Medicolegal perspectives of interpersonal violence: A review of first-contact clinical notes.

BACKGROUND: South Africa has one of the highest rates of interpersonal violence (IPV), in all its forms, in the world. Incidents of assault are largely under-reported and place an immense burden on the healthcare, fiscal and judicial systems. The first contact a victim of IPV has with a medical practitioner may be the only opportunity to identify, record and preserve valuable evidence, as evidence not captured on this occasion may be lost forever. The accuracy and quality of clinical notes taken at the time may be of paramount importance in facilitating the administration of justice. OBJECTIVES: (i) To investigate the adequacy of medicolegal note keeping by doctors in cases where subsequent legal proceedings may ensue; and (ii) to apprise clinicians of their shared responsibility in contributing to the administration of justice through both appropriate patient management and objective and contemporaneous recording of findings from a medicolegal perspective. METHODS: A prospective descriptive study was conducted over a period of 18 months from 2016 to 2018. The investigators reviewed patient files and critically appraised first-contact clinical notes in fatal-outcome cases of IPV admitted to the Pretoria Medico-Legal Laboratory during the study period. The cases were reviewed using rubrics specifically designed by the investigators to critically but consistently assess the adequacy of documentation of the medicolegal aspects applicable to each case. RESULTS: One hundred cases met the defined criteria for inclusion in the study. The victims were predominantly male (98%), and most (79%) were aged <40 years. Blunt-force injuries were the most frequent type of injury (43%), while gunshot wounds accounted for 36% of cases and sharp-force injuries were documented in 11%. Insufficient medicolegal documentation, wound description and evidence collection, by medical practitioners, was identified across all wounding modalities in the study sample. CONCLUSIONS: This study showed that medicolegal documentation in cases of IPV is suboptimal, with many important parameters not being routinely recorded, which is likely to impact negatively on criminal investigations and downstream legal proceedings. Greater emphasis on these issues is required during the undergraduate training of healthcare workers in a society as severely afflicted by IPV as SA. Although this study focused on fatal-outcome cases, these conclusions are equally applicable to many more cases where investigators, prosecutors and presiding judicial officers may be dependent on findings contemporaneously and objectively recorded by medical professionals.

Thermal fatalities in Pretoria: A 5-year retrospective review.

In South Africa, research on burn mortality has emanated primarily from specialised burn centres and has focused on specific age groups and hospital-based fatalities. This study describes the demographic profile and the pathology of trauma related to burn fatalities as seen at the Pretoria Medico-Legal Laboratory (PTA MLL), a large urban medico-legal mortuary over a 5-year period from January 2011 to December 2015. Mortuary admission records and autopsy reports were used to gather information on demographics, circumstances of injury, apparent manner and cause of death, pathology of burns, toxicology and histology reports and identification of the decedents. RESULTS: Of the 9558 unnatural deaths admitted to the PTA MLL during this time period, 291 (3.0%) of the fatalities met the inclusion criteria. The male:female ratio was 2.9:1. Most fatalities occurred between the ages of 0-4 years. One hundred and forty-two (142) decedents were charred beyond recognition. Identification was confirmed in 134 (94.4%) of the charred remains. In 208 (69.8%) of the cases the manner of death was deemed to be accidental, 23 (7.9%) were homicidal and 11 (3.8%) were suicides. Two hundred and fifty-five (87.4%) of the fatalities were as a result of open flames/fires. Shack fires were responsible for 105 (36%) of all fatalities. In 32 (11.0%) cases of open flame/fire fatalities where death occurred at the scene of injury, more than one fatality was reported per incident. In 122 (79.2%) of scene fatalities, soot deposition was noted in the upper and lower airways. Forty-five (32.8%) of hospital fatalities occurred within 24 h of admission. The most common complications in hospital fatalities were from the respiratory system. The mean blood alcohol concentrations (BAC) was 0.09 g/100 ml. The mean carboxyhaemoglobin concentrations (COHb) was 19.9%. All available cyanide results were negative. CONCLUSION: The study is the first of its kind in South Africa to generate bimodal descriptive statistics for burn fatalities. Approximately 3% of unnatural deaths at the PTA-MLL were due to burns, occurring at a rate of ±1 death per week. The data provides a platform for funding, collaborative research, planning and development of public health programs.

