Forensic Unit Research Articles

Walking a tightrope: ethical tensions in managing severe self-harm in a forensic mental health unit for young people

ABSTRACT While there is extensive research on how general mental health professionals respond to self-harm (SH) by adults, there is comparatively little research on the management of severe SH in forensic mental health settings for young people. This study aimed to explore how different professionals make decisions on managing SH in this population. A qualitative methodology was employed to investigate participants’ experiences. Focus groups were conducted with 14 professionals working in a UK medium-secure forensic mental health unit for young people, where severe SH is recurrent. Following the method of thematic analysis, two themes were identified. The first (‘walking a tightrope’) illustrates how professionals saw their role as allowing young people to make decisions within restrictive boundaries; how they negotiated ethical tensions between facilitating decision-making and intervening to prevent harm; and how this was perceived externally. The second theme (‘strategies employed’) describes professionals’ approaches to managing severe SH. Our findings add insight into how staff in forensic settings make complex ethical decisions, which are often concealed under the catch-all label of ‘clinical judgement’.

Inflammation markers in patients with psychotic disorder who have committed offenses and their relationship with criminal behavior

Inflammation markers in patients with psychotic disorder who have committed offenses and their relationship with criminal behavior

UK National Fingerprint Collaborative Exercise 2022-23

In 2022–2023 the Defence Science and Technology Laboratory (Dstl) designed and conducted a two-part fingerprint Collaborative Exercise (CE). The CE focussed on fingermarks contaminated in blood as they provide a complex scenario for forensic units and it involved both fingermark visualisation and comparison elements. Participants were requested to treat the exercise as a major crime submission following internal protocols and were invited to provide comments relating to how the marks were deposited (if appropriate). Overall, forensic units performed well within both parts of the exercise. The exercise highlighted the importance of conducting sequential fingermark visualisation techniques, utilising additional lighting techniques and maintaining detailed notes throughout the fingerprint examination process. The outputs from the CE provided opportunities for forensic units to learn from one another, raise the level of understanding of blood contaminated fingermarks and identify areas of improvement which can be incorporated into internal processes.

Balancing on a slack line - Staffs' experiences of talking about sexuality and sexual health with patients cared for in forensic psychiatry in Sweden.

Sexuality is a central part of being human, however, talking about sexual health is generally avoided in forensic psychiatry. The aim of this qualitative study was to explore how healthcare professionals experience talking about sexuality and sexual health with patients cared for in forensic psychiatry. Individual interviews were conducted with eighteen healthcare professionals from ten different forensic psychiatry care units in Sweden. The interviews were semi-structured, and the data was analyzed with qualitative content analysis. The findings showed the overarching theme "Balancing on a slack line". The conversations the healthcare professionals have about sexuality and sexual health with patients in this setting are affected by forensic psychiatry's dual mission; to provide care and at the same time protect patients and society. These conversations can be about opening up for having responsive conversations, but also closing conversations since the field of sexuality and sexual health is fraught with norms and preconceptions. To be able to conduct these conversations can be a challenge since the professionals can experience uncertainty due to a lack of competence, indicating that knowledge and resources are needed to facilitate conversations. In conclusion, the study indicates that there is a lack of support and structure for performing conversations about sexuality and sexual health in forensic psychiatry care, and there is a need for increased knowledge among healthcare professionals. In order to support staff, the forensic psychiatry services need to acknowledge the national guidelines for sexual and reproductive health and rights and to develop and adapt the local guidelines.

The Role of Nurses in the Implementation of Positive Behavior Support in a Secure Forensic Setting

ABSTRACT Positive Behavior Support (PBS) is a framework that attempts to help reduce challenging behaviors displayed by service users however, little is known about the role of nurses and their perceptions of PBS. This qualitative study aimed to explore nurses’ perceptions and their roles in the PBS implementation in two forensic learning disabilities units in London. 19 nursing staff with experience implementing PBS were interviewed. Six themes were derived from thematic analysis, with findings in line with previous research. Recommendations highlighted introducing protected time for nursing staff to discuss PBS on the ward and providing more structured training and informed supervision.

The Impact of Patients and Student Mental Health Nurses Sharing Time Together in Forensic Units.

