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Practice of clinical forensic medicine in Sri Lanka: Does it need a new era?
Legal Medicine 14 (2012) 167–171
Contents lists available at SciVerse ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Practice of clinical forensic medicine in Sri Lanka: Does it need a new era? Sarathchandra Kodikara ⇑ Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
a r t i c l e
i n f o
Article history: Received 25 October 2011 Received in revised form 13 January 2012 Accepted 6 February 2012 Available online 12 April 2012 Keywords: Clinical forensic medicine Practice Sri Lanka
a b s t r a c t Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms. Ó 2012 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice of clinical forensic medicine in Sri Lanka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Service function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Examination for drunkenness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Investigations, referrals and the final report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Subsequent legal procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Undergraduate and in-service training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Postgraduate training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suggestions for reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a coun-
Abbreviations: GMO, Government Medical Officers; MLEF, Medicolegal Examination Form; SLMC, Sri Lanka Medical Council; DLM, Diploma in Legal Medicine; MD, Doctorate in Forensic Medicine; MLR, Medicolegal Report; DMJ, Diploma in Medical Jurisprudence. ⇑ Tel.: +94 777 801286; fax: +94 812 389106. E-mail address: [email protected] 1344-6223/$ - see front matter Ó 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2012.02.003
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try. This includes examination and report on patients of: assault, road traffic and industrial accidents, sexual assault, elder, spousal and child abuse, neglect and starvation, torture, self-infliction, criminal abortion, criminal poisoning, and drunkenness/intoxication by alcohol or any other means. Some of these areas need highly specialised skills for a proper examination and expert opinion. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately [1–3] while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology [4–9]. Unlike
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the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice in this discipline [1,2]. Moreover, the types of practitioners who perform clinical forensic medicine examination, governing laws, framework of examination, vary from one jurisdiction to the other [1–9]. Also, undergraduate and postgraduate training in clinical forensic medicine is different across the world [3–9]. Although the practice of clinical forensic medicine is divergent worldwide, this is rarely a topic of discussion. This paper reviews the current practice of clinical forensic medicine in Sri Lanka with a view to reforming. 2. Practice of clinical forensic medicine in Sri Lanka 2.1. Service function Sri Lanka is an island of 65,610 km2 in size with a population of 21 million, located off the southern coast of the Indian subcontinent. It is surrounded by the Indian Ocean, the Gulf of Mannar and the Palk Strait and lies in the vicinity of India and the Maldives. The country was under Portuguese and Dutch rule during the period of 1505–1815. It was under the British Empire from 1815 to 1948. Consequently, the current legal system of the country is a model of the Roman–Dutch law, heavily inclined by the English law. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers who practice forensic pathology (GMO) devote their daily routine to clinical forensic medicine as well. The day starts with morning clinical forensic rounds followed by autopsy rounds. This is similar to the setup in Egypt and Tunisia, where the forensic medical examiner and the forensic practitioner respectively provide both clinical forensic and forensic pathology services [6,8]. The designated medical officer who practices forensic pathology provides the clinical forensic medicine service in Bangladesh and Uganda [4,5]. Forensic physicians in England, Wales, and Scotland [1,2]; medical officers of public health in the Netherlands [1,2]; forensic medical workers in China [1,2]; and forensic nurses in the Province of Ontario, Canada [10], provide clinical forensic medicine service. In Kentucky, United States of America, forensic examinations are undertaken by emergency medicine physicians [11]. In the Netherlands child sexual abuse cases are examined by a paediatrician while adult sexual abuse victims are examined by a gynaecologist with or without another hospital doctor [12]. In Greece, forensic pathologists are responsible for the forensic examinations in sexual assault cases, while participation of a psychiatrist and a toxicologist is essential in clinical examination of intoxicated patients [13]. Although forensic pathologists in Singapore are consulted in clinical forensic medical cases, they do not routinely examine forensic patients [14]. In Japan, where forensic pathology has achieved a great success, there is less interest in clinical forensic medicine due to limited training and remuneration [15] and it is practiced by private practitioners [1,2]. According to the Criminal Procedure Code of Sri Lanka, when any information before a medical officer who examines a patient discloses a reasonable suspicion that a crime has been committed, he is legally bound to disclose it to the nearest police authority [16]. Where any officer in charge of such police authority considers that the examination of any person by a GMO is necessary for the conduct of an investigation, he may, with the consent of such a person, cause such a person to be examined by a GMO [16]. In addition, during a magisterial hearing, if the magistrate deems that any party before him should undergo a medicolegal examination, then he/she can also refer the patient to GMO [16]. These patients are examined either as in-ward or out patients. The GMO shall report to the police officer or the magistrate, as the case may be, setting out the result of the examination [16].
