Scene of death investigation in apparent suicidal deaths in Rotterdam, the Netherlands.

Guidelines from the Netherlands describe that unnatural deaths should be investigated by a forensic physician and Crime Scene Technicians, but this is not always the case. In this study, we aimed to determine what predicts the non-attendance of the Crime Scene Technicians at the scene of the death of suicides in the police region in Rotterdam, the Netherlands. Data of 315 suicides (2016-2017) that have been externally examined by forensic physicians and reports from the Crime Scene Technicians were analysed. Statistical analysis was performed to determine the factors predicting the involvement of the Crime Scene Technicians at the scene of death. The Crime Scene Technicians were not attending in 23% (n = 72) cases, and over half of these cases were not found in the registration system of the Crime Scene Technicians. About some the Crime Scene Technicians was not informed. Predictors of the non-attendance of the Crime Scene Technicians were suicide by poisoning, the individual was found by an acquaintance or family, a history of suicide attempts and examination of the deceased in the hospital. In this study, we observed that the Crime Scene Technicians were sometimes not attending the investigation of apparent suicides. More research on this topic should be done to investigate the value of the presence of the Crime Scene Technicians at the scene before concluding that non-attendance of Crime Scene Technicians on-site influences the quality of the scene of death investigation and corresponding conclusions. Since 2017, several quality improvements were made, but an (inter)national conjoint protocol for uniform and structural suicide investigation could secure the quality of the scene of death investigation of suicides and would provide information useful for evaluation.

Performance of an on-site urine multidrug test used by forensic physicians in determining the cause of death.

Forensic physicians in the region of Amsterdam routinely collect blood and urine samples during external examinations. A rapid on-site multidrug test is used to screen the urine samples for the presence of commonly used drugs classes. Urine and blood samples are sent to the laboratory for additional toxicological analysis. This study aimed to investigate how the substances found in urine using the on-site multidrug test relate to the substances identified with laboratory methods. In 2018 and 2019, 465 cases underwent an on-site multidrug test as well as toxicological laboratory analyses and were included in this study. Fifty-three percent (n = 247) of these cases included a positive on-site multidrug test for at least one substance. The level of total agreement between the on-site multidrug test performed by the forensic physician and the laboratory analyses either in urine or in blood varied per substance groups, with the best results for barbiturates, cocaine, ecstasy and methadone. In conclusion, the on-site multidrug test appeared to perform well for certain substance groups and is an economical and rapid tool. However, the results from the laboratory analyses in blood occasionally provided additional insights concerning the circumstances that could be of importance in the cause of death.

Suicide by helium inhalation in the Netherlands between 2012 and 2019.

INTRODUCTION: In 2012 and 2013 a movie and a book about a 'dignified end of life' were published in the Netherlands. These items described suicide using an 'exit bag' to establish asphyxiation using helium (the helium method). 'Right-to-die-organisations' inform the elderly about this method. The purpose of this study is to investigate whether the use of suicidal asphyxiation by means of the helium method substituted other, related, methods following its publication in the Netherlands. MATERIAL AND METHODS: We analysed suicides in the Netherlands over the period from 1 July 2012 to 30 June 2019. We compared the number of deaths caused by the helium method with other, related, cases. Secondly, we related these deaths to the total number of inhabitants and suicides recorded by Statistics Netherlands. RESULTS: The study showed a stable trend in the use of the helium method in the period 2012-2019 and this was the same for the other, related methods. Individuals using the helium method were significantly younger than those using other, related, methods. At the scene of death, information about suicide and suicide notes were found more often at 'helium method' cases than with the 'other, related, methods' cases. Family was significantly more often present during a helium method suicide than during suicide by other, related, methods. DISCUSSION: The number of suicides by the helium method and other, related, cases is stable in the Netherlands over the past years. Therefore, we conclude that there is no substitution effect within this category of suicides. Whilst 'right-to-die-organisations' strive to inform the old and sick of the helium method, it is noteworthy that the individuals using the helium method are significantly younger than the individuals who choose other, related, methods.

[Forensic implications of humane self-chosen death in the Netherlands]. / Zelfgekozen levenseinde: een forensisch dilemma.

Euthanasia is legal in the Netherlands. Nevertheless, some individuals decide to plan their self-chosen death without the help of a physician. 'Right-to-die' organisations provide advice about humane deaths, which include voluntary refusal of food and fluids, the helium method and use of a lethal overdose of medication. It is known that suicides are sometimes influenced by the media and internet. Since 2013, 'right-to-die' organisations have informed individuals about the use of a deadly barbiturate overdose and the helium method. A rise in suicides resulting from these methods has subsequently been observed in the Netherlands. Suicides are recorded as deaths resulting from unnatural causes and are therefore investigated by a forensic physician, forensic investigator and tactical investigator. Investigation should determine the cause of death and rule out a staged crime, 'criminal' assisted suicide or an accident.