Student mental health nurses have greater patient contact than registered nurses, and this is appreciated by patients. This phenomenological study explored the impact of patients and student mental health nurses' time shared on forensic units for men carrying a personality disorder diagnosis. Phenomenology was the underpinning philosophy of this research. Patients and student mental health nurses in forensic hospitals participated in unstructured hermeneutic interviews. The time students and patients shared together was considered a gift, enabling them to feel that they were "just people" and valued, strongly impacting on their sense of person. The impact the students have on patients' quality of life is meaningful. When the students and patients connected, it had powerful implications for their sense of humanness and value, highlighting the reciprocal impact they each have on another and the importance of having student nurse clinical placements in forensic wards and facilities.Implications for Clinical Forensic Nursing Practice: This article offers a unique contribution to forensic practice by exploring the experiences of the time patients and students share together in forensic units. Students, who often have the greatest contact with patients, represent the present and future of nursing, and their time is appreciated by patients. Previous research focuses on attitudes and therapeutic relationships, rather than the impact of shared contact. In addition to this, patients in forensic services with personality disorder diagnoses can be the most stigmatized group in mental health care, and exploration of their experiences is lacking. These experiences must be shared.

Exploring the correlates of head-banging behaviour in a female forensic mental health unit: a mixed-methods study

ABSTRACT Despite the documented high prevalence of head-banging being used as a form of self-harm in forensic settings, little research has investigated its correlation with demographic and clinical factors. This mixed-methods study explores head-banging episodes (n = 145) within a female forensic mental health unit in England between 2019 and 2021. Using between-groups analyses, the study identifies clinical and demographic risk factors associated with head-banging behaviour in the sample. Results showed that White ethnicity, younger age, and a diagnosis of personality disorder were associated with an increased likelihood of head-banging. A subsequent regression analysis underscored the statistical significance of White ethnicity and younger age as predictors of head-banging behaviour in the sample. A thematic analysis of descriptive incident reports provided insights into the underlying psychological factors driving head-banging behaviour, which often emerged as a response to interpersonal factors or psychotic symptomatology. It is hypothesised that head-banging may vary in function across diagnoses. Further research should focus on using in-depth qualitative methods to better understand the functions of head-banging, developing effective management strategies for head-banging, as well as assessing its impact on healthcare staff.

Evaluating the Functional Impairment of Assault Victims in a Judicial Context: A Multicentered Retrospective Study in Seven French Forensics Units.

Functional impairment is of major importance in the evaluation of assault victims. French law assesses the seriousness of the violence in terms of the functional impairment experienced by the victims, quantified by the duration of the victims' inability to fulfill their usual daily activities, measured in days of "total incapacity to work" (TIW). Significant variations in the duration of TIW have been reported depending on the examination centers or physician. To date, few studies, all monocentric, have focused on the determinants of this variability. We aimed to study the functional impairment of assault victims by searching for determinants of TIW. We conducted a retrospective multicenter study, including assault victims from seven forensic medicine units. The data were automatically extracted from the medical certificates drawn up and gathered within the ORFéAD database. Thirty-eight variables were studied, relating to the victim's characteristics, the circumstances of the examination and the assault, the physical and psychological symptoms, and the duration of TIW. A total of 5,663 victims were included, including 2,438 (43%) women. The median age was 32 years (min; max [10; 98]). The median duration of TIW was 2 days (min; max [0; 182]). Male gender, age, time to examination, examination center, traumatic injuries (ecchymosis, hematoma, wound, bone fracture), use of a weapon, and functional limitation were associated with the duration of TIW (p < .05). The associations formerly identified in a monocentric setting were confirmed and new determinants were identified. This study has allowed a better understanding of the factors influencing the evaluation of functional impairment and determination of the TIW of assault victims. This first study using ORféAD is intended to be supplemented by the participation of other forensic units, and the inclusion of other variables, such as violence type, victim categories, or the examining physician.

Good-enough Care? How Patients' Perceptions of Counselors' Professional Skills Relate to Everyday Life in Forensic Long-stay Units.

The overall goal of long-term forensic care is to strive toward acceptable levels of adaptation and quality of life (QoL) of the forensic patient in the institutional context. While the bulk of the literature has focused on the deleterious consequences of personality pathology in this regard, research investigating the contribution of the quality of the therapeutic relationship has remained rather scant. Assuming that the perceived competence of the direct counselor, as perceived by patients, forms an important aspect in this regard, the central aim of this study was to investigate the relationship between patients' perceptions of their therapist's professional skills, their self-reported maladaptive behavior on the ward, and their experienced QoL. To this end, we recruited patients (N = 60) in long-stay forensic units and investigated their perceptions of 10 specific skills displayed by their therapist, along a "too little-too much" rating scale. The results revealed that patients who had the overall impression that their counselor was equipped with an adequate set of professional skills showed less maladaptive behavior and perceived a higher QoL on the ward. Conversely, at a more specific competence level, only a positive relationship between a counselor's predictability and self-reported QoL was found. Taken together, these results highlight that an overall professional skill evaluation matters in the context of forensic patients' adaptation and QoL in their long-stay units, with the counselor's predictability serving as a crucial aspect in obtaining the most favorable outcomes.

