The Journal of Forensics

Volume 27

Number 4

Winter 2016 THEegal JOURNAL OF Nurse Consulting

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10 37 NORTH AMERICA’S EVOLVING THE CONTINUING ENIGMA OF SUDDEN NURSING SPECIALTY UNEXPECTED INFANT DEATH By Sheila Early, RN, BScN Thomas Andrew, MD, FCAP, FAAP 16 48 THE ROLE OF THE FORENSIC SANE DEATH INVESTIGATION IN MARYLAND NURSE IN PEDIATRIC SEXUAL ASSAULT By Bruce Goldfarb, BS By Jennifer L. Orr, BSN, RN, CLNC 21 WORKING WITH DEFENSE 02 Manuscript Review Process By Cari Caruso, RN SANE-A 03 Article Submission Guidelines 25 04 From the President FORENSIC PSYCHIATRIC NURSING 05 From the Editor AND THE LNC By Rachel Regan Boersma, Ph.D., R.N. 06 Letters to the Editor 07 Test Your Screening Skills 31 08 Legal Eagle A LEGAL NURSE CONSULTANT AS DEATH EXAMINER By Melissa Becker, RN, BA, CFN

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 1 | PURPOSE American Association of The purpose of The Journal is to promote legal nurse consulting within the medicallegal community; Legal Nurse Consultants to provide novice and experienced legal nurse consultants (LNCs) with a quality professional 330 North Wabash Ave. publication; and to teach and inform LNCs about clinical practice, current legal issues, and Suite 2000 professional development. Chicago, IL 60611 877/402-2562 312/321-5177 MANUSCRIPT SUBMISSION Fax: 312/673-6655 E-mail: [email protected] The Journal accepts original articles, case studies, letters, and research. Query letters are welcomed Web site: www.aalnc.org but not required. Material must be original and never published before. A manuscript should be submitted with the understanding that it is not being sent to any other journal simultaneously. BOARD OF DIRECTORS Manuscripts should be addressed to [email protected]. Please see the next page for Information for President Authors before submitting. Susan Carleo, RN CAPA LNCC President-Elect MANUSCRIPT REVIEW PROCESS Debbie Pritts, RN LNCC We send all submissions blinded to peer reviewers and return their blinded suggestions to the Past President author. The final version may have minor editing for form and authors will have final approval before Varsha Desai, BSN RN CNLCP LNCC publication. Acceptance is based on the quality of the material and its importance to the audience. Secretary/Treasurer Kim Beladi, RN BSN LNCC The Journal of Legal Nurse Consulting is the official publication of the American Association of Directors at Large Legal Nurse Consultants (AALNC) and is a refereed journal. Journal articles express the authors’ Elizabeth Murray, BSN RN LNCC views only and are not necessarily the official policy of AALNC or the editors of the journal. The Laura Nissim, RN MS CNS LNCC Jennifer Phillips, BSN RN CWCP association reserves the right to accept, reject or alter all editorial and advertising material submitted LNCC for publication.

The content of this publication is for informational purposes only. Neither the Publisher nor THE JOURNAL OF LEGAL AALNC assumes any responsibility for any injury and/or damage to persons or property arising NURSE CONSULTING out of any claim, including but not limited to product liability and/or negligence, arising out of Editor the use, performance or operation of any methods, products, instructions, or ideas contained in Wendie A. Howland, MN, RN-BC, the material herein. The reader shall assume all risks in connection with his/her use of any of the CRRN, CCM, CNLCP, LNCP-C, LNCC information contained in this journal. Neither the Publisher nor AALNC shall be held responsible Editorial Committee For This Issue: for errors, omissions in medical information given nor liable for any special, consequential, Randall Clarke, BSN, RN or exemplary damages resulting, in whole or in part, from any reader’s use of or reliance on Tracy Coles, BSN, RN this material. Lauren Danahy BS RN BA CCM LNCC Cheryl Gatti, BSN RN LNCC CCRN-R The appearance of advertising in the The Journal of Legal Nurse Consulting does not constitute Stormy Green Wan, RN, BSHS, RNFA, a guarantee or endorsement of the quality or value of such product or of the claims made for it CLNC by its manufacturer. The fact that a product, service, or company is advertised in The Journal of James Hanus, BSN, RN, OCN, MHA Legal Nurse Consulting shall not be referred to by the manufacturer in collateral advertising. For Regina Jackson, RN, BS, CCM, LNCC advertising information, contact [email protected] or call 877/402-2562. Elizabeth Murray BSN RN LNCC Ann Peterson EdD, MSN, RN, FNP- Copyright ©2016 by the American Association of Legal Nurse Consultants. All rights reserved. BC, LN For permission to reprint articles or charts from this journal, please send a written request noting Lynn Sayre Visser MSN BS RN CEN CPEN CLN the title of the article, the year of publication, the volume number, and the page number to Deborah S. (Susie) White, BSN, RN, Permissions, Journal of Legal Nurse Consulting, 330 North Wabash Ave., Suite 2000, Chicago, IL LNCC 60611; JLNC@ aalnc.org. Permission to reprint will not be unreasonably withheld.

Journal of Legal Nurse Consulting (ISSN 2470-6248) is published digitally by the American Association STAFF of Legal Nurse Consultants, 330 North Wabash Ave., Suite 2000, Chicago, IL 60611, 877/402-2562. Members of the American Association of Legal Nurse Consultants receive a subscription to Journal Executive Director Kristin Dee of Legal Nurse Consulting as a benefit of membership. Subscriptions are available to non-members for $165 per year. Back issues are avaiable for free download for members at the Association website and $40 per copy for non-members subject to availability; prices are subject to change without notice. Back issues more than a year old can be obtained through the Cumulative Index to Nursing & Allied Health Literature (CINAHL). CINAHL’s customer service number is 818/409-8005. Address all subscriptions correspondence to Circulation Department, Journal of Legal Nurse Consulting, 330 North Wabash Ave., Suite 2000, Chicago, IL 60611. Include the old and new address on change requests and allow 6 weeks for the change.

| 2 | THE JOURNAL OF LEGAL NURSE CONSULTING ARTICLE SUBMISSION The Journal of Legal Nurse Consulting (JLNC), a refereed publication, is the official journal of the American Association of Legal Nurse Consultants (AALNC). We invite interested nurses and allied professionals to submit article queries or manuscripts that educate and inform our readership about current practice methods, professional development, and the promotion of legal nurse consulting within the medical-legal community. Manuscript submissions are peer-reviewed by professional LNCs with diverse professional backgrounds. The JLNC follows the ethical guidelines of COPE, the Committee on Publication Ethics, which may be reviewed at: http://publicationethics.org/resources/ code-conduct.

We particularly encourage first-time authors to submit manuscripts. The editor will provide writing and conceptual assistance as needed. Please follow this checklist for articles submitted for consideration.

INSTRUCTIONS FOR TEXT • Manuscript length: 1500 – 4000 words • Use Word© format only (.doc or .docx) • Submit only original manuscript not under consideration by other publications • Put title and page number in a header on each page (using the Header feature in Word) • Place author name, contact information, and article title on a separate title page, so author name can be blinded for peer review • Text: Use APA style (Publication Manual of the American Psychological Association, 6th edition) (https://owl.english.purdue.edu/owl/resource/560/01/) • Legal citations: Use The Bluebook: A Uniform System of Citation (15th ed.), Cambridge, MA: The Harvard Law Review Association • Live links are encouraged. Please include the full URL for each. Be careful that any automatic formatting does not break links and that they are all fully functional. • Note current retrieval date for all online references. • Include a 100-word abstract and keywords on the first page • Submit your article as an email attachment, with document title articlename.doc, e.g., wheelchairs.doc

INSTRUCTIONS FOR ART, FIGURES, TABLES, LINKS • All photos, figures, and artwork should be in JPG or PDF format (JPG preferred for photos). Line art should have a minimum resolution of 1000 dpi, halftone art (photos) a minimum of 300 dpi, and combination art (line/tone) a minimum of 500 dpi. • Each table, figure, photo, or art should be submitted as a separate file attachment, labeled to match its reference in text, with credits if needed (e.g., Table 1, Common nursing diagnoses in SCI; Figure 3, Time to endpoints by intervention, American Cancer Society, 2003)

INSTRUCTIONS FOR PERMISSIONS The author must accompany the submission with written release from: • Any recognizable identified facility or patient/client, for the use of their name or image • Any recognizable person in a photograph, for unrestricted use of the image • Any copyright holder, for copyrighted materials including illustrations, photographs, tables, etc. • All authors must disclose any relationship with facilities, institutions, organizations, or companies mentioned

GENERAL INFORMATION Acceptance will be based on the importance of the material for the audience and the quality of the material, and cannot be guaranteed. All accepted manuscripts are subject to editing, which may involve only minor changes of grammar, punctuation, paragraphing, etc. However, some editing may involve condensing or restructuring the narrative. Authors will be notified of extensive editing. Authors will approve the final revision for submission.

The author, not the Journal, is responsible for the views and conclusions of a published manuscript. The author will assign copyright to JLNC upon acceptance of the article. Permission for reprints or reproduction must be obtained from AALNC and will not be unreasonably withheld.

A Message from the President

Dear AALNC Members & JLNC readers, riting this message gives me the opportunity to remind everyone of the tremendous benefits of being an AALNC member. If you want to broaden your professional W network by building connections with other LNCs, expand your knowledge with con- Susan Carleo tinuing education resources, and grow your practice, now is the time! RN, CAPA, LNCC When you’re a member, you benefit from discounts on AALNC’s online resources, including President, AALNC educational webinars and our online bookstore, where you can find ourPrinciples and Practices of Legal Nurse Consulting. The AALNC’s updated legal nurse consulting course will be online in its entirety in March 2017, perfect for aspiring or new LNCs to expand their horizons and prepare for certification. When you become certified as a Legal Nurse Consultant Certified (LNCC), you assure your colleagues, clients, employers, and other medical legal professionals that you are knowledgeable, experienced, and committed to the specialty practice of legal nurse consulting.