The rise of suicides using a deadly dose of barbiturates in Amsterdam and Rotterdam, the Netherlands, between 2006 and 2017.

INTRODUCTION: The three 'advised' suicide methods are helium asphyxiation, voluntarily stop eating and drinking and the use of a deadly dose of medication such as barbiturates. The aim of this study was to analyse the number of suicides resulting from barbiturate overdose and examine the influence of publications and internet on this suicide method in the two larger cities of the Netherlands. METHODS: Data of suicides by medication and drugs overdose were extracted from the electronic registration systems of the forensic physicians of the district of Amsterdam and Rotterdam over the period 1 January 2006-31 December 2017. We analysed whether or not the number of suicides using barbiturate overdose has significantly risen since 2013. This was the year 'right-to-die-organisations' informed individuals about this method and a book was published describing this as a humane death. In addition, a regression analysis was used to examine which factors predict a suicide resulting from barbiturate overdose. RESULTS: A total of 553 overdose suicides were identified and 91 suicides resulting from barbiturate overdose were included for further evaluation. During 2013-2017 there were significantly (p < 0.00) more suicides resulting from barbiturate overdose compared to 2007-2012. Individuals using barbiturate overdose to die by suicide were significantly (p < 0.00) older than those using other medication and drugs (65 years compared to 55 years respectively). 48% of these cases were male. In barbiturate suicides, information sources (books or information on the internet, p < 0.01) and the presence of family during suicide (p < 0.00) occurred significantly more often than in suicides resulting from other medication and/or drugs overdose. The odds for barbiturate suicides were 4.8 higher (CI 2.6-9.2) after 2013 compared to before 2013 after correction for age, sex, city and postmortem toxicology results. DISCUSSION: Our data showed a rise in suicides resulting from barbiturate overdose whereas the total number of inhabitants and suicides resulting from medication overdose has remained more or less constant. Easy access of information or medication through the internet and 'right-to-die-organisations' may have directly impacted the rise in suicides resulting from an overdose of barbiturates. To our knowledge this is the first study analysing the rise of barbiturate suicides and the influence of media in published literature.

[Increase in reporting of child deaths; analysis of recent forensic services data]. / Dood minderjarige steeds vaker gemeld.

OBJECTIVE: We investigated the degree of reporting of child deaths in 2017 and compared this with data from 2012. Furthermore, we assessed the characteristics of these deaths and in how many cases the forensic doctor performed a post-mortem examination. DESIGN: Observational research. METHOD: We requested data from 25 public health services (GGDs in Dutch) and the private organization Forensisch Artsen Rotterdam-Rijnmond (FARR) concerning child deaths that occurred in 2017. We distinguished between stillbirths, live births with death occurring ≤28 days post-partum and live births with death occurring > 28 days post-partum. Using mortality figures for 2017 obtained from Statistics Netherlands (CBS), the percentage of child death cases where discussions took place between the treating physician and a forensic doctor was determined both at regional and national level. RESULTS: In 2017, a total of 928 out of 1303 child death cases known to CBS was reported to the regional forensic doctor; this means a reporting rate of over 70%. For stillbirths the national reporting rate was 46.0% (200/435), for live births who died ≤ 28 days post-partum 84.0% (300/357) and for live births where death occurred > 28 days post-partum 83.8% (428/511). The reporting rate differed per province, Zuid-Holland having the highest reporting rate (93.1%) and Gelderland the lowest (74.1%). The reporting rate increased compared to 2012 in relation to stillbirths as well as live births. The forensic doctor was most likely to perform a post-mortem examination in cases where the death occurred outside the hospital and where it involved the death of minors older than 28 days. CONCLUSION: Treating physicians are increasingly fulfilling their legal obligation to report deceased minors to a forensic doctor, but the reporting rate is still not 100%. We therefore advise continued investment in order to improve the reporting rate, especially in regions where figures lag behind the national average.

Forensic Nursing Education and Practice in the Netherlands: Where Are We at?