When such a medicolegal patient does not consent to being so examined, the police officer may apply to a magistrate within whose jurisdiction the investigation is being made for an order authorising a GMO named therein to examine such person and report thereon [16]. Where such an order is made, such a person shall submit to an examination by such GMO who shall report to the magistrate setting out the result of the examination [16]. A patient may be produced for a clinical forensic medical examination through an attorney, for the purpose of filing a civil plaint for compensation. The medicolegal patient comes to the GMO with a prescribed police form called ‘‘Medicolegal Examination Form’’ (MLEF). The MLEF is a brief report which gives information about the nature of the injury, nature of weapon used, the category of injury based on the Penal Code of Sri Lanka [17], and level of intoxication. Although this common form is used to examine the whole range of medicolegal patients, it is exclusively structured towards the assaulted medicolegal patients and does not entirely fit with medicolegal patients of sexual abuse, torture, neglect, starvation, criminal abortion, criminal poisoning, elder and child abuse. Various hierarchical levels of GMO who perform clinical forensic medicine examinations include: (1) an ordinary medical officer with a basic medical degree registered at the Sri Lanka Medical Council (SLMC); (2) Assistant Judicial Medical Officers who have the additional qualification of Diploma in Legal Medicine (DLM); (3) Senior Registrars with DLM and a Doctorate in Forensic Medicine (MD); (4) Board Certified Consultants in Forensic Medicine with a DLM, MD and 1 year post MD overseas training in forensic pathology; and (5) university academics in forensic medicine. However, there is an uneven distribution of these positions throughout the country. Service of many Board Certified Consultants and university academics are concentrated in and around Colombo, the capital city of the country. For clinical medicolegal emergencies such as scene visits, examination of sexual assault victims and alleged assailants, and examination for drunkenness, there is an organised round the clock on call system in all major forensic units. This setup is somewhat equal to the 24-h clinical forensic medical services provided by a forensic medical examiner in London [3], a forensic medical officer in Melbourne [3] and the Ministry of Health doctors in Uganda [4]. These major units in Sri Lanka have physical facilities (e.g. rape kit) for such an emergency examination. However, this is not the case in the majority of peripheral units due to unavailability of the Board Certified Consultants, university academics and physical facilities. As interpreted by law [16], the police authority and magistrates are privileged to select the most suitable GMO to perform the clinical forensic medical examination based upon their qualification and experience of the GMO on a case-by-case basis. However, this privilege is not often used. Mostly the cases in one jurisdiction are referred to the GMO in the same locality, irrespective of their qualification and experience. In such instances, the police authorities and magistrates are rather concerned about the difficulty in transportation of the patient, cost, time and related matters. As such, complicated cases may be referred to an ordinary GMO while routine natural cases are referred to a Professor of Forensic Medicine/ Board Certified Consultant. 2.2. Examination for drunkenness According to the section 151 of the Motor Traffic (amendment) Act No. 40 of 1984 [18], no person shall drive a motor vehicle on a highway after he has consumed alcohol or any drug. Where a police officer suspects that the driver of a motor vehicle on a highway has consumed alcohol, he may require such person to submit himself immediately to a breath test for alcohol or an examination by a
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GMO in order to ascertain whether such a person has consumed alcohol and the person shall comply with any such requirement, as the case may be. Following this amendment act, certain regulations were imposed in this regard. They refer to:
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be taken with the GMO when they are transferred to another station [20]. All the reports should be preserved for at least 25 years [20]. There is no peer-review or quality assurance process to scrutinise the medicolegal reports issued by the GMO. 2.4. Subsequent legal procedures
(1) The breath test for alcohol shall be carried by a police officer by means of a device approved by the Inspector General of Police for that purpose [18]. (2) The concentration of alcohol presents in the persons blood at or above which a person shall be deemed to have consumed alcohol shall be a concentration of 0.8 g of alcohol per 100 ml of blood [18]. (3) He is deemed to have consumed alcohol if he is found to be ‘‘under the influence of alcohol’’ after a clinical examination carried out by a GMO [18]. (4) If he refuses to subject himself either to a clinical examination by a GMO or to a breathalyser test by a police officer, he is presumed to have consumed alcohol unless evidence to the contrary has been adduced [18]. Clinical examination for drunkenness is highly subjective and does not reflect the exact blood alcohol level concentration. Also it is not sufficiently sensitive to detect intoxication at low levels at which experimental evidence has showed impairment of the ability to drive and with increased risks [19]. The clinical diagnosis is made on the positive clinical findings and smell of alcohol. In addition all the clinical symptoms and signs when taken individually can be explained by a cause other than alcohol intoxication. Most of these other causes can be excluded only by observation in a ward. Moreover, a person may be only smelling of alcohol but may be diagnosed as under the influence of alcohol if the positive clinical signs are due to some other medical condition. In addition, a person may be under the influence of alcohol, but may not be smelling of alcohol due to a particular brand of liquor consumed. Likewise, many other non-alcoholic consumable substances can give the smell of alcohol following their consumption, leading to a wrong diagnosis. An analysis of blood and/or urine to determine a blood alcohol level is the best method to determine the blood alcohol concentration. However, there are no legal provisions to request for a sample of blood from the suspect driver. This is a major drawback in current Sri Lankan law in this regard. As clinical examination alone for the diagnosis of drunkenness does not support for an evidenced-based approach, a fair administration of justice is questionable. 2.3. Investigations, referrals and the final report Radiological facilities are routinely available in major forensic units but not in peripheral units. Some basic investigations such as vaginal and penile swab analysis are done by the examining GMO. However, there is no proper agency to analyse other trace evidence collected during clinical forensic examination. The Government Analyst Department, the sole authority of the country for analysing forensic evidence and samples, exclusively provides its services in forensic pathology cases. DNA analysis is expensive and is therefore not performed very often. Most of the peripheral units do not have facilities for microscopic examination, photography and data storage facility. Therefore, reviewable data cannot be produced. A complicated case from a peripheral unit can be referred to the nearest Professor or Consultant. When some cases need integrated approach from a number of health professionals from various other specialities, the patient may be referred to such medical specialists for their opinion. Such an opinion is incorporated into the final report. All notes and reports are the personal property of the examining GMO and should
