Essential Forensic Medicine

Cover
Title Page
Copyright Page
Contents
List of Contributors
Series Foreword
Preface
Acknowledgements
Chapter 1 The Legal System, Courts, and Witnesses
1.1 Introduction
1.1.1 Common law
1.1.2 Civil law (Roman law)
1.2 British courts
1.3 The Supreme court of the United Kingdom
1.4 English and welsh courts
1.4.1 Court of appeal
1.4.2 High court
1.4.3 County courts
1.4.4 Crown court
1.4.5 Magistrates’ courts
1.4.6 Tribunals
1.5 Scottish courts
1.5.1 The court of session
1.5.2 The high court of justiciary
1.5.3 The sheriff court
1.5.4 Justice of the peace courts
1.6 Northern ireland courts
1.7 Other courts
1.7.1 The court of justice of the european union
1.7.2 The european court of Human Rights
1.7.3 Court martial (military court)
1.7.4 International courts
1.7.5 Coroner courts
1.8 Types of witnesses and evidence
1.8.1 Ordinary witness
1.8.2 Professional witness versus the expert witness
1.8.3 Expert evidence
1.8.4 Common knowledge rule
1.8.5 Basis rule
1.8.6 Ultimate issue rule
References
Chapter 2 Investigation of the Deceased and Their Lawful Disposal
2.1 Introduction
2.2 Certification of details of death by the Registrar of births and deaths and lawful disposal of the body
2.3 Death certificate
2.4 When may a doctor issue a death certificate?
2.5 The form of the certificate in England and Wales
2.6 Legal procedures in the coroner system
2.6.1 Notification of cases to the coroner
2.7 Deaths abroad
2.8 Inquests
2.8.1 Scope of the inquest
2.8.2 Inquest conclusions
2.9 Registration of death
2.10 Burial
2.11 Cremation
2.11.1 Introduction
2.11.2 The current cremation procedure
2.12 The Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006
2.12.1 Existing holdings
2.14 Legal procedures in death investigation: Other systems
2.14.1 Scotland
2.14.1.1 View and grant
2.14.1.2 F ull autopsy
2.14.1.3 Fatal accident inquiry
2.14.2 Medico-legal death investigation in the United States
2.14.3 The generic criminal investigation and judicial system
References
Chapter 3 The Duties of a Registered Medical Practitioner and the General Medical Council
3.1 Medical Acts
3.2 Role of the GMC
3.3 Consent
3.4 Decisions involving children and young people
3.5 Consent and capacity
3.6 Medical confidentiality
3.7 Consent for disclosure
References
Chapter 4 General Principles of Scene Examination
4.1 Concept of the scene
4.2 Scene investigation and Locard’s principle
4.2.1 Management of the scene
4.2.2 Health and safety
4.2.3 Climatic conditions
4.3 Scene location and associated problems
4.3.1 Types of scenes encountered
4.3.2 Indoor location
4.3.3 Outdoor location
4.3.4 Outdoor location with Case study
4.3.5 Recovery of buried remains from clandestine graves
4.3.6 Attendance at a scene where a decomposed body is found
4.4 Type of incidents
4.4.1 Number of deceased persons
4.5 The forensic pathologist and other medical personnel at the scene
4.5.1 Introduction
4.5.2 The pathologist
4.5.3 The pathologist’s approach
4.5.4 Examination of the body and its environment
4.5.5 Ascertaining the fact of death
4.5.6 Assessing the post‐mortem interval (time of death)
4.5.7 Artefacts due to resuscitation attempts
4.5.8 Retrospective scene visit
4.5.9 Documentation of the scene
References
Further reading
Chapter 5 The Medico-legal Autopsy
5.1 Introduction
5.2 Historical background
5.3 Types of autopsy
5.4 Types of autopsy in the Coroner system
5.5 Autopsy procedure
5.5.1 Review of the circumstances surrounding death and other information
5.5.2 Identification procedure
5.5.3 Documentation of the post‐mortem examination
5.5.4 External examination of the body
5.5.5 Internal examination of the body
5.5.6 Other Investigations
5.6 Examination of the exhumed body
5.6.1 Exhumation of legally interred remains
5.6.2 Investigation of single or multiple clandestine graves
5.7 Safety in the mortuary and dealing with high‐risk cases
References
Further reading
Chapter 6 Interpretation of Injuries: General Principles, Classification, and Age Estimation
6.1 Introduction
6.2 General aspects
6.2.1 Mechanism of injury
6.2.2 Strength of force at impact
6.2.3 Types of injuries
6.2.4 Development and ageing of injuries
6.2.5 Factors affecting the development of bruises
6.3 Timing of bruises
6.3.2 Gross naked eye and photographic assessment
6.3.3 Microscopical changes in bruises
6.4 Colour measurement of bruising
6.4.1 Colorimetry
6.4.2 Spectrophotometry
6.5 Differentiation from artefacts and other post‐mortem appearances
6.5.1 ‘Post-mortem bruising’