When you’re listed in the LNC Locator database on the AALNC website at www.aalnc.org, you increase your visibility to potential clients and collaborators. AALNC members also benefit from discounts with: • AmWins Group Benefits Program: health and disability insurance • Elsevier ClinicalKey Access: online search tool • WordRake software: to edit all written reports and work products • Nurses Service Organization Professional Liability Insurance • VerdictSearch print publications for newsletters, books, binders, and indexes • LexisNexis CaseMap software: chronologies & attorney work products Join or renew, and take advantage of AALNC’s amazing benefits. Now is the time! Remember: “Your big opportunity may be right where you are now.” ~Napoleon Hill Sincerely,

Susan Carleo, RN, CAPA, LNCC President AALNC

| 4 | THE JOURNAL OF LEGAL NURSE CONSULTING FROM THE EDITOR

Editor’s Note

was in Chicago in September and happened to have a day free, so I put on my old Kevin Youki- lis Red Sox jersey and cap and went over to Wrigley Field to take in a ballgame. One of Boston’s Iformer pitchers started for the Cubbies; there was jubilation in the stands when the big W banner went up as they clinched their division. Soon thereafter Cubs and the Cleveland Wendie Howland Indians commenced one of the best Series MN, RN-BC, CRRN, ever (and both teams loaded with Red Sox CNLCP, LNCC talent, so we rooted for both sides at our Editor, JLNC house). Two days before Election Day, it came right down to the wire: a thrilling Game 7 at the end of an incredible set of circumstances, not the least of which being that the Cubs hadn’t won a World Series in 108 years, and Cleveland since 1948. As you can imagine, both sides’ fans were boisterous, passionate, and aching, just aching for victory, but also holding their breaths with anxiety, knowing that one team had to lose. The announcement came over the PA: “To honor America with a performance of our national anthem, we invite the fans to sing along as we welcome members of the string section of The Cleve- land Orchestra.” If you weren’t watching, you can see and hear people of all sizes, shapes, and colors, Cubs and Indians fans side by side, joining in, singing, and cheering lustily in unison at https://www. youtube.com/watch?v=81h_JvXKrq8. I recommend it. My first thought was that this was remarkable so close to the end of a dreadful election cycle. Here it was. This, THIS is what our country needed, for us to put acrimony on hold, if only for a few minutes to start, do something meaningful together, and celebrate our great good fortune to be here, because what we share is always so much more than what divides us. I want to see this at every game forever— the National Anthem sung not by a rock star or a celebrity, or even a cute kid, but the entire stadium, all of us. Well, we all know how the Series ended. It was by the closest of margins, just one run, in overtime, after a rain delay, with both teams giving it everything they had, and we wished it could have gone on forever. One team may have lost. But not baseball: baseball, sweet baseball, won. As I write this, our national elections have just finished. Our fellow citizens, and many citizens of other nations, await our nation’s future with the same kinds of anticipation and apprehension. Fortunately for us all, as a nation of laws we have a longstanding tradition of peaceful transition between governments. While some of us are elated and some of us crushed, it’s up to all of us to take a deep breath and do what we know is best: consider what we want for the well-being of the country, not just now, or for the next two or four years, but for everyone’s children and grandchil- dren. If we can all do that, even a little bit at a time, then no matter who wins an election on any given Tuesday, we all win.

Wendie A. Howland [email protected]

LACK OF VETTING “SANE” However, post conviction the defense violation: the Court found that 1) the SINKS CASE found out that not only was she not prosecution suppressed the evidence In this issue there are several references certified as a SANE nurse at the time of of the nurse’s lack of certification from the defense and 2) the evidence that to sexual assault cases. Recently I saw the trial, but also that the TX Board of the nurse presented was material to the a ruling out of the U.S. 10th Circuit Nursing previously found in 2007 that person’s conviction. Court of Appeals, where a SANE nurse she misrepresented herself as a certified (or that was what she claimed to be SANE nurse in a different case when So the prosecution is in trouble because on the stand) testified in a case in OK she stated she was “certified by the Texas they didn’t vet their star witness, and the and her testimony basically is what Attorney General’s office.” nurse is probably in trouble with both the jury used to convict the defendant. In this case the Court of Appeals grant- the Texas and OK boards of nursing. ed a writ of habeas corpus and ordered James Hanus, RN, BSN, OCN, MHA (Link at http://caselaw.findlaw.com/ the State of OK to “retry him within Clinical Appeals Specialist us-10th-circuit/1733655.html) a reasonable time,” due to a Brady JLNC Editorial Committee

STUDY: MEDICAL ERRORS THE THIRD BIGGEST CAUSE OF DEATH IN US This link will take you to an article describing this study. It also includes links to a series of search results for statistical data regarding deaths and outcomes from medical errors. http://tinyurl.com/gvja4nm David Dillard Temple University (215) 204 - 4584 [email protected]

CAUSES OF DEATH, US 2013 Based on the estimate, medical error is the 3rd most common cause of death in the US

All causes 2,597k Heart Disease Cancer Medical Error 611k 585k 251k

| 6 | THE JOURNAL OF LEGAL NURSE CONSULTING SCREENING SKILLS

Test Your Case Screening Skills

You’re an in-house LNC in a med-mal firm, and your secretary took these notes from phone calls and passed them along. You decide: reject, or investigate? Answers on page 35.

Test Your Case Screening Skills

Elizabeth Zorn, RN, BSN, LNCC

Case #1 Case #2

Intake 7/23/02: (39 yr old female). Sur- John Simon called re: his newborn son, tion. Mary’s care was taken over by gery on back by Dr. Brad Pitt on 4/9/01 Tom, born 5 weeks prematurely on Dr. Singer. John said that he and Mary at Mercy Hospital – he has since left 4/27/11. He was diagnosed at birth repeatedly asked for internal exams but for Glendale, MO. Four doctors since with Beckwith Wiedemann Syndrome Mary never had one during her whole surgery have looked at the x-rays and (BWS) - enlarged organs. His kidneys pregnancy. They returned to the office weekly to have the baby measured. Had diagnostic studies and told her that the are adult sized. Weighed 7 lbs. 7 oz.at 5-7 ultra sounds - why weren’t they problem was that he screwed into the 5 weeks early. He was delivered in an ambulance by a paramedic on the way told if there was an issue? They did main nerve of her leg. Recent surgery to Mercy Hospital. John found out that decline amnio. Found out that Mary was by Dr. Clooney at Park Ridge who the paramedic left the cord attached had a corrupted cervix (open the whole took the screw off. - not cut soon enough and that the pregnancy) - again, nobody told them. John & Mary complained for two days She was a factory worker at Emco, Inc - baby had stopped breathing twice in that the baby’s eyes were rolling to the has been out of work since 4/9/01. Still the ambulance (and not documented). back of his head - found out that was has weakness in the leg with numbness, Three days later the baby was trans- ferred to Children’s Hospital. an apnea issue brought on by low sugar. pain, foot turns out - Dr. Clooney told Beckwith Wiedemann can cause a per- her the nerve had been pinched off John and his wife Mary have many son to develop cancerous tumors on liver for some eight months and may have issues and questions. Mary’s OBGYN, and can cause sugar management issues. permanent consequences and may not Dr. Wall, retired just before the birth come back. without any warning or communica- Check your answers on page 35.4

A Case with Nursing and Medical Experts

E. Kenneth Snyder, JD, BSN Editor/Publisher Legal Eagle Eye Newsletter for the Nursing Profession

A recent case from the Court of Appeals of Texas showed how nursing and medical experts can work effectively together within their own spheres of expertise. The case was featured in the July 2016 issue of Legal Eagle Eye Newsletter for the Nursing Profession.*

GENERAL STANDARDS failed to meet the standard of care factual basis for the expert’s opinion FOR EXPERT OPINIONS IN and further testimony explaining the is insufficient or that the expert is not MALPRACTICE CASES cause-and-effect relationship between qualified to state the opinion that he or that failure and the harm alleged to have she has tried to give. Only two out of To make out a prima facie civil case of befallen the patient. three of these essential elements is not professional negligence by a physician, two-thirds of a case, it is nothing. nurse or other healthcare provider, the On the other side, the defendant plaintiff patient or deceased patient’s individual healthcare provider or NURSING VERSUS family must provide the court with institution may be able to defend expert testimony setting out the the case by showing that any one of MEDICAL EXPERTS applicable standard of care, specific the above essential elements of the As a general rule nurses can testify as evidence showing how the provider plaintiff ’s case is missing or that the to the standard of care for nurses, but

| 8 | THE JOURNAL OF LEGAL NURSE CONSULTING cate timely with the physicians and the patient’s neurological injury. It would A court will accept a physician as an have been wholly inappropriate for a expert on the standard of care for nurses nurse or even the family practice physician to try to testify as an expert on that if and only if the physician can show that highly technical question. he or she has sufficient expertise. THE PATIENT’S NURSING EXPERT The court said the opinion of the patient’s nursing expert, a nurse, would nurses cannot testify as to the standard finally told a hospitalist physician that carry the day for the patient as to the of care for physicians. Conversely, most the patient was complaining of numb- nursing standard of care, even if the physicians cannot testify as to the ness and tingling in her right leg, the first hospital’s objection to the family practice standard of care for nurses. A court such report by a nurse to a physician. physician as nursing expert was sustained will accept a physician as an expert on and his testimony was thrown out. the standard of care for nurses if and The morning after that a nurse found that the patient could not move her only if the physician can show that he The nurse testified a nurse has a funda- legs at all. Her breast cancer physician or she has sufficient expertise, perhaps mental responsibility to communicate examined her at 8:10 a.m. and ordered from experience supervising nurses in promptly with the physician as to sig- a “stat” MRI which was not done until the workplace or by teaching nurses in a nificant changes in the patient’s health 12:40 p.m. and not read until 1:42 p.m. hospital or educational context. status. Her review of the chart showed Surgery was started at 6:30 p.m. but a complete absence of documentation as As to the cause-and-effect relationship could not remove a blood clot from a to the weakness in the lower extremity linking nursing negligence to harm spinal hematoma which had rendered being brought to a physician’s attention suffered by the patient, a court will not the patient paraplegic. during the critical time from 9:30 p.m. accept a nurse as an expert, except per- the first evening until noon the next day. haps in the most straightforward cases, The court accepted expert testimony on behalf of the patient from a nurse and like a broken leg caused by a fall caused Again, the patient’s nursing expert a physician that the nurses violated the by failure of the nurses to assess the was not qualified and did not attempt standard of care by failing to commu- patient and implement fall precautions. improperly to state an opinion that nicate promptly the weakness in the patient’s lower extremities to at least one the patient was harmed by the delay in THE FACTS OF THE CASE of the patient’s physicians or physician’s coming to grips with the full extent of A patient who had recently had breast assistants. The court further faulted the the problem, performing an MRI and cancer surgery was taken to the hos- nurses for not expediting the “stat” MRI. starting a surgical intervention. That pital by ambulance for severe back was a critically important fact for the pain radiating down her right leg. The The physician is board certified in patient’s case that could not be proven emergency physician ordered pain med- family practice, emergency medicine and even with the family practice physician’s ication, an antibiotic and an abdominal geriatrics. His medical board certifi- opinion, but only with an opinion from a and pelvic CT which showed bladder cations, however, did not qualify him neurosurgeon. Of course, the neurosur- and bowel distention. as an expert on the standard of care geon, by the same token, would not have for nurses. Instead, the court accept- been accepted by the court as an expert Around 9:30 p.m. that evening the ed him as an expert because he had on the nursing standard of care. patient’s nurse became aware that worked with nurses caring for patients the patient had started to experience in hospitals since 1973 and had taught a REFERENCES weakness in her lower extremities, but college course for nurses which included the nurse did not communicate that a segment on the standard of care. *Communication With Physician: Court significant change in her health status to Sees Nursing Negligence, Legal Eagle Eye The patient also brought in a second Newsletter for the Nursing Profession (24)7 any of the physicians. Jul. ’16 (page 6). www.nursinglaw.com/ physician, a neurosurgeon, to estab- jul16hd41q.htm See Tenet Hospitals v. De The next morning the patient still had lish the essential cause-and-effect link La Rosa, No. 08-13-00290-CV, 2016 WL severe back pain. Around noon a nurse between the nurses’ failure to communi- 1696867 (Tex. App., June 8, 2016).

