cases in
double strands are separated to allow a complementary which the use of DNA evidence was crucial.
strand to be produced and annealed. Each PCR cycle, if
it were 100 per cent efficient, would double the amount DNA Statistics and Bayes Theorem
of DNA present within each sample. Around 28 cycles Discussion of DNAprofiling inevitably involves terms such
are used in a standard DNA17 analysis. A short comple as 'likelihood of a match', or 'match probability'. These are
mentary 'primer' labelled with an attached fluorescent used in the expression of the strength of the evidence and
dye starts the process by annealing to the flanking region the methodology used relies on the use of Bayesian statis
of the STR and enables labelled copies of the STR to be tics, methods that use the theories developed by Thomas
detected and its size measured. Bayes, an 18th-century clergyman. These differ from the
282 Principles of forensic science and crime scene investigation
1738 ■
0-
X 17 12 10 13 9 7 14
1508 1680 1670 1433| 1568 1220 1521 1372
Y 18 13 15 11
1453 1580 1738 1298 1214
9 13 12
3071 3085 2 33lj
18 ET! I13 1
2368 1244-91 124061
1802
0 * I I
E
S 9.3
m i l 1024
IP22S104S \
400 500
14 18 23
------ JL
1035 1284 1099
[PYS391 1FGA~
2000
0 . *
10 20 18 17
2348 2719 2692; 2831
Box 21.5 Historic legal cases in which DNA evidence was significant
First UK criminal conviction utilising DNA evidence A man was subsequently overheard in a public
In November 1987, Robert Melias was convicted in house saying that he had 'taken the place' of a friend
Bristol, England for rape following comparison of his during the screening; that man, Colin Pitchfork, was
DNA profile with that contained in a semen sample arrested and a DNA profile of his blood matched that
recovered from the victim. He pleaded guilty and was of Dawn's killer. He confessed to her murder and that of
sentenced to eight years in prison. Linda Mann, and was convicted in 1987.
First UK murder conviction utilising DNA evidence: First UK post-conviction exoneration utilising DNA
Colin Pitchfork evidence
Following the rape and murder of a 15-year-old school In 1988, Michael Shirley was convicted of the rape and
girl, Dawn Ashworth, in Leicestershire in 1986 - less murder of Linda Cook; a semen sample was recovered
than a mile from the discovery of the body of Linda but was of insufficient volume to permit DNA profiling.
Mann, another 15-year-old schoolgirl in 1983 - a local Low copy number DNA analysis was performed in
youth was arrested and charged with Dawn's murder. 1999, the results of which were inconclusive. Further
DNA analysis, however, showed that he could not work in 2001 revealed 'foreign' DNA bands that did not
have been her assailant, and he was released. Police match Shirley or Cook, and the Court of Appeal ruled
invited all young men in the area to give blood sam that his original conviction was unsafe. He was released
ples for profiling, but screening of some 5 000 samples in 2003.
failed to reveal a 'match'.
Sample analysis I 283
frequentist approach often encountered in scientific anal the ethnicity of the subject will be extremely low for a
yses as they include a measure of subjectivity to assist in full profile but will increase when the profile is incom
determining the probability of an outcome. For example, plete (contains fewer loci available to match). The ratio
when undertaking a long series of experiments tossing a of the two probabilities, A and B, provides the likelihood
coin, we expect that the frequency of getting a head would ratio. In Bayesian inference, this could be restated as:
be 50% (probability 0.5). If, however, the coin has a small
weight attached to one side this would tend to bias the out Posterior odds
come. Bayes theorem offers a way to condition the prob (of guilt after considering all the evidence)
ability to account for additional information. In its odds
= Genetic odds
form Bayes Theorem is more simply stated as:
(of getting a full matching profile)
Posterior odds = Likelihood ratio x Prior odds
x Non-genetic odds
in which the prior odds (belief that the frequency of get
(prior odds of guilt after considering
ting a head when tossing a coin is 50%) is multiplied by
the likelihood ratio. In terms of the coin throwing, the all the other evidence)
likelihood ratio can be defined as:
It is very important when considering DNA evidence
Probability that the coin (and indeed other forensic evidence), that it is expressed
T1M , . is fair as the probability of the scientific evidence (E) given
Likelihood ratio —----- --------------- —---------
Probability that the coin two hypotheses put forward by the prosecution and the
is not fair defence (Hpor Hd) under consideration of the scientific evi
dence. This is distinct from the probability of the hypoth
Bayesian inference is useful in forensic investiga esis given the evidence, which is the question addressed
tions because the likelihood ratio, which represents the by the jury, which considers all of the evidence. This high
probability of the evidence under two propositions, is lights the danger of a jury considering the scientific evi
provided as part of the investigation and we can use it dence alone, such as a piece of very strong DNA evidence,
to update the prior odds at the time. In relation to DNA without considering reasons for the DNA being present
evidence, if a single DNA profile from a crime scene that may not be associated with the crime. Presenting the
matches a given individual, one can assess the prob sometimes very persuasive scientific evidence in isolation
ability of the evidence given two hypotheses: is called the ‘prosecutor's fallacy' or ‘transposing the con
ditional' where the relative positions of the conditional (|)
A . The DNA originated from that person
probability are more easily seen when the above equation
B. The DNA originated from another, random, unre is represented in the formula:
lated person.
P(Hp|E) p(E|Hp) , ; p(Hp)
The probability of the outcome being true in regards to p(Hd|E) p(E |Hd) p(Hd)
hypothesis (A) is 1.0. Looking at the alternative hypoth
esis (B), one has to consider a number of factors such as See Box 21.6 for an exploration of how forensic scien
the rarity of each allele and any potential knowledge of tists interpret forensic evidence.
National DNA Database also been used to differentiate venous and menstrual
blood, for example.
The UK National DNA Database (NDNAD) is the oldest
DNA database in the world. It holds the details of people
Blood
arrested in connection with an arrestable offence under
the Police and Criminal Evidence Act 1984 as well as The presence of blood is normally suggested by its colour
data relating to crime stains for which there are no refer and the chemical reaction it gives when a presumptive
ence profiles. Crime scene samples are searched against test is applied. Blood, however, does not always appear
the database and compared with each other, nightly, in as red/brown in colour and may have been diluted. This
order to identify whether or not there could be a match can make it very challenging to locate stains, particu
to someone on the database, or a link to another crime. larly on a darker surface.
It is highly efficient as around 10% of the population Stains that are to be tested are scraped with the edge
(mostly young to middle-aged men) have their profiles of a piece of folded sterile filter paper. The presumptive
recorded on the database. Over 60% of cases in which a tests used are generally leuco-malachite green (LMG)
DNA profile is obtained from the crime scene provides or Kastle-Meyer (K-M). Both involve the addition of the
a name to police. The power of the database also means reduced form (colourless) of each reagent to the filter
that there is a strong possibility that a familial link paper followed a few seconds later by hydrogen perox
would be uncovered but such searches require special ide. If a rapid colour change occurs after the addition of
authorisation for privacy reasons and are limited to seri both chemicals, and the colour of the scraping is typical
ous cases. Typically, there are under 20 such compari (green for LMG, pink for K-M) of a bloodstain, then the
sons made annually. presence of blood is indicated. The colour change occurs
There have been considerable concerns raised about as blood has a peroxidase-like activity due to haemoglo
the NDNAD by many, including those with an interest bin, which catalyses the oxidation of each chemical to
in civil liberties, about the appropriateness of retention its coloured form.
and the delay or absence of destruction of profiles. This When bloodstains cannot be seen, different methods
is especially with regards to those who never go to trial of detection can be used. For example, luminol, in solu
for the allegation for which they were arrested, those tion, provides a blue chemiluminescent signal in the
who are acquitted and the vulnerable, such as children. presence of iron (present in haemoglobin) and provides
The judgement in the case of S an d M arper v UK (2008) a very sensitive technique for latent bloodstains.
before the European Court of Human Rights, in which
the petitioners had requested that their DNA profiles Semen
were removed from the NDNAD but were refused by
Human semen is made up of both a liquid and a cellu
UK courts, led to the Protection of Freedoms Act (PoFA)
lar fraction in non-vasectomised post-pubescent males.
2012. This law ensures that samples are destroyed
Semen is detected by forensic scientists using the acid
within six months, and profiles from those who are
phosphatase (AP) test, as AP occurs in high levels in
not convicted are held for a maximum of three years,
human semen. When testing clothing or other larger
although there is special consideration in exceptional
items, a press-test of filter paper onto a dampened item
circumstances, or if the individual is a minor.
suspected of bearing semen staining is used. The filter
paper is then removed and sprayed with the AP reagent.
Body fluid analysis If a purple colour develops, the presence of semen is
Forensic scientists will often be requested to conduct indicated (Figure 21.5). Bacterial infections can give
searches for a number of biological fluids, including false reactions with AP reagent (a pinkish colour). False
blood, semen, saliva, urine, faeces and others in attempts positives can also occur from vaginal AP; however, gen
to identify individuals (and in some instances species) erally only AP from semen produces the quick change to
who may have left the stains (using DNA analysis) as well a strong purple colour.
as interpreting them in the context of their location. Most Semen is confirmed by locating the stained area on
identifications are done through chemical tests but these the garment and extracting some of the stain before
are done on samples that are distinct from the material making up a microscope slide containing some of the
used for DNA and the link between body fluid and indi extract. If spermatozoa are seen, the presence of semen
vidual cannot be made. Methods to co-extract DNA and is confirmed.
RNA from such samples can be used to provide a more If swabs are to be tested, they can also be pressed
robust body fluid source identification and person associ onto a piece of filter paper before AP is applied or, alter
ation: techniques include use of messenger RNA (mRNA), natively, the swab can be extracted, the cellular frac
micro RNA (miRNA), and epigenetic approaches, are tion spun down and a fraction of the liquid supernatant
most commonly described and these techniques have tested instead to conserve cellular material. In a similar
Blood pattern analysis I 287
Downward drips
Downward drips are formed when blood falls from a
surface (such as the end of a finger) under the force of
gravity. If they land on a flat surface, they will make a
characteristic circular stain, although if the surface is not
smooth (e.g., pavement) the stain can be quite distorted
(Figure 21.6).
If blood is dropped onto an absorbent surface such as
carpet, the stain can be much smaller while still being of
the same volume. If a number of drops fall onto the same
location, a distribution which could be confused with
a more active event is created as the blood makes con
tact with other wet staining already present. The force of
the blood drops falling into wet blood that has already
fallen results in a number of smaller, satellite drops
being projected away from the area of impact. Such sat Figure 21.6 Blood dripped onto (a) painted metal,
ellite droplets can be projected for quite some distance (b) wood and (c) concrete.
from the centre of the distribution; this is dependent on (Courtesy of Manlove Forensics Ltd.)
the height from which the blood is falling, the texture
and absorbance of the surface and the amount of blood
already present.
Luminol
If attempts have been made to clean away blood staining,
the scientist can use chemical means to visualise stain
ing that may have been present prior to those efforts.
The use of luminol, a highly sensitive chemiluminescent
compound, can help the scientist visualise where blood
Figure 21.10 Projected blood pattern: arterial staining had been present before any such cleaning
spurt/gush. (Image copyright Forensic Science Service efforts. It should be noted that the carrier for this chemi
[FSS]. Reproduced with permission.) cal is primarily water so its use should be one of the final
actions at a scene (Figure 21.12).
Damage assessment
When items are broken, it can be possible, by visual and
microscopic examination, to tell whether or not two or
more items are fragments of one original item; for exam
ple, the two broken halves of a plate. This is achieved
by comparing gross features as well as finer details. The
more points of comparison that can be made, the stron
ger the opinion that can be offered.
By examining the edges of, and fibre damage to,
clothing items that have been torn or cut, it may be
possible to comment on what type of damage actually
occurred, as in many cases where allegation of tearing
occurs, a cut has been used to start a tear. It is also pos
sible to comment on how recently damage may have
occurred.
Using controlled tests and reconstructions, it is also
Figure 21.11 Blood mixed with another body fluid possible to comment on whether or not a specific item
projected onto a wall. Note the dilute appearance. or action caused an area of damage.
Figure 21.12 (a) A section of carpet with no blood staining visible, (b) The same section treated with luminol,
revealing superimposed hand and footwear marks.
Footwear 291
Fingerprints
Fingerprints are formed within the womb at approxi
mately 1 2 weeks of gestation and, apart from damage
by environmental factors do not alter during one's life
time. There is some debate as to the purpose of these
ridges, with support for the notion that the presence
of fingerprints leads to an increase in grip, and/or
enhances the sensitivity for the perception of texture.
The overall nature of a fingerprint can be described in
terms of loops, whorls or arches, describing the overall
appearance of the pattern of ridges. On a smaller scale
Figure 21.14 A finger mark in blood left on the blade of
the ridges themselves form the next level of detail within
a knife. The finger was wet with blood prior to touching
the fingerprint; they can terminate or can divide into
the blade.
two. These characteristics enable particular patterns
to be formed that are termed ridge ending, bifurcation,
short ridge, spur, dot, bridge, lake or delta. Furthermore,
an impression into a surface, such as one coated with
the sweat glands on the ridges themselves give an addi
grease or blood (Figure 21.14).
tional area for comparison should this be required.