Criminal courts in Sri Lanka have a hierarchy of four levels: Magistrates Court, High Court, Court of Appeal and Supreme Court of Sri Lanka. There are approximately 75 Magistrate’s Courts in the country and they are vested with original criminal jurisdiction except for the indictable crimes listed in the Criminal Procedure Code [16]. The preliminary trail of the indictable crimes is held by the Magistrate’s Court [16]. The 26 High Courts in the country have original jurisdiction for all criminal prosecutions on indictment [16] in addition to its civil and commercial jurisdiction. The Court of Appeal hears appeals from the High Court and Magistrate’s Court while the Supreme Court is the highest judicial instance. Following the completion of clinical forensic medicine examination, the MLEF is submitted to the issuing police authority. This police authority scrutinises it along with police enquiry findings. If overall findings reveal sufficient evidence as to a crime, the police will file a complaint in the Magistrates Court. The police authority is the prosecutor at this level and sometimes a state counsel may assist with the trial, when the case is crucial. During this trial, if the court needs to obtain more medicolegal information on the patient, summons will be issued to the GMO to submit a detailed report in a printed format. This is called the Medicolegal Report (MLR) and is usually sufficient for the magisterial trial. As such, the relevant GMO is not called upon to give oral testimony at this level. A special authority from Attorney-General is needed to call upon the GMO for a magisterial trial [16]. For minor (non-indictable) offences, the trial will be completed with a verdict at this stage. For major (indictable) offences, following the completion of magisterial trial, the proceedings are submitted to the Attorney-General for his assessment [16]. If the Attorney-General’s assessment reveals sufficient evidence for an indictable crime, then the alleged assailant will be indicted at the High Court [16]. At this stage, the relevant GMO is summoned for oral testimony on his MLEF and MLR. However, the medicolegal issues are usually not seriously argued, as most of the counsels (prosecuting/defence) do not have a sound background knowledge in clinical forensic medicine. Defensive clinical forensic medicine is rarely practised due to an unawareness of its importance and the unavailability of reviewable data. In civil litigation and workmen compensation cases, a MLR is requested by the District Court and Workmen’s Compensation Court, respectively. The District Court has the first instance civil judicial powers while the Workmen’s Compensation Court has workplace compensation jurisdiction. When these two courts require further medicolegal information, the GMO is summoned for oral testimony. 2.5. Undergraduate and in-service training Forensic Medicine is a separate discipline in the local medical undergraduate curriculum. All seven medical faculties have separate Departments of Forensic Medicine and medical undergraduates are exposed to theoretical and hands-on experience in clinical forensic medicine, in addition to forensic pathology. Theoretical knowledge is given by a series of lectures and tutorials while the hands-on experience is gained by examination and reporting on forensic patients and ward classes. Assessment is by way of written question papers and objective structured practical examinations. Scoring pass marks (50% or above) for the subject of forensic medicine is sine qua non to qualify for the final degree programme. However, following graduation, except those who un-
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dergo postgraduate training, other GMO are not exposed to any formal in-service training in clinical forensic medicine. A similar undergraduate training is offered in Bangladesh and Tunisia [5,6]. Although the medical officers are supposed to examine forensic patients in Uganda, the medical schools do not have formal Departments of Forensic Medicine [4].
important in their residency curriculum [6]. Although clinical forensic medicine is an essential component in postgraduate forensic medicine training in France, the course lasts 2 years [7]. There is no formal postgraduate course or accredited certification in clinical forensic medicine in Uganda [4]. 3. Suggestions for reforms
2.6. Postgraduate training The Postgraduate Institute of Medicine, Sri Lanka, which is gazetted by an ordinance and affiliated with the University of Colombo, is responsible for postgraduate training in forensic medicine [21]. Following a screening test, medical graduates with a one-year internship and a minimum of one-year post intern clinical experience, are enroled to the DLM. This consists of a two-year, full time course in clinical forensic medicine and forensic pathology. During this period, in addition to forensic pathology training, trainees while under supervision, gain basic work experience in scene and patient examination. The trainees are also required to prepare and submit a casebook which consists of four clinical forensic cases and six autopsy cases. Approval of the casebook is a prerequisite to qualify for the DLM examination. The examination consists of: (1) a short essay question paper, (2) a long essay question paper, (3) clinical forensic medicine examination and report on three patients, (4) an autopsy examination and report, (5) gross specimen examination and report, (6) examination of histopathological slides and report, and (7) a viva-voce in clinical forensic medicine and forensic pathology. Candidates must pass (with a grade of 50% or above) in all individual components in order to be successful. The number of attempts is unlimited. A similar postgraduate diploma programme is offered in Bangladesh [5]. The Diploma in Medical Jurisprudence (DMJ-Clinical) offered by the Society of Apothecaries of London is an equivalent to DLM. DLM is a prerequisite for the enrolment to the training programme