Medico-legal Reports Research Articles

Survey of medico-legal investigation of homicides in the city of Turku, Finland

Finland has one of the highest homicide rates in western Europe but the clear-up rate is also exceptionally high. To create a detailed analysis of homicides ( n = 161) in a region of western Finland during the 20-year period from 1983 to 2002 all available information was collected retrospectively from multiple sources including medico-legal reports, reports of police investigations, and court proceedings. Among the data collected and analysed were location, time, circumstances, and motives of homicides, forensic pathologists’ role at the scene-of-the-crime and in court, autopsy findings, demographics and substance abuse of both victims and offenders, criminal background, forensic psychiatric examinations, and the verdicts of the offenders. A typical homicide was committed without premeditation during the weekend by a drunken male with a knife at hand and with a history of violent crimes. The perpetrator was later found guilty of manslaughter and received a prison sentence. Some noted shortcomings both in the police and the medico-legal investigation procedures are discussed, as well as the forensic pathologist’s role in the judicial process in Finland.

Medicolegal rounds: Medicolegal issues and alleged breaches of standards of medical care in a patient motor vehicle accident allegedly related to chronic opioid analgesic therapy

The objective of this medicolegal case report is to present the details of the case of a chronic pain patient (CPP) who was placed on chronic opioid analgesic therapy (COAT) and was involved in a motor vehicle accident, alleged in litigation to be related to COAT. COAT standards are in a process of evolution, and this process is influenced by recent literature developments. We aim to present both the plaintiffs and defendant's expert witnesses' opinions on whether the defendant physician fell below the "standard" in allowing the CPP to drive. Both the methadone and the driving literature are utilized to explain the defendant's and plaintiffs experts' opinions and the differences between them. Based on these opinions, we have attempted to develop some recommendations on how pain physicians should approach the problem of deciding whether patients should be allowed to drive when on COAT.

The DSM Classification of Depressive Disorders: Debating its Utility

Allow me to start this editorial with question. A patient with DSM-IV diagnosis of major depression (or dysthymia) is sitting in front of you. What does the diagnosis tell you about its causes and management strategies? Little of value, I would suggest. A diagnostic system's utility is limited when it advances descriptive categories that are remote from causality, have limited validity and reliability, and fail to provide management options. The DSM model has had its uses, but in light of present knowledge, it is now time to contemplate an update. As most journal readers received their psychiatric education following the introduction of the seminal DSM-III model in 1980, any challenge to this system may appear discomforting and this editorial unnecessarily provocative. The DSM's relevance to most clinicians is high, at least to those who recognize its potential to meet small set of quite practical needs; its lexicon offers ready communication to colleagues and many patients, its status aids the writing of medicolegal reports, and the gravitas of some diagnoses (for example, major depression) assists patients' access to insurance and hospitalization. Its designers, however, were more aspirational. In the introduction to DSM-IV, the Task Force states that the utility and credibility of DSM-IV require that it focus on its clinical, research, and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide helpful guide to clinical practice . . . An additional goal was to facilitate . . . More than any other nomenclature of mental disorders, DSM-IV is grounded in empirical evidence (p xv-xvi). In this issue of The Canadian Journal of Psychiatry, the utility of the DSM classificatory system for depressive disorders is considered from polarized positions. Being aware of Robert Goldney's support for the system and his capacity to marshal cogent points, I invited him to put forth the argument for maintaining the current DSM model, while I provide an opposing critique. Goldney argues that the DSM operational definitions of broad depressive syndromes, allows a comprehensive description of each depressive episode, and has proven to be ... as an international tool for psychiatric research (1, p 876). In my opposing piece (2), I note intrinsic logical limitations to any strategy that dimensionalizes categories and categorizes dimensional constructs. I suggest that, in practice, DSM categories are poorly defined, its criteria sets are problematic (compromising reliability estimates), and it lacks utility or explanatory power in terms of informing us about causes or treatments. I further suggest that these consequences are hardly surprising when constructs such as major depression are reified without challenge. Such charges proceed beyond being polemical-they are either supported or rejected by evidence. This journal is to be congratulated on initiating such debate, as it allows the parameters to be defined and challenges us to engage further with such issues. Goldney is provoked by my writing style on such matters. While the issues should be debated on their substance, in relation to style, I plead the Ricky Gervais defense: you're not offending someone, you're not doing anything. As colleague once observed, collegiality can be compromising, and every organization should have prickly bastard who keeps asking questions. The question that I raise is: If the DSM provides model for the depressive disorders that compromises and clinical practice, then, and invoking another observation, what's the use of running if we're on the wrong road? Certainly, as Goldney argues, the DSM is influential in offering tool for psychiatric research. Most reports respect the DSM model and describe depressive samples as meeting DSM criteria for major depression or dysthymia. However, being influential does not necessarily imply or demonstrate utility. …