North America’s Evolving Nursing Specialty

Sheila Early RN, BScN

orensic nursing as a nursing spe- violence in the mid-1970s. It was not nursing practice by developing, pro- cialty has been evolving at warp until 1986 when Virginia Lynch artic- moting and disseminating information Fspeed over the past two decades. ulated the interrelationships between internationally about forensic nursing The beginnings of what we now call nursing science, forensic science, and science (IAFN, 2016).” forensic nursing actually began formally criminal justice in her master’s thesis The growth of forensic nursing not only in the 1940s in Britain and mid-1970s at the University of Texas that forensic in North America but globally speaks to in Canada. Future-minded health nursing became known. 1992 saw the the recognition that: care providers recognized the need for formation of the International Asso- addressing their patients’/clients’ legal ciation of Forensic Nurses (IAFN), “Violence and its associated trauma needs as well as their health care needs which has become the global leader are widely recognized as critical health around the United States of Ameri- for forensic nursing with the mission problems throughout the world” (Lynch ca (USA) particularly around sexual to “Provide leadership in forensic and Barber Duvall, 2011).

| 10 | THE JOURNAL OF LEGAL NURSE CONSULTING FEATURE

Since the American Nurses Association recognized forensic nursing as a spe- Since the American Nurses Association cialty in 1995, the concept has spread recognized forensic nursing as a specialty to several countries and has developed many subspecialties that speak to the in 1995, the concept has spread to several need of all health care providers to be cognizant of the principles of forensic countries and has developed many nursing science. subspecialties that speak to the need of IN THE BEGINNING.... all health care providers to be cognizant of Since current definitions of forensic the principles of forensic nursing science. nursing vary depending on the source, this article will use definition approved by IAFN in their 2009 Scope and Standards of Practice: “Forensic nursing is the practice of nursing globally when In 1992, a group of mostly sexual • 2009 Forensic Nursing: Scope and health and legal systems intersect. assault nurse examiners met in Minne- Standards of Practice revised and (IAFN, 2009)” apolis MN hosted by Dr. Linda Ledray. published with ANA Many pioneers of forensic nursing were Florence Nightingale can easily be called • 2009 Forensic Nurse Death Investiga- there, including Virginia Lynch who tor Education Guidelines developed a forensic nurse as she cared for victims introduced forensic nursing as a scientif- • 2013 of war, trauma, and violence during the ic discipline in 1989 (Forensic Nursing, Intimate Partner Nurse Examin- published Crimean War (Wikipedia, 2016). Lynch 2009). Of the 72 individuals attending, er Education Guidelines (Lynch and Barber Duvall, 2006) states two were Canadian nurses. After much • 2013 Forensic Nurse Death Investi- in her first textbook that prior to the debate over terminology, the Interna- gator Education Guidelines (revised) French Revolution, midwives testified in tional Association of Forensic Nurses published incidents of sexual assault and pregnan- was formed with Virginia Lynch as its • 2013 Atlas of Sexual Violence pub- cy. So they too could be called forensic first president. lished nurses by today’s definition. Forensic psychiatric nurses have been part of the For over two decades IAFN has grown • 2015 Sexual Assault Nurse Examiner British health care system for centuries to its current membership at 3,600 Adult and Pediatric Education Guide- (Lynch and Barber Duvall, 2006) from 24 countries (IAFN, 2016) with lines published combining previous significant developments in practice and separate Adult/Adolescent and In 1975, Canadian forensic pathologist education resources including: Pediatric documents Dr. John Butt of the Calgary, Alber- • 2016 Core Curriculum for Forensic ta’s Medical Examiner’s Office hired • 1995 ANA recognizes forensic nurs- Nurses published registered nurses (RN) to work as death ing as a nursing specialty One main avenue for dissemination of investigators (Early, 2016). This was the • 1997 Scope and Standards of Foren- forensic nursing education and research beginning of RNs being formally linked sic Nursing Practice published in the IAFN Annual conferences held in to forensic sciences, health sciences, and conjunction with ANA USA and Canada. From those known justice system in Canada. At the same • 2002 Certification for Nurse Exam- as the “Minneapolis 72” to the 2016 time, RNs and nurse practitioners in iners in Adult/Adolescent Sexual conference in Denver CO with 900+ USA communities such as Memphis Assault (SANE-A©) registered delegates, forensic nurses TN, Minneapolis MN, and Amarillo TX from many countries have come togeth- were implementing nursing protocols • 2004 Core competencies for er to share their similarities and discuss for the care of their sexually assaulted advanced practice forensic nurses their differences in forensic nursing. patients in the form of Sexual Assault established Nurse Examiner (SANE) programs • 2005 Journal of Forensic Nursing© (Forensic Nursing, 2009). Interest in the published EVOLUTION OVER TWO SANE role spread slowly and mostly • 2006 Certification for Nurse DECADES by early published articles and word of Examiners in Pediatric Sexual Forensic nursing roots began in North mouth in those pre-Internet years. Assault ( SANE-P©) America in death investigation and care

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 11 | of the sexually assaulted patient/client Forensic nurse investigator: The regis- expert with a strong educational and in the 1970s. Now there are many tered nurse working within a medical experiential foundation is qualified forensic nursing roles within the health examiner or coroner’s role “represents to assess adherence to standards and care system and beyond. Some are well the decedent’s right to social justice guidelines of practice as applied to known, while others struggle for rec- through a scientific investigation of the nursing practice.” ognition. Looking at these indicate the scene and circumstances of death.” directions forensic nursing has taken. Nurse attorney: A registered nurse who Forensic nurse examiner: The reg- also has a valid “Juris Doctorate degree In her seminal book Forensic Nursing istered nurse can provide analysis of who practices as an attorney-at-law (2006) Virginia Lynch described nine roles: “physical and psychological trauma, generally specializing in civil or criminal questioned deaths and or psychopa- cases involving healthcare-related issues.” • clinical forensic nurse thology evaluations related to forensic • forensic nurse investigator cases and interpersonal violence” and “is Nurse coroner: The registered nurse • forensic nurse examiner cross-trained in several subspecialties and may be either elected into this position serves a wider range of forensic patients.” as in the USA or be hired into the role • sexual assault nurse examiner as in Canada. The role provides specific • forensic psychiatric nurse Sexual assault nurse examiner: This jurisdictional powers to provide “inves- • forensic correctional, institutional or role requires the registered nurse to have tigation and certification of questioned custodial nurse specialized education and skills to pro- deaths, to determine the cause and man- vide a comprehensive forensic-medical • legal nurse consultant ner of death as well as the circumstances examination and evaluation as well as pertaining to the decedent’s identifica- • nurse lawyer “maximizing the collection of biological, tion and notification of next of kin.” • nurse coroner trace and physical evidence and mini- Hammer, Moynihan and Pagliaro mizing the patient’s emotional trauma.” Emergency Nurse: There are additional reiterate these in their book (2006). roles in nursing that encompass forensic Forensic psychiatric nurse: The Constantino, Crane and Young in 2013 nursing principles and practice. The registered nurse “specializes in the added forensic assessment and consulta- Emergency Nurse routinely cares for assessment and intervention of criminal tion team and Amar and Sekula (2016) individuals related to trauma, violence, defendants, patients in legal custody added forensic clinical nurse specialist intentional/unintentional injury, work- who have been accused of a crime, or and risk manager to the list. Their brief place injuries, vehicular events, medical descriptions of each role follows: have been court mandated for psychiat- emergencies that may have legal impli- ric evaluation.” cations, are deceased or dying, human Forensic Clinical Nurse Specialist: The trafficking, stabbings, gunshot wounds, registered nurse is “prepared to provide Forensic correctional, institutional or or interpersonal violence of all kinds. expert forensic patient care while also custodial nurse: The registered nurse They may see perpetrators of trauma, serving colleagues as consultants, edu- “specializes in the care, treatment, and cators and researchers.” (Sekula, 2005; rehabilitation of persons who have been violence and/or crimes, and persons Amar and Sekula 2016) sentenced to prisons or jails for violation who are convicted of crimes, suffer from of criminal statutes and require medical mental illness, addiction, and intention- Risk Manager: “with a strong back- assessment and intervention.” al/unintentional drug ingestions. ground in forensic science, nurses with advanced degrees in forensics are well Legal nurse consultant: The American Henderson, Nahoka and Amar (2012) prepared to serve as forensic investiga- Association of Legal Nurse Consultants state “the era has come when compe- tors and as experts in risk management.” (AALNC) lists legal nurse consulting tent and proficient forensic practice as “the analysis and evaluation of facts within the ED setting should no longer Forensic Assessment and Consultation and testimony and the rendering be a consideration but a constant and Team members from sexual Team: of informed opinions related to the minimum standard.” Their study of assault and domestic violence teams delivery of nursing and other healthcare the forensic knowledge, practice and combine to provide examinations and services and outcomes, and the nature experiences of ED nurses and physi- assessment for both victims and/or and cause of injuries. The legal nurse cians found that, “to provide competent suspects that are referred to the team consultant is a licensed registered nurse care to this patient population, pro- Clinical forensic nurse: The registered who performs a critical analysis of viders could benefit increased forensic nurse “provides care for the survivors of clinically related issues in a variety of education.” Eisert (2010) previously crime related injury and deaths.” settings in the legal arena. The nurse concluded that “as victims of violence

