Fatal drug poisonings: medico-legal reports and mortality statistics

The entire fatal drug poisoning panorama in Finland is considered in terms of three catergories: accidental, self-inflicted and undetermined (whether accidental or with intent to harm) deaths. The study material consisted of all 500 deaths in 1997 that medical examiners, after examination(s) at the Forensic Toxicology Division (FTD) of the Department of Forensic Medicine, University of Helsinki, officially certified as resulting from drug poisoning. These deaths were matched with data on the same deaths registered at Statistics Finland (SF), the national mortality statistics office. The SF register included 72 additional instances of deaths resulting from drug poisoning. In all but two of these cases, the cause-of-death determination was based on a medico-legal inquest with autopsy and forensic toxicological examination(s) and was certified, in most of the cases, as due to the alcohol component in multiple-toxicant combinations. Reclassifying these deaths at SF to the category of drug component is in accordance with current International Classification of Diseases (ICD-10) regulation of coding "to the medicinal agent when combined with alcohol"; the principle and practice, which is recommended to be amended to equalize the status of alcohol and drug when explicitly stated by a forensic examiner as the principal toxicant in combined poisonings. With regard to manner-of-death, the agreement rates between medico-legally proven deaths from drug poisoning and those registered at SF were 79.8% for accidents, 98.5% for suicides and 0% (nil) for undetermined deaths, at the level of three-character external cause codes (E-code). All deaths originally certified as undetermined were re-assigned, most frequently to the category of accidental death. Since within an advanced and sophisticated medico-legal system, a medical examiner's evidence-based statement, even when the conclusion reached is undetermined (as to intent), should be taken as a compelling argument, the practice of reclassification cannot be considered advisable because assembled information is lost. Concerning the assigned drug-specific groups, the agreement according to the manner-of-death between certifications and registrations was fairly good. From among the accidents, however, opioid poisonings were re-assigned in 11 (29.7%) cases, mostly to the drug abuse/dependence categories, i.e. they were considered as natural deaths by the statistics office. The drug-specific observations were possible only by using the codes from the Anatomical Therapeutic Chemical (ATC) classification of drugs. This is why the incorporation of ATC codes into the ICD system, whenever reasonable, is recommended.     

Ireland and medical research with minors: some medico-legal aspects

The practice of medical research with minors in Ireland consist of practices pertaining to therapeutic and non-therapeutic medical research. Clinical trials (a category of therapeutic research), is governed by legislation. However, any other therapeutic research (non-clinical trials research) and non-therapeutic research, e.g. observational medical research such as a longitudinal study of children or non-therapeutic research such as blood sample collection for analysis of cause of disease, are unregulated by legislation. This, article will outline and describe some of the medico-legal issues involved in both types of research and will comment on matters such as what national law exists, how the directive on good clinical practice has been implemented, what guidelines, if any, exist.     

Medical examination of sexually abused children: medico-legal value

The Department of Forensic Medicine (forensic pathology and clinical forensic medicine), Aarhus, Jutland, Denmark, performs examinations of children suspected to have been sexually abused when reported to and requested by the police in Jutland, Denmark. Jutland covers an area of 210,000 km2 with about 300,000 inhabitants in Aarhus. A colposcope initially equipped with an Olympus camera, but now with a video camera attached has been used since 1994. Since 1994 the department has performed more than 100 examinations of children suspected of having been sexually abused. A preliminary study was taken to evaluate all cases from 1995 including the legal outcome. RESULTS: The material included 34 cases with three boys, mean age 11 years, and 31 girls, mean age 8 years, at the time of the examination. The sexual abuse events were fondling including penetration of the vagina, vaginal (14), anal (7), and oral (5) intercourse as well as cunnilingus and nontouching abuses. The medical examination was most often performed more than a week after the abuse. The examination revealed normal findings in 23 cases, nonspecific findings including erytherma in 13 cases, and in only one child was a traumatic lesion with rupture of the hymen seen. The perpetrators were above 25 years of ane and were family members or someone known to the child. Nine perpetrators were convicted at court, of whom three admitted having abused the child. CONCLUSION: A medical examination in cases of sexual child abuse seldom provides a legal proof of sexual abuse. The most important is the story told by the child. Therefore, the examination is a supplement which may support or remain neutral to the story told by the child.     