It is the theory that fingerprints are unique to each
As there are sweat glands within the ridges, an
person which enabled them to become one of the pri
impression of these secretions can be left as a fingerprint
mary methods by which identifications of suspected
on a surface (latent marks). Such marks usually com
offenders were made. Fingerprints have been used for
prise a mixture of water-soluble and fat-soluble com many years to identify individuals and, for example,
pounds. As the fingerprint is made up of compounds
have been known to confirm identity by the Chinese in
from the body, their chemical composition can reveal, the 3rd century b e .
for example, that someone is a smoker or drug user. It
Fingerprints were traditionally recorded from an
is often necessary to use specialised light, or chemical individual by coating their fingers with black ink and
enhancement, on fingerprints so that all available parts rolling them onto a card form. A record of the palmprint
of the mark can be seen. Different wavelengths of light, is now also taken. This ensures that all available detail
and specialised chemicals, are used to enhance the dif is recorded. While this method is still the main way by
ferent compounds within a fingerprint (Figure 21.13). which fingerprints are recorded, scanning machin
Fingerprints may also be left (patent marks) if ery is more commonly being used and, as technology
there is a contaminant such as ink, blood or paint - for improves, will supersede the ink-based method.
example, on the finger before it makes contact with a Databases of fingerprints are held on a card-based
surface. Another way of leaving a fingerprint is to make system using the 'Tenprint' forms used to take inked fin
gerprints (Figure 21.15). In recent years, each individ
ual's ridge detail characteristics have also been loaded
onto computer-based searchable databases. In the
UK, this was initially NAFIS (the National Automated
Fingerprint Identification System) but this only held
data from England &Wales. IDENT1 now combines data
from England, Scotland and Wales allowing the search
of around 7 million records against marks (including
palm marks).
Footwear
Footwear marks
When people wearing footwear come into contact with
a surface, they often leave an impression. The extent to
which this occurs may depend on many factors, such as
how dirty the sole of the shoe is or the floor surface itself.
The resulting footwear impression can be photographed,
Figure 21.13 A fired shotgun cartridge: (a) untreated, lifted using a variety of media, or it can be recovered
and (b) treated with cyanoacrylate (superglue) fumes, whole (marks on paper, for example) and submitted to a
revealing finger marks. laboratory for a suitable method of enhancement.
292 I Principles of forensic science and crime scene investigation
5. RIGHt IITTLE
There are many different methods of enhancing foot contact with the ground. Damage detail in the form of
wear marks, some of which are used in the enhancement cuts and nicks may also be formed in a random fashion
of fingerprints. Often photographing under controlled- on the sole of the footwear (Figure 21.16). Examination
lighting conditions, or the addition of specialist light of footwear involves comparing the sole pattern, size
sources, can improve the detail within a mark. When and degree of wear in the mark found at a scene, with
a mark warrants a more intensive examination (e.g., in a test mark made from an item of footwear. If damage
a serious assault) the enhancement may be carried out detail is present in the scene mark, and it corresponds
using chemicals. For soil deposits, potassium or ammo with damage in the test mark, it is sometimes possible to
nium thiocyanate can be used, which reacts with metal state conclusively that a mark left at the scene was made
lic ions in the soil. Marks in blood may be enhanced by a particular shoe, and by no other.
using Amido Black solution, which reacts with the pro When determining the size of a sole pattern, it is not
teins in the blood. There are many other methods of usually possible to establish the exact shoesize, because
chemically enhancing marks. of the many variations in sole patterns of a particular
To carry out a comparison of the recovered footwear model distributed throughout the population. It is pref
marks with a suspect shoe, a test impression of the sole erable to estimate the size of a shoe from its sole pattern
pattern is required. This can be prepared by brushing by giving a range of sizes that the shoe could be. This
the sole with aluminium or black powder, and then plac allows for variation in sole pattern between different
ing the shoe, sole-side down, onto adhesive plastic. The moulds, and manufacturers.
plastic is then placed onto an acetate sheet and labelled
to identify the shoe and ensure the correct orientation Footwear marks and skin
of the impression. This can then be laid over the photo When contact is made with a person with sufficient
graph of the mark recovered from the crime scene and a force, by kicking or stamping, skin deposits may be
comparison made between them. transferred to the inner surface of clothing while next
When shoes are compared, various details are con to the skin. Such deposits may require specialist light
sidered. As the footwear is worn, general wear charac sources, and chemical treatment, to increase the con
teristics develop in the areas of the sole that come into trast between the mark and the background, and allow
effective photographic recording.
When forceful contact is made directly to the surface
of the skin, it is possible for a patterned injury to be left
on the skin, forming a mark which may be characteris
tic of the surface that made the contact. In the case of
shoe marks, the surface is often made up of regularly-
spaced components that may leave a patterned injury
which corresponds with the pattern of sole components.
The pressure exerted during such a forceful contact
may force blood in the surface of the skin into the gaps
Figure 21.16 Recovered footwear mark showing damage between the sole pattern components, leaving what is
features. (Image copyright Napier Associates Ltd. often referred to as a negative impression. Forceful con
Reproduced with permission.) tact with skin that is close to a bone often results in a
Bibliography and information sources I 293
patterned injury which bears a greater degree of detail. In cases where there are multiple layers of paint in
However, as the surfaces (of the body and the patterned a sample, it may be possible to state that the evidential
surface of interest) are not flat, distortion can interfere sample came from a suspect car; however, it is often
with visual comparison techniques, including those used as corroborative evidence in a case. In graffiti cases
relying on photographic 'overlays' between scaled pho it is possible to recover microscopic particles of aero-
tographs of the patterned injury and patterned surfaces solised paints in colours that match the colours used in
of interest. Photographic overlay techniques can be a specific incident of vandalism.
used to determine comparisons.
Fibres
Trace evidence Clothing and soft-furnishings are made in a wide array
This type of evidence can include anything that has of fabrics that come from all manner of sources. Natural
been transferred by means such as contact with a sur fibres, such as wool, cotton and linen have been used for
face or a person and this is the practical application of centuries and they are often combined with man-made
Locard's exchange principle. Often the material is very fibres to improve their versatility. Within the types of
small and requires microscopic examination. Organic fibre used there may be many different dyes and other
material such as pollen can be considered as trace evi materials incorporated into them which give different
dence but more often it involves man-made materials properties to the finished garment. All of these charac
such as glass, paint and fibres. teristics enable the forensic fibre examiner to identify
sources of fibres and compare them with fibres that
have been transferred to other garments or furnish
Glass
ings. Identification of the fibres involves microscopic
Glass is manufactured for use in construction by float and analytical techniques, and it is possible to use the
ing it on the surface of molten tin. This produces a glass results in tandem with the number and location of the
that is very flat and can be mass-produced. A mixture of recovered fibres to give an interpretation of the circum
silicon and various other minerals is added to a furnace stances that caused the transfer to occur. For example,
and then poured onto the molten tin. Glass can also be it may be possible to state in which seat of a car a sus
moulded into containers or pressed into sheets with pat pect was sitting, so that their version of events of the
terns. When glass is broken, small fragments are show incident can be evaluated. It is sometimes possible to
ered into the surrounding area. If a person were near find an original source of a fibre that is prevalent in a
to the breaking glass it would be expected that some of case by going to manufacturers and obtaining details of
these fragments would transfer to the individual. These the amount and geographic distribution of a particular
fragments will remain on the individual's clothing until product.
such time that they fall off. The length of time that these
glass fragments remain on clothing depends on many
factors, such as the type of clothing, and the activity of Bibliography and information
the individual.
Glass fragments recovered in the laboratory, or from
sources
Balding DJ. Weighx-of-evidence for Forensic DNA Profiles. Honoken:
assault victims and suspects, can be compared with
John Wiley & Sons; 2005.
another source of glass by various means, including the
Bandelt H-J, Richards M, Macaulay V (eds). Fluman Mitochondrial
measurement of their refractive index and their chemi DNA and the Evolution of Flomo Sapiens. Berlin-Heidelberg:
cal composition. Springer-Verlag Press; 2006.
Barbasin M, Shewale JG. Assessment of DNA extracted from
Paint forensic samples prior to genotyping. Forensic Sci Rev
2010;22:199-214.
There are many varieties of paint for many different Butler JM. Fundamental of DNA separation and detection. In:
uses. If damage is caused to a painted surface, small Butler J (ed). Fundamentals of Forensic DNA Typing. San Diego:
flakes can be transferred. In road traffic collisions, for Elsevier Academic Press; 2010,175-203.
example, there may be a two-way transfer of material. Butler JM. Short tandem repeat typing technologies used
Once recovered, paint evidence is examined microscop in human identification testing. BioTechniques 2007;43(4):
ically to identify it, and determine whether it is made up Sii-Sv.
Caddy B, Taylor GR, Linacre AMT. Review of the science of low
from different layers of paint. Each type of paint may be
template DNA analysis, https://www.gov.uk/government/
discriminated by its colour, texture and composition.
publications/review-of-the-science-of-low-template-dna-
Various light sources may be used to distinguish differ analysis (Accessed 21 May 2019).
ent types of paint, or the components can be identified Crown Prosecution Service. DNA 17 profiling: legal guidance. Gov
using chemical tests and analytical techniques, such as UK. https://www.cps.gov.uk/legal-guidance/dna-17-profiling
chromatography and spectrophotometry. (Accessed 21 May 2019).
294 I Principles of forensic science and crime scene investigation
EuroForGen. Network of Excellence. Making Sense of Forensic Kirk PL. Crime Investigation: Physical evidence and the Police
Genetics, 2017. https://www.euroforgen.eu/dissemination- Laboratory. New York: Interscience Publishers Inc, 1953.
activities/making-sense-of-forensic-genetics/ (Accessed 21 Locard E. L'enquete criminelle et les methods scientifiques. Paris:
May 2019). Flammarion, 1920. In: Crispino F, Ribaux 0, Houck M, Margot
Forensic Science Regulator. Guidance: DNA Mixture P. Forensic science: a true science? Aus J Forensic Sci 2011;
Interpretation. FSR-G-222, Issue 2, 2018. https://www.gov.uk/ 43:157-176.
government/publications/dna-mixture-interpretation-fsr- Mullis K, Faloona F, Scharf S, et al. Specific enzymatic ampli
g-222 (Accessed 21 May 2019). fication of DNA in vitro. Cold Spring Harb Symp Quant Biol
Forensic Science Regulator. Guidance: The Control and Avoidance 1986;51:263-273.
of Contamination in Crime Scene Examination involving Ong SY, Wain A, Groombridge L, Grimes E. Forensic identification
DNA Evidence Recovery FSR-G-206. Issue 1. https://www. of urine using the DMAC test: a method validation study. Sci
gov.uk/government/publications/crime-scene-dna-anti- Justice 2012;52:90-95.
contamination-guidance (Accessed 21 May 2019). Parson W, Bandelt H-J. Extended guidelines for MtDNA typing
Gelman A, Carlin JB, Stern HS, et al. Bayesian Data Analysis, 3rd ed. of population data in forensic science. Forensic Sci Int Genet
London: Chapman and Hall/CRC; 2013. 2007;11:21-50.
Gill P. Application of low copy number DNA profiling. Croat Med Phillips C, Fernandes-Formoso L, Garcia-Magarinos M, et al.
J 2001;52:229-232. Analysis of global variation in 15 established and 5 new
Green RL, Lagace RE, Oldroyd NH, et al. Developmental validation European Standard Set (ESS) STRs using the CEPH human
of the AmpFISTR NGM Select PCR Amplification Kit: a next- genome diversity panel. Forensic Sci Int Genet 2011;5:155-169.
generation STR multiplex with the SE33 locus. Forensic Sci Int President's DNA Initiative. Forensic Biology Screening Workshop:
Genet 2013;7:41-51. Other Body Fluids and Tissues, http://projects.nfstc.org/
Harbison S, Fleming R. Forensic body fluid identification: state of workshops/resources/presentations/screening-body_fluids/
the art. Res Reports Forensic Med Sci 2016;6:11-23. data/downloads/biological%20screening%20-%20body.ppt
Home Office and National Police Chiefs' Council. National DNA (Accessed 21 May 2019).
Database Strategy Board Annual Report. https://www. Stray JE, Liu JY, Brevnov MG, Shewale JG. Extraction of DNA from
gov.uk/government/publications/national-dna-database- forensic biological samples for genotyping. Forensic Sci Rev
annual-report-2016-to-2017 (Accessed 21 May 2019). 2010;4:68-87.
Jarman PG, Fentress SL, Katz DE. Mitochondrial DNA validation in Stuart HJ; Eckert WG. Interpretation of Bloodstain Evidence at Crime
a state laboratory. J Forensic Sci 2009;54:95-102. Scenes. Boca Raton: CRC Press; 1998.
Jobling MA, Pandya A, Tyler-Smith C. The Y chromosome SyndercombeCourt D. Human genetics. In: Naish J, Sundercombe
in forensic analysis and paternity testing. Int J Leg Med Court D (eds). Medical Sciences. Oxford: Elsevier Health
1997;110:118-124. Sciences; 2018,153-208.
22 Principles of toxicology
mortem blood specimens. When blood is drawn in the hair at autopsy, place it in a sealed envelope and file the
hospital, either for therapeutic drug monitoring or drug sample. For reasons that are not entirely clear, the par
detection, only the plasma is analysed. In death, con ent drug is often found in higher concentrations within
centrations in whole blood are measured. Drug con the hair than is the metabolite. Should questions about
centrations, especially the concentration of alcohol, are drug use arise some time in the distant future, they will
different in plasma and whole blood. Serum and plasma be easily answered if a hair sample has been retained.
contain 10-15% more water than whole blood. It follows
that plasma ethanol concentrations are 10-15% higher Liver
than corresponding whole-blood concentrations. The
difference may seem small, but it is more than enough Liver analysis can be especially valuable in cases where
to convict or exonerate a driver accused of driving under the drug sought (such as a tricyclic anti-depressant) is
the influence. highly bound to protein. Liver analysis is also valuable
Urine was once the preferred specimen for post mor if the drug undergoes enterohepatic circulation. Some
tem drug screening but, increasingly, blood samples are drugs, such as morphine, may be detectable in the liver
considered a better testing matrix. Advances in technol long after they have been cleared from the blood, only
ogy have substantially reduced the costs of gas chroma because they remain in the enterohepatic circulation for
tography/mass spectrometry (GC/MS), and screening so long. There is, however, one important caveat: most
whole blood involves not much more expense than the drugs readily diffuse from the stomach into the right
cost of screening urine, but provides greatly enhanced lobe of the liver so, as a rule, only the left lobe of the liver
sensitivity. After death, drug concentrations tend to should be used for analytical testing.
increase faster in cardiac blood, for example, than else
where in the body, making such samples more sensitive Stomach
indicators of drug use, although they are less specific.