leading to MD. This offers a 2-year full time training in clinical forensic medicine and forensic pathology. In addition to the work experience gained under supervision, the course consists of several forensically oriented clinical rotations: cardiothoracic surgery, ear, nose and throat surgery, dentistry, psychiatry, neuropathology, obstetrics and gynaecology, ophthalmology, orthopaedic surgery, radiology, and sexually transmitted diseases. Non-clinical rotations include forensic toxicology, serology and finger printing. In addition, they are trained as expert witnesses by the Attorney-General Department. Preparation of a case book (four clinical cases including one workman compensation case and six autopsy cases) and its approval is mandatory to qualify for the MD examination. The evaluation components and the pass mark of the MD examination are the same as in DLM. Here too, the number of attempts is unlimited. For the MD examination, an internationally qualified and reputed forensic pathologist with an academic excellence participates as an external examiner in order to maintain the international standards of the examination. A separate expert in clinical forensic medicine is not usually invited for the clinical forensic medicine component. Further, the trainee has to undergo a post MD 1 year local training and 1 year of overseas training at a place of excellence. The post MD local training includes gaining work experience in clinical forensic medicine and forensic pathology under the supervision of a Board Certified Consultant. The post doctoral overseas training is only oriented for forensic pathology and the trainee does not get an opportunity to gain overseas training in clinical forensic medicine at a place of excellence. Despite heavy workload and few funding sources, some attempt at research [22] has been made. Continuing medical education is mostly oriented towards forensic pathology. The forensic medicine residency in Tunisia is an equivalent to this programme and training in clinical forensic medicine remains
To regulate the clinical forensic referral system, a GMO Register for clinical forensic medicine should be maintained by the SLMC. The Register should be available to the judiciary and police authorities, so that they can select the most suitable GMO for the case. Only those medical officers on the Register will be eligible to perform clinical forensic examinations pursuant to a referral. The Register is divided into two categories: (1) GMO eligible to conduct all clinical forensic examinations (e.g. Professors in Forensic Medicine, Board Certified Consultants, Senior Lecturers and Senior Registrars) and (2) GMO eligible to conduct clinical forensic examinations excluding the cases of sexual assault, child abuse, torture, industrial accidents, criminal abortion, and criminal poisoning (e.g. Lecturers, Assistant Judicial Medical Officers and ordinary GMO). The criteria for such division should be based upon educational, experiential and other standards as deemed appropriate by the SLMC. The term on the Register should be renewed following a specific time period. The GMO should meet the renewal criteria such as continuing medical education, experiential, quality assurance requirements and other standards as set out by the SLMC. Reclassification, suspension, or removal from the Register may be done where in the opinion of the SLMC it is in the public interest to do so. Ordinary GMO, who practise medicolegal duties, should be given a proper in-service training in clinical forensic medicine. During the post doctoral training period, the trainee must be given a comprehensive training in clinical forensic medicine in addition to forensic pathology. The postgraduate trainees need to be encouraged and facilitated to sit for and get through the DMJ (clinical) examination. A proper continuing medical education programme, similar to that in the State of Victoria, Australia [23], should be designed and implemented. Distribution of GMO at various hierarchical levels throughout the country should be uniform. Trained consultants must be appointed and physical facilities must be provided for peripheral forensic units to enhance their quality of function. A round the clock, on call system needs to be expanded island-wide, as to cater to all medicolegal emergencies. The units need to be all equipped with microscopic, photographic and data storage facilities, so that the cases would be high in quality and reviewable. The service of the Government Analyst Department should be required to expand to facilitate the department being able to carry out clinical forensic investigations. The MLEF should be reformed in a manner so as to benefit wide spectrum of medicolegal patients. Laws and regulations governing examination of drunkenness need revision, empowering the GMO to analyse blood and urine in order to detect the drunkenness along with clinical examination. A peer-review and quality assurance process must be implemented. The forensic professionals must be encouraged and funded for research in clinical forensic medicine. The professional bodies in the country such as, the College of Forensic Pathologists of Sri Lanka, the Medico-Legal Society of Sri Lanka, the Sri Lanka Medical Association, and the Bar Association of Sri Lanka can start an immediate dialogue on these overwhelming issues. Such dialogue will be fruitful, when it is done in collaboration with governmental policy making and funding agencies such as the SLMC, the Ministries of Health and Justice, and the Postgraduate Institute of Medicine of Sri Lanka.
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Acknowledgements I would like to thank Senior Prof. Cyril Jeffry Babapulle and Dr. M. Dayananda and Dr. Alper Keten for their valuable feedback and Mr. V. Sahadevan and Mr. A. Amjad for assistance in preparing the manuscript. References [1] Payne-James J. The history and development of clinical forensic medicine worldwide. In: Stark MM, editor. A physician’s guide to clinical forensic medicine. Totowa, New Jersey: Humana Press; 2000. p. 1–14. [2] Payne-James J, Busuttil A. History and development of forensic medicine and pathology. In: Payne-James J, Busuttil A, Smock W, editors. Forensic medicine: clinical and pathological aspects. London: Greenwich Medical Media Ltd.; 2003. p. 3–12. [3] Howitt JB. Clinical forensic medicine services: London and Melbourne contrasted. J Clin Forensic Med 1995;2:17–24. [4] Bimenya GS, Bhootra BL, Mukasa N. Forensic medicine services in Ugandapresent and future. J Clin Forensic Med 2005;12:81–4. [5] Islam MN, Islam MN. Forensic medicine in Bangladesh. Leg med 2003;5:357–9. [6] Chadly A. Forensic medicine training in Tunisia. J Clin Forensic Med 1998;5:69–71. [7] Chariot P, Bourokba N, Durigon M. Forensic medicine in France. Am J Forensic Med Pathol 2002;23:403. [8] Kharoshah MAA, Zaki MK, Galeb SS, Moulana AAR, Elsebaay EA. Origin and development of forensic medicine in Egypt. J Forensic Leg Med 2011;18:10–3.
