[Giving medico-legal opinions in cases with suspicion of medical mistake. part 2. Expert evidence in cases with suspicion of medical mistake - expectations, possibilities, threats ].

Problems of medical mistake and therapeutic failure are inextricably linked with realization of medical services. In recent years, mostly by the media and increasing demanding attitude, a rapid increase of initiated cases opened by judicial body in conjunction with medical mistake made by medical staff is observed. Making medico-legal opinions is not easy task and often face many difficulties. These consist of lacks in medical documentation, time rigor, formal tightening and need to create team that consist of both forensic medicine specialist and clinicians, who together shall write complex medico-legal opinion. This article touches the essence of the opinion-making problem in the aspect of medical mistake. It shows specifics of the role of forensic medicine specialist, his challenges and difficulties in creating opinions. The article confronts real possibilities of court experts with expectations of judicial body, outlining new challenges and dangers which court experts have to face.

[Giving medico-legal opinions in cases with suspicion of medical mistake.part 1. between medicine and justice.]

Creating medico-legal opinion is a sophisticated investigative, analytical, decision-making and creative process. Forensic medicine specialist in cooperation with clinical medicine consultants, on the basis of evidence analysis, which was gathered during procedures and contained in the acts has to create an objective and essential opinion. This opinion is a vital, very important and irreplaceable proof in every case. Judicial body consults with forensic medicine specialist or specialists if there are circumstances for settlement of which there is a need of classified informations - art. 193 of Penalty Code. Forensic medicine specialists face many difficulties which may have effect on quality, positiveness of opinion, compliance with the deadline, increasing expectancy of judicial body or sides. It is very difficult to find clinical specialists which except their clinical knowledge have basic knowledge about law, the role and duties of an court expert. In this article we discuss creating-opinion problems, role and position of court expert in confrontation with expectations of judicial body and the Justice with particular emphasis on medical mistakes and assessment of medical proceedings. We show the complexity of creating of medical opinions, especially these institutional.

[Euthanasia - an attempt to organize issue].

This article is an attempt to complete and holistically discuss problem of euthanasia, especially its ethical and legal aspects, comparing to Polish law. The subject of euthanasia arouse interest of the society because it touches one of the most important aspects of life, which is the death. Even bigger emotions are aroused amongst physicians. They are forced to put on the line the life as biggest value on the one side and autonomy of human being on the other. It also touches the empathy for suffering. The euthanasia was divided into three forms: active euthanasia, passive euthanasia and assisted suicide. Any form of euthanasia is illegal in Poland according to both the Penal Code and Code of Medical Ethics. Range of possible penal consequences perpetrator is very wide from waiver of punishment to life imprisonment and it comes from different penal qualification of the euthanasia. Qualification of the euthanasia is based on terms of intent of perpetrator's act, request of patient, strong empathy for suffering if the patient and decision based on up-to-date medical knowledge. It is valuable to mention "do-not-resuscitate" DNR procedure, which in case of medical futility is legally accepted in Poland, but in other form may be qualified as passive euthanasia.

[The teaching of medical ethics in medical school].

Medical ethics constitutes some kind of core, which enables the physicians to decide in complicated clinical situations. This subject is taught during medical studies through only one semester. Number of teaching hours designed for this crucial in later physician's practice subject is insufficient. Additional problem in teaching process is inconsistence between the Law and the Code of Medical Ethics. As a result it causes alarmingly weak preparation of students to take practical decisions according to ethical and moral values of the Code of Medical Ethics. What is also important, in 2012 a medical studies schedule was changed, which in author's opinion had very negative effect on medical ethics teaching. In our opinion it is vital to increase number of teaching hours spent on medical ethics, create a model of gradual ethical knowledge transfer to students on every year of studies, which should be based on clinical subjects in master-student relations. Authors of this article discuss in a complex way problems of medical ethics teaching at medical studies supporting their thesis with author's survey carried out on large group of students of Medical University of Silesia in Katowice.