Fatalities involving illicit drug use in Pretoria, South Africa, for the period 2003 - 2012.

BACKGROUND: Globally, illicit drugs are responsible for many fatalities annually, yet accurate data on the nature and extent of these deaths in South Africa (SA) are lacking. OBJECTIVES: To investigate the presence and profile of illicit drugs detected in deceased persons who were subjected to medicolegal autopsies and upon whom analyses were carried out in search of illicit drugs in their body fluids at the Pretoria Medico-Legal Laboratory (PMLL), SA, over a 10-year period. METHODS: A retrospective descriptive case audit was conducted for the period 2003 - 2012. RESULTS: Screening for illicit drugs was requested in 385 out of 22 566 medicolegal autopsies. Results were available for only 281 of these cases, with 154 cases showing the presence of one or more illicit drugs. The demographic profile of positive cases indicated the majority to be male (90.3%) and white (85.1%). Decedents who tested positive for illicit drugs were predominantly aged between 20 and 30 years (51.9%). The most frequently detected drug was heroin, the presence of which was confirmed in 35.2% of cases, followed by cocaine in 19.9%. Alcohol in combination with an illicit drug or drugs was detected in 56 cases (36.4%). CONCLUSIONS: Results from this study indicate that illicit drugs were implicated in a considerable number of fatalities in Pretoria. However, it is believed that the figures are a gross under-representation of the actual number of drug users who died during this period. It is therefore recommended that further research be conducted and that drug screening be requested routinely when unnatural deaths are investigated at medicolegal mortuaries, not only to ensure the administration of justice but also to obtain more accurate data for purposes of public health programmes and improve insight into the burden of illicit drug use in SA.

Drowning in Pretoria, South Africa: A 10-year review.

Drowning is classified as the 3rd leading cause of accidental deaths worldwide and is deemed to be a preventable cause of death. Bodies retrieved from a water medium pose several challenges to the forensic pathologist with the diagnosis of drowning being primarily one of exclusion. The aim of this study was to do a retrospective descriptive case audit of bodies retrieved from water and immersion related deaths, which were investigated at the Pretoria Medico-Legal Laboratory (PMLL) over a 10 year period (January 2002 through December 2011). A total of 346 cases were identified for inclusion into this study. In 6% (20) of these cases, the death was not related to drowning; in 14% (48) no clear cause of death could be ascertained and in 278 cases (80%) the cause of death was considered to have been due to drowning. Infants (under 1 year, of age) constituted 41 (15%) of the cases; toddlers (aged 1-2 years) comprised 52 (19%) cases; children (aged 2-13 years) 49 (18%) cases; adolescents (aged 13-18 years) comprised 10 (3%) cases; adults (above 18, years) made up 126 (45%) of the cases. The majority of the drownings, occurred in swimming pools [125 cases (38%)]. In infants 23 (56%) of, drownings occurred in swimming pools followed by buckets [7 cases (17%)]. Sixty-nine per cent of toddler drownings (36 cases) occurred in swimming, pools. In the adult population, 40 (32%) of cases occurred in pools and 35 cases (28%) in rivers. Positive blood alcohol results were recorded in 48, (42%) out of 113 cases where the test was requested, 40 (35%) of these, cases higher than 0.05 g per 100 ml. This study suggests that many drowning deaths in Pretoria may be preventable by introducing greater public awareness of the risks and instituting relatively simple, protective measures.

The medico-legal investigation of abandoned fetuses and newborns--a review of cases admitted to the Pretoria Medico-Legal Laboratory, South Africa.

