- Email: [email protected]
Continuing Education Programme — Victorian Institute of Forensic Medicine and Department of Forensic Medicine, Monash University
Journal of Clinical Forensic Medicine (2001) 8, 45±47 ß APS/Harcourt Publishers Ltd 2001 doi: 10.1054/jcfm.2001.0470, available online at http://www.idealibrary.com on
Continuing Education Programme Ð Victorian Institute of Forensic Medicine and Department of Forensic Medicine, Monash University SUMMARY. Given the increasing requirement of the courts for forensic experts to engage in ongoing education, a continuing education programme was developed in forensic medicine at the Victorian Institute of Forensic Medicine to cater for both clinicians and pathologists. The programme consists of a series of cases which are circulatged several times per year. All are actual cases and are reflective of the types of presentations experienced in forensic medicine. Each case includes relevant and appropriate details/findings and may include photographs. A series of questions follow which are answered usually in short-answer format. The answers are returned and correlated by a review panel, and a commentary with the response outcome is distributed to all those involved. The cases presented here are selected from this programme. ß APS/Harcourt Publishers Ltd 2001 REFERENCE 1. Gall JA. Continuing education in forensic medicine: an exercise in distance learning. J Clin Forens Med 1997; 4: 117±120
QUARTERLY FORENSIC CLINICOPATHOLOGICAL CASES
FEEDBACK AND COMMENTARY The case relates to an allegation of assault on a prisoner, supposedly by a member or members of staff. You were required to explain what action you would take and why. Dealing with the ®rst part of the question, the responses were somewhat varied. Twelve per cent did not provide an answer to this part and 9% considered it outside their area of expertise (although one of these respondents provided a very good answer). Most respondents stated that they would note the allegations and conduct an examination with many (63%) being more speci®c about what they would do, which included a combination of some or all of the following:
CASE 1 Dr John A. M. Gall BSc, MB, BS, PhD, MACLM, DMJ, Forenic Physician and Co-ordinator, Continuing Education Programme, Victorian Institute of Forensic Medicine, Honorary Senior Lecturer, Department of Forensic Medicine, Monash University, 57±83 Kavanagh St, Southbank, 3006 Australia You are conducting a general medical examination on a prisoner and ®nd a number of bruises and abrasions on his back and thighs highly suggestive of being beaten with a baton at least 10 times. The prisoner alleges that he has been beaten by staff but states that he does not wish to make any complaint for fear of reprisal. Brie¯y explain what action you would take and why.
. . . . . .
Dr John A.M. Gall, Forensic Physician and Co-ordinator, Continuing Education Programme, Victorian Institute of Forensic Medicine, Honorary Senior Lecturer, Department of Forensic Medicine, Monash University, 57±83 Kavanagh St, Southbank, 3006, Victoria, Australia. Tel.: 61 3 9684 4480; Fax: 61 3 9684 481; E-mail: [email protected]
. .
obtain consent for the documentation of the allegations and ®ndings con®rm con®dentiality of the information take detailed notes of the allegations document the injuries photograph the injuries conduct any medical investigations (e.g. X-rays, etc) that may be warranted treat the injuries if necessary discuss options for appropriate action (reporting the matter to the authorities) with the patient.
Other actions raised by a few included: 45
46 . . . . . .
.
Journal of Clinical Forensic Medicine seek advice on what to do from more senior medical staff consider the possibility that the injuries are selfin¯icted arrange protection of the prisoner observe and review the prisoner inform human rights groups inform the press if the matter was ignored by prison authorities (an approach that the reviewer feels may not be entirely productive) remove the prisoner from his/her current location.
Most raised the issue of only divulging the information to authorities upon authorization from the prisoner with a signi®cant number (30%) planning to report the matter to the authorities without the patient's consent. It should be noted that for respondents from some countries, there was a legal obligation to report the matter. Although most would document their ®ndings, only two respondents raised concerns about the security and real con®dentiality of the medical notes. Three expressed concerns about dealing with these situations in prisons and raised issues about protecting prisoners in environments where warder brutality persisted. With regards the second part of the question, most indicated a need to have the allegations and injuries documented should the issue be investigated further by the authorities. Only a few provided a reason(s) for reporting the case to the authorities.
