Current status of undergraduate teaching in forensic & legal medicine in Europe.

The European Council of Legal Medicine (ECLM) is the body established in 1992 to represent practitioners forensic & legal medicine and is composed of delegates of the countries of the European Union (EU) and from other countries which form part of Europe to a current total of 34 member countries. The aims of this study were to determine the current status of undergraduate forensic & legal medicine teaching in the curriculum of medical studies in ECLM countries and to use the results of this study to determine whether it would be appropriate to develop new guidelines and standards for harmonising the content of undergraduate forensic medicine training across ECLM member countries. A detailed questionnaire was sent to all individuals or organisations listed on the ECLM contact database. Responses were received from 21 of 33 countries on the database. These responses showed considerable emphasis on undergraduate teaching of forensic medicine in all countries with the exception of Belgium and the United Kingdom. There was great general consistency in the subjects taught. The data from this survey provide a baseline which should assist in developing a strategy to harmonise forensic & legal medicine undergraduate training in member countries of the ECLM. The ECLM is now in a good position to establish a pan-European working group to coordinate a consensus document identifying an appropriate and modern core undergraduate forensic medicine curriculum that can be presented to the medical education authorities in each country, and which can be adapted for local requirements, based on available personnel, the forensic medicine structure in the country, and most importantly, the needs of the local population.

A clinical investigation into the ability of subjects with lung disease to provide breath specimens using the EvidenzerIRL evidential breath analyser in alcohol intoxicant driving in criminal justice evidence.

The EvidenzerIRL instrument has been in use as an evidential breath analyser in the application of drink driving laws in the Republic of Ireland since 2011. The result of the analysis is used as evidence in prosecutions before the Courts in per se offences of driving under the influence of alcohol as distinct from screening results at the roadside. This study aims to assist doctors, lawyers and judges in assessing drivers' failure to provide valid evidential breath specimens. Since the introduction of the EvidenzerIRL, approximately 10% of evidential breath tests annually result in failure or refusal to provide a successful breath specimen, this is an offence under Irish road traffic laws. The presence of lung disease has been given as a reason for the driver failing to provide evidential breath specimens. The aim of this study is to assess the ability of subjects with lung disease to provide breath specimens using the EvidenzerIRL. Pulmonary function tests (PFT) were carried out on volunteers from outpatients of the pulmonary laboratory in St Vincent's University Hospital, Dublin (n = 58) and a control group with no underlying lung disease (n = 19). After the PFTs all volunteers were asked to provide breath specimens using the EvidenzerIRL. Fourteen (24%) out of 58 lung disease volunteers failed to provide a breath specimen, no one from the control group was unsuccessful. Thirteen females and one male volunteer could not successfully provide. Female volunteers were more likely to fail to provide than male volunteers. A significant difference was found between the median age of successful (62.2 years) and unsuccessful (69.2 years) lung disease volunteers. Only one PFT, percentage predicted of Forced Expiratory Volume in 1 second (FEV1), had a significant difference between the mean of successful (86.6%) and unsuccessful (66.5%) lung disease volunteers. A subject with lung disease was more likely to be successful than unsuccessful. Drivers' effort and operators' guidance through the process were found to be crucial parts to a successful outcome.

COVID-19 pandemic: Coroner's database of death inquiries with clinical epidemiology and total and excess mortality analyses in the District of Kildare March to June 2020.

