Medico-legal Procedures Research Articles

Attribution to abusive head trauma (AHT): Proposal of a checklist for use in medico-legal procedures

Attribution to abusive head trauma (AHT): Proposal of a checklist for use in medico-legal procedures

Transsexuality under Surveillance in Iran

Recent scholarly research on the Iranian transsexual raises significant issues about the position of Islam toward members of the transsexual community and about the challenges facing sexual lifestyles that are aberrant to heteronormative behavior in Iran. In 1967, the exiled Ayatollah Ruhollah Khomeini published a fatwa declaring that there is no religious restriction on sex reassignment surgery for hermaphrodites. In 1985, he issued an appendage to this fatwa to include transsexuals suffering from gender dysphoria. This reissuance impelled the process that culminated in new state-sanctioned medico-legal procedures regarding transsexuality as it has shifted from a method of reconciling one’s gender dysphoria to a medical, legal, and religious policing of sexuality. This paper examines the evolution of Khomeini’s original fatwa to argue that the Iranian ulama are manipulating Khomeini’s fatwa and using it as a medicalization device to enforce sexually normative behavior and shape sexual desires through state-sanctioned and governmentally implemented surgery.

Marks of autopsy and identification of victims of human rights violations exhumed from cemeteries: the case of the Spanish Civil War (1936–1939)

The presence of autopsy marks in human skeletal remains indicates a medicolegal procedure related to ascertaining the cause and manner of death. We present here four cases where signs of autopsy were observed in the remains recovered from mass graves and cemeteries of prisoners from the Spanish Civil War (1936-1939), victims of extrajudicial executions, and of death in prison, respectively. With respect to the former, historical evidence indicate that during the first weeks after the coup, official removal of cadavers and autopsy procedures were carried out to the first victims of extrajudicial killings, whose corpses were found abandoned in the road. Once the civil war was established and systematic extrajudicial killings were systematic, official military orders were issued to stop standard forensic proceedings. Therefore, autopsy marks observed in the remains exhumed from mass graves located in cemeteries may be indicative of an earlier chronology of the killings, and this information proved to be relevant for the identification process in one of the cases presented. In a cemetery of political prisoners, autopsy signs were also observed in two skeletal remains and in the official records of two prisoners, a corroboration of information also relevant for the identification process. These findings indicate that autopsy marks can be found in the remains of victims of human rights violations exhumed from cemeteries. Skeletal and archival information could be useful for the identification process in other cases of large-scale violence, where the first victims of extrajudicial executions were buried unidentified in cemeteries after autopsy procedures.

Is the Medicolegal Issue Avoidable in Neurosurgery? A Retrospective Survey of a Series of 115 Medicolegal Cases from Public Hospitals

Since the mid-1950s, neurosurgery has benefited from the remarkable progress due to tremendous advances in neuroimaging techniques, neuroanesthesia, neurostimulation, and brain-computer interfaces, as well as breakthroughs in operating microscopes and surgical instruments. Yet, this specialty has to do with delicate human structures and is hence considered as highly risky by insurance companies. In France, although neurosurgery's casualty rate (6%) is lower than in other specialties, the number of legal prosecutions has increased since 2002 because of easier access to medicolegal procedures. In order to avoid patients' resorting to the law courts, it becomes necessary to clearly identify the risk factors. From the data bank of the insurer Société Hospitalière d'Assurances Mutuelles (SHAM, main insurance company for public hospitals in France), we retrospectively analyzed 115 files (34 cranial and 81 spinal surgeries) covering the period 1997-2007 for the reasons for complaints against French neurosurgeons working in public hospitals. Five main causes were identified: surgical site infection (37%), technical error (22%), lack of information (14%), delayed diagnosis (11%), and lack of supervision (9%). Some causes are definitely avoidable at no cost to the hospital. Besides basic preventive safety procedures, we reiterate the mandatory steps for a good defense when being prosecuted. The evolution of patients' attitudes toward medical institutions observed in most countries has forced surgeons to adapt their practice. In this context, a common action certified by learned societies on sustainable health care quality, patient safety, and respect of good practices appears as the golden path to maintain a favorable legal, insurance, and financial environment.

