Medical and Legal Uncertainties and Controversies in "Shaken Baby Syndrome" or Infant "Abusive Head Trauma"

Uncertainties and controversies surround "shaken baby syndrome" or infant "abusive head trauma". We explore Vinaccia v The Queen (2022) 70 VR 36; [2022] VSCA 107 and other selected cases from Australia, the United Kingdom and the United States. On expert opinion alone, a "triad" of clinical signs (severe retinal haemorrhages, subdural haematoma and encephalopathy) is dogmatically attributed diagnostically to severe deliberate shaking with or without head trauma. However, the evidence for this mechanism is of the lowest scientific level and of low to very low quality and therefore unreliable. Consequently, expert opinion should not determine legal outcomes in prosecuted cases. Expert witnesses should reveal the basis of their opinions and the uncertainties and controversies of the diagnosis. Further, the reliability of admissions of guilt while in custody should be considered cautiously. We suggest abandonment of the inherently inculpatory diagnostic terms "shaken baby syndrome" and "abusive head trauma" and their appropriate replacement with "infantile retinodural haemorrhage".

Trauma-Focused Mitigation Testimony in Capital Sentencing Hearings

When capital trials of convicted defendants reach the sentencing phase, forensic mental health experts often testify as part of mitigation evidence. Three aspects of such testimony hold particular promise. First, developmental traumas in the lives of the defendants are especially well conceptualized in terms of complex posttraumatic stress disorder, as described in the ICD-11. Second, Cunningham's framework, which critically examines the impact of harmful and protective factors over the course of a defendant's development, allows for an examination of moral culpability apart from legal culpability. Third, specific training on trauma and its effects on personality and psychopathology allows forensic mental health professionals to more skillfully complete trauma mitigation evaluations.

Navigating the Regulatory Landscape to Develop Pediatric Oncology Drugs: Expert Opinion Recommendations

Regulatory changes have been enacted in the United States (US) and European Union (EU) to encourage the development of new treatments for pediatric cancer. Here, we review some of the factors that have hampered the development of pediatric cancer treatments and provide a comparison of the US and EU regulations implemented to address this clinical need. We then provide some recommendations for each stage of the oncology drug development pathway to help researchers maximize their chance of successful drug development while complying with regulations. A key recommendation is the engagement of key stakeholders such as regulatory authorities, pediatric oncologists, academic researchers, patient advocacy groups, and a Pediatric Expert Group early in the drug development process. During drug target selection, sponsors are encouraged to consult the Food and Drug Administration (FDA), European Medicines Agency (EMA), and the FDA target list, in addition to relevant US and European consortia that have been established to characterize and prioritize oncology drug targets. Sponsors also need to carefully consider the resourcing requirements for preclinical testing, which include ensuring appropriate access to the most relevant databases, clinical samples, and preclinical models (cell lines and animal models). During clinical development, sponsors can account for the pharmacodynamic (PD)/pharmacokinetic (PK) considerations specific to a pediatric population by developing pediatric formulations, selecting suitable PD endpoints, and employing sparse PK sampling or modeling/simulation of drug exposures where appropriate. Additional clinical considerations include the specific design of the clinical trial, the potential inclusion of children in adult trials, and the value of cooperative group trials.

Mock jurors' evaluation of firearm examiner testimony

OBJECTIVES

Firearms experts traditionally have testified that a weapon leaves "unique" toolmarks, so bullets or cartridge casings can be visually examined and conclusively matched to a particular firearm. Recently, due to scientific critiques, Department of Justice policy, and judges' rulings, firearms experts have tempered their conclusions. In two experiments, we tested whether this ostensibly more cautious language has its intended effect on jurors (Experiment 1), and whether cross-examination impacts jurors' perception of firearm testimony (Experiment 2).

HYPOTHESES

Four hypotheses were tested. First, jurors will accord significant weight to firearm testimony that declares a "match" compared to testimony that does not (Experiments 1 and 2). Second, variations to "match" language will not affect guilty verdicts (Experiment 1). Third, only the most cautious language ("cannot exclude the gun") would lower guilty verdicts (Experiment 1). Fourth, cross-examination will reduce guilty verdicts depending on specific language used (Experiment 2).

METHOD

In two preregistered, high-powered experiments with 200 mock jurors per cell, participants recruited from Qualtrics Panels were presented with a criminal case containing firearms evidence, which varied the wording of the examiner's conclusion and whether cross-examination was present. These variations include conclusion language used by practitioners, language advised by government organizations, and language required by judges in several cases. Participants gave a verdict, rated the evidence and expert in all conditions.