Practitioner Review: Assessment and treatment of refugee children and adolescents who have experienced war‐related trauma

Increasingly clinicians are being asked to assess and treat young refugees, who have experienced traumatic events due to war and organised violence. However, evidence-based guidance remains scarce. Published studies on the mental health difficulties of refugee children and adolescents, associated risk and protective factors, as well as effective interventions, particularly those designed to reduce war-related post-traumatic stress disorder (PTSD) symptoms, were identified and reviewed. The findings are summarised. Young refugees are frequently subjected to multiple traumatic events and severe losses, as well as ongoing stressors within the host country. Although young refugees are often resilient, many experience mental health difficulties, including PTSD, depression, anxiety and grief. An awareness of relevant risk and protective factors is important. A phased model of intervention is often useful and the need for a holistic approach crucial. Promising treatments for alleviating symptoms of war-related PTSD include cognitive behavioural treatment (CBT), testimonial psychotherapy, narrative exposure therapy (NET) and eye movement desensitisation and reprocessing (EMDR). Knowledge of the particular needs of unaccompanied asylum-seeking children (UASC), working with interpreters, cross-cultural differences, medico-legal report writing and the importance of clinician self-care is also necessary. More research is required in order to expand our limited knowledge base.

A review of violent and traumatic deaths in Kathmandu, Nepal

The objective was to study the external causes of death reported in the autopsy centre in Kathmandu, Nepal. A retrospective review of case report documentation of all violent and traumatic death autopsies was conducted in Kathmandu from mid-July 2000 to mid-July 2004. A total of 4383 autopsies were conducted by the Department of Forensic Medicine in Kathmandu. There were 1072 (25%) cases of suicide, 380 (9%) homicide, 1399 (32%) accidental, 598 (14%) deaths as a result of natural diseases and 923 (21%) undetermined causes of death. The number of males was almost twice that of females (sex ratio 2.2:1). Persons aged 15 to 44 years comprised about two-thirds of the total reported fatalities (65.4%). Suicides were mostly reported due to hanging, homicides mostly due to firearms and explosives, accidents mostly due to road traffic injuries. More than 60% of road traffic injuries resulted among pedestrians. Suicides, homicides and accidental deaths remain a poorly identified public health issue in Nepal. Medico-legal autopsy reports can serve as an important tool in understanding fatalities from violence and injuries for countries similar to Nepal. Strengthening a regular mechanism for compilation and utilization of the information, however, remains a major challenge.

Eski ve Yeni Türk Ceza Yasasına Göre Düzenlenen Adli Raporların Karşılaştırılması

Çalışmamızda eski ve yeni TCY’ye göre düzenlenen adli raporlar; travmanın ağırlık derecesinin belirlenmesinde ortaya çıkan değişikliklerin karşılaştırılarak, düzenlenen adli raporların bilimsel ve nesnel kriterlere uygunluğunun ve kişilerin olası hak kayıplarının önlenmesi açısından tartışılması amaçlanmıştır. Mersin Üniversitesi Tıp Fakültesi Adli Tıp Anabilim Dalı’nda 2004-2005 yıllarında düzenlenen adli raporlar eski ve yeni TCY kapsamına göre değerlendirildi. 2004-2005 yıllarında 957 olguya adli rapor düzenlenmiş olup yaş ortalaması 28.6 + 15.5, %.26.4’ü kadın ve %73.6’sı erkekti. En sık görülen travma türlerinin; trafik kazaları (%36.4), kesici delici alet yaralanmaları (%14.4) ve zehirlenmeler (%10.9) olduğu saptandı. Adli raporların %75.3’ünde hayati tehlike olmadığı saptandı. Eski TCY’ye göre yaralanmaların; %42.4’ünde mutad iştigalden geri kalma süresi 0-10 gündü, %11.9’u çehrede sabit eser, %2.7’si uzuv zaafı, %2.6’sı uzuv tatili niteliğindeydi. Yeni TCY’ye göre yaralanmaların; %58.4’ü basit tıbbi müdahale ile giderilemeyecek nitelikteydi, %12.6’sında yüzde sabit iz, %3.7’sinde işlevde sürekli azalma %1.7’sinde işlev yitimi tespit edildi. 337 olguda kemik kırığı mevcut olduğu tespit edildi. Yeni TCY’ye göre kırığın hayat fonksiyonlarına etkisi en sık orta derecedeydi (%56.4). Yeni TCY kapsamında özellikle kemik kırıklarının skorlan-ması ve yüzde sabit iz açısından boyun bölgesinin de yüz sınırları içerisine dahil edilmesi olumlu bir gelişme olmakla birlikte, kemik kırıklarında kullanılan puanlama sisteminin yeniden gözden geçirilmesi, basit tıbbi müdahale, işlevin azalması ve yi 1 timi değerlendirmelerinde daha bilimsel ve nesnel parametreler kullanılması gerektiği kanısındayız.Anahtar kelimeler: Adli rapor, eski TCY, yeni TCY, skorlama

