Radiology Cases In Pediatric Emergency Medicine

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CASES



Case 1 - Toxic Infant With a Full Fontanelle
Case 2 - The Stomach Flu ? - The Target, Crescent, and Absent Liver Edge Signs
Case 3 - Abdominal Pain With a Negative Abdominal Examination
Case 4 - Persistent Abdominal Pain
Case 5 - Cervical Spine Malalignment - True or Pseudo Subluxation ?
Case 6 - Diminished Breath Sounds and Air in the Chest
Case 7 - Hamman's Sign
Case 8 - Foreign Body Aspiration in a Child
Case 9 - Respiratory Distress: That's a Tension Pneumothorax, Isn't It ?
Case 10 - Drooling, Stridor, and a Barking Cough: Croup ??
Case 11 - Elbow Ossification Centers in a Child
Case 12 - Radiographic Examination of the Elbow - The Hourglass Sign
Case 13 - Child With a Sprained Wrist
Case 14 - A Hand Contusion
Case 15 - Monteggia's Injury
Case 16 - Galeazzi's Injury
Case 17 - Elbow Sprain in a Child
Case 18 - Salter-Harris
Case 19 - Swollen Elbow with a Normal X-Ray
Case 20 - Sever's Disease
Volume 2 - March 1995 (Copyright 1995, L. Yamamoto)
Case 1 - Hemoptysis Identifies an Esophageal Coin
Case 2 - Seizure and VSD in a 2-Month Old Infant
Case 3 - Wheezing and Cyanosis in a 16-Month Old
Case 4 - Ignoring an E.D. Nurse's Assessment
Case 5 - Tachypnea and Abdominal Pain
Case 6 - Wheezing and Respiratory Distress in a 7-Week Old
Case 7 - Recurrent Pneumonia
Case 8 - Recurrent Abdominal Pain and Vomiting in a 7-Year Old
Case 9 - A Second Look at a Coin in the Stomach
Case 10 - Thigh and Knee Pain in an Obese 10-Year Old
Case 11 - Occult Hip Injury - 18-Month Old Won't Bear Weight
Case 12 - Hip Pain in a Hefty 13-Year Old
Case 13 - Vomiting Following Reduction of Intussusception
Case 14 - Hematemesis in a 6-Day Old Infant
Case 15 - Hematochezia and Cold Symptoms in an Infant
Case 16 - Sweeping the Airway for a Foreign Body
Case 17 - Sudden Thigh Swelling in a 6-Week Old Infant
Case 18 - Test Your Skill in Reading Pediatric Elbows
Case 19 - Rule Out Epiglottitis
Case 20 - Test Your Skill in Reading Pediatric Lateral Necks
Volume 3 - August 1995 (Copyright 1995, L. Yamamoto)
Case 1 - Myocardial Failure in a 2-Month Old
Case 2 - Severe Chronic Lung Disease and Respiratory Distress
Case 3 - Ankle Injuries: A Sprained Ankle ?
Case 4 - Foot Pain in Triage
Case 5 - Test Your Skill in Reading Pediatric Ankles
Case 6 - Aspirating the Ankle Joint
Case 7 - Hemoptysis and Anemia in a 12-Year Old
Case 8 - Dice Ingestion
Case 9 - Moyamoya Disease
Case 10 - Abdominal Pain with Faint Intra-Abdominal Calcifications
Case 11 - Respiratory Distress and Abdominal Distention
Case 12 - Severe Acute Chest Pain in an Adolescent
Case 13 - Acute Chest Pain in a Tall Slender Teenager
Case 14 - Severe Hypernatremia - Salt Poisoning
Case 15 - Severe Hyponatremia and Non-Reactive Pupils in a 3-Year Old
Case 16 - Failure to Thrive and Vomiting in a 1-Month Old
Case 17 - Bilious Vomiting in a 3-Month Old
Case 18 - Test Your Skill in Distinguishing Bowel Obstruction From Ileus
Case 19 - Abdominal Pain and the Peritoneal Fat Margins
Case 20 - Test Your Skill in Reading Pediatric Chest Radiographs
Volume 4 - January 1996 (Copyright 1996, L. Yamamoto)
Case 1 - Focal Seizure in a 5-Year Old
Case 2 - Bucket Handle and Corner Fractures
Case 3 - Tachypnea in a 2-Month Old
Case 4 - Pearl-Like Chest Calcifications
Case 5 - Test Your Skill In Reading More Pediatric Chest Radiographs
Case 6 - T.B. in the E.D.
Case 7 - Avoid This Airway Complication
Case 8 - Right Lower Quadrant Pain in an 13-Year Old Female
Case 9 - Periumbilical Abdominal Pain
Case 10 - Post-Surgical Febrile Seizure and Vomiting
Case 11 - Acute Knee Pain Following Trauma
Case 12 - Closed Reduction of a Dislocated Shoulder
Case 13 - Blunt Shoulder Trauma: Fracture, Dislocation, or AC Separation
Case 14 - Fractured Radius From a Fall, Rule-Out Foot Fracture
Case 15 - Osteoid Osteoma
Case 16 - A Limping 6-Year Old
Case 17 - Fever and Refusal to Walk In a 4-Year Old
Case 18 - The Toddler's Fracture: Accident or Child Abuse ?
Case 19 - Adolescent Female With Hip Pain
Case 20 - Acute Hip Pain in a Sprinting Teen

Volume 5 - October 1996 (Copyright 1996, L. Yamamoto)
Case 1 - Fever With Neck Stiffness . . . Rule Out Meningitis?
Case 2 - Cervical Spine Radiographs
Case 3 - The Hangman's Fracture
Case 4 - The Jefferson Fracture
Case 5 - Other Cervical Spine Fractures
Case 6 - Intracranial Hypertension and Brain Herniation Syndromes
Case 7 - Intracranial Hemorrhages
Case 8 - Lethargy and Fever
Case 9 - Infant Skull Fractures
Case 10 - Lethargy and Vomiting Following Child Abuse
Case 11 - Hip Pain in an 11-Year Old
Case 12 - Abdominal/Hip Pain With Fever in a 2-Year Old
Case 13 - Hemoptysis in an 11-Year Old: Scimitar Syndrome
Case 14 - Pulmonary Sequestration
Case 15 - Near Drowning
Case 16 - CAST Syndrome
Case 17 - Gastric Dilatation in a 3-Week Old
Case 18 - Right-Sided Abdominal Pain in a 10-Year Old
Case 19 - Bowel Obstruction With Intraintestinal Sand
Case 20 - Membranous Croup

Volume 6 - July 1999
Case 1 - Shoulder Pain After Throwing a Football
Case 2 - Fussiness Following Minor Trauma in an Infant
Case 3 - Vomiting and Coughing in a 3-Month Old with Weak Bones
Case 4 - Wrist Swelling in a Neonate
Case 5 - Elbow Swelling in a 2-Year Old with Liver Disease
Case 6 - Knee Sprain in a Teenager
Case 7 - Acute Knee Deformity
Case 8 - Sunrise View of the Knee
Case 9 - Orbital Injury
Case 10 - Orbital Pseudotumor
Case 11 - Chronic Lower Extremity Pain
Case 12 - Chest Pain in a 6-Year Old
Case 13 - Backache in a 16-Year Old
Case 14 - Bloody Diarrhea and Dehydration in a 5-Month Old
Case 15 - Hip and Knee Pain in a 4-Year Old
Case 16 - Forearm Deformity in a 4-Year Old
Case 17 - Recurrent Wheezing in an Infant
Case 18 - Appendicoliths
Case 19 - Difficulty Breathing Throughout Infancy
Case 20 - Recurrent Coins and Recurrent Respiratory Infections

Volume 7 - Final Release Date Pending
Case 1 - Fever and Upper Back Tenderness
Case 2 - A Growing Skull Fracture
Case 3 - Prolonged Cough and Fever
Case 4 - Proteus Syndrome
Case 5 - Urolithiasis
Case 6 - A Large Calcified Kidney Stone
Case 7 - Forearm Swelling, Pain, and Numbness Following Trauma
Case 8 - Multiple Trauma in a 2-Year Old
Case 9 - Herpes Encephalitis
Case 10 - A Complication of a Retropharyngeal Abscess
Case 12 - Painless Scrotal Swelling
Case 18 - Find the Intussusception Target and Crescent Signs

