Medicine,Science and the Law

A medical examiner (ME) system was introduced to England and Wales in 2019 intended to ensure appropriate notification of cases to HM Coroner (HMC). The aim of the study is to determine and compare: (a) the nature of notifications to HMC for Norfolk from the Norfolk and Norwich University Hospital (NNUH) in 2018 compared with 2022; (b) to determine the outcome of those notifications and (c) to establish patterns of change in the number and nature of such notifications. HMC and ME datasets were interrogated to determine differences between notifications to HMC and outcomes in 2018 compared with 2022. From deaths at NNUH (2018 – n  =  2605; 2022 – n  =  2969), there were significantly fewer HMC notifications in 2022 compared with 2018 (25.3% vs. 17.6%). A decrease in notifications was noted for persons undergoing any ‘treatment or procedure of a medical or similar nature’ (24.0% vs. 16.2%) p < 0.0014. An increase in notifications was noted for neglect, including self-neglect (3.3% vs. 12.2%) p < 0.001. Of the coronial outcomes, there were significant increases in the numbers of post-mortem (PM) examinations (29.3% vs. 35.5%) p  =  0.0276 and inquests (26.0% vs. 31.4%) p  =  0.0485). There was a significant decrease in no further action by HMC (5.7 vs. 2.3) p  =  0.0485. The study shows that the introduction of the medical examiner service has resulted in significant change in the nature of HMC notification categories. The notifications appear to be more appropriate, with an increased proportion of inquests and PM examinations and with a reduction in 100 A or ‘no further action’ outcomes.

Many people are living in prison with a range of social care needs, for example, requiring support with washing, eating, getting around safely, and/or maintaining relationships. However, social care for this vulnerable group is generally inadequate. There is uncertainty and confusion about who is legally responsible for this and how it can best be provided, and a lack of integration with healthcare. We used realist-informed approaches to develop an initial programme theory (IPT) for identifying/assessing social care needs of, and providing care to, male adults in prison and on release. IPT development was an iterative process involving (a) an initial scoping of the international prison literature; (b) scoping prison and community social care policy documents and guidelines; (c) full systematic search of the international prison social care literature; (d) insights from the community social care literature; (e) stakeholder workshops. Information from 189 documents/sources and stakeholder feedback informed the IPT, which recommended that models of prison social care should be: trauma-informed; well integrated with health, criminal justice, third-sector services and families; and person-centred involving service-users in all aspects including co-production of care plans, goals, and staff training/awareness programmes. Our IPT provides an initial gold standard model for social care provision for people in prison and on release. The model, named Empowered Together, will be evaluated in a future trial and will be of interest to those working in the criminal justice system, care providers and commissioners, local authorities, housing authorities, voluntary groups, and service-users and their families.

Many femicide cases are initially reported as missing persons to the police. Women who go missing have a greater risk of being a victim of homicide. This study explores the circumstances surrounding the disappearance and killing of women and girls in the Republic of Ireland from 1962 to 2023. A total of fifty-four cases were analysed, 52 cases were homicides. Most femicides occurred during 1990–1999 (n = 13; 24%) and 2000–2009 (n = 17; 32%). Twenty-five victims knew the offender and the leading cause of death was strangulation with 27 cases. Dumping/leaving the body on open ground with little or no concealment was the predominant method of disposal. The leading risk factors were the engagement of the victim in a fight or row before disappearance and domestic violence. The ‘suicide narrative’ should be treated with extreme caution in the disappearance of women.

Opioid abuse is a leading cause of drug-related morbidity and mortality worldwide. It has been suggested that the age of opiate users in Australia is rising. To evaluate this further in a local population, toxicology and pathology case files from Forensic Science SA, Adelaide, South Australia, were examined for all cases with lethal opioid levels from 2000 to 2019 (n = 499; M:F 2.3:1; age range 18–91 years, median age 42 years). The median age of opiate deaths increased significantly by approximately 16 years (p = 0.007, R²= 0.34) with a significant increase in total deaths in the 45–54 years and 55–64 years age groups (p = 0.009, R²= 0.32) (p = < 0.001, R²= 0.54). Deaths due to heroin overdose showed the lowest median age (39 years, n = 184), with deaths from tramadol toxicity having the highest (50.5 years, n = 32). Recent changes in the demographic profile of opioid users in cases of lethal overdose involve an aging population. Forensic and clinical practitioners should be aware of significant opioid abuse in certain individuals at older ages as this raises the possibility that this may exacerbate the effects of age-related chronic diseases in this group and/or contribute to fatalities.

