Clinical Forensic Medicine

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Clinical Forensic Medicine

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F O R E N S I C

S C I E N C E -

^{A N D}

- M E D I C I N E

Steven B. Karch, MD,SERIES EDITOR

CLINICAL FORENSIC MEDICINE:A P^HYSICIAN'^S G^UIDE, S^ECOND E^DITION edited byMargaret M. Stark, 2005

DRUGS OF ABUSE:B^ODY F^LUID T^ESTING

edited byRaphael C. Wong and Harley Y. Tse, 2005

FORENSIC MEDICINE OF THE LOWER EXTREMITY: HUMAN IDENTIFICATION AND TRAUMA

ANALYSIS OF THE THIGH, LEG,AND FOOT,byJeremy Rich, Dorothy E. Dean, and Robert H. Powers, 2005

FORENSIC AND CLINICAL APPLICATIONS OF SOLID PHASE EXTRACTION,byMichael J.

Telepchak, Thomas F. August, and Glynn Chaney, 2004

HANDBOOK OF DRUG INTERACTIONS:A CLINICAL AND F^ORENSIC G^UIDE,edited by Ashraf Mozayani and Lionel P. Raymon, 2004

DIETARY SUPPLEMENTS:TOXICOLOGY AND C^LINICAL PHARMACOLOGY,edited by Melanie Johns Cupp and Timothy S. Tracy, 2003

BUPRENOPHINE THERAPY OF OPIATE ADDICTION, edited by Pascal Kintz and Pierre Marquet, 2002

BENZODIAZEPINES AND GHB: DETECTION AND PHARMACOLOGY, edited by Salvatore J.

Salamone, 2002

ON-SITE DRUG TESTING, edited by Amanda J. Jenkins and Bruce A. Goldberger, 2001 BRAIN IMAGING IN SUBSTANCE ABUSE:RÊSEARCH, C^LINICAL,ÂND FÔRENSIC APPLICATIONS,

edited byMarc J. Kaufman, 2001

TOXICOLOGY AND CLINICAL PHARMACOLOGY OF HERBAL PRODUCTS, edited byMelanie Johns Cupp, 2000

CRIMINAL POISONING:INVESTIGATIONAL G^{UIDE FOR} LÂW E^NFORCEMENT, TOXICOLOGISTS, FÔRENSIC S^CIENTISTS,ÂND A^TTORNEYS,

byJohn H. Trestrail, III, 2000

A PHYSICIAN’S GUIDE TO CLINICAL FORENSIC MEDICINE, edited byMargaret M. Stark, 2000

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C ^LINICAL F ^ORENSIC M ^EDICINE

Edited by

Margaret M. Stark,

^LLM

,

^MB

,

^BS

,

^DGM

,

^DMJ

,

^DAB

The Forensic Medicine Unit, St. George's Hospital Medical School, London, UK

Foreword by

Sir John Stevens

Commissioner of the Metropolitan Police Service, London, UK

A Physician's Guide

S ^ECOND E ^DITION

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Library of Congress Cataloging-in-Publication Data

Clinical forensic medicine : a physician's guide / edited by Margaret M.Stark.-- 2nd ed.

p. ; cm. -- (Forensic science and medicine)

Rev. ed. of: A physician's guide to clinical forensic medicine. c2000.

Includes bibliographical references and index.

ISBN 1-58829-368-8 (alk. paper) 1. Medical jurisprudence.

[DNLM: 1. Forensic Medicine--methods. W 700 C641 2005] I. Stark, Margaret. II. Physician's guide to clinical forensic medicine. III. Series.

RA1051.P52 2005 614'.1--dc22

2004024006

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Dedication

In memory of Smokey and to Amelia and Feline Friends once again!

v

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vii

Foreword

The Metropolitan Police Service (MPS), now in its 175th year, has a long tradition of working with doctors. In fact, the origin of the forensic physician (police surgeon) as we know him or her today, dates from the passing by Parliament of The Metropolitan Act, which received Royal Assent in June of 1829. Since then, there are records of doctors being “appointed” to the police to provide medical care to detainees and examine police officers while on duty.

The MPS has been involved in the training of doctors for more than 20 years, and has been at the forefront of setting the highest standards of working practices in the area of clinical forensic medicine. Only through an aware- ness of the complex issues regarding the medical care of detainees in custody and the management of complainants of assault can justice be achieved. The MPS, therefore, has worked in partnership with the medical profession to ensure that this can be achieved.