RESULTS

Guilty verdicts significantly increased when a match was declared compared to when a match was not declared. Variation in conclusion language did not affect guilty verdicts nor did it affect jurors' estimates of the likelihood the defendant's gun fired the bullet recovered at the crime scene. In contrast, however, a more cautious conclusion that an examiner "cannot exclude the defendant's gun" did significantly reduce guilty verdicts and likelihood estimates alike. The presence of cross-examination did not affect these findings.

CONCLUSION

Apart from the most limited language ("cannot exclude the defendant's gun"), judicial intervention to limit firearms conclusion language is not likely to produce its intended effect. Moreover, cross-examination does not appear to affect perceptions or individual juror verdicts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Forensic mental telehealth assessment (FMTA) in the context of COVID-19

Due to the present COVID-19 pandemic, forensic mental telehealth assessment (FMTA) is an increasingly utilized means of conducting court-sanctioned psychiatric and psychological evaluations. FMTA is not a novel development, and studies have been published during the past two decades that opine on the positive and negative implications of conducting testing and interview procedures online, in forensic and traditionally clinical matters alike. The present article examines prospects for eventual legal challenges to FMTA, describes considerations for conducting FMTA in both institutional and residential settings, and concludes that FMTA is now-due to predicted accommodations on the part of courts, attorneys, institutions, and professional guilds-a permanent part of the forensic evaluation landscape, even once the present COVID-19 pandemic has subsided.

A balanced opinion? Considering the role of the external clinical advisor in ACC processes

The role of the external clinical advisor is critical to the adjudication of complex claims in the processes of the Accident Compensation Corporation (ACC). This is particularly true of claims for treatment injury that occur during birth, which are often very complicated. In most cases external clinical advisors are non-treating doctors, whose opinion strongly guides the hand of ACC. This viewpoint considers the impact of the role of the external clinical advisor by using extracts from an external clinical advisor's report to show how a power imbalance can be enacted in ACC decision making processes. Also considered are the way that the normal checks and balances in the system, particularly those provided by the Health & Disability Commissioner, are bypassed in most cases. Finally, a recommendation is made to potential external clinical advisors to precisely following the standards set by the Medical Council in all cases when writing reports for ACC.

‘Munchausen's syndrome by proxy’ or a ‘miscarriage of justice’? An initial application of functional neuroimaging to the question of guilt versus innocence

‘Munchausen's syndrome by proxy’ characteristically describes women alleged to have fabricated or induced illnesses in children under their care, purportedly to attract attention. Where conclusive evidence exists the condition's aetiology remains speculative, where such evidence is lacking diagnosis hinges upon denial of wrong-doing (conduct also compatible with innocence). How might investigators obtain objective evidence of guilt or innocence? Here, we examine the case of a woman convicted of poisoning a child. She served a prison sentence but continues to profess her innocence. Using a modified fMRI protocol (previously published in 2001) we scanned the subject while she affirmed her account of events and that of her accusers. We hypothesized that she would exhibit longer response times in association with greater activation of ventrolateral prefrontal and anterior cingulate cortices when endorsing those statements she believed to be false (i.e., when she ‘lied’). The subject was scanned 4 times at 3 Tesla. Results revealed significantly longer response times and relatively greater activation of ventrolateral prefrontal and anterior cingulate cortices when she endorsed her accusers' version of events. Hence, while we have not ‘proven’ that this subject is innocent, we demonstrate that her behavioural and functional anatomical parameters behave as if she were.

Psychological impediments to marriage - forensic and psychiatric opinions. Part II

Episcopal courts adjudicate in proceedings for declaring a marriage void and in these cases psychiatrists and psychologists are appointed as experts. Expert judgment requires the expert to follow a specific substantive approach when preparing the expertise, as well as knowledge of canon legal provisions. Canon law makes validity of a relationship dependent on fulfilment of premises of a valid marriage at the time of the marriage, thus accepting the possibility of an invalid marriage. The so-called consensual and indirectly mental incapacity to marry is dealt with in canon 1,095, which says that the following are incapable of contracting marriage: (1) those who lack the sufficient use of reason; (2) those who suffer from a grave defect of discretion of judgment concerning the essential matrimonial rights and duties mutually to be handed over and accepted; and (3) those who are not able to assume the essential obligations of marriage for causes of a psychic nature. Episcopal courts use terminology that is not found in psychiatry or clinical psychology. However, specific psychopathological conditions stand behind specific formulations in the Code, and they should be taken into account by experts in their analyzes. In proceedings before common courts, only mental illness and mental retardation are taken into account, and no specific disorders are mentioned in Church legislation, which means that experts must consider a wide range of mental dysfunctions in their assessments.

