World without borders: integrating clinical perspectives into the coronial jurisdiction in Victoria, Australia.

A professional world without borders would allow for more appropriate collaboration between the Coroner's office and the healthcare sector in their endeavours to improve patient safety. In Victoria (Australia), the Clinical Liaison Service draws on the distinct experiences and expertise of medical, nursing and research personnel to evaluate clinical evidence for the investigation of healthcare deaths reported to the State Coroner's Office. This approach allows for greater intersectoral collaboration between the Coroner's office and healthcare sector than a traditional English-style coronial system that relies on the expertise of coroners, forensic pathologists and police officers to investigate unexpected deaths. Encouraging collaboration between these two sectors may have averted or at least mitigated the atrocities caused by Harold Shipman or the events at Bristol's Royal Infirmary. This paper describes the work processes employed by the Clinical Liaison Service (CLS) to investigate healthcare deaths in a coronial setting. To describe how this work has fostered the advancement of patient care.

Fly pupae and puparia as potential contaminants of forensic entomology samples from sites of body discovery.

Fly pupae and puparia may contaminate forensic entomology samples at death scenes if they have originated not from human remains but from animal carcasses or other decomposing organic material. These contaminants may erroneously lengthen post-mortem interval estimates if no pupae or puparia are genuinely associated with the body. Three forensic entomology case studies are presented, in which contamination either occurred or was suspected. In the first case, blow fly puparia collected near the body were detected as contaminants because the species was inactive both when the body was found and when the deceased was last sighted reliably. The second case illustrates that contamination may be suspected at particularly squalid death scenes because of the likely presence of carcasses or organic material. The third case involves the presence at the body discovery site of numerous potentially contaminating animal carcasses. Soil samples were taken along transects to show that pupae and puparia were clustered around their probable sources.

Potential contamination of forensic entomology samples collected in the mortuary: a case report.

Carrion insects originating from infested bodies may establish small mortuary populations. Two Victorian Institute of Forensic Medicine cases are presented to illustrate how these insects can potentially contaminate forensic entomology samples collected in the mortuary. The first case proves that bodies can be colonised in the mortuary: when a decomposed body in freezer storage was thawed for a procedure in the main mortuary, it was colonised within five minutes of exposure by the beetle Necrobia rufipes De Geer (Cleridae, Coleoptera). The second case illustrates that immobile juvenile insects can be transferred between bodies, and describes the transfer of an Eristalis sp. (Syrphidae, Diptera) pupa from a decomposed to a fresh body. While the contamination risk is slight, it can be further minimised by checking mortuary-collected samples against those taken from the body discovery site, by mortuary pest control, and by checking previous mortuary admittance records for possible contamination sources.

Experience with practice guidelines for medico-legal death investigations: the case of falls-related deaths in hospital.

Western philosophical and political thought has focussed on the significance of individual relativism. The legal system's approach to the investigation and regulation of medical practice is generally ad hoc and based on case law. In contrast, medical knowledge and understanding is progressively shifting towards a system of taxonomies and norms. Clinical guidelines and evidence-based medical practice are now commonplace in clinical practice. Due to the polarity of professional frameworks underpinning medicine and law, there has been an on-going struggle for the successful use of medical law that benefits both the quality of medical practice as well as its practitioners. This paper discusses the principles in developing and implementing a standard investigation tool for the coronial sector using the Falls Investigation Standard as an example, which has been in use for 12 months in the state of Victoria, Australia. It is hoped that using a standardised tool can balance the often conflicting tensions between medical and legal sectors by enabling an in-depth review of each issue while also strengthening the health system's capacity for self-regulation.

Isolated dissection of the coronary artery: a postmortem study of seven cases.

We present the clinical and postmortem findings in seven adults (four females and three males), who died with dissection of the coronary arteries. The median age was 56 years. Five of the coronary artery dissections (CADs) were spontaneous and two followed trauma: one a motor vehicle accident, the other occurred during angiography. Four cases died suddenly or within 30 minutes. Three had symptoms of at least 24 hours duration and, not unexpectedly, had histological evidence of myocardial infarction. Four dissections involved the left anterior descending coronary artery, two the right coronary artery and one a dominant circumflex artery. Histological examination of the dissected arteries in four cases demonstrated necrosis of the medial smooth muscle which was intimately related to intimal tears and/or an inflammatory reaction. From a review of the literature and this study of seven cases, we conclude that CAD is multifactorial in causation and has a wide spectrum of clinical presentations. Presently the role of coronary vasospasm and prior trauma appears underestimated, and in many cases of CAD the nature of the primary initiating event remains open to speculation.

Issues in child homicides: 11 cases.

For a variety of reasons, child homicides are the most difficult cases for forensic pathologists. For example, the events are usually not witnessed, accidental explanations are offered, often there is more than one carer spanning the period over which the injuries might have occurred and there can be conflicting opinions between the various medical specialities. Eleven cases of fatal child abuse are presented to illustrate and briefly discuss particular difficulties. Reference is also made to interaction with the legal process and parallel difficulties the law has with fatal child abuse.

Unacceptably high site variability in postmortem blood alcohol analysis.