Evisceration and intestine damage as a rare form of suicide in forensic and psychiatric practice - description of two cases.

Suicide is a major public health problem around the world. Case reports include extreme suicidal self-inflicted injuries, in which extensive damage to the abdominal wall associated with injury or even excision of fragments of the intestine and its fragmentation are present. These cases usually give rise to doubts of investigators as to the course of the incident, the circumstances of death and the possibility of participation of other people. At the same time they are interesting from the medico-legal and psychiatric perspective. The aim of this study is the presentation of two extremely rare cases of suicides through evisceration and intestinal injury from the clinical and opinioning practice of the authors, one of which ended with survival and the second one with death. Regardless of the final result of the suicide attempt (death or survival), good practice of the investigative teams in such cases should include a detailed examination of the place of the suicide attempt, obtaining opinion of an expert in the field of forensic medicine with full post-mortem diagnosis, and in-depth forensic psychological and psychiatric analysis of, among others, lifeline, mental state and suicidal motivation (so-called psychological autopsy).

Traumatic basal subarachnoid haemorrhage or ruptured brain aneurysm in 16-year-old boy? - case report

Traumatic basal subarachnoid haemorrhage (TBSAH) represents only 1.8% of all subarachnoid haemorrhage cases diagnosed during autopsy. This report presents such a case from the current practice of the authors. Sixteen-year-old boy was beaten by the aggressors. Suddenly he lost his consciousness and fall after he received a single blow in the neck. He was resuscitated immediately, but died at the scene. During the external examination we did not find any significant external injuries. Autopsy revealed large contusion of right sternocleidomastoid muscle. In the cranial cavity we found extensive subarachnoid haemorrhage, located mainly on brain basis, in the posterior cranial fossa and covering the subtentorial structures. During the preparation of blood vessels we noticed a slight change of morphology suggesting damaged vessel or aneurysm, or vascular malformation located in the basilar artery bifurcation, which was taken to detailed microscopic evaluation using the special stainings. Histological examination showed vital interruption of the basilar artery wall with massive haemorrhage, without the presence of general microscopic pathology. From the medico-legal viewpoint, to determine traumatic background of haemorrhage it is necessary to find the coexistence of the following circumstances: a sustained trauma, post-mortem findings consistent with a time of injury, the presence of temporal relationship between injury and death, and morphological vital injury of the brain vessel, as well as the absence of prior vascular malformations. For this purpose Verhoeff-van Gieson's, Masson's, Turnbull's and Gomori' histological stainings may be successfully used.

[Virological tests in diagnostic management of sudden unexpected deaths in children]. / Badania wirusologiczne w diagnostyce naglych niespodziewanych zgonów dzieci.

Based on the present knowledge, the review paper attempts to answer the general question whether virological tests are justified in cases of sudden deaths in children. In particular, the question addresses their importance in establishing the cause of death. The authors also attempt to answer additional questions, namely: (1) whether histopathology provides an adequate basis for establishing the cause of death, (2) whether extending histological evaluation to exclude immunohistochemistry is warranted, and (3) whether there is a correlation between detection of a virus and "intensity" of inflammatory infiltration detected by histology. At the same time, the present paper is an introduction to discussing the results of research in the above field carried out by the authors. In cases of sudden deaths of chil- dren, numerous investigators point to a viral infection as a significant etiopathogenic factor. Nevertheless, no uniform strategy has been developed to date in post-mortem diagnostic management in this field. This is also true with respect to answering what viruses should be isolated and by what techniques when sudden infant death syndrome (SIDS) and/or sudden unexpected death in infancy (SUDI) are suspected. The review of the literature on the subject allows for stating that virological tests are not justified in all cases of SIDS/SUDI, the more so that these tests are not commonly available and inexpensive. Detection of a virus rarely allows for determining the cause of death, demonstrating only the presence of the virus in the tested material. On numerous occasions, demonstrating the presence of a virus by polymerase chain reaction (PCR) has not been in any way reflected in basic and extended histology. In the opinion of the authors, in cases of SIDS/SUDI suspicion, while determining the cause of death, primarily basic histological tests are recommended, as they are the most valuable screening tests. In justified cases basic tests should be extended to include additional immunohistochemical tests, and in exceptional cases--PCR to isolate a virus. PCR may be performed both in frozen and in formalin/paraffin fixed material.