Is Whiplash a Life Event?

General Practitioner (GP) attendances for non-specific disease increase after life events. Whiplash injury has the effect of a life event in some people. The aim of this study was to compare GP attendance rates in the year before and after whiplash injury to establish their rate and cause. Ninety-eight subjects (62 women and 36 men) with whiplash injuries examined for medicolegal reports, with complete GP records for a year before and after injury. The number of attendances and the reason for attendance. Consultations after the accident were subdivided into those for neck pain and for other reasons. Subjects were reviewed more than one year after injury. All described neck pain 11% mild, 62% moderate and 27% severe. GP attendance rates before the accident were within the normal range but increased after (p=0.0001) because of neck pain symptoms. There was no association between attendance rates before and after injury but consultations for neck pain rose in proportion to severity of symptoms (p = 0.0015). Attendances unrelated to neck symptoms fell after injury (p = 0.002). GP attendances for non-specific disorders increase after life events, but not after whiplash injury as patients focus on their neck symptoms.

Letters

In his paper on how to make pressure ulcer prevention and management truly multiprofessional (Journal of Wound Care, May 2005), Dr Michael Clark did not mention doctors. I feel very strongly about this, and wonder if readers would like to comment on the opening remarks I wrote in a recent medico-legal report about a pressure ulcer. This is reproduced, with permission, below:

Report writing for the criminal court

This contribution provides guidance on the preparation of medico-legal reports for the criminal court. The main task is described as translating psychiatric findings into language that the court can understand, including translation into medico-legal language. When accepting instructions, the report writer must provide the court with sufficient information on timescales, etc., to allow the court to function efficiently. Report writers must assure themselves that they have the necessary competence to provide the report and trainees must ensure they are properly supervised. The psychiatrist in court has a dual role, acting for the welfare of the patient/defendant but providing the court with information on the defendant's condition and attendant risk which may be used for non-welfare purposes in sentencing (including longer-than-commensurate sentences). These ethical tensions (and related issues of confidentiality) must be addressed in training and continuing professional development. The central purpose of a medico-legal report is to provide the court with an opinion on mental disorder, its medico-legal consequences and any recommendations arising from the medical assessment. The body of the report should set out the actions taken to produce the report and the ‘facts’ upon which the report's opinion is based. This contribution ends with advice on the management of contractual arrangements with employers in cases where such work is undertaken outside the normal work contract.

Functional capacity evaluation reports for clients with personal injury claims: A content analysis.

Functional capacity evaluations (FCEs) for personal injury claimants are rigorously scrutinized by the stakeholders because of their financial implications. This study examined 51 medico-legal FCE reports for clients all of whom suffered with spinal pain attributed to a motor vehicle accident. The FCEs were completed by 14 occupational therapists. Content analysis of the FCE reports identified categories and sub-categories of objective and subjective information on which occupational therapists reported. They included employment, activities of daily living, pain, functional physical capacities and job demands. Recommendations included the suitability of current and future jobs. However, the reasoning behind occupational therapists' recommendations in the FCE reports was frequently not stated. This content analysis demonstrated that these detailed FCE reports had a consistent focus on work capacity; further, the researchers suggest refinements to FCE reporting practices so that findings, recommendations and predictions about work outcomes for clients are interpreted clearly and realistically.