There is a dearth of literature on the extent of fetal or newborn abandonment or "dumping" and the medico-legal investigation procedures these cases require. This is despite the fact that these occurrences are a worldwide phenomenon and by definition involve criminal law concerns such as illegal abortion, concealment of birth, murder, or neonaticide, depending on the country concerned. This article contributes to current literature in both respects and provides a retrospective case audit for the period 2004-2008 pertaining to all abandoned newborns and fetuses admitted to the Pretoria Medico-Legal Laboratory (PMLL) in South Africa. Demographic details, scope, and nature of the medico-legal investigation as well as formulation of cause of death were recorded. A total of 289 cases were identified for inclusion in this study, 57% of which were considered to have been non-viable fetuses, while 45 of the viable fetuses were deemed to have been stillborn. These instances involve the crimes of concealment of birth and at times illegal abortion, yet prosecution of these cases are relatively unheard of. Signs of live birth were identified in 38 of the cases in the study. Of these infants, 9 were deemed to have died from injuries they have sustained, and in a further 9 cases, no anatomical cause of death could be identified. Homicidal cases should be brought in cases where death ensued as a result of abandonment; however, it is not known how many cases were prosecuted. A comparatively large number of cases were found to have been admitted to the Pretoria Medico-Legal Laboratory. This is alarming because South African abortion laws are liberal and services are free at point of access in the public health care sector. A substantial percentage of cases of abandoned infants were found to have shown signs of life after birth implying a homicidal manner of death or death by abandonment, but it seems these cases are merely shelved.

The forensic autopsy as a teaching tool: attitudes and perceptions of undergraduate medical students at the University of Pretoria, South Africa

Background. Numerous articles have been published on the use of autopsies in training medical students in anatomy and different branches of pathology. Some authors have described the emotional response of students who attend such postmortem sessions. Forensic pathology is an important subdivision of pathology. In some countries undergraduate medical students are expected to attend postmortem examinations on persons who died from traumatic causes. Objective. To determine the attitudes and perceptions of 5th-year medical students with regard to forensic postmortem examinations at the University of Pretoria; South Africa. Methods. A questionnaire was voluntarily completed by medical students on the last day of the practical rotation.Results. The overall rating of the practical rotation was 82%. The strengths; weaknesses; opportunities and threats (SWOT) analysis indicated the following as strengths: record keeping; legislation review and traumatology description; as weaknesses: emotional trauma and nightmares; as opportunities: the attendance of autopsies; and as threats: physical dangers. Conclusion. The current study was similar to international studies with regard to students' emotional response to attending autopsies. The autopsy remains a valuable teaching tool for undergraduate students. Emotional support is currently available for all students to assist them in overcoming their fear of attending forensic autopsy sessions

The prevalence of HIV in Pretoria's Medico-Legal Laboratory cases; RSA; in 2009

The purpose of this study was to determine the prevalence of Human Immunodeficiency Virus (HIV) amongst decedents admitted to the Pretoria Medico-Legal Laboratory (MLL). The study was designed as a cross sectional study. It is not standard procedure for the pathologist to do a HIV test at autopsy. Post mortem (PM) blood samples were obtained from all bodies admitted to the Pretoria MLL during one month in 2009. Analysis of the blood samples was performed using standardised laboratory procedures. Two hundred and thirty-eight PM blood samples were collected. In 43 cases (17); the test results were invalid. Of the 195 valid test samples; 51 (26.2) were HIV-positive. The prevalence of HIV in this study was 15 higher than that reported in a similar study done 10 years previously

The prevalence of HIV in Pretoria's Medico-Legal Laboratory cases; RSA; in 2009

The purpose of this study was to determine the prevalence of Human Immunodeficiency Virus (HIV) amongst decedents admitted to the Pretoria Medico-Legal Laboratory (MLL). The study was designed as a cross sectional study. It is not standard procedure for the pathologist to do a HIV test at autopsy. Post mortem (PM) blood samples were obtained from all bodies admitted to the Pretoria MLL during one month in 2009. Analysis of the blood samples was performed using standardised laboratory procedures. Two hundred and thirty-eight PM blood samples were collected. In 43 cases (17); the test results were invalid. Of the 195 valid test samples; 51 (26.2) were HIV-positive. The prevalence of HIV in this study was 15 higher than that reported in a similar study done 10 years previously

Subendocardial fibrosis in left ventricular hypertrabeculation-cause or consequence?

Left ventricular noncompaction has been classified as a primary cardiomyopathy with a genetic origin. This condition is morphologically characterized by a thickened, two-layered myocardium with numerous prominent trabeculations and deep, intertrabecular recesses. Recently, it has become clear that these pathological characteristics extend across a continuum with left ventricular hypertrabeculation at one end of the spectrum.The histological findings include areas of interstitial fibrosis.We present a case of left ventricular hypertrabeculation which presented as sudden infant death syndrome. Histologically areas of subendocardial fibrosis was prominent and we propose that this entity may be a hidden cause of arrhythmic death in some infants presenting as sudden infant death syndrome., with areas of subendocardial fibrosis as possible arrhythmogenic foci.