6.5.2 Hypostasis and congestion
6.5.3 Post-mortem injuries
6.5.4 Resuscitation injuries and handling after death
6.6 Decomposition
References
Further reading
Chapter 7 Blunt Impact Trauma
7.1 External surface injuries
7.1.1 Abrasions
7.1.2 Bruises
7.1.3 Lacerations
7.2 Types of incidents in which blunt impact trauma is the predominant feature
7.2.1 Road traffic collisions and other transportation-related incidents
7.2.1.1 Incidence
7.2.1.2 Types of injuries and their assessment in road users
7.2.1.3 Injuries to vehicle occupants
7.2.1.4 Types of injuries sustained by different body regions
7.2.1.5 Injuries from motorcycle collisions
7.2.1.6 Injuries to pedestrians
7.2.1.7 Injuries to pedal cyclists
7.2.1.8 Injuries from train collisions
7.2.2 Other incidents that involve blunt impact injuries
7.2.2.1 Serious assaults involving beating with objects, kicking, and punching
7.2.2.2 Falls from a height
7.2.3 Head injuries from blunt impact trauma or non‐impact forces on the head
7.2.3.1 Injuries to the head from blunt trauma
7.2.3.2 Types of fractures to the skull
7.2.3.3 Intracranial injuries
7.2.3.4 Focal head injuries
7.2.3.5 Diffuse injuries
7.2.3.6 Diffuse axonal injury
7.2.3.7 DAI in children
7.2.3.8 Intracranial haemorrhage
References
Chapter 8 Sharp Force Trauma
8.1 Introduction
8.2 Characteristics of sharp force trauma scenes
8.2.1 Location
8.2.2 Blood distribution
8.2.3 Homicide or suicide?
8.3 Incised (slash) wounds
8.3.1 Incised wounds to the neck (cut throat wounds)
8.3.2 Incised wounds to the wrists
8.3.3 Incised wounds to other parts of the body
8.4 Stab wounds and their assessment
8.4.1 Forces causing injury
8.4.2 Examination of clothing
8.4.3 Number of wounds
8.4.4 Position on the body
8.4.5 Defence wounds
8.4.6 Characteristics (morphology) of surface wounds
8.4.7 Assessment of wound tracts
8.4.8 Effects of injury
8.4.9 Activity after stabbing injury
8.4.10 Manner of death
8.5 Glass injuries
8.5.1 Glass injuries from assaults
8.5.2 Other types of glass injury
8.5.3 Accidental glass injury: Case study
8.6 Injuries from other sharp objects
References
Chapter 9 Firearm and Explosion Injuries
9.1 Firearm injuries
9.2 Types of firearms
9.3 Recoil
9.4 Handguns
9.4.1 Pistols
9.4.2 Revolvers
9.5 Rifles
9.5.1 Machine guns and military rifles
9.5.2 Ammunition used in rifled firearms
9.6 Shotguns
9.7 Wounds from firearms and other missile injuries
9.8 Investigation of firearm injuries
9.8.1 The scene
9.8.2 Radiological examination
9.8.3 Gross autopsy examination
9.9 Wounds and range of discharge from rifled firearms
9.9.1 Contact wounds
9.9.1.1 Close contact and loose contact
9.9.2 Near contact
9.9.3 Intermediate range
9.9.4 Distant gunshot wounds
9.10 Entry and exit wounds from single bullets
9.10.1 Entry wounds
9.10.2 Exit wounds
9.10.3 Entry or exit?
9.10.4 Graze wounds
9.10.5 Ricochet wounds
9.11 Shotgun Wounds
9.11.1 Contact wounds
9.11.2 Near-range wounds
9.11.3 Intermediate-range wounds
9.11.4 Location of wadding
9.11.5 Intermediate target
9.12 High-velocity rifle wounds
9.13 Modified projectiles