As a part of a study of suicide in children aged 17 years and under in three centers—Hennepin County in the United States (US), Auckland in New Zealand (NZ), and South Australia in Australia (AUS) from 2008 to 2017 it was decided to characterize potential risk factors and to determine whether these differed by jurisdiction. Reviewed data included a history of psychiatric illness, symptoms prior to suicide, events preceding suicide, previous suicidal ideation or suicide attempts, and communication of suicidal intent. The most common events preceding suicide were arguments with family/friends and relationship issues; in addition depression with or without expressed suicidal ideation, self-harming behavior, sadness, distress, drug/substance abuse, and anorexia were documented. Suicidal intent was on occasion communicated via technological means. In 79.5% of cases in South Australia decedents had a previously diagnosed psychiatric illness, with 62% in Hennepin County. This compared to a much lower proportion of cases in Auckland (23.8%). Whether this reflects more limited access to psychiatric services or a reluctance to seek support and therapy in Auckland is unclear. It does, however, demonstrate that risk factors for child suicide are not uniform among communities and so extrapolation of data from one area to another may not be appropriate. Disturbingly parents/carers were not aware of the decedent's suicidal intent in 84–87.2% of cases.

The methods employed to detect latent fingerprints during crime scene investigations are continually refined and enhanced. The implementation of dusting techniques on surfaces that are unfeasible for laboratory transport often yields a lower percentage of identifiable fingerprints. This issue is predominantly due to the inherent properties of these surfaces and their respective levels of contamination. Furthermore, the application of laboratory procedures, typically designated for the cyanoacrylate fuming method, is of paramount importance for efficient fingerprint development in field conditions. In this study, five donors (three males and two females) deposited natural fingerprints on readily available materials in day-to-day life, such as microscope slides, both rough and smooth mica, and galvanized sheet metal. The analysis of fingerprints was conducted at seven distinct time intervals: 1 day, 1 week, 1 month, 3 months, 6 months, 9 months, and 12 months. Each of the 280 fingerprints used was divided into two equal parts, resulting in a total of 560 fingerprint segments for examination. The findings of the current study showed that 52.9% of fingerprints suitable for identification were developed with the dusting method, 89.3% with the cyanoacrylate fuming method, and 95% especially with the cyanoacrylate spraying method. These results underscore the potential significance of the cyanoacrylate spraying method as an essential scientific technique in the resolution of criminal cases.

The recent Julian Assange case raised a number of important issues regarding the role of expert witnesses in court. While written from a personal perspective, this paper will suggest that these issues need much fuller discussion than they have received to date. They will be discussed in the context of what actually happened in this case, the details of which were reported only sketchily (and sometimes inaccurately) in the press. First, there is the question of what is properly a medical or a legal responsibility. A second issue concerns whether re-litigation of already determined matters should be permitted in higher courts, when the expert does not have the opportunity to respond. A third matter involves the apparently differing professional views and ethos of the legal and other professions regarding matters of personal privacy for non-participants, particularly with respect to the safeguarding of children. Other issues include the language which may be used by some lawyers in criticising expert testimony, the protection of experts from potentially libellous reporting in the press, and the use and abuse of diagnostic classifications, such as the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual (DSM). These various matters have implications for larger concerns regarding the recruitment of suitable expert witnesses to the courts.

The majority of homicides do not occur in mass disasters but are often solitary events. This enables medicolegal investigations to be targeted around the features of a specific case. Mass disasters may, however, result in a large numbers of bodies being brought in over relatively short periods of time. Such disasters may also occur in isolated locations with limited resources and facilities resulting in full autopsies not being undertaken, with faster processing of cases than is usual. For this reason it is possible that injuries due to inflicted trauma may not always be identified. Given the varied circumstances of mass disasters, ranging from the London Blitz of WWII to the 2004 South East Asian tsunami, the possibility of concealed homicides should always be considered.

This article describes the utility of postmortem CT and MRI in diagnosing pediatric bowel obstruction (BO) as the cause of septic shock-induced death. Six pediatric cases with confirmed septic shock were retrospectively analyzed. Postmortem CT scans revealed clear signs of BO in all cases, with volvulus, intussusception, diaphragmatic hernia, or Meckel's diverticulum identified. MRI scans, performed in three cases, did not provide additional diagnostic information. The presented case series highlights the potential of postmortem CT for diagnosing BO in children, potentially aiding in understanding the cause and manner of death. While MRI offered limited additional benefits, its role in conjunction with CT and autopsy warrants further exploration. Combining these modalities could enhance diagnostic accuracy and provide a more complete picture of the cause of death in children.

Nonthrombotic pulmonary embolism is defined as the partial or total occlusion of the pulmonary circulation by various nonthrombotic agents, such as biological, nonbiological and foreign body material. A case is reported of lethal embolism of fragments of a renal calculus: A 64-year-old woman collapsed and died following laser lithotripsy. At autopsy calculous debris was found in the calyces of the right kidney with widespread microscopic fragments of birefringent foreign material in keeping with renal calculus within the pulmonary arterioles. Death was due to pulmonary calculus embolism complicating lithotripsy of a right renal calculus. Review of other causes of nonthrombotic pulmonary embolism revealed fat, bone marrow, amniotic fluid, trophoblast, tumours, septic material, hydatid cysts, bone, soft tissue/organ parenchyma, gastrointestinal tract contents/bile, gas, and foreign material that was introduced iatrogenically and non-iatrogenically. All of these possibilities should be considered at autopsy in the appropriate setting, with pulmonary microscopy often being essential to establishing the diagnosis.