MENTAL HEALTH

Road Traffic Offences
Introduction
The forensic clinician enters a complex world in his/her dealings with the Road Traffic Acts (RTA)
where a knowledge of driver statute and case law may be more important than in any other field.
At first it seems simple, that the FME is called out, turns up, takes blood samples and fills in some
forms, and for the vast majority of cases that is the end of the matter.
It is for the few cases which are not simple that a wider knowledge is required.
RTA case law is full of examples where procedure rather than simple fact has been the lynch pin of
a defended case.
By the "RTA", in this text, reference is being made to the Road Traffic Act 1988, the last in a series
of Acts. The latter act is the source of virtually all the discussion in this chapter. Any other statute
will be cited and described with its full title, but otherwise RTA will mean the '88 Act.
Technical Matters
The current RTA kits involve the doctor transferring blood from a single syringe to two containers
with a "rubberised" membrane through which the blood can be injected. It is hard to conceive of any
other procedure in medical practice today which is designed to be as hazardous to the user from the
point of view of needle-stick injury or aerosol blood spray as this.
In 1994, a sub-committee of the Association of Police Surgeons met with representatives of the
Home Office Forensic Science Services to address this problem amongst others. There appeared to
be no problem in attitude from the scientists with regard to the re-organisation necessary for analysis
using a different and safer venesection process. However the legal advice sought suggested that any
other system available whereby two samples were obtained could not be deemed
to have satisfied the Road Traffic Offenders Act 1988 s15 (5)r until it had been through the courts. It
was not satisfactory therefore to change procedure without a change in statute.
The transfer of the blood to the container is best facilitated by allowing the syringe plunger to be
pushed back up the barrel by the pressure increase of the blood from the first container before filling
the second.
It is equally acceptable to insert another sterile needle into the membrane to allow pressure
equalisation. If this is done the FME should record the presence of two holes in the membrane.
One anecdotal case had the accused specimen container sporting 16 holes whilst the "police"
specimen had 1. Not all cases of interference would be as easy to spot as that, and it is good practice
to record multiple perforation of the membrane.
It is sensible to develop a routine with RTA cases.
As the consent for a blood specimen is requested in front of a police officer who witnesses the
response, there is no real requirement to have the consent to the simple transaction recorded in the
clinician's record. If, however, the case is a more complex one involving examination then written
consent should be obtained.
Many defences appear spurious and it helps to have developed a set notation for the record of the
sampling, so that it can be seen that a detailed procedure was followed.
Recording:
• From which arm the sample was obtained.
• How much blood was obtained (if the syringe was not full).
• Who packaged the specimen.
• Was it "selotaped" and by whom?
• Was the accused given information about approved laboratories?
• The name of the authorised operator or police officer running the procedure.
and such like can all help.
r "Where, at the time a specimen of blood or urine was provided by the accused, he asked to be provided with
such a specimen, evidence of the proportion of alcohol or any drug found in the specimen is not admissable on
behalf of the prosecution unless—
(a) the specimen in which the alcohol or drug was found is one of two parts into which the specimen provided
by the accused was divided at the time it was provided, and
(b) the other part was supplied to the accused."
to have satisfied the Road Traffic Offenders Act 1988 s15 (5)r until it had been through the courts. It
was not satisfactory therefore to change procedure without a change in statute.
The transfer of the blood to the container is best facilitated by allowing the syringe plunger to be
pushed back up the barrel by the pressure increase of the blood from the first container before filling
the second.
It is equally acceptable to insert another sterile needle into the membrane to allow pressure
equalisation. If this is done the FME should record the presence of two holes in the membrane.
One anecdotal case had the accused specimen container sporting 16 holes whilst the "police"
specimen had 1. Not all cases of interference would be as easy to spot as that, and it is good practice
to record multiple perforation of the membrane.
It is sensible to develop a routine with RTA cases.
As the consent for a blood specimen is requested in front of a police officer who witnesses the
response, there is no real requirement to have the consent to the simple transaction recorded in the
clinician's record. If, however, the case is a more complex one involving examination then written
consent should be obtained.
Many defences appear spurious and it helps to have developed a set notation for the record of the
sampling, so that it can be seen that a detailed procedure was followed.
Recording:
• From which arm the sample was obtained.
• How much blood was obtained (if the syringe was not full).
• Who packaged the specimen.
• Was it "selotaped" and by whom?
• Was the accused given information about approved laboratories?
• The name of the authorised operator or police officer running the procedure.
and such like can all help.
r "Where, at the time a specimen of blood or urine was provided by the accused, he asked to be provided with
such a specimen, evidence of the proportion of alcohol or any drug found in the specimen is not admissable on
behalf of the prosecution unless—
(a) the specimen in which the alcohol or drug was found is one of two parts into which the specimen provided
by the accused was divided at the time it was provided, and
(b) the other part was supplied to the accused."
ulation, could be due to a drug and therefore would seem to satisfy the requirements of the act.
What has been tested in the court is that the doctor must give an oral indication to the constable concerning the presence may cause the specimen to be inadmissable.
There appears to be no requirement in the RTA for an accused to consent to a full examination, but there is also nothing practitioner to do a full consensual examination before advising the police officer. It seems perfectly acceptable for accused, record as much as possible of his/her observations and if there is a demonstrable condition satisfying the The police surgeon must record accurately all the findings

EXAMINATION OF SUSPECT IN SEXUAL ASSAULT

Examination of Suspect in Sexual Assault
This chapter is short.
The brevity with which this particular aspect of FME work has been treated is inversely proportional
to its importance.
The two previous Chapters (7 & 8) need to be read.
The standard of detail with which a specific suspect needs to be examined is no less than in the
examination of an alleged victim.
The forensic clinician owes a duty to accused, victim and the courts to perform a thoroughly
professional appraisal.
If the alleged offence is remote from the examination of the suspect, such that weeks have passed, it
may not be worthwhile looking for forensic material other than blood for identification.
It should be remembered that bruises may be visible for 14 days. 70 They may be visualised with
specialist UV photography (mainly of benefit in bite-marks) for up to 4 months.75
If a particular scar, skin lesion or other distinguishing mark has been mentioned by the complainant,
it may be appropriate to perform an inspection whatever the delay.
Repeated here is the opinion emphasised in the previous chapter.
It is not improper for the clinician examining the suspect, to discuss, by telephone, any
peculiar findings with the police surgeon examining a complainant.
Discussions have, apocryphally, attracted a condemnation of this practice as collusion. Such is not
the case. There is no difference between giving the forensic scientist as much information as
possible to enable him/her to carry out a professional analysis and extending the same courtesy to
ones clinical colleagues. In all cases the clinician's role is to gather evidence which will help any
court make a balanced decision.
Procedure
Discuss with the Senior Investigating Officer (SIO) the purposes of the examination. No forensic
clinician should be satisfied with a request to simply ''get blood and hair samples please". Full
discussion should take place about the complexities of the case and then the police surgeon should
inform the SIO about the extent and restrictions of any examination. The FME should also ensure
that the appropriate requirements for the obtaining of intimate samples (v.i.) have been fulfilled.
The suspect should have the right to be seen without the presence of a police officer. Though as has
been mentioned previously in the guidelines, the custody officer may object to this if there is a
safety consideration.
If the suspect wishes the solicitor to be present, then this should pose no problem. However undue
delay should not be contemplated at the risk of losing forensic evidence. Fibre evidence, for
example, may degrade within a few hours.
Written consent should be obtained. This should include in the dialogue a mention of why the
examination is being performed. An example would be "in the case of an alleged rape". The
examination structure and sample procedure should be outlined. The disclosure pathways should be
mentioned (see Chapters 2 & 3).
If consent is refused, then the police surgeon can still make observations and record those findings.
Intimate Samples
If intimate samples are required then consent under PACE requirements which includes the written
consent of the examinee will already have been obtained. 76 This should not deter the clinician from
obtaining his/her own consent. A simple explanation that such consent is a medical ethic rather than
a legal requirement usually produces amicable compliance.
Intimate samples are defined under Police and Criminal Evidence Act 1984 s65 as amended by the
Criminal Justice and Public Order Act 1994 s58
Intimate samples are:-
• Dental impression
• Sample of blood
• Sample of semen
• Any other tissue fluid
• Urine
• Pubic hair
• Swab from a body orifice other than the mouth.
With the exception of urine, none can be taken by anyone other than a registered dental or medical
practitioner.
Having obtained consent, a history of the alleged incident should be requested. As many allegations
relate to the question of consent or what actually occurred rather than the identification of who the
perpetrator was this is not as fruitless as it may at first seem.
Sometimes, however, no event related history is forthcoming.
The examination should proceed.
A sexual offences kit should be used and, unless the clothes have already been obtained by the
police, the examinee undressed on a paper sheet as with a victim. The clothes should be carefully
packaged and the same courtesy of dignity extended to the patient as is given to the victim.
Clinical findings and the sample harvest should be performed meticulously and recorded accurately.
If injuries are discovered duing the examination, the examinee can be asked to account for them,
even if no history was obtained, and even if legal advice, or the patient himself results in no
response. The police surgeon should record "no response" without expression or comment and carry
on with the procedure. Though "comments" should not be made, it is good clinical practice to
maintain a discourse with the examinee throughout the contact, even if only in so far as explaining
exactly what is entailed in the examination process. However the doctor should not embark on an
interrogation that should properly be conducted by the investigating officer.
The genital examination should be as gentle as possible but thorough. The area, as with the rest of
the body should be viewed under UV light for fluoresence, and any stain swabbed. Even in the
absence of fluorescence a swab should be taken of the coronal sulcus.
The anal and peri-anal area should be inspected and examined in more detail depending on the
allegations and findings. Though it must be remembered that consent may be witheld for any
individual part of the examination process, and such a decision must be respected.
At the end of the examination it could be advantageous to ask the suspect and particularly the
solicitor, if present, if they have any comment or criticism to voice. Record any answer.
The samples should be labelled in the same manner as described in Chapter 8 and also disposed of
similarly.
The Doctor at the Scene of Death
Introduction
Police surgeons get called to many scenes of death.
The majority will not become the scene of a major crime investigation.
It is imperative that the clinician brings his/her skills and knowledge to the scene, alert from the
beginning. It is likely that the police surgeon is the only one present with the medical and scientific
training to perceive some anomalies which may give rise to suspicion.
FMEs are usually called to a death, because it is "suspicious", sudden or the General Practitioner of
the deceased is unknown or not contactable. Suspicious deaths, in this context, are likely to include
homicide, suicide or accidents, as well as some cases of natural death.
This chapter is not intended to be a panorama of death and its forensic aspects but to draw attention
to the main areas of consideration.
These are:-
1. Approach to the scene
2. Communication
3. FMEs actions at the scene
4. Safety
All police surgeons should be familiar with the Scenes of Crime Directive produced by their Police
or by the Home Office Forensic Science Laboratories (or the Metropolitan Service).
Approach to the Scene
Contamination of the scene should be avoided.
The only exception to a slow measured and controlled approach to a body is the possibility
that the life may be preserved in which case the primary responsibilty is the patient. Such
preservation should not be under
taken without first making sure the scene is without danger to the doctor or others (see "Safety"
below).
Approaching the scene of death, the doctor should alight from his/her transport no closer than the
nearest police vehicle, unless directed to a particular area by a uniformed police officer or other
official. It may appear that some vehicle is closer to the scene, but that may be one that is connected
with the death.
If the FME is only the second or third person to arrive, he should discuss with the reporting officer
the circumstances of the case before inspecting the body, and determine life to be extinct with as
little disturbance to the scene as possible. If it is early in the case, or there may need to be an
investigation, the police surgeon should not hesitate to inform his police colleagues about protection
of the scene and the prevention of intrusion by unwanted observers.
If an investigation team is already there, it is likely that one officer will be keeping the log. The
doctor should report his/her arrival to that log-keeper. Discussion with the Senior Investigating
Officer (SIO) or equivalent should occur to determine the path of entry to the body and the known
circumstances. The FME should keep to this path, which should be marked, with tape or stepping
plates, where necessary.
The metaphor that it is best to keep ones hands in ones pocket should be taken literally. If without
pockets, thinking about this adage should be enough to keep ones hands away from anything other
than the body.
Having determined that life is extinct, no further interference with the body should take place
without clearance from the SIO, and until after the Scenes of Crime Officers (SOCO) have
completed their evidence gathering from the undisturbed body and environs. If the case is one
without suspicion and no investigation is taking place it is still good practice for the professionals
there to be informed before the doctor moves the body. In these latter circumstances, if the doctor is
intending to take photographs for his/her clinical records, they should also be started before moving
the body.
It is good practice, even in the most obvious and benign cases, for the body to be inspected on all
sides, just in case a suspicious lesion or object lurks beneath.
The doctor should exit by the agreed pathway.
In the case of suspicious deaths, the doctor should remain, whenever possible, to offer to the
investigating team his/her expertise, until the Home Office Pathologist arrives, or the body is
removed. It is educational, if ever case load permits, for the clinician to attend the autopsy if
possible