Sexual offences – selected cases

Expert testimony on violence victims also includes victims of sexual assault. The role of an expert is to classify the injuries by their severity as defined in art. 157 156 or 217 of the Criminal Code pertaining to crimes against health and life. Also, the role of an expert opinion is to determine whether the injuries identified during the exam occurred at the time and under the circumstances stated in medical history. The examination of sexual assault victims is conducted by two experts: a gynecologist and a forensic physician. Most examinations are performed at different times and various medical centers. The conclusions are presented in an official report. Regardless of victim age, all sexual crimes are investigated ex officio by the Police Department and the Prosecutor's Office. Further legal classification of criminal offenses is the task of an appropriate legal body and the offenses are codified in accordance with the provisions of chapter XXV of the Criminal Code, articles 197 - 205. In controversial cases, i.e. when two different expert opinions appear on the same case, or if, according to the law enforcement, a medical opinion is insufficient for some reason, an appropriate expert or team of experts is appointed to resolve the problem. To present selected cases of sexual violence victims treated at the Department of Gynecology and assessed at the Department of Forensic Medicine with reference to the challenges regarding qualification of the sustained injuries and clinical diagnoses. Research material included selected forensic opinions developed for law enforcement offices that involved victims of sexual violence. The expert opinions were prepared either on the basis of submitted evidence, or both, submitted evidence and examination of the victim at the Department of Forensic Medicine. Moreover the article presents a case of a patient examined and treated at the Department of Gynecology in Poznan. Based on the selected cases, the authors conclude that a medico-legal expert cannot uncritically accept previous diagnoses. Moreover every expert is given the right and obligation to verify them. The need for complete, rapid and almost simultaneous colaboration between physicians in charge of the case, forensic doctors, police officers and prosecutors was demonstrated. Lack of cooperation may give rise to different opinions, leading to unnecessary elongation of the medico-legal procedures. It was observed that time plays a crucial role if qualification of an injury is required. The obligation of medical staff to inform the law enforcement about all cases of child abuse was also emphasized.

Siyatik Sinir Enjeksiyon Nöropatileri: Bir Elektrofizyoloji Laboratuarının Tecrübesi ve Türkiye'de Medikolegal Yaklaşım

Correspondence Address/Ya z›fl ma Ad re si: Aysegul Gunduz MD, Istanbul University Cerrahpasa School of Medicine, Department of Neurology, Istanbul, Turkey Gsm: +90 542 745 20 95 E-mail: draysegulgunduz@yahoo.com Re cei ved/Ge lis ta ri hi: 06.26.2011 Ac cep ted/Ka bul ta ri hi: 07.31.2011 © Arc hi ves of Neu ropsy chi atry, pub lis hed by Ga le nos Pub lis hing / © No rop si ki yat ri Ar si vi Der gi si, Ga le nos Ya yi ne vi ta ra f›n dan ba s›l m›fl t›r. ABS TRACT Objective: The gluteal region is usually the preferred site for intramuscular injections. However, reported complications include pain, abscess formation, hematoma formation and peripheral nerve injury, most frequently sciatic nerve injury. Here, we aimed to analyze the demographical, clinical and electrophysiological features of patients with sciatic nerve injury following gluteal intramuscular injections and to summarize the legal procedure in Turkey. Methods: We retrospectively investigated the clinical and electrophysiological features of 33 patients who were admitted to our electrophysiology department between January 1995 and June 2006 with symptoms and signs of sciatic nerve injury which appeared after intramuscular injection in the gluteal region and we reviewed the legal procedure. Results: There were 16 male (48.5%) and 17 female (51.5%) patients. Age range was between 1.5 and 81 years. The interval between nerve injury and admission to our laboratory ranged from 20 days to 25 years. 24 patients were admitted within 6 months after the injury, 32, within 1 year and, only one was admitted after 25 years. The patients who were admitted within the first 6 months after the injury, were commonly admitted for diagnosis and determination of prognosis, whereas the patients in the late periods were referred as a part of medico-legal procedure. All patients expressed burning and shock-like pain radiating to the whole lower extremity. The other symptoms were weakness (50%), numbness (9.1%), and paresthesia (4.5%). Electrophysiologically, both divisions of the sciatic nerve were affected in 9 (27.2%) and axonal involvement of the lateral division predominated in the remaining patients. Conclusion: Injection neuropathy constitutes the major part of the sciatic nerve injuries. Most frequent symptoms are burning pain and weakness. In any traumatic sciatic neuropathy, the peroneal nerve seems to be involved more frequently resulting from the more lateral and superficial location of the fibers supplying the peroneal nerve. Axonal involvement is generally predominating in injection neuropathies. Patients even in the late period are referred to the electrophysiology laboratory for determination of sequela and medico-legal procedures. All medical staff should be aware of clinical and electrophysiological findings and medicolegal approach in this condition. (Arc hi ves of Neu ropsy chi atry 2012; 49: 208-211)