9.14 Air-gun injuries
9.15 Injuries from humane veterinary killers, industrial stud guns, and blank cartridge guns
9.16 Injuries from rubber and plastic bullets
9.17 The effects of being shot
9.18 Explosions
9.19 Effects of an explosion
9.20 Explosion injuries
9.21 Investigating the cause of the explosion
References
Further reading
Chapter 10 Forensic Aspects of Asphyxia and Drowning
10.1 Non-mechanical asphyxia
10.1.1 Reduced atmospheric pressure in aircraft cabin failure or at high altitude
10.1.2 Asphyxia from other gases
10.1.3 Cyanide poisoning
10.2 Mechanical asphyxias
10.2.1 Introduction
10.2.2 Signs of mechanical asphyxia
10.2.2.1 Petechial haemorrhages
10.2.2.2 Cyanosis
10.2.2.3 Congestion of organs
10.2.2.4 Pulmonary oedema
10.2.2.5 Fluidity of blood
10.3 Types of mechanical asphyxias and related conditions
10.3.1 Smothering (external airway obstruction)
10.3.2 Choking (internal airway obstruction)
10.3.3 Aspiration
10.3.4 Postural (positional) asphyxia
10.3.5 Traumatic (compression) asphyxia
10.3.6 Manual strangulation
10.3.7 Neck holds in law enforcement
10.3.8 Ligature strangulation
10.3.9 Ligature marks
10.3.10 Hanging
10.3.11 Judicial hanging
10.3.12 Auto-erotic asphyxia
10.4 Drowning
10.4.1 The scope of the problem
10.4.2 Initial considerations and approach
10.5 Mechanism and pathophysiology of drowning
10.5.1 Mechanisms of drowning
10.5.1.1 Dry drowning
10.5.1.2 Wet drowning
10.5.2 Pathophysiology of drowning
10.6 Diatoms and their use in the investigation of drowning
References
Chapter 11 Forensic Medical Aspects of Human Rights Issues
11.1 Torture
11.1.1 The use of torture throughout history
11.1.2 Modern methods of torture and its investigation
11.1.2.1 Investigation of cases of torture
11.1.3 Torture and International Law
11.1.4 The use of torture by the State
11.2 Development of Humanitarian Law and the Geneva Conventions
11.2.1 Humanitarian and Human Rights Law
11.2.2 Recent international conventions or instruments
11.2.2.1 Universal Declaration of Human Rights
11.2.3 Global support for human security
11.3 Responses to torture and its eradication
11.4 Physician participation in torture
11.5 Physician participation in Capital punishment
11.5.1 Stages of participation in an execution
11.5.2 Ethical considerations
11.6 The investigation of mass graves/multiple deaths related to armed conflict
11.6.1 Planning
References
Chapter 12 Sexual Offences
12.1 Introduction
12.2 Sexual offences
12.3 Responding to sexual offences
12.4 Attendance at scenes of sexual violence
12.5 Examination for injuries in sexual assault
12.5.1 Head
12.5.2 Face
12.5.3 Neck
12.5.4 Trunk
12.5.5 Limbs
12.5.6 Ano-genital region
12.6 Interpretation of findings
12.7 Examination of Fatal Sexual Assault
12.7.1 Evidence of Asphyxia
12.7.2 Modes of death
References
Further reading
Chapter 13 Paediatric Forensic Medicine
13.1 Introduction
13.2 Stillbirth/neonatal deaths
13.2.1 Child destruction
13.2.2 Determination of Live Birth and Infanticide
13.3 Sudden death in infancy syndrome
13.3.1 Scene examination