All Covid-19 deaths and all nursing home and residential home deaths in Ireland must by law be reported to the Coroner, the independent Judicial Officer of the State, in the District in which they occur. This enables accurate and early collation of these death reports. Between January 1, 2015 and June 30, 2020 3342 deaths were reported to the Coroner's District for Kildare. From March 11, 2020, when the first Covid-19 death occurred in Ireland in County Kildare, to June 30, 2020 there were 1738 Covid-19 deaths nationally of which 139 were reported in Kildare with 113 (81%) of these deaths in nursing and residential homes. The calculated excess number of deaths notified for January to June 2020 compared with 2015-2019 was 198 (41%) of the 484 total deaths reported with a 131 (45%) excess in the 293 deaths in nursing and residential homes. Covid-19 deaths accounted for 70% and 86% of these excess deaths respectively. Following subtraction of the 18 non-natural cause deaths and 139 Covid-19 deaths from the total excess there remained an unexplained excess of 60 deaths due to natural causes in March to June of 2020 compared with 2015-2019. The peak excess total death percentage was 359% in April 2020, commencing with a small excess in March (30%), continuing into May (63%) and falling again in June (37%). In the nursing and residential home setting those excess death percentages were most marked at 527% in April, with 27% in March, 54% in May and 17% in June. Underlying medical conditions were recorded in 99% of those dying from Covid-19 and the average age of the deceased was 82.5 years with median of 78 years and 55% of those dying were female and 45% male. The clinical epidemiology and documented excess mortality of the reported deaths are chronicled and analysed to learn also about the future challenges with the continuing Covid-19 infection. A centralized national mortality database providing near real-time death certification enhances infectious disease surveillance and prompt clinical epidemiology and mortality excess studies and reduces under-reporting of Covid-19 deaths.

A clinical investigation into the ability of subjects with a lung disease to provide breath specimens using the Dräger 6510.

In the enforcement of drink driving laws failing to provide a breath specimen for alcohol analysis at the roadside when requested by a Police Officer is an offence in many countries. Some drivers claim that a lung disease prevented their ability to be successful. This study aims to investigate the relationship between the presence of a lung disease and the ability to provide a successful breath specimen using the Dräger 6510 screening device. Sixty participants with lung disease and nineteen control participants underwent pulmonary function tests and were then tested with a Dräger 6510 screening device. Only one participant was unsuccessful using the Dräger 6510, this participant suffered from interstitial lung disease. The pulmonary function test results did not indicate if someone would be successful or how many attempts would be needed to be successful. The presence of a lung disease did not indicate if a driver would be unsuccessful however all participants were free from infection and the participants with a lung disease were stable at the time of testing. Correct instruction, subject cooperation and the technique used by the driver to provide a breath specimen were found to be important factors in the success of a breath test.

Repatriation of human remains following death in international travellers.

BACKGROUND: Death during international travel and the repatriation of human remains to one's home country is a distressing and expensive process. Much organization is required involving close liaison between various agencies. METHODS: A review of the literature was conducted using the PubMed database. Search terms included: 'repatriation of remains', 'death', 'abroad', 'tourism', 'travel', 'travellers', 'travelling' and 'repatriation'. Additional articles were obtained from grey literature sources and reference lists. RESULTS: The local national embassy, travel insurance broker and tour operator are important sources of information to facilitate the repatriation of the deceased traveller. Formal identification of the deceased's remains is required and a funeral director must be appointed. Following this, the coroner in the country or jurisdiction receiving the repatriated remains will require a number of documents prior to providing clearance for burial. Costs involved in repatriating remains must be borne by the family of the deceased although travel insurance may help defray some of the costs. If the death is secondary to an infectious disease, cremation at the site of death is preferred. No standardized procedure is in place to deal with the remains of a migrant's body at present and these remains are often not repatriated to their country of origin. CONCLUSIONS: Repatriation of human remains is a difficult task which is emotionally challenging for the bereaving family and friends. As a travel medicine practitioner, it is prudent to discuss all eventualities, including the risk of death, during the pre-travel consultation. Awareness of the procedures involved in this process may ease the burden on the grieving family at a difficult time.

Suicide among regular-duty military personnel: a retrospective case-control study of occupation-specific risk factors for workplace suicide.