The medico-legal investigation of sudden, unexpected and/or unexplained infant deaths in South Africa: where are we--and where are we going?

Sudden Infant Death Syndrome (SIDS) has been reported to be the leading cause of death in infants under 1 year of age in many countries. Unfortunately, a paucity of published research data exists in South Africa, with regard to the incidence of and investigation into the circumstances surrounding Sudden Unexplained Deaths in Infants (SUDI) and/or SIDS. Currently, even though most academic centers conform to a protocol consistent with internationally accepted standards, there exists no nationally accepted infant death investigation protocol in South Africa. It is the aim of this study to review the current practice of infant death investigation in two representative but geographically and demographically distinct centers. Retrospective case audit over a five-year period (2000-2004) was conducted at two large medico-legal mortuaries in Pretoria (Gauteng) and Tygerberg (Cape Town). Case files on all infants younger than 1 year of age were reviewed. The outcome measures included number of deaths, demographic details and the nature and final outcome of the post mortem examinations. A total of 512 cases were identified as possible SIDS cases and of these, 171 was classified as SIDS. The study showed marked inter-case and inter-divisional variation in terms of the investigation of infant deaths at the two institutions. It is envisaged that this study will focus attention on the current lack of usable data regarding sudden/unexplained/unexpected infant deaths in South Africa, and aid in the formulation and implementation of a practical (yet internationally accountable) infant death investigation protocol, which could facilitate comparisons with other countries and initiate further structured research in this field.

Sudden infant death syndrome and left ventricular hypertrabeculation-hidden arrhythmogenic entity?

Left ventricular noncompaction/hypertrabeculation is a condition which is characterized by a highly trabeculated, "spongy" myocardium.It can present at any age with heart failure, arrhythmia and/or thromboembolic events.A wide variety of mutations have been found to be a cause of hypertrabeculation and it is possible that there is a continuum of hypertrophic cardiomyopathy, dilated cardiomyopathy and hypertrabeculation/noncompaction.We present a case of left ventricular hypertrabeculation which presented as sudden infant death syndrome and we propose that this entity may be a hidden cause of arrhythmic death in some infants presenting as sudden infant death syndrome.

Post-mortem echocardiography as a guide to cardiac autopsy-a worthwhile concept?

Sudden and unexpected death in the young is a common and worldwide problem. Sudden, unexpected death in infancy (SUDI), clinically unexpected death in an infant between one week and one year of age, affects around 1 in 1000 infants. Autopsy will reveal a specific cause of death in only one third of cases. This has led to various ancillary examinations in an effort to increase the diagnostic yield of the autopsy.In this case report it is suggested that another diagnostic modality, that of the post-mortem echocardiogram might be a worthwhile concept to explore.

The South African National Non-Natural Mortality Surveillance System--rationale, pilot results and evaluation.

BACKGROUND: While individual mortuaries have recorded data for non-natural deaths in time-limited studies, there have been no systematic efforts to draw forensic-medical services and state mortuaries into a nationwide fatal injury surveillance system. Beginning in June 1998, the National Non-Natural Mortality Surveillance System (NMSS) commenced pilot operation. OBJECTIVE: To evaluate the NMSS and illustrate its utility from sample findings. DESIGN: Data entered into the system by mortuary staff were checked against a random sample of cases for which separate forms were completed by an independent researcher. Process observations and follow-up with data users were used to assess the system's acceptability, timeliness and data usefulness. SETTING: Eighteen mortuaries in six provinces representing approximately 35,000 cases per year, or around 50% of all non-natural deaths. PARTICIPANTS: The National Departments of Health; Safety and Security; and Arts, Culture, Science and Technology; national and provincial forensic medico-legal services; the South African Police Services; universities and science research councils. MAIN OUTCOME MEASURES: Surveillance system simplicity, flexibility, acceptability, sensitivity, positive predictive value, representativeness, timeliness, data usefulness and resources. RESULTS: The NMSS was established at 10 target sites. Lack of equipment, personnel resistance, and closure of some mortuaries prevented implementation in the remaining eight mortuaries. Sensitivity was internally assessed and ranged from 65% to 95% for manner of death. Positive predictive value was also internally measured, and ranged from 74% to 80% for manner of death and from 71% to 82% for mechanism of death. Timeliness was good, and basic reports covering most items were available 6 weeks after a case had been examined. While staff found the system simple, acceptability depended on the individuals involved at different mortuaries, and the system was compromised to some extent by bureaucratic barriers. End users found the data to be of great value. NMSS set-up costs totalled approximately R26,000 per mortuary, and it is estimated that maintenance costs will be R8.00 per case registered. CONCLUSIONS: With minimal resources, the NMSS uses existing investigative procedures to describe and report the epidemiology of fatal injuries. The pilot study demonstrates the feasibility of the system, and identifies the need to remove organisational constraints and individual barriers if it is to be sustained and expanded beyond the pilot sites.