| 12 | THE JOURNAL OF LEGAL NURSE CONSULTING FEATURE

enter emergency departments, the staff Forensic Nurse Educators: The cur- nursing education beyond the training members have the unique opportunity rent general nursing curriculum lacked of sexual assault nurse examiners until to recognize, collect, and preserve foren- formal education in forensic nursing’s the early 2000’s when University of sic evidence.” body of knowledge; specialty education Calgary, Mount Royal College (now progressed slowly from Lynch’s teach- Mount Royal University) and British In light of current research in the ED, ings in 1986 to the late 1990s. Forensic Columbia Institute of Technology it follows that forensic nursing prin- nursing had to differentiate itself from developed specific forensic nursing ciples and practice are also applicable other nursing specialties before forensic or forensic health sciences programs. to the clinical practice of other crit- nursing curricula could advance. Arlene Forensic nursing in Canada is recog- ical care nurses. Hoyt (2006) stated Kent-Wilkinson, a Canadian forensic nized as a special interest group and “becoming involved in forensic nursing nurse educator and researcher, stud- not a nursing specialty at this time. is a distinct duty of professional nurses ied North American forensic nursing Advanced degrees are also lacking and is not an option.” education as her PhD thesis in 2008. unless master’s and doctoral students Public Health Nursing was defined In her 2009 JFN article she conclud- choose a forensic focus for research. by the Association of Public Health ed “the forensic nursing process is a Nurses (APHN) in 1996 as “the prac- combination of the nursing process, the Forensic nursing education is finding its tice of promoting and protecting the scientific process and the legal process way into general and specialized nursing health of populations using knowledge (Kent-Wilkinson, 2009).” programs as forensic nurses create from nursing, social, and public health unique opportunities for themselves sciences.” Public health nurses give care So forensic nursing education had based on their specialized backgrounds, in settings which allow them to see to include nursing science, forensic experiences, and interests. For example: into patients’ homes and communities. science AND criminal justice including They care for patients/clients across the criminal laws of the land. Simmons • A registered nurse with a back- lifespan, especially vulnerable popula- and Grandfield also described the value ground in law enforcement and death tions, being well positioned to address of forensic nursing education thusly investigation creates a role within a the World Health Assembly (WHA) “strengthening forensic nursing educa- workplace safety organization that Resolution WHA49.25 “Prevent- tion would produce positive outcomes, investigates serious and fatal working violence: a public health priority” including improved patient care, better place events. (World Health Assembly, 2002). Thus, patient safety, enhanced access to ser- • A registered nurse working in public health nurses are mandated to be vices, less burden on the health care occupational health and addictions knowledgeable and skilled in forensic system, increased confidence and skill monitoring for workplaces becomes nursing principles and guidelines in of nurses providing care, higher patient a sexual assault nurse examiner and order to promote and protect the health satisfaction and more options for those transfers forensic nursing principles of the populations they serve. Ferguson in violent situations (Simmons and to her “day job” by instituting chain and Speck (2010) stated “While foren- Grandfield, 2013).” of custody documentation for all toxi- sic nurses have routinely kept to specific specialty areas such as sexual assault Forensic nursing specialty certificates cology urine samples collected and by and death investigation, public health and advanced degrees to the level of applying expert witness skills in testi- offices would benefit from the content PhDs proliferated in the USA. Cana- mony at inquiries and investigations. expertise of forensic nursing specialty in da, however, continued to have limited • A registered nurse with forensic a variety of ways.” educational opportunities for forensic education provides consultation

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 13 | to a neonatal ward when tracking utes to changes in practice. We will • strengthen health service delivery donated breast milk becomes a risk continue to need research in many and health workers’/providers’ management issue. areas of forensic nursing into the fore- capacity to respond • A forensic nurse examiner (FNE) seeable future. • strengthen programming to prevent is asked to assess a patient in the In 2009, IAFN established the interpersonal violence ICU after staff ’s concerns of possible Ann Burgess Forensic Nursing • improve information and evidence elder abuse. The FNE performs a Research Award to honor forensic (WHO, 2016) head to toe assessment of the patient nursing researchers who have made Forensic Nurses provide care to victims and reviews all documentation since significant contributions to the body and perpetrators of violence, trauma admission. The FNE finds documen- of forensic nursing research as related and/or crime. So the WHO directives tation on the paramedic call sheet to application of research to the to the health system leadership and indicating there was damage to the clinical practice of forensic nurses. delivery of care can only strengthen kitchen wall near the unconscious The yearly recipients of this award the roles of forensic nurses in all their patient. The patient was found to have already changed past practice subspecialties within the health sys- have significant bruising behind one to “best practice.” tems globally. The forensic nurse also ear, a possible indication of blunt has a role in prevention of violence and force trauma. GLOBAL PERSPECTIVES this is exactly what is being asked for • An emergency nurse educator reviews Forensic nursing concepts expanded in this global plan of action. Forensic a civil case regarding a 6-year-old globally, to Canada with the formation Nurses in all the subspecialties and who suffered brain damage after a of the Forensic Nurses Society (now the unique roles must become familiar with missed diagnosis of meningitis at age Canadian Forensic Nurses Association) WHO’s plan and then advocate for its 18 months. By using forensic nursing in 2007 and beyond North America, adoption by the health systems they skills in chart review and patient his- with organizations in Australia (Aus- work in. The plan has a 15 year life tory, the nurse moves into the realm of tralian Forensic Nurses Association) span and the time is right for forensic legal nurse consulting. and United Kingdom (United Kingdom nurses to be leaders in prevention of • An operating room nurse cleans a Association of Forensic Nurses and violence as well as delivering skilled bullet retrieved from a patient’s chest Paramedics). Japan has a newly-formed health care to their patients/clients. with a hard plastic brush before association and countries such as Kenya, handing it over to the attending South Africa, India, Italy, and Nether- CONCLUSION police officer. Subsequently it is lands, for example have had groups of Forensic nursing’s path to specialty found that markings on the bul- forensic nurses for several years. Virginia let have been damaged. The nurse Lynch has traveled to over 30 countries nursing status globally is still a work becomes the project leader to develop introducing the concepts of forensic in progress because forensic nursing a forensic evidence retrieval policy for nursing science to diverse nursing and is made up of so many subspecialties the operating room. medical populations around the globe interacting uniquely with forensic (Lynch, personal communication, 2016). science and the criminal justice sys- Forensic Nurse Researchers: Sackett tem. What IS complete, however, is in an editorial of the British Medical In May 2016, the 69th World Health the change in health care delivery and Journal (Sackett, 1996) described Assembly adopted resolution WHA.9 patient outcomes that all forensic nurses evidence-based medicine as “the con- ~~ “WHO global plan of action to have accomplished in the past three scientious, explicit and judicious use strengthen the role of the health system decades. The care of those who have of current best evidence in making with a national multisectoral response undergone sexual violence as children, decisions about the care of individual to address interpersonal violence in adolescents, adults, or elders will not patient.” This concept evolved into what particular against women and girls go back to what it was before; forensic we now know as evidence based practice and against children (WHA, 2016),” corrections and forensic psychiatric (EBP), the cornerstone for changes in in development since the release of nurses have also changed the care their clinical practice. WHO’s World Report on Violence and patients/clients receive. The future for Health in 2002. The global plan focuses forensic nursing is bright as innovative Forensic nursing researchers link on four strategic directions: findings to clinical practice as forensic ways to improve care of those who nursing’s body of knowledge expands. • strengthen health system leadership have been subjected to violence, trau- Forensic science research also contrib- and governance ma, and/or crime continue to evolve.

| 14 | THE JOURNAL OF LEGAL NURSE CONSULTING The care of those who have undergone sexual violence as children, adolescents, adults, or elders will not go back to what it was before; forensic corrections and forensic psychiatric nurses have also changed the care their patients/clients receive.

Forensic nursing is not for the faint of Forensic Nursing A Handbook for Practice Jones November 2013, p.633. Retrieved September heart but it is for those who want to be and Bartlett Publishers ISBN 0-7637-2610-9 25, 2016 game-changers in the health systems of International Association of Forensic Nursing Wikipedia (2016) Florence Nightingale. https:// the world. 4 (IAFN) (n.d.) iafn.site-ym.com/?page=Over- en.wikipedia.org/wiki/Florence_Nightingale, view Accessed September 22, 2016 accessed September 19, 2016 REFERENCES …. Forensic Nursing: Scope and Standards of World Health Assembly (2002) Resolution Practice. American Nurses Association, Silver WHA49.25 http://www.who.int/violence_inju- Amar A.F and Sekula L. K. (2016) A Practi- Spring MD. 2009, page 3 ry_prevention/violence/world_report/en/ cal Guide to Forensic Nursing: Incorporating summary_en.pdf Retrieved September 25, 2016 Forensic Principles into Nursing Practice.. …. Membership Director, September 23, 2016 SigmaTheta Tau International Honor Society of …. Resolution WHA.9: WHO global plan Henderson E, Nahoka H. and Amar A. (2012) Nursing. ISBN 9781940446349 of action apps.who.int/gb/ebwha/pdf_files/ Caring for the forensic population: recognizing WHA69/A69_9-en.pdf Retrieved September American Association of Legal Nurse Consul- the educational needs for emergency department 25, 2016 tants www.aalnc.org/ nurses and physicians. Journal of Forensic Nurs- ing Volume 8, page 172 World Health Organization (WHO) (2016) Association of Public Health Nurses (APHN) WHO Global Campaign for Violence Preven- (1996) www.phnurse.org/What-is-Public- Hoyt C. (2006) Integrating forensic science tion Newsletter May 30, 2016 Health Retrieved September 25, 2016 into nursing processes in the ICU. Critical Care Nursing Quarterly Volume 29 Issue 3 page 259 Constantino R.E., Crane P. A. and Young S. E. Forensic Nursing Evidence-Based Principles and Kent-Wilkinson A. (2009) An exploratory study Sheila Early, RN, BScN, has of forensic nursing education in North America: Practice, 2013 F. A. Davis Company ISBN 978- an extensive background in constructed definitions of forensic nursing. Jour- 0-8036-2185-5 emergency and forensic nal of Forensic Nursing Volume 5 2009, p.208. Early, Sheila (2016). The Lawyer’s Guide to nursing and legal nurse the Forensic Sciences. Caitlin Pakosh, editor. Lynch V. A. and Barber Duval J. , eds. Forensic consulting private practice. Irwin Law, Inc. September 2016. ISBN 978-1- Nursing. Elsevier Mosby, 2006. ISBN 0-323- She has been a member of 55221-412-1 02826-8 the International Association of Forensic Eisert, P. et al. (2010) CSI New York: develop- Lynch V. A. and Barber Duval J., eds. Forensic Nursing since 1995 and served as the ment of forensic evidence collection guidelines Nursing Science, 2nd Edition. Elsevier Mosby first non-USA member elected President for the emergency department. Critical Care 2011. ISBN978-0-323-06637-2 in 2014. She is co founder of the Canadi- Nursing Quarterly, Volume 33 Issue 2 p.198 The Lawyer’s Guide to the Forensic Sciences an Forensic Nurses Association ( 2007) as well as a longstanding member of the Ferguson CT and Speck P.M. (2010) The foren- (2016) September National Emergency Nurses Association sic nurse and violence prevention and response Sackett D. (1996) Editorial. British Medical (NENA) Canada. Currently she is Coordi- in public health. Journal of Forensic Nursing, Journal 3:12 pages 71-73 Volume 6 page 154. nator/Instructor Forensic Health Sciences Sekula, L.K. (2005) The advance practice foren- Option, Forensic Science and Technology Forensic Nursing: Scope and Standards of Prac- sic nurse in the Emergency Department. Topics in Program, British Columbia Institute of tice. American Nurses Association, Silver Spring Emergency Medicine January/March 27(1) 5-14. Technology, Burnaby, British Columbia MD. 2009, page 3 Simmons B, and Grandfield K. (2013) Focusing ( B.C.) Canada. She can be contacted at Hammer R.M, Moynihan B. Pagliaro E.M. 2006 on forensic nursing education. www.jenonline.org [email protected].