Interpretation of neuropathological lesions: Its limitations in medico-legal experts’ reports

Aggressive or paradoxical behaviour may reflect an organic dementia. The most frequent is Alzheimer's disease, which results from an abnormal structural conformation of tubulin-associated protein (tau) and beta-amyloid protein that, respectively, aggregate in certain neurons as intracellular neurofibrillary tangles (NFTs) and in the extracellular environment as senile plaques. These lesions progress in the brain tissue according to the stages described by Braak and Braak. Staging of neurofibrillary pathology has proven anatomical and clinical correlation, which can be used in a medico-legal procedure. We report two cases demonstrating discrepancies between anatomical and clinical features, which should encourage medical expert to prudence when interpreting neuropathological reports.

Sexual violence legislation in sub-Saharan Africa: the need for strengthened medico-legal linkages

Six sub-Saharan African countries currently have laws on sexual violence, including Kenya, and eight others have provisions on sexual violence in other legislation. Effective legislation requires functioning medico-legal linkages to enable both justice to be done in cases of sexual violence and the provision of health services for survivors of sexual violence. The health sector also needs to provide post-rape care services and collect and deliver evidence to the criminal justice system. This paper reviews existing data on sexual violence in sub-Saharan Africa, and summarises the content of sexual violence legislation in the region and the strengths and weaknesses of existing medico-legal linkages, using Kenya as a case study. Many sub-Saharan African countries do not yet have comprehensive post-rape care services, nor substantial co-ordination between HIV and sexual and reproductive health services, the legal and judicial systems, and sexual violence legislation. These need to be integrated by cross-referrals, using standardised referral guidelines and pathways, treatment protocols, and medico-legal procedures. Common training approaches and harmonised information across sectors, and common indicators, would facilitate government accountability. Joint and collaborative planning and working at country level, through sharing of information and data between the different systems remain key to achieving this.

Ethical issues in medico-legal exposures

The Medical Exposure Directive (MED) 97/43/Euratom defines medico-legal procedures as 'procedures performed for insurance or legal purposes without a medical indication'. The term 'medico-legal exposures' covers a wide range of possible types of exposures, very different in nature, for which the only feature in common is the fact that the main reason for performing them does not relate directly to the health of the individual being exposed to ionising radiation. The key issue in medico-legal exposures is justification. Balancing the advantages and disadvantages of such exposures is complex because not only can these be difficult to quantify and hence compare, but often the advantage may be to society whereas the disadvantage is usually to an individual. This adds an additional layer of ethical complexity to the problem and one, which requires input from a number of sources beyond the established radiation protection community. Because medico-legal exposures are considered to be medical exposures, they are not subject to dose limits. In medico-legal exposures where the benefit is not necessarily to the individual undergoing the exposure, the question must be asked as to whether or not this is an appropriate framework within which to conduct such exposures. This paper looks at the current situation in Europe, highlighting some of the particular problems that have arisen, and tries to identify the areas, which require further clarification and guidance.

International collaboration in mass disasters involving foreign nationals within the EU: medico-legal investigation of Finnish victims of the Milan Linate airport SAS SK 686 aircraft accident on 8 October 2001.