Genital Examination in Girls

A small child is often most easily examined on her mother's knee, particularly if only a visual
inspection is needed. The mother can hold the child's legs apart. Alternatively a similar inspection
can be done with the child lying prone over the mother's knee with the clinician examining from
behind.
With older children, the usual technique is for the child to be examined lying supine on the medical
couch with her knees flexed and hips externally rotated. Whilst in this position the labia may be
gently separated (labial separation) by the examiner's fingers or traction exerted in a forward and
downward direction with the examiner holding the labia gently between thumb and forefinger
(labial traction).
The genital area can also be examined thoroughly with the child in the kneechest position.p In this
position the important posterior edge of the hymen can often be seen more clearly than when the
child is lying supine on the couch.
Ideally the child should be examined in both positions. The child should however be given control
over the choice. Many children appear to prefer the knee chest position.
Ideally a colposcope should be used, but in the absence of this a magnifying glass or optical loups
are an alternative. The colposcope should include optical measurement and recording.
In many cases when the genitalia are examined in different positions, the edge of the hymen will
have been clearly visualised without the need for any kind of intrusive examination, but in some
cases it is helpful to use a glass probe (Glaister's globe).
Glaister's globes are glass rods with a diameter of 0.6 mm with one end of the rod being expanded
into a globe from 1-2.5 cm in diameter. They can be inserted gently behind the hymen to display its
edges over the glass. In this way apparent folds and indentations often smooth out and small nicks
and tears can be more easily identified. Glass rods used in this way, with explanation and
demonstration to the child, are much less traumatic than using a moistened cotton wool swab which
often causes pain in a delicate area.
If swabs have been taken for forensic purposes, or to carry out tests for STD, then it is helpful to
show the child an unused swab. In some cases it helps to allow the child to use the swab herself and
keep control. Again the child should be allowed to halt the proceedings if distressed.
In most cases where indecent acts are alleged it is not necessary, after the above procedures, to
insert any object into the vagina. However, where there is an allegation of full sexual intercourse or
findings such as a completely torn hymen,
p Crouched on the examination couch with the small of the back arched downwards, knees flexed under the
chest and bottom in the air.
then in some cases it is appropriate to carry out a gentle digital examination of the vagina to
establish whether:
—The hymenal ring is completely torn
—Whether the vagina can admit an object the size of an erect penis and
—Whether its walls are rugose or smooth and the canal enlarged
In older girls it may be appropriate to carry out a full gynaecological examination, including the
insertion of a speculum, to inspect the cervix. Bimanual palpation may indicate pregnancy and a
pregnancy test may be advisable.
Genital Examination in Boys
There is rarely any genital injury in boys who have been indecently assaulted. The penis and
testicles should be thoroughly inspected for signs of bruising, tears of the frenulum, or "love-bites"
and signs of sucking. The root of the penis may show bruising or other lesions. It is important to
consider that the penis may have been sucked and to swab for saliva, in the knowledge that saliva,
on the unwashed penis, may survive for up to one week.
The testicles should be examined for signs of bruising or biting.
The Anal Area
The anus should be inspected in every case. This may be done in the left lateral or knee-chest
position.
The buttocks should be gently separated, without applying traction, and the anal orifice observed for
about 30 seconds to see if there is any dilatation. Slight twitchiness or dilatation of the external
sphincter is probably of no significance. Anal dilatation in the presence of a stool in the rectum is
regarded by most experienced examiners as being unlikely to be a sign of abuse. If observed,
however, it should be recorded.
The anal folds should be regular and symmetrical around the anal opening but there is often a
redundant fold, particularly in boys, anteriorly which can be confused with a skin tag or healed
fissure. A midline raphe extending backwards from the scrotum is normal and should not be
confused with signs of injury.
Prominent veins have sometimes been claimed to be significant pointers to abuse. However, they
often come up during the examination as the child tenses and relaxes his muscles, and no great
significance can be attached to them, though they must, of course, be noted.
If no abnormality is seen on careful inspection of the anus then it is appropriate to do no more.
However if there is an allegation of anal abuse then a finger gently can be placed against the anal
orifice to test its tone. A very good estimate
of anal tone can be obtained in this way without doing a full digital examination. In some cases a
digital examination should be done, the subject asked to squeeze the examining finger to test the
anal tone. It is important to remember, however, that this procedure relies on a subjective
assessment of the examiner based on experience and can be unreliable.