Variations in reliability and validity do not influence judge, attorney, and mock juror decisions about psychological expert evidence

OBJECTIVE

We tested whether the reliability and validity of psychological testing underlying an expert's opinion influenced judgments made by judges, attorneys, and mock jurors.

HYPOTHESES

We predicted that the participants would judge the expert's evidence more positively when it had high validity and high reliability.

METHOD

In Experiment 1, judges (N = 111) and attorneys (N = 95) read a summary of case facts and proffer of expert testimony on the intelligence of a litigant. The psychological testing varied in scientific quality; either there was (a) blind administration (i.e., the psychologist did not have an expectation for the test result) of a highly reliable test, (b) nonblind administration (i.e., the psychologist did have an expectation for the test result) of a highly reliable test, or (c) blind administration of a test with low reliability. In a trial simulation (Experiment 2), we varied the scientific quality of the intelligence test and whether the cross-examination addressed the scientific quality of the test.

RESULTS

The variations in scientific quality did not influence judges' admissibility decisions nor their ratings of scientific quality nor did it influence attorneys' decisions about whether to move to exclude the evidence. Attorneys' ratings of scientific quality were sensitive to variations in reliability but not the testing conditions. Scientifically informed cross-examinations did not help mock jurors (N = 192) evaluate the validity or the reliability of a psychological test.

CONCLUSION

Cross-examination was an ineffective method for educating jurors about problems associated with nonblind testing and reliability, which highlights the importance of training judges to evaluate the quality of expert evidence. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Interpreting Evidence of Torture

The Istanbul Protocol provides a scheme for giving evidence of signs of torture. This scheme does not conform with the principles of logical inference, revolving as it does round the concept of 'consistency'. The shortcomings of the Protocol are explained using the evidence given in the recent case of KV(Sri Lanka) and the logical approach to such evidence explained.

No Docs of All Trades: Ruling Reinforces Expert Witness Reforms

Before Texas' landmark liability reforms passed in 2003, gray areas in the law often led to serious green for people who sued physicians.

Lessons from Canadian Courts for All Expert Witnesses

Expert witnesses have a special place in court, bringing their knowledge and skills in the form of opinion evidence to educate the court. This allows the fact-finder to make legal decisions more effectively. Although experts are often allowed a role in civil and criminal matters, this brings certain risks to the court process. Admissibility of expert witness testimony in Canada has generally paralleled American law, including the standards enunciated in Daubert v Merrell Dow Pharmaceutical, Inc. (1993). Recently, there has been a series of decisions in Canadian law that has focused on the role of the expert witness in the court. Although only having precedence in Canada, these cases highlight important legal principles that all expert witnesses must navigate, regardless of their jurisdiction. We review these significant cases to assist forensic psychiatrists in recognizing and professionally navigating potential pitfalls in giving expert opinions.

Unfitness to plead in England and Wales: Historical development and contemporary dilemmas

Fitness to plead refers to a criminal defendant’s ability to participate at trial. The purpose of fitness-to-plead laws is to protect the rights of vulnerable individuals who are unable to defend themselves in court and to preserve natural justice in the legal system while balancing the needs to see justice served and protection of the public. Early legal systems treated mentally disordered defendants with leniency, but over time those found unfit to plead have been subjected to indefinite incarceration, breaching their right to liberty while protecting their right to a fair trial. Conversely, the threshold for being found unfit is high, and there are concerns that many unfit defendants are being unfairly subjected to trial. The approaches to balancing the competing demands have changed over time and have led to confusing and contradictory practices. In order to understand better how and why the current problems have come to exist, this paper analyses the historical development of the legal framework for fitness to plead from Medieval England to the turn of the 21st century. It isolates core dilemmas: (a) what the normative standard of fitness to plead is and whether the current test for determining fitness adequately reflects this standard; (b) whether fitness to plead should be disability neutral or whether unfitness requires the presence of a psychiatric diagnosis; and (c) how the courts should deal with those found unfit to plead, including insuring against the deprivation of liberty of innocents while ensuring the public are adequately protected.