13.4 Child abuse
13.5 Types of child abuse
13.5.1 Physical abuse
13.5.1.1 T ypical physical injuries
13.5.2 Emotional and psychological abuse
13.5.3 Child sexual abuse and exploitation
13.5.4 Scene examination
13.6 Management of child abuse
13.6.1 Safeguarding and protecting children
13.6.2 The United Nations Convention on the Rights of the Child
13.6.3 Working together to safeguard children
13.6.4 Safeguarding risks to children
References
Chapter 14 Sudden Natural Death
14.1 Introduction
14.2 Sudden/Unexpected deaths where findings at autopsy are non‐specific
14.2.1 Sudden infant death syndrome
14.2.2 Sudden unexplained death in infancy
14.2.3 Sudden adult death syndrome
14.2.4 Sudden unexpected death in epilepsy
14.2.5 Dead in bed syndrome
14.2.6 Sudden Unexpected Death in Alcohol Misuse
14.3 Deaths involving different body systems
14.3.1 Cardiovascular deaths
14.3.1.1 Ischaemic heart disease
14.3.1.2 Hypertensive heart disease
14.3.1.3 Valvular heart disease
14.3.1.4 Cardiomyopathies
14.3.1.5 Other cardiac conditions
14.3.1.6 Pulmonary thromboembolism
14.3.1.7 Dating of pulmonary emboli and deep vein thrombi
14.3.1.8 Intracranial vascular conditions
14.3.1.9 Aneurysms
14.3.2 Other intracranial causes
14.3.2.1 Epilepsy
14.3.2.2 Other conditions
14.4 Sudden death in Schizophrenia
14.5 Respiratory causes
14.5.1 Bronchial asthma
14.5.2 Chronic obstructive pulmonary disease
14.5.3 Aspiration of gastric contents
14.5.4 Tuberculosis
14.6 Gastrointestinal causes
References
Chapter 15 Heat, Cold, and Electricity
15.1 Deaths from the effects of heat
15.1.1 Fires
15.1.1.1 Introduction
15.1.1.2 T he scene
15.1.1.3 Findings in fire deaths
15.1.1.4 Burns
15.1.1.5 Scalds
15.1.2 Heatstroke and Hyperthermia
15.2 Deaths from the effects of cold
15.2.1 Hypothermia
15.2.1.1 T hermoregulation and features of hypothermia
15.3 Deaths from electricity
15.3.1 Epidemiology
15.3.2 Electrocution
15.3.2.1 Mechanism of injury
15.3.2.2 Injuries
15.4 Lightning
References
Chapter 16 Diagnosing Death and Changes after Death
16.1 Introduction
16.2 Is the person really dead?
16.3 Types of death
16.3.1 Somatic death
16.3.2 Cellular death
16.4 Diagnosis of circulatory death
16.5 Diagnosis of brain death
16.6 Diagnostic tests for brain stem death
16.7 Organ donation
16.7.1 Management of the brain dead person
16.7.2 Donation after circulatory death
16.7.3 Organ donation (opt in/out) policy in the UK
16.7.4 Family’s role in organ donation
16.7.5 Position of the coroner
16.8 Early Indications of Death
16.8.1 Within a few minutes of death
16.8.2 Early changes after death up to 12 hours
16.8.2.1 Cooling of the body
16.8.2.2 Use of a nomogram for estimating the time of death
16.8.2.3 Rigor mortis
16.8.2.4 Hypostasis (syn. Livor mortis)
16.8.3 Intermediate changes after death
16.8.3.1 Putrefaction
16.8.3.2 Adipocere
16.8.3.3 Mummification
16.8.3.4 Post-mortem action by predators
16.8.3.5 Late changes
References
Chapter 17 Identification: General Principles, including Anthropology, Fingerprints, and the Investigation of Mass Deaths
