Four hundred adult claimants underwent medico-legal assessment following upper limb injuries. Dynamometry was performed on each using the Jamar five handle-position test. Injury causes loss of power and there is a significant relationship between the percentage loss of power and the measured whole limb impairment. This paper presents a new approach for the analysis of the tests. The normal physiological length–tension pattern of muscle is maintained in the majority of claimants albeit with modifications due to the specific effects of injury on hand function. This paper provides normative data for the analysis of dynamometry in this population and makes recommendations for parameters that suggest that a test is a true reflection of capacity and thus useable in court.
This study was conducted at the M. S. Ramaiah Medical College, Bangalore, between October 2007 and September 2009 to analyse the age and sex distribution of unnatural deaths in children, patterns and manner of death. Detailed information regarding the circumstances of death was sought from the relatives, friends and police. The scene of occurrence was visited, and photographs of the scene of occurrence were examined in relevant cases. Unnatural deaths in children constituted 6.62% of the total autopsies conducted. The majority of childhood deaths were in the age group of 15–18 years of both sexes constituting 46.88%. Males constituted 55.22% of cases. Suicide accounted for 40.63% of the cases. Most children committed suicide by hanging (82.05%). The main reason was academic failure and some of the cases were accidental (48.96%). Road traffic accidents accounted for 26.04% of the cases, where most children were pedestrians (56%). Drowning accounted for 15.63% of the cases. Most of the children drowned while playing near ponds (83.33%). Homicide accounted for 9.36% of the cases – either killed by their mother as part of a pedicide–suicide event or by the father, and in two cases the children were sexually abused before being killed.
Bulldozer fatalities are usually due to accidental crushing of the body at the workplace. However, severance of the skull cap simulating a chopping injury to head is rare in the literature. Medico-legal investigation may be posed with different challenges when carrying out an autopsy of a victim with this devastating head injury. The police will seek an opinion about the type of weapon responsible for the injuries, the nature of injuries produced and manner of death. In the present case, the victim was hit at dusk by a protruding part of the bulldozer blade as he crossed in front of a bulldozer that was approaching his tractor from the opposite side of the road. His skull cap was severed and he died instantly. This report considers the circumstances of his death, its mechanisms and strategies for preventing such deaths.
A consecutive group of 250 patients underwent medico-legal assessment at a mean of 24 (±13) months following upper limb injuries. Each had completed questionnaires to assess function (Quick-DASH) and cold intolerance (CIQ36) before clinical assessment following which their whole limb impairment percentage was calculated. The mean(±SD) whole limb impairment, QDASH and CIQ36 scores were 9(±14)%, 43(±24) and 17(±10), respectively. There was a significant correlation between whole limb impairment and QDASH, although some patients reported surprisingly high disability levels despite minimal or no objective functional impairment. Whilst useful qualitative information can be obtained from questionnaires, the correlation between subjective and objective scores is weak albeit statistically significant. Individual patients can show marked discrepancies between objective and subjective functional scores. The results of questionnaires in individual medico-legal patients should be treated with caution.
We describe an unusual case of drowning in fluid other than water in an industrial setting. A 26-year-old man was working in an industry which performs surface treatment of mechanical steel parts with quenching oil. He fell into the quenching oil (which was hot due to immersion of red hot metal parts), and as he was working alone in the particular section, there was a fatal outcome. A medico-legal autopsy was performed. The causes of death were found to be multiple, with the association of drowning, extensive superficial burns and asphyxia due to laryngeal oedema. To our knowledge, it is the first report of drowning in hot quenching oil, and only nine previous observations of drowning in industrial environments have been reported in the international literature. Even though rare, these kinds of accidental deaths can be prevented in dangerous industries with proper precautions and strict adherence to standard operating procedures.
Capacity is assumed to be present unless proven otherwise. Assessments of specific decision-making capacity for financial and legal decisions, although challenging in the general population, becomes almost impossible for individuals with language disorders (i.e. aphasia) in the absence of appropriate communication aids. Several capacity aids exist for the general population; however, it is unclear whether any communication aids exist specifically for the aphasic population to assist assessment of financial and legal decision-making capacity.
A literature review was conducted of six databases with the assistance of a research librarian. From 171 articles screened, 12 were included in the final review.
The literature focus was on medical decision-making capacity, and in particular, patient consent. Few articles addressed legal or financial decision-making capacity. Several articles identified the presence of general and specific capacity aids for the general population; however, there was a clear absence of similar communication aids available for the aphasic population with only one communication aid identified to assist with decision-making capacity assessment for healthcare and accommodation decisions only.