EXAMINATION OF VICTIM OF ALLEGED SEXUAL ASSAULT

Examination in the Case of Alleged Sexual Assault
Introduction
There is no doubt that examinations of adults in this arena, along with those involving children, can
be the most demanding of circumstances.
The first part of this chapter will deal with the adult. The second with the child where this differs.
This is not to say that other areas of clinical forensic medicine can be approached with less skill and
more superficial knowledge; they cannot. In these areas however, the FME will be faced with
establishing an ambience which will allow the necessary comprehensive examination to take place.
• Whilst preserving the dignity of the examinee as well as the forensic specimens
• By coaxing the patient to be compliant whilst allowing them to regain a control which may have
been severely damaged during any assault
• Whilst accepting the patient's communications with total belief and compassion yet maintaining a
scientific objectivity so that any evidence can be presented without bias or prejudice
"Examination" is a euphemism for the whole doctor/patient interface, involving as it does in good
forensic practice, skills, knowledge and attitudes which go a long way beyond the ability to record
genital findings.
Ideally the "processing" of a complainant, should take place within an organised structure involving
not only appropriately trained and experienced forensic clinicians but also:
1. Trained police officers
2. Trained counsellors
 3. Sexually Transmitted Disease (STD) screening facilities and specialist adviser.
4. Obstetric and Gynaecology/Urology/Paediatric specialist back up services
5. Specialist suites.
It is important that where possible the patient has a choice of gender of those who are going to have
intimate contact with them.
In this chapter the use of the term "victim" must be read as "alleged victim". There is no intent that
any forensic clinician should have a prejudicial bias. It is the court that will decide guilt or
innocence, whatever the initial percieved truth of the matter.
Appendix 8a shows a schematic outline of Greater Manchester Services in this field.
General Issues
Medical records are important. Chapter 1 should be read.
Some centres (eg St Mary's Sexual Assault Centre (SMSAC) in Manchester) have developed their
own proformata. If there are confidential notes or common notes which are important for continuing
care such as counselling or STD treatment, it may be a policy that those notes are not removed from
the centre. Otherwise the advice about record responsibility is as discussed in Chapter 1.
Consent has been covered in Chapter 2. Examination of a victim may present forensic and
therapeutic aspects and the doctor must ensure that the appropriate informed consent is obtained.
The police surgeon must be clear in his/her own mind before explaining the features of each to the
examinee.
Though this chapter describes the situation with regard to females, the procedure apart from the
obvious exception of the genital examination applies equally to male complainants. For examination
of the penis, the section in the following chapter should be read.
It is extremely important that the patient understands that any relevant detail of the exchange
between him/herself and the doctor may be discussed in public court.
The Examination
Introduction
The FME should introduce him/herself, explaining what must be done.
The complainant should be asked how they would like to be addressed. It should not be assumed
that they wish to be called by their first name.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Sympathy to their plight is important (remembering, but in no way expressing, that this predicament
is only alleged at this stage), it can be expressed whilst the details of the thoroughness of the
examination and sample taking procedure are explained. Attention should be drawn to the way the
evidence can help in court, but additionally the examinee informed that no promises can be given as
regards the outcome of any court case.
The benefit of being able to reassure as to the lack of anatomical damage can be comforting.
Explaining to the patient that they are in control, and even though the examination may be long and
tedious, it should never be more than uncomfortable at the most and that they can call a halt at any
time, may help to dispel some of the feeling of vulnerability which can be left after an assault.
Continuing to converse with or talk to the patient throughout the examination can be reassuring.
Specific medical problems can also be addressed such as STD. It is worth reminding the patient that
this information is not recognised generally as being of value as forensic evidence, and that the
disclosure is covered by law (see Chapter 3). If AIDS is mentioned as a specific concern, then it
must be addressed in superficial general terms and specialist counselling arranged with pre and post
HIV testing counselling sessions provided, otherwise it is best left for any counsellors to deal with
it, if necessary, at a later date.
History of Event
This should be obtained from the sources available. This usually means the reporting police officer
and then the complainant. Detailed notes should be made and checked with the patient with
particular reference to any discrepancies that exist between any versions received (see page 10
"WHAT").
A complainant may not mention all that has happened, and careful probing may be needed to elicit
the full history of events (for example a female may be reluctant to admit buggery). Leading
questions, as always, should be used as a last resort.
The history should also include recent sexual intercourse before and after the event.
General Medical History
Current medical problems, and past medical, surgical, injury (not considered by some to be a
medical problem) and obstetric & gynaecological history should be obtained.
Gynaecological history is important as is history of recent intercourse.Clinical features should all be recorded. Height, weight, general appearance and demeanour, as well
as any fetor or other stigmata may all be important.
A thorough inspection of the body is necessary. The general body inspection can be done in sections
to preserve the dignity of the patient as much as possible.
Any injury or significant lesion should be notated. See page 92 on examination in cases of assault.
Photography can be useful as an adjunct to the handwritten records and/or sketches and are
extremely useful as a teaching accessory later. Whenever possible a photograph of a lesion, as
opposed to a scene, should contain a scale. If photography is considered necessary for evidential
purposes then the FME should contact the Senior Investigating Officer with regard to use of
the professionally trained police photographer. It helps if female Scenes of Crime Officers
(SOCOs) trained in evidential photography are available.
As well as the general injuries mentioned in the previous chapter there are further specific findings
which may be of evidential value:-
Bite-marks, as well as photography and the referral to a forensic odontologist, should be swabbed.
The swab should be moistened with water from a sterile ampoule, and twisted around on the bite
area. If photography is performed without the presence of the odontologist the views should be
ideally 1:1, with two scales at right angles, and three views perpendicular and either side at 45 ° in
the same plane.
The eyes should be inspected for redness or petechiae.
The scalp may show petechiae, purpura or pin-point haemorrhage at the hair roots when the hair has
been pulled. Hair loss may also be noted. The scalp should be palpated for soft tissue swelling.
The mouth should be inspected as should the auditory meatus and behind the pinnae.
It is possible that fellatio occurred causing petechiae on the palate. 72
As well as soft tissue damage, the nails should be inspected for breaks or possible fibres or skin
from the "assailant".
Genital Examination
The vulva should be inspected, under illuminated magnification, for redness, grazes, splits in the
fourchette and bruising.
External swabs should be taken, including the peri-anal area.
Low vaginal swabs should be taken after gentle separation of the labia. Care must be taken not to
introduce any external contaminant into the vagina.

EXAMINATION IN CASES OF ASSAULT

Examination in Cases of Assault
The examination of a patient in the case of an alleged assault should follow the same pattern
whether the examinee is the complainant or accused.
Standard medical history taking techniques should be involved
• Introduction
• Consent
• History
• Examination
• Investigation
• Diagnosis
The "Diagnosis" in the forensic context, of course, as has been alluded to in other chapters, is a
formulation of opinion about causation.
Introduction
The FME should introduce him/herself to the patient explaining
1. The purpose of the examination
2. The procedure to be adopted
3. The investigations needed to be done (if any)
Consent
Consent should then be taken, including explicit parameters regarding disclosure, investigation and
photography etc. Chapter 2 on Consent should be read.
History
The history of the alleged events insofar as that history has a direct bearing on the clinical appraisal
should be taken.
Account must also be taken of factors which may affect such an appraisal. This would include any
intoxicants, or other drugs, past medical and surgical history, any medication being taken, and any
social history which may reflect on the condition of the patient, such as homelessness and having
lived "rough". Any other recent physical confrontation, of any form, which may have produced
stigmata must also be obtained.
Examination
A full body examination should be performed. It is classically known that in the stress of a physical
confrontation, symptoms of trauma, and memory of causation may be absent. This dictum is also
true in the examination of a police officer in the case of alleged "police assault". The oft related
habit of examining a constable's hands does a disservice to the profession and creates a two tier
standard with a reduced level of competency for the police. To the police officer in such a situation
should be extended the full facilities of a complete, competent and consensual examination.
The examination should be performed carefully. The order of the facets of the complete examination
is completely at the discretion of the individual doctor, though developing a standard format and
using proformata (see Chapter 4) can be helpful. It is important however, that any samples that
should be obtained are taken at a time when they are not going to have been contaminated by
previous procedures. This is particularly true in, but not exclusive to, sexual offences, and is covered
in Chapters 8 & 9.
Injuries
The recording of injuries accurately is absolutely vital.
The use of body charts (see Appendix 1c) is of great aid.
Any injury or lesion which can be measured, should be measured.
There are six objective parameters to any such traumatic lesion:
• Type of lesion
• Position
• Size
• Appearance
• Orientation
• Direction of causation
In addition to these there are the subjective symptoms of:
• Pain
• Tenderness
• Stiffness

Clinical Assessment of Interviewee

The previous chapter on Fitness to be Detained should be read.
Physical Illness
Any detainee who is suffering from a specific physical illness should be stable before interview
takes place. It is difficult to be specific. For example the hypertensive does not have to be
normotensive, only preferably so. Some hypertensive patients are stable at a theoretically
hypertensive level. It behoves the clinician to establish, if possible, the "normal" state for that
patient, if a higher blood pressure reading than expected is obtained. This, of course, can be a
difficult or even impossible task in the middle of the night, in which case the clinical judgement of
the FME must be exercised. A similar approach can also be taken towards other conditions such as
diabetes mellitus. In the latter case no clinical appraisal should be considered complete without a
blood sugar estimation.
If a patient is on medication then the treatment protocol should be ratified and
written up on whatever is the accepted format for care instructions for detainees (see Appendix 3c
for the example of the Greater Manchester Police form).
The detainee who is injured or suffering from a musculoskeletal disorder needs assessing and any
appropriate analgesia given. If serious injury is considered they should have that condition assessed
and treated before interview. The British National Formulary (BNF) describes both Aspirin and
Paracetamol as particularly useful for musculoskeletal pain and pyrexia. The former can be used (if
not contra-indicated in the individual) where anti-inflammatory action is required. The BNF points
out that any combined analgesic, containing an opioid, has no substantiated benefit over the simple
drug, if the dose is low, and carries all the side effects of the opioid if containing a higher dose.
Visceral pain is however more responsive to opioid analgesics.
Care must be taken not to give an opioid analgesia in a dose which may cause drowsiness, during
the interview, in a patient unused to strong drugs.
In police surgeon practice the above example infrequently presents. The specific case of drug
addicts is dealt with below.
Examination
The examination should include:-
1. A full medical history including family, social, and past medical/surgery/ (obstetric) histories.
2. Medication details including any alcohol or illicit drugs used.
2.1 For illicit drugs it is of help to use the regional data base forms as part of the medical
record (see Chapter 3 Section and Appendices 3a & b).
2.2 It is worthwhile remembering the availability of legal "herbal" highs.
2.3 The history should include habitual use as well as intake in the last 24 hours.
3. Nutrition
3.1 General condition, and
3.2 Food intake—when and what?
4. Full clinical examination with particular reference to stigmata of drug abuse and/or withdrawal.
4.1 Does the patient normally wear spectacles (or contact lenses)?, or
4.2 Have a hearing deficit? (important if going to be interviewed or asked to sign anything).
5. The CNS examination should include.
5.1 Locomotor function.
5.2 Co-ordination.
5.3 Temporo-spatial orientation.