17.1 Introduction
17.2 Reasons for identification
17.3 Reasons for identification in deceased individuals
17.4 Reasons for identification in living persons
17.5 Approach
17.6 Biological (general) identification (what type of individual are we trying to identify?)
17.6.1 Stature
17.6.2 Age
17.6.3 Ancestry
17.6.4 Gender
17.7 Personal identification
17.7.1 Recognition
17.7.1.1 Recognition in the deceased
17.7.1.2 Recognition in the living
17.7.1.3 Comparative methods using ante-mortem information
17.7.1.4 Identification of skeletal remains
17.8 Victim identification and management in disasters (mass fatality incidents)
17.8.1 Functions of the post‐mortem team
17.8.2 Functions of the Ante‐mortem team
17.8.3 Identification commission functions
17.8.4 Commission procedure
17.9 Practical procedures for identification
17.10 Identification of buried human remains
17.11 The use of fingerprints in identification
17.11.1 Introduction
17.11.2 Current techniques in fingerprint analysis
17.11.3 Classification and matching
17.11.4 The process of identification
17.11.5 Recent developments
17.11.6 Recent legal developments
References
Chapter 18 Use of DNA in Human Identification
18.1 DNA fingerprint discovery
18.2 Identification using DNA
18.2.1 DNA in human identification
18.2.2 The human genome
18.2.3 PCR analysis
18.2.4 STR analysis
18.3 The National DNA database
18.4 Forensic analysis
18.4.1 DNA inhibition
18.4.2 DNA degradation
18.4.3 Low-level DNA
18.4.4 DNA contamination
18.5 DNA mixtures
18.6 Lineage markers
18.6.1 Y Chromosome analysis
18.6.2 X Chromosome analysis
18.7 Mitochondrial analysis
18.8 Kinship testing
18.9 Missing persons investigations
18.10 Disaster victim identification
References
Chapter 19 Forensic Odontology and Human Identification
19.1 The human dentition
19.2 The dental identification process
19.2.1 Dental records
19.2.2 Radiographs
19.3 Post-mortem procedure
19.3.1 Access to the mouth
19.4 Dental ageing
19.5 Dental reconciliation
19.6 Identification outcomes
19.6.1 No Comparison can be Made
19.7 Bite Marks
References
Further reading
Chapter 20 Crime and Mental Health/Forensic Psychiatry
20.1 Introduction
20.2 Mental disorder
20.3 Mental disorder and criminal behaviour
20.4 Organic disorders
20.4.1 Dementia
20.4.2 Delirium
20.4.3 Brain damage and personality change
20.4.4 Epilepsy and sleeping disorders
20.5 Substance misuse disorders
20.6 Mood disorders
20.7 Psychotic disorders
20.8 Neurotic and anxiety disorders
20.9 Personality disorders
20.10 Learning disabilities
20.11 Sexual offending and mental disorders
20.11.1 Morbid jealousy
20.11.2 Erotomania
20.12 Mental health legislation
20.13 Section 48: transfer of unsentenced prisoners
20.13.1 Restriction orders and restriction directions
20.14 Section 41: restriction order
20.15 Section 49: restriction direction
20.16 Specific psychiatric issues during criminal proceedings
20.16.1.1 Psychiatric Defences
20.16.1.2 Mens Rea and Actus Reus
20.16.1.3 Fitness to Plead
20.17 Serial killers
20.18 Clinical forensic psychiatry
20.18.1 The role of the forensic psychiatrist
20.18.1.1 Clinical assessment and diagnosis
20.18.1.2 Aspects of treatment and management
20.18.1.3 Addressing areas of risk
20.18.2 Providing a good‐quality rehabilitation package
20.19 Secure forensic mental health services
20.19.1 Admission Criteria to High Security Services
20.19.2 Admission Criteria to Medium Secure Services
20.19.3 Admission Criteria to Low Secure Services
20.19.4 Specific provision
20.19.4.1 Physical Security
20.19.4.2 Procedural Security
20.19.4.3 Relational Security
20.20 Conclusions and final thoughts
References