The Role of the Forensic SANE Nurse in Pediatric Sexual Assault

Jennifer L. Orr, BSN, RN, CLNC

egal nurse consultants (LNC) enable the LNC to assist the pros- (US Department of Health and Human reviewing pediatric sexual assault ecution or defense. A subspecialty, Services, 2014). Reports showed that L cases should have advanced train- pediatric sexual assault nurse examiner 12% - 25% of girls and 8% - 10% of ing as a forensic nurse when becoming (SANE-P), is an asset to hospitals and boys were sexually abused by age 18, involved in criminal cases. Nurses pediatric practices nationwide. most often by a male family member who want to consider legal forensic or trusted acquaintance. Pediatric nursing as a career will benefit from STATISTICS sexual abuse is far more common than a background in trauma, critical care, The Department of Health and Human childhood cancer, juvenile diabetes, or emergency nursing. Deoxyribonu- Services documented thirty thousand and congenital heart disease combined. cleic acid (DNA) analysis, toxicology, fewer child sexual assault cases in 2012 Unfortunately, many cases are not and interpreting forensic evidence will (686,000) compared to 2008 (716,000) reported until later in adulthood.

| 16 | THE JOURNAL OF LEGAL NURSE CONSULTING HISTORY AND DEFINITION 18 years-of-age and sexual assault has • If the child is less than 4 years’ age OF PEDIATRIC SEXUAL occurred, the standard protocol requires difference from the sexual partner ASSAULT NURSE EXAMINER law enforcement and social services be and above the age of consent for the notified immediately. Additionally, when sexual activity the family does not The first use of sexual assault nurse examining a child, the local crisis center have to file a report. examiners (SANEs) began in the should be contacted to support the • If a child is 16 years of age, which is late 1970s in Minnesota, Tennessee, non-offending family members during and Texas. In 1992, members from considered the legal age of consent, the initial examination (Jenny and a parent can file a report if the sex- 31 SANE programs from the United Crawford-Jakubiak, 2013). ual partner is age 18 or older. The States and Canada founded the Inter- prosecuting attorney may charge the national Association of Forensic Nurses Educating the general public and law 18-year-old adult with a misdemeanor. (IAFN). The American Nurses Asso- enforcement officials about the differ- ciation recognized forensic nursing as a ent forms of physical and non-physical • When an adolescent with cognitive specialty area in 1995. The first Adult/ sexual abuse is important when inves- or physical deficits has been coerced, Adolescent (SANE-A) credentialing tigating pediatric sexual abuse patients. forced, or deceived, a sexual abuse was in 2002 and the first Pediatric Many law enforcement professionals report must be filed. believe the only form of pediatric sexual (SANE-P) in 2007. WHY IT’S IMPORTANT TO abuse is through violent sexual penetra- The SANE-P training includes skills tion where injury or death occurs. The USE A PEDIATRIC SEXUAL for evidence-based and patient-centered SANE-P has an incredible opportuni- ASSAULT NURSE EXAMINER care, including specialized examination, ty to educate the differences between (SANE-P) documenting injuries (e.g., genital and physical injury and non-physical injury Emergency and primary care medical anogenital), and collecting and preserv- (i.e. fondling, oral-genital, genital or anal professionals recognize the need have ing forensic evidence. SANE-Ps testify contact without penetration), and how forensic medical exams and advocacy for as experts, provide emotional support to each contributes to the emotional trau- pediatric patients be properly trained the child and family, and make referrals ma of pediatric sexual abuse patients. and certified. If primary care physicians to appropriate crisis and community lack specialized training, they should counseling centers vital for future emo- IDENTIFYING CONSENSUAL refer the patient to a skilled sexual tional and psychological recovery. ASSAULT assault provider/institution and report to law enforcement. After SANE foren- IDENTIFYING PEDIATRIC Law enforcement handles consensual sexual assault differently. According to sic nursing programs began, there was SEXUAL ASSAULT the Guidelines for Child Abuse Report- significant improvement in the docu- Trained physicians, SANE-Ps, nurse ing of Consensual Sexual Activity, mentation and evaluation of anogenital practitioners, and physician assistants mandatory reports must be filed with injury and sexually transmitted infec- play an integral part in pediatric sexual law enforcement agencies by jurisdiction tion testing (STIs) (Horner, Thackeray, assault cases where examiners recog- and to the Department of Children and Scribano, et al., 2012). nize 80% of cases fail to reveal physical Family Services (each law varies by state In a study by Nationwide Children’s forensic evidence. The American Acad- and department); see the applicable Hospital, Columbus OH, prosecution emy of Pediatrics cautions that body jurisdiction details. outcomes when trained SANE-Ps swabs collected in pre-pubertal children assessed pediatric sexual abuse patients >24 hours after a sexual assault may When should a parent or adolescent were compared with the outcomes when yield questionable forensic evidence. child file a report? untrained, non-pediatric emergency Clothing or undergarments most fre- • If the child is 15 years or younger, a room physicians and pediatricians quently contain forensic evidence used case must be filed. performed the assessment (Horner, in court. (Girardet, Bolton, et al., 2011) • If the child is 13, 14, or 15 and the Thackeray, Scribano, et al., 2012). Careful identification through prop- sexual partner is 4 years older than The study reported that 36% of cases er forensic interview of the pediatric the patient, a report must be filed. reviewed by SANE-Ps resulted in plea patient guides the SANE-P to either • If the sexual partner is 18 years of bargains and trial convictions, versus initiate collection of forensic evidence age, but less than 4 years older than 17% in the non-pediatric trained group. or refer to appropriate counseling and the child, the law may charge the This study demonstrates the neces- crisis center. If the patient is under teen with corruption. sity for hospital facilities to employ

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 17 | sexual assault, the next assessment must SANE-Ps testify as experts, provide include differentiating, in a compassion- emotional support to the child and family, ate and non-threatening way, whether the child is experiencing signs of sexual and make referrals to appropriate crisis and abuse or some other form of abuse or neglect. Child sexual abuse symptoms community counseling centers vital for future most often are non-specific, making it emotional and psychological recovery. difficult to decipher from normal child physiologic developmental behavior. The SANE-P’s knowledge, skill, and training is critically important for making this determination based on advanced trained certified professionals include aggression, problems in school, the following (U.S. National Library of as well as an obligation for non-pedi- regression, thumb sucking, using past Medicine, 2014): atric facilities to provide specialized security objects, depression, and change Suspicious signs include: training for their employees. If an insti- in appetite. According to the U.S. tution is unable to provide a certified National Library of Medicine (2014), • A child keeping secrets and/or with- examiner, then appropriate referral to one in 4 girls and 1 in 10 boys are sexu- drawn behavior ally assaulted before they turn 18. outside resources should be expected. • Having an adult within the family This will only benefit the child. • Sexual abuse is any activity where display a sense of control over the the abuser becomes sexually aroused child interacting with other adults SYMPTOMS OF PEDIATRIC or it can be without any physical • The child has tried to run away SEXUAL ABUSE contact. To distinguish between two • The child understands, talks about Staff working in acute and non-acute forms of sexual assault and decide on sex, and shows promiscuous behavior settings may see pediatric patients how to proceed to an age appropriate outside the normal developmental with symptoms concerning for sex- forensic interview to document event range ual assault. When a child is brought disclosure, the examiner will consider the following (The National Center • The child has trouble sitting or to the ED within 72 hours from the standing alleged sexual assault, these signs and for Victims of Crime, n.d.): • The child tells another adult of being symptoms include anogenital trauma, Sexual abuse where the abuser becomes sexually abused bleeding, genital irritations, encopresis, aroused includes the following: enuresis, pregnancy, oral trauma, or a • A family or family member has wit- • Touching the child’s genitals and STI diagnosis. Most children do not nessed abuse digital penetration report abuse to family members imme- Physical symptoms: diately or present to the ED for months • Rubbing the child’s genitals against a • Encopresis, bowel control issues or years. Because the sexual assault child’s skin or over top of clothing occurred over an extended period of • Inserting objects into the child’s anus, • Headaches and stomachache time, physical injury would be difficult vagina, or mouth • Sleeping problems to identify and collection of forensic • Penetration of the vagina or anus • Genital or rectal problems such as evidence would not be warranted. How- Sexual abuse without physical contact pain while urinating, discharge, or ever, it is important to identify subtle includes: vaginal itching clues to identify a minor in a potential- • Change in eating behaviors, loss of • Masturbation in front of the child ly harmful environment. (Jenny and appetite; anorexia Crawford-Jakubiak, 2013). • Forcing a child to watch pornography Adolescent signs and symptoms may • Forcing a child to pose for pornog- include: SIGNS OF SEXUAL ABUSE raphy IN PEDIATRICS • Exposure of one’s own genitals in the • Use of illicit drugs or alcohol Sexually-abused children typically presence of a child • Promiscuous behavior and engaging exhibit psychosocial, behavioral, and Once the SANE-P has identified in risky sexual behaviors medical problems. Behavioral changes and documented a suspected form of • Poor grades in school

