Essential Forensic Medicine

Peter Vanezis, MB, ChB, MD, PhD, FRCPath, FRCP (Glasg.), FFLM, FCSFS, FAFMS (UK), DMJ (Path), He has been Professor of Forensic Medical Sciences and Director of the Cameron Forensic Medical Sciences at Barts and the London (Queen Mary University of London) since 2006 (now Emeritus). He was formerly Regius Professor of Forensic Medicine and Science at the University of Glasgow. He is a Fellow of The Royal College of Pathologists, Fellow of Royal College of Physicians of Glasgow, Fellow of the Faculty of Forensic and Legal Medicine and Fellow of the Chartered Society of Forensic Scientists. Peter Vanezis was awarded an OBE in June 2001, for Forensic Pathology Services in Kosovo.

List of Contributors xix

Series Foreword xxi

Preface xxiii

Acknowledgements xxv

1 The Legal System, Courts, and Witnesses 1
Peter Vanezis

1.1 Introduction 1

1.2 British courts 2

1.3 The Supreme court of the United Kingdom 2

1.4 English and Welsh courts 3

1.5 Scottish Courts 4

1.6 Northern Ireland Courts 6

1.7 Other courts 6

1.8 Types of witnesses and evidence 7

References 11

2 Investigation of the Deceased and Their Lawful Disposal 13
Peter Vanezis

2.1 Introduction 13

2.2 Certification of details of death by the Registrar of births and deaths and lawful disposal of the body 13

2.3 Death certificate 14

2.4 When may a doctor issue a death certificate? 14

2.5 The form of the certificate in England and Wales 14

2.6 Legal procedures in the coroner system 14

2.7 Deaths abroad 19

2.8 Inquests 19

2.9 Registration of death 21

2.10 Burial 21

2.11 Cremation 21

2.12 The Human Tissue Act 2004 and Human Tissue (Scotland) Act 2006 24

2.13 Exhumation is discussed in detail in Chapter 5 25

2.14 Legal procedures in death investigation: Other systems 25

References 27

3 The Duties of a Registered Medical Practitioner and the General Medical Council 29
Peter Vanezis

3.1 Medical Acts 29

3.2 Role of the GMC 30

3.3 Consent 32

3.4 Decisions involving children and young people 33

3.5 Consent and capacity 34

3.6 Medical confidentiality 35

3.7 Consent for disclosure 35

References 36

4 General Principles of Scene Examination 37
Peter Vanezis

4.1 Concept of the scene 37

4.2 Scene investigation and Locard’s principle 38

4.3 Scene location and associated problems 40

4.4 Type of incidents 46

4.5 The forensic pathologist and other medical personnel at the scene 47

References 52

Further reading 53

5 The Medico‐legal Autopsy 55
Peter Vanezis

5.1 Introduction 55

5.2 Historical background 55

5.3 Types of autopsy 57

5.4 Types of autopsy in the Coroner system 58

5.5 Autopsy procedure 60

5.6 Examination of the exhumed body 67

5.7 Safety in the mortuary and dealing with high‐risk cases 69

References 70

Further reading 71

6 Interpretation of Injuries: General Principles, Classification, and Age Estimation 73
Peter Vanezis

6.1 Introduction 73

6.2 General aspects 73

6.3 Timing of bruises 77

6.4 Colour measurement of bruising 80

6.5 Differentiation from artefacts and other post‐mortem appearances 82

6.6 Decomposition 85

References 86

Further reading 87

7 Blunt Impact Trauma 89
Peter Vanezis

7.1 External surface injuries 90

7.2 Types of incidents in which blunt impact trauma is the predominant feature 97

References 110

8 Sharp Force Trauma 111
Peter Vanezis

8.1 Introduction 111

8.2 Characteristics of sharp force trauma scenes 112

8.3 Incised (slash) wounds 113

8.4 Stab wounds and their assessment 116

8.5 Glass injuries 124

8.6 Injuries from other sharp objects 127

References 127

9 Firearm and Explosion Injuries 129
Peter Vanezis

9.1 Firearm injuries 129

9.2 Types of firearms 129

9.3 Recoil 130

9.4 Handguns 130

9.5 Rifles 131

9.6 Shotguns 132

9.7 Wounds from firearms and other missile injuries 134

9.8 Investigation of firearm injuries 135

9.9 Wounds and range of discharge from rifled firearms 137

9.10 Entry and exit wounds from single bullets 141

9.11 Shotgun Wounds 143

9.12 High‐velocity rifle wounds 146

9.13 Modified projectiles 147

9.14 Air‐gun injuries 147

9.15 Injuries from humane veterinary killers, industrial stud guns, and blank cartridge guns 147

9.16 Injuries from rubber and plastic bullets 147

9.17 The effects of being shot 147

9.18 Explosions 148

9.19 Effects of an explosion 148

9.20 Explosion injuries 149

9.21 Investigating the cause of the explosion 152

References 152

Further reading 153

10 Forensic Aspects of Asphyxia and Drowning 155
Peter Vanezis

10.1 Non‐mechanical asphyxia 156

10.2 Mechanical asphyxias 158

10.3 Types of mechanical asphyxias and related conditions 161

10.4 Drowning 174

10.6 Diatoms and their use in the investigation of drowning 177

References 178

11 Forensic Medical Aspects of Human Rights Issues 181
Peter Vanezis

11.1 Torture 181

11.2 Development of Humanitarian Law and the Geneva Conventions 189

11.3 Responses to torture and its eradication 191

11.4 Physician participation in torture 191

11.5 Physician participation in Capital punishment 192

11.6 The investigation of mass graves/multiple deaths related to armed conflict 194

References 197

12 Sexual Offences 199
Philip Beh

12.1 Introduction 199