The field of clinical forensic medicine has developed in recent years into a specialty in its own right. The importance of properly trained doctors working with the police in this area cannot be overemphasized. It is essential for the protection of detainees in police custody and for the benefit of the criminal justice system as a whole. A book that assists doctors in the field is to be applauded.

Sir John Stevens

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ix

The field of clinical forensic medicine has continued to flourish and progress, so it is now timely to publish Clinical Forensic Medicine: A Physician's Guide, Second Edition, in which chapters on the medical aspects of restraint and infectious diseases have been added.

Police officers are often extremely concerned about potential exposure to infections, and this area is now comprehensively covered. The results of the use of restraint by police is discussed in more detail, including areas such as injuries that may occur with handcuffs and truncheons (Chapters 7, 8, and 11), as well as the use of crowd-control agents (Chapter 6). The chapter on general injuries (Chapter 4) has been expanded to include the management of bites, head injuries, and self-inflicted wounds.

Substance misuse continues to be a significant and increasing part of the workload of a forensic physician, and the assessment of substance misuse problems in custody, with particular emphasis on mental health problems (“dual diagnosis”), has been expanded. Substance misuse is too often a cause of death in custody (Chapter 10).

Traffic medicine is another area where concerns are increasing over the apparent alcohol/drugs and driving problem. There has been relevant research conducted in this area, which is outlined Chapter 12.

Forensic sampling has undergone enormous technological change, which is reflected in the chapter on sexual assault examination (Chapter 3).

The chapter on the history and development of clinical forensic medicine worldwide has been updated (Chapter 1). Chapters on fundamental principles (Chapter 2), nonaccidental injury in children (Chapter 5), and care of detainees (Chapter 8) are all fully revised, as are the appendices (now containing a list of useful websites). Although the subject is constantly evolving, some fundamental principles remain.

I was very pleased with the response to the first book, and there appears to be a genuine need for this second edition. I hope the good practice outlined in this book will assist forensic physicians in this “Cinderella speciality.”

Margaret M. Stark

Preface to the Second Edition

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xi

Preface to the First Edition

“Clinical forensic medicine”—a term now commonly used to refer to that branch of medicine involving an interaction among the law, the judiciary, and the police, and usually concerning living persons—is emerging as a specialty in its own right. There have been enormous developments in the subject in the last decade, with an increasing amount of published research that needs to be brought together in a handbook, such as A Physician’s Guide to Clinical Forensic Medicine. The role of the health care professional in this field must be indepen- dent, professional, courteous, and nonjudgemental, as well as well-trained and informed. This is essential for the care of victims and suspects, for the criminal justice system, and for society as a whole.

As we enter the 21st century it is important that health care professionals are

“forensically aware.” Inadequate or incorrect diagnosis of a wound, for example, may have an effect on the clinical management of an individual, as well as a significant influence on any subsequent criminal investigation and court proceedings. A death in police custody resulting from failure to identify a vulnerable individual is an avoidable tragedy. Although training in clinical forensic medicine at the undergraduate level is variable, once qualified, every doctor will have contact with legal matters to a varying degree.

A Physician’s Guide to Clinical Forensic Medicine concentrates on the clinical aspects of forensic medicine, as opposed to the pathological, by endeavoring to look at issues from fundamental principles, including recent research developments where appropriate. This volume is written primarily for physicians and nurses working in the field of clinical forensic medicine—forensic medical examiners, police surgeons, accident and emergency room physicians, pediatricians, gynecologists, and forensic and psychiatric nurses—but such other health care professionals as social workers and the police will also find the contents of use.

The history and development of clinical forensic medicine worldwide is outlined, with special focus being accorded the variable standards of care for detainees and victims. Because there are currently no international standards of training or practice, we have discussed fundamental principles of consent, confidentiality, note-keeping, and attendance at court.

The primary clinical forensic assessment of complainants and those suspected of sexual assault should only be conducted by those doctors and nurses

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xii Preface who have acquired specialist knowledge, skills, and attitudes during both theoretical and practical training. All doctors should be able to accurately describe and record injuries, although the correct interpretation requires considerable skill and expertise, especially in the field of nonaccidental injury in children, where a multidisciplinary approach is required.

Avoidance of a death in police custody is a priority, as is the assessment of fitness-to-be-detained, which must include information on a detainee’s general medical problems, as well as the identification of high-risk individuals, i.e., mental health and substance misuse problems. Deaths in custody include rapid unexplained death occurring during restraint and/or during excited delirium. The recent introduction of chemical crowd-control agents means that health professionals also need to be aware of the effects of the common agents, as well as the appropriate treatments.

Custodial interrogation is an essential part of criminal investigations.