| 18 | THE JOURNAL OF LEGAL NURSE CONSULTING • The pediatrician is often the first professional to become aware that sexual assault has occurred. • Social services or law enforcement professionals bring the suspected pediatric patient or adolescent to the pediatrician or ED for a non-acute medical evaluation as part of the initial investigation. • In acute situations (less than 96 hours from the alleged incident), the child has a medical evaluation, forensic evidence collection, and crisis • Withdrawing from social events; a practitioners, police officers, social management in the ED. change from regular activity workers, and other personnel and must • The child presents to the pediatrician • Fears, more than just a typical devel- be labeled with the photographer’s or ED because a caregiver or other opmental anxiety or fear children and initials. Any physical evidence, including individual suspects abuse because of adolescents frequently encounter photographs, must also be marked with the jurisdiction’s case number. (New behavioral or physical symptoms. COLLECTION OF FORENSIC Hampshire, Office of the Attorney • The pediatrician notes behavioral or EVIDENCE General, 2015). physical signs of sexual abuse during Forensic evidence to help identify perpe- a routine physical assessment (Jenny Obtaining complete and detailed infor- & Crawford-Jukubiak, 2013). trator and methods of assault includes: mation about the alleged assault may • Biological evidence: blood, semen, include questions regarding the use of THE EXAMINATION OF sperm, hair, or skin fragments. condoms or lubricants, and whether the THE PRE-PUBESCENT CHILD • Carpet fibers, debris, clothing, and victim has washed, voided, defecated, or IN THE PRIMARY CARE undergarments bathed since the contact. In the ado- SETTING lescent population, the history should Rape evidence collection kits are avail- As a representative example, New also document if a female patient is able in many EDs and routinely include Hampshire law mandates that any and all menstruating (Girardet et al., 2011). detailed instructions for careful han- suspicious pediatric sexual assault cases Diagnosis in most pediatric sexual dling of clothes and specimen collection under the age of 18 be reported to law assault cases is based on the statement (New Hampshire, Office of the Attor- enforcement and child protection author- of the patient obtained by a qualified ney General, 2015). ities immediately (New Hampshire, physician, SANE-P, or another forensic Office of the Attorney General, 2015). The time frame for forensic evidence expert. Documentation of disclosures collection has been extended to 96 should be conducted in a non-biased • An interview should be done in an hours in the acute care setting and manner and should be quote the age-appropriate environment and should be conducted using the pediat- patient’s exact words (Jenny and Craw- independently, without the parent or ric sexual assault protocol (Botash, A., ford-Jakubiak, 2013). caregiver present if at all possible. n.d.). The U.S Department of Justice • Examination is conducted in a child (2014) indicates any local law enforce- SEEKING TREATMENT advocacy center or a pediatric hospi- ment must follow proper handling of all Seeking treatment for those affected tal by a SANE-P, certified physician forensic evidence by jurisdiction. by sexual assault can be an emotional or physicians’ assistant. Proper collection of physical evidence and traumatizing experience. Many • Thorough anogenital exams should requires that the examiner mark any children are fearful of “breaking the be conducted only if absolutely specimens obtained with the exam rules” and don’t want to upset or necessary (<72 hours from the sus- date, examiner’s initials, victim’s name, disappoint the alleged abuser, which is pected assault) with the avoidance of and chain of custody when samples why so many of these cases go unre- unnecessary multiple exams, as this are transported. Photographs may ported into adulthood. The following can be traumatizing for children. be taken by physicians, nurses, nurse scenarios are common: • When examining the adolescent

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 19 | patient, the American Academy of appropriate examination techniques, care: Trace forensic evidence, ano-genital injury, Pediatric guidelines will be followed; providing emotional support, and refer- and judicial outcomes. https:/www.ncbi.nlm. these suggest using a speculum for ring to crisis and community services gov/pubmed/22925125 intra-vaginal examination. Speculum have proven to be a starting point to the Jenny, C., Crawford-Jakubiak, J. 2013, The examination is only required after emotional and psychological recovery evaluation of children in the primary care setting an acute sexual assault to document of the child or adolescent sexual assault when sexual abuse is suspected. Pediatrics, August 2013, Volume 132/Issue 2, The Amer- injuries and collect forensic speci- patients. Community services remain ican Academy of Pediatrics. AAP Gateway. mens. Speculums are NOT to be in constant communication providing pediatrics.aappublications.org. Retrieved used in the pre-pubescent children therapy and support groups to families September 8, 2016 to avoid additional emotional trauma and children. New Hampshire, Office of the Attorney General, (New Hampshire, Office of the 2015, Sexual assault: an acute care protocol for Attorney General, 2015). SUGGESTIONS FOR THE LNC medical/forensic evaluation. www.doj.nh.gov/ criminal/victim/assistance/documents/ • Testing for sexually transmitted 1. Review documents related to date infections is now required for all age acute-care-protocol pdf. Retrieved December and time of injury and the age of the 11, 2015. groups. Treatment is given only after patient at the time of the assault. positive results. Bacterial vagino- Thackeray JD, et al., 2011, Forensic evidence sis and genital candidiasis are not 2. Review documents related to any collection and DNA identification in acute child sexual assault. Pediatrics. 2011 Aug; 128(2):222- indicators of sexual abuse (Jenny and forensic evidence collected at the 32. doi: 10.1542/peds.2010-3498. Epub 2011 Crawford-Jakubiak, 2013). time of assault. Jul 25. www.ncbi.nlm.nih.gov. Retrieved September 8, 2016. THE EXAMINATION OF THE 3. Review documents from child pro- PRE-PUBESCENT CHILD IN tection agency, social services, crisis The National Center for Victims of Crime, n.d. Useful definitions for reporting on child sexual THE EMERGENCY SETTING centers, psychologists, and SANE- P’s who conducted the examination, abuse. www.victimsofcrime.org. Retrieved September 12, 2016. In pre-pubertal children, it is highly and any law enforcement reports, if unlikely to have body swabs positive for applicable. U.S Department of Health and Human Services evidence 24 hours after a sexual assault. Administration for Children and Families However, failure to collect evidence on 4. Distinguish what form of sexual Administration on Children, Youth, and Families pre-pubertal children could result in assault occurred at the time of the Children’s Bureau (2016). Child Maltreat- missed opportunities to identify addi- incident: physical sexual abuse or ment, 2014. www.acf.hhs.gov/programs/cb/ research-data-technology/statistics-research/ tional forensic evidence that could be non-physical sexual abuse. child-maltreatment. Retrieved 12/15/2015 submitted in court proceedings. With advancement in DNA technology, it will 5. Review any documents from com- U.S National Library of Medicine, 2014, Child neglect and emotional abuse. www.nlm.nih.gov/ be necessary to frequently re-evaluate munity and counseling centers that provide follow-up crisis interventions medlineplus/eny/article/007225.htm. Retrieved clinical and forensic practices in the September 7, 2016. collection of forensic evidence (Thac- to patients and their families. 4 keray et al., 2011). Research states that “although body swabs were important REFERENCES Jennifer Orr, BSN, RN, sources of evidence for older children, Botash, A., n.d. Child sexual abuse in emergency CLNC served 16 years medicine clinical presentation. www.emedi- they were significantly less likely than bedside nursing experience nonbody specimens to yield DNA cine.medscape.com/article/800770-clinical. Retrieved January 1, 2016 in pediatrics, neonates, and among children younger than 10” chronically ill children and (Girardet R., et al., 2011). Girardet R. et al., 2011, Collection of forensic adults. She is member of evidence from pediatric victims of sexual assault. the American Nurses Association (ANA) Pediatrics. 2011 Aug; Volume 128 / Issue 2. and the National Alliance for Certified SUMMARY AAP Gateway. pediatrics.aappublications.org. Legal Nurse Consultants (NACLNC). She The development and implementation Retrieved September 8, 2016 has been a guest speaker for the of SANE-P’s in the clinical setting for Guidelines for child abuse reporting of consen- Columbus Ohio Association for Justice pediatric sexual assault patients has not sual sexual activity, n.d. www.odh.ohio.gov/ (COAJ). As a LNC, Jennifer continues to only improved documentation of inju- media/HealthyOhio/Assets/Files/SADVP. work with attorneys and insurance ries but also increased plea bargains and Retrieved January 7, 2016. nationwide on medical malpractice and trial convictions of the abuser. Advocat- Horner, G., Thackeray, J., Scribano, P., et al., personal injury cases. She can be reached ing for the patient and family through 2012. Pediatric sexual assault nurse examiner at [email protected]

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Working for the Defense

Cari Caruso RN SANE-A

Keywords: Forensic nursing, SANE, legal nurse consulting, defense, objective

ur healthcare and the legal maintains our impartiality as testifying FORENSIC NURSING systems intersect in forensic experts. Those who work with patients PRACTICE: SANE nursing (Forensic Nursing with interpersonal and sexual violence O The forensic examination should Science, 2011). We interact with law are aware that their own credibility be done methodically using critical enforcement and the crime lab, provide as forensic nurse examiners depends thinking, nursing judgment, and the medical intervention, obtain advoca- on their own integrity and impartial- guidelines of the National Protocol (US cy for the patient, and, if the case is ity. While many people are familiar Department of Justice, 2013) and those assessed to have merit, work within the with SANE work with sexual assault of the program’s own policies, proce- legal system. victims, some work with the defense, dures, and protocols. Forensic nursing critiquing the prosecution expert’s work includes providing compassionate, As registered nurses, we advocate for in these cases to help assure that the personalized nursing assessment, while patients’ health and well-being, but as innocent have the defense they deserve. objectively documenting, collecting forensic nurses, we are not advocates. This article describes information need- physical evidence and photographing That sets us apart from others and ed for that process. what we have heard, observed, and