Blood alcohol concentration is a frequently requested test in forensic pathology. The variability of this value was studied by measuring the blood alcohol concentration from six sites in nine subjects at necropsy in whom alcohol was the implicated cause of death. There were small consistent differences in the blood alcohol concentrations between the sites in the nine subjects (p < 0.04). Calculation of the mean blood:vitreous humour alcohol concentration ratio (B:V ratio) showed that vitreous humour alcohol concentration most closely reflected the concentration at the femoral vein (B:V ratio = 0.94, r = 0.98), which is considered the optimal site for blood alcohol measurement. The correlation of left heart blood with femoral blood was lower compared with the other sites. There is a potential for an unacceptably large variation in the postmortem measurement of blood alcohol within each subject.

Digital 3D image reconstruction of ventriculocapillary communication as revealed in one case after transmyocardial laser revascularization.

TMR (Transmyocardial Laserrevascularization) was performed on the partially dyskinetic left ventricular anterior wall with stenotic coronary blood supply in a 61 year old woman with a history of angina and myocardial infarction. As an ischemic aneurysm developed in the anteroapical region of the TMR treated area, it became clear that TMR did not provide a substitute for coronary blood supply in this very heart region. The aneurysm was removed surgically 7 months after TMR and showed histopathologic features of an acute aneurysm. Three-dimensional image analysis helped prove the presence of linear tracks through several serial sections which were not easily visible in routine histology sections. Also, three-dimensional vessel reconstruction showed a connection between a small endocardial pit on one serial section with the capillary network in the adjacent serial sections. The results should not be generalized, as currently aneurysmectomy is an end point not reached by the majority of TMR-treated patients.

Continuing education programme - Victorian Institute of Forensic Medicine.

With the increasing requirement of the courts for forensic experts to engage in ongoing education, a continuing education programme (CEP) was developed in the field of clinical forensic medicine at the Victorian Institute of Forensic Medicine in 1996. This programme has been described and was initially established to provide a means of education for the contracted forensic medical officers who provide forensic services to the police via the Institute throughout the State of Victoria. Owing to the sparsity of the population and the considerable distances between forensic practitioners, the CEP was designed to cater for individuals who are working alone: in effect, a distance education programme. Forensic pathologists expressed interest in the programme and it was subsequently modified to include forensic pathology cases. Currently, the programme caters for both clinicians and pathologists, and takes the form of four to five cases with related questions which are circulated several times per year. The cases include a mixture of both challenging and ordinary procedural types that may present to practitioners working in either clinical forensic medicine or forensic pathology, or both. The areas covered include: * injury interpretation * procedural matters in relation to adult and child sexual and physical assault * pharmacology/toxicology interpretation of findings * medico-legal issues (e.g. confidentiality, consent, etc.) * issues relating to alcohol and drugs * traffic medicine * clinical and legal aspects of sudden natural death * suspicious deaths * suicide * interpretation of findings at autopsy * fitness for interview * fitness to plead * psychiatric issues * general clinical medical issues. The presentation of each case includes relevant and appropriate details/findings and may include photographs. A series of questions follow which are answered in either short answer or multiple-choice format. The answers are returned and are correlated by a review panel of forensic physicians and pathologists, and a commentary with the response outcomes is distributed to all those involved. This also includes pertinent references. The cases presented here and in subsequent issues are selected from this programme.

Homicide trends in the State of Victoria, Australia.

Limited data about homicide in Australia have been published. Data on homicide occurring in the state of Victoria, Australia, are presented. Since 1945 there has been a doubling of the population and an increase in the rate of homicide. The most common method of killing was shooting, and most homicide victims were known to their assailants. Male assailants far outnumber female assailants. Men are the most frequent victims, but female victims far outnumber female assailants. The data are compared with data on other Australian states and published data from other countries.

Homicide-suicide in Victoria, Australia.

Thirty-nine incidents of homicide-suicide occurring in Victoria, Australia between 1985 and 1989 were examined. In 33 cases the assailants were men. The victims were spouses or women living in a de facto marriage. The majority of the victims were shot, and this was also the most frequent method of suicide. Breakdown in a relationship was the most frequent reason for killing. Mental illness of the assailant accounted for the killing in approximately 20% of cases. Physical ill health and financial stress were identified as important associative factors, particularly in the elderly. The pattern of homicide-suicide in Victoria is similar to that observed in other jurisdictions and represents an important and distinct subgroup of homicide.

Sudden death and benzodiazepines.

A study of 16 deaths associated with toxic concentrations of benzodiazepines during the period of 5 years leading up to July 1994 is presented. Cases where other drugs, including ethanol, had contributed to the death were excluded. All cases were subject to a full macroscopic and microscopic examination by pathologists, and all cases were subject to a full toxicological work-up. Preexisting natural disease was a feature of 11 cases. In the remaining five cases, death was caused solely by benzodiazepines. There were 14 suicides. Nitrazepam and temazepam were the most prevalent drugs detected, followed by oxazepam and flunitrazepam. Minimum toxic femoral blood concentrations of 7-aminonitrazepam, 7-aminoflunitrazepam, and oxazepam were estimated as 0.5, 0.2, and 2 mg/L, respectively. Relating these deaths to prescription rates in Victoria suggest that flunitrazepam may be inherently more toxic if misused than other benzodiazepines currently available on the Australian market.