The testing of stomach contents is only worthwhile if
The routine screening of cardiac blood also helps avoid
(1 ) the volume of the gastric contents is recorded, (2 ) a
another problem: at autopsy, there is often no urine in
homogeneous specimen is analysed and (3) the total
the bladder. Some centres have dispensed with urine
drug content within the stomach is computed. It does
testing entirely; they first screen cardiac blood with
no good to know the drug concentration in gastric fluid
GC/MS and then confirm their findings in a peripheral
if the total volume of the gastric contents is not also
blood sample.
known. It may also be possible to identify small pill
fragments by microscopic examination of the gastric
Vitreous humour fluid. Very little should be made of low-level drug con
Vitreous humour is a useful testing medium, especially centrations found in stomach, as ion trapping may cause
for the diagnosis of electrolyte disorders, renal failure, small amounts of some charged drugs, such as cocaine
hyperglycaemia and ethyl alcohol ingestion. The vitre and morphine, to appear in the gastric contents, even if
ous humour is, in many ways, protected from the exter the drug has been injected intravenously. However, the
nal environment, and it may be the only reliable testing detection of high concentrations of some drugs in the
matrix available when individuals have drowned or stomach (such as morphine) does not necessarily prove
when bodies are found after an extended period of oral ingestion; it may just be an artefact produced by
environmental exposure. Measurement of alcohol con enterohepatic circulation.
centrations in the vitreous humour may even help dis
tinguish between post mortem alcohol formation and Interpretation
ante mortem ingestion. There is an emerging tendency
Post mortem drug concentration measurements can
to also measure the concentrations of abused drugs in
not be interpreted in isolation, if for no other reason
the vitreous humour, although for the present, too few
than that tolerance eventually emerges to most abused
measurements have been reported to allow accurate
drugs. A living heroin addict may very well have a higher
extrapolation from vitreous humour concentrations to
morphine concentration than an occasional heroin user
concentrations in other tissues.
lying in the mortuary, but both might have much lower
morphine concentrations than a hospice patient treated
Hair testing with a diamorphine syringe driver. Tolerance is not the
Measurement of abused drug concentrations in hair can only issue.
yield valuable information about drug exposure and Drugs taken previously are likely to be stored in
drug compliance, and sometimes hair testing can reveal deep body compartments, only to be released as the
the presence of drugs that were completely unexpected. body decomposes (a process that begins immediately
Once deposited in hair, drugs and their metabolites are after death). Drug measurements made under these
stable indefinitely. It requires very little effort to collect circumstances might give the false impression that the
300 Principles of toxicology
drugs were, in fact, circulating in the blood at the time 2D6, causing her to produce much more morphine
of death. This phenomenon was strikingly illustrated in when taking codeine than would normally be expected.
a study of post mortem blood fentanyl concentrations. Individuals with a normal genetic compliment convert
Fentanyl concentrations were measured in post mor roughly 1 0 % of codeine into morphine, accounting for
tem specimens collected in 2 0 medical examiner cases codeine's modest pain-relieving effects, but because of
from femoral blood, heart blood, heart tissue, liver tissue the mother's genetic make-up, much higher concentra
and skeletal muscle. In a subset of seven cases femoral tions of morphine were found in the infant than would
blood was obtained shortly after death and then again normally be predicted, even though the mother was not
at autopsy. The mean collection times of between the taking excessive doses of codeine.
two post mortem samples were 4.0 hours and 21.6 hours,
respectively. In four of the cases fentanyl concentrations
rose from 'none detectable' in the samples taken shortly
Bibliography and information
after death, to concentration as high as 52.5 jig/L. If only sources
the toxicology results were considered in isolation, a American Psychiatric Association. Diagnostic and Statistical
pathologist confronted with a case of unexpected sud Manual of Mental Disorders (DSM-V). Arlington: American
den death might very well make the mistake of classify Psychiatric Association; 2013. https://www.psychiatry.org/
ing fentanyl as the cause of death, even though none was psychiatrists/practice/dsm/about-dsm (Accessed 13 May
present in the blood at the time of death. 2019).
Finally, there is the issue of genetic polymorphism. Arora B, Velpandian T, Saxena R, et al. Development and valida
Not only does post mortem redistribution (Figure 22.1) tion of an ESI-LC-MS/MS method for simultaneous identifica
tion and quantification of 24 analytes of forensic relevance
ensure that concentration measured at autopsy will be
in vitreous humour, whole blood and plasma. Drug Test Anal
higher than in life, there is always the possibility that 2016 ; 8 ( 1): 86 —97.
high drug concentrations, even those measured in life, Cook DS, Braithwaite RA, Hale KA. Estimating antemortem drug
do not always reflect drug overdose: the individual concentrations from postmortem blood samples: the influ
simply may not have been able to metabolise the cor ence of postmortem redistribution. J Clin Pathol 2000;53:
rect dose of drug they had been given. This possibility 282-285.
was only realised a few years ago when a newborn died Cooper GA, Kronstrand R, Kintz P. Society of Hair Testing guide
of morphine poisoning that originated in the mother's lines for drug testing in hair. Forensic Sci Int 2012;218(1 —3):
breast milk. As is often the case, she had been pre 20-24.
scribed codeine for post-labour pain. When the infant Drummer OH. Forensic toxicology. EXS 2010;100:579-603.
Fernandez P, Seoane S, Vazquez C, et al. Chromatographic deter
died unexpectedly it was discovered that the mother
mination of drugs of abuse in vitreous humor using solid-
was an ultra-rapid metaboliser of cytochrome P450
phase extraction. JAppI Toxicol 2013;33(8):740-745.
Ferner RE. Post-mortem clinical pharmacology. BrJClin Pharmacol
2008;66:430-443.
Nasal cavity Jung BF, Reidenberg MM. Interpretation of opioid levels: com
parison of levels during chronic pain therapy to levels from
forensic autopsies. Clin Pharmacol Ther 2005;77:324-334.
Karch SB, Drummer O. Karch's Pathology of Drug Abuse, 5th ed.
Oeosophagus Boca Raton: CRC Press; 2015.
Karch SB, Goldberger BA, Druid H. Karch's Drug Abuse Flandbook,
3rd ed. Boca Raton: CRC Press; 2019.
Karch SB, Stephens BG, Ho CH. Methamphetamine-related
deaths in San Francisco: demographic, pathologic, and toxi
Heart cologic profiles. J Forensic Sci 1999;44:359-368.
Kintz P, Villain M, Cirimele V. Hair analysis for drug detection. Ther
Liver Drug Monit 2006;28:442-446.
Koren G, Cairns J, Chitayat D, et al. Pharmacogenetics of mor
Stomach phine poisoning in a breastfed neonate of a codeine-pre-
scribed mother. Lancet 2006;368:704.
Kuwayama K, Miyaguchi H, Iwata YT, et al.Time-course measure
Figure 22.1 Post mortem redistribution. Blood values ments of drug concentrations in hair and toenails after single
measured after death have little or no relationship administrations of pharmaceutical products. Drug Test Anal
2017;9(4):571—577.
between levels that existed in life. Aspiration of stomach
LeBeau M, Moyazani A. Drug-Facilitated Sexual Assault, A Forensic
contents into the lungs often occurs at the time of death,
Handbook. London: Academic Press; 2001.
and drugs that were in the lungs diffuse into the heart. Leung KW, Wong ZCF, Ho JYM, et al. Surveillance of drug abuse
Blood from the illiofemoral vessels is generally consid in Hong Kong by hair analysis using LC-MS/MS. Drug Test Anal
ered preferable for testing. 2018;10(6):977—983.
Bibliography and information sources 301
Levine B. Principles of Forensic Toxicology, 3rd ed. Washington: Pelissier-Alicot AL, Gaulier JM, Champsaur P, Marquet P.
American Association for Clinical Chemistry; 2010. Mechanisms underlying postmortem redistribution of drugs:
Metushi IG, Fitzgerald RL, McIntyre IM. Assessment and compari a review. JAnal Toxicol 2003;27:533-544.
son of vitreous humor as an alternative matrix for forensic toxi Pounder DJ, Jones GR. Post-mortem drug redistribution: a toxi-
cology screening by GC-MS. JAnal Toxicol 2016;40(4):243-247. cological nightmare. For Sci Int 1990:45:253-263.
Moriya F, Hashimoto Y. Redistribution of basic drugs into cardiac Salomone A, Tsanaclis L, Agius R, et al. European guidelines for
blood from surrounding tissues during early-stages postmor workplace drug and alcohol testing in hair. Drug Test Anal
tem. J Forensic Sci 1999;44:10-16. 2016;8(10):996-1004.
Olson KN, Luckenbill K,Thompson J, etal. Postmortem redistribu White RM. Drugs in hair. Part I. Metabolisms of major drug classes.
tion of fentanyl in blood. AmJ Clin Pathol 2010;133:447-453. Forensic Sci Rev 2017;29(1):23—55. Review.
23 Alcohol
Widmark's equation relates these variables accord Note that we had to convert the 0.15 g/100 mL and
ing to: the 0.015 g/100 mL/h to kg/L which simply amounts
Equation 2 to moving the decimal point two places to the left.
Solving for A we find:
dependent and other binge drinkers 19 mg/100 mL/h the UK produced a leaflet B lood Alcohol Concentration
may be more appropriate. Studies have also shown that an d General Effects (Figure 23.1) but the majority of cli
females eliminate alcohol at a faster rate than males nicians would be uncomfortable classifying the effects
which may relate to relative liver/weight ratio. (even in general terms) within quite such narrow spe
cific quantified ranges, as described in this publication,
Ethanol measurement because of the huge variability in response to consum
ing alcoholic drinks. It does, however, give a reasonable
Evidential breath testing is used by most law enforce
indication of the progression of alcohol intoxication.
ment agencies in most countries with respect to road
It is also important to understand that there are
traffic (driving) offences. A wide variety of devices are
substantial risks for those who are dependent on alco
available for measuring the ethanol content of expired
hol and suffer alcohol withdrawal. Untreated alcohol
air, and the mode of operation of most devices caused
withdrawal can be fatal and those involved in clinical
ethanol contained in the sample to be oxidised with an
assessment and management must understand how
electrochemical sensor. The value provided is directly
to diagnose and treat such individuals. The degree of
proportional to the concentration of the ethanol pres
alcohol withdrawal can be quantified using the Clinical
ent in the body. Quality control and standardisation of
Institute Withdrawal of Alcohol Assessment Scale -
such evidential machines is important to ensure accu
revised (see Chapter 16, Figure 16.1b).
rate analysis. In the presence of factors such as use of
alcohol-containing mouthwash or regurgitation of
stomach contents, different jurisdictions may apply dif Post mortem considerations
ferent protocols, to overcome risks of false elevations,
The situation is much more complicated after death.
by repeating evidential breath tests after a period of
Bacterial enzymes (predominantly alcohol dehydro
time or replacement by either blood or urine analysis.
genase and acetaldehyde dehydrogenase) act upon
Alcohol-based or alcohol-containing hand-washes or
carbohydrates within the cadaver. Glycogen or lactate
swabs should be avoided in the vicinity of evidential
is converted to pyruvate and then ethanol. The amount
breath devices because of the possibility of affecting
of alcohol produced depends on the amount of glyco
the result of analysis.
gen or substrate available. Accordingly, post mortem
ethanol production will be greater in some tissues than
Clinical effects of alcohol in others. For example, the glycogen content of liver is
Ethanol is a central nervous system depressant, and 8 g / 1 0 0 g wet tissue weight, whereas that of vitreous
the degree of apparent intoxication generally correlates humour is only 90 mg/100 g.
with the amount consumed. As blood concentrations Other factors also help determine how much alcohol
rise, initial feelings of relaxation and disinhibition give will be produced. Terminal hyperthermia, such as might
way to blurred vision, loss of coordination and behav be seen in a patient with sepsis, or storage of the body at
ioural issues, including risk-taking behaviour. As alco high ambient temperatures, will accelerate alcohol pro
hol levels continue to rise, unconsciousness can occur. duction, as will bowel trauma or disruption of the bowel
The highest levels of consumption can lead to death as owing to surgery or malignancy. Aircraft accidents or
a result of cardiorespiratory arrest. There is substantial other causes of severe body disruption almost always
inter-subject variation with tolerance in the alcohol- cause the production of ethanol in large quantities.
dependent that may allow the consumption of massive Whether any alcohol detected was formed before or
amounts of alcohol and result in BACs that result in after death is fairly easy to determine. The easiest way
death in the non-alcohol dependent. Thus, single BACs is to compare the ethanol content of urine (UAC) which,
have very little meaning when taken in isolation except unless the decedent was diabetic, contains no carbo
that, of course, a large amount of alcohol has been con hydrates, and vitreous humour (which only contains
sumed. A BAC exceeding 0.40 per cent (400 mg%) may very small amounts of carbohydrate) with the amount
be lethal in a non-drinker but might produce few, if measured in blood. If the ethanol was definitely con
any, symptoms in a chronic alcoholic. If an individual sumed and not formed post mortem, then determina
is severely intoxicated, aspiration of vomit may lead to tion of the ratio between vitreous humour and blood
asphyxiation and death. Chronic alcohol dependence alcohol concentrations can be very useful. If the UAC:
is associated with a wide range of medical conditions BAC ratio is less than 1 :2 , this is generally considered
including the development of hepatitis, liver cirrhosis, confirmation that ethanol concentrations were rising
portal hypertension and oesophageal varices, liver fail at time of death. A ratio of greater than 1:3 suggests that
ure and heart failure with potentially fatal outcomes. the decedent was in the post-absorptive stage. Ratios
Prior to being closed down as part of austerity measures much greater than 1:3 indicate heavy consumption over
by the UK government, the Forensic Science Service in a long period of time.
