Acknowledgment

Acknowledgment

Acknowledgment     

Medical malpractice as reflected by the forensic evaluation of 4450 autopsies

A multicentre retrospective analysis of 4450 autopsies carried out due to suspicion of medical malpractice in 17 German institutes of forensic medicine from 1990 to 2000 was performed for the German Federal Ministry of Health. During the time period analysed an increase of cases could be mentioned. The main results of the study are: in the cooperating institutes the total number of autopsies due to suspected medical malpractice ranged from 1.4 to 20%. In more than 40% of the cases preliminary proceedings were started because the manner of death was certified as non-natural or not clarified. Hospital doctors were more affected by medical malpractice claims than doctors in private practice. However, the number of confirmed cases of medical malpractice was higher for doctors in private practice than for hospital doctors. Although surgery is still at the top of the disciplines involved in medical malpractice claims the number of confirmed surgical cases was below the average. Mistakes in care were confirmed to be above the average. Medico-legal autopsies are still a very sufficient method to evaluate cases of medical malpractice: 2863 cases could already be clarified by autopsy. Up to now there is no systematic registration of medical malpractice charges in Germany. A systematic registration should be initiated to build up and/or improve error reporting systems and, thus, to improve patient safety. Compared to other sources of medical malpractice claims (arbitration committees of the medical chambers, reference material of health and insurance companies, files of civil courts) the data of the present multicentre study are in so far unique as only lethal cases were evaluated and a complete autopsy report was available as basis of an expert opinion in alleged medical malpractice cases.     

Retrieving the ‘subject’ of European integration

In this article, a critical reinterpretation of citizens as subjects of European integration moves the focus of EU law from EU citizens' subjection to their subjectification. This analysis draws on post‐structural social theory in arguing that the law is instrumental to securing the material conditions for transnational political subjectification because it regulates both EU citizens' access to transnational social relations and the perception of difference between them. However, the law also reinforces constraints on the process of transnational subjectification. Systematic obstacles, which must be taken into account, are not limited to economic status, but include other variables like gender or age. It will be argued on this basis that EU law needs to develop a more coherent politics of subjectivity. Towards this goal, the law must carefully attend to what is (and is not) depoliticising in EU citizenship rights.     

Youth participation informing care in hospital settings

Abstract

In this article, we use an ecocultural framework to understand young people’s experiences of the care provided by a specialist children’s hospital. This framework conceptualizes hospital culture as situated and embodied rather than separate from people and practices. Young people’s responses, gathered during a one-day forum at the hospital, suggest ways in which a hospital can respond to them not just as individual bodies but also as members of the families and peer groups who form their broader web of care. Their input highlights the importance of consulting young people about the operations of health services themselves, not just about the patient-medico relationships that they experience whilst using a service.     

CYP2D6 and CYP2C19 genotypes and amitriptyline metabolite ratios in a series of medicolegal autopsies

In a series of 202 postmortem toxicology cases, the CYP2D6 and CYP2C19 genes were genotyped, and the concentrations of amitriptyline (AT) and six metabolites were analyzed. The polymorphic CYP2D6 and CYP2C19 genes encode enzymes participating in the metabolism of several potentially toxic drugs, and mutations in these genes may lead to adverse drug reactions, possibly even intoxications. AT was chosen as the substrate of interest because it is mainly metabolized by these enzymes, is considered relatively toxic, and ranks among the major causes of fatal drug poisoning in Finland. Our objective was to evaluate genetically determined interindividual variation in conjunction with metabolite ratios of drugs found in toxicological analysis in a series of medicolegal autopsies. Positive correlations were found between the proportion of trans-hydroxylated metabolites and the number of functional copies of CYP2D6 and between the proportion of demethylated metabolites and the number of functional copies of CYP2C19. None of the accidental or undetermined AT poisonings coincided with the CYP2D6 or CYP2C19 genotype which predicts a poor metabolizer phenotype. However, an unusually high femoral blood concentration of AT, 60mg/l, was found in one suicide case with no functional CYP2D6 genes. Our study shows a concordance of AT metabolite patterns with CYP2D6 and CYP2C19 genotypes in the presence of confounding factors typical for postmortem material. This result demonstrates the feasibility of postmortem pharmacogenetic analysis and supports the dominant role of genes in drug metabolism.     