Toward an Integrated Sexual Policy in Forensic Psychiatry: A Mixed Method Pilot Study.

Forensic inpatients reside for long periods in restricted environments, which do not support the presence of sexual experiences or the expression of existing needs. However, sexuality and sexual health are important aspects in the overall recovery from mental illness. Given the lack of national policies, management decisions are bestowed upon individual institutions and staff members. This research aims to describe the current sexual policies in 32 forensic psychiatric wards in Flanders (the Dutch-speaking part of Belgium), varying from low to high security, and explore the perspective of forensic inpatients regarding such policies. The research questions were answered using a survey that questioned the different forensic units. Only 56% of the wards had a sexual policy at the hospital level. Results showed no significant differences in the applicable sexual policies between the security levels, but individual differences and inconsistencies exist in the rules and agreements applied among different wards. Subsequently, 15 semi-structured in-depth interviews with inpatients were conducted using a phenomenological approach. Most of the respondents were dissatisfied with their sexuality and experienced various barriers in meeting their sexual wants and needs. The results have an added value for clinical practice and lead to recommendations in the development of an integrated sexual policy.

Enhancing safety in forensic units: insights from South African psychiatric nurses

Enhancing safety in forensic units: insights from South African psychiatric nurses

Improving the Visibility and Accessibility of Physical Health Information in a Forensic Medium-Secure Inpatient Unit

Improving the Visibility and Accessibility of Physical Health Information in a Forensic Medium-Secure Inpatient Unit

The Ten-Point Treatment Programme: Design and Evaluation of an Easy Read Document in a Forensic Learning Disability Unit

The Ten-Point Treatment Programme: Design and Evaluation of an Easy Read Document in a Forensic Learning Disability Unit

Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infections among sexual assault victims referred to three French clinical forensic units

BackgroundChlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are the most common bacterial sexually transmitted infections (STIs) worldwide. These STIs are frequently asymptomatic, which often delays diagnosis and treatment with the risk of serious long-term complications. Current French recommendations call for targeted screening of populations considered to be at risk, including victims of sexual assault. However, no recent data on the prevalence of these STIs in this population are available in France. The aim of this study was therefore to determine the prevalence of CT/NG infections among victims of sexual assault attending three Clinical Forensic Units (CFUs). MethodsWe retrospectively reviewed the forensic records of patients aged over 12 years reporting a sexual assault and referred between January 1, 2020 and December 31, 2021 to the CFU of Montpellier, Angers or Saint-Denis de La Réunion. Patients who had been screened for CT and NG infections were included. Results341 alleged victims of sexual assault (324 women, 17 men, median age = 23 years) were screened for CT/NG STIs during the inclusion period (Montpellier, n=196; Angers, n=63; Saint-Denis, n=82). The median time between the sexual assault and the examination was 1 day. CT and NG were detected in 28 patients (8.2 %) and 8 patients (2.3 %) respectively, with no men tested positive. Positive results concerned genital samples, except for two CT-positive anorectal samples and one NG-positive oropharyngeal sample. Two patients (0.6 %) were co-infected with CT/NG. The overall prevalence of CT/NG STIs was 10.0 % and was higher in the 18–24 age group, reaching 13.2 % for CT. ConclusionsThis multicenter study confirms the high prevalence of CT/NG STIs in victims of sexual assault, and the vulnerability of the youngest age groups to these infections. Systematic screening for CT/NG STIs at the time of the forensic examination is the key to early diagnosis and effective treatment to prevent transmission and subsequent complications in these patients.