Chapter 21 Maternal Deaths
21.1 Introduction and definitions
21.2 Causes of maternal deaths
21.3 The autopsy in maternal death
21.4 Specialised pathology in pregnancy
21.4.1 Amniotic fluid embolism
21.4.2 Pre-eclampsia, eclampsia, and hypertension
21.4.3 Haemorrhage
References
Chapter 22 The Examination of Detainees and Death in Custody
22.1 Defining death in custody
22.2 Ministerial Council on Deaths in Custody
22.3 Deaths in custody in England and Wales
22.4 Management of detainees in police custody
22.4.1 Risk assessment
22.4.1.1 Role of the doctor
22.5 Role of the Independent Office for Police Conduct
22.5.1 Investigation types
22.6 Deaths related to restraint
22.7 Excited Delirium Syndrome/Acute Behavioural Disturbance
22.8 Conflict resolution (De-escalation)
22.9 Methods of restraint
22.9.1 Physical contact involving pressure to the body
22.9.2 Use of baton guns (previously ‘rubber bullets’)
22.9.3 Conducted electrical device CED (Taser gun)
22.9.4 Chemical sprays/gas
22.9.5 Drug administration
22.10 Addendum
22.10.1 Recent developments in the UK
References
Chapter 23 Forensic Toxicology: Clinico-pathological Aspects and Medico-legal Issues
23.1 Introduction
23.2 Biological samples collected for toxicological analysis
23.2.1 Blood
23.2.2 Urine
23.2.3 Liver
23.2.4 Vitreous humour
23.2.5 Stomach contents
23.2.6 Hair and nails
23.3 Interpretation of toxicology results
23.4 Interactions between drugs
23.5 Assessing the cause of death
23.6 Alcohol
23.6.1 Physiological effects of alcohol with a forensic interest
23.6.2 Effects on performance and behaviour
23.6.2.1 General effects and symptoms
23.6.2.2 Schematic summary of alcohol-related effects
23.6.3 Alcohol and driving
23.6.3.1 Legislative measures
23.6.4 Acute alcohol poisoning
23.6.4.1 Post-mortem findings in acute alcoholic poisoning
23.6.4.2 The ‘fatal level’ in acute alcoholic poisoning
23.6.5 Alcoholic ketoacidosis
23.6.6 Causes of death directly related to chronic alcohol abuse
23.6.7 Biomarkers of Chronic alcohol abuse
23.6.8 Ethanol and its metabolites
23.6.9 Liver enzymes
23.6.10 MCV
23.6.11 CDT
23.7 Alcohol withdrawal syndrome
23.8 Alcohol interaction with other drugs
References
Chapter 24 Illicit Drug Use
24.1 Definitions
24.1.1 Illicit drug use
24.1.2 Substance abuse
24.1.3 Drug misuse
24.1.4 Recreational drug use
24.1.5 Problem drug use
24.1.6 Tolerance
24.1.7 Chronic drug use
24.1.8 Addiction
24.1.9 Craving
24.2 Type of substances
24.2.1 Cannabis
24.2.2 Cocaine
24.2.3 Heroin
24.2.4 Amphetamine/Methamphetamine
24.2.5 Hallucinogens
24.2.6 Inhalants
24.2.7 New psychoactive substances
24.3 The legal scenario of drug use
24.3.1 International law
24.3.2 EU drug policy
24.3.3 UK level
24.4 The drug scene today
24.4.1 Drug demand
24.4.2 Drug supply
24.4.3 New psychoactive substances
24.4.4 Internet and cybercrime
24.4.5 Fentanyl-related intoxications and deaths
24.4.6 Debate on cannabis legalisation
24.5 Consequences of drug use
24.5.1 Effects on mental health
24.5.1.1 Cannabis
24.5.1.2 Cocaine
24.5.1.3 Heroin
24.5.1.4 Methamphetamine
24.5.1.5 Hallucinogens
24.5.1.6 Inhalants
24.5.1.7 New psychoactive substances
24.5.2 Effects on the organism
24.5.2.1 Cannabis
24.5.2.2 Cocaine
24.5.2.3 Heroin
24.5.2.4 Amphetamine/Methamphetamine
24.5.2.5 Hallucinogens
24.5.2.6 Inhalants
24.5.2.7 New psychoactive substances
24.5.3 Drug use and related infectious pathologies
24.5.4 Criminal behaviour
24.5.5 Drugs and driving
24.5.5.1 Cannabis
24.5.5.2 Cocaine
24.5.5.3 Opioids
24.5.5.4 Amphetamine/Methamphetamine
24.5.5.5 Benzodiazepines and other medicines
24.5.5.6 Drug use in the workplace
References
Index
EULA