Fitness to be Interviewed

This area of the police surgeons work has steadily grown in the last few years from an embryo to a
potential monster.
There has been no formal training on the subject, the expectations placed upon FMEs vary
depending on the particular interest, slant and responsibility of the lay professional viewing the
doctor, and it is unclear exactly what is the responsibility of the police surgeon.
It appears that this whole area of work stemmed from the original Codes of Practice constituting s
66 of the Police and Criminal Evidence Act 1984 (PACE).
In this chapter and Chapter 11 on Mental Health when referring to the codes of practice in
general, the PACE codes will be referred to as Codes (PACE) and the Codes of Practice of the
Mental Health Act 1983 will be referred to as Codes (MHA).
In paragraph 12.3 of Code C of PACE it states
"No person who is unfit through drink or drugs to the extent that he is unable to appreciate the
significance of questions put to him and his answers may be questioned about an alleged offence in
that condition except in accordance with Annex C. [See Note 12C]"
Annex C is still extant and is discussed on page 86.
Note 12B states
"The police surgeon can give advice about whether or not a person is fit to be interviewed in accordance with
paragraph 12.3 above".
There is no mention of the police surgeon being involved with regard to fitness for interview in any
other condition including mental health disorders.
The only apparent change between the original Codes (PACE) and the current edition which became
effective on 10 April 1995 is that Note 12C had become Note 12B on publication of the second draft
of the Codes (PACE) and remains so.
There is mention of calling the police surgeon, and immediately so, if a person brought to the police
station appears to be suffering from a mental illness or is incoherent except through drunkenness
alone, 58 but there is no mention of involvement with fitness for interview.
However it is apocryphally stated that FMEs are involved in fitness to be interviewed for many
detainees suffering from a legion of conditions.
There is no claim in this text that such a use of forensic clinicians is improper, but it is an area
which had not been specifically researched with a goal of producing set parameters for such an
assessment.
As there are no set protocols to assess fitness for interview, this rests with the clinical judgement of
the forensic clinician in attendance.
It is interesting that the Victoria Police Forensic Medical Officers Manual, published in 1992
written and compiled by Drs David Wells, Edward Ogden, Simon Young and Faika Jappie, adopted
a similar approach to this in their advice for fitness to interview.
That Manual states:
"You do not have to make a definitive diagnosis. You simply need to establish:-
1. Is (s)he mentally alert and orientated to answer questions?
2. Is (s)he physically well enough to answer questions?"
Other work which will be mentioned may suggest that more needs to be done than answering the
simple questions above.
This chapter will explore this area and, for convenience only, the subject has been split into the
following headings:
General Aspects
Clinical Assessment of Interviewee
Responsibilities of Forensic Clinician
General Aspects
There has been much publicity and, now, not inconsiderable work on false confessions.
Though the FME cannot audit interrogation techniques, they can do their best to apply their clinical
skills to identify vulnerable patients.
It must be remembered that not everyone interviewed is in detention. Not everyone interviewed is a
suspect. A police surgeon may come across a situation where they are asked to assess an individual
who is a complainant or a non participating witness to the alleged events.
The assessment for fitness to be interviewed could be considered to be threefold. Firstly that an
interview, which may be verbally rigorous, does no harm. Secondly that the interviewee is fit such
that they are capable of recall and recounting the "facts". Lastly, that they are not so vulnerable that
they are

Specific Conditions

Most patients seen with heart disease are well controlled and on regular medication and present no
problems.
The most difficult complaint to assess is that of chest pain. It is obviously important to decide
whether it is cardiac or has some less life-threatening cause.
Most commonly a patient will be seen with a chronic condition such as angina, cardiac failure or a
stable arrhythmia such as atrial fibrillation. In these cases the regular medication can be continued
and prescribed in the normal way and the custody record annotated with drug dosage and the times
they should be given. Simple advice can be given such as, please ring me if the patient gets worse,
i.e. has chest pain, becomes breathless or is sweating.
The problems will arise with chest pain of a cardiac type and differentiating angina from infarction.
The police surgeon must take a detailed history of the type of pain and record this on the notes.
He/she must record the clinical examination of the heart and blood pressure and pulse rates and any
evidence of cardiac failure. The basic values apply as in general practice and referral to hospital is
indicated if in any doubt and a letter should be sent with the patient.
In cases where medication is needed, it should be prescribed in the doses and at the times that the
detainee would normally take it outside custody. If the detainee is on symptom led medication such
as a nitrate, he should be allowed to keep that in his cell unless there is a specific reason not to.
Doubt as to the identity of the medication, or regular abuse of any medication are examples of
where greater care of freedom to access of therapy is needed.
Epilepsy
The approach here is similar to that of cardiac disease. If you would not be happy to manage a
patient at home then hospital referral is safer.
Most epileptics seen in police custody are well controlled and know their own disease well.
However, many prisoners do not take their medication as prescribed and some have a high incidence
of fits.
The history is important and should elucidate:
—The type of epilepsy & the type or frequency of fits
—When the prisoner last had a fit
—The medication taken in detail
—When the last dose was taken
—What doses are necessary for that day and subsequent days in custody
Page 54
It is felt that one self limiting fit in custody is acceptable but a prisoner having more than one fit
needs hospital review. Similarly if the fit is the first ever, then this needs hospital investigation as
one would in general practice. Police officers are capable of immediate first aid and should be
instructed to put the patient in the recovery position and inform the doctor.
It is worthwhile recording clearly the type of Epilepsy.
Epilepsy is a group of syndromes, they constitute "a chronic brain disorder of various aetiologies
characterised by recurrent seizures due to excessive discharge of cerebral neurones." 34
The epilepsies can be classified in a number of ways. The International League Against Epilepsy
(ILEA) has produced a classification35 based on the clinical seizure type and the ictal and post ictal
EEG. As the police surgeon does not have recourse to sophisticated tertiary investigations, and often
has little history from the patient and none available from previous doctors, the seizure type
classification can be simplified thus:36