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 21 | experienced without exaggeration, Forensic nursing includes providing editorializing, or speculation on the history’s veracity. The forensic nurse’s compassionate, personalized nursing role is not whether to believe or not to believe the patient; it is to document assessment, while objectively what the patient reports. documenting, collecting physical evidence The forensic nurse will inspect the patient’s body and anogenital struc- and photographing what we have heard, tures, note unusual findings or apparent observed, and experienced without injuries, and apply differential diagnosis to the findings. Standard of practice is exaggeration, editorializing, or to diagram and photograph findings and speculation on the history’s veracity. collect appropriate samples that could be used for evidence and exemplars, provide resources for the patient, and provide the patient with prophylaxis for sexually transmitted infections (STI) and pregnancy (CDC, 2015) If bias is evident, the examiner loses motivations and influences for false or objectivity and credibility and can no unsubstantiated reporting. Only the jury The expert’s assessment comprise longer be a neutral medical professional can make the final decision. (Federal the elements within her/his scope of but has become a representative for one Rules of Evidence 702-704, n.d.) practice regarding forensic examination of the parties. The examiner’s find- and documentation, nursing care, and ings may determine case management RECORDS medical care of the patient. The initial decisions, including whether or not to examination ought to have been con- prosecute or defend it; reckless or biased All consequential records must be pro- ducted comprehensively and objectively interpretation of findings can wrongly vided in order for the expert to conduct and its findings documented appropri- influence the investigation and litiga- a proper review. The initial forensic ately. However, this is often not the case. tion, with devastating results. examiner has one perspective of the case; there is always at least one other The examining expert can err for a If a case goes to trial, the nurse exam- perspective. number of reasons, including knowledge iner who had conducted the forensic deficit and overstating findings. The examination on the reported victim or Many examiners do not consider the examiner must be knowledgeable about suspect of a sexual assault event will fact that someone else may review their differentiating normal findings, normal most likely be called to testify by the work. Other than for court proceedings, variants, hygiene issues, and common prosecution. The examiner could also be the records and photographs can be skin and medical conditions that could called by defense. used for peer review, chart review, case review, education, and evaluation of the be confused with injury. When sexual The examiner who had conducted the medical professional to ensure accuracy assault or abuse is reported, there may examination will only have the perspec- and competence. A defense expert may be findings related to sexual contact, tive of the reporting victim. In contrast, findings of a non-sexual nature, or no the reviewing defense forensic nurse see the examiner’s reports, photographs, anogenital findings at all. expert will have records from a variety and documentation, too. The forensic nurse examiner may also of sources, transcripts, photographs, and Report language should be descriptive, examine the suspect, inquiring only interviews of those involved including with common, understandable language about the suspect’s health and current any possible witnesses. (e.g., “redness,” not “erythema” and physical condition, but not the circum- Intimate crimes such as sexual assault, “bruises,” not “contusions” or “ecchy- stances of the reported event; that would domestic and interpersonal violence, and mosis”), since lay people such as law be up to law enforcement (LE). Suspect child physical and sexual abuse, require enforcement and attorneys will read the examinations and history do not include careful and objective investigation. An reports. However, terminology must an interview regarding the accusations. investigation may uncover cause to still be extremely specific and accurate (Markowitz and Faugno, 2011). move forward with the case or various regarding anatomical structures.

| 22 | THE JOURNAL OF LEGAL NURSE CONSULTING • Forensic exam record, unredacted • Exam photos/videos (on disc or flash drive) • All documentation related to exam • Reported victim statements/interviews • Forensic examiner’s curriculum vitae • Additional medical records • Crime lab reports • Program policies, procedures, protocols • Police reports • Preliminary hearing • Witness statements • Investigator’s reports • Interviews and transcripts • Other court proceedings • Defendant statements • Charge summary & priors • Miscellaneous applicable records, e.g., phone, weather, texts EXAMINATION When a victim presents for medical attention, emergent and urgent medical issues take priority and the forensic issues will be secondary. The forensic examination for reporting victims is completely voluntary, and under the Records are usually obtained from the before the examination begins. The Violence Against Women Act (US district attorney (DA) through dis- age of consent for this may be different Department of Justice, 2005), they may covery. Any expert should know what than the usual age of consent for other choose to have an evidence kit collected records are generally included for a giv- medical examination. For example, in and stored, but do not have to cooperate en type of case. The request will likely California a person must be 12 years with law enforcement or go forward ask for, “Any and all records and imaging old and older to sign their own consent with the investigation. related to this patient’s case.” However, for examination and treatment (Office the DA may not have received all needed of Criminal Justice Planning, 2001), At this time, the time limit within which records initially. Sometimes, the pros- to perform an acute examination for an In many jurisdictions, documents used ecutor has not turned them over and adolescent (12 years and older or puber- for official criminal investigations are sometimes the prosecutor does not know tal) and an adult (18 years old and older) exempted and are treated differently they exist. The SANE defense expert has been up to 120 hours after the event will be expecting a forensic examination from ordinary medical records. In most since the early 2000s. Some programs report and photographs. There may also jurisdictions forensic records are kept have extended their window of oppor- be nurse’s notes, a narrative report, a separate from medical records and may tunity to collect biological evidence as medical administration record, aftercare only be obtained by subpoena. technology advances and smaller sample instructions, addenda, and dictation. quantities can be analyzed. Some documents that may be helpful The patient should have signed a con- in a review, depending upon the history, If an examination is outside of the acute sent for examination and photography are listed below: time frame, it is considered non-acute.

International Association of Forensic Nurses. The goal of reviewing the forensic Forensic Nursing Scope and Standards of Prac- tice. American Nurses Association, Silver Spring, examiner’s report is to provide an Maryland, 2015. analysis of the examiner’s work with Markowitz, J., Faugno, D. The sexual assault suspect examination. In Ch. 8, Medical Response to scrutiny for correct terminology, correct Adult Sexual Assault, Linda E. Ledray, Ann W. Burgess, and Angelo Giardino, eds. STM Learn- identification of anatomical structures, ing, Inc. St. Louis MO, 2011 www.stmlearning. com/media/excerpts/978-1-878060-11-2.pdf and accurate identification of findings. US Department of Justice (2005) Office of Vio- lence Against Women. Violence Against Women Act. www.justice.gov/ovw See also Grant Pro- grams: www.justice.gov/ovw/grant-programs US Department of Justice (2013) Office of The examiner performs the same victim of care and policies, procedures, and Violence Against Women. National Protocol for interview for medical and event history protocols that are customary for the Sexual Assault Medical Forensic Examinations, and the same physical examination, but specialty (International Association of Adults/Adolescents, 2nd edition. www.ncjrs. will collect no samples, depending upon Forensic Nurses, 2015) from patient gov/pdffiles1/ovw/241903.pdf how distant the event in time. presentation to discharge. The reviewer Children’s programs (prepubertal or 12 will also look for presence or absence of Cari Caruso RN SANE-A years old and under) may vary, but gen- bias, exaggeration, critical thinking, and nursing judgment. has been a Sexual Assault erally, the time frame for an acute exam Nurse Examiner (SANE) and is between 48 and 72-96 hours. The attorney client deserves an honest a Charter Member of the and candid opinion. We can provide International Association of REVIEWING AN the facts of our observations and pro- Forensic Nurses (IAFN) EXPERT’S REPORT vide opinions but we cannot come to since 1990, establishing a private practice called Forensic Nurse Professionals, Inc. in The goal of reviewing the forensic exam- the ultimate decision; we allow those 2003. She conducts forensic evidentiary iner’s report is to provide an analysis who will adjudicate the case to put examinations on reported victims and of the examiner’s work with scrutiny all the pieces together and come to an suspects of sexual assault events, collects for correct terminology, correct identi- educated decision. 4 evidence for legal paternity testing and fication of anatomical structures, and DUI for prosecution and defense, and accurate identification of findings. The REFERENCES serves as a consultant and expert witness defense forensic nurse examiner must California Office of Criminal Justice Plan- in criminal and civil sexual assault cases, have a working knowledge of differential ning (2001) California Medical Protocol For and is a Continuing Education provider. diagnosis; keeps current; and knows Examination of Sexual Assault and Child Sexual She teaches forensic nursing at the how to use available literature, tools, Abuse Victims p. 7. www.caloes.ca.gov/Grants- University of California, Riverside and and their limitations and reliability. ManagementSite/Documents/2-923%20 presents for various universities, law to%202-950%20Protocol.pdf Accessed enforcement agencies, professional Literature can become obsolete and 10/10/16. organizations, medical personnel, invalidated over time. So can many Centers for Disease Control and Prevention students, community groups, and legal techniques in the forensic nursing (CDC) (2015) Sexually Transmitted Diseases entities. world, yet are still in use although more and Treatment Guidelines. www.cdc.gov/std/ She is published in the Virginia Lynch and contemporary practices are or should be tg2015/sexualassault.hlm Accessed October Janet Barber textbook, Forensic Nursing used. The defense expert reviewer will 8, 2016. Science, Elsevier, and also participated in have an eye out for outmoded references Federal Rules of Evidence 702-704, Washington, the development of the Sexual Assault and practice. DC, Department of Justice, US Government Nurse Examiner Education Guidelines, for Printing Office. Advisory Comm.n.Retrieved the International Association of Forensic The nurse reviewer will expect to see http://uscourts.gov/uscourts/rules/rules-evi- Nurses. She may be contacted at fnpi@ that the examiner adhered to standards dence. PDF sbcglobal.net

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Forensic Psychiatric Nursing and the LNC

Rachel Regan Boersma, Ph.D., R.N.

aw and professional practice present in every setting: outpatient and requires very different competencies standards codified at the state and inpatient, on a general medical-surgical and strategies for care and management. L federal levels govern all domains unit, in a mental health specialty unit, in The two major mental illnesses (bipolar and areas of nursing practice. Ethical a community, jail, or prison. disorder and schizophrenia) have sub- nursing practice is governed by profes- types and have their own very different sional organizations in the national and The Diagnostic and Statistical Manu- competencies and strategies. international spheres of professional al of Mental Disorders, Fifth Edition practice. The legal nurse consultant (American Psychiatric Association, Individuals may experience multiple must be fluent in both. 2013), DSM-5, is the bible of psychiat- psychiatric disruptions throughout ric practice. The DSM-5 delineates 10 the life span, ranging from mild to Psychiatric nursing or mental health distinct personality disorders divided severe, such as anxiety, grief, depression, nursing focuses on the identification into three distinctive groups: the odd post-traumatic stress disorder, bipolar and treatment of mental illnesses. or bizarre cluster, the dramatic cluster, disorder, schizophrenia, and various Individuals with psychiatric illnesses and the anxious or fearful cluster. Each personality disorders. Clearly knowing