A 20-Year Autopsy Study of Myocardial Bridging Among Sudden Deaths

Myocardial bridging (MB) is a condition, where the cardiac muscle overlies the intramyocardial segment of the major epicardial coronary artery. This study aims to analyse the demographics and anatomical characteristics of MB within a pool of 2093 sudden cardiac-related death cases examined at the Forensic Unit of Universiti Kebangsaan Malaysia Medical Centre between 2000 and 2019. In this cross-sectional study, postmortem data collected were gender, racial affiliations, MB anatomical properties, and association with cardiac pathologies entered into the statistical software SPSS version 25 for analysis. The prevalence of MB was 12.9%. It was commoner in males (91.5%). MB was predominant between age 21-40 years old (50.2%). Chinese race showed the highest number of recorded MB cases (24.3%) among local races. MB was mostly found in left anterior descending (LAD) artery (98.2%), with the commonest length of 11-20mm (44.6%), depth of 1-5mm (49.8%), and distance from the ostium of 21-40mm (54.0%). The prevalence of isolated MB (43.2%) was nearly comparable to that of MB with cardiac pathologies (56.8%). MB was mostly associated with atherosclerosis (50.1%) and atheroma formation was mostly proximal to MB (78.3%). MB is a common occurrence and commonly found in the LAD as a single entity. It has a higher preponderance in the male gender among the adult population. In conclusion, the findings not only contribute to a deeper understanding of MB but also hold potential implications for identifying and managing risks related to sudden cardiac-related deaths. It is a pathological condition at a certain length and depth whether it exists as an isolated entity or associated with cardiac pathologies. Atherosclerosis tends to form proximal to MB and might pose a risk for myocardial infarction.

‘You Still Need to Care for the patient’. Experiences of Forensic Mental Health Professionals with Inpatient Aggression

Forensic mental health professionals are frequently exposed to inpatient aggression, which may negatively affect their physical and mental health. Current studies offer limited insight into how this may affect staff-patient interactions in the aftermath of aggression. A qualitative study was conducted to explore professionals’ experiences with exposure to aggression. Thirteen semi-structured interviews and three focus groups were conducted with 25 professionals working in a high secure forensic mental health unit. A thematic analysis was conducted in consensus among three researchers. Five main themes were generated in the analysis: exposure to different forms of aggression, factors that shape the impact of aggression, emotional reactions, managing emotional reactions, and managing relationships with patients. These themes form a complex interplay. Feelings of anger and fear, intrusive memories, and avoidant or agitated behavior toward patients are frequently reported, affecting both the personal and professional lives of participants. Interpersonal relationships between team members can promote or hinder adequate management of feelings that arise after exposure to aggressive incidents. The tremendous impact that exposure to inpatient aggression may have on professionals, and the way that they care for their patients requires more attention.

Using forensic intelligence as a model for determining future toxicology methods: TBI forensic toxicology and forensic drug chemistry nitazene identification.

The Tennessee Bureau of Investigation (TBI) serves all 95 counties of Tennessee, but the data included in this article are primarily focused in Upper East and East Tennessee (the parts of the state included in the eastern time zone). The forensic chemistry (seized drug) unit of the TBI began reporting nitazene analogues in late 2019. The primary analogues found in forensic chemistry cases were isotonitazene and metonitazene. After discussion and review of reporting statistics, the forensic toxicology unit began to monitor for these compounds in toxicology samples by using ion characteristics with the nitazene analogues. Between March 2021 and December 2023, TBI toxicology received 49,639 cases statewide. Of those, 20,105 (40.5%) received toxicology testing. Approximately 95% of TBI toxicology cases are related to Driving Under the Influence (DUI)/motor vehicle-related incidents. Fatal overdoses and cases from the medical examiner office comprise <5% of TBI toxicology caseload. The toxicology section utilizes the SCIEX 3200 Qtrap with a SCIEX Exion LC AC autosampler system to monitor multiple reaction monitoring transition of nitazene analogues. The ion monitoring for two nitazene analogues, isotonitazene and metonitazene, started in March 2021. Ion monitoring should not be construed as a confirmed result but rather as an indication that a drug may be present. A comparison of this data from the forensic toxicology and forensic chemistry units revealed the rise of new drugs that required a more in-depth review to understand the magnitude and scope. This article is also intended to encourage collaboration between forensic toxicology and forensic chemistry (seized drug) units.