BACKGROUND: Forensic nursing is a new discipline to the Netherlands. Since 2013, a program has been in place to train experienced nurses in several aspects of forensic nursing, including injury assessment and wound documentation, sexual assault examination, assessment of child abuse, death investigation, and primary care for detainees of the police. OBJECTIVE: The purpose of the study was to provide information on the working environment, self-rated competencies, and practice experiences of forensic nurses after having completed the program. METHODS: In 2017, an online questionnaire was developed by the researchers and distributed among the 114 Dutch forensic nurses who had completed the program. RESULTS: Eighty-three nurses responded to the questionnaire, resulting in a 73% response rate. Nurses who practiced in the emergency and ambulance sector or as pediatric nurses continued to work in these roles after having finished the program. Upon completion of the program, more nurses were employed at sexual assault centers. Overall, respondents indicated that they felt competent with performing forensic nursing tasks. Respondents had a positive outlook of their work as forensic nurses, with a large majority seeing possibilities for further expansion of their roles (87%). Forty-eight percent reported that, at times, they experienced resistance to their involvement with forensic matters from other professionals in their work environments. DISCUSSION: Forensic nursing in the Netherlands is an emerging profession. Although its foundation has been established, further developments will only be achieved through collaboration with the wider medical field.

Characteristics and Post-Decision Attitudes of Non-Reporting Sexual Violence Victims.

Although the physical and psychological consequences of sexual violence can be severe, many victims do not report the violence to the police force. The current study examined the characteristics and the post-decisional attitude of the non-reporting sexual violence victims. In total, 287 victims of sexual violence completed an anonymous online questionnaire that assessed characteristics of the violence, whether or not the crime was reported, reasons for not reporting, and aspects that would have convinced non-reporters to report in retrospect. Eighty percent of the victims did not report the most recent sexual violence incident to the police ( n = 229). Nevertheless, 65% of the non-reporting victims ( n = 148) in retrospect would have reported to the police ("potential reporters"). Specific reasons for non-reporting and incident characteristics appear to relate to the post-decision attitude of non-reporting victims of sexual violence. "Lack of evidence" and "feelings of shame, guilt, and other emotions" appear to be more frequently mentioned by potential reporters as reasons for their decision to not report as compared with the definitive non-reporters. Likewise, being raped or sexually assaulted is predictive of potential reporting. Our findings are useful for policy makers to develop strategies to increase reporting rates of sexual violence victims.

A record linkage study on former police detainees who died in Amsterdam between 2013 and 2015.

BACKGROUND: Police detainees are known to have inferior health. This study identifies the number of former police detainees who received medical care among deaths examined by forensic physicians and presents their death characteristics. METHODS: We included all deaths that were examined by forensic physicians of the Public Health Service Amsterdam from 2013 to 2015. Patient files of subjects were scanned for the presence of a prior medical consultation in the police cell and death characteristics were collected from post-mortem examination reports. We performed statistical analyses to discover what characteristics at post-mortem examination were associated with a prior consultation in the police cell. RESULTS: We identified n = 2618 subjects that met the inclusion criteria. Eight percent of subjects had one or more medical consultation(s) in the police cell in a mean follow up time of 4.8 (±3.0) years. No difference was found in the share of unnatural deaths between subjects with and without a prior consultation (68%), but distribution of death causes differed significantly. Male gender OR 2.3 (p < 0.001), age OR 0.98 (p < 0.001), unspecified unnatural dead OR 1.8 (p = 0.002), crime related dead OR 2.2 (p = 0.012) and accidental drowning and submerging death OR 4.6 (p < 0.001) were independently associated with the presence of an earlier consultation in the police cell. CONCLUSION: Our data suggest that a small percentage of police detainees seen by forensic physicians for provision of medical care are also examined after death by these physicians, typically young males who seem to display risk-taking and criminal behavior resulting in unnatural dead.

Medical death certification by forensic physicians in the Netherlands: Validity and interdoctorvariation.

The aim of the study was to assess interdoctorvariation and validity in death certification by forensic physicians using 19 written scenarios. The scenarios described typical cases from forensic-medical practice. Physicians were asked to determine the manner of death (natural/unnatural) and to provide an ICD-10 code for the cause of death. In contrast to most studies on this topic, the measure of agreement among physicians was chance-corrected and a standard was used to assess the correctness of the assigned cause and manner of death. Forty-seven physicians participated in the survey. The study demonstrated that forensic physicians varied widely in their conclusions. With respect to manner of death, adequate agreement (defined as kappa>0.70) was achieved in six scenarios (32% of all scenarios). Concerning the underlying cause of death, adequate agreement was reached in three cases (16% of all scenarios). Furthermore, predictors for the correctness of manner and cause of death were studied using logistic regression. Years of experience as a forensic physician significantly predicted the correctness of cause of death (p < 0.05). Other predictors remained insignificant. With regard to manner of death, none of the studied predictors proved to be significant. To conclude, there appears to be a lack of consistency among forensic physicians regarding death certification. The ICD-10 coding of causes of death applied by forensic physicians is questionable. Less experienced physicians need supervision by more experienced colleagues when making judgments concerning the cause of death. Altogether, there is an urgent need to work out consensus-based guidelines for forensic physicians on how to certify deaths.