The Physician as Expert Witness

Any physician who has authored an Independent Medical Evaluation or medical record review can and should anticipate being called as an expert witness (EW). Litigants rely on EW testimony in most civil cases. The most common areas in which EWs participate and provide opinions and testimony are workers' compensation, personal injury, and medical malpractice. This report will become part of the discovery process, the process by which a party to a lawsuit can obtain information from another party or other entities involved in the lawsuit.

Life Expectancy Expert Reports: Common Mistakes and Appropriate Process

Life expectancy expertise must comply with court-mandated evidentiary standards. A proper opinion should abide by 3 principles; it should be generated by a qualified expert who applies proper methods to appropriate facts. Several common mistakes can make opinions unsuitable for admission into testimony by straying from 1 or more of these 3 principles. Examining life expectancy opinions in light of these principles allows consumers of life expectancy expertise to evaluate the quality of the opinions proffered.

Clinician testimony in suicide litigation: A cause to be uneasy

This is an illustrative article rather than a research study. We offer opinions and recommendations about what we view as unfortunate clinician testimony in suicide-related malpractice cases, testimony that - inadvertently or not - supports or encourages inadequate care of suicidal patients. The principles apply to both psychiatrists and non-psychiatrists, although the former appear more often in our work. We particularly consider the roles and testimony, in court or at deposition, of psychiatrists, whether as defendants, expert witnesses, or fact witnesses. We cite examples of what we view as poor, disingenuous, dishonest and even dangerous testimony that we believe moves the profession toward unsafe patient care. The examples illustrate what we (and sometimes others) describe as normalization of deviance, pre-suit puffery, self-serving defendant testimony, expert pride supplanting testimonial responsibility, expert arrogance, expert parroting of attorney suggestions, witness ignorance and avoiding facts, unconscious expert bias, inexperience thwarting justice, misleading use of terms such as "predictability," and expert witnesses who lack the direct-care experience that jurisdictions often require in order to opine about defendant clinicians' day-to-day patient care. The examples often reveal concerns beyond the category chosen, and should not be expected to convey all of the facts of a particular case.

Applying statistics to the gatekeeping of expert evidence: Introducing the Structured Statistical Judgement (SSJ)

Daubert required judges to base their decisions about the admissibility of expert witness testimony in large part on the reliability and validity of empirical observations. Because judges have a wide array of duties and may not be equipped to understand the complexities of statistical analysis, some jurists have recommended that court-appointed experts assist judges in their gatekeeping function. To assist such experts in scrutinizing empirical papers, we propose a Structured Statistical Judgement (SSJ) that takes advantage of advances in the various statistical methods - such as effect sizes that adjust for error - which have allowed researchers to report increasingly more reliable and valid observations. We also include supplementary materials that court-appointed experts can use both as a codebook to operationalize the SSJ and as a quick reference that will aid consultation with judges. An initial application of the SSJ examined all 93 empirical articles published in Psychology, Public Policy, and Law and Law and Human Behavior in 2015 and resulted in excellent interrater reliability (π = 0.83; π = 0.95; π = 0.97), at the same time it indicated that a majority of the articles fail to include the comprehensive and transparent statistical analysis that would be most useful to courts.

Breaking Up Is Hard to Do: Physicians Can Get Subpoenaed in Divorce Cases

Physicians subpoenaed to participate in a divorce case, whether to testify or simply to supply medical records to the court, could find themselves at the center of an acrimonious split. There are certain things they should know.

Mild traumatic brain injury: Is DTI ready for the courtroom?