The Processing of Forensic Investigative Leads in Criminal Investigations Conducted by the South African Police Service

The adverse impact of crime undermines not only a nation’s peace and stability, but also the safety and security of its communities. Furthermore, crime affects a nation’s economy, its citizens’ standard of living, and its standing with prospective foreign investors and tourists. Forensic investigative leads (FILs) are crucial in the investigation and resolution of crime. The South African Police Service (SAPS) allocates significant resources to analyse exhibit materials and forensic databases containing vital forensic biometric information. By conducting comparative searches in these databases, FILs are generated and communicated to detectives to facilitate investigation, detection and conviction. This article does an in-depth analysis of local and international literature, examines data from the CAS/ICDMS system and reports on qualitative interviews conducted with SAPS detectives, forensic examiners, and international forensic experts. It delineates the consequences of the underutilisation and an inadequate understanding of FILs on detection rates within the criminal justice system. The research not only identifies barriers to reporting and utilising FILs, but also recommends ways to enhance the regulatory framework, information technology systems, and detective training programmes within the SAPS. Emphasising adherence to ISO standards to maintain FIL reliability during forensic examinations, the study underscores the resource constraints faced by detectives, which affect FIL utilisation and impede the desired outcomes in detection and conviction rates. The article proposes that the SAPS can overcome these challenges by prioritising resource allocation to detective forensic investigative units to enable them to follow up and investigate FILs.

Prediction model for anabolic androgenic steroid positivity in forensic autopsy cases – a new tool to the autopsy room

Non-prescription use of anabolic androgenic steroids (AAS) is associated with an increased risk of premature death. However, these substances are seldom screened in connection with forensic cause-of-death investigation, unless the forensic pathologist specifically suspects use, often based on a positive AAS use history. Since AAS use is often concealed from others, this practice may lead to mistargeting of these analyses and significant underestimation of the true number of AAS positive cases undergoing forensic autopsy. Thus, more accurate diagnostic tools are needed to identify these cases. The main objective of this study was to determine, whether a multivariable model could predict AAS urine assay positivity in forensic autopsies. We analyzed retrospectively the autopsy reports of all cases that had been screened for AAS during forensic cause-of-death investigation between 2016–2019 at the Finnish Institute for Health and Welfare forensic units (n = 46). Binary logistic regression with penalized maximum likelihood estimation was used to generate a nine-variable model combining circumferential and macroscopic autopsy-derived variables. The multivariable model predicted AAS assay positivity significantly better than a “conventional” model with anamnestic information about AAS use only (area under the receiver operating characteristic curve [AUC] = 0.968 vs. 0.802, p = 0.005). Temporal validation was conducted in an independent sample of AAS screened cases between 2020–2022 (n = 31), where the superiority of the multivariable model was replicated (AUC = 0.856 vs. 0.644, p = 0.004). Based on the model, a calculator predicting AAS assay positivity is released as a decision-aiding tool for forensic pathologists working in the autopsy room.

Increasing Physical Activity in Medium Secure Mental Health Services in the UK: (IMPACT) - Preliminary Results from the Phase 4 Feasibility Study, with a highlight into the Women’s Services

IntroductionIn the UK there are 3500 individuals detained in medium secure forensic psychiatry units. Service users in such settings have complex and serious mental illness (SMI), often with co-morbid physical health problems and a life expectancy of at least 10 years shorter than the general population. They often have low levels of physical activity. There is little evidence about physical activity interventions for medium secure service users in the United Kingdom.ObjectivesOur objective is to co-produce, with medium secure service users, the content and delivery of an intervention to increase physical activity. We shall assess feasibility, acceptability, and pilot data collection methods for outcomes relevant for a future randomised controlled trial.MethodsThis is a 30-month mixed-methods project that will follow the Medical Research Council (MRC) framework Developing and Evaluating Complex Interventions. The study has 4 phases. Phases 1-2 will gather information required to co-develop an evidence-based intervention in Phase 3. Phase 4 will assess the intervention in a feasibility study, evaluating and testing the intervention for a future pilot study.Study settings: Two NHS Medium Secure In-Patient Psychiatric Hospitals in the UK.ResultsThis paper presents the preliminary findings from Phase 4 and also offers a highlight into the results from the Women’s Services from both study sites. A total of thirty-three service users from both study sites participated in Phase 4 of the study and twenty-six completed the physical activity intervention, known as the IMPACT Intervention. Between both study sites, there were two Women’s Standard Medium Secure Services and one Women’s Enhanced Medium Secure Service, involved in this study. A total of nine female service users participated in Phase 4.ConclusionsThe preliminary findings of Phases 4 are allowing the team to move forward and evaluate the effect of the IMPACT Intervention.Disclosure of InterestNone Declared