Identification of and investigation into the cause of death of foreign nationals in mass disasters are generally conducted according to the jurisdiction of the country in which the disaster occurs. However, such identification can be achieved only through co-operation with the authorities of the victims' countries of residence. On October 8th 2001 at Linate airport in Milan, Italy, an MD87 SAS airplane with 110 crew members and passengers on board collided on the ground with a Cessna Citation II jet with 2 pilots and 2 passengers. The plane then caught fire after having crashed into an airport baggage hangar causing the death of 4 other victims among the groundstaff. The accident claimed a total of 118 victims of 9 nationalities. Based on our experience from investigation of the Finnish victims, we explore how current national legislations of the EU member states and varying compliance with existing recommendations may influence the medico-legal investigation of a mass disaster. Legislative measures and further harmonisation of medico-legal procedures in connection with mass disasters within the EU are needed.

Consent Issues in Medico-Legal Procedures: How Competent Are Children to Make Their Own Decisions?

The rights and competence of children in relation to medico-legal matters (for example, medical and/or psychological treatment, custody dispute) have become matters with which professionals have been expected to become more familiar. These issues are reviewed in terms of addressing the criteria of age and psychological maturity and their significance for determining a child's competence for making decisions when consent is involved. Evidence indicates that assessment of a child's competence to make informed decisions requires systematic examination of a number of important considerations and factors over and above the child's age and wishes.

Forensic evidence collection for sexual assault: a South African perspective

The incidence of rape in South Africa is approximately 300 per 100 000 women, with a conviction rate of approximately 10% of cases. Poor medical evidence is responsible in part for the low conviction rate. The district surgeon system that was responsible for medico-legal procedures and examinations is being phased out which has left the examination of sexual offences to all state employed medical practitioners. Lack of training and expertise make the present system untenable. There are several proposals being considered and implemented in the Western Cape Province to address this deficiency, which include the formation of ‘one-stop centers’, training, and complete evidence collection kits.

A Review of Death Investigation and Examination Medicolegal Guidelines and Checklists

Abstract The notebook, edited by the Executive Director and the Chairman of the Forensic Sciences Foundation, consists of a ten-part series of guidelines and checklists concerning a variety of medicolegal procedures. The contributors are forensic science experts in their respective fields. These fields include scene investigation, postmortem examination, toxicology, odontology, physical anthropology, and jurisdictional problems. There is also a selected bibliography covering some of the major forensic science areas.

Application of enzyme-linked immunosorbent assay (ELISA) to identification of Anopheles mosquito bloodmeals

The microplate method of the ELISA described by Voller et al. (1974) was manipulated for identification of Anopheles bloodmeals. Blood samples collected from man and from laboratory animals were put in small amounts (1 to 2 μl) on filter paper. Also bloodmeals from A. stephensi fed on human volunteers and guinea-pig were smeared on filter paper one, six 12, 24 and 48 hours after ingestion. The samples were tested by a modified microplate ELISA, using alkaline phosphatase anti-human IgG conjugate. Results showed that ELISA is a quite specific and sensitive technique for the detection of a small amount of human blood, even 24 hours after ingestion by anopheline mosquitoes. The ELISA seems to be a more practical and reproducible method than the precipitin test for identification of arthropod blood-meals, and could also be used for identification of blood spots in forensic laboratories. The anthropophilic index of anopheline mosquitoes is an important factor in the role of different Anopheles mosquitoes in malaria transmission. The technique which has been most commonly used for determination of the source of Anopheles bloodmeals is the precipitin test which was first employed by Uhlenhuth et al. (1908) as a medicolegal procedure for the identification of human blood stains. Later it was used and modified for determining the sources of bloodmeals in mosquitoes and other insects ( King & Bull, 1923 ; Rice & Barber, 1935 ). Although the precipitin test is quite a specific and reliable test, the microplate indirect method of enzyme-linked immunosorbent assay (ELISA) developed by Voller et al. (1974) may be more practical for the identification of human blood in engorged anopheline mosquitoes. The ELISA test has, therefore, been modified for mosquito bloodmeal identification in this study.