Important advances in neuroscience and neuroimaging have revolutionized our understanding of the human brain. Many of these advances provide new evidence regarding compensable injuries that have been used to support changes in legal policy. For example, we now know that regions of the brain involved in decision making continue to develop into the mid-20s, and this information weighs heavily in determining that execution or automatic sentence of life without the possibility of parole for someone younger than 18 years old, at the time of the crime, violates the 8th Amendment prohibition against "cruel and unusual punishment." The probative value of other testimony regarding neuroimaging, however, is less clear, particularly for mild traumatic brain injury (mTBI), also known as concussion. There is nonetheless some evidence that new imaging technologies, most notably diffusion tensor imaging (DTI), may be useful in detecting mTBI. More specifically, DTI is sensitive to detecting diffuse axonal brain injuries in white matter, the most common brain injury in mTBI. DTI is, in fact, the most promising technique available today for such injuries and it is beginning to be used clinically, although it remains largely within the purview of research. Its probative value is also not clear as it may be both prejudicial and misleading given that standardization is not yet established for use in either the clinic or the courtroom, and thus it may be premature for use in either. There are also concerns with the methods and analyses that have been used to provide quantitative evidence in legal cases. It is within this context that we provide a commentary on the use of neuroimaging in the courtroom, most particularly DTI, and the admissibility of evidence, as well as the definition and role of expert testimony. While there is a great deal of evidence demonstrating cognitive impairments in attention, processing speed, memory, and concentration from neuropsychological testing following mTBI, we focus here on the more recent introduction of DTI imaging in the courtroom. We also review definitions of mTBI followed by admissibility standards for scientific evidence in the courtroom, including Daubert criteria and two subsequent cases that comprise the so-called Daubert trilogy rulings on the admissibility of expert testimony. This is followed by a brief review of neuroimaging techniques available today, the latter with an emphasis on DTI and its application to mTBI. We then review some of the court rulings on the use of DTI. We end by highlighting the importance of neuroimaging in providing a new window on the brain, while cautioning against the premature use of new advances in imaging in the courtroom before standards are established in the clinical arena, which are informed by research. We also discuss further what is needed to reach a tipping point where such advances will provide important and meaningful data with respect to their probative value.

Legal Hearings During Psychiatry Residency

American general psychiatry residents are significantly involved in legal hearings related to mental health. Training to become a psychiatrist involves considerable exposure to medicolegal matters, and psychiatry residents frequently participate in high-stakes legal hearings concerning their patients. Although psychiatry residents are physicians, residents are also trainees who may lack full medical licensure, board certification, or basic preparation to testify in legal settings. Legal hearings are important educational experiences for psychiatrists-in-training, but these proceedings can upend traditional patient-doctor relationships and pose ethics challenges to trainees. In this article, I examine ways in which residency programs can prepare budding psychiatrists for legal testimony. This is an overlooked topic deserving more attention, since the participation of physicians in training in legal hearings carries profound implications for mental health care in the United States.

Response to Disclosure as an Indicator of Competence to Stand Trial

Ethics guidelines recommend that forensic mental health professionals begin in-person assessments by explaining the nature and purpose of the examination. To learn whether evaluees have understood and can give consent, forensic practitioners may ask evaluees to paraphrase the explanation. This article explores how a forensic evaluee's disclosure response (DR) reveals substantive information relevant to the purposes of a forensic examination. We examined archival data from 255 reports on competence to stand trial (CST) that a Midwest public sector hospital had previously submitted to courts. We classified each evaluee's DR at one of three levels: DR = yes (accurate paraphrasing), DR = no (inability to paraphrase or provide a relevant response), or DR = other (an intermediate level implying a less-than-accurate response). None of the 28 DR = no evaluees was CST, and only 7 (17%) of the 48 DR = other evaluees were CST. Thus, a CST evaluee who cannot paraphrase an examiner's explanation is likely to be incompetent to stand trial, and an examiner would need to adduce a strong argument to support any opinion to the contrary.

Mental state at time of offense in the hot tub: An empirical examination of concurrent expert testimony in an insanity case

The role of experts and their presentation of testimony in insanity cases remain controversial. In order to decrease possible expert bias associated with this testimony, a number of different alternatives to adversarial presentation have been suggested. Two such alternatives are the use of court-appointed experts and the use of concurrent testimony (or "hot-tubbing"), in which opposing experts provide testimony concurrently and converse with each other directly. An experiment using a sample of venire jurors (n = 150) tested the effect of these alternatives. Results indicate that participants' pre-existing attitudes towards the insanity defense had significant effects on their comprehension of expert testimony, their evaluations of the two opposing experts, and their eventual verdicts, over and above the presentation format (i.e., concurrent vs. traditional testimony) or the use of court-appointed experts (vs. traditional adversarial experts). When concurrent testimony was presented, defense-favoring experts were perceived by jurors as more credible than their traditional counterparts, though comprehension of the testimony did not increase; nor did the presentation format or the affiliation of the experts affect verdicts. The legal and policy implications of the incorporation of the hot-tubbing procedure to US courts are discussed.

Medical evidence and proof of cause of death in Nigerian courts

Medical evidence has continued to be given and evaluated in Nigerian courts since Nigeria's independence from Britain. The attitudes of the courts have been largely varied against a background of the individual judge's appreciation of forensic science and who should be considered an expert witness. The prosecution and defence lawyers equally display limited knowledge of forensic science. This paper reviews some of the decided cases, the reasons for the verdicts, forensic concerns and recommendations for the improvement of the criminal justice system. There is need to improve the knowledge base of the bar and the bench.