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 25 | FEATURE how to care for and about a diverse group of individuals, any of whom could be Forensic nurses practice at the intersection suffering with one or frequently more of forensic science and nursing science in psychiatric disorders, can be challenging. almost all practice areas including but not Individuals with a diagnosable psychiatric disorders have higher rates of limited to victims and perpetrators (living substance use disorders than the general population; in 2014, 20.2 million US and deceased) in the health care system, adults had a substance use disorder and court systems, or child protection systems. 7.9 million or 39.1 percent also had diagnosable mental illness as defined by the DSM-5 (Center for Behavioral Health Statistics and Quality, 2015). Caring for mentally ill patients suffer- What records would be necessary and the specific unit staffing ing with substance use disorders (dual for a preliminary screening for merit, during the shift (Adequate if a diagnosis patients) is considered a and what records would need closer patient with suicidal ideation sub-specialty of psychiatric nursing. scrutiny? The LNC was not a psychi- is admitted?) atric nursing professional or forensic –– Shift to shift report for the day (if Forensic nurses practice at the inter- psychiatric nursing professional, so con- available) section of forensic science and nursing sultation with an expert was necessary. science in almost all practice areas –– Patient acuity scales including but not limited to victims Nurses offer expert opinions on nursing –– Copies of any unit communica- and perpetrators (living and deceased) care; physicians do not. The LNC tion book or log book pages for in the health care system, court and counsel will need both. An expert that day forensic psychiatric nurse will identify systems, or child protection systems. –– Unit surveillance tapes for the day LNCs may consult such nursing records, documents, reports, standards –– Detailed unit floor plan (Blind experts for cases that are primarily of professional practice, and current spots and review the use of and psychiatric or medical cases with a peer reviewed research, either behind placement of convex mirrors?) complicating psychiatric component. the scenes or as a testifying expert. Materials the expert will need include: • Licensing and Accrediting Agencies and Organizations SAMPLE CASES • General Records of Interest –– Sentinel event records at both The following cases were real cases • Hospital Records state licensing levels, e.g., Depart- in which the author was the forensic –– All current and past psychiatric ment of Public Health and the psychiatric nursing testifying expert. treatment records (inpatient and Department of Mental Health Specific details of the cases were omit- outpatient) ted or changed to protect the identity of –– The Joint Commission on –– Medical records for at least the last the individuals. Accreditation of Healthcare five years to determine if a co-ex- Organizations (JCAHO) or Case #1 – Suicide on a Locked isting medical condition could other accrediting agency sentinel Psychiatric Unit have exacerbated the psychiatric event records condition A legal nurse consultant (LNC) –– Previous facility and unit inspec- –– Contemporary nursing, unit-spe- performed a case review for merit tions and surveys cific, and laboratory policies and concerning a suicide on a locked psy- procedures. Request the index of –– Professional practice disciplinary chiatric unit. The LNC knew that any policies and procedures because records for involved licensed pro- inpatient suicide would trigger myriad if a specific title is not requested fessionals formal reviews, both internally and by during discovery then a valuable • Forensic and Legal Agencies and accrediting and licensing agencies and resource may not be produced. Organizations. recognized also that others, such as the medical examiner or coroner (depend- –– Training records for all unit nurs- –– Postmortem or autopsy records ing upon the state’s model where the ing and ancillary staff, a copy of –– Police records (including photo- death occurred) would be involved. the unit master staffing pattern, graphs and videos)

| 26 | THE JOURNAL OF LEGAL NURSE CONSULTING –– Emergency Medical Services foot. Because of his disorganized think- of aggression, and frequent fecal soiling (EMS) records including call ing, he is found walking the unit with he wears non-slip socks, not sneakers or transcripts feces down his legs and on his feet. The shoes. The staff diligently showered him –– Toxicology results from the medi- aides shower him. and made certain that he always wore cal examiner’s/coroner’s office the socks to prevent falling, but they also After approximately three weeks, his indicated how agitated and suspicious Case #2 - The Medically Compro- wife notifies the nursing staff about he was under running water. The TE mised Aggressive Psychiatric Patient several new blackened lesions/ulcers on hypothesized that Mr. M. lacked the his foot. His vital sign record shows a capacity to cooperate after a shower and Mr. M. (age 64) has a long history of slight fever occurring over the past three that his feet perhaps were damp prior to bipolar disorder and aggressive behav- days, but the mental health worker being dressed in his socks. ior. He is diabetic, has a Charcot’s foot, charged with taking vital signs did not diabetic ulcerations on his feet, arterial report this. The attending psychiatrist The TE requested copies of mainte- insufficiency, and a upper respiratory and medical physician decide to transfer nance records for the unit, specifically infection (URI) for which he is receiv- Mr. M. to a medical unit with one-to- the shower stalls, and noted that there ing antibiotic treatment. He is entering one supervision. were frequent tickets filed for slow a hypomanic state (elevated mood with draining showers clogged with patient disinhibition) or manic state (excite- The infected ulcers worsen and he hair, toilet paper, and other foreign sub- ment, euphoria or irritability, delusions, becomes increasingly ill and delirious. stances. After reviewing these records, grandiosity, and the like) and has been He has a below the knee amputation the TE subsequently hypothesized that threatening, verbally aggressive, sus- (BKA) to prevent further sepsis. Two fecal material may not have been ade- picious, destroyed property at home weeks later he undergoes above the quately rinsed off Mr. M’s feet because (punching walls, breaking objects), knee amputation when the BKA site he would be standing in undrained and ultimately brandishing a knife at becomes necrotic. He remains septic water. Due to Mr. M.’s agitation and family members. A neighbor hears the with sequential organ failure, and dies. foot pain, the unit psychiatric nurse commotion and calls the police. The The family consults an attorney. failed to remove his socks and inspect police enter the home and take Mr. M. his feet prior to applying ointment. into custody after he waves the knife Recognizing the psychiatric and medical This chain of events might be the at them and transports him to the complexities, the LNC contacts a testi- catalyst for his subsequent sepsis and Emergency Department (ED) where he fying expert (TE) forensic psychiatric premature death. requires restraints after continuing his nurse who reviews the records closely, aggressive posturing and language. He especially regarding the medical care of All of the autopsy records, laborato- is evaluated by a licensed psychiatric this aggressive, disorganized psychiatric ry records including wound cultures, professional and after consultation with patient. The TE is thoroughly famil- educational records, and other materials the attending physician and psychiatrist iar with the Scope and Standards of supported the TE’s conclusion that on call and is admitted to the locked Mental Health Nursing, the state Nurse the chain of events resulted in infec- psychiatric unit. Practice Act (especially regarding dele- tion, including the psychiatric nurses’ gation to and supervision of unlicensed failures to remove his socks, inspect his The unit psychiatric social worker workers), nursing interventions, the feet, and apply the topical medication. contacts the family and learns that Mr. MAR for the patient, etc. This did not exonerate other health M. has not been taking his psychiatric care professionals in this case from medications recently. Mr. M’s psychiat- The TE prepares a chart that graphs all responsibility, but the TE opined ric mood stabilizers and anti-psychotic medications, mood and behaviors, and that psychiatric nursing practice and medications are restarted. However, vital signs. A pattern emerges; pattern standards of practice on a locked unit after two weeks he is still agitated and at recognition is part of forensic nursing included such basic professional practice times aggressive. He has also developed education. The TE notes that ointment standards as administering topical med- diarrhea as a side effect of his antibiotic for the diabetic foot ulcers was often not icines (as delineated in basic nursing treatment. The nursing staff try to keep given and recognizes that omitting the textbooks) in additions to the standards his diabetic foot ulcers clean and try to foot ointment may have exacerbated his for psychiatric practice. The case settled have him remain in a wheelchair rather underlying medical condition. The TE out of court for many millions of dollars than risk further injury to his Charcot’s notes that due to his foot deformity, level for the family.

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 27 | Case #3 – The Dually-Diagnosed were involved. The LNC identified a ed contract. This would reveal whether Patient Who Overdosed forensic psychiatric nurse TE with a psychiatric care and supervision were subspecialty in substance abuse treat- based on funding resources for out-of- Ms. S., aged 23, had a long history of ment to review the case. This expert network providers or on retainer. self-cutting, bulimia, alcohol, cocaine, recognized significant details: and amphetamine abuse, and post The facility’s and insurance compa- traumatic stress disorder (PTSD) • PTSD ny utilization initial and concurrent arising from childhood sexual abuse. • Bulimia nervosa reviews provided answers to more More recently, she abused intravenous • Alcohol abuse questions: Was this the proper facility IV heroin after her orthopedic surgeon for this patient? Was psychiatric assess- discontinued her prescription for oxy- • Cocaine abuse ment and intervention appropriate? codone and acetaminophen (Percocet). • Amphetamine abuse Was the referral to the halfway house She later revealed that only opioids • Heroin abuse and IOP appropriate for Ms. S’s level of offered relief from the intrusive recol- • Self-cutting psychiatric and substance use disorders? lections of her sexual abuse; alcohol no • Court mandated treatment and longer helped. Review of Ms. S’s hospital discharge subsequent court ordered probation and referrals revealed deviation from After an arrest for driving under the supervised out of state but originally national standards of practice: appoint- influence of drugs and alcohol, she imposed in Ms. S.’s home state ments with an outpatient provider entered inpatient drug rehabilitation • An inpatient substance abuse treat- should have been set prior to discharge. for two weeks and detoxed successful- ment center that was part of a chain The utilization review nurse for the ly. She was stabilized on psychotropic of treatment centers owned by a facility learned on Friday that Ms. S.’s medications to treat her PTSD and larger for-profit corporation last covered day was on Sunday with discharged to her parents’ home with • A half-way house owned by a discharge on Monday morning. Dis- a prescription for a one-month supply. non-profit corporation charge planners did not work on the weekends and no one had the foresight Subsequently, her parents insisted that • A IOP based in a hospital lacking a she enter a halfway house residence and psychiatric service to set an outpatient psychiatric appoint- intensive outpatient program (IOP) in a ment timely despite knowing that nearby state to continue her recovery. This complex case crossed diagnostic discharge would be soon. groups, levels of care, and state lines. She walked from the halfway house Therefore careful review required scru- The halfway house was not licensed for to the IOP daily and attended 12-step tiny of professional practice standards dual diagnosis clients, nor adequately meetings there nightly. This halfway specific to each diagnosis, level of care, supervised or staffed for these complex house was in a neighborhood with an and state. patients. Regarding their clinicians’ active drug trade. Ms. S. did not make education, expertise, training, and Records showed that Ms. S. had a an appointment to be followed by an supervision, all except for the house minor criminal record for shoplifting outpatient psychiatrist for medication manager were unlicensed persons and uttering. The TE developed a list of management and ran out of her psy- whose expertise derived from their own other documents to be sought through chiatric medications after one month. historical substance abuse. Although discovery, which proved to contain some Approximately two weeks later, she a policy of random drug screens was very important information. overdosed on IV heroin during her in place, in practice such drug screens evening walk to a 12-step meeting. Her First, neither the treatment center nor were rarely conducted. parents consulted an attorney who sent its parent company was licensed to Similar review of the intensive outpa- the limited case information to an inde- provide services to dually-diagnosed tient program and the probation system pendent LNC for review. individuals, only to individuals with for appropriateness of this level of care primary substance use disorders. Upon initial screening, it appeared for a dually-diagnosed individual, the