Abortion laws and medical developments: a medico-legal anomaly in Queensland

In October 2010 the District Court sitting in Cairns, Queensland, found Tegan Leach not guilty of attempting to procure her own abortion and Sergie Brennan not guilty of supplying Leach with the drugs Mifepristone and Misoprostol to procure an abortion. Brennan obtained the drugs from his sister in the Ukraine through the regular postal system. R v Brennan and Leach was the first case in Queensland's history where a woman was charged with procuring her own abortion. The drugs are accepted by the medical profession worldwide for medical abortions. A prosecution witness gave evidence that Mifepristone is not harmful or injurious to the health of a woman and it is listed as an essential medicine by the World Health Organisation and approved for use by the Australian Therapeutic Goods Administration. The jury found the defendants not guilty because they were not satisfied beyond reasonable doubt that the combination of the drugs Mifepristone and Misoprostol was a "noxious" substance under the Criminal Code (Old). This article concludes that there is no regulatory miracle which will stop the traffic of Mifepristone and Misoprostol into Australia and therefore an intelligent regulatory response is required which would make it unnecessary for women to seek Mifepristone and Misoprostol from overseas networks and the internet. Among other things, this would include the repeal of confusing, inappropriate and ineffective abortion laws.     

Sudden infant death--focus subject of medico-legal research

The compilation of research activities concerning SID in the field of legal medicine could only choose those out of a great abundance of high-quality examinations which represent applied research. By this they have contributed either to the clarifying of the aetiology which has not been cleared up or to the prophylaxis. For this looking through in a widest sense the basic approach was to consider SID being the result of an intrinsic and/or extrinsic disturbance of the modulation of respiratory regulation of the infant. This namely means a metabolic disturbance of respiratory neurons. One must not share this opinion even if it is given a certain plausibility by newer physiological examinations. But this also means that some examinations did not receive the acknowledgement which they would have received if there had been an immunological approach. The compilation was completely done without a presentation of the primary crisis intervention and the long-term care as being a fundamental medico-legal approach. Altogether may be summarized that legal medicine has completely fulfilled its duty to take care of the problem SID and that the examinations did not remain without success.     

Quality of health care and the role of relationships: bridging the medico-legal divide

This Article focuses on an often overlooked barrier to efforts to enhance the quality of health care: the relationship crisis that currently exists between physicians and patients. This state of affairs has resulted from the divide between the medical and legal worlds. The medical arena has understandably tended to view the doctor-patient relationship as a purely medical issue, ignoring the law's impact in generating and sustaining problematic relationship patterns. The legal world has yet to fully recognize this state of affairs, and the law's role in its evolution and persistence. We offer a relational approach to health-care law as a means of bridging the divide between the two disciplines. In the malpractice context, this would entail adopting a no-fault compensation scheme, which is committed to strengthening collaborative doctor-patient relations, enhancing patient safety and systemic learning, while providing adequate compensation.     

Exorcising excision: medico-legal issues arising from male and female genital surgery in Australia

Genital surgery is one of the most controversial and contested practices, yet it is frequently described and referred to with little or no attention to cultural and social context. This article examines the practice, performed on both men and women, and the extent to which it clashes with issues of consent and capacity, as well as multicultural concepts of toleration for minority group practices. It then questions why female genital surgery, unlike male genital surgery, is legally prohibited in Australia. It argues that such legal gender bias stems from a liberal conception of "tolerance" and the limits of consent in Australia, placing female genital surgery in an "unacceptable" category and male genital surgery in an "acceptable" category.     

Diagnostic value of the placenta in medico-legal practice

In three suspected cases of infanticide, histological examinations of the placentas were effective in clarifying the circumstances. We have estimated the 5th month of pregnancy from pieces of the placenta in one case and diagnosed the causes of perinatal abnormalities in two cases, those being acute chorioamnionitis and possible premature separation of normally implanted placenta.     

Fibromuscular dysplasia of the basilar artery: an unusual case with medico-legal implications

A 28-year-old male car driver was reported to suddenly loose the control over his vehicle, to hit the right and middle crash barrier, and to be unconscious as the car came to a halt in a position at right angles to the road. The car was hit in its left side by an automobile with high velocity, and the 28-year-old driver died. Examination of the brain revealed a massive isolated basal subarachnoid hemorrhage and a complete tearing of the basilar artery. A macroscopically detectable aneurysm was not found. However, histological examination of the large arteries at the base of the brain showed (i) fibromuscular dysplasia (FMD) mostly involving the basilar artery (ii) with a ruptured micro-aneurysm in its upper third part. The observations of the eye witnesses that the driver initially lost control over his car were judged in favour of the accused to be due to that rupture of the micro-aneurysm, while complete transverse tearing of the basilar artery occurred during the car crash due to hyperextension and rotation of his neck. Intracranial FMD is a rare cause in the differential diagnosis of isolated basal subarachnoid hemorrhage. The medico-legal implications of this entity are described in the presented case.     

The value of the medico-legal examination in sexual offences

A review is presented of medico-legal examinations performed on two series of rape and attempted rape in 1975 and 1980 with a total of 74 victims. Judicial outcome was known in 93% of the cases and is compared with the results of the medico-legal examinations. Between the two series, public discussions and pressure from feminist movements concerning the procedure in rape cases together with modifications of civil penal code resulted in alterations of police practice. Eighteen percent of known offenders in 1975 and 42% in 1980 were charged, 50% and 90%, respectively, of these were convicted. A correlation between the judicial outcome and the results of the medico-legal examination was not found in all cases. The importance of psychological guidance to the victim at the medico-legal examination is stressed.     

