Changes in the nature and outcome of notifications to HM Coroner from the Norfolk and Norwich University Hospital, UK, before and after the introduction of a medical examiner service: 2018 versus 2022.

A medical examiner (ME) system was introduced to England and Wales in 2019 intended to ensure appropriate notification of cases to HM Coroner (HMC). The aim of the study is to determine and compare: (a) the nature of notifications to HMC for Norfolk from the Norfolk and Norwich University Hospital (NNUH) in 2018 compared with 2022; (b) to determine the outcome of those notifications and (c) to establish patterns of change in the number and nature of such notifications. HMC and ME datasets were interrogated to determine differences between notifications to HMC and outcomes in 2018 compared with 2022. From deaths at NNUH (2018 - n = 2605; 2022 - n = 2969), there were significantly fewer HMC notifications in 2022 compared with 2018 (25.3% vs. 17.6%). A decrease in notifications was noted for persons undergoing any 'treatment or procedure of a medical or similar nature' (24.0% vs. 16.2%) p < 0.0014. An increase in notifications was noted for neglect, including self-neglect (3.3% vs. 12.2%) p < 0.001. Of the coronial outcomes, there were significant increases in the numbers of post-mortem (PM) examinations (29.3% vs. 35.5%) p = 0.0276 and inquests (26.0% vs. 31.4%) p = 0.0485). There was a significant decrease in no further action by HMC (5.7 vs. 2.3) p = 0.0485. The study shows that the introduction of the medical examiner service has resulted in significant change in the nature of HMC notification categories. The notifications appear to be more appropriate, with an increased proportion of inquests and PM examinations and with a reduction in 100 A or 'no further action' outcomes.

The role of a Medical Examiner Service in an acute NHS hospital: Perspectives from doctors and next of kin.

A new Medical Examiner system was introduced in England and Wales in 2019 to scrutinise all non-coronial deaths. The three key roles of independent Medical Examiner scrutiny are to establish accurate causes of death, determine whether coronial referral is required and identify any care concerns. This is the first published service evaluation exploring the views of doctors and next of kin with whom Medical Examiner Services interact. The aims were to understand whether the Medical Examiner Service was achieving its three main roles. Surveys were sent electronically to the qualified attending practitioners, and by post to the next of kin, of a consecutive series of deceased patients reviewed by an acute NHS hospital Medical Examiner Service in the East of England. Recruitment took place over a five month period in 2023. Results are based on 100 returned surveys from doctors (response rate 35%) and 179 completed by next of kin (response rate 65%). Findings suggest the Medical Examiner Service was successfully achieving its three key roles and well received by both doctors and next of kin. Service user feedback is clearly important as Medical Examiner Services continue to develop into the statutory phase during 2024, when they are anticipated to review approximately 400,000 deaths per annum in England and Wales. This study demonstrates such feedback is not only useful for service development, but also eminently possible.

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.

The workload of a medical examiner service at an acute National Health Service hospital during the COVID-19 pandemic: The Norfolk & Norwich University Hospital experience.

The COVID-19 pandemic commenced in March 2020. In May 2019, a new Medical Examiner system was introduced to scrutinise deaths of patients dying within acute National Health Service Trusts. The Coronavirus Act 2020 which came into force in March 2020 modified certification of death requirements. Newly formed Medical Examiner Services were advised they could suspend scrutiny during the pandemic. The Norfolk & Norwich University Hospital Medical Examiner Service (NNUH MES) continued to scrutinise patient deaths throughout. This study summarises the workload of the NNUH MES from 1st June 2020 to 31st May 2021 over which period 2856 deaths were recorded and 2687 scrutinised by the Medical Examiners.

Statement of the Independent Forensic Expert Group on Conversion Therapy.

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is premised on a belief that an individual's sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries. In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual's sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual's head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and "corrective" rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual's sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual's sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

Healthcare and forensic medical aspects of police detainees, suspects and complainants in Europe.

Death and harm is well-recognised in detainees in police custody worldwide. Based on the results of previous global surveys and the CPT (European Committee for the Prevention of Torture) recommendations a questionnaire was developed to summarise the current medical aspects of police custody in European countries. The survey was distributed to named contacts in all European countries. Data from 25 European countries was obtained. The results reveal significant differences in the regulations among the different countries, with nothing close to a harmonised European standard in place at present. This study has identified interesting variations in the methods and standards of healthcare and forensic medical services to detainees in police custody (e.g. quantitative mode of monitoring, qualification of the doctors, maximum time allowed for holding a detainee in police custody, body or an organisation that investigates complaints against the police). There are both very detailed legal regulations in some countries while in others there are only generally observed provisions that sometimes are only given in the form of recommendations. A multinational, multiprofessional expert group is required to identify best practices, recommend basic standards of care and identify qualifications which would be appropriate for healthcare professionals working in this field.

