FMT 400

Introduction to Forensic Medicine Dr David Chumba MBcHB, MMED (Human Pathology), Dip. For Med (SA)

‡ Forensic medicine is a branch of medicine where emphasis of the role of the doctor, responsibilities, obligations to his patients towards administration of justice in criminal as well as civil cases. This means that the doctor must be conversant with medical law, bioethics and medicolegal aspects of clinical practice for he/she to discharge his/her obligations and avoid malpractice. ‡ It divided loosely Forensic pathology and clinical forensic medicine ‡ Forensic pathology deals with the study of disease and injury to tissue by scientific methods. Thus it refers to investigations to the effect of injury, poisoning, occupational hazards and certain natural diseases ‡ This investigation is carried out on the instruction of a legal authority such as police commissioner or magistrate and the aim of the investigation is directed at public good ‡ Thus the inquiry seeks to ascertain the cause of unnatural, suspicious, sudden deaths by means of investigating the scene of death, the postmortem or autopsy. This is usually done by trained forensic pathologists but in Kenya the majority of autopsies are done by medical officers and pathologist who have little or no formal training in forensic pathology. ‡ Since you will definitely be called to carry out an autopsy in your routine practice, this course is very important. ‡ Apart from attending the scene of death, performing an autopsy, the doctor must take specimens for laboratory evaluation e.g. histology and toxixology ‡ Tissue, blood and urine is usually taken for analysis

‡ Necropsy is the most accurate description of investigative dissection of a dead body but autopsy has been used to replace the same procedure ‡ Post mortem though used regularly is not specific and may mean even external examination of a dead body ‡ The principles of modern medico-legal practice was based on the codes of the sixteenth century europe the Bamberg code 1507, Caroline code 1532 and Theresian code of 1769 ‡ Clinical autopsy was made meaningful when modern concepts of pathogenesis of disease by Carl Von Rokitansky (1804-1902) and cellular pathology by Rudolf Virchow (1821-1902) ‡ Procedure of the forensic autopsy is today's practical

‡ Clinical forensic medicine: This is a discipline where the doctor examines and completes medicolegal reports mainly on living persons. ‡ The duty is usually carried out by the police surgeons and medical officers ‡ The cases involved include examination of rape survivors, victims of assault, alleged perpetrators of crime and drunken drivers ‡ This entails clinical evaluation and laboratory assessment of specimens before writing a medicolegal report and subsequently being tabled in court as evidence ‡ Both forensic pathology and clinical forensic medicine and not recognized specialities in Kenya and therefore there is no post graduate training of the same. Further training in this fields require traveling abroad e.g. South Africa, and other developed nations ‡ Medicolegal practice encompasses both forensic pathology, clinical forensic medicine, medical law, bioethics and medicolegal aspects of all disciplines in medicine

‡ Medical law deals with aspects of medical practice with the law and arises from the laws of Kenya ‡ The laws of Kenya are divided into two Public and private law ‡ Private law is further divided into civil and common law which is made up of the ancient customs and practices of England that have been recognized and given the force of the law, the country also adopts it own laws in matters of personal status e.g. marriage, custody, maintainance, burial disputes etc and this is referred to as African Customary law ‡ Civil law include customary law, islamic law, canon law etc ‡ Public law constitutes the 1. constitutional law which the highest law in the land and takes precidence over any other law 2. The criminal law which is the law that prohibits a person to do or not to do things that are considered harmful to the society. 3. Administrative law which governs different aspects of public administration

‡ Court structure in Kenya: ‡ Court of Appeal ‡ High court ‡ Resident magistrates court ‡ District magistrates court District magistrates court ‡class,class, 2nd class, 3rd class 1st 2nd class, 3rd class 1st ‡Imprisonment: Up to seven years Imprisonment: Up to seven years Fines : Money up to 20,000 ‡ Fines : Money up to Corporal punishment: Strokes 20,000 ‡ Corporal punishment: Strokes

‡ Aspects of Kenyan law releveant ot health care workers: ‡ The consitution: The Bill of right chapter V of the constitution provide provisions that directly affect health care workers and their patients and they serve as fundamental right to individuals ‡ Common law: This are acts that directly affect health care proffesionals ‡ Ethical rules: This do not have the weight of the law, but may be relied upon by the courts as guidelines to determine whether a health care professional has acted unproffesionally