Bibliography and information sources I 305
5 0 - 1 0 0 mgs% Inc rea s e d self-confidence and ta lk a tiv e n e s s , m ild euphoria, red uced c o -o rd in a tio n
and slightly slow ed reactions. Legal lim it fo r driving is 80 mgs%
1 0 0 - 1 5 0 mgs% Im p a ire d balance, thickened speech, clum siness, reduced alertness, lo w e re d social
reserve, increased garrulousness and volu b ility
Bibliography and information Baraona E, Gentry RT, Lieber CS. Blood alcohol levels after pro
longed use of histamine-2-receptor antagonists. Ann Intern
sources Med 1994;121:73-74.
Al-Abdallat IM, Al Ali R, Hudaib AA, et al. The prevalence of Baraona E, Gentry RT, Lieber CS. Bioavailability of alcohol: role of
alcohol and psychotropic drugs in fatalities of road-traffic gastric metabolism and its interaction with other drugs. Dig
accidents in Jordan during 2008-2014. J Forensic Leg Med Dis 1994;12:351-367.
2016;39:130-134. Baselt RC. Disposition of Toxic Drugs and Chemicals in Man, 7th ed.
Backman JT, Filppula AM, Niemi M, Neuvonen PJ. Role of Seal Beach, CA: Biomedical Publications, 2004.
Cytochrome P450 2C8 in drug metabolism and interactions. Batra A, Muller CA, Mann K, Heinz A. Alcohol dependence and
Pharmacol Rev 2016;68(1):168-241. harmful use of alcohol. Dtsch Arztebl Int 2016;113(17):301 -310.
306 I Alcohol
Bielefeld L, AuwarterV, Poliak S,Thierauf-Emberger A. Differences Jones AW, Holmgren P. Urine/blood ratios of ethanol in deaths
between the measured blood ethanol concentration and the attributed to acute alcohol poisoning and chronic alcohol
estimated concentration by Widmark's equation in elderly ism. Forensic Sci Int 2003;135:206-212.
persons. Forensic Sci Int 2015;247:23-27. Jones AW. Evidence-based survey of the elimination rates of
Caplan YH, Levine B. Vitreous humor in the evaluation of ethanol from blood with applications in forensic casework.
postmortem blood ethanol concentrations. J Anal Toxicol Forensic Sci Int 2010;200(1 -3):1 -20.
1990;14:305-307. Jones AW. Alcohol: breath analysis. In: Payne-James JJ, Byard RW
Cederbaum Al. Alcohol metabolism. Clin Liver Dis 2012;16(4):667- (eds). Encyclopedia of Forensic and Legal Medicine, 2nd ed.
685. 2016, Oxford: Elsevier, 119-137.
Cooper WE, Schwar TG, Smith LS. Alcohol, Drugs and Road Traffic. Mitchell MCJr,Teigen EL, RamchandaniVA. Absorption and peak
Cape Town: Juta Legal and Academic Publishers, 1979. blood alcohol concentration after drinking beer, wine, or spir
Dubowski KM. Alcohol determination in the clinical laboratory. its. Alcohol Clin Exp Res 2014;38(5):1200-1204.
Am J Clin Pathol 1980;74:747-750. Moriya F, Ishizu H. Can microorganisms produce alcohol in
Ellerhorn, MJ, Barceloux DG, eds. Medical Toxicology, Diagnosis body cavities of a living person?: a case report. J Forensic Sci
and Treatment of Human Poisoning. London: Elsevier Science, 1994;39:883-888.
1988. Palmer RB. A review of the use of ethyl glucuronide as a marker
Emerson BL, Whitfill T, Baum C, et al. Effects of alcohol-based for ethanol consumption in forensic and clinical medicine.
hand hygiene solutions on breath alcohol detection in the Semin Diagn Pathol 2009;26(1):18-27.
emergency department. Am J Infect Control 2016;44(12): Pounder DJ, Smith DR. Postmortem diffusion of alcohol from the
1672-1674. stomach. Am J Forensic Med Pathol 1995;16:89-96.
Erwin VG, Radcliffe RA, Jones BC. Chronic ethanol consump Rainio J, Kultti J, Kangastupa P, et al. Immunoassay for ethyl
tion produces genotype-dependent tolerance to ethanol in glucuronide in vitreous humor: a new tool for postmor
LS/lbg and SS/lbg mice. Pharmacol Biochem Behav 1992;41 tem diagnostics of alcohol use. Forensic Sci Int 2013;226(1 -3):
:275— 281. 261-265.
Esser MB, Wadhwaniya S, Gupta S, et al. Characteristics associated Roberts C, Robinson SP. Alcohol concentration and carbonation
with alcohol consumption among emergency department of drinks: the effect on blood alcohol levels. J Forensic Leg Med
patients presenting with road traffic injuries in Hyderabad, 2007;14(7):398-405.
India. Injury 2016;47(1):160-165. Sadler DW, Lennox S. Intra-individual and inter-individual varia
Ferris J, Killian J, Lloyd B. Alcohol-related serious road traffic tion in breath alcohol pharmacokinetics: variation over three
injuries between 2000 and 2010: a new perspective to deal visits. J Forensic Leg Med 2015;34:88-98.
with administrative data in Australia. Int J Drug Policy 2017;43: Stark MM, Payne-James JJ, Scott-Ham M. Symptoms and Signs of
104-112. Substance Misuse, 3rd ed. Boca Raton: CRC Press; 2016.
Fiorentino DD, Moskowitz H. Breath alcohol elimination rate as a Sturner WQ, Coumbis RJ. The quantitation of ethyl alcohol in vit
function of age, gender, and drinking practice. Forensic Sci Int reous humor and blood by gas chromatography. Am J Clin
2013;233(1 -3):278-282. Pathol 1966;46:349-351.
Forensic Science Service. Blood Alcohol Concentration and Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alco
General Effects. London: Forensic Science Services; 2007. hol withdrawal: the revised Clinical Institute Withdrawal
Gardner JD, Mouton AJ. Alcohol effects on cardiac function. Assessment for Alcohol Scale (CIWA-Ar). Br J Addict
Compr Physiol 2015;5(2):791 -802. 1989;84:1353-1357.
Hezaveh AM, Cherry CR. Walking under the influence of the alco Walls HJ and Brownlie AR. Drink, Drugs and Driving, 2nd ed.
hol: a case study of pedestrian crashes in Tennessee. Accid London: Sweet & Maxell, 1985.
Anal Prev 2018;121:64-70. Widmark EMP. Principles and Applications of Medicolegal Alcohol
Hoiseth G, Wiik E, Kristoffersen L, Morland J. Ethanol elimination Determination. Seal Beach, CA: Biomedical Publications; 1981.
rates at low concentrations based on two consecutive blood Winek CL, Carfagna M. Comparison of plasma, serum, whole
samples. Forensic Sci Int 2016;266:191-196. blood ethanol concentrations. J Anal Toxicol 1987;11:267-268.
24 Licit and illicit drugs
Table 24.2 Drug classification and penalties in England & Wales 2018
Supply and
Class Drug Possession production
A Crack cocaine, ecstasy (MDMA), heroin, LSD, magic Up to 7 years in prison, an unlimited Up to life in
mushrooms, methadone, methamphetamine fine, or both prison, an
(crystal meth) unlimited fine,
or both
Table 24.3 Drugs classified into eight main groups according to their mode of action
manifest symptoms of florid paranoid psychosis. The International Classification of Diseases entity, the exis
unique feature of methamphetamine psychosis is that it tence of this disorder is accepted by forensic patholo
may reoccur years after drug usage has been discontin gists, forensic physicians, forensic toxicologists and
ued. Its occurrence seems to be related to methamphet- by many authoritative bodies, including the American
amine-induced damage to cortical white matter. These Medical Association and the American Academy of
pathological changes can be visualised with magnetic Emergency Physicians. The syndrome, which is some
resonance imaging (MRI) scanning. This ability is not times lethal, is notable for the acute onset of hyper
shared by cocaine or other stimulants. therm ia and agitated violent behaviour that often
The most feared consequence of any type of stim culminates in a sudden unexplained death. The contri
ulant abuse is the syndrome referred to as 'excited bution of restraint, struggle and the use of conducted
delirium'. Although not recognised as a specific energy devices (CEDs) to the cause of death in these
Commonly misused drugs I 311
%*
if -- , \
t1 *
t i*V*
w
* ^
• V
h '% *
*
It %
% i
*
___
Figure 24.8 Zone of micro-infarction in the Figure 24.10 'Crystal meth'. (Photo by DJ Young, courtesy
heart secondary to stimulant abuse. oftheUSDEA.)
(Courtesy of Steven B Karch.)
The vascular complications of stimulant abuse are
cases is the subject of considerable controversy; there numerous. Mostly, but not entirely, they relate to cate
is good evidence that a central nervous system (CNS) cholamine excess. Excessive amounts of norepinephrine
dysfunction of dopamine signalling underlies the (noradrenaline) damage the walls of blood vessels, and
delirium and produces fatal autonomic dysfunction can cause vascular wall dissection, stroke and coronary
(see also Chapter 16). artery spasm. The presence of excess norepinephrine also
312 I Licit and illicit drugs
Number of
cannabis
“ecstasy"
accelerates the onset of coronary artery disease, induces are contributing to the high number of fatalities. This
cardiac enlargement and produces scarring (referred to builds on the decision by the Commission at its 60th
as interstitial fibrosis of the myocardium). The combi session, in 2017, to place two precursor chemicals used
nation of myocardial fibrosis and cardiac enlargement in the manufacture of fentanyl and an analogue under
is referred to as myocardial remodelling. Remodelling international control. The Report also makes reference
greatly favours the occurrence of sudden cardiac death. to addiction to tramadol, rates of which are soaring in
Both cocaine and methamphetamine interact with the parts of Africa. Non-medical use of this opioid pain
ion pores controlling the normal electrical cycling of killer, which is not under international control, is also
the heart (the action potential) but react with different expanding in Asia. The impact on vulnerable popula
channels. Cocaine blocks the sodium channel (a prop tions is a cause for serious concern, putting pressure on
erty shared by all local anaesthetics) and the hERG potas already strained healthcare systems. At the same time,
sium channel. Methamphetamine does not share either more new psychoactive substances are being synthe
of those properties, but does interact with L-type calcium sised, and more are available than ever, with increasing
channels, which provides another reason for how meth reports of associated harm and fatalities. In the UK, the
amphetamine can cause arrhythmias. Together, these prescribed drugs gabapentin and pregabalin are con
interactions lead to prolonged repolarisation of the heart sidered at substantial risk for misuse.
cells, another abnormality that is arrhythmogenic mech
anism associated with a greatly increased risk of sudden Opiates and opioids
death (Figure 24.11). The term 'opiates' refers to morphine, other contents
The World Drug Report 2018, published by the United of the opium poppy (such as codeine), and compounds
Nations Office of Drug and Crime Control (UNODC), made by modification of the morphine molecule. Box
notes that the range of drugs and drug markets are 24.1 lists commonly abused opioids. Opioids are syn
expanding and diversifying as never before. There is thetic molecules. Opiates and opioids both exert their
a potential supply-driven expansion of drug markets, effects by binding to the \ix opiate receptor located on
with production of opium and manufacture of cocaine neurons throughout the brain. Similar receptors are also
at the highest levels ever recorded. Figure 24.12 shows found in the intestine, explaining why opiate users are
the usage of some groups of drugs worldwide. almost always constipated. Stimulation of the \lyrecep
Markets for cocaine and methamphetamine are tor relieves pain, depresses respiration and reduces gut
extending beyond their usual regions and, while drug motility. The only important difference between heroin,
trafficking online using the 'darknet' (i.e. that part of the morphine and all the other synthetic opioids is their rel
Internet hidden from public view) continues to repre ative affinity for the \lyreceptor. Some opioids conform
sent only a fraction of drug trafficking as a whole, it con to the shape of the |ij receptor better than others and,
tinues to grow rapidly. Non-medical use of prescription accordingly, produce greater or lesser effect, with some
drugs has reached epidemic proportions in parts of the synthetic opioids being more than 1 0 0 0 times as potent
world. The opioid crisis in North America has resulted as morphine itself.
in the Commission on Narcotic Drugs scheduling six Opiate use can be accom panied by numerous
analogues of fentanyl, including carfentanil, which medical complications often related to the process of
Commonly misused drugs I 313
but has a completely different structure. Although the appear to be taking rapid action to address these prob
structure of Spice is very different from THC, it none lems. They are frequently referred to in the media, and
theless avidly binds at the same Cl and C2 receptor, at by users, by the umbrella name 'Spice'.
exactly the same sites where THC is active. The effects Governments and authorities face an uphill struggle
produced are said to be the same as smoking marijuana, as ways to develop substances that avoid legal sanc
but are believed to last much longer. The potential use of tion are used to get around the inevitable clamp down
this compound as a transdermal pain reliever is under as some legal highs become fashionable. In 2016, the
investigation, but if it ever does come to market there Psychoactive Substances Act 2016 was introduced in
will, no doubt, be a thriving black-market trade. the UK with the intent of restricting the production, sale
and supply of a new class of psychoactive substances.
Table 24.4 summarises the main effects and intentions
Solvents of the Act.