Trial helplessness of defendant healthcare facilities in cases concerning nosocomial infections / Nieporadnosc procesowa pozwanych jednostek ochrony zdrowia w sprawach o zakazenia szpitalne.

The number of pecuniary cases involving patient claims due to nosocomial infections has been increasing for many years, and with it, the amount of adjudged compensations has also been increasing. In this situation, it is important for defendant healthcare facilities to implement a proper policy, both before the trial and during the court proceedings. Unfortunately, as a rule, defendant facilities commit a variety of errors, such as: wrong strategy, inability to cooperate on the part of those involved in the matter and improper preparation and usage of evidence. The result is that the risk of unfavorable assessment of the case increases significantly.

Employment of auditory brainstem responses in verification and objectification of impairment of hearing in criminal legal proceedings / Wykorzystanie badan sluchowych potencjalów wywolanych pnia mózgu w weryfikacji i obiektywizacji uszkodzen sluchu dla potrzeb postepowania karnego.

There are numerous subjective and objective diagnostic methods which allow for assessing the degree of the hearing loss and its anatomical location. Despite widespread availability of those methods, especially the subjective ones, such as pure tone audiometry or speech audiometry, diagnostic errors still frequently occur. They may lead to drawing false conclusions and issuing a fallacious medicolegal expert opinion, which obviously aggravates the situation of the defendant. Medicolegal experience has shown that these errors may result from employment of classic, subjective only methods of hearing examination and failure to perform objective tests, in particular auditory brainstem responses (ABR), autoacustic emissions (OAEs) and audiometry impendance (AI).

A unique case of malignant neoplasm--choriocarcinoma in a 24-year-old man--difficulties in differential diagnostics of intracranial injuries in the aspect of medicolegal opinion / Niezwykle rzadki przypadek nowotworu zlosliwego--kosmówczaka u 24-letniego mezczyzny--trudnosci w diagnostyce róznicowej uszkodzen sródczaszkowych w aspekcie opiniowania sadowo-lekarskiego.

Differential diagnostics of pathologic and traumatic lesions based on image techniques may in some cases cause serious difficulties or even be the cause of a medical error resulting in incorrect medicolegal opinion. The authors present a unique case of primary malignant neoplasm of the testicle (choriocarcinoma) in a 24-year-old man. Several days after the event, he was admitted to Department of Neurology with CT-confirmed traumatic intracerebral hematoma communicating with the ventricular system. Discharged in a good general condition, the patient died several days later. A postmortem examination combined with histopathology demonstrated numerous metastases of the primary carcinoma, which also involved the brain, arousing suspicions of head injury in consequence of a crime.

[Troponin in forensic medicine]. / Troponina w medycynie sadowej.

In this review we try to answer the question whether and to what degree contemporary forensic pathology takes advantage of quantitative and qualitative troponin determinations. The report is simultaneously an introduction to discussing our results in this area. To perform this review we used the database "PubMed". Polish literature, concurrent with the objective of the study and not included in "PubMed" or included in "OLDMEDLINE" was also analyzed. The identified publications, which were concurrent with the aim of the study, were read and citations were checked. If among the cited papers we found one that was concurrent with the subject of the review, it was also included. While several studies support the use of post-mortem blood and body fluid levels of cardiac troponin T and I as a marker of sudden cardiac death, in our opinion, further research is required to determine the effects of post-mortem autolysis, microbial activity, metabolic derangement and the use of different sample matrices in autopsy cases.

[Smuggling of the cocaine in the gastrointestinal tract ended in sudden death--the first case report from the Upper Silesia]. / Przemyt kokainy w przewodzie pokarmowym zakonczony naglym zgonem--opis pierwszego przypadku na Górnym Slasku.