A technique to capture, analyze, and quantify anterior teeth rotations for application in court cases involving tooth marks

Anterior teeth within the human dentition have a specific numerical rotation value. Bite marks show an array of angled indentations, abrasions, microlacerations, and contusions. These marks generally represent the incisal surfaces of the suspect's dentition reflecting the rotation values of the teeth in the dental arch. This study described a method for capturing and analyzing anterior dental rotations. The rotations of individual anterior teeth within the study population were categorized as common, uncommon, and very uncommon according to Allen's classification. In the absence of a large number of incisal patterns present in a bite mark, a single but heavily weighted tooth rotation could be of equal discriminatory potential to several common rotation values. No prevalence studies quantifying individual tooth rotations are available. The measurement of each individual tooth rotation together with its individual discrimination potential will enhance the evaluation of the concordant features observed in bite marks.     

An unusual occupational accident: fall into a sewage plant tank with lethal outcome

Occupational accidents, often presenting with lethal outcomes, are a rarely reported issue in forensic literature. However, these incidents are part of medicolegal casework with special regard to reconstruction, liabilities and insurance law-related issues, respectively. We report on a lethal occupational accident in a metropolitan sewage plant. When performing routine controls, a technician fell into an overflow sewer and was immediately pulled into a 30 cm diameter drain. Rescue efforts were initiated immediately, but had to be terminated due to gas warning. Rescue teams continued the search, however, the body remained undiscoverable. Forty-eight hours later, the cadaver was found in an adjacent digester tank, from where it was finally rescued. It was concluded, that the body had been transported between the overflow sewer and the digester tank through a 120 m pipeline with several 90 degrees bendings and branch connections with a minimum diameter of 25 cm at the discharge valve. On medicolegal examination, the cadaver showed marked signs of advanced decomposition caused by anaerobic microorganisms in the 37 degrees C biomass environment. Moreover, as a consequence of the passage of the pipeline system, signs of massive trauma (several comminuted and compound fractures) were disclosed at autopsy. To us, this is the first report on a lethal occupational accident in a sewage plant; our observations demonstrate the rapid progress of putrefaction in a warm anaerobic bacterial environment and the massive trauma sustained.     

Committed to Coordination? Intergovernmental Councils as a Federal Safeguard

In this research note, I suggest that the design of intergovernmental councils (IGC) accounts for the extent to which they are able to prevent the federal government from encroaching on subnational jurisdictions. IGC operate in areas of interdependence where the federal government faces incentives to restore to hierarchical coordination. The effect of the intergovernmental safeguard is measured by the absence or presence of federal encroachment. Two concepts are useful to explain it: the extent to which governments are committed to coordination and the dominance of the federal government of vertical IGC. I argue that different combinations of the two variables help to understand the safeguarding effect of intergovernmental councils. In particular, I contend that in any configuration in which federal dominance is present the federal government can encroach on subnational jurisdictions. The research note shows how the concept of federal safeguards can be applied empirically.     

Transnational Partnerships: Conditions for Successful Service Provision in Areas of Limited Statehood

Transnational public–private partnerships (PPPs) are external governance actors in the field of development cooperation and vary in composition, potentially including nonprofit and for‐profit organizations, state and public agencies, and intergovernmental organizations. This article analyzes the conditions under which PPPs have been successful in providing access to basic services (water, sanitation, and food) in areas of limited statehood in Bangladesh, India, and Kenya. We focus on 10 projects carried out by two PPPs that differ in two key respects: legitimacy and institutional design. We show that partnerships with high empirical legitimacy and an appropriate institutional design are best able to fulfill complex tasks in contexts of limited statehood. A participatory approach can promote legitimacy and thus success; projects that lack legitimacy are prone to failure. Additionally, a project's institutional design must address problems that commonly affect areas of limited statehood: It should provide access to resources for capacity development, ensure adequate monitoring, and be tailored to local needs.