THE CASE This is an interesting case which raises issues relating to the doctor's involvement in the provision of health care within the custodial system. There are two matters that need to be considered and these provide the reasons as to why the doctor should take or not take any action. Firstly, the doctor is bound by both international instruments and medical ethics not to become involved in any activity which may contribute to acts of abuse or torture.1 It may also be argued successfully that for the doctor to do nothing to prevent such acts is a form of participation. Secondly, the relationship between the medical of®cer and the prisoner is that of doctor to patient which includes respecting and ensuring medical con®dentiality. With this in mind, there would appear to be two questions to consider: 1. should consideration be taken of the prisoner's fear of reprisal? 2. should the matter be reported to the prison director/warden or other authority?
To be brief, the answer to both questions should be `yes', particularly if the allegations appear to be legitimate. Local circumstances will dictate the degree of concern that there may be for reprisal and if there are concerns, how best to manage the patient to stop this occurring. The alleged assault should be reported and investigated but consideration must be given to the patient's wishes, and the con®dentiality of the consultation preserved unless otherwise authorized. In some jurisdictions, and under some extenuating circumstances, reporting of assaults may be appropriate without the consent of the victim. REFERENCES 1. Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhumane or Degrading Treatment or Punishment. United Nations General Assembly resolution 371194 of 18th December 1982
CASE 2 Dr John A. M. Gall BSc, MB, BS, PhD, MACLM, DMJ, Forenic Physician and Co-ordinator, Continuing Education Programme, Victorian Institute of Forensic Medicine, Honorary Senior Lecturer, Department of Forensic Medicine, Monash University, 57±83 Kavanagh St, Southbank, 3006 Australia Consider the following case. You have attended at a detention centre at the request of police to examine a male person, X, who assaulted another person on that day. X appears to be alcohol affected (drowsy and smelling of alcohol) but consents to your examination of him and to the taking of a sample of blood for the express purposes of determining his blood alcohol concentration (BAC). You examine X, collect a sample of blood and provide the police with a report detailing your ®ndings. The sample is given to the police at the time of the examination who arrange for it to be analyzed in their laboratory. Some months later you receive a subpoena to attend a committal hearing regarding X. In the witness box, the defence barrister provides you with the laboratory analysis of X's blood (the ®rst time you have seen or become aware of the results). It reveals a BAC of 0.214% and the presence of metabolites of heroin and benzodiazepines. Do you have any concerns about this case? Brie¯y list them.
Continuing Education Programme FEEDBACK AND COMMENTARY This case was set as an activity for the subject, Custodial Medicine, of the Graduate Diploma of Forensic Medicine (Monash University) as well as being used for the Continuing Education Programme (CEP). The responses from the diploma students were very good, but those received from the CEP group were varied. Two CEP respondents considered the case outside their area and two did not identify the issues of the case. Most of the remainder raised the issue of consent which was the principal purpose of this case. The main concerns raised were: a. Was the person ®t to given consent to your examination and the taking of the blood sample (and their implications) particularly in the light of his appearing to be alcohol-affected and given the laboratory ®ndings? At a BAC of 0.214%, it is highly unlikely that he was ®t to give consent to any procedure/examination and clinically this should have been evident. b. Consent (whether valid or not) was only given for the blood to be analyzed for its alcohol content. There was no consent for any other analysis. c. Was consent provided by the subject for the release of the clinical ®ndings to the police and, if it was, was it valid? Again, consent, whether given or not, was most probably not valid. d. The person most probably would have been un®t for police interview if he had been interviewed immediately prior to or shortly after the medical examination. e. The person was probably un®t to be detained in a police cell. f. The results of the examination and laboratory ®ndings may be inadmissible in a court of law given the absence of valid consent.
47
g. Is the doctor liable to a charge of assault (trespass/ battery)? Only two people alluded to this!! Depending upon legislation current in your jurisdiction, the answer to this concern is `yes'. There are defences against liability and these include whether the practitioner: i. performed the procedure in an emergency situation (not the case here) ii. obtained effective waiver of liability from the patient (not the case here) iii. acted strictly in accordance with an overriding statue (probably not the case here as there was not a court order for the examination and procedure). Whether the doctor would be charged or not would depend upon the subject. Other matters raised in the answers included: a. The need for the examining doctor to exclude other causes of drowsiness such as a head injury. b. The failure of the prosecution to advise you of the laboratory ®ndings before court. In the Victorian jurisdiction, it is very rare that forensic physicians are provided with the result of any police laboratory ®ndings before attending court regarding the case. c. Concern that the detained person was unable to select their own physician to satisfy the Declaration of Lisbon. d. Independent analysis of blood samples ± this sample was analyzed by the police. This is an important issue and certainly one that the advocates of DNA data banks apparently have not publicly raised. e. Two respondents queried whether the person would have been capable of assaulting anyone given his level of inebriation. Clinical experience shows that at this and higher BAC levels, aggression is not uncommon and is certainly possible.