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Bill of rights: Section 70 provides for the fundamental rights of the individual Section 71 provides for the protection of right to life Section 72 right to personal liberty Section 73 protection from slavery and forced labor Section 74 protection from torture and inhuman degrading treatment 75 protection from compulsory deprivation of property 76 protection against arbitrary search or entry 77 provides for secure protection of the law and fair hearing within a reasonabel time 78 protection of freedom of conscience 79 freedom of expression 80 freedom of assemply and association 81 freedom of movement 82 protection form discrimination on grounds of race, status or class etc

‡ Common law: ‡ Medical practitioners and dentist act (cap 253) this provides for the qualifications, registration, licensing and practice of medicine and dentistry ‡ Nurses act cap 257 provides for the training, enrolment licensing and practice of nurses ‡ The pharmacy and poisons act cap 244: Provides for conducting inquiries and inquests into deaths arising from suicide, accidents, homicide, or suspicious deaths ‡ Penal code cap 63: Defines the term causing death, out laws sexual offences such as rape, abduction, indecent assault, incest, unnatural offences, and defilement. Makes it a misdeameanour to conceal birth, outlaws procuring of abortins, provides for indemnity from criminal liability for surgical operations conducted in good faith and with reasonable care and skill, outlaws the intentional or negligent administration of poisons ‡ Human tissue act cap 252: Allows for the use of bodies of deceased persons for therapeutic, purposes, medical education and research ‡ The public health act: Provides for securing and maintianing health by imposing duties on local authority to provide and protect water and food suplies, duties to report and control epidemics, procedures of exhumations, the establishment of cemettries, and disposal of bodies and rules governing nursing homes, private hospitals, maternity homes etc ‡ Science and technology act cap 250: provides for the coordination of research

‡ Mental act cap 248 provides for care and custody of psychiatric patienst, management and control of mental institutions ‡ Children and young persons act cap 141 protection and discipline of children, juveniles and young persons ‡ The anatomy act: Makes provisions of donating bodies to schools of anatomy prohibits the illegal removal of parts of the body ‡ Births and deaths registration act cap 149 provides for the notification of birth, death and issuing of burial permits ‡ Local government act (cap 265) this section empowers local authorities to make necessary for health, safety and well being of the inhabitants and prevention of nuisance (e.g. regulations of disposal of unclaimed bodies)

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Ethical rules and guidelines The rules of medical practitioners and dentists board Hippocratic oath Geneva declaration of 1948 (modern version of Hippocratic oath) International code of medical ethics of 1949 Declaration of Sydney (statement of death) 1968 Declaration of Oslo 1970 on abortion Declaration of Helsinki 1964 recommendations on biomedical research on human subjects Statement of use and misuse of psychotropic drugs of Tokyo 1975 Regulations in time of armed conflict of Havana 1956 Declaration of Venice on terminal illness Statement of family planning of 1967 (Madrid) Recommendations of medical care in rural areas of 1994 Helsinki Recommendations concerning boxing as a sport 1983 Venice Twelve principles of provison of health care in any national health care system 1963 New York

‡ Doctor-patient relationship: ‡ A patient seeing a doctor enters a contract with the doctor or the hospital where the doctor works and the doctor or the hospital owes the patient duty of service. The contract takes the form of an implied agreement for the doctor to diagnose the patients complaint and treat in the normal manner eccording to acceptable medical procedures and refer where necessary to the specialist in the field. ‡ The patient is to follow the doctors instructions and pay the required fees. ‡ The contract does not guarantee cure ‡ The doctor may not be paid if he departs from instructions or does not refer as agreed ‡ The doctor must complete treatment of the patient unless he
± ± ± ± ± Leave to another competent doctor Issue sufficient instructions for further treatment Patient is cured and does not need further instructions The patient refuses further treatment Doctor gives sufficient notice that he intends to stop treatment

‡ Consent: Consent means that the patient has the following concerning the prescribed treatment:
± ± ± ± Knowledge of the extend of the arm or risk of the procedure Appreciates the nature of arm or the risk Consented to arm or assumed risk Comprehensive including the entire transaction inclusive of it consequences