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[9] Salgado MSL. Forensic medicine and medicolegal investigation in Sri Lanka. Am J Forensic Med Pathol 1986;7:137–45. [10] McNair SM, Finigan AB. The role of a forensic clinical nurse specialist in a sexual assault treatment program. J Clin Forensic Med 1996;3:29–30. [11] Smock WS. Development of a clinical forensic medicine curriculum for emergency physicians in the USA. J Clin Forensic Med 1994;1:27–30. [12] Turnbull JA, Hannaford PF, Busuttil A. Dutch and Scottish clinical forensic medicine: a comparison. J Clin Forensic Med 1996;3:15–9. [13] Michalodimitrakis M, Tsatsakis A. The changing status of forensic medicine in Greece. J Clin Forensic Med 1997;4:159–62. [14] Cheng CT. Forensic medicine in Singapore. Am J Forensic Med Pathol 1988;9:179–81. [15] Tsunenari S, Yonemitsu K, Kibayashi K, Miyakita S. Forensic medicine: education and practice in Japan. J Clin Forensic Med 1994;1:9–12. [16] Criminal Procedure Code of Sri Lanka. [17] Penal Code of Sri Lanka. [18] Motor Traffic (amendment) Act No. 40 of 1984. [19] Banks S, Catcheside P, Lack L, Grunstein RR, McEvoy D. Low levels of alcohol impair driving simulator performance and reduce perception of crash risk in partially sleep deprived subjects. Sleep 2004;27:1063–7. [20] Manuel on management of teaching, provincial, base and special hospitals. Ministry of Health and Social Welfare 1995. [21] Regulations and guidelines for Postgraduate Diploma in Legal Medicine and MD in Forensic Medicine, Postgraduate Institute of Medicine Sri Lanka, University of Colombo 2008. [22] Kodikara S. Uneventful recovery from suicidal hanging. Med Sci Law 2006;46:89–91. [23] Gall JA. Continuing education in forensic medicine: an exercise in distance learning. J Clin Forensic Med 1997;4:117–20.
Contents lists available at SciVerse ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Practice of clinical forensic medicine in Sri Lanka: Does it need a new era? Sarathchandra Kodikara ⇑ Department of Forensic Medicine, Faculty of Medicine, University of Peradeniya, Sri Lanka
a r t i c l e
i n f o
Article history: Received 25 October 2011 Received in revised form 13 January 2012 Accepted 6 February 2012 Available online 12 April 2012 Keywords: Clinical forensic medicine Practice Sri Lanka
a b s t r a c t Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a country. Practice of clinical forensic medicine is evolving, but deviates from one jurisdiction to another. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology. Unlike the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice or training in this discipline. Besides, this is rarely a topic of discussion. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers practice both clinical forensic medicine and forensic pathology. Practice of clinical forensic medicine, and its teaching and training in Sri Lanka depicts unique features. However, this system has not undergone a significant revision for many decades. In this communication, the existing legal framework, current procedure of practice, examination for drunkenness, investigations, structure of referrals, reports, subsequent legal procedures, undergraduate, in-service, and postgraduate training are discussed with suggestions for reforms. Ó 2012 Elsevier Ireland Ltd. All rights reserved.
Contents 1. 2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Practice of clinical forensic medicine in Sri Lanka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Service function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Examination for drunkenness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Investigations, referrals and the final report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Subsequent legal procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Undergraduate and in-service training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Postgraduate training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suggestions for reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction Clinical forensic medicine is a sub-specialty of forensic medicine and is intimately associated with the justice system of a coun-
Abbreviations: GMO, Government Medical Officers; MLEF, Medicolegal Examination Form; SLMC, Sri Lanka Medical Council; DLM, Diploma in Legal Medicine; MD, Doctorate in Forensic Medicine; MLR, Medicolegal Report; DMJ, Diploma in Medical Jurisprudence. ⇑ Tel.: +94 777 801286; fax: +94 812 389106. E-mail address: [email protected] 1344-6223/$ - see front matter Ó 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.legalmed.2012.02.003
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try. This includes examination and report on patients of: assault, road traffic and industrial accidents, sexual assault, elder, spousal and child abuse, neglect and starvation, torture, self-infliction, criminal abortion, criminal poisoning, and drunkenness/intoxication by alcohol or any other means. Some of these areas need highly specialised skills for a proper examination and expert opinion. Most English-speaking countries practice clinical forensic medicine and forensic pathology separately [1–3] while most non-English-speaking countries practice forensic medicine which includes clinical forensic medicine and forensic pathology [4–9]. Unlike
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the practice of forensic pathology, several countries have informal arrangements to deal with forensic patients and there are no international standards of practice in this discipline [1,2]. Moreover, the types of practitioners who perform clinical forensic medicine examination, governing laws, framework of examination, vary from one jurisdiction to the other [1–9]. Also, undergraduate and postgraduate training in clinical forensic medicine is different across the world [3–9]. Although the practice of clinical forensic medicine is divergent worldwide, this is rarely a topic of discussion. This paper reviews the current practice of clinical forensic medicine in Sri Lanka with a view to reforming. 2. Practice of clinical forensic medicine in Sri Lanka 2.1. Service function Sri Lanka is an island of 65,610 km2 in size with a population of 21 million, located off the southern coast of the Indian subcontinent. It is surrounded by the Indian Ocean, the Gulf of Mannar and the Palk Strait and lies in the vicinity of India and the Maldives. The country was under Portuguese and Dutch rule during the period of 1505–1815. It was under the British Empire from 1815 to 1948. Consequently, the current legal system of the country is a model of the Roman–Dutch law, heavily inclined by the English law. In the adversarial justice system in Sri Lanka, the designated Government Medical Officers who practice forensic pathology (GMO) devote their daily routine to clinical forensic medicine as well. The day starts with morning clinical forensic rounds followed by autopsy rounds. This is similar to the setup in Egypt and Tunisia, where the forensic medical examiner and the forensic practitioner respectively provide both clinical forensic and forensic pathology services [6,8]. The designated medical officer who practices forensic pathology provides the clinical forensic medicine service in Bangladesh and Uganda [4,5]. Forensic physicians in England, Wales, and Scotland [1,2]; medical officers of public health in the Netherlands [1,2]; forensic medical workers in China [1,2]; and forensic nurses in the Province of Ontario, Canada [10], provide clinical forensic medicine service. In Kentucky, United States of America, forensic examinations are undertaken by emergency medicine physicians [11]. In the Netherlands child sexual abuse cases are examined by a paediatrician while adult sexual abuse victims are examined by a gynaecologist with or without another hospital doctor [12]. In Greece, forensic pathologists are responsible for the forensic examinations in sexual assault cases, while participation of a psychiatrist and a toxicologist is essential in clinical examination of intoxicated patients [13]. Although forensic pathologists in Singapore are consulted in clinical forensic medical cases, they do not routinely examine forensic patients [14]. In Japan, where forensic pathology has achieved a great success, there is less interest in clinical forensic medicine due to limited training and remuneration [15] and it is practiced by private practitioners [1,2]. According to the Criminal Procedure Code of Sri Lanka, when any information before a medical officer who examines a patient discloses a reasonable suspicion that a crime has been committed, he is legally bound to disclose it to the nearest police authority [16]. Where any officer in charge of such police authority considers that the examination of any person by a GMO is necessary for the conduct of an investigation, he may, with the consent of such a person, cause such a person to be examined by a GMO [16]. In addition, during a magisterial hearing, if the magistrate deems that any party before him should undergo a medicolegal examination, then he/she can also refer the patient to GMO [16]. These patients are examined either as in-ward or out patients. The GMO shall report to the police officer or the magistrate, as the case may be, setting out the result of the examination [16].