Confidentiality & consent in police custody: General principles.

The care of detainees (prisoners) in police custody has had much focus in recent years. The nature of the role of the doctor or other healthcare professionals within the police custodial setting may often be subject to conflicts, but their respective duties as healthcare professionals should generally overide any police or forensic issue that may be relevant. The laws or rules or statute that govern doctor, nurse or paramedic practice may vary from country to country, but the broad principles of healthcare ethics are universal and have been formulated not only by national healthcare regulatory bodies but by international organizations such as the World Medical Association. This article discusses in particular the duties of consent and confidentiality within the police custodial setting, giving examples of where conflicts may arise, and how they should be dealt with.

Guidelines for photography of cutaneous marks and injuries: a multi-professional perspective.

Investigators assessing the likelihood of physical abuse, must make a decision as to whether the injury seen matches the explanation given. In some instances the pattern of these injuries can give the investigator a possible link to the cause of the injury. Thus, matching an injury pattern to an implement or weapon used has forensic implications. The current method of capturing patterned injuries together with poor scale placement often result in some form of distortion that causes a change to the shape of the patterned injury. The aim of this guideline is to assist individuals dealing with the capture of photographic evidence for the investigation of suspected non-accidental patterned cutaneous injuries (PCI), and to ensure high standards of image quality are met for both evidential records and for forensic analysis. The technical equipment specified within these guidelines are recommended by the authors as a basic requirement for imaging best practice, due to their ability to capture detailed and critical data. For precise pattern matching analysis, it is vital that both the injury and the suspected implement are photographed in accordance with this guidance.

Focussing on the future: survey results on the image capture of patterned cutaneous injuries.

An investigator who is involved in assessing the likelihood of physical abuse must make a decision as to whether the injury seen matches the explanation given. In some instances the pattern of these injuries can give the investigator a possible link to the cause of the injury. Photographic imaging is used to record the patterned cutaneous injuries (PCI) and to facilitate forensic interpretation. The current method of capturing PCI often results in some form of distortion that causes a change to the shape of the patterned injury. The Dermatological Patterned Injury Capture and Analysis (DePICA) research group was formed to assess current image capture methods and practices. An online survey was set up to assess the value of localised imaging protocols and training specific to imaging PCI and was made available to law enforcement professionals, forensic investigators and hospital staff. 80 participants responded to the survey. The majority of the survey participants have had training in medical or forensic photography, however 66 (83%) have not had specific training in how to photograph PCI. 41 (51%) of the participants responded that they always use a rigid scale and 34 (43%) position the camera so that it is perpendicular to the scale and injury. Comments made about the quality of images obtained and produced raises concerns about how much knowledge those initiating such images have about image relevance in criminal cases. It is evident that a clear and comprehensive guide to photographing PCIs is required to improve the quality of the photographic evidence that is collected.

Problems of capacity, consent and confidentiality.

For the clinician managing a woman who has been violated sexually, core values of compassion, understanding and concern for the woman's distress are essential. The nature of the violation itself places the woman in a uniquely dependant, anxious, vulnerable and exploitative state. Capacity, consent and confidentiality derive from the principle of autonomy. Informed consent entails a process of information sharing and decision making based on mutual respect and participation. Practitioners should have communication, listening and interpretative skills. One of the greatest challenges is the difficulty in ascertaining whether or not the woman truly understands and grasps the nature of her condition. There are many challenges to obtaining a valid consent in the real world. Information obtained from the woman could be shameful and embarrassing, but would be used in a court of law. She should be informed of the potential for breach of confidentiality. These issues are explored and examples of practical application of the relevant themes are given from the England and Wales jurisdiction.

Excited delirium syndrome (ExDS): redefining an old diagnosis.

Recently, the National Institute of Justice (NIJ) of the United States of America convened a meeting of experts in the area of Excited Delirium Syndrome (ExDS). The history of ExDS, the clinical presentation, the pathophysiology, differential diagnoses and management options were discussed. Though the specific pathophysiological pathways of ExDS have yet to be formally defined, considerable research has been undertaken on this topic. It is important for law enforcement, medical and other healthcare professionals to be familiar with current knowledge about the syndrome. This paper summarizes the current state and knowledge of ExDS.