Mental health and health-care use of detainees in police custody.

BACKGROUND: In many countries, forensic physicians function as primary care providers for detainees in police custody. Their task is comparable to the tasks of general practitioners. Nevertheless, problems presented by both patient populations may differ. We therefore aimed to systematically compare presented problems and medication use in a population of police detainees to those of regular patients in general practice. METHODS: Health problems and prescription medications of 3232 detainees seen by the Amsterdam Forensic Medical Service were compared to those of general practice patients (n = 78,975) adjusted for age and gender during a 12-month period. RESULTS: Among those obtaining medical attention (28% of all detainees), almost 50% were diagnosed with mental health problems, with substance abuse as the leading reason for consultation. Forty-two percent received at least one prescription affecting the nervous system. In general practice, 17% (P < 0.001) of patients consulting their GP were diagnosed with mental health problems and 22% (P < 0.001) were prescribed medications affecting the nervous system. CONCLUSION: The magnitude of mental health problems among police detainees has significant implications for the qualifications of police health staff and those who provide health care in the police setting especially concerning substance abuse.

Detainees in Amsterdam, a target population of the Public Mental Health System?

The Forensic Medical Service of the Public Health Service offers health care to detainees in police cells in Amsterdam. This study describes the registered mental health, addiction and social problems and compares them to the self-reported problems among a sample of detainees. Registers of the Forensic Medical Service are related to information from registers of police detention episodes. A general assessment of substance use, mental health and social problems is obtained by interviewing a sample of 264 detainees. The Forensic Medical Service was contacted in 24% of the 17,321 detention episodes. In 14% of the episodes mental or substance related disorders were observed. Within the sample 59% scored positively on indicators of substance abuse or mental health problems, 35% had additional social problems (debts, unemployment, housing). This proportion increased with age. It is concluded that substance abuse and mental health problems combined with social problems are highly prevalent among detainees, especially among the older ones. This urges for a close cooperation between Public Mental Health Care and Forensic Medical Services.

Screening for mental illness among persons in Amsterdam police custody.

OBJECTIVE: Research on the mental health of police detainees is scarce. This study aimed to identify the proportion of persons detained by the Police Service Amsterdam-Amstelland who screened positive for a serious mental condition. METHODS: A survey conducted in 2009 among 264 randomly selected detainees assessed demographic characteristics and general medical and mental health and included use of the Brief Jail Mental Health Screen (BJMHS) (N=248). RESULTS: Almost 40% of survey respondents screened positive on the BJMHS, indicating a need for further evaluation. This rate was lower than the rate reported for police detainees in Australia but substantially higher than the rates reported for persons incarcerated in U.S. jails. CONCLUSIONS: More systematic research is needed to examine reasons for reports of different rates of mental illness among detainees in different countries.

Prevalence and medical risks of body packing in the Amsterdam area.

AIM: Body packing is a way to deliver packets of drugs across international borders by ingestion. The aim of the study was to provide an estimate of the medical risks of body packing, describe predictors for hospital referral in detained body packers and provide an estimate for the prevalence of body packing in the Amsterdam area. METHODS: From May 2007 to December 2008, we studied medical records of body packers immediately detained after arrival at Amsterdam Schiphol airport, hospital records of both detained body packers and self-referrers at two emergency departments of hospitals in Amsterdam and records kept by forensic physicians in charge of post-mortem examinations of all unnatural deaths in the area (years 2005-2009). RESULTS: In airport detainees, the hospital referral rate was 4.2% (30 out of 707 detained body packers), the surgery rate was 1.3%. Significant predictors of hospital referral were delayed production of drug packets after arrest, cigarette smoking and country of departure. The surgery rate in self-referrers was comparable to the rate observed in those referred from the detention centre to hospital (30% vs. 31%). In addition, from 2005 to 2009, 20 proven cases of lethal body packing were identified. Based on our data, it is estimated that minimally 38% of all incoming body packers were missed by airport controls. CONCLUSION: The risk for lethal complications due to body packing is low on a population basis and comparable to other studies. This also applies for the hospital referral and surgery rates found in this study. Cigarette smoking has not yet been described in the literature as a potential predictor for hospital referral in detained body packers and therefore deserves attention in future research. A substantial fraction of body packers manages to remain undiscovered.

Health-care issues and health-care use among detainees in police custody.