When such a medicolegal patient does not consent to being so examined, the police officer may apply to a magistrate within whose jurisdiction the investigation is being made for an order authorising a GMO named therein to examine such person and report thereon [16]. Where such an order is made, such a person shall submit to an examination by such GMO who shall report to the magistrate setting out the result of the examination [16]. A patient may be produced for a clinical forensic medical examination through an attorney, for the purpose of filing a civil plaint for compensation. The medicolegal patient comes to the GMO with a prescribed police form called ‘‘Medicolegal Examination Form’’ (MLEF). The MLEF is a brief report which gives information about the nature of the injury, nature of weapon used, the category of injury based on the Penal Code of Sri Lanka [17], and level of intoxication. Although this common form is used to examine the whole range of medicolegal patients, it is exclusively structured towards the assaulted medicolegal patients and does not entirely fit with medicolegal patients of sexual abuse, torture, neglect, starvation, criminal abortion, criminal poisoning, elder and child abuse. Various hierarchical levels of GMO who perform clinical forensic medicine examinations include: (1) an ordinary medical officer with a basic medical degree registered at the Sri Lanka Medical Council (SLMC); (2) Assistant Judicial Medical Officers who have the additional qualification of Diploma in Legal Medicine (DLM); (3) Senior Registrars with DLM and a Doctorate in Forensic Medicine (MD); (4) Board Certified Consultants in Forensic Medicine with a DLM, MD and 1 year post MD overseas training in forensic pathology; and (5) university academics in forensic medicine. However, there is an uneven distribution of these positions throughout the country. Service of many Board Certified Consultants and university academics are concentrated in and around Colombo, the capital city of the country. For clinical medicolegal emergencies such as scene visits, examination of sexual assault victims and alleged assailants, and examination for drunkenness, there is an organised round the clock on call system in all major forensic units. This setup is somewhat equal to the 24-h clinical forensic medical services provided by a forensic medical examiner in London [3], a forensic medical officer in Melbourne [3] and the Ministry of Health doctors in Uganda [4]. These major units in Sri Lanka have physical facilities (e.g. rape kit) for such an emergency examination. However, this is not the case in the majority of peripheral units due to unavailability of the Board Certified Consultants, university academics and physical facilities. As interpreted by law [16], the police authority and magistrates are privileged to select the most suitable GMO to perform the clinical forensic medical examination based upon their qualification and experience of the GMO on a case-by-case basis. However, this privilege is not often used. Mostly the cases in one jurisdiction are referred to the GMO in the same locality, irrespective of their qualification and experience. In such instances, the police authorities and magistrates are rather concerned about the difficulty in transportation of the patient, cost, time and related matters. As such, complicated cases may be referred to an ordinary GMO while routine natural cases are referred to a Professor of Forensic Medicine/ Board Certified Consultant. 2.2. Examination for drunkenness According to the section 151 of the Motor Traffic (amendment) Act No. 40 of 1984 [18], no person shall drive a motor vehicle on a highway after he has consumed alcohol or any drug. Where a police officer suspects that the driver of a motor vehicle on a highway has consumed alcohol, he may require such person to submit himself immediately to a breath test for alcohol or an examination by a
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GMO in order to ascertain whether such a person has consumed alcohol and the person shall comply with any such requirement, as the case may be. Following this amendment act, certain regulations were imposed in this regard. They refer to:
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be taken with the GMO when they are transferred to another station [20]. All the reports should be preserved for at least 25 years [20]. There is no peer-review or quality assurance process to scrutinise the medicolegal reports issued by the GMO. 2.4. Subsequent legal procedures
(1) The breath test for alcohol shall be carried by a police officer by means of a device approved by the Inspector General of Police for that purpose [18]. (2) The concentration of alcohol presents in the persons blood at or above which a person shall be deemed to have consumed alcohol shall be a concentration of 0.8 g of alcohol per 100 ml of blood [18]. (3) He is deemed to have consumed alcohol if he is found to be ‘‘under the influence of alcohol’’ after a clinical examination carried out by a GMO [18]. (4) If he refuses to subject himself either to a clinical examination by a GMO or to a breathalyser test by a police officer, he is presumed to have consumed alcohol unless evidence to the contrary has been adduced [18]. Clinical examination for drunkenness is highly subjective and does not reflect the exact blood alcohol level concentration. Also it is not sufficiently sensitive to detect intoxication at low levels at which experimental evidence has showed impairment of the ability to drive and with increased risks [19]. The clinical diagnosis is made on the positive clinical findings and smell of alcohol. In addition all the clinical symptoms and signs when taken individually can be explained by a cause other than alcohol intoxication. Most of these other causes can be excluded only by observation in a ward. Moreover, a person may be only smelling of alcohol but may be diagnosed as under the influence of alcohol if the positive clinical signs are due to some other medical condition. In addition, a person may be under the influence of alcohol, but may not be smelling of alcohol due to a particular brand of liquor consumed. Likewise, many other non-alcoholic consumable substances can give the smell of alcohol following their consumption, leading to a wrong diagnosis. An analysis of blood and/or urine to determine a blood alcohol level is the best method to determine the blood alcohol concentration. However, there are no legal provisions to request for a sample of blood from the suspect driver. This is a major drawback in current Sri Lankan law in this regard. As clinical examination alone for the diagnosis of drunkenness does not support for an evidenced-based approach, a fair administration of justice is questionable. 