Medicolegal evaluation of vascular injuries of limbs in Turkey

This study evaluated 372 cases of post-traumatic extremity vessel lesions, for which the Forensic Medicine Council, Istanbul, Turkey prepared medicolegal evaluation reports between 1998 and 2000. The study group ( n=372) comprised of 346 men (93.0%) and 26 women (6.9%), and their ages ranged between 6 and 73 years (30.18 ± 6.13). There were 378 artery (74.5%), and 131 vein injuries (25.5%) out of a total of 509 limb vascular injuries. The most frequently injured arteries and veins were the femoral artery ( n=73), and the deep femoral vein ( n=41), respectively. The causes of injuries were as follows: cutting and stabbing complements, in 160 cases (43.0%); gunshots in 136 cases (36.6%); traffic accidents in 52 cases (14%); work accidents in 23 cases (6.2%); and blunt trauma in one case (0.3%). These injuries were accompanied by local nerve lesions (27.1%), local bone lesions (37.1%), and injuries to other organs (11.0%). The medicolegal assessments by the Forensic Medicine Council showed that there were risk of death in 371 cases. Additionally, there was ‘organ dysfunction’ in 37 (9.9%) and ‘organ loss’ in 53 (14.2%) cases. The results of this study suggested that the main causes of severe vascular injuries (i.e. those accompanied by bone and nerve lesions) had serious consequences such as amputation, permanent disorders or loss of function and were caused by gunshot and traffic accidents.

Psychiatric issues in retrospective challenges of testamentary capacity

Challenges to Wills on the basis of lack of testamentary capacity are likely to increase due to a combination of economic factors, high prevalence of mental disorders in old age and the complexity of many modern families. Geriatric psychiatrists and other experts will be asked to provide expert assessment of the testamentary capacity of individuals whose Wills are being challenged retrospectively. The traditional criteria described in the Banks vs Goodfellow case have been held as the standard for testamentary capacity. However, these criteria may not be comprehensive enough for the coming generation of expert assessors. The literature and selected international case law relevant to testamentary capacity were reviewed. Particular focus is placed on the conceptual and empirical approaches to the assessment of complex capacities that may inform the development of specific legal standards. In addition, 25 consecutive medico-legal reports on retrospective testamentary capacity were analyzed according to co-morbid medical and psychiatric disorders as well as psychosocial and behavioural variables. Illustrative case vignettes are included. The typical profile for retrospective challenges to testamentary capacity included a radical change from a previous Will (72%), where undue influence was alleged (56%), in a testator with no biological children (52%), who executed the Will less than a year prior to death (48%). Co-morbid conditions were dementia (40%), alcohol abuse (28%) and other neurological/psychiatric conditions (28%). While Banks vs Goodfellow continues to provide a sound basis for assessing testamentary (task-specific) capacity, the complexity and subtlety of the issues reflected in these cases highlight the need to go beyond the traditional criteria and assess situation-specific factors. Expert assessors need to determine whether the testator appreciated the consequences of executing or changing a Will, especially when there has been a radical change in the context of a complex or conflictual family environment. Empirical studies addressing the cognitive functions relevant to testamentary capacity and the development of legal standards based on a competency construct may also help to inform retrospective capacity assessments.

A Placebo for the Pain: A Medico-legal Case Analysis

The objectives of this medico-legal case report are to consider the current status of the use of placebos in pain medicine from clinical, ethical, and legal perspectives. The focus of the analysis is a particular case in which the deceptive use of placebo pain therapy on an adolescent gave rise to professional grievances filed by the patient's mother against the physician who ordered and several nurses who administered the placebo. The medical board declined to take disciplinary action against the physician, and disciplinary action by the board of registered nursing against the nurses was successfully challenged by two of the charged nurses in an administrative review. While there is a growing literature that challenges the need for or justification of the deceptive use of placebos, the practice continues and, as the case under consideration indicates, retains some influential supporters. This is a case report from a community hospital. The patient, referred to here as KC, was an adolescent with migraine headaches. The substitution of a placebo (saline solution) for an opioid analgesic (morphine) was made during KC's treatment. The patient's pain subsided sufficiently following the administration of a placebo to permit his discharge from the hospital. The subsequent discovery by the patient's mother of the deceptive use of a placebo prompted her to file charges of professional misconduct against the treating physician and three nurses with their respective professional licensing boards. The medical board declined to take disciplinary action against the physician, and the disciplinary action by the board of registered nursing was successfully challenged in a ruling by an administrative law judge following a hearing in which expert witnesses took conflicting positions on the acceptability of the deceptive use of a placebo. While there is a developing literature that challenges the ethical legitimacy of the deceptive use of placebos in pain medicine, that literature has yet to be recognized as unqualifiedly setting the standard of care or of professionalism in medicine and nursing.