Fitness to be Detained

The booklet Health Care of Detainees in Police Stations reported jointly by the British Medical
Association (BMA), Ethics Committee and the Association of Police Surgeons and available from
the BMA should be mandatory reading for all police surgeons.
The request by a custody officer to see if a prisoner is fit to be detained is probably the commonest
problem a police surgeon encounters. Most cases are relatively straightforward but some can pose
difficult problems. Occasionally the surgeon will be called to court to assess a case or to see
individuals who are assisting the police but who are not under arrest.
In all cases the FME is duty bound:-
1. To practise good medicine and treat all persons with courtesy and respect
2. To obtain appropriate consent and explain to the patient the implications of the examination (see
Chapters 2 & 3)
3. To respect confidentiality within the constraints of personal safety and public duty
4. To provide proper instructions to the police
4.1 To enable them to care for the patient
4.2 To advise the police about potential bio-medical hazards
These are difficult criteria to fulfill and at times may appear to present great conflict. The source of
prevention of this conflict is the maintenance of high levels of communication and professional
integrity, wherever possible.
This chapter will deal with the detainee in custody, but the advice is just as relevant for the other
areas where fitness to be detained is the issue.
It is now common for police surgeons to be requested to assess whether a detainee is fit to be
interviewed and this is dealt with in the next chapter.
General Information
There are various conditions with which the police surgeon may be faced:
1. The police surgeon is called because of the requirements of the Police and Criminal Evidence Act
1984 (PACE).
2. Existing disease, with or without medication
3. Detainees exhibiting substance abuse
4. Observed signs, injuries or abnormalities of behaviour requiring assessment.
With regard to the last of these, abnormalities of behaviour may indicate a psychiatric problem and
this subject is dealt with in Chapter 11.
There is no intention of this advice becoming a large tome of internal medicine.
It will however approach the subject from a general point of view and also focus on a few common
conditions which may cause problems.
Procedures
Discussion with Custody Officer
On arrival at the police station it is imperative to discuss the case with the Custody Sergeant. This
establishes:-
• How or why the person is detained
• What the custodian is concerned about
• What questions need to be answered, i.e. fit to be detained, fit for interview, disposal
• What are the time constraints and any other problems faced by the custody.
It is also sensible to discuss the case with the arresting officer, if possible, to hear the circumstances
of the arrest and the reason for detention. This enables one to have a clearer idea of the avenues of
disposal available, i.e. home circumstances, relatives at home, etc.
It is then important to decide where you are going to see the patient/prisoner. It is usually
appropriate to see them in the medical room. Violent, aggressive detainees or those with a degree of
stupor are often best seen where they are, either in the cells, or holding rooms. The Custody
Officer's opinion must be taken into consideration, particularly with potentially violent patients as
he/she has responsibility for the safe running of the whole custody suite including other detainees.
There is no room, however, for the abrogation of the FME's clinical responsibilities.
Any instructions given about the care necessary should be written. This may be done on the custody
record or on special forms, designed for the purpose (see Appendix 3c for an example). The police
surgeon should keep a copy. If a sepa
General Information
There are various conditions with which the police surgeon may be faced:
1. The police surgeon is called because of the requirements of the Police and Criminal Evidence Act
1984 (PACE).
2. Existing disease, with or without medication
3. Detainees exhibiting substance abuse
4. Observed signs, injuries or abnormalities of behaviour requiring assessment.
With regard to the last of these, abnormalities of behaviour may indicate a psychiatric problem and
this subject is dealt with in Chapter 11.
There is no intention of this advice becoming a large tome of internal medicine.
It will however approach the subject from a general point of view and also focus on a few common
conditions which may cause problems.
Procedures
Discussion with Custody Officer
On arrival at the police station it is imperative to discuss the case with the Custody Sergeant. This
establishes:-
• How or why the person is detained
• What the custodian is concerned about
• What questions need to be answered, i.e. fit to be detained, fit for interview, disposal
• What are the time constraints and any other problems faced by the custody.
It is also sensible to discuss the case with the arresting officer, if possible, to hear the circumstances
of the arrest and the reason for detention. This enables one to have a clearer idea of the avenues of
disposal available, i.e. home circumstances, relatives at home, etc.
It is then important to decide where you are going to see the patient/prisoner. It is usually
appropriate to see them in the medical room. Violent, aggressive detainees or those with a degree of
stupor are often best seen where they are, either in the cells, or holding rooms. The Custody
Officer's opinion must be taken into consideration, particularly with potentially violent patients as
he/she has responsibility for the safe running of the whole custody suite including other detainees.
There is no room, however, for the abrogation of the FME's clinical responsibilities.
Any instructions given about the care necessary should be written. This may be done on the custody
record or on special forms, designed for the purpose (see Appendix 3c for an example). The police
surgeon should keep a copy. If a sepa

Opinion The question of giving an opinion is a thorny one.

The question of giving an opinion is a thorny one.
The police surgeon is a professional witness, and as such the court has the right to expect the medic
to give a presentation of the appropriate "history", "examination" and "diagnosis

The last of these constitutes the opinion in a forensic case.
Giving an opinion or interpretation of ones own findings in the light of the history given at the time
of the examination, or in the light of an alternative aetiology presented in court is part of the duty of
a professional witness. Such duty does not carry the appelation to convert the witness into an expert.
Early in these guidelines the caveat of "opining too far" was referred to. The professional witness
who is asked to go further than considering only his/her own findings and is asked to look at other
clinical or scientific documents is then being asked to give an expert opinion. The doctor should not
permit him/herself to be pressurised into opining on such material without the time to give it due
consideration and thought. Such consideration of alternative medico-scientific material is asking, of
the doctor, an expert's countenance, and the doctor has a right to be expected to be treated as such.
Extreme caution is advised to any doctor who accepts such a responsibility, to ensure that they have
the appropriate qualifications and experience to complete the task. The doctor who can say quite
simply that a certain topic is beyond or without their experience, does a favour to the court and the
forensic profession. He/she also strengthens the acceptability of those areas on which they are
prepared to opine.

Oral Evidence

The rules pertaining to statement writing also apply to giving oral evidence, with the exception that
there is less time to think during the latter.
The old adage of "Dress up, Stand up, Speak up and Shut up" still reigns.
There exists a basis of expectation that the professional man or woman will look the part. That the
quality of evidence given does not depend on twinset and pearls or shirt and tie is irrelevant. The
prejudices of the jury and justices should be recognised and catered for. The forensic witness is not
there to make a political or sociological point. He/she is there to aid the court in the administration
of justice. Suits and ties and smart skirts or dresses or suits worn according to the traditonally
accepted mode for your gender should be the norm.
Be prepared, locate your clinical records in advance.
Arrive at court in plenty of time if possible.
You may be allowed to refresh your memory from your statement before going into court. This
should be done to link the form and structure of your statement with the clinical notes from which it
was made. The statement is usually more succinct and ordered than the clinical notes, but the
evidence must be given by referral to the latter.
The FME will be allowed to refer to the contemporaneous clinical notes made at the time of the
examination whilst giving evidence. He/she will also be allowed to give evidence from memory.
Care must be taken where this varies from the clinical notes and the FME should be certain that no
confusion has arisen with other cases. Considering the time it takes to come to trial, it is quite
possible that the doctor has seen many hundreds of cases subsequent to the one in question, and any
confusion by the doctor which can be elicited by counsel could invalidate the value of the clinical
evidence.
The rules by which a witness is allowed to refresh memory are encapsulated in the case of R v
DaSilva (1990 1 All ER).
If the contemporaneous notes are lost it may be possible to refer to the statement. The judge in a
criminal trial has a discretion to permit a witness to refresh his memory even after beginning to give
evidence.
For this benefit to be given the judge be satisfied that:
1. The statement was made whilst the events recorded were fresh even if not contemporaneous.
2. The witness can no longer recall the events in question because of the lapse of time since the
event.
3. That the witness did not read the statement before going into the witness box.
4. That the witness wishes to read the statement before continuing.
The witness may then be allowed to refer to the statement in or out of the witness box, but in either
case must do so without communication, and on resuming evidence the statement must be removed
from him.
If the statement were made immediately after the examination, it could be considered to be
contemporaneous, though any discrepancy between the clinical notes and the statement would
increase the potential for doubt as to accuracy. A statement should include everything that is
appropriate to ease the course of justice but should be a considered and carefully constructed
document, and it does not lend itself to hurried preparation.
The question may arise as to contemporaneity of a document or statement, and it may be argued that
there is no hard and fast rule as to when the witness may be allowed to refresh his/her memory. It is
generally accepted that when a long time has elapsed between making a statement, fairly soon, but
not contemporaneously, after the events, the witness should be allowed to refresh his memory from
the statement before giving evidence.
With regard to professional medical witnesses the courts are often very accommodating in allowing
reference to a statement, and in many cases will actually draw the statement into the examination, or
more likely cross-examination. It is important that the form and content of the statement stands
scrutiny in public.
Posture in the witness box is also important. The witness may be asked if he/she wishes to sit. The
choice is open, but do not sit without being invited so to do. There is no need to sit or stand rigidly
to attention, but it is important to stand or sit without slouching or leaning. Such a posture not only
makes it easier to project the voice but also adds to the professionalism of the testimony.
Before reaching the witness box the professional witness should have rehearsed a number of things.
1. Whether the oath or affirmation is to be taken, and if the former, on which deity or authority the
oath will be sworn. If it is more comfortable to recite the appropriate words from memory or from
the printed cards, try and speak to the Court Clerk, prior to giving evidence to agree the procedure in
your particular case.
2. A verbal version of your profile, including who and what you are, your experience and
qualifications. It may be that at the beginning of the examination in chief, counsel will lead you
through this, but you may just be asked to tell the court who you are. A concise rehearsed passage
will immediately indicate that you are professionally prepared and will forewarn the jury that your
testimony will be in a similar state of health.
One difficulty in court is deciding to whom one should speak. It should be the "judges". In a crown
court that includes the jury who judge the facts and in the magistrates court, the bench.
Even experienced expert witnesses can find themselves entering into an exclusive dialogue with the
counsel asking questions, and that should be avoided.
One simple aid to achieve this has been suggested at the Expert Witness Seminar run by Bond-
Solon in London. Their suggestion is to stand with feet firmly pointing towards the judge. On being
asked a question by counsel the body can be partially rotated to present a receptive face towards the
advocate, and on responding the natural position can be resumed, the body swinging back towards
the judge. The limitations of these relatively small movements will usually mean that the response
to the question is projected somewhere between the judge and jury, hopefully satisfying both their
needs.
The voice should be projected, with an increase in volume but not tone if possible.
Due consideration should be given before answering, and the answer delivered in plain English in as
concise and as meaningful a manner as possible. As in statement writing use non specialist language
to translate technical terminology.
If a SWOT analysisf was done on being a witness there may be a tendency to see every question as a
Threat, when in fact each should be considered an Opportunity. The police surgeon is there to serve
justice; questions should be answered truthfully. Do not try to bias the answers to fit in with a
prejudicial view of the court case. It is for the jury to decide the outcome (or the bench).
Barristers are trained for the job, do not underestimate them, if it is not possible to answer a question
simply, say so.
Double questions are a frequent weapon of the advocate, they require clarification or two answers. If
possible give the hidden answer first and the prompted one second; an example follows.
The question asked was thus "you have seen the injuries suffered by the complanant, haven't you
doctor, and without doubt she came off worse in the exchange". A full answer should include the
fact that as the accused was not examined at the time no comparison can be made but, yes you did
see the complainant's injuries which you have described,
Other apocryphal examples are shown below and it must also be recognised that questions are
sometimes phrased as statements; failure to answer plainly may be an opportunity to the advocate.
"wasn't it at 4 o'clock in the morning doctor when you were tired?"
"didn't the examination only take 20 minutes doctor? you were obviously in a hurry"
"the examination took nearly 2 hours doctor didn't it? you must have been unsure of your findings" (Note that
the second "question" in this example was also phrased as a statement).
It is unusual for a competent professional medic to be pressurised in the witness box. If undue
pressure is being felt then an appeal to the justices in the case to allow the evidence to be given
fairly will usually achieve the necessary relief. It is important however to concede a point which has
a right to be adduced.
In most cases the police surgeon as a professional witness will not be party to the whole procedings.
It is not appropriate to start on a monologue introducing items which are irrelevent to the way that
the case is evolving. When the various stages of the examination are finished the doctor should then
stop speaking (hence "shut up"). The one exception relates to the doctor being left with a feeling
that the facts that were being introduced had been done so unfairly, or that a particular relevant
question concerning facts already covered was not asked. It is the responsibility of the professional
witness to bring the judge's attention to this problem. This may result in the jury being expelled
whilst a point of law is discussed. The responsibility of whether or not the presumed omission is
corrected has been passed on to the court and the FME will have behaved properly and fairly.