Continuing Education Programme Ð Victorian Institute of Forensic Medicine and Department of Forensic Medicine, Monash University SUMMARY. Given the increasing requirement of the courts for forensic experts to engage in ongoing education, a continuing education programme was developed in forensic medicine at the Victorian Institute of Forensic Medicine to cater for both clinicians and pathologists. The programme consists of a series of cases which are circulatged several times per year. All are actual cases and are reflective of the types of presentations experienced in forensic medicine. Each case includes relevant and appropriate details/findings and may include photographs. A series of questions follow which are answered usually in short-answer format. The answers are returned and correlated by a review panel, and a commentary with the response outcome is distributed to all those involved. The cases presented here are selected from this programme. ß APS/Harcourt Publishers Ltd 2001 REFERENCE 1. Gall JA. Continuing education in forensic medicine: an exercise in distance learning. J Clin Forens Med 1997; 4: 117±120
QUARTERLY FORENSIC CLINICOPATHOLOGICAL CASES
FEEDBACK AND COMMENTARY The case relates to an allegation of assault on a prisoner, supposedly by a member or members of staff. You were required to explain what action you would take and why. Dealing with the ®rst part of the question, the responses were somewhat varied. Twelve per cent did not provide an answer to this part and 9% considered it outside their area of expertise (although one of these respondents provided a very good answer). Most respondents stated that they would note the allegations and conduct an examination with many (63%) being more speci®c about what they would do, which included a combination of some or all of the following:
CASE 1 Dr John A. M. Gall BSc, MB, BS, PhD, MACLM, DMJ, Forenic Physician and Co-ordinator, Continuing Education Programme, Victorian Institute of Forensic Medicine, Honorary Senior Lecturer, Department of Forensic Medicine, Monash University, 57±83 Kavanagh St, Southbank, 3006 Australia You are conducting a general medical examination on a prisoner and ®nd a number of bruises and abrasions on his back and thighs highly suggestive of being beaten with a baton at least 10 times. The prisoner alleges that he has been beaten by staff but states that he does not wish to make any complaint for fear of reprisal. Brie¯y explain what action you would take and why.
. . . . . .
Dr John A.M. Gall, Forensic Physician and Co-ordinator, Continuing Education Programme, Victorian Institute of Forensic Medicine, Honorary Senior Lecturer, Department of Forensic Medicine, Monash University, 57±83 Kavanagh St, Southbank, 3006, Victoria, Australia. Tel.: 61 3 9684 4480; Fax: 61 3 9684 481; E-mail: [email protected]
. .
obtain consent for the documentation of the allegations and ®ndings con®rm con®dentiality of the information take detailed notes of the allegations document the injuries photograph the injuries conduct any medical investigations (e.g. X-rays, etc) that may be warranted treat the injuries if necessary discuss options for appropriate action (reporting the matter to the authorities) with the patient.
Other actions raised by a few included: 45
46 . . . . . .
.
Journal of Clinical Forensic Medicine seek advice on what to do from more senior medical staff consider the possibility that the injuries are selfin¯icted arrange protection of the prisoner observe and review the prisoner inform human rights groups inform the press if the matter was ignored by prison authorities (an approach that the reviewer feels may not be entirely productive) remove the prisoner from his/her current location.
Most raised the issue of only divulging the information to authorities upon authorization from the prisoner with a signi®cant number (30%) planning to report the matter to the authorities without the patient's consent. It should be noted that for respondents from some countries, there was a legal obligation to report the matter. Although most would document their ®ndings, only two respondents raised concerns about the security and real con®dentiality of the medical notes. Three expressed concerns about dealing with these situations in prisons and raised issues about protecting prisoners in environments where warder brutality persisted. With regards the second part of the question, most indicated a need to have the allegations and injuries documented should the issue be investigated further by the authorities. Only a few provided a reason(s) for reporting the case to the authorities.
THE CASE This is an interesting case which raises issues relating to the doctor's involvement in the provision of health care within the custodial system. There are two matters that need to be considered and these provide the reasons as to why the doctor should take or not take any action. Firstly, the doctor is bound by both international instruments and medical ethics not to become involved in any activity which may contribute to acts of abuse or torture.1 It may also be argued successfully that for the doctor to do nothing to prevent such acts is a form of participation. Secondly, the relationship between the medical of®cer and the prisoner is that of doctor to patient which includes respecting and ensuring medical con®dentiality. With this in mind, there would appear to be two questions to consider: 1. should consideration be taken of the prisoner's fear of reprisal? 2. should the matter be reported to the prison director/warden or other authority?