OBJECTIVE: The purpose of this study was to examine the epidemiology, phenomenology, and occupation-specific risk factors for suicide among regular-duty military personnel as a model for other professions at risk for workplace suicide. METHOD: Suicide incidence and methods were determined in a retrospective military cohort comprising all deaths (N=732) of regular-duty military personnel in the Irish Defence Forces between 1970 and 2002. A retrospective, case-control study using pair-matched military comparison subjects was conducted to determine occupation-specific risk factors for suicide, particularly by firearm, among military personnel. Risk factors were subjected to chi-square analysis or independent t tests and entered into a binary logistic regression analysis model. RESULTS: The period-averaged suicide rate for the cohort was 15.3/100,000. Firearm suicides accounted for 53% of the cases. Suicides that took place on duty occurred predominantly when personnel were alone shortly after duty commencement in the morning. Bivariate and logistic regression analyses identified psychiatric illness and a past history of deliberate self-harm, morning duty (shortly after duty assumption and consequent access to firearms), and a recent medical downgrading as independent risk factors predicting firearm suicide among military personnel. CONCLUSIONS: Occupation influences suicide method. Access to and opportunity to use lethal means in the workplace are distinct but related occupation-specific suicide risk factors in the military and in other at-risk professions. In professions where access to lethal means is inevitable, moderating opportunity for suicide is crucially important. In regular-duty military personnel, a medical downgrading, combined with risk factors established in civilians such as younger age, male gender, psychiatric illness, and past self-harm, increases the risk of suicide. The findings may be used to guide military harm-reduction strategies and have applicability in strategies for other professions at risk for workplace suicide.

A study of suicides in Kildare, 1995-2002.

This paper focuses on 109 cases of suicide that occurred in Kildare from 1995 to 2002. These statistics were obtained by examining the records of the Kildare County Coroner. There is no central national location for the records of the 48 coroner jurisdictions in Ireland and all coroners are required by law to retain the files on each inquest indefinitely. However, the actual record of verdict given at inquest is not the one used for determining the suicide rate in the country. This is achieved by the Central Statistics Office (CSO) Form 104, which asks for the investigating police officer to give his or her opinion as to the cause of death. This results in discrepancies between what the coroner records and what the official suicide rate is presumed to be. These figures are further influenced by some coroners choosing to return a verdict "death in accordance with the medical evidence" as opposed to a verdict of suicide. The files were also examined to find the high-risk groups or those groups which have a tendency towards suicide. Over 84% of suicides were male and 32 men were between the ages of 20 and 30. It is suggested that the standardisation of recording verdicts of suicide be implemented as soon as possible as the current situation leads to variances between coroner's records and those kept by the CSO.

Maternal brain death, pregnancy and the foetus: the medico-legal implications for Ireland.

This paper examines some of the medico-legal issues that arose as a result of a situation which occurred in May 2001 in Ireland when a woman who was a British citizen and who was fourteen weeks pregnant collapsed and suffered a brain haemorrhage. She was taken to hospital where she was placed on life support but declared brain-dead. As a result of the uncertainty regarding the hospital's obligation to the foetus, life-support was maintained until further opinion was sought. After two weeks the foetus died and life support was only then discontinued. In Ireland there currently exists neither medical guidelines nor legislation to regulate such areas of medical practice. Also, the courts have not had the opportunity to comment on this particular matter and thus there exists widespread concern as to how healthcare providers will act if such situation were to occur again in the future. This article examines the following difficult medico-legal implications that arise from the above situation and especially in light of the constitutional protection of the unborn child in Ireland.

The case for a cost-effective central coronial database following an analysis of coronial records relating to deaths in nursing homes.

In order to demonstrate the potential wider epidemiological application of the data held in coroners' files, this paper uses an analysis of nursing home deaths reported to the coroner in County Kildare, Ireland. We examine the deaths in relation to ages, primary causes of death and rates of post-mortem examination. Knowing that Europe's population is increasing in age, the analyses presented here show the type of information that could be made available relating to certain population cohorts. Currently, there is no easily accessible way to obtain this information in Ireland, so we present the case for the implementation of a central coroner's database with potential for application in other jurisdictions but with the caveat that it must be cost-effective and use current resources, rather than establishing new ones.