2.3. Investigations, referrals and the final report Radiological facilities are routinely available in major forensic units but not in peripheral units. Some basic investigations such as vaginal and penile swab analysis are done by the examining GMO. However, there is no proper agency to analyse other trace evidence collected during clinical forensic examination. The Government Analyst Department, the sole authority of the country for analysing forensic evidence and samples, exclusively provides its services in forensic pathology cases. DNA analysis is expensive and is therefore not performed very often. Most of the peripheral units do not have facilities for microscopic examination, photography and data storage facility. Therefore, reviewable data cannot be produced. A complicated case from a peripheral unit can be referred to the nearest Professor or Consultant. When some cases need integrated approach from a number of health professionals from various other specialities, the patient may be referred to such medical specialists for their opinion. Such an opinion is incorporated into the final report. All notes and reports are the personal property of the examining GMO and should
Criminal courts in Sri Lanka have a hierarchy of four levels: Magistrates Court, High Court, Court of Appeal and Supreme Court of Sri Lanka. There are approximately 75 Magistrate’s Courts in the country and they are vested with original criminal jurisdiction except for the indictable crimes listed in the Criminal Procedure Code [16]. The preliminary trail of the indictable crimes is held by the Magistrate’s Court [16]. The 26 High Courts in the country have original jurisdiction for all criminal prosecutions on indictment [16] in addition to its civil and commercial jurisdiction. The Court of Appeal hears appeals from the High Court and Magistrate’s Court while the Supreme Court is the highest judicial instance. Following the completion of clinical forensic medicine examination, the MLEF is submitted to the issuing police authority. This police authority scrutinises it along with police enquiry findings. If overall findings reveal sufficient evidence as to a crime, the police will file a complaint in the Magistrates Court. The police authority is the prosecutor at this level and sometimes a state counsel may assist with the trial, when the case is crucial. During this trial, if the court needs to obtain more medicolegal information on the patient, summons will be issued to the GMO to submit a detailed report in a printed format. This is called the Medicolegal Report (MLR) and is usually sufficient for the magisterial trial. As such, the relevant GMO is not called upon to give oral testimony at this level. A special authority from Attorney-General is needed to call upon the GMO for a magisterial trial [16]. For minor (non-indictable) offences, the trial will be completed with a verdict at this stage. For major (indictable) offences, following the completion of magisterial trial, the proceedings are submitted to the Attorney-General for his assessment [16]. If the Attorney-General’s assessment reveals sufficient evidence for an indictable crime, then the alleged assailant will be indicted at the High Court [16]. At this stage, the relevant GMO is summoned for oral testimony on his MLEF and MLR. However, the medicolegal issues are usually not seriously argued, as most of the counsels (prosecuting/defence) do not have a sound background knowledge in clinical forensic medicine. Defensive clinical forensic medicine is rarely practised due to an unawareness of its importance and the unavailability of reviewable data. In civil litigation and workmen compensation cases, a MLR is requested by the District Court and Workmen’s Compensation Court, respectively. The District Court has the first instance civil judicial powers while the Workmen’s Compensation Court has workplace compensation jurisdiction. When these two courts require further medicolegal information, the GMO is summoned for oral testimony. 2.5. Undergraduate and in-service training Forensic Medicine is a separate discipline in the local medical undergraduate curriculum. All seven medical faculties have separate Departments of Forensic Medicine and medical undergraduates are exposed to theoretical and hands-on experience in clinical forensic medicine, in addition to forensic pathology. Theoretical knowledge is given by a series of lectures and tutorials while the hands-on experience is gained by examination and reporting on forensic patients and ward classes. Assessment is by way of written question papers and objective structured practical examinations. Scoring pass marks (50% or above) for the subject of forensic medicine is sine qua non to qualify for the final degree programme. However, following graduation, except those who un-
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dergo postgraduate training, other GMO are not exposed to any formal in-service training in clinical forensic medicine. A similar undergraduate training is offered in Bangladesh and Tunisia [5,6]. Although the medical officers are supposed to examine forensic patients in Uganda, the medical schools do not have formal Departments of Forensic Medicine [4].