Solvents such as toluene volatize at room temperature, Many of these newly abused drugs belong to the
allowing users to inhale the fumes, a practice referred to chemical class known as piperazines, derived from
as 'huffing'. Use of these agents and others such as glue, piperazine and benzyl chloride. Piperazines were origi
or gas fuel for cigarette lighters is much less common nally used as worming agents in humans and in veteri
now than previously. Glue-sniffing was more frequent nary medicine, particularly in the treatment of round
in the 1980s but still occurs. Clinical examination may worms (especially Ascaris); they paralyse the worms
reveal traces of the inhalant, such as glue, around an so they are flushed out by peristalsis. However, the
individual's mouth and face, with the persistent odour medicinal use of piperazines is banned in many coun
of the relevant inhalant. Some individuals may have tries. Ironically, more than half of the cocaine sold in
evidence of singeing of beard or hair, or evidence of old the USA is contaminated with levamisole, a piperazine
burn injury to the face, as many of the agents used for anti-helminthic drug, which was initially withdrawn
such practices are highly flammable and do not asso from the US market because it is known to induce bone
ciate well with lighted cigarettes. Toluene, as opposed marrow suppression. Several piperazines derivatives
to the solvents found in hair spray, dry-cleaning fluid are now in circulation.
and gasoline, is the agent most often responsible for fatal 1-Benzylpiperazine (BZP) is a stimulant. It is sold as
intoxication. The mechanism seems to be the disruption an alternative to amphetamine, methamphetamine and
of normal cardiac electrical activity. Inhalation of any MDMA and, on occasion, is misrepresented as MDMA.
solvent will result in transient euphoria, headache and It interacts with numerous different receptors, but the
ataxia. Members of this group selectively destroy brain net effect produced more or less resembles that of an
white matter, and a distinctive pattern can be identi amphetamine-type drug. Consequently, the adverse
fied in the MRI scans of chronic abusers. Solvents share effects associated with BZP use are likely to include
some properties with other depressants such as barbi confusion, agitation, vomiting, anxiety and palpita
turates, benzodiazepines and even alcohol. However, tions. There is strong evidence that higher plasma levels
the solvents, as a group, interact with so many different of BZP are associated with an increased incidence of
receptor subtypes that their actual mechanism of action seizures. Co-ingestion of ethanol increases the likeli
remains unclear. hood of adverse BZP-induced symptoms, but reduces
the incidence of BZP seizures.
Novel psychoactive substances When taken in small doses the piperazine com
monly abbreviated as TFMPP (trifluoromethyl-
(legal highs) phenylpiperazine) is said to produce effects like those
These drugs first emerged in New Zealand during of MDMA. However, in large doses, or when combined
the early 2 0 0 0 s, but use has quickly spread to involve with BZP, or alcohol or both, it may be toxic. A recent
Europe and the USA. By the end of 2015, more than 560 clinical trial employing a fixed dose of TFMPP and BZP
NPS had been reported to the European Monitoring had to be discontinued early because so many of the par
Centre for Drugs and Drug Addiction. The most popu ticipants experienced agitation, anxiety, hallucinations,
lar compounds are synthetic cannabinoids and psy vomiting, insomnia and migraine. As with BZP, many of
chostimulatory derivatives of cathinone (so-called the effects resemble those produced by amphetamines,
(3-keto-amphetamines). These drugs are commonly (and including increased heart rate and blood pressure and
sometime incorrectly) known as ‘legal highs'. Their legal insomnia.
status is generally an evolving one, and what was legal Meta-chlorophenylpiperazine (MCPP) is also a piper
one day may, by virtue of new legislation, become illegal azine and a non-selective serotonin receptor agonist. It
almost overnight. Governments are concerned by the is sold as legal alternative to illicit stimulants, mostly in
proliferation of such substances, many of which may New Zealand. Like the other piperazines, MCPP is some
be sold in corner shops or over the Internet, and they times sold as faux MDMA. MCPP causes headaches in
318 I Licit and illicit drugs
Table 24.4 Main Effects & Intentions of the Psychoactive Substances Act 2016
• Makes it an offence to produce, supply offer to supply, possess with intent to supply, possess on custodial premises,
import or export psychoactive substances; that is, any substance intended for human consumption that is capable
of producing a psychoactive effect The maximum sentence will be 7 years'imprisonment
• Excludes legitimate substances, such as food, alcohol, tobacco, nicotine, caffeine and medical products from the
scope of the offence, as well as controlled drugs, which continue to be regulated by the Misuse of Drugs Act 1971
• Exempts healthcare activities and approved scientific research from the offences under the act on the basis that
persons engaged in such activities have a legitimate need to use psychoactive substances in their work
• Includes provision for civil sanctions - prohibition notices, premises notices, prohibition orders and premises orders
(breach of the 2 orders will be a criminal offence) - to enable the police and local authorities to adopt a graded
response to the supply of psychoactive substances in appropriate cases
• Provides powers to stop and search persons, vehicles and vessels, enter and search premises in accordance with a
warrant, and to seize and destroy psychoactive substances.
Source: https://www.gov.uk/government/collections/psychoactive-substances-bill-2015.
humans, and has been used as a challenge agent for test poly-drug use complicates the interpretation of the
ing potential anti-migraine medications. Up to 10 per forensic toxicological analysis.
cent of those who take MCPP will develop a migraine NPSs are also associated with injection use and the
headache, and 90 per cent of individuals who commonly accompanying risks (e.g., hepatitis C).
suffer from migraines will have an attack if challenged
with MCPP. This has tended to limit the use of MCPP as a
recreational drug, and may explain why no deaths have Drug facilitated sexual assault
been reported after its use. There are also reports that Drug facilitated sexual assault (DFSA) is a matter of
MCPP has been used as a cocaine adulterant. substantial public concern. All published data indicates
Harm reduction measures on the club and rave scene that alcohol intoxication combined with voluntary drug
have included on-the-spot analysis of drugs to ensure consumption presents the greatest risk factor for DFSA,
that what has been bought (even though illegal) is what despite populist perceptions that covert drink-spiking
it is purported to be rather than something more dan is a common occurrence. There is a need to develop
gerous. policies that encourage early responders to suspected
As these drugs are relatively new, with little expo DFSA (e.g., law enforcement agencies, medical staff,
sure experienced by humans, there are many concerns support agencies), to collect detailed information about
for possible ill-health effects that remain unknown. It the individual's licit and illicit drug consumption his
should be noted that some amphetamine analogues tory, in order to assist in providing appropriate and more
containing paramethoxy group are known to cause thorough contextual information.
severe hyperthermia and even death owing to concur Certain drugs have been identified as having par
rent monoamine oxidase inhibitor (MAOI) and mono ticular potential for use in DFSA and these include,
amine releasing action. The deaths of two young men ethanol, chloral hydrate, BZs, non-BZ sedative-hyp-
in Sweden in 2009 were attributed to methadrone over notics, GHB, ketamine, opioids, dextromethorphan,
dose. barbiturates, anticholinergics and antihistamines.
As time progresses, and the usage of specific NPS Clinical examination, and early collection of blood,
increases, neuropharmacological and clinical knowl urine and hair samples as soon as possible after an
edge has progressed for a number of these substances alleged incident may assist in determining the possi
such as mitragynine ('Kratom'), synthetic cannabinoids ble drug group involved (if any), and the time at which
(e.g., 'Spice'), dimethyltryptamine and novel serotoner it was administered. Such information may assist the
gic hallucinogens, the cathinones mephedrone and toxicology laboratory in directing appropriate investi
methylone, ketamine and novel dissociative drugs, gation techniques. Possibly the most important future
^-hydroxybutyrate, ^-butyrolactone, and 1,4-butane- need is for education to ensure that children and young
diol. Mephedrone, for example, had blood concen people understand the implications of drug-induced
trations in cases of fatal intoxications higher than in risky decisions, reduced inhibitions and reduced abil
non-fatal cases. However, in both circumstances there ity to resist.
is great variability in mephedrone concentration mea GHB is produced as a post mortem artefact, both in
sured, potentially attributable to interindividual differ the urine and the blood, and post mortem GHB blood
ences in pharmacokinetics-pharmacodynamics and measurements are particularly difficult to interpret.
Bibliography and information sources I 319
Different laboratories have different 'cutoffs' for reporting Ferreira B, Dias da Silva D, Carvalho F, et al. The novel psycho
GHB results, and these values may vary from country to active substance 3-methylmethcathinone (3-MMC or
country and from laboratory to laboratory. GHB is widely metaphedrone): a review. Forensic Sci Int 2019;295:54-63.
used in club scenes as a 'party drug' and consumed with Finn SP, Leen E, English L, O'Briain DS. Autopsy findings in an
alcohol, benzodiazepines, opiates, stimulants and ket- outbreak of severe systemic illness in heroin users following
injection site inflammation: an effect of Clostridium novyi exo
amine. There is an unpredictable risk of fatality which is
toxin? Arch Pathol Lab Med 2003;127:1465-1470.
increased in the presence of other substances. Fiorentin TR, Logan BK. Toxicological findings in 1000 cases of
suspected drug facilitated sexual assault in the United States.
Bibliography and information J Forensic Leg Med 2019;61:56-64.
Fox J, Smith A, Yale A, et al. Drugs of abuse and novel psychoac
sources tive substances at outdoor music festivals in Colorado. Subst
Abbara A, Brooks T, Taylor GP, et al. Lessons for control of heroin- Use Misuse 2018;53(7):1203-1211.
associated anthrax in Europe from 2009-2010 outbreak case Goldberger BA, Cone EJ, Grant TM, et al. Disposition of heroin
studies, London, UK. Emerg Infect Dis 2014;20(7):1115-1122. and its metabolites in heroin-related deaths. J Anal Toxicol
Advisory Council on the Misuse of Drugs. Consideration of 1994;18:22-28.
the Cathinones. https://assets.publishing.service.gov.uk/ Graddy R, Buresh ME, Rastegar DA. New and emerging illicit psy
government/uploads/system/uploads/attachment_data/ choactive substances. Med Clin North Am 2018;102(4):697-714.
file/119173/acmd-cathinodes-report-2010.pdf (Accessed 21 Hall J, Goodall EA, MooreT. Alleged drug facilitated sexual assault
May 2019). (DFSA) in Northern Ireland from 1999 to 2005: a study of
Advisory Council on the Misuse of Drugs. Consideration of the blood alcohol levels J Leg Med 2008;15:497-504.
Naphthylpyrovalerone Analogues and related compounds. Harm Reduction International. Global State of Harm
https://assets.publishing.service.gov.uk/government/ Reduction, 6th ed. 2018. https://www.hri.global/global-
uploads/system/uploads/attachment_data/file/1 19085/ state-harm-reduction-2018 (Accessed 21 May 2019).
naphyrone-report.pdf (Accessed 21 May 2019). Hassan Z, Bosch OG, Singh D, et al. Novel psychoactive sub-
Advisory Council on the Misuse of Drugs. Consideration of stances-recent progress on neuropharmacological mecha
the Novel Psychoactive Substances ('Legal Highs') 2011. nisms of action for selected drugs. Front Psychiatry 2017;8:152.
https://assets.publishing.service.gov.uk/government/ Huestis MA, Elsohly M, Nebro W, et al. Estimating time of last
uploads/system/uploads/attachment_data/file/119139/ oral ingestion of cannabis from plasma THC and THCCOOH
acmdnps2011.pdf (Accessed 21 May 2019). concentrations. TherDrug Monit 2006;28:540-544.
Akbulut D, Grant KA, McLauchlin J. Improvement in laboratory Karch S. A Brief Flistory of Cocaine, 2nd ed. Boca Raton: CRC Press;
diagnosis of wound botulism and tetanus among injecting 2005.
illicit-drug users by use of real-time PCR assays for neurotoxin Karch SB, Billingham ME. The pathology and etiology of cocaine-
gene fragments. J Clin Microbiol 2005;43(9):4342-4348. induced heart disease. Arch Pathol Lab Med 1988;112:225-230.
Ambre JJ, Connelly TJ, Ruo Tl. A kinetic model of benzoylecgo- Karch SB, Drummer O. Karch's Pathology of Drug Abuse, 5th ed.
nine disposition after cocaine administration in humans. J Boca Raton: CRC Press; 2015.
Anal Toxicol 1991;15:17-20. Karch SB, Stephens B, Ho CH. Relating cocaine blood concentra
Anderson LJ, Flynn A, Pilgrim JL. A global epidemiological per tions to toxicity: an autopsy study of 99 cases. J Forensic Sci
spective on the toxicology of drug-facilitated sexual assault: 1998;43:41-45.
a systematic review. J Forensic Leg Med 2017;47:46-54. King A, Foley D, Arfken C, et al. Carfentanil-associated mortal
Bae SC, Lyoo IK, Sung YH, et al. Increased white matter hyper ity in Wayne County, Michigan, 2015-2017. Am J Public Health
intensities in male methamphetamine abusers. Drug Alcohol 2019;109(2):300-302.
Depend 2006;81:83-88. Kugelberg FC, Holmgren A, Eklund A, Jones AW. Forensic toxicol
Bertol E, Di Milia MG, Fioravanti A, et al. Proactive drugs in DFSA ogy findings in deaths involving gamma-hydroxybutyrate. Int
cases: toxicological findings in an eight-years study. Forensic J Leg Med 2010;124:1-6.
Sci Int 2018;291:207-215. Lalovic B, Kharasch E, Hoffer C, et al. Pharmacokinetics and phar
Concheiro M, Chesser R, Pardi J, Cooper G. Postmortem toxicol macodynamics of oral oxycodone in healthy human sub
ogy of new synthetic opioids. Front Pharmacol 2018;9:1210. jects: role of circulating active metabolites. Clin Pharmacol
Corkery JM, Loi B, Claridge H, et al. Gamma hydroxybutyrate Ther 2006;79:461-479.
(GHB), gamma butyrolactone (GBL) and 1,4-butanediol (1,4- Langford AM, Bolton JR. Synthetic cannabinoids: variety is defi
BD; BDO): a literature review with a focus on UK fatalities nitely not the spice of life. J Forensic Leg Med 2018;59:36-38.
related to non-medical use. Neurosci Biobehav Rev 2015;53: Larney S, Peacock A, Mathers BM, et al. A systematic review of
52-78. injecting-related injury and disease among people who
Dai Z, Abate MA, Smith GS, et al. Fentanyl and fentanyl-analog inject drugs. Drug Alcohol Depend 2017;171:39-49.
involvement in drug-related deaths. Drug Alcohol Depend LeBeau MA, Montgomery MA, Morris-Kukoski C, et al. A compre
2019;196:1-8. hensive study on the variations in urinary concentrations of
Dinis-Oliveira R. Metabolomics of cocaine: implications in toxic endogenous gamma-hydroxybutyrate (GHB). J Anal Toxicol
ity. Toxicol Mech Methods 2015;25(6):494-500. 2006;30:98-105.