12.2 Sexual offences 199

12.3 Responding to sexual offences 201

12.4 Attendance at scenes of sexual violence 203

12.5 Examination for injuries in sexual assault 204

12.6 Interpretation of findings 208

12.7 Examination of Fatal Sexual Assault 209

References 211

Further reading 211

13 Paediatric Forensic Medicine 213
Philip Beh and Peter Vanezis

13.1 Introduction 213

13.2 Stillbirth/neonatal deaths 213

13.3 Sudden death in infancy syndrome 214

13.4 Child abuse 216

13.5 Types of child abuse 217

13.6 Management of child abuse 228

References 231

14 Sudden Natural Death 233
Peter Vanezis

14.1 Introduction 233

14.2 Sudden/Unexpected deaths where findings at autopsy are non‐specific 234

14.3 Deaths involving different body systems 237

14.4 Sudden death in Schizophrenia 240

14.5 Respiratory causes 240

14.6 Gastrointestinal causes 242

References 243

15 Heat, Cold, and Electricity 245
Peter Vanezis

15.1 Deaths from the effects of heat 245

15.2 Deaths from the effects of cold 253

15.3 Deaths from electricity 255

15.4 Lightning 259

References 259

16 Diagnosing Death and Changes after Death 261
Peter Vanezis

16.1 Introduction 261

16.2 Is the person really dead? 262

16.3 Types of death 264

16.4 Diagnosis of circulatory death 266

16.5 Diagnosis of brain death 267

16.6 Diagnostic tests for brain stem death 268

16.7 Organ donation 268

16.8 Early Indications of Death 270

References 283

17 Identification: General Principles, including Anthropology, Fingerprints, and the Investigation of Mass Deaths 285
Peter Vanezis

17.1 Introduction 285

17.2 Reasons for identification 286

17.3 Reasons for identification in deceased individuals 286

17.4 Reasons for identification in living persons 286

17.5 Approach 286

17.6 Biological (general) identification (what type of individual are we trying to identify?) 287

17.7 Personal identification 288

17.8 Victim identification and management in disasters (mass fatality incidents) 292

17.9 Practical procedures for identification 296

17.10 Identification of buried human remains 305

17.11 The use of fingerprints in identification 305

References 310

18 Use of DNA in Human Identification 311
Denise Syndercombe Court

18.1 DNA fingerprint discovery 311

18.2 Identification using DNA 312

18.3 The National DNA database 316

18.4 Forensic analysis 319

18.5 DNA mixtures 324

18.6 Lineage markers 328

18.7 Mitochondrial analysis 329

18.8 Kinship testing 330

18.9 Missing persons investigations 330

18.10 Disaster victim identification 331

References 333

19 Forensic Odontology and Human Identification 335
Philip Marsden

19.1 The human dentition 335

19.2 The dental identification process 336

19.3 Post‐mortem procedure 338

19.4 Dental ageing 339

19.5 Dental reconciliation 340

19.6 Identification outcomes 340

19.7 Bite Marks 341

References 342

Further reading 343

20 Crime and Mental Health/Forensic Psychiatry 345
Vivek Khosla and Orlando Trujillo‐Bueno

20.1 Introduction 345

20.2 Mental disorder 346

20.3 Mental Disorder and Criminal Behaviour 347

20.4 Organic disorders 348

20.5 Substance Misuse Disorders 349

20.6 Mood Disorders 349

20.7 Psychotic Disorders 349

20.8 Neurotic and Anxiety Disorders 350

20.9 Personality Disorders 350

20.10 Learning Disabilities 351

20.11 Sexual Offending and Mental Disorders 351

20.12 Mental Health Legislation 352

20.13 Section 48: transfer of unsentenced prisoners 353

20.14 Section 41: restriction order 353

20.15 Section 49: restriction direction 353

20.16 Specific psychiatric issues during criminal proceedings 353

20.17 Serial Killers 357

20.18 Clinical Forensic Psychiatry 357

20.19 Secure Forensic Mental Health Services 359

20.20 Conclusions and final thoughts 360

References 361

21 Maternal Deaths 363
Mahomed Dada

21.1 Introduction and definitions 363

21.2 Causes of maternal deaths 366

21.3 The autopsy in maternal death 366

21.4 Specialised pathology in pregnancy 368

References 369

22 The Examination of Detainees and Death in Custody 371
Peter Vanezis

22.1 Defining death in custody 371

22.2 Ministerial Council on Deaths in Custody 372

22.3 Deaths in custody in England and Wales 373

22.4 Management of detainees in police custody 374

22.5 Role of the Independent Office for Police Conduct 375

22.6 Deaths related to restraint 376

22.7 Excited Delirium Syndrome/Acute Behavioural Disturbance 377

22.8 Conflict resolution (De‐escalation) 377

22.9 Methods of restraint 378

22.10 Addendum 380

23 Forensic Toxicology: Clinico‐pathological Aspects and Medico‐legal Issues 383
Nadia Porpiglia, Chiara Laposata, and Franco Tagliaro

23.1 Introduction 383

23.2 Biological samples collected for toxicological analysis 383

23.3 Interpretation of toxicology results 385

23.4 Interactions between drugs 387

23.5 Assessing the cause of death 388

23.6 Alcohol 389

23.7 Alcohol withdrawal syndrome 401

23.8 Alcohol interaction with other drugs 402

References 402

24 Illicit Drug Use 405
Giovanni Serpelloni and Claudia Rimondo

24.1 Definitions 405

24.2 Type of substances 407

24.3 The legal scenario of drug use 412

24.4 The drug scene today 416

24.5 Consequences of drug use 420

References 434

Index 443