Epidemiological research on the physical health status of police detainees is scarce. The present study fills this gap by first studying the somatic reasons for consultation (n = 4396) and related prescriptions (n = 4912) as assessed by the forensic medical service during police detainment. Secondly, a health interview survey was conducted among randomly selected police detainees (n = 264) to collect information regarding their recent disease history and use of health care. Somatic health problems, medical consumption and health risk measures of the detainees were compared with those seen in the general population using general practitioner records and community health survey data. The study showed that, in police detainment, several chronic health conditions more often were the reason for consultation than in the general practice setting. In addition, the health interview survey data demonstrated that after adjustment for age and gender, the police detainees were 1.6 times more likely to suffer from one or more of the studied chronic diseases than the members from the general population. Furthermore, differences in several health risk measures, including body mass index, smoking and alcohol habits and health-care use were observed between the interviewed police detainees and the general population. These results provide insight into the variety of physical health problems of police detainees and are essential to develop optimal treatment strategies in police custody.

Health care seeking among detained undocumented migrants: a cross-sectional study.

BACKGROUND: As in many European countries, access to care is decreased for undocumented migrants in the Netherlands due to legislation. Studies on the health of undocumented migrants in Europe are scarce and focus on care-seeking migrants. Not much is known on those who do not seek care. METHODS: This cross-sectional study includes both respondents who did and did not seek care, namely undocumented migrants who have been incarcerated in a detention centre while awaiting expulsion to their country of origin. A consecutive sample of all new arrivals was studied. Data were collected through structured interviews and reviews of medical records. RESULTS: Among the 224 male migrants who arrived at the detention centre between May and July 2008, 173 persons were interviewed. 122 respondents met inclusion criteria. Only half of the undocumented migrants in this study knew how to get access to medical care in the Netherlands if in need. Forty-six percent of respondents reported to have sought medical help during their stay in the Netherlands while having no health insurance (n = 57). Care was sought most frequently for injuries and dental problems. About 25% of these care seekers reported to have been denied care by a health care provider. Asian migrants were significantly less likely to seek care when compared to other ethnic groups, independent from age, chronic health problems and length of stay in the Netherlands. CONCLUSION: The study underlines the need for a better education of undocumented patients and providers concerning the opportunities for health care in the Netherlands. Moreover, there is a need to further clarify the reasons for the denial of care to undocumented patients, as well as the barriers to health care as perceived by undocumented migrants.

Post-mortem toxicological urine screening in cause of death determination.

This study evaluated standard toxicology screening by forensic physicians during external post-mortem examination. Collected urine samples of decedents were screened on-site for the presence of 10 commonly used drugs by means of a rapid multidrug test. Urine samples of 53% of the cases appeared to be positive for one or more compounds. Importantly, several cases were revealed which were positive for toxicology screening without indications for use of these drugs at the scene of death or from medical history. Based on these (preliminary) results, further action to incorporate routine post-mortem toxicology as a tool in forensic death investigation is recommended.

[Cocaine use and sudden death: excited delirium syndrome]. / Cocaïnegebruik en plotseling overlijden: het geagiteerd-deliriumsyndroom.

Three patients, men aged 30, 33 and 32 years respectively, died in police custody in Amsterdam, the Netherlands. According to autopsy reports, all patients died from excited delirium syndrome induced by cocaine use. Excited delirium is a state of mental and physiological hyperarousal commonly associated with the use of cocaine. Patients suffering from excited delirium can be extremely hostile and violent. If a physical struggle arises with police or medical personnel, the episode can end in death due to adrenergic overstimulation. Patients in acute excited states should be regarded as a medical emergency with a serious mortality risk, and should be transferred to the hospital rather than the police station. Medical and police staff should aim to reduce confrontation. When patients are too agitated to cooperate, benzodiazepines should be used for sedation of the patient. Beta blockers and antipsychotic medication should not be administered, as these medications can exacerbate the fatal cardiac effects seen in excited delirium.

A cohort study of the long-term impact of a fire disaster on the physical and mental health of adolescents.

The literature on adult trauma survivors demonstrates that those exposed to traumatic stress have a poorer physical health status than nonexposed individuals. Studies on physical health effects in adolescent trauma survivors, in contrast, are scarce. In the current study, it was hypothesized that adolescents who have been involved in a mass burn incident (N = 124) will demonstrate more physical and mental health problems than an unaffected cohort from the same community (N = 1,487). Health data were extracted from electronic medical records, covering 1-year prefire and 4-years postfire. When compared to the prefire baseline, survivors showed significantly larger increases in mental, respiratory, and musculoskeletal problems than community controls during the first year after the fire, but not during the later years.