To be brief, the answer to both questions should be `yes', particularly if the allegations appear to be legitimate. Local circumstances will dictate the degree of concern that there may be for reprisal and if there are concerns, how best to manage the patient to stop this occurring. The alleged assault should be reported and investigated but consideration must be given to the patient's wishes, and the con®dentiality of the consultation preserved unless otherwise authorized. In some jurisdictions, and under some extenuating circumstances, reporting of assaults may be appropriate without the consent of the victim. REFERENCES 1. Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhumane or Degrading Treatment or Punishment. United Nations General Assembly resolution 371194 of 18th December 1982
CASE 2 Dr John A. M. Gall BSc, MB, BS, PhD, MACLM, DMJ, Forenic Physician and Co-ordinator, Continuing Education Programme, Victorian Institute of Forensic Medicine, Honorary Senior Lecturer, Department of Forensic Medicine, Monash University, 57±83 Kavanagh St, Southbank, 3006 Australia Consider the following case. You have attended at a detention centre at the request of police to examine a male person, X, who assaulted another person on that day. X appears to be alcohol affected (drowsy and smelling of alcohol) but consents to your examination of him and to the taking of a sample of blood for the express purposes of determining his blood alcohol concentration (BAC). You examine X, collect a sample of blood and provide the police with a report detailing your ®ndings. The sample is given to the police at the time of the examination who arrange for it to be analyzed in their laboratory. Some months later you receive a subpoena to attend a committal hearing regarding X. In the witness box, the defence barrister provides you with the laboratory analysis of X's blood (the ®rst time you have seen or become aware of the results). It reveals a BAC of 0.214% and the presence of metabolites of heroin and benzodiazepines. Do you have any concerns about this case? Brie¯y list them.
Continuing Education Programme FEEDBACK AND COMMENTARY This case was set as an activity for the subject, Custodial Medicine, of the Graduate Diploma of Forensic Medicine (Monash University) as well as being used for the Continuing Education Programme (CEP). The responses from the diploma students were very good, but those received from the CEP group were varied. Two CEP respondents considered the case outside their area and two did not identify the issues of the case. Most of the remainder raised the issue of consent which was the principal purpose of this case. The main concerns raised were: a. Was the person ®t to given consent to your examination and the taking of the blood sample (and their implications) particularly in the light of his appearing to be alcohol-affected and given the laboratory ®ndings? At a BAC of 0.214%, it is highly unlikely that he was ®t to give consent to any procedure/examination and clinically this should have been evident. b. Consent (whether valid or not) was only given for the blood to be analyzed for its alcohol content. There was no consent for any other analysis. c. Was consent provided by the subject for the release of the clinical ®ndings to the police and, if it was, was it valid? Again, consent, whether given or not, was most probably not valid. d. The person most probably would have been un®t for police interview if he had been interviewed immediately prior to or shortly after the medical examination. e. The person was probably un®t to be detained in a police cell. f. The results of the examination and laboratory ®ndings may be inadmissible in a court of law given the absence of valid consent.
47
g. Is the doctor liable to a charge of assault (trespass/ battery)? Only two people alluded to this!! Depending upon legislation current in your jurisdiction, the answer to this concern is `yes'. There are defences against liability and these include whether the practitioner: i. performed the procedure in an emergency situation (not the case here) ii. obtained effective waiver of liability from the patient (not the case here) iii. acted strictly in accordance with an overriding statue (probably not the case here as there was not a court order for the examination and procedure). Whether the doctor would be charged or not would depend upon the subject. Other matters raised in the answers included: a. The need for the examining doctor to exclude other causes of drowsiness such as a head injury. b. The failure of the prosecution to advise you of the laboratory ®ndings before court. In the Victorian jurisdiction, it is very rare that forensic physicians are provided with the result of any police laboratory ®ndings before attending court regarding the case. c. Concern that the detained person was unable to select their own physician to satisfy the Declaration of Lisbon. d. Independent analysis of blood samples ± this sample was analyzed by the police. This is an important issue and certainly one that the advocates of DNA data banks apparently have not publicly raised. e. Two respondents queried whether the person would have been capable of assaulting anyone given his level of inebriation. Clinical experience shows that at this and higher BAC levels, aggression is not uncommon and is certainly possible.