‡ Types of consent: The patient can consent orally or in writing or tacitly by conduct. There is no difference in these types except that written is easier to prove if there is a dispute ‡ The consent is only valid if the person giving is legally capable not a minor or an insane persons ‡ Consent in case of minors: The consent is given by the parent or guardian except
± If the person is over 18 yrs he/she can consent independently ± Any person over 14 yrs can consent to medical treatment without the guardian or the parent

‡ The mental health act allows certain persons to consent for the mentally sick people these include:
± the curator appointed by the court ± Spouse of the sick person, parent, major child brother or sister. These persons have precedence in the order given

‡ Confidentiality: ‡ Patient discuss intimate and personal details about themselves and therefore have a right to expect their disclosures will be held in confidence by doctors and medical professionals. If this were not the case patient would not be giving any important details to the doctor ‡ Therefore ethically the doctor should not divulge any information unless
± Consent is given by the patient ± Deceased person consented by next of kin

‡ Exceptions: The law recognizes that confidentiality is important unless
± The court of law orders them to make a disclosure ± Act of parliament requires them to make a disclosure ± There is a moral or legal obligation on them to make a disclosure to a person or agency that has reciprocal or legal obligation ± Patient consents to disclosure

‡ When does the court order disclosure: ‡ 1. Over 90% is due to physical injuries where there is life insurance policy and claims for damages for bodily harm after an injury ‡ 2. Psychiatric patients: in proceeding to have a patient hospitalized in a mental institution, where the patients put her mental state as a defense e.g. in murder cases, ‡ 3. Child custody cases ‡ 4. Where there necessity to establish mental capacity to testator ‡ 5. Moral, social and legal duty. A patient is HIV positive and has not told the partner the status and has not taken the necessary steps to prevent infection, the docotor can disclose to the partner.

‡ Medical malpractice: This refers to failure by the medical practitioner to exercise the degree of skill and care in his or her field. A greater skill is required for the specialists. In deciding that there was negligence the general skill of the doctor is assessed based on what doctors of that skill can do e.g. TAH by an MO, if a patient dies of severe hemorrhage while the MO in good faith was trying to save a woman life who had ruptured uterus during delivery ‡ Homicide: This takes the form of murder and culpable homicide. The former may include active euthanasia and doctor assisted suicide ‡ Murder is unlawful and intentional killing of another person even if the motive is good ‡ Culpable homicide is negligent and unlawful killing of a person by another. Negligence is failure to act a reasonable medical practitioner ‡ Euthanasia: Defined as mercy killing of hopelessly ill or injured persons where the doctor or the family members actively participate in the death of the patient. The practice is regarded as murder in Kenyan and South African law ‡ Passive euthanasia is where treatment is withdrawn from a hopelessly ill patient (discuss) what are some medicines that be witheld from the dying? ‡ Legal aspects of HIV
± Infecting a person knowingly if the patient later dies the latter is charged with culpable homicide ± Others are charged for assault if he does not warn others of his/her HIV status ± It is unlawful to expose anyone to HIV even if not infected

‡ Outline ‡ Traumatology:
± ± ± ± ± Wounds Asphyxia Thermal, electrical and radiation injuries Firearm and explosion injuries Transportation injuries

‡ Clinical forensic medicine
± Domestic violence ± Sexual offences ± Medicolegal aspects of drugs and poisons including alcohol Relevant toxicology: divide into mainly four
‡ ‡ ‡ ‡ a) alcohol poisoning b) carbon monoxide and agrochemical poisoning c) poisoning by medicines and d) narcotic and hallucinogenic drugs

± Torture and custody related deaths

‡ Forensic pathology
± ± ± ± ± ± ± Examination of the scene of death Autopsy Death and post mortem changes Sudden un expected deaths Human identification Mass disasters Forensic odontology

‡ A2 or D1 form ‡ P 3 form completion: ‡ Legal documents to be filled in routine Forensic medicine:
± P3 police form: Mainly used in clinical forensic medicine ± Police A23: Post-mortem form ± Medical reports





Hospital pm Forensic PM

Form A2 filled P23A form

Disposal permit


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