important in their residency curriculum [6]. Although clinical forensic medicine is an essential component in postgraduate forensic medicine training in France, the course lasts 2 years [7]. There is no formal postgraduate course or accredited certification in clinical forensic medicine in Uganda [4]. 3. Suggestions for reforms
2.6. Postgraduate training The Postgraduate Institute of Medicine, Sri Lanka, which is gazetted by an ordinance and affiliated with the University of Colombo, is responsible for postgraduate training in forensic medicine [21]. Following a screening test, medical graduates with a one-year internship and a minimum of one-year post intern clinical experience, are enroled to the DLM. This consists of a two-year, full time course in clinical forensic medicine and forensic pathology. During this period, in addition to forensic pathology training, trainees while under supervision, gain basic work experience in scene and patient examination. The trainees are also required to prepare and submit a casebook which consists of four clinical forensic cases and six autopsy cases. Approval of the casebook is a prerequisite to qualify for the DLM examination. The examination consists of: (1) a short essay question paper, (2) a long essay question paper, (3) clinical forensic medicine examination and report on three patients, (4) an autopsy examination and report, (5) gross specimen examination and report, (6) examination of histopathological slides and report, and (7) a viva-voce in clinical forensic medicine and forensic pathology. Candidates must pass (with a grade of 50% or above) in all individual components in order to be successful. The number of attempts is unlimited. A similar postgraduate diploma programme is offered in Bangladesh [5]. The Diploma in Medical Jurisprudence (DMJ-Clinical) offered by the Society of Apothecaries of London is an equivalent to DLM. DLM is a prerequisite for the enrolment to the training programme leading to MD. This offers a 2-year full time training in clinical forensic medicine and forensic pathology. In addition to the work experience gained under supervision, the course consists of several forensically oriented clinical rotations: cardiothoracic surgery, ear, nose and throat surgery, dentistry, psychiatry, neuropathology, obstetrics and gynaecology, ophthalmology, orthopaedic surgery, radiology, and sexually transmitted diseases. Non-clinical rotations include forensic toxicology, serology and finger printing. In addition, they are trained as expert witnesses by the Attorney-General Department. Preparation of a case book (four clinical cases including one workman compensation case and six autopsy cases) and its approval is mandatory to qualify for the MD examination. The evaluation components and the pass mark of the MD examination are the same as in DLM. Here too, the number of attempts is unlimited. For the MD examination, an internationally qualified and reputed forensic pathologist with an academic excellence participates as an external examiner in order to maintain the international standards of the examination. A separate expert in clinical forensic medicine is not usually invited for the clinical forensic medicine component. Further, the trainee has to undergo a post MD 1 year local training and 1 year of overseas training at a place of excellence. The post MD local training includes gaining work experience in clinical forensic medicine and forensic pathology under the supervision of a Board Certified Consultant. The post doctoral overseas training is only oriented for forensic pathology and the trainee does not get an opportunity to gain overseas training in clinical forensic medicine at a place of excellence. Despite heavy workload and few funding sources, some attempt at research [22] has been made. Continuing medical education is mostly oriented towards forensic pathology. The forensic medicine residency in Tunisia is an equivalent to this programme and training in clinical forensic medicine remains
To regulate the clinical forensic referral system, a GMO Register for clinical forensic medicine should be maintained by the SLMC. The Register should be available to the judiciary and police authorities, so that they can select the most suitable GMO for the case. Only those medical officers on the Register will be eligible to perform clinical forensic examinations pursuant to a referral. The Register is divided into two categories: (1) GMO eligible to conduct all clinical forensic examinations (e.g. Professors in Forensic Medicine, Board Certified Consultants, Senior Lecturers and Senior Registrars) and (2) GMO eligible to conduct clinical forensic examinations excluding the cases of sexual assault, child abuse, torture, industrial accidents, criminal abortion, and criminal poisoning (e.g. Lecturers, Assistant Judicial Medical Officers and ordinary GMO). The criteria for such division should be based upon educational, experiential and other standards as deemed appropriate by the SLMC. The term on the Register should be renewed following a specific time period. The GMO should meet the renewal criteria such as continuing medical education, experiential, quality assurance requirements and other standards as set out by the SLMC. Reclassification, suspension, or removal from the Register may be done where in the opinion of the SLMC it is in the public interest to do so. Ordinary GMO, who practise medicolegal duties, should be given a proper in-service training in clinical forensic medicine. During the post doctoral training period, the trainee must be given a comprehensive training in clinical forensic medicine in addition to forensic pathology. The postgraduate trainees need to be encouraged and facilitated to sit for and get through the DMJ (clinical) examination. A proper continuing medical education programme, similar to that in the State of Victoria, Australia [23], should be designed and implemented. Distribution of GMO at various hierarchical levels throughout the country should be uniform. Trained consultants must be appointed and physical facilities must be provided for peripheral forensic units to enhance their quality of function. A round the clock, on call system needs to be expanded island-wide, as to cater to all medicolegal emergencies. The units need to be all equipped with microscopic, photographic and data storage facilities, so that the cases would be high in quality and reviewable. The service of the Government Analyst Department should be required to expand to facilitate the department being able to carry out clinical forensic investigations. The MLEF should be reformed in a manner so as to benefit wide spectrum of medicolegal patients. Laws and regulations governing examination of drunkenness need revision, empowering the GMO to analyse blood and urine in order to detect the drunkenness along with clinical examination. A peer-review and quality assurance process must be implemented. The forensic professionals must be encouraged and funded for research in clinical forensic medicine. The professional bodies in the country such as, the College of Forensic Pathologists of Sri Lanka, the Medico-Legal Society of Sri Lanka, the Sri Lanka Medical Association, and the Bar Association of Sri Lanka can start an immediate dialogue on these overwhelming issues. Such dialogue will be fruitful, when it is done in collaboration with governmental policy making and funding agencies such as the SLMC, the Ministries of Health and Justice, and the Postgraduate Institute of Medicine of Sri Lanka.
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