Using Technology to Improve the Objectivity of Criminal Responsibility Evaluations

Criminal responsibility (or insanity) evaluations require forensic clinicians to reconstruct a defendant's decision-making abilities, behavioral control, and emotional state at the time of the criminal act. Forensic evaluators are ultimately tasked to evaluate whether an individual had the capacity to understand right from wrong, and in some jurisdictions, determine whether the defendant lacked substantial capacity to conform his behavior to the requirements of the law as a result of a threshold condition (e.g., mental illness). Insanity evaluations are inherently complex, because they require the clinician to determine someone's mental state at some point in the past (weeks, months, or even years). Recent research on insanity evaluations underscores significant problems with the reliability and validity of these evaluations. However, technological advances including social media (e.g., Facebook and Twitter), mandating that law enforcement videotape interrogations, and the use of body and dashboard cameras can aid clinicians in improving the precision and quality of insanity evaluations. This article discusses practical guidelines and ethics-related concerns regarding the use of technology to improve the objectivity of criminal responsibility evaluations.

The expert and the foreigner: Reflections of forensic transcultural psychopathology on a total of 86 reports by experts on criminal liability

In recent times Italy has been experiencing massive migration flows, therefore the attention on the issue of crimes committed by foreigners is increasing. But within trials, in the evaluation of criminal liability of foreigners, how do experts deal with them? Do the performed evaluations take cultural diversity into account? The present study took origin from these questions and examined a total of 86 reports by experts on criminal liability of foreign persons (16 females and 70 males). Examinees have been declared indictable in 31 cases (36%), totally mentally ill in 40 cases (45%) and with diminished liability in 15 cases (17%); when liability was excluded, examinees were diagnosed in 11 cases with mood disorders, in 23 cases with personality disorders, in 4 cases with adaptation disorders and post-traumatic stress disorder and in 10 cases with different diagnoses (in some cases more than one diagnosis was present). None of the reports used the section of the DSM concerning "cultural framing". Tests were used in 48 surveys (56% of cases), with more tests for each examinee, for a total of 39 Rorschach, 14 Raven test, 8 Minnesota Multiphasic Personality Inventory - MMPI - 4 Wechsler Adult Intelligence Scale - WAIS - level test, 8 Thematic Apperception test. When subjects were diagnosed with mental disorder and with diminished liability, 42 (79%) were also socially dangerous. Results highlight the importance of the relationship between the expert and the foreigner. Many factors ought to be critically considered by experts dealing with foreigners, like cultural awareness, knowledge of verbal communication, critical consideration of meanings and diagnosis, knowledge of the foreigners' personal story, presence of tests with inexact information and cultural fallacy.

Understanding Tattoos in Medicolegal Assessments

Tattoos have held different meanings throughout history, with particular significance in cultural, social, and clinical contexts. Psychiatrists have long been interested in understanding the relevance of the tattooed body in a clinical or forensic evaluation and in settling on interpretive models that hold reliable value. Some studies have indicated that tattoos may be associated with markers of high-risk behaviors, mental illness diagnosis, and personality disorders. We attempt to provide an updated and comprehensive guide for forensic evaluators, so they can incorporate the observation of tattoos into their assessments with a review of the scientific literature that supports the interpretations and places them in context. The association between tattoos and risk, mental health, or behavioral implications is not as clear or linear as one might initially imagine, and mental health professionals should have a sophisticated understanding of the practice.

[Handling of retrieved implants in orthopedic surgery : Results of a survey within the framework of the EndoCert initiative]

BACKGROUND

Although investigations of retrieved medical implants can provide valuable information about the cause of the revision, there is a lack of information, which could be avoided by consequent failure analyses. In the framework of the EndoCert certification system it is obligatory to record and report incidents.

OBJECTIVES

The present work examines how the willingness to report has developed in certified arthroplasty centers and which method of handling retrievals is preferred and actually used.

MATERIALS AND METHODS

On the basis of a questionnaire for handling retrievals, all 508 arthroplasty centers that were certified till June 1, 2016, were included (return rate = 97.2%).