Hearsay

Including in a statement, or voicing in court, that which is considered hearsay is always a danger
and one of which the FME, or any clinician, should be aware.
The rule against hearsay is encapsulated thus:-
"An assertion other than one made by a person while giving oral evidence in the proceedings is
inadmissible as evidence of any fact asserted."29 This applies to any kind of assertion whether by
mouth, writing or gesture, eg a nod.
The rule will be strictly applied.
This rule does influence what the FME includes in the statement (or in evidence).
An example follows.
In the case of an alleged rape, the complainant tells the doctor that the assailant held a knife point to her
throat and said "I know what I am doing I have done it before".
In the doctor's statement, it is right and proper to include the history declared by the examinee of having the
knife held against her throat, as this may directly relate to the clinical findings on examination. The assertion
of having "done it before" may be hearsay and the doctor should not be surprised to have that statement square
bracketed. However it should still be included. This is discussed below.
In the above case the prosecution may want to adduce the spoken evidence as a matter of its cause
and effect on the state of mind of the alleged victim, in which case it may be allowed. It is unlikely
to be allowed if it were being introduced to "prove" the fact of the other assault.
Certain declarations made by the complainant may be admissible, under some circumstances. The
doctor on quickly seeing an alleged victim shortly after an alleged sexual offence may give
particulars of the complainant, which relate to the charge against the defendant, not as proof of the
allegation complained of, but as evidence of consistency of the conduct of the complainant as
exhibited by her testimony.
A further exception to the hearsay rules may occur which can affect the FME's statement.
Under the rule of Res Gestae,30 evidence of words used by a person may be admissible in that they
from part of the transaction (the assault for example) subject to legal proceedings. In the case of
alleged rape, and early declaration and examination by a forensic clinician, the highly distressed
complainant may make utterances to the doctor which can safely be regarded as a true reflection of
what she is experiencing because of the trauma. Such utterances may be allowed to be given by the
physician.
If there is doubt, spoken evidence should be included anyway. The doctor should not be offended if
he/she later finds that inclusion "square-bracketed"
out of the statement. Such an occurrence would suggest that the legal profession did not consider
that evidence to be a justifiable exception to the hearsay rules.
It is conceivable that an FME being part of the investigation team, may make a record of something
stated by a complainant which later may be admissible, even though it would otherwise constitute
hearsay, if the patient died, or is unfit to give evidence or who, through, fear does not give oral
evidence. 31 The court has the right to decide whether justice will be better served by introducing
it.32 The court must have regard to nature, source, relevance and authenticity of the statement and it
therefore behoves the police surgeon to keep the clinical forensic record as pristine and legible as
possible.
There are further exceptions to the hearsay rule which make fascinating reading for the interested
student but which do not directly affect the production of evidence by the FME and will not
therefore be included here.

Semantics

This is a further area of contention. The terms used everyday by physicians such as acute and
chronic may be understood by the non-medical person, but not in the same way as was meant by the
medic. Thus evidence may be given at length, in a relaxed and thoroughly professional manner, and
the doctor leaves the court (or is not present, the "section 9" statement having been read). The judge,
jury and counsel are left with an understanding of the medical matters in the case totally different
from that which was intended by the doctor.
An example is given here from the lecture given by Crown Prosecution Service to North-West
Police Surgeons Development Training Course 18 February 1994.
In a real statement, used as an example, the doctor had used the words "he denied using illicit drugs. . ." as
part of his summary of the medical history of the examinee. The Crown Prosecutor leading the session voiced
her opinion that "denied" was a poor choice of word, as the doctor gave no indication to indicate why he knew
the individual was using illicit drugs. That the doctor involved, as well as the other assembled medics, all
accepted the use of this particular phrase as standard medical practice to show that to a question about the use
of illicit drugs, the person had answered "no'', and that there was no slant, weight or any other opinion
inherent in the phrase, was futile if the lay person would understand something different. Here the Crown
Prosecutor had assumed that this particular structure of words had indicated a refutation by the examinee of a
practice assumed by the doctor to be part of the examinee's profile and about which the police surgeon had
issued a challenge.
The fault in the above illustration lies with the medics. No assumption should be made by police
surgeons that everyday words used by them in practice, which are not properly classified as
technical words (see terminology above), can be used casually in an evidential manner.

Terminology

A repeated plea from the legal profession is for doctors to use plain English.
Any medical term should always be accompanied by an appropriate lay word or phrase.
Such translations can be included contemporaneously in the document or listed in a glossary. The
former appears to be customary.
What is not consistent is whether the scientific or lay word is the substantive one with the other
following in parenthesis. One advantage of using the medical term substantively is the maintenance
of accuracy. The lay term may be chosen as an illustrative one. An example could be "haematoma
(swollen bruise)". The lay term in this illustration is not particularly accurate, but does describe the
finding, whereas haematoma has a specific medical meaning.
Accuracy of terminology is also pre-eminent.
There may be justifiable variations of understanding about certain words. Petechiae have been
described as a haemorrhage into the skin of less than 1 mm 26 or £2 mm,27 whereas the former
reference of these two would class 2 mm diameter haemorrhages as purpura. It is important that the
forensic clinician decides which definition is acceptable to him/her and uses it consistently. The
example given above is of little, if any, consequence in the interpretation of injuries.
The use of "laceration" for a cut to the skin caused by a sharp object is as deplorable as it is
incorrect. In due course it may contribute to a miscarriage of justice and/or expose the doctor who
casually used a term wrongly to professional embarrassment. Charges of assault commonly revolve
around the use or not of a sharp weapon. The use of the terms incision and laceration may be critical
in such cases.

STATEMENT, REPORT WRITING THE WITNESS STATEMENTS

Statements
Statements and reports are here treated in the same manner.
In general the use of the word "statement" in clinical forensic terms refers to a document produced
in terms that are acceptable to a criminal court in a form as laid down by section 9 of the Criminal
Justice Act 1967. This act allows for evidence to be read out in court and to be treated with the same
weight and value as if the evidence had been given in person. Such evidence can only be offered to
the court if counsel for both sides agree that the contents are acceptable.
Reproduced here in Figure 4.1 is the appropriate paragraph that must be appended to a report (in
England & Wales) for it to be in an acceptable form to satisfy presentation in court. Besides
including and signing this declaration, each individual page must be signed also.
The FME producing a report, whether it is in "section 9" form or not, owes a duty to produce a
document that is clear, concise and understandable to a non medically trained person. Subject to the
"section 9" declaration, no distinction will be made between reports and statements.

