Current Practice in Forensic Medicine, Volume 2

Forensic medicine is a broad and evolving field with areas of rapid progress embracing both clinical and pathological aspects of practice, in which there may be considerable overlap. This is the second volume in a series that provides a unique, in-depth and critical update on selected topics of direct relevance to those practising in the field of clinical forensic medicine and related areas including lawyers, police, medical practitioners, forensic scientists, and students.

The chapters endeavour to maintain a relevance to an international, multi-professional audience and include chapters on:

• DNA decontamination,
• The toxicity of novel psychoactive substances,
• The relevance of gastric contents in the timing of death,
• The effects of controlled energy devices,
• The main risk factors for driving impairment,
• The risk factors for harm  to health of detainees in short-term custody,
• Autoerotic deaths,
• Child maltreatment and neglect, and
• The investigation of potential non-accidental head injury in children.

Also included are chapters on excited delirium syndrome, automatism and personality disorders. Two topics not generally covered in standard clinical forensic medical textbooks include a forensic anthropological approach to body recovery in potential crimes against humanity and risk management and security issues for the forensic practitioner investigating potential crimes against humanity in a foreign country.

Dr John Gall is a consultant forensic physician. He is Director of Southern Medical Services Pty Ltd; Associate Professor in the Department of Paediatrics at The University of Melbourne; Consultant at the Victorian Forensic Paediatric Medical Service at the Royal Children's Hospital and Monash Medical Centre; President of the World Police Medical Officers; and Vice-President of the Australasian Association of Forensic Physicians.

Jason Payne-James is a Consultant Forensic Physician & Specialist in Forensic & Legal Medicine. He is Honorary Consultant at the Paediatric & Emergency Medicine at St George's Hospital, London; Honorary Senior Lecturer at the Cameron Forensic Medical Sciences, Barts and the London SMD; President at the Faculty of Forensic & Legal Medicine (Royal College of Physicians); and Director of Forensic Healthcare Services Ltd.

List of Contributors ix

Preface xix

Chapter One: DNA contamination – a pragmatic clinical view 1

Contamination considerations 1

DNA profiling 6

DNA deposits 10

Decontamination 11

General approach to DNA decontamination 20

Contamination 20

Cleaning and the DNA laboratory 22

Cleaning and decontamination of forensic examination suites – the way forward 26

References 31

Chapter Two: The toxicity of the novel psychoactive substances 35

Introduction 35

Acute toxicity 35

Chronic toxicity 40

Deaths 41

References 44

Chapter Three: Postmortem gastric content analysis: its role in determining time since death 47

Introduction 47

The physiology of gastric emptying 48

Gastric motility and emptying 49

Methods for measuring gastric emptying 52

Experimental studies 52

Factors affecting gastric emptying (in adults) 53

Analysis of gastric contents 56

Usefulness of gastric contents in time of death estimations 61

Conclusion 62

Acknowledgments 63

References 63

Chapter Four: Conducted energy devices 67

Overview 67

What are conducted energy devices? 67

Modes of use of the TASER® X26, TASER® X26P and TASER® X2 68

The electrical outputs of the TASER® X26, X26P and X2 68

Operationally exploited effects of TASER® CEDs: pain and neuromuscular incapacitation 70

Adverse effects associated with use of the TASER® X26 71

Conclusions 76

References 77

Chapter Five: Autoerotic deaths 81

Historical context 81

Definition 83

Incidence 85

Investigation of autoerotic deaths 86

Typical methods of autoerotic death 88

Atypical methods of autoerotic deaths 91

Typical and atypical victims 92

Summary 94

References 94

Chapter Six: Excited Delirium Syndrome: aetiology, identification and treatment 97

Introduction 97

Aetiology 101

Diagnosis 103

Initial approach and work�]up 104

Medication treatment options for ExDS 106

Supportive treatment 110

Conclusions 112

References 114

Chapter Seven: Automatism – wading through the quagmire 119

Introduction 119

Definitions of automatism 120

The law 121

Medical conditions capable, or possibly capable, of founding a defence of automatism 123

Sentencing and mitigation 134

Proposals for reform in England and Wales 135

Acknowledgments 135

Law reports 135

References 136

Chapter Eight: Classification of personality disorders, clinical manifestations and treatment 139

Introduction 139

What is personality disorder? 139

Dimensional or categorical diagnostic approaches? 141

Prevalence 142

The hybrid model 143

Assessment 143

Specific issues in forensic medicine settings 149

References 150

Chapter Nine: Driving impairment: the main risk factors 153

Introduction 153

Legislative approaches 155

Sobriety assessment 158

Specific drugs 162

Forensic specimens in drug driving cases 168

Medical conditions and fitness to drive 169

Sleep deprivation 171

Conclusions 172

References 172

Chapter Ten: Risk factors for death or harm to health for detainees in short�]term police custody 179

Introduction 179

The background to healthcare in police custody 179

The nature of health problems of detainees 180

Deaths and harm in police custody 185

Excited Delirium Syndrome 190

Broad principles of care 191

Identification and diversion 197

Prevention of death and harm in police custody 202

References 203

Chapter Eleven: The utility of radiological investigation of suspected abusive head trauma in children 207

Introduction 207

Injury patterns 207

Anatomy of the head 208

Scalp injury 209

Skull injury 209

Estimate of time of injury of skull fractures 213

Mimics of skull fractures 214

Tips for investigating suspected skull fracture 217

Intracranial manifestations of head injury 218

Subdural haemorrhage 219

Subarachnoid haemorrhage 233

Extradural haemorrhage 234

Cortical contusions 235

Diffuse axonal injury (shear injury) 235

Brain oedema, swelling and hypoxic ischaemic brain injury 236

Conclusion 240

References 240

Chapter Twelve: Child maltreatment: detection and diagnosis 243

Introduction 243

Defining child abuse and neglect 244

The physician’s role in detecting child abuse 244

Contributing and risk factors for child abuse 246

General signs and symptoms of child abuse 246

Physical signs of child abuse 247

Fabricated or induced illness 257

Specific clinical presentations suspect for child abuse 259

Recognizing neglect 260

Screening instruments for detection of child abuse in Emergency Departments 260

Medical conditions that mimic child abuse 262

Summary and conclusion 262

References 265

Chapter Thirteen: Recovery of remains in potential crimes against humanity investigations – a forensic anthropological approach 269

Forensic anthropology and investigations into human rights violations and crimes against humanity 269

The characteristics of forensic anthropological investigations into human rights violations and crimes against humanity 272

The main mistakes made in forensics 274

Phases of the forensic anthropological investigation in the context of human rights violations 275

A multidisciplinary approach 281

Complex cases 282

Lessons learned and considerations 283

Conclusions 284

Acknowledgments 284

References 285

Chapter Fourteen: Field missions 287

Introduction 287

S: Situation 288

M: Mission 289

E: Execution 289

A: Administration and logistics 291

C: Communications and command 295

S: Security 295

Other mission�]related matters 296

Strategic security assessments 297

Conclusion 311

Appendix A-Mission plan template 312

Appendix B-Example of team functions for personnel required for the exhumation of human remains from a mass grave 314

Index 317

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