RESULTS

A total of 93.3% of the centers have established an algorithm for handling of retrievals and 83.0% of the centers prefer to hand out the retrieval to the patient, while only 25.7% wish to store it in the center for research purposes. In the case of a potential incident as the cause of revision, centers prefer to forward the retrieval to damage analysis, whereby the centers act in different ways, depending on the case. An implant fracture is, e.g., considered a reportable event in most cases without temporal limitation. On the other hand, breakage or failure of surgical instruments is considered not to be reported in the case of more than half of the centers. In 2014 and 2015, approximately 71% of EPZs reported no incidents.

CONCLUSIONS

According to our survey, many certified arthroplasty centers are sensitized to careful handling of retrievals. The treatment of the explanted components is conducted in different ways. The assessment of whether an incident is to be reported shows large differences. In view of the relatively high number of revision surgeries, the number of reports to the authorities appears to be low.

[Analysis of final judgements in cases of medical negligence occurred in Ukraine]

OBJECTIVE

Introduction: The peculiarities of the disadvantages of providing medical care in Ukraine are not well-known abroad. The aim: To study the peculiarities of court decisions in cases of unfavorable consequences of medical activity.

PATIENTS AND METHODS

Materials and methods: The article analyzes the official data of the General Prosecutor's Office of Ukraine and the website of court decisions regarding criminal cases against medical practitioners.

RESULTS

Review: Approximately 600 cases of alleged medical malpractice cases are registered annually in Ukraine. Only less than one percent of them are brought to the court. The guilt of medical practitioners was proven in majority (80,8%) of court decisions. Acquittals of defendants were pronounced in 5,9% of court verdicts. Obstetrics and gynecology, surgery, internal medicine and anesthesiology are in the top of high-risk medical specialties.

CONCLUSION

Conclusions: Majority of medical malpractice litigations are sued in Ukraine baselessly. In cases of medical negligence majority of defendants are acquitted as usual.

Giving evidence in court

Richard Griffith, Senior Lecturer in Health Law at Swansea University, discusses the elements of effective evidence giving when appearing before a court or fitness to practise panel.

Review of serious events in cases of (suspected) child abuse and/or neglect: A RoSE by any other name?

Child abuse and neglect (CAN) cases presenting to health-services may be complex; when things go seriously wrong such as a child death or near miss, cases are reviewed and health-services and professionals subject to intense scrutiny. While there are a variety of mechanisms to review critical incidents in health-services no formal process for the review of cases where child protection is the primary concern exists in Australia. We aimed to develop a systematic process to review serious events in cases of suspected CAN across two health districts in Sydney, so that shared learnings could fuel system change. Drawing upon mapping, case review, literature findings and using quality improvement methodology, we developed a model named Review of Serious Events (RoSE), in suspected cases of CAN. The RoSE model has the key features of: being child focused; seeking to examine care over a period of time; using child protection staff as lead reviewers; involving health professionals/services in the review who have been involved with the child; and actioning systems change at local levels. The RoSE model was trialled through 2014-2015. Eight cases were reviewed using RoSE; cases were similar to those reviewed prior to having a model. Participant feedback from RoSE group processes was overwhelmingly positive; outputs were transparent and accessible to key stakeholders, there was mixed progress with implementation. The RoSE model is a serious case review process that is strongly child-focused, is both investigative and reflective, led by child protection experts; and can be adapted to other settings and systems.

[Expert Assessment of Traumatic Disc Herniations]

In numerous legal areas, expert assessments are needed to clarify the causality of herniated discs: Was the damage caused by an accident? The literature mentions specific requirements regarding the trauma mechanism as well as temporal criteria, which prescribe the causality test. These are essentially high-energy traumas with immediate functional impairments. Accident-related MRI examinations are of paramount importance in the expert assessment process to confirm the primary body harm. In examining the causality constituting liability, competitive causes must be assessed. Since the legal requirements of the causality test differ in civil and social law, legal norms need to be taken into account. We present a test scheme that supports the assessment process through entry, implementation and decision-making levels.

Peer review in forensic science

Peer review features prominently in the forensic sciences. Drawing on recent research and studies, this article examines different types of peer review, specifically: editorial peer review; peer review by the scientific community; technical and administrative review; and verification (and replication). The article reviews the different meanings of these quite disparate activities and their utility in relation to enhancing performance and reducing error. It explains how forensic practitioners should approach and use peer review, as well as how it should be described in expert reports and oral testimony. While peer review has considerable potential, and is a key component of modern quality management systems, its actual value in most forensic science settings has yet to be determined. In consequence, forensic practitioners should reflect on why they use specific review procedures and endeavour to make their actual practices and their potential value transparent to consumers; whether investigators, lawyers, jurors or judges. Claims that review increases the validity of a scientific technique or accuracy of opinions within a particular case should be avoided until empirical evidence is available to support such assertions.