Reduced punishment in Israel in the case of murder: bridging the medico-legal gap

The psychiatrist's assessment of criminal responsibility of an accused in court for an act of crime has always been a matter of great difficulty. In 1997, clause 300a was incorporated into the Penal Code of Israel, thereby permitting a more lenient punishment for murder than mandatory life imprisonment. The clause includes the definition of what is meant by "severe mental disorder" and "significantly restricted capacity" by the defendant to understand the criminal nature of his or her act and to refrain from committing it. Usage of the concepts "disorder" and "significantly restricted capacity" in addressing the issue of diminished responsibility of the mentally ill is new to the Israeli legal code. The emergence and evolvement of the above concepts are presented through a historical review of the Israeli encoded law concerning mental illness, analyzed from a psychiatric perspective.     

Knitted fractures of the laryngopharynx framework as a medico-legal matter

The article presents the analysis of knitted trauma to the hyoid bone and laryngeal cartilages, revealed while searching for fresh fractures of the laryngopharynx skeleton for medico-legal purposes. Neck organocomplexes (n = 440) were completely prepared after fixation in formalin. Old injuries were found in 17.3% of cases, and in 3.2% of cases two elements of the complex were formerly broken. More often there was consolidated trauma to the thyroid (11.4% of cases) and cricoid cartilages (7.3%) and, rarely, to the hyoid bone (1.6%) and cervical part of the trachea (0.2%). These injuries occurred twice as often in men (20.3% of cases) than in women (P < 0.01). Substantiated conclusions are: (1) people of working age are most prone to neck trauma; and (2) from the 1960s the percentage of such traumas in the St. Petersburg region has grown due to urbanization. This article presents data on the localization and morphology of the injuries, as well as a review of symptoms and the course of blunt neck trauma. Despite the difficulties associated with the complete regeneration of injured tissues, forensic pathologists can obtain certain information which police officials may be interested in.     

Detection of injuries in traumatic deaths. The significance of medico-legal autopsy

A material of 218 medico-legal autopsies on persons with traumatic injuries was analysed. All these persons had been admitted to hospital. In 75 (34%) injuries had been missed in hospital. In 11 (5%) the overlooked injuries were the sole cause of death, while in 51 (23%) they were contributory. The missed injuries were found in all regions: 27% were moderate (AIS 2), 28% serious (AIS 3), 40% severe (AIS 4), and 5% critical (AIS 5). It is concluded that medico-legal autopsies are necessary for an exhaustive evaluation of traumatic deaths. They are of significance not only to legal security, but also to the social need for analysing injury mechanisms and the consequent possibility of preventive efforts.     

Violent crime and substance abuse: a medico-legal comparison between deceased users of anabolic androgenic steroids and abusers of illicit drugs

Several case reports and survey studies have indicated that abuse of anabolic androgenic steroids (AAS) often leads to increased aggressiveness and feelings of hostility that may occasionally trigger violent behaviour. Other observations indicate that many users of AAS also abuse alcohol and/or various illegal substances. Since substance abuse is a well-known risk factor for violent behaviour, it could be that violence committed by AAS users might, at least in many cases, actually be caused by abuse of other drugs. In order to examine this possibility further here, the criminal histories (in terms of incidences of convictions) of deceased users of AAS with (AASpos-subst.pos) and without (AASpos-subst.neg) signs of abuse of other illegal substances were compared to the corresponding histories of deceased users of illicit substances testing negatively for AAS (subst.pos-AASneg) at the time of autopsy. The risk of being convicted for a crime against property was significantly higher in the subst.pos-AASneg group than in either the AASpos-subst.neg or AASpos-subst.pos groups (RR=0.048 versus 0.408). At the same time, the risk of being convicted for a crime of violence was at least as high for the two AAS-positive groups as for the AAS-negative group. Furthermore, when compared with the first 3 years after the first criminal conviction, a pronounced increase in the proportion of incidence of violent crimes and a marked reduction in the proportion of incidence of crime against property was observed during the 3-year period immediately preceding death only among the AASpos-subst.neg subjects. In conclusion, the incidence of violent crime among users of AAS without signs of other drug abuse was comparable to the corresponding incidences for drug addicts without AAS use. This observation suggests that the violent criminality observed among AAS users is not confounded in any systematic fashion by abuse of other drugs. The findings also indicate that use of AAS in certain predisposed individuals might cause a high rate of violent crimes, especially if the use of AAS is combined with the use of other illegal substances.     

A method of estimating errors in medical treatment during medico-legal expert evaluation

The authors worked out "Informative chart on medical treatment defects" which is recommended for use in cases of revealing the defects in medical treatment by medicolegal expert.