However, in recent years there have been a number of well-publicized miscarriages of justice in which the conviction depended on admissions made during interviews that were subsequently shown to be untrue. Recently, a working medical definition of fitness-to-be-interviewed has been developed, and it is now essential that detainees be assessed to determine whether they are at risk to provide unreliable information.

The increase in substance abuse means that detainees in police custody are often now seen exhibiting the complications of drug intoxication and withdrawal, medical conditions that need to be managed appropriately in the custodial environment. Furthermore, in the chapter on traffic medicine, not only are medical aspects of fitness-to-drive covered, but also provided is detailed information on the effects of alcohol and drugs on driving, as well as an assessment of impairment to drive.

In the appendices of A Physician’s Guide to Clinical Forensic Medicine, the relevant ethical documents relating to police, nurses, and doctors are brought together, along with alcohol assessment questionnaires, the mini-mental state examination, and the role of appropriate adults; the management of head-injured detainees, including advice for the police; the Glasgow Coma Scale, and an example of a head injury warning card; guidance notes on US and UK statutory provisions governing access to health records; an alcohol/drugs impairment assessment form, along with a table outlining the peak effect, half-life, duration of action, and times for detection of common drugs.

Margaret M. Stark

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Contributors

xv

KARI BLAHO-OWENS,PhD • Research Administration, University of Tennessee Health Science Center, Memphis, TN

JACK CRANE,MB BCH,FRCPath,DMJ(Clin & Path),FFPath,RCPI • The Queen’s University of Belfast and Northern Ireland Office, State Pathologist’s Department, Institute of Forensic Medicine, Belfast, Northern Ireland, UK JUDITH A. HINCHLIFFE,BDS,DipFOd • School of Clinical Dentistry, University

of Sheffield, Forensic Odontologist, General Dental Practitioner, and Honorary Clinical Lecturer, Sheffield, UK

STEVEN B. KARCH,MD • Assistant Medical Examiner, City and County of San Francisco, CA

MARY NEWTON,HNC • Forensic Sexual Assault Advisor, Forensic Science Service London Laboratory, London, UK

FELICITY NICHOLSON,MB BS,FRCPath • Consultant in Infectious Diseases and Forensic Physician, London, UK

GUY NORFOLK,MB ChB,LLM,MRCGP,DMJ • Consultant Forensic Physician and General Practitioner, Stockwood Medical Centre, Bristol, UK NICHOLAS PAGE,MB BS,DCH,DRCOG,DMJ,MRCGP • General Practitioner

and Forensic Physician, Ludlow Hill Surgery, Nottingham, UK ROY N. PALMER,LLB,MB BS,LRCP,MRCS,DRCOG • Barrister-at-Law, H. M.

Coroner, Greater London (Southern District), Croydon, UK JASON PAYNE-JAMES,LLM,MB,FRCS,DFM,RNutr • Consultant Forensic

Physician, London, UK

DEBORAH ROGERS,MB BS,DCH,DRCOG,MRCGP,DFFP,MMJ • Honorary Senior Lecturer, The Forensic Medicine Unit, St. George’s Hospital Medical School, London, UK

RICHARD SHEPHERD,MB BS,FRCPath,DMJ • Senior Lecturer, The Forensic Medicine Unit, St. George’s Hospital Medical School, London, UK MARGARET M. STARK,LLM,MB BS,DGM,DMJ,DAB • Honorary Senior Lecturer,

The Forensic Medicine Unit, St. George’s Hospital Medical School, London, UK

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SIR JOHN STEVENS • Commissioner of the Metropolitan Police Service, London, UK AMANDA THOMAS,MB BS,DCH,MmedSc,MA,FRCPCH • Consultant Community

Paediatrician, Department of Community Paediatrics, St. James’

University Hospital, Leeds, UK

IAN F. WALL,MB ChB(Hons),FRCGP,DMJ,DOccMed • Consultant Forensic Physician and General Practitioner, Kettering, UK

xvi Contributors

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xvii

Clinical Forensic Medicine

Clinical Forensic Medicine

F O R E N S I C

S C I E N C E -

- M E D I C I N E

C LINICAL F ORENSIC M EDICINE

Edited by

Margaret M. Stark,

,

,

,

,

,

Foreword by

Sir John Stevens

A Physician's Guide

S ECOND E DITION

Dedication

Foreword

Preface to the Second Edition

Preface to the First Edition

Contents

Contributors

Value-Added eBook/PDA

C ^LINICAL F ^ORENSIC M ^EDICINE

S ^ECOND E ^DITION