Is the French criminal psychiatric assessment in crisis?

The criminal psychiatric assessment in France seems to be facing growing criticism related to disagreements between experts and, on the other hand, a lack of interest of psychiatrists for the assessment. We start by explaining the current framework of the criminal psychiatric assessment in France, which differs from the assessment used in English-speaking countries, where Roman law applies. Then, we will describe the disagreements through a literature review and two clinical vignettes. Finally, we will try to understand the causes of discrepancies between experts and the reasons for a supposed lack of interest of the psychiatrists for the expertise. For this, we conducted a survey among the psychiatric experts. We individually questioned experts on the discrepancies and on their awareness of the expertise. We found that 75% of the experts we surveyed had already faced the divergent opinion of a colleague. In addition, the experts were divided on their conclusions related to the fictional scenario we gave them for an a priori assessment (a person with schizophrenia who was accused of murder), particularly in the specific contexts that we submitted to them. The main cause of disagreement between experts was the various schools of thought that influence the psychiatric experts in the forensic discussion and, therefore, the conclusions of a case. Moreover, the experts believed that the decrease in the number of psychiatric experts could be attributed to the adverse financial situation of the assessment, the considerable workload required, and the extensive responsibility that falls on the expert. Calling on a team of forensic experts to perform assessments seems to be the first solution to this crisis. Furthermore, if the experts were better compensated for the assessments, more people would want to undertake this work.

[Giving medico-legal opinions in cases with suspicion of medical mistake.part 1. between medicine and justice.]

Creating medico-legal opinion is a sophisticated investigative, analytical, decision-making and creative process. Forensic medicine specialist in cooperation with clinical medicine consultants, on the basis of evidence analysis, which was gathered during procedures and contained in the acts has to create an objective and essential opinion. This opinion is a vital, very important and irreplaceable proof in every case. Judicial body consults with forensic medicine specialist or specialists if there are circumstances for settlement of which there is a need of classified informations - art. 193 of Penalty Code. Forensic medicine specialists face many difficulties which may have effect on quality, positiveness of opinion, compliance with the deadline, increasing expectancy of judicial body or sides. It is very difficult to find clinical specialists which except their clinical knowledge have basic knowledge about law, the role and duties of an court expert. In this article we discuss creating-opinion problems, role and position of court expert in confrontation with expectations of judicial body and the Justice with particular emphasis on medical mistakes and assessment of medical proceedings. We show the complexity of creating of medical opinions, especially these institutional.

[National and international aspects of the medico-legal examination of injured witnesses and defendants in criminal proceedings]

Depending on the type of offence, the medico-legal examination of victims of violence for the purpose of collecting evidence in criminal proceedings requires prompt physical examination of the victim, the exact description and, wherever possible, photographic documentation of the injuries and their forensically correct interpretation. Examination, documentation and assessment have to meet minimum standards. In addition it must be ensured that the examiner or expert has an independent organisational, administrative and financial status. An independent expert must not be an organisational part of the police force, the public prosecution and the court. Legal regulations have to make sure that the expert cannot be influenced "through official channels". His or her financial independence must make attempted bribery at least improbable. The independence of the expert is particularly important, if persons become victims of violence while they are under the custody of the state, especially the police, in prisons and after compulsory commitment to a psychiatric hospital.

[Matching bite marks using modeling wax plates]

Bite marks are rarely seen in forensic medical examinations. In most cases one can easily differentiate whether a bite mark is of human or animal origin due to the arched shape and crushed character of human bite marks. From a forensic point of view it is more interesting whether a dental imprint has been caused by an adult or a child, because children are often abused for a defensive statement. Two cases of bite injuries in children are presented. In the first case, a two-month-old infant was presented by pediatricians. The second case deals with a one-year-old boy who had allegedly been bitten several times by a two-year-old girl in a nursery school. A comparison could be performed between the bite mark impressions on the victim's skin (based on photographic documentation) and dental imprints of single teeth measuring the tooth width on the one hand and the intercanine distance on the other hand with the help of modeling wax plates. This procedure showed good correlations between the bite marks on the victim and the dental status of the biter. Especially for taking bite impressions on children, modeling wax plates are a simple, fast and cheap alternative to dental impression-taking.