Bloodborne viruses in forensic medical practice in South Africa.

Health care workers are at risk of exposure to bloodborne viruses including human immunodeficiency virus types 1 and 2 (HIV-1 and -2), hepatitis B virus (HBV) and hepatitis C virus (HCV). However, limited data is available regarding these risks to forensic medical personnel who are exposed daily to large numbers of severely traumatized bodies in South Africa, a country that has an existing and growing HIV epidemic and a high HBV seroprevalence. Because no specific prescriptions ensuring occupational safety in this regard exist for forensic medical personnel in South Africa, the prevalence of bloodborne viruses within this setting must be determined. Blood was taken randomly from 263 bodies examined at the Medicolegal Laboratory in Pretoria. Serologic tests to detect antibodies to HIV, HCV, and human T-cell lymphotropic virus types I and II (HTLV-I and -II) and to detect the presence of HBV surface antigen (HBsAg) were performed and positive results confirmed using conventional serologic assays. Serologic tests detected at least one of the four bloodborne viruses in 21% of cases. The overall seroprevalence for HIV-1/2 was 11%, rising to 19% in the sexually active reproductive age group (15 - 49 years). The HBsAg prevalence overall was 8%, rising to 9% in sexually active reproductive individuals. There was a low overall HCV seroprevalence of 1% and an even lower HTLV-I/II seroprevalence of 0.01%. Forensic medical personnel in South Africa are therefore at risk of exposure to bloodborne viral pathogens in, on average, 1 of 5 bodies autopsied. This risk is compounded by the high daily workload, traumatized state of many of the bodies, and adverse working conditions. It is imperative that occupational health safety guidelines be created for the forensic medicine discipline and crime scene attendants in South Africa.

Forensic medicine in South Africa--time for change?

Forensic medical services in South Africa are rendered by state-employed district surgeons and forensic pathologists, who are obliged to utilize the physical infrastructure and personnel of the South African Police in their examinations. Recent highly publicized incidents have (again) highlighted the alleged involvement of the South African Police and/or state security forces in political killings and deaths in custody. The perception has arisen that the South African Police is often a party to a dispute and yet may have virtually unlimited access to evidence and findings, thereby gaining unfair advantage and opportunity for prejudicing the eventual outcome of the investigation. Furthermore, the perceived allegiance (and even possible subservience) of doctors to the South African Police has tarnished the reputation of forensic medical practitioners in this country. It is imperative that the public and the courts perceive the rendering of medicolegal services to be independent and scientifically objective. A model is proposed for the restructuring of medicolegal services in South Africa so as to be autonomous and without the integral involvement of the South African Police. Regard should be had to the opportunity for change now presenting itself in South Africa.

Adolescent adjustment to parental divorce: an investigation from the perspective of basic dimensions of structural family therapy theory.

This study, conducted within the framework of concepts of structural family therapy, examined the relationship of four family-based, clinical dimensions to the adjustment of 45 adolescents during the first 18 months of parental separation. There were two samples of mother-custody families: an Aided group that applied for treatment, and an Unaided group of paid volunteers. The inclusion of this variable addressed a major methodological deficit of previous studies. There was a significant association between perceived postseparation family structure and adolescent adjustment, demonstrating that individual adolescent adjustment is contingent on structural features of the contemporary postseparation family. Further, Aided families were perceived as more chaotic, disengaged, and enmeshed than Unaided families, while Aided adolescents were characterized by more behavior problems than Unaided adolescents. This suggests that divorce, as an unscheduled transition, might be within the realm of adaptation for many families and adolescents and is not necessarily "disastrous."