Fifty-year old man was found dead in the bathroom of his apartment. Forensic autopsy was ordered to determine the cause and manner of death. Autopsy revealed the presence of 55 latex "balls" in the stomach and foregut. In the past the victim was suspected of drug's dealing and smuggling. The content of "balls" and biological material (blood, urine, bloody fluid from internal organs) were analysed with LC MS/MS in the Chair and Department of Forensic Medicine and Forensic Toxicology, Medical University of Silesia in Katowice. The range of cocaine' concentration in the "balls" was 91.2-96.1%, whereas concentration in blood - 107.50 microg/ml, in urine - 284.60 microg/ml and in bloody fluid - 192.30 microg/ml. The cause of death was acute cocaine intoxication.

[Cardiac deaths in hard coal-mining industry as an indicator of efficiency of occupational medicine services]. / Zgony sercowe w górnictwie, jako wskaznik wydolnosci sluzby medycyny pracy.

Deaths in hard-coal mining industry can be divided into: accidental (usually of a single character) and non-accidental-intentional (homicide, suicide) and natural (with a pathological background, 'without external factors'). The main cause of natural deaths is myocardial infarction (MI). Its risk is increased by environmental factors in working place, unhealthy life style, cigarette smoking and alcohol drinking, which is often an attempt at coping with chronic stress, so proper prevention, qualification and periodic examination of workers is indispensable. The aim of the study is to analyze cases of miners' cardiac deaths investigated in Department of Forensic Medicine in Katowice and the number of natural deaths in hard-coal mines in the years 1999-2010. There were 298 accidental and 122 natural deaths, the latter showing an increasing tendency in the years 2002-2004, 2006, 2008 and 2010. Natural deaths--in 95% sudden cardiac deaths--constituted 29% of all deaths in hard-coal mining industry. Autopsies supplemented by histopathological investigations often revealed advanced atherosclerosis and coronary heart disease, which should disqualify a candidate from working underground. A high number of natural deaths in hard-coal mining industry and morphological post mortem assessment of victims indicate insufficiency of occupational medicine services. We propose an improvement of its quality and a higher frequency of periodic examinations of workers (especially in groups with the highest risk of MI), as well as courses of Basic Life Support (BLS). Forensic medicine may be socially useful in assessing the efficiency of occupational medicine services in mining industry.

[Opinion-forming difficulties in establishing paternity resulting from the lack of data on the relationship between biological and putative father]. / Trudnosci opiniodawcze w ustalaniu ojcostwa spowodowane brakiem informacji o pokrewienstwie biologicznego i domniemanego ojca.

Among a large number of expert opinions concerning disputed paternity cases prepared in the Chair of Forensic Medicine and Medico-Legal Toxicology, Silesian University of Medicine, Katowice, there were those in which the use of a standard 15 autosomal loci AmpFISTR Identifiler kit was not sufficient to give an unequivocal opinion. The authors report a case of disputed paternity, in which the analysis done by applying an AmpFISTR Identifiler kit showed no paternity heredity in 2 loci in the child. As allele distribution did not exclude mutation, further genetic markers were determined using PowerPlex ESX and FFFL kits and further three exclusions were found. Moreover, X-chromosome loci were determined using a MentypeAngusX8 test, which confirmed the exclusion of paternity in further 4 loci.

[An unusual case of gunshot wounds caused with an air gun]. / Niezwykly przypadek postrzalu z broni pneumatycznej.

A 28-year-old woman was shot in the face with an air gun while driving a car. The patient was examined in the Department of Forensic Medicine in Katowice. An inconspicuous scar was found near the medial angle of the right eye. Further ophthalmological and radiological examinations revealed the presence of small foreign bodies in the vitreous body of the right eye, the sphenoid sinus and the ethmoid cells. The authors issued an expert opinion, in which they stated that the sustained injuries had not caused any significant organ dysfunction.