Police Complaints Authority

Until July 1994 an examination performed in connection with a case of alleged police assault gave
rise to a unique doctor/patient relationship. It appeared that the findings of that examination when
produced in a report form could not be disclosed to another party (i.e. other than the Police
Complaints Authority (PCA)) in a civil action without the courts having decided that the interests of
justice overruled the Public Interest Immunity.
There is a catalogue of case law relating to this; 23 the main authority being Neilson v Laugharne.
There were a number of cases where disclosure was allowed, in any case, such as criminal
proceedings24 against the police officer or against the complainant.
However a recent House of Lords ruling in two cases25 has overruled Neilson v Laugharne. Though
Public Interest Immunity (PII) may still apply to certain documents of a Police Complaints
Authority investigation, it is now no longer considered that all documents produced in such an
investigation form a class of documentary evidence that should be so protected. It appears inherent
in this recent judgement of Wiley and Sunderland, that medical reports are not covered by PII.
As long as the FMEs findings do not contain information which relates to police operational
procedure, or to the identification of third parties, the doctor should be free to provide a report freely
in consideration only of the consent obtained.
What Should be Disclosed
This is a difficult question. The forensic examiner should make comprehensive notes including all
that may possibly be relevant.
It may be that part of the medical record is then considered not only irrelevant but a potential source
of mischief.
The FME in these circumstances must remember that he or she is party to only one aspect of a case.
There may be items which the FME does not wish to disclose. An example may be previous sexual
history from a complainant. Sexual intercourse with a male other than the one accused only hours
before must be included in the findings as such a situation may have great significance to the
interpretation of the scientific evidence. The time scale in this example can be arbitrary. In the
principal authors opinion seven days should be the minimum dividing linee before an FME
considers excluding the section of such information with regard to a previously sexually active
female.
The example above is often not the case and previous sexual history may not be considered to be
relevant to the case in question. If that is so, such ''confidential" knowledge need not be disclosed at
the time, but its existence should be declared along with the opinion of the FME concerning its
irrelevance and with a claim of Public Interest Immunity. It may then be left for the judge to decide
whether the evidence can be looked at in court, initially in the absence of the jury, if so requested by
an expert advising the other side.
Hard and fast rules cannot easily be made to safeguard the disclosure of material
e NB Chapter 8 should be read with regard to the recovery of genetic material.
that is relevant and only that material, and each case must be judged on its own merits.
FMEs cannot become judge and jury and must serve the judicial system . . . warts and all!
Quick Reference
• Check consent form to determine for whom information disclosure permission was granted.
Write report for only those persons indicated by the consent.
• Was informed consent received for disclosure?
Write to patient to request section consent.
• Is there confidential information in your notes which you believe is irrelevant to the subject in
question?
Omit this other information, write a covering letter indicationg its presence and claim
Public Interest Immunity from disclosure.

Forensic!!

A forensic examination confers no immediate health benefit to the patient. There is an argument that
the examination of a victim of assault of any type, may have a therapeutic effect in the gathering of
supportive evidence alone, though this could, in the long term, with the absence of a conviction,
have a deleterious effect. There appears to be no research which has been done with this in mind.
The immediate forensic examination does give the caring, compassionate and competent forensic
clinician the opportunity for early counselling and reassurance. However the forensic examination is
performed to gather evidence, for the benefit of the community, through the courts, which will
support or refute an allegation in criminal proceedings. It is not made for therapeutic reasons.
The consent should be written. Though verbal consent is just as valid in theory it can never replace
the evidential value of the written word. The consent should include the reasons for performing the
examinationa and also preferably include the taking of samples. Photography can be useful as an
adjunct to the handwritten records and/or sketches and is extremely useful as a teaching accessory
later. If photography is considered necessary for evidential purposes then the FME should
contact the Senior Investigating Officer with regard to use of the professionally trained police
photographer. The consent should include this aspect of the record as a separate item which can be
deleted if inappropriate or if the consent is withheld. The use of photography,b for the clinical
record, should be a matter between the doctor and the patient alone. Only the latter has the right to
consent (and/or parent if appropriate) and only the former is fit to judge whether it would be a useful
way of recording part of the clinical record or useful for forensic education. Arguments have been
offered to suggest that police surgeons should not take their own photographs, as these are
essentially amateur by nature. The argument progresses by suggesting that such photographs could
be used adversely in any subsequent court case. Such an argument is fallacious so long as it is made
clear that the photographs were only an adjunct to the written clinical records. The photograph
should no
a By examination I refer to the whole medical interface, including history, record keeping, clinical examination
and obtaining samples.
b By photography I also include electronic visual recording devices and not just photographic ones.
circumstances (see "OPINION" in Chapter 4). A copy of any statement so issued should be
available for the CPS at the same time as it is provided to the defence.
In the absence of criminal proceedings, and if it is suspected that any civil action is contemplated by
the examinee, take advice from your Medical Defence Organisation (MDO) before releasing any
information. Though police surgeons are independent of the police forces who contract them and are
there to serve the community and the courts above all else, it would be unprofessional and
imprudent to release information to a "fishing expedition" which then resulted in a civil case against
oneself or the Chief Constable, without first taking appropriate legal advice oneself. Do not be put
off with indefinite advice from the MDO on the lines of "say nothing". Forensic clinicians have a
duty to be totally impartial and detached from the cases they serve and not to appear to be playing a
part in "protectionism".
A difficulty may arise in the case of an unconscious patient. A particular case illustrates this point.
A male was in Intensive Care in hospital after a head injury. A bloody battle had occurred involving
more than two people and in which one had already died. The unconscious patient had blood stains

Consent by Police Surgeons

Consent by Police Surgeons
A Summary
(Certain aspects of this chapter will be repeated later in this book for purposes of clarity and ease

Clinical Records for Police Surgeons

Clinical Records for Police Surgeons
It is absolutely vital that FMEs keep a permanent record of their clinical findings in any work done
in the forensic field.
This chapter is divided into sections. These sections will indicate:-
—The chronometry of the record ''WHEN"
—The method of keeping "HOW"
—The content of the record "WHAT" and
—The storage of the record "WHERE"
When
If your clinical note is going to be used in court then the record should be made at the time of the
examination.
During or immediately after the contact is equally acceptable. Any delay could cast doubt on the
accuracy of the record. The acceptability of a record and its contemporaneity is dealt with in more
detail in chapter 4 dealing with Statements and Court.
If the record is found to be incomplete or incorrect, hours, days or even much later, and your
memory of the omission or mistake is absolutely clear, then any amendment made to the record
should be in a form which clearly distinguishes it from the original and from which it should be
physically separate, such as on another sheet of paper. The timing of the amendment should be
clearly recorded. Any additional information justifying or qualifying the changes should also be
added. If a statement or report has already been submitted, or copies of the notes disclosed before
the amendment is considered, then the additional material should be forwarded to the appropriate
party under a fresh statement heading see Chapter 4 for statement writing.
The record should be kept for at least the natural life of the FME.
Even if the doctor has given up forensic work, it is possible that the content of
the record may be called upon through the courts many years later. The recent history of
miscarriages of justice (eg Kisco, Judith Ward) would indicate the necessity for the preservation of
any record for at least decades. The FME has an ethical duty to the patient and the authorities who
requested the examination, to preserve that record for all time.
The NHS Executive has recently issued guidance 1 on the subject of General Practice Medical
Records and has recommended an increase in preservation time of the records which in broad
summary is now 10 years after the patient's death. Though this directive does not relate directly to
FME's records it indicates the importance placed on the long term availability of clinical records.
How
The written record is still the most common form of hard copy for clinical records in forensic
medicine. In today's practice there are numerous other options available. Audiotape, video tape,
computer discs using the various memory options available, are examples. Whatever method is used
it must be remembered that the original recording is the contemporaneous note, and not a transcript!
For example a hand held micro cassette recorder produces a micro-cassette of electromagnetic tape
as the original record. It is that which comprises the record which must be preserved and to which

Principles of Forensic Medicine2012 + pdf -,mediafire

INTRODUCTION
A Police Surgeon is a registered medical practitioner, who is contracted to provide services by a
particular Police Force. These services should be provided from a standpoint of total objectivity and
independence. Apart from any statutory obligations, they should relate only to the clinical demands
of the case in question.
These guidelines have been produced for Greater Manchester Police, for the use of their Police
Surgeons.
The contents contain fact, references and opinion. The opinion is that of the author, but hopefully
represents a consensus of what is considered good practice in clinical forensic medicine.
Greater Manchester Police (GMP) is the largest Constabulary Force in England, outside the
Metropolitan Police Service; however, as each force in the United Kingdom is autonomous certain
specific aspects of this document will be parochial to GMP and will not be relevant to other forces.
Such variance will only relate to specific named forms and procedures, and the application will be
just as valid to Police Surgeons in other forces, even if the documentation varies.
The Police Surgeon's work does fall into certain categories, some of which are more natural than
others. For the sake of this document an arbitrary division has been devised thus:-
1. Clinical records
2. Consent
3. Disclosure
4. Statement & Report Writing
5. Fitness to be Detained
6. Fitness to be Interviewed
7. Examination in Cases of Assault
8. Examination of Victim in Cases of Sexual Assault
9. Examination of Suspect in Cases of Sexual Assault
10. The Scene of Death
11. Mental Health
12. Road Traffic Offences
13. Appendices
List of Acronyms, References and Index
It is advised that the whole document is read so that the reader can familiarise him/herself
with the layout and relationship of the chapters. Most of the chapters can be read
independently.