Fatal drug poisonings: medico-legal reports and mortality statistics

The entire fatal drug poisoning panorama in Finland is considered in terms of three categories: accidental, self-inflicted and undetermined (whether accidental or with intent to harm) deaths. The study material consisted of all 500 deaths in 1997 that medical examiners, after examination(s) at the Forensic Toxicology Division (FTD) of the Department of Forensic Medicine, University of Helsinki, officially certified as resulting from drug poisoning. These deaths were matched with data on the same deaths registered at Statistics Finland (SF), the national mortality statistics office. The SF register included 72 additional instances of deaths resulting from drug poisoning. In all but two of these cases, the cause-of-death determination was based on a medico-legal inquest with autopsy and forensic toxicological examination(s) and was certified, in most of the cases, as due to the alcohol component in multiple-toxicant combinations. Reclassifying these deaths at SF to the category of drug component is in accordance with current International Classification of Diseases (ICD-10) regulation of coding “to the medicinal agent when combined with alcohol”; the principle and practice, which is recommended to be amended to equalize the status of alcohol and drug when explicitly stated by a forensic examiner as the principal toxicant in combined poisonings. With regard to manner-of-death, the agreement rates between medico-legally proven deaths from drug poisoning and those registered at SF were 79.8% for accidents, 98.5% for suicides and 0% (nil) for undetermined deaths, at the level of three-character external cause codes (E-code). All deaths originally certified as undetermined were re-assigned, most frequently to the category of accidental death. Since within an advanced and sophisticated medico-legal system, a medical examiner’s evidence-based statement, even when the conclusion reached is undetermined (as to intent), should be taken as a compelling argument, the practice of reclassification cannot be considered advisable because assembled information is lost. Concerning the assigned drug-specific groups, the agreement according to the manner-of-death between certifications and registrations was fairly good. From among the accidents, however, opioid poisonings were re-assigned in 11 (29.7%) cases, mostly to the drug abuse/dependence categories, i.e. they were considered as natural deaths by the statistics office. The drug-specific observations were possible only by using the codes from the Anatomical Therapeutic Chemical (ATC) classification of drugs. This is why the incorporation of ATC codes into the ICD system, whenever reasonable, is recommended.

Myasthenia Gravis

In the past, at Association of British Neurologists’ dinners, I accepted that I was usually the only neurologist in Highland evening dress, but to that idiosyncrasy I can now add...

Functional outcomes following surgical repair of wrist extensor tendons

The long term results following the repair of open injuries to extensors carpi radialis longus and brevis and extensor carpi ulnaris have not previously been reported. A retrospective case note review was performed and patients were called back for assessment following surgical repair. Grip strength and pinch strength were reduced by 9.9% ( p=0.017) and 11.5% ( p=0.049). Wrist movement was also reduced. This demonstrates that the division of these tendons should not be regarded as trivial as they may have long-term adverse effects on wrist function. Information gained from this study may be beneficial in patient education at the time of injury and may provide useful information when preparing medico legal reports.

Medicolegal Reporting in Orthopaedic Trauma

Medicolegal Reporting in Orthopaedic Trauma

Medico-legal rounds: Medico-legal issues and breaches of "standards of medical care" in opioid tapering for alleged opioid addiction.

The objectives of this medico-legal case report are the following: 1) To present an example of a medico-legal problem that developed as a result of reports of alleged opioid addiction that resulted in a decision to taper a chronic pain patient (CPP) from opioids; 2) To present both the plaintiff's and defendant's expert witness opinions as to if and how the care of that patient fell below the "standard of medical care"; and 3) Based on these opinions, to develop some recommendations on how, in the future, pain medicine physicians and other physicians should proceed in similar circumstances in order to avoid allegations of breach of "standard of medical care." Case Report. Regional Hospital Pain Clinic. CPP Interventions. Opioid tapering because of aberrant drug-related behaviors (addictive behaviors). During the tapering process, the CPP committed suicide. This had medico-legal consequences. Expert witnesses could not rule out the possibility of pseudoaddiction in this CPP. Further research into the concept of pseudoaddiction is required.

In reply: Hindsight bias in medicolegal expert reports

In reply: Hindsight bias in medicolegal expert reports

Hindsight bias in medicolegal expert reports.

Malpractice litigation is now a substantial cost in the provision of healthcare. Despite new attitudes of Australian courts towards medical evidence, expert reports remain the cornerstone of most medical negligence cases. There is evidence that hindsight bias, which may cause the expert to simplify, trivialise and criticise retrospectively the decisions of the treating doctor, is inevitable when the expert knows there has been an adverse outcome. If possible, outcome information should be withheld from experts providing reports. If outcome information is not withheld, courts should be made aware of the probability of hindsight bias.