Whilst a significant amount of research has been done on decision-making capacity, it is mostly focused on healthcare; in particular, on patient consent for treatment for the non-aphasic population. Although a communication aid exists to aid assessment of decision-making capacity for healthcare for aphasic individuals, no similar tools exist to aid financial and legal decision-making capacity assessments. This paper highlights an important problem encountered during clinical practice which requires further research.
We described a neonate with severe and multiple abnormalities following use of isotretinoin, in spite of the mother's previous knowledge of drug complications. Initial physical examination after delivery showed congenital absence of both eyes and both auricles as well as anal atresia and a cleft palate. Due to severe respiratory distress and atresia of the anus, the neonate was admitted to a neonatal intensive care unit and underwent reconstructive surgery. The drug should not have been used during pregnancy. Using this drug within pregnancy with awareness of its side effects may have legal consequences.
This study aimed to explore the most common hand injury errors occurring in Emergency Departments in England. A Freedom of Information request was made to the NHS Litigation Authority for claims data related to hand injuries in English Emergency Departments from 2004 to 2014. All successful hand injury claims against an individual DGH ED were also analysed. Two hundred and eighteen successful claims were made, costing a total of £6,273,688.22. Diagnosis error was the most common successful claim (97). Four successful claims were brought against the Emergency Department. Causes of error included the use of inappropriate views and failure to correlate imaging with clinical findings. Hand injury diagnostic error has been the most common cause of successful litigious claims against Emergency Departments over the past 10 years. This paper demonstrates that fracture recognition and clinical diagnosis of hand injuries are key areas to target to reduce error rates.
Ovarian hyperstimulation syndrome is a rare, but potentially life-threatening iatrogenic disorder arising from ovulation induction or ovarian hyperstimulation for assisted reproduction techniques. We report a case of a 26-year-old multiparous woman, an anonymous egg donor, who died a few hours after undergoing a procedure to donate eggs at an in vitro fertilization clinic. Her husband alleged that medical negligence had led to her death. The autopsy confirmed death due to ovarian hyperstimulation syndrome. We know of no previous descriptions of fatal ovarian hyperstimulation syndrome in an anonymous egg donor in medico-legal literature.
The taking of an ethical-legal oath is a "rite of passage" for many medical practitioners. A 1997 paper noted that half of medical schools in the UK administer an oath. I performed a survey of UK medical schools to see whether these are still used today. An electronic survey was sent to 31 UK medical schools, asking them whether the Hippocratic Oath (in any version) was taken by their medical students; non-respondents were followed up by telephone. Information was obtained from 21 UK medical schools, giving a response rate of 68% (21/31). A total of 18 (86%) institutions use an oath. Ethical-legal oaths are therefore taken in the vast majority of UK medical schools today. However, a great variety are used, and there are advantages in standardisation. My recommendation is that the Standard Medical Oath of the UK (SMOUK) is adopted by all medical schools, and that this is also taken regularly by doctors as part of revalidation.
The doctrine of res ipsa loquitor can allow a plaintiff to raise an inference of negligence which a defendant is then compelled to refute. However, the doctrine has rarely been applied in clinical negligence contexts because courts have been reluctant to require doctors to refute an inference of responsibility for pathophysiological outcomes. But does that imperative apply equally to aesthetic surgery? A recent case shows that it does.
Ingestion of a foreign body is mostly accidental in children and intentional in prisoners to achieve hospitalization; however, use of this method of suicide is rare. We report a case where the victim first ingested a safety razor blade, but failed to die and then hanged himself, but failed again and finally succumbed to the complications on the sixth day. He had also attempted suicide by inflicting multiple incised wounds on his neck four days before the safety blade ingestion, but none were fatal.
Venomous insect stings are a cause of morbidity and mortality worldwide. The sting reactions are unpredictable and vary among individuals. A case of fatal insect sting in an elderly female is presented to discuss the associated challenges during necropsy.
Cut-throats can be of homicidal, suicidal or accidental origin. In cases of death from a cut-throat, distinguishing the cause is one of the important functions in crime investigation. The features that differentiate suicidal and homicidal cut-throat injuries are the presence of hesitation cuts, depth of wound, signs of struggle, edges of the wound, etc. In the case of a suicidal cut-throat, it is not uncommon to find hesitation cuts but in a homicidal cut-throat, it is uncommon. We present a case of a homicidal cut-throat injury but with hesitation cuts and tailing over the neck, unlike the classical description of homicidal cut-throat injury. This resulted from a curved, sharp and moderately heavy weapon.
The history of our current law dates from Palaeolithic times. The first written laws were codified by the rulers of Mesopotamian kingdoms, from the beginning of the second millennium B.C.E. This history, and those of the medico-legal specialties in particular, trace their origins to Hammurabi’s Code. Hammurabi (ruled 1792–1750 B.C.E.) was the sixth King of the First Dynasty of ancient Babylon, today an archaeological site in modern-day Iraq. Hammurabi’s Laws (c.1760 B.C.E.), inscribed on at least one diorite stele, were set up in public places in Babylon, towards the end of the King’s 43-year reign. Comprising almost 300 specific laws, with judicial punishment for transgressions, Hammurabi’s Code reflects his role both as a guardian of the vulnerable and as a protector of the weak and powerless. Just as medical papyri from ancient Egypt (e.g. the Edwin Smith papyrus c.1600 B.C.E.) are regarded as the origins of western medicine, so Hammurabi is the pioneer of "medical" laws as these have evolved to their sophisticated state today.
Snakebites are an important cause of death in rural and suburban India. Most of these deaths occur due to envenomation. The incidence of snake bite is highest in developing countries with the most common site of such bites in the lower limbs. Here, we present a case where a 12-year-old boy had been bitten on his face which is an unusual site and as a consequence the treating doctor failed to make the correct diagnosis promptly and the boy died.
Injury or death by strangulation, unless otherwise explained, is almost always homicidal. Accidental strangulation may occur but only very rarely. We present such a case of accidental strangulation and survival in a motorbike pillion rider. A long scarf (dupatta) clad woman, sitting at the back of a two wheeler motorbike, fell after her long scarf got caught in the back wheel. The lady was first taken to a local clinic and then later was referred to a hospital for a suspected spine injury where she made an uneventful recovery. This case report exposes the precarious position of women pillion riders wearing a long scarf and emphasizes the need for extra caution and the need for wheel guards on spoked wheels in particular.
A suicide note is an important tool for medico-legal investigation on the manner and circumstances surrounding the death. It can also act as a facilitator for organ donation when the victim expresses their wish to do so. This article cites four examples, where the victims had specifically mentioned a "last wish" to donate their organs. The importance of such "expressed consent" in suicide notes is discussed. Such observations are not found in available scientific literature and are of importance in countries where there is a long waiting list for organ recipients and a very large number of suicidal deaths.
Cor adiposum is a rare disorder of the heart, where the normal heart tissue is replaced by fibro-fatty infiltrates. We report one such case of a middle-aged female who was declared dead shortly after a syncopal episode. At autopsy, the pericardium was intact and firmly adhered to the heart. Histopathology revealed fatty infiltrates extending into the left ventricle of the heart. A post-mortem diagnosis of Cor adiposum was made which is an uncommonly reported cause of sudden cardiac death.
A healthy 2-year-old girl bit a green chilli accidentally following which she had many bouts of vomiting. She became unconscious and was immediately admitted to hospital. In spite of all medical intervention, she died after one day. The autopsy confirmed that the death was caused by respiratory failure due to acute respiratory distress syndrome following aspiration of gastric contents into tracheobronchial tree. Aspiration of gastric contents resulting in acute respiratory distress syndrome and death is not uncommon; however, death following the accidental bite of a chilli is rarely reported in medical-legal literature.
In deaths due to hanging and strangulation, the position, course and direction of the ligature mark, the kind of knot used and injuries to the neck structures help in deducing the cause and manner of death. Two cases of suicidal hanging are reported where the unusual positioning of ligature and presence of the ligature mark on the face raise doubts concerning the circumstances of death. The presence of a ligature mark on the face is an unusual and rarely reported phenomenon that can have serious medico-legal implications.
One of the main problems in forensic medicine is the autopsy diagnosis of drowning, especially in the case of delay in the victim’s recovery. The body of a 37-year-old woman was delivered to Kahrizak autopsy centre for post mortem. She was drowned in a public Jacuzzi because when she bent down to pick up her hairpin from the bottom of the Jacuzzi, her right arm became stuck in the drainage pipe and was sucked in. Unfortunately, she was not resuscitated after being pulled out of the Jacuzzi. The ambulance arrived too late, and she was already dead on arrival at the hospital. Her family pursued a claim against the managers and personnel of the pool for poor security management and failure to resuscitate. A forensic examination was needed to determine the manner of her death (natural, accidental, suicide and homicide).
Posthumous sperm retrieval is a procedure in which spermatozoa are extracted from a man after he has been pronounced legally brain dead. Sperm retrieval from the penis has not been studied previously to the best of our knowledge. Our purpose was to determine the motility and viability of sperm from the penis with increasing time intervals from death. There was a progressive decrease in sperm motility with increasing post-mortem intervals, with a progressive increase in non-motility. Similarly, the sperm viability also showed a decreasing pattern with the increasing post-mortem interval. The sperm were found to be viable up to 24 h after death. Penile tract sperm retrieval has not been previously studied as far as we know.
In a forensic setting, haemothorax is usually seen in cases of trauma. The main non-traumatic cause for haemothorax is an intrathoracic rupture of an acute aortic dissection or an aortic aneurysm that is almost always fatal. Here we present one such case of sudden natural death caused by rupture of an acute aortic dissection. The deceased was a middle-aged, unidentified male who was subjected to autopsy at the Department of Forensic Medicine, M.S. Ramaiah Medical College, after having been brought in dead to the hospital. It is a type III DeBakey dissection as it originates in the descending aorta and it is quite unusual that a rare retrograde extension was also observed.
In India, it is estimated that about 13 million people are homeless. As these individuals have no close acquaintances, in the event of death, their bodies remain unclaimed. These unclaimed corpses pose a major challenge for the local law enforcement agencies in identification and thus become an obstacle in solving the cases of missing persons. We sought to review the autopsy characteristics and causes of death in the unclaimed/unidentified bodies autopsied at the All India Institute of Medical Sciences (AIIMS) from 2006 to 2012. Among the total of 11,786 cases autopsied during the year 2006 to 2012, 1335 (11%) were unclaimed. Most of the cases were males (91%) with a male-to-female ratio of 9:1. Mean age of the cohort was 43 years (range, 1–85 years). Natural events were the foremost cause of death and were more commonly seen in males. While accidental, suicidal and homicidal modes were common in younger age groups; natural manner of death predominated in the elderly. Most of the cases were found dead on the roadside. This paper also compares with the previous study in the same set-up during the time period 2001 to 2005. The authors believe that knowledge about the existing healthcare facilities need to be reinforced and their utilisation promoted.
Stab wounds encountered in medico-legal practice are caused by sharp or blunt pointed weapons such as a kitchen knife, dagger, screwdriver, iron rod, etc. Atypical entry wounds may result from elasticity of skin, relative movement of the victim or the offending weapon or both. These are often described in the literature. We report an unusual incised stab injury of the thigh where a single atypical entry wound resulted in injury to the femoral vessels. The precise causation of such a peculiar entry wound cannot be explained, though it can be considered within the dynamic processes involved between victim, assailant and the offending weapon. It is recorded because of its academic curiosity.
Legal issues around the duty of care in common law with regard to addictive legal drugs are evolving. Two recent cases came before the Irish courts dealing with the issue of duty of care of alcohol suppliers to intoxicated individuals. In both cases the intoxication was self-induced and the consequences were lethal. The juxtaposition of personal autonomy and duty of care cannot ignore personal responsibility. Do we need protection from ourselves?
Castration is an anthropogenic procedure by which the person loses the functions of the testicles or ovaries; it can be performed by surgery or by administering chemicals. The motivation was primarily eugenic, to weed out the "unfit" from the human gene pool. In 1996, California first introduced chemical castration under s 645 of the California Penal Code for child molestation and this legal template has spread globally to counter sexual offences. The anti-androgenic pharmacotherapy used for chemical castration includes cyproterone acetate or medroxy-progesterone acetate (Depo-Provera), which reduces testosterone levels and reduces male sexual urge and fantasies. However, the associated health hazards with anti-libido drugs put a question mark on such State sponsored penal response. Castration destroys human dignity, breaches the right of privacy and procreation and attracts the cruel and unusual punishment clause. The failed Oregon castration experiment and Moldova Court verdict in July 2013 indicate that the stage is set to right this wrong.
Rapid advancements of information and communication technology in the form of electronic mails, mobile phones, social networking sites, etc have an increasing impact on people's day to day life. It has been observed that these readily available applications are used frequently to express suicidal intentions. There are many studies on conventional handwritten suicide notes but suicide note in electronic format is an emerging issue and an under-researched phenomena. The authors have termed it as "E-suicide note" and discuss its medico-legal implications in India with examples from their observations.
The principle of personal autonomy means that patients are free not to attend scheduled medical appointments and to risk the complications that may occur as a consequence of their non-attendance. But the situation may be more complicated if the patient’s doctor recognises that the patient may be vulnerable to a particular risk. What are the limits of the doctor's obligation to follow-up or recall the patient for a further consultation? Some recent cases cast light upon this issue.
Forensic pathologists encounter a wide range of deaths due to natural causes. Natural deaths can be sudden and unexpected, occurring in apparently healthy people. All such cases have to be investigated and a medico-legal autopsy should be conducted to ascertain the cause of death, and to rule out any criminal cause of death. Here, we report a case of a 46-year-old male who collapsed at his workplace and died. There was no history of significant natural disease. The case was investigated due to the suddenness of his death and absence of a history of significant medical illness. An autopsy revealed that the death was due to coronary artery insufficiency as a result of massive cardiomegaly, although there was absence of significant occlusion of the coronary arteries.