Medicolegal Aspects of Victims of Assault Admitted to a Tertiary Care Hospital in Sri Lanka

Introduction: Violence with physical assault is a common cause of morbidity and mortality prevalent but not limited to underdeveloped countries. The opinion of the forensic expert is often indispensable in such cases to determine the penalties. This study was planned to describe the pattern of presentation of the victims and evaluate the strengths and limitations in formulating a scientific medicolegal opinion based on the findings of the victim. Methods: A retrospective descriptive study based on the case records of the victims of assault admitted to Colombo North Teaching Hospital, Ragama, Sri Lanka, was conducted for four years. Results: Out of the 400 victims, the majority (72% n = 290) were males and of the age-group of 21 to 40 (n = 216). The reason for assault in the majority was sudden provocation (n = 99, 25%), followed by previous long-duration enmity (n = 89, 22%). The majority (83%) had isolated blunt force trauma, and the injuries were nongrievous (74%). Defense injuries were significantly associated with attempted defense (p = 0.000) and sharp force trauma (p = 0.002). The underlying reason for the assault was not significantly associated with the causative weapon (p = 0.228) or body region injured (p = 0.195). Conclusions: Even though the presentation and the pattern of injures are definitely of value in formulating a scientific opinion, the study identified the limitations of the forensic experts, and the need for a holistic approach at the investigations was highlighted.

Double Suicide Due to the Ingestion of Levamisole-Adulterated Cocaine: Case Report and Review of the Literature

Suicide is a major public health issue and the risk of attempting and committing suicide increases with age. We present the case of an elderly couple who decided to commit suicide together by self-poisoning using levamisole-adulterated cocaine. The choice of committing a double suicide, the method selected (self-poisoning), the drug self-administered (cocaine), and the route of administration (ingestion) are events rarely encountered in the forensic pathology practice, especially not in combination. In this article, we will review the literature regarding the frequency and features of these methods of suicide. An overview of the effects and mechanism of action of levamisole is also provided, highlighting the importance of including this substance and its metabolites in the routine toxicological analyses for cocaine deaths.

Bases of Forensic Pathology Expert Testimony With Emphasis on Iowa v Tyler

Judicial scrutiny of the forensic sciences is increasing. This scrutiny targets the bases for expert opinions. Forensic pathologists must understand that when they express an opinion it must have an articulable underlying basis. Iowa v Tyler provides a cautionary tale where testimony from a forensic pathologist on the cause and manner of death based exclusively on police reports and audio and video recordings of police interviews of the suspect rather than on medical evidence were held to be inadmissible. Tyler has an odd and distinguishable set of facts, but has been widely cited as an example of problematic forensic pathology testimony.

Firsthand Experience in Graduating Three Cohorts of Forensic Pathologists Trained With Competency by Design (CBD) Curriculum

Introduction: The University of Toronto experienced graduating three cohorts of forensic pathologists trained with Competency by Design (CBD) curriculum. We achieved this as a result of multiyear development of Entrustable Professional Activities (EPAs), Required Training Experience (RTEs), and Specialty Competency Requirements (SCRs) by the Royal College of Physicians and Surgeons of Canada’s Forensic Pathology Speciality Committee, the Ontario Forensic Pathology Service, and the University of Toronto. Method: Our academic year is comprised of 13 blocks. We divided the 13-block period into 4 stages to map all the EPAs and RTEs. The first stage, Transition to Discipline, is 1 block, the second stage, Foundation of Discipline, consists of 3 blocks; the third stage, Core of Discipline, consists of 6 blocks, and the final fourth stage, Transition to Practice, consists of 3 blocks. Board-certified faculty members in Forensic Pathology with more than five years of experience supervised the trainees. We graduated 5 Canadian and 4 international trainees at the end of the third cycle of CBD-based training program. Conclusion: Using the Royal College Speciality Committee blueprint, the University of Toronto started in 2016 planning the CBD curriculum in the forensic pathology training program. By the end of June 2021, we graduated nine trainees from our CBD-based Forensic Pathology training program. We are training the fourth cohort, and they will be graduating at the end of June 2022. This article aims to share our firsthand experiencing in CBD training in forensic pathology.

The “Magnificent Seven Errors” in Forensic Autopsy Practice: The Italian Context

According to the Italian legal system, forensic autopsies are performed by a medical doctor specialized in legal medicine, otherwise known as a medicolegal expert (MLE), who has a range of very complex responsibilities. Indeed, the quality of forensic autopsy activity is always questioned in courts of law; incorrect assessments are dangerous because they can jeopardize the validity of a criminal investigation and thus affect the outcome so that a real culprit may be acquitted or an innocent person convicted. Nonconformities also discredit the professionalism of the specialist who performs the autopsy. The work of a MLE implies a series of assignments and duties that should be given constant consideration, but when certain aspects of this activity are underestimated or overlooked, this can lead the expert to make mistakes with irreparable consequences for the judicial investigation. In this article, for the first time, we present a summary of seven known errors related to autopsy activity following death by unnatural causes, with the purpose of alerting MLEs who work under the Italian judicial system to the potential dangers of such errors. These relate to: oversights in autopsy technique, incorrect collection of photographic and video material, unauthorized attendance at the autopsy, missing/mistaken reporting at any stage of the forensic activity, failure to notify the party forensic consultant, using histological or toxicological nonaccredited laboratories for forensic activities, and lack of observance of the chain of custody.