Du Mont J, Macdonald S, Rotbard N, et al. Drug-facilitated sexual Leen JLS, Juurlink DN. Carfentanil: a narrative review of its
assault in Ontario, Canada: toxicological and DNA findings. J pharmacology and public health concerns. Can J Anaesth
Forensic Leg Med 2010;17:333-338. 2019;66(4):414-421.
320 I Licit and illicit drugs
Lucas CJ, Galettis P, Schneider J. The pharmacokinetics and the Schifano F, Papanti GD, Orsolini L, Corkery JM. Novel psychoac
pharmacodynamics of cannabinoids. Br J Clin Pharmacol tive substances: the pharmacology of stimulants and halluci
2018;84(11):2477—2482. nogens. Expert Rev Clin Pharmacol 2016;9(7):943-954.
McAuley A, Yeung A, Taylor A, et al. Emergence of Novel Stark MM, Payne-James JJ, Scott-Ham M. Symptoms and Signs of
Psychoactive Substance injecting associated with rapid rise Substance Misuse, 3rd ed. Boca Raton: CRC Press; 2016.
in the population prevalence of hepatitis C virus. Int J Drug Toennes SW, Harder S, Schramm M, et al. Pharmacokinetics of
Policy 2019;66:30-37. cathinone, cathine and norephedrine after the chewing of
Misuse of Drugs Act 1971. http://www.statutelaw.gov.uk/content. khat leaves. BrJClin Pharmacol 2003;56:125-130.
aspx?activeTextDocld=1367412 (Accessed 21 May 2019). United Nations Office on Drugs and Crime. Global Overview of
Noguchi TT, DiMona J. Coroner. New York: Simon & Schuster; Drug Demand and Supply. Latest trends, cross-cutting issues.
1983. https://reliefweb.int/sites/reliefweb.int/files/resources/
Papaseit E, Olesti E, de la Torre R, et al. Mephedrone concen WDR18_Booklet_2_GLOBAL.pdf (Accessed 21 May 2019).
trations in cases of clinical intoxication. Curr Pharm Des Vardakou I, Pistos C, Spiliopoulou C. Spice drugs as a new trend:
2017;23(36):5511-5522. mode of action, identification and legislation. Toxicol Lett
Poon WT, Lai CF, Lui MC, et al. Piperazines: a new class of drug 2010;197:157-162.
of abuse has landed in Hong Kong. Hong Kong Med J 20'\0-,‘\6: WHO International Statistical Classification of Diseases and
76-77. Related Health Problems, 10th Revision, http://apps.who.int/
Pope JD, Drummer OH, Schneider HG. The cocaine cutting agent classifications/apps/icd/icd10online/(Accessed 21 May 2019).
levamisole is frequently detected in cocaine users. Pathology Wood DM, Davies S, Puchnarewicz M, et al. Recreational use of
2018;50(5):536-539. mephedrone (4-methylmethcathinone, 4-MMC) with associ
Ramsay CN, Stirling A, Smith J, et al. An outbreak of infection ated sympathomimetic toxldty.J Med Toxicol 2010;6:327-330.
with Bacillus anthracis in injecting drug users in Scotland. Wood DM, Greene SL, Dargan PI. Clinical pattern of toxicity asso
EuroSurveill 20]0',]5{2). pii: 19465. ciated with the synthetic cathinone mephedrone. Emerg Med
Rivera JV, Vance EG, Rushton WF, Arnold JK. Novel psycho J 2011 ;28(4):280— 281.
active substances and trends of abuse. Crit Care Nurs Q Wright NM, Allgar V, Tompkins CN. Associations between
2017;40(4):374-382. injecting illicit drugs into the femoral vein and deep
Rook EJ, Huitema AD, van den Brink W, et al. Pharmacokinetics vein thrombosis: a case control study. Drug Alcohol Rev
and pharmacokinetic variability of heroin and its metabo 2016;35(5):605-610.
lites: review of the literature. Curr Clin Pharmacol 2006;1(1): Zawilska JB. An expanding world of novel psychoactive sub
109-118. stances: opioids. Front Psychiatry 2017;8:110.
Rosenberg NL, Grigsby J, Dreisbach J, et al. Neuropsychologic Zvosec DL, Smith SW, Porrata T, et al. Case series of 226
impairment and MRI abnormalities associated with chronic ^-hydroxybutyrate-associated deaths: lethal toxicity and
solvent abuse. J Toxicol Clin Toxicol 2002;40:21 -34. trauma. Am J Emerg Med 2011;29(3):319-332.
25 Medicinal poisons
status changes; agitation; hyperreflexia; myoclonus; interval to lengthen, become pathologically long and
diaphoresis; shivering; tremor; diarrhoea; incoordina produce an arrhythmia. The diagnosis is made by DNA
tion; fever. Generally, the Hunter Criteria are considered resequencing.
more specific and more sensitive than the Sternbach An acquired form of this disorder also exists and is,
Criteria. A list of drugs known to cause SS is given in in fact, much more common than the heritable form
Box 25.1. of the syndrome. Acquired LQTS is the result of a drug
interaction between a drug and one of the channels
QT interval prolongation (long QT which controls the orderly sequence of depolarisa
tion within the heart's individual cardiomyocytes. The
syndrome) structure in question is called the 'rapid delayed repo-
Since the 1990s, the concept of primary 'inherited' larising channel', abbreviated as hERG. The molecular
arrhythmia syndromes, or ion channelopathies, structure of the hERG channel is shown in Figure 25.2.
has developed from advances in molecular genet Some individuals carry mutations that make them
ics. Alterations in genes coding for membrane pro more subject to hERG interactions. The end result
teins, such as ion channels or their associated proteins is the same as with any hereditary cause of the dis
responsible for the generation of cardiac action poten ease: QT prolongation, arrhythmia and sudden death.
tials (AP), cause specific malfunctions which eventu Methadone is perhaps the most notorious of the drugs
ally lead to cardiac arrhythmias. These arrhythmic that produces this syndrome but, as indicated in Box
disorders include a wide variety of conditions. Among 25.2, the list of drugs is a long one and is growing con
these, long QT, and Brugada, syndromes are the most tinuously. Routine toxicology screening will not reveal
extensively studied, and drugs cause a phenocopy of whether this interaction has occurred, and there will be
these two diseases. More than 10 different genes have no detectable changes at autopsy, making a thorough
been reported to be responsible for each syndrome. review of the medical history mandatory; even then the
Individuals with long QT syndrome (LQTS) experience diagnosis may be impossible to make at autopsy.
abnormal prolongation of the QT interval - the portion
of the electrocardiogram (ECG) that represents repolari
sation of cardiomyocytes (Figure 25.1). The QT interval Drugs with unique modes of action
extends from the onset of the Q wave to the end of the Some drugs have unique modes of action. Examples
T wave. The normal rate-adjusted length for the QT include lithium, which though itself is devoid of any
interval is less than 440 milliseconds. A prolonged QT psychoactive effects except as a mood stabiliser, has a
interval favours the occurrence of a lethal form of ven very complex mode of action. In fact, its mode of action
tricular tachycardia known as torsades des pointes. The is not known with certainty. There is some evidence that
QT prolongation may be caused by genetic aberration an excitatory neurotransmitter could be involved. It has
or it may be acquired. Even those with the genetic form also been proposed that lithium alters gene expression.
of the disease may have a perfectly normal-appearing Chronic lithium poisoning is characteristically asso
electrocardiogram until some event causes the QT ciated with greater toxicity than acute ingestion, and
Drugs with unique modes of action I 323
Narcotic analgesics
Buprenorphine
Fentanyl
Hydrocodone
Merperidine
Oxycodone
Pentazocine
Figure 25.1 Electrocardiogram (ECG) showing QT interval
Tramadol which can be prolonged in the repolarisation of cardio-
Stimulant drugs myocytes. (Courtesy of Steven B Karch.)
Cocaine
All amphetamines No discussion of forensic toxicology would be com
plete without some mention of insulin poisoning via the
Methylphenidate
exogenous administration of insulin. Insulin poisoning
Migraine treatments was once a popular means of homicide; now it is rare.
Insulin overdose can cause fatal brain damage, but if
All triptans (agents that bind type 1 serotonin
overdose is suspected it can be confirmed by several dif
receptors
ferent methods. Analysis of homicidal insulin overdose
Psychedelics
LSD (lysergic acid diethylamide)
MDMA (3,4-methylenedioxymethamphetamine,
commonly known as ecstasy)
MDA (3,4-methylenedioxyamphetamine)
■ Arsenic ■ Lead
■ Carbon monoxide ■ Methanol
■ Cyanide ■ Bibliography and information sources
CAsIDS is the use of bone arsenic load as an essential and include: relative concentrations of CO and oxygen,
criterion for the individual risk assessment of chronic alveolar ventilation, duration and intensity of exposure.
arsenic intoxication, combined with a systemic clini However, chronic exposure to high levels of CO leads
cal assessment. Such cases (fatal and non-fatal) provide to CO binding to proteins with less affinity than hae
complex clinical conundra. moglobin, such as myoglobin and cytochromes of the
P450 system, particularly a3. Differential affinity may
Carbon monoxide also account for some of the variations in response to
exposure. Hypoxic stress caused by CO exposure alone
Intoxication from carbon monoxide (CO) is a phenom
would not seem to account for some of the longer-term
enon that occurs in a wide variety of settings worldwide.
effects and it is believed that CO also initiates a cascade
CO is a major environmental toxin whose effects were
of events culminating in oxidative stress.
described over a century ago by Haldane. It is consid
The World Health Organisation has issued guide
ered a public health issue in many countries. It is a
lines for the level of CO in the air that will prevent blood
colourless, odourless and non-irritant gas produced by
the incomplete combustion of hydrocarbons and found COHb levels from rising above 2.5 per cent. Exposure to
CO may be difficult to detect. Work, domestic and lei
whenever organic matter is burned in the presence of
sure settings may all account for exposure. If exposure
insufficient oxygen. The highest concentrations to be
found in the modern urban environment are generated is suspected, it is appropriate to use a system such as
by motor vehicles, petrol-powered tools, heaters and the CH2OPD2 mnemonic to try to explore the source of
barbecues. Ambient air concentrations of more than environmental exposure (enquiring about Community,
10 0 ppm are considered dangerous to human health.
Home, Hobbies, Occupation, Personal, Diet and Drug
The effects observed include a variety of physical and issues). Systematic enquiry is the most efficient way of
neurological signs and symptoms ranging from none establishing a cause and a source.
to death. Exposure occurs in two main ways: (1) acute Poisoning by CO is described as a 'disease with a
exposure for varying lengths of time where the effects thousand faces' because of its many different clinical
are generally immediately obvious, and (2 ) delayed or presentations. Classic acute CO intoxication is said to
chronic exposure where the effects may be unrecog cause the triad of cherry-red lips, cyanosis and reti
nised for days, months or years. The diagnosis of CO nal haemorrhages, but this type is rare. In many cases
exposure may be one of exclusion. Figure 26.1 shows a more insidious presentation develops and the only
Public Health England's guidelines for diagnosing CO indicator may be a general m alaise or suspicion of a
poisoning. viral-type illness. Specific symptoms include headache,
The problems of recognising low-grade exposure to dizziness, nausea, shortness of breath, altered vision,
CO may result in a considerable underestimation of the altered hearing, chest pain, palpitations, poor concen
problem. Between 1995 and 2018, a total of 697 deaths tration, muscle aches and cramps and abdominal pain.
from unintentional CO poisoning occurred in the UK, Sometimes these may occur in clusters and sometimes
with a male to female ratio of 2:1. The number of deaths in isolation. More serious effects include loss of con
each year has reduced dramatically from 65 deaths in sciousness, myocardial ischaemia, hypotension, con
1995/96 to 3 deaths in 2017/18. gestive cardiac failure, arrhythmias, mental confusion
CO dissolves in plasma and binds to oxygen-trans and mood variation. These symptoms and signs may be
porting proteins haemoglobin (in plasma) and myoglo present during acute exposure at higher level in non
bin, and the cytochrome system in tissues. The most fatal cases, but also in the more chronic or prolonged
significant affinity is for haemoglobin. CO is absorbed exposures.
through the lungs and binds to haemoglobin (Hb) form In addition to the symptoms and signs discussed
ing carboxyhaemoglobin (COHb). This a reversible reac there are a variety of neurological, psychiatric and psy
tion that can be described as follows: chological sequelae that may develop days, months and
years after initial exposure.
H b0 2 + CO —>COHb + 0 2 Diagnosis is made by measurement of venous COHb
levels; however, there is no absolute level that can confirm
The affinity of Hb for CO is up to 250 times greater the presence or absence of poisoning. A level above 10 per
than that for oxygen and the presence of CO results in cent is considered to confirm the diagnosis, unless the
a shift of the oxygen-haemoglobin dissociation curve individual is a heavy smoker (Box 26.1). Concentrations
to the left, causing decreased oxygen-carrying capacity of COHb in arterial blood are not significantly different
and impaired delivery of oxygen to the tissues. Cellular from venous concentrations and so an arterial sample
hypoxia results and cardiac function is diminished is not required for diagnosis. Arterial blood gas mea
because of hypoxia. The link between levels of CO and surements can show a mixed picture of normal partial
effects is not direct. The amount of uptake is governed pressure of oxygen, variable partial pressure of carbon
by a number of variables, all of which are interrelated dioxide, and decreased oxygen saturation, all in the
Carbon monoxide I 327
CouldthisbeacaseofC O poisoning?