[The evaluation of the mechanism and cause of death of mine rescuers during the group accident in the Niwka-Modrzejów Coal Mine in Sosnowiec in 1998]. / Ocena mechanizmu i przyczyny smierci ratowników górniczych podczas wypadku zbiorowego w Kopalni Wegla Kamiennego "Niwka-Modrzejów" w Sosnowcu w 1998 roku.

On February 24, 1998, in the Niwka-Modrzej6w Coal Mine in Sosnowiec, a group accident occurred and, as a result, six miners died and four others were injured. Mine rescuers, proceeding to work in out of action mining excavation, separated by an isolative dam, were using oxygen escape breathing apparatuses AU-9 type and oxygen breathing apparatuses for work WU-70 type. A comprehensive evaluation of the accident circumstances, medical papers, autopsy, histopatological and chemico-toxicological reports, technical surveys of the Central Station of Mine Rescue and the Military Institution of Chemistry and Radiometry (WIChiR), taking into consideration the microclimatic conditions in the sidewalk and testimonies of the survivors allowed for determining the cause of death in the victims. The authors emphasized special difficulties in compiling the comprehensive opinion in the reviewed case and the significant evidential value of the technical survey prepared by WIChiR that showed numerous and serious abnormalities in the performance of oxygen breathing apparatuses, which in a short time led in their users to acute respiratory insufficiency due to anoxia with its further consequences.

[Toxicological and medico-legal analyses of sudden deaths resulting from butane inhalation]. / Toksykologiczna i medyczno-sadowa ocena naglych zgonów w przebiegu narkotyzowania sie butanem.

Butane is known to be a suffocating gas with narcotic activity, especially at high concentrations. Within the past five years, a few cases of sudden deaths in teenage boys who had inhaled butane, a component of gas for lighters, were investigated in the Forensic Medicine Department, Medical University of Silesia, Katowice. Analyses of biological materials secured at autopsies and evidence from places of deaths was carried out using GC/FID. Butane was found in blood, lung and brain samples of the deceased. Moreover, histopathological examinations were performed. Results of autopsies and additional analyses were appraised from the point of view of their significance and usefulness in giving medico-legal opinions on the cause of death.

[Medico-legal assessment of the injuries of fatal victims of building collapse at Katowice International Fair in Katowice/Chorzów on January 28, 2006]. / Sadowo-lekarska ocena obrazen u smiertelnych ofiar katastrofy budowlanej na terenie Miedzynarodowych Targów Katowickich w Katowicach/Chorzowie w dniu 28.01.2006 roku.

On January 28, 2006, during an exhibition of carrier pigeons, the roof of one of the buildings at Katowice International Fair collapsed. At the time of accident, there were 700 people in the building--65 died and 171 were injured. It was the biggest building disaster in the history of modern Poland. The aim of this study was to present the type (character) of the observed injuries, the cause of death of 48 fatal victims and the range of activities and medico-legal examinations performed in the Department of Forensic Medicine, Medical University of Silesia in Katowice. In the period of January 29-February 1, 2006, on February 14, 2006, and February 17, 2006, post-mortem examinations of the 48 deceased were carried out, and in some cases additional dissecting techniques were employed. During autopsies, numerous specimens for various additional examinations (histopathological, toxicological) were collected. For identification purposes, photographic material and specimens, necessary for genetic identification, were secured. Additionally, the bodies were identified by families. The post-mortem procedures eventually allowed for establishing the cause of death of all the victims. The authors emphasize the range of necessary medico-legal procedures and examinations that should be carried out in a Department of Forensic Medicine in case of a building collapse with a large number of fatalities in order to determine the type of injuries, cause and mechanism of death and to identify the deceased.

[The evolution of autopsy technique--from Virchow to Virtopsy]. / Ewolucja techniki sekcyjnej--od Virchowa do Virtopsy.

The autopsy technique evolves with extending knowledge and technical and technological progress in medical sciences. The objective of this report is to present the main autopsy techniques and an outline of transformations that occurred in the methodology of post mortem examinations with a focus on the Polish literature. Additionally, we present examples of paintings inspired by autopsy.