Aortoesophageal Fistula Secondary to Esophageal Diverticulum Resulting in Sudden Unexpected Death

Aortoesophageal fistula (AEF) is a rarely encountered clinical outcome that is often fatal. It is most commonly a postoperative complication of vascular surgery (secondary AEF). Reported primary causes of AEF include aortic aneurysm, atherosclerosis, infection, foreign objects, achalasia with megaesophagus, gastrointestinal malignancy, and radiotherapy. Aortoesophageal fistula is often not a top diagnostic consideration for clinicians or pathologists and has the potential to be overlooked. This report describes a rare case of AEF secondary to an esophageal traction diverticulum and associated abscess that resulted in the sudden unexpected death of a 78-year-old male. Aortoesophageal fistula is an important consideration for pathologists and requires careful consideration in the postmortem setting.

Acute Esophageal Necrosis (Black Esophagus): An Autopsy Case Series

Introduction: Acute esophageal necrosis (AEN), also known as black esophagus and acute necrotizing esophagitis, is a rare pathologic finding of unknown etiology. It was first characterized as diffuse, circumferential black discoloration of the esophageal mucosa that affects predominantly the distal esophagus with sharp transition to normal-appearing mucosa at the gastroesophageal junction. Case frequency of AEN remains low and mainly found incidentally, with up to 0.2% in autopsy and endoscopy studies. Men are 4 times more commonly affected and overall mortality is approximately 32%. Methods: Black esophagus was incidentally found during ten forensic autopsy cases. Complete autopsies with photographs, histological examination, and toxicological analysis were performed. Case background information was reviewed. A review of literature was done, with research criteria including previous case reports, diagnosis, and autopsy, endoscopic, and microscopic findings of AEN. Results: Nine of ten deceased were male, with an age range of 26 to 67 years old. The most common preexisting pathological condition was chronic alcohol consumption, seen in six of ten cases, and in eight cases, the death occurred suddenly at home. “Classic” black esophagus was only seen in four cases. Upper gastrointestinal hemorrhage due to acute necrotizing esophagitis was established as the immediate cause of death in six of ten cases. Discussion: This case series demonstrates ten cases of AEN with variation in appearance, yet diagnosis supported by histology, ancillary testing, and case information. The case frequency was higher than previously reported, 0.7%, suggesting that the prevalence of AEN may be underestimated, especially in forensic death investigations.

Fatal Necrotizing Fasciitis as a Consequence of Blunt Trauma: A Case Report

Necrotizing fasciitis is an uncommon lethal bacterial infection that involves the subcutaneous tissue and fascia. It can be mono or polymicrobial infection. The diagnosis is mainly dependent on clinical signs and symptoms. Trauma is the commonest cause for it. The early signs and symptoms may mimic cellulitis. We present a case of necrotizing fasciitis following an assault. The patient was received in a state of shock. Despite all measures, the patient could not be saved. Early debridement and antibiotic therapy have a key role in the prognosis of the disease. Medicolegal issues can arise when the disease develops post-assault because of the vague and unpredictable nature of the disease and its challenging prognosis.

Study on Evaluation of Knowledge, Attitude, and Practice of Sri Lankan Traffic Police Officers Related to Examination of Drunk Drivers, in Two Most Populated Districts of Sri Lanka

Introduction: Driving under the influence (DUI) of alcohol is one of the substantial predisposing factors for mishaps among road users. A traffic police officer will be the first authoritative personnel a drunk driver encounters in the legal system. The absence of accurate skills and knowledge of these officers impedes the structuring of legal procedures and may lead to miscarriage of justice. Objective: To assess the knowledge, attitude and practice of Sri Lankan traffic police in handling and managing an alleged case of driving under influence of alcohol. Methods: This was a descriptive cross sectional study carried on a sample of 384 traffic police officers attached to the districts of Colombo and Gampaha, through a questionnaire. Results: Out of 384, only 75 of police officers knew the correct preliminaries to perform before administering a breathalyzer test. 79.7% knew the correct instructions for using a breathalyzer, but only 3.4% knew the colour changes of the breathalyzer. Significantly poor attitude was observed among the police officers, regarding the importance of producing a drunk driver for medico-legal examination ( P = 0.001) Only 222 (57.8%) answered correctly that a drunk driver needs to be subjected to a medico-legal examination as early as possible. Significantly poor practice and attitude was observed in officers with longer service duration but no significant association was observed between ranks of officers and attitude and practice ( P = 0.199). Conclusions: The results of our study demonstrate that the knowledge attitude and practice on efficiently handling a case of DUI among traffic police officers is poor, even though all of them are engaged in DUI duties irrespective of their service duration. The need for continuous professional development programmes was highlighted.