Patien t p resen tin g w ith :
Headache, nausea/vomiting, drowsiness, dizziness, dyspnoea, chest pain
_ri
c Im
ssan yopn eveelswehiennthou etporofptheretbyuailfdein
cgte?d(‘(bientcleurdoin gtdpoeotsrs)?’)
D oyou rA sreyym p to im ro u
A sk the patient: YES/NO
ourfuel-burningappD lioan
yocueshaanvdevaen catsrbpornopm eroln
yom xiadin
etaalianremd??
C Cohabitees/companions Y/N
O Outdoors Y/N
M Maintenance Y/N
A Alarm
D o s e g o p elfitaisngfodrocuoobkleinggla?zing)?
If you a re s u s p ic io u s th e n a sk:
H
H a s th e r
e
aoveesyyoou b
nw e n a n y
otoirckedinavn c h a n g e in v en tila tio n in yo u
ylvseopootsyssibtaleinesxaproosuunrdeatoppslm r h om e
iaonkcee,sfu r
orme c e n tly
aensionrcm (e g
reoatsoerin choin deeenxshaatiu
osnt??
D
Isyourhom ur edetached,sem o i-detached,teraced,flat,bedsit,hostelorm v e cl
obilehom e?
_______g
ED :
GP; breath test for exhaled CO if device is available. (Note that this only indicates recent
exposure; interpretation is difficult in smokers. For interpretation of results see TOXBASE®.)
heparinised venous blood sample for COHb estimation. For interpretation of results
see TOXBASE and contact the National Poisons Information Service (NPIS).
ED :
2 M a n a g e m e n t - c o m m e n c e o x y g e n th era py
GP; follow advice on TOXBASE; refer to ED if required.
follow advice on TOXBASE. Contact the NPIS for severe poisoning. See CMO/CNO
letter (11/2013): www.gov.uk/government/publications/carbon-monoxide-poisoning.
3 P ro te c t yo u r p a tie n t a n d o th e rs - contact your local PHE centre, which will coordinate
services for your patient and provide further guidance on CO.
NO T
Provide your patient with the phone number for gas, oil or solid fuel helplines (see the notes).
4 DO
appliances.
allow your patient to go home without a warning to use the suspect N O T
ED :
5 F o llo w -u p
GP; note that symptoms may persist or develop later.
advise the patient to see their GP for follow-up. Note this advice in discharge letter.
□ If th e p a tien t d o e s n o t im p ro v e :
• contact the NPIS for advice
• contact your local PHE centre for advice
• reconsider diagnosis
.... B
See overfornotesonboxes1-4
Figure 26.1 Diagnosing CO poisoning. (From Public Health England, 2015.) (Continued)
presence of a metabolic acidosis. Problems arise, par Table 26.1 shows the symptoms produced by increas
ticularly in chronic, lower-dose exposures, because the ing concentrations of CO within the body.
COHb concentration will revert to 'normal' values once CO was once a frequent means of suicide, but changes
the source of exposure has been removed; however, the in technology have led to a marked decrease in the num
removal process is dependent on the half-life of COHb in ber of deaths. In the 1950s, inhaling coal gas accounted
the particular setting. Normal COHb levels do not neces for nearly half of all suicides in the UK, but the rate
sarily rule out CO poisoning. markedly declined after natural gas replaced coal gas
328 I Miscellaneous poisons
Box 1 C a rb on m o n o x id e is a m im ic
CO poisoning is notorious for simulating other more common conditions, including flu-like illnesses,
thinkC
migraine, food-poisoning, tension headaches and depression.
Headache is the most common symptom - O
!
Box 2 S o u rc e s o f c a r b o n m o n o x id e
The source of CO may be in the home, in the car due to a leaking exhaust system, in the workplace
or in tents or caravans.
Malfunctioning gas, oil, coal, and coke and wood fuel heating and cooking appliances are the most
common sources in the home. There may be more than one source of CO. BBQs must never be
taken indoors or into tents or caravans, even when extinguished and cold to the touch.
CO poisoning can occur in all income groups and types of housing.
CO can leak into a semi-detached or terraced house/flat from neighbouring premises.
erbreakorduringH
aan
veuynoeuxpreeccetn
edtlycosltdarstpedelt?ore-useheatingappliances/boilersafterthe
It is worth asking about the sort of heating devices in use.
sum
m
It is also worth asking:
I Royal College of
I General Practitioners
S
u
eppaprotrm
D teedntbyoftH
heealth
) Crown copyrigh t 2015 (first published 2009) PH E publications ga tew a y num ber: 2013323
Figure 26.1 (Continued) Diagnosing CO poisoning. (From Public Health England, 2015.)
in the 1960s. The introduction of catalytic converters for amounts of CO may be generated if a car is left with
automobiles has reduced, but not quite eliminated, sui its engine running in a closed garage. The majority of
cides committed by inhaling the exhaust fumes from a accidental poisonings and suicides by CO occur as a
car engine operating in an enclosed space. The catalytic result of burning charcoal in a confined space. In the
converters found in cars today eliminate over 99 per most frequent scenario, a charcoal barbecue is lit in a
cent of the CO produced but, even then, very substantial closed room. If death was solitary and intended, then
Methanol I 329
the windows and doors are likely to have been sealed off.
If not, it may be difficult to determine whether or not the
Lead
cause of death was accident or suicide. Routes of lead exposure include contaminated air,
water, soil, food and certain lead-containing consumer
products, particularly those made in China. It has been
Cyanide associated with the use of Ayurvedic medicines and
Cyanide ions prevent cells from utilising oxygen; they food contamination. In adults, the most common cause
inhibit the enzyme cytochrome c oxidase. High concen of lead poisoning is occupational exposure, whereas in
trations of cyanide lead to cardiac arrest within minutes children it is the lead paint that exists in older homes.
of exposure. Exposure to lower levels of cyanide over a Aged lead paint is likely to peel off walls and may look
long period (e.g., after use of cassava roots as a primary like an attractive item of food to children. Lead is toxic
food source, which is a relatively common occurrence in because it can substitute for calcium in many funda
tropical Africa) results in increased blood cyanide lev mental cellular processes, although how it does so is
els, which can cause weakness and a variety of symp not entirely clear: neither the electronic structures nor
toms including permanent paralysis. Cigarette smoking the ionic radii of the two elements bear any particular
also increases blood cyanide concentrations, although resemblance. Nonetheless, lead can cross red blood cell
membranes as well as the blood-brain barrier and enter
the neuroglia cells which support brain function. This
Table 26.1 Symptoms produced by carbon monoxide explains why exposed children may develop permanent
learning and behavioural disorders.
Concentration
Symptoms of lead poisoning include abdominal pain,
(ppm) Symptom
headache, anaemia, irritability and, in severe cases, sei
35 Headache, dizziness zures, coma and death. X-rays will expose dense lines
100 Headache, dizziness in the long bones of children, and red cells undergo a
change known as basophilic stippling, where blue-stain
200 Headache, loss of judgement ing remnants of destroyed DNA are seen lining the mar
400 Frontal headache gins of the red cells. This change is diagnostic for lead
800 Dizziness, nausea, convulsions poisoning. The main tool for diagnosis is measurement
of the blood lead level. Treatment depends on the blood
1600 Tachycardia, nausea, death in less level and is designed to remove the lead from the body
than 1 hour (chelation therapy).
3200 Tachycardia, nausea, death in less
than 20 minutes
Methanol
6400 Convulsions, respiratory arrest,
death in 1-2 minutes Like ethanol, methanol can cause fatal central nervous
system (CNS) depression. Methanol intoxication is an
12,800 Unconsciousness after two breaths, uncommon but serious poisoning. Its adverse effects are
death in 3 minutes due primarily to the impact of its major metabolite formic
330 I Miscellaneous poisons
acid and lactic acid resulting from cellular hypoxia. All of CO-Gas Safety. The Carbon Monoxide and Gas Safety Society.
these processes occur in the liver. Formic acid (formate) Analysis of deaths and injuries. http://www.co-gassafety.
is toxic because it inhibits mitochondrial cytochrome c co.uk/information/co-gas-safetys-statistics-of-deaths-and-
oxidase, causing hypoxia at the cellular level. Symptoms injuries/ (Accessed 10 June 2019).
Croxford B, Leonardi GS, Kreis I. Self-reported neurological symp
including abdominal pain and loss of vision can appear
toms in relation to CO emissions due to problem gas appli
a few hours to a few days after exposure, reflecting the
ance installations in London: a cross-sectional survey. Environ
time necessary for accumulation of the toxic byprod Health 2008;7:34.
uct. Methanol also causes metabolic acidosis. Methanol Dani SU, Walter GF. Chronic arsenic intoxication diagnostic score
poisoning most often occurs after drinking windscreen- (CAslDS). J Appl Toxicol 2018;38(1):122-144.
washer fluid, but methanol is also used in copy machines Downs JCU. Carbon monoxide exposure: autopsy findings. In:
and can be found in many other products, even embalm Payne-James JJ, Byard RW (eds). Encylopedia of Forensic and
ing fluid. Methanol poisoning still remains a well-known Legal Medicine. Volume 1, 2nd ed. Oxford: Elsevier; 2016,
consequence of 'moonshine' liquor ingestion, although 444-460.
this practice is increasingly uncommon. When paedi Fortin JL, Desmettre T, Manzon C, et al. Cyanide poisoning and
cardiac disorders: 161 cases. J Emerg Med 2010;38:467-476.
atric poisoning occurs, it is usually the result of having
Gensheimer KF, Rea V, Mills DA, et al. Arsenic poisoning caused
ingested methanol-containing household products.
by intentional contamination of coffee at a church gather
Ingestion of even small amounts of methanol, in addi ing: an epidemiological approach to a forensic investigation.
tion to causing profound metabolic acidosis, may lead to J Forensic Sci 2010;55:1116-1119.
blindness or even multiorgan failure and death. Goyal T, Zawar V, Varshney A. Chronic arsenic poisoning: a spec
The initial symptoms of methanol intoxication trum of clinical manifestations in a single patient, a diagnostic
include CNS depression, with headache, dizziness, challenge. Q Ital Dermatol Venereol 2016;151(4):457—459.
nausea, lack of coordination and confusion. Large doses Glaister J. A Text-Book of Medical Jurisprudence, Toxicology and
quickly lead to unconsciousness and death. Once the Public Health. Edinburgh: Livingstone; 1902.
initial symptoms have passed, a second set of symptoms Iqbal S, Clower JH, BoehmerTK, et al. Carbon monoxide-related
hospitalizations in the U.S.: evaluation of a web-based query
can be observed 10-30 hours after the ingestion. These
system for public health surveillance. Public Health Rep
include blindness and worsening acidosis. These sec
2010;125:423-432.
ondary symptoms are caused by accumulating levels of llano AL, Raffin TA. Management of carbon monoxide poisoning.
formate in the bloodstream. The process may progress Chest 1990;97:165-169.
to death by respiratory failure. Karayel F, Turan AA, Sav A, et al. Methanol intoxication: pathologi
Methanol poisoning treatment can include admin cal changes of central nervous system (17 cases). AmJ Forensic
istration of ethanol or fomepizole, both inhibitors of the Med Pathol 2010;31:34-36.
enzyme alcohol dehydrogenase to prevent formation Karch S, Drummer O. Karch's Pathology of Drug Abuse, 5th ed. Boca
of its metabolites, and hemodialysis to remove metha Raton: CRC Press; 2015.
nol and formate. Supplemental treatment with sodium Kraut JA. Approach to the treatment of methanol intoxication.
Am J Kidney Dis 2016;68(1):161-167.
bicarbonate for metabolic acidosis and haemodialysis
Lundquist P, Rosling H, Sorbo B, Tibbling L. Cyanide con
or even haemodiafiltration can be used to remove meth
centrations in blood after cigarette smoking, as determined
anol and formate from the blood. by a sensitive fluorimetric method. Clin Chem 1987;33:
Because of its toxic properties, methanol is frequently 1228-1230.
used as a denaturant additive for ethanol manufactured Mehta V, Midha V, Mahajan R, et al. Lead intoxication due to
for industrial uses as this addition of methanol exempts ayurvedic medications as a cause of abdominal pain in
industrial ethanol from liquor excise taxation. Methanol adults. Clin Toxicol(Phila) 2017;55(2):97-101.
is often referred to as 'wood alcohol' because it was once Nouioui MA, Araoud M, Milliand ML, et al. Biomonitoring chronic
produced chiefly as a by-product of the destructive dis lead exposure among battery manufacturing workers in
tillation of wood. Tunisia. Environ SciPollutRes Int 2019;26(8):7980-7993.
Paasma R, Hovda KE, Jacobsen D. Methanol poisoning and long
term sequelae: a six years follow-up after a large methanol
Bibliography and information outbreak. BMC Clin Pharmacol 2009;9:5.
Payne-James JJ. Carbon monoxide poisoning: clinical findings:
sources sequelae in survivors. In: Payne-James JJ, Byard RW (eds).
Andresen H, Schmoldt Hf Matschke J, et al. Fatal methanol intoxi Encylopedia of Forensic and Legal Medicine. Volume 1, 2nd ed.
cation with different survival times: morphological findings Oxford: Elsevier; 2016,461-466.
and postmortem methanol distribution. Forensic Sci Int Piantadosi CA. Diagnosis and treatment of carbon monoxide
2008;179:206-210. poisoning. Respir Care Clin NAm 1999;5:183-202.
Balakumar P, Kaur J. Arsenic exposure and cardiovascular disor Public Health England. Diagnosing poisoning: carbon monox
ders: an overview. Cardiovasc Toxicol 2009;9:169-176. ide. https://assets.publishing.service.gov.uk/government/
Coentrao L, Moura D. Acute cyanide poisoning among jewelry uploads/system/uploads/attachment_data/file/485581/
and textile industry workers. AmJ Emerg Med 2011;29:78-81. C0_diagnosis_algorithm_2015.pdf (Accessed 21 May 2019).
Bibliography and information sources I 331
Rose JJ, Wang L, Xu Q, et al. Carbon monoxide poisoning: patho Sy SMT, Salud-Gnilo CM, Yap-Silva C, Tababa EJL. A retrospective
genesis, management, and future directions of therapy. AmJ review of the dermatologic manifestations of chronic arsenic
Respir Crit Care Med 2017;195(5):596-606. poisoning in the Philippines. IntJ Dermatol 2017;56(7):721 -725.
Roychowdhury T. Groundwater arsenic contamination in one of Tirima S, Bartrem C, von Lindern I, et al. Food contamination as a
the 107 arsenic-affected blocks in West Bengal, India: status, pathway for lead exposure in children during the 2010-2013
distribution, health effects and factors responsible for arsenic lead poisoning epidemic in Zamfara, Nigeria. J Environ Sci
poisoning. IntJHyg Environ Health 2010;213:414-427. (China) 2018;67:260-272.
Saukko P, Knight B. Carbon monoxide poisoning. In: Saukko P, Tournel G, Houssaye C, Humbert L, et al. Acute arsenic poisoning:
Knight B (eds). Knight's Forensic Pathology, 4th ed. Boca Raton: clinical, toxicological, histopathological, and forensic features.
CRC Press; 2016, 589-594. J Forensic Sci 2011;56(suppl 1):S275-S279.
Sheikhazadi A, Saberi Anary SH, Ghadyani MH. Nonfire carbon Wolf SJ, Maloney GE, Shih RD, et al. Clinical policy: critical issues in
monoxide-related deaths: a survey in Tehran, Iran (2002- the evaluation and management of adult patients presenting
2006). Am J Forensic Med Pathol 2010;31:359-363. to the emergency department with acute carbon monoxide
Shumy F, Anam AM, Kamruzzaman AK, et al. Acute arsenic poi poisoning. Ann Emerg Med 2017;69(1):98-107.
soning diagnosed late. TropDoct 2016;46(2):93-96. World Health Organisation. Environmental Health Criteria 213.
Singh N, Kumar D, Sahu AP. Arsenic in the environment: effects Carbon monoxide, https://apps.who.int/iris/bitstream/han-
on human health and possible prevention. J Environ Biol dle/10665/42180/WHO_EHC_213.pdf;jsessionid=38F809A4
2007;28(Suppl):359-365. CFAD6CED3294C22E5DFD95D1?sequence=1 (Accessed 21
Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alco May 2019).
hol withdrawal: the revised Clinical Institute Withdrawal Ye X, Wong O. Lead exposure, lead poisoning, and lead regula
Assessment for Alcohol scale (CIWA-Ar). Br J Addict tory standards in China, 1990-2005. Regul Toxicol Pharmacol
1989;84:1353-1357. 2006;46:157-162.
Index
A aneurysm phases and signs, 162-166
atheromatous, of the aorta, 73-74 restraint, 171-172, 209
abdomen
Charcot-Bouchard, 76 aspiration of water, 193-194
asphyxia due to pressure on,
circle of Willis, 75 assault
173-174
dissecting, of the aorta, 74 child, see children
injury, 159-160
intracranial, 75-76 occasioning actual bodily harm,
child, 160, 248
ruptured berry, 75-76 offence of, 106
organs, see organs
syphilitic, 74-75 sexual, see sexual assault
abortion, 78
animals subarachnoid haemorrhage and,
abrasion, 113-116 decomposition, predation and, 75,152-153
abuse, child, see child abuse 60, 63-64, 67-68 asthma, 77, 79-81
Abusive Head Trauma (AHT), 98 transplanted material from, 35 atheromatous aortic aneurysm,
accident anthropology, forensic, 53,63, 68, 73-74
children, 102 145,198, 203 atheromatous plaque, 70
fire death, 184-185 antidepressants, 308, 314 Attenuating Energy Projectile
firearms death due to, serotonin syndrome, 308, 323 (AEP), 141
142-143 anus (in sexual assault) autoerotic asphyxia, 171-172
accidental trauma in infants, 98 examination, 237 autopsy (post mortem
acid bath murders, 278 child, 252 examination;
acid phosphatase test, 286 penetration/intercourse, 237 necropsy), 45-49
actual bodily harm, offence of aorta clinical, 45
assault occasioning, 106 aneurysms, 73-74 Coronary commissioning/
adipocere, 62 stenosis (incl. aortic valve), requiring, 11
adjudication (fitness to practice 71-72 diagnostic approach, 45
procedures), 25 appeal (doctor's right of) against drowning, 194
affidavit, 8 decision on fitness-to- examination, 46
affirmation, 8, 9 practice, 26-28 facilities, 46,48
age determination appearance after death medicolegal, 4 5 ,46 ,4 7,48
bruising, 112 early post mortem interval, Minnesota protocol, 49-52
decomposed remains, 203 55-58 permission for organ/
fetal, 85 facial, 57,202 tissue harvesting for
gestational, 85 arms, defence injuries, 122-123 transplantation, 34
living, 204, 205 arrhythmias, 69,71 quality, 48
air bags, 265 drowning, 194-195 rate variations between
air rifles, 133,140 drug-induced, 322 jurisdictions, 44
aircraft fatalities, 267-268 arrhythmogenic right ventricular reports, 11
airgun, 133,140 cardiomyopathy, 73 aviation incidents, 267-268
airway in drowning, 194 arsenic, 325-326 axonal injury, traumatic, 155
alcohol, see ethanol; methanol hERG channel and, 297
Alcohol Use Disorders Identification artefactual injuries, immersed
Test (AUDIT), 218
B
body, 193
allergic drug reactions, 297 arterial disease bacteria and decomposition, 59
amphetamines, 308,309-310 coronary, 69-71 ballistic injuries, 133-147
designer, 315 extracardiac, 73-76 Barleycorn Public House
amputation arterial spurting, 289 Murder', 169
in torture, 273 asphyxia, 162-175 baroreceptors, carotid sinus,
by train, 267 classification/types, 162,163, 166,167
amylase test, 287 166-172 baton(s), 210-211
333
334 Index
hair as drug testing matrix, 299 human immunodeficiency virus, infanticide, 83-85
hallucinogens (psychedelics) 229, 239, 307 infection
serotonin syndrome, 323 Human Rights Act 1998, 33 intravenous drug users, 307
hallucinogens, 314-315 human, identifying remains as, 203 sexually-transmitted, 229
hand guns, 134-135 humane killers, 141 'Inflicted Head Injury' (IHI), 98
hand(s); see also empty hand restraint hyperextension injury (neck), 158 inhalant abuse, 317
defence injuries, 122-123 hyperflexion injury (neck), 158 injection of illicit drugs, 307
strangulation using, 168-169 hypersensitivity reactions, drug, 297 injuries (trauma)
handcuffs, 209-210 hypertensive heart disease, 71 ballistic, 133-147
hanging, 162,170-171,172 hyperthermia, 180 body response to, 106-107
harm reduction with drugs, 307, hypertrophic cardiomyopathy, 73 cold, see hypothermia
308,318 hypnotics, 314 documentation, 127-130
head injuries, 149-156 hypostasis, post mortem, 56-58 electrical, see electrical trauma
child/infant, 88-98, 248 hypothermia, 185-187 from force or restraint, 209-214
Health & Care Professions Council cold water, 185-187,193,196 head, 149-156
(HCPC), 15-16 heat, 177-185
heart; see also arrhythmias immersed body, artefactual, 193
I
disease/disorders, 69-73 law, 105-106
drowning and, 192 ICD (International Statistical non-accidental, see non-accidental
stimulant-related, 309 Classification of Diseases injury
reflex cardiac arrest, 167 and Related Health non-fatal violence-related injury,
heat injury, 177-185 Problems), 37-38 106-107
height determination from IDENT1,291 post mortem, 63-64
decomposed/skeletalised identification (of the dead or living), regional, 149-160
remains, 203 198-205 infants and children, 83-103,151
helmets, motorcycles, 265 dental, 122,199-201 self-inflicted, 124-126
Henssge's nomogram, 64,65 fingerprints, 201,290-291 in sexual assault, 237
hepatic, see liver fire victims, 182 subarachnoid haemorrhage due
hepatitis, viral, 229, 307 infant (dead) and mother, 85 to, 75,152-153
hERG potassium channel, 297, 322, methods, 198-202 survival after, 123-124
323 criteria, 198-199 terminology, 105
heroin, 297, 298, 299, 307, 312-313 DNA profiling, 199 transportation, 257-268
adulterants, 313 morphological characteristics, types of, 108-123
hesitation' or 'tentative' 201-202 inquest, 4 3,44
injuries, 124 tattoos and body piercings, 202 insects (and entomology),
'hickey' bites, 111 idiosyncratic drug reactions, 297 decomposition, predation
hide and die syndrome, 186-187 imaging (radiology), post mortem, and, 60, 63, 67-68
High Court, 3-4 44,48-49 insulin poisoning, 323-324
Appeal against Fitness to Practice fire victims, 182 interactions, drug, 297
decision, 26-28 immersion (in water), 60-2,191—196; interim orders tribunal, 26
Hippocratic Oath, 13,14 see also drowning International Committee of the Red
HIV, 229, 239, 307 diagnosis, 191,193-194 Cross, 271,272
homicide (incl. murder), 40-42 evidence of, 191-192 international dimensions
domestic violence-related, 41-42 hypothermia, 185-187,193,196 legal systems, 1
familial, 87 torture, 126 medical ethics, 14,15,16
fire, 184-185 immersion and, 60-62 International Statistical
firearms, 142 impact rounds, 211-213 Classification of Diseases
global data impact spatter (blood), 288-289 and Related Health
by age, 40,41 incised wounds, 118 Problems (ICD), 37-38
by gender, 40-41 self-inflicted, 125 interpersonal violence, 40-42
incidence, global, 40 infant(s); see also child abuse intervertebral disc injury, 158
infant, 83-85 deaths, 83-85 intestine (bowel)
mechanism, 42 non-accidental, 83-85, 249, 250 infant injuries, 100-101
as public health problem, 41 skull fractures, 88-98,151 infarction, 77
homologous transplantation, 33 newborn, see neonates intimate examination, guidance, 14
Index I 339
spinal injury, 157-158 fires, cyanide poisoning, 329 toxicology (poisoning), 295-330;
pedestrians, 261,262 hypothermia, 185 see also drugs
spit guards/hoods, 214 spectrum of, 31 definitions, 296-297
splenic injury, 158 trauma, 123-124 interpretation of measurements,
stab wounds, 118-120 spinal, 157 299-300
self-inflicted, 124 suspension (torture), 273 testing matrices, 298
stamping, 111,114,120-122, 292 suspicious deaths trace evidence, 144, 232,279-280,
standards of proof, see proof autopsies, 49 292-293
statements and reports, 7-8; blood patterns, 157 train injuries, 266-267
see also documentation photographs, 48,49 tramadol, 323
content of, 10-11 swearing in (taking the oath), 8,9 tramline bruises, 111,113
medicolegal, preparation of, 9-10 sworn statement, 8 transplantation, 33-35
preparation, 9-10 Sydney Shark Case' (1935), 202 transportation, 257-268
stature determination from syphilitic aneurysm, 74-75 trauma load, 107
decomposed/skeletonised trauma, see injuries
remains, 203 traumatic asphyxia, 174
T traumatic brain injury, 32
sternal fracture, 158-159
stillbirths, 83 Tardieu spots, 164 triage, mass disasters, 145
stimulants, 308-12 Taser®, 213-214 trifluoromethylphenylpiperazine
serotonin syndrome, 308-309, 323 tattooing, 138,139, 202 (TFMPP), 317
stomach, see entries under gastric tattoos, 202 trunk, asphyxia die to pressure on,
strangulation, 162,167-170 teeth and associated structures, 173-174
signs of, 168 identification from, trust (doctor-patient), 17,19
stroke (cerebrovascular 199-201 tuberculosis, pulmonary, 77
accident), 76 temperature; see also heat injury; tyre-tread bruising, 262,263
strontium-90 hypothermia
blood, drowning, 196 body, and time of death, 57-58,
U
bone dating, 63 64-67
stud guns, 141 environmental, 57 unarmed restraint, 209
subarachnoid haemorrhage, 75-76 and rigor mortis, 56 undressing in hypothermia,
traumatic basal, 75,152-153,154 tetrahydrocannabinol (THC), 316 paradoxical, 186-187
subdural haemorrhage, 98,152,153 TFMPP (trifluoromethyl- urine, 287
subpleural haemorrhage, 194 phenylpiperazine), 317 as drug testing matrix, 298-299
substance misuse, see drugs; THC (tetrahydrocannabinol), 316
toxicology thermal injury, see heat injury;
V
sudden and unexpected death hypothermia
diagnosis, 37 thorax, see chest vagal inhibition, 167
Form B4, 92-97 thromboembolism, pulmonary, vascular disorders and lesions,
infants (SIDS), 86-87 76-77 stimulant-related,
from natural causes, 69-81 thrombosis 308-309, 311 ] see also
suffocation (deliberate/intentional), cerebral, 76 aneurysm
86,172-173 mesenteric, 77 vegetative state (VS), 31-33
suicide time of death (post-mortem vehicle accidents, see driving; road
carbon monoxide inhalation, interval) traffic accidents
327-329 early, 55-59 ventricular cardiomyopathy,
fire, 185 estimation, 64-68 arrhythmogenic right, 73
firearms, 142-143 body temperature, 58-59 ventricular tachycardia
hanging, 172 tissue transplantation, 33-35 with QT interval
railway, 267 tolerance (drug), 296 prolongation, 322
suffocation, 172 opiates, 313 vertebrae, injury, 158
Supreme Court, 2 torsades des pointes, 322 vertebral artery trauma, 75,153
survival torture, 271-274 violent crime, data on, 106
asphyxial episode, 166 identification in police custody, virtual autopsy, 49
hanging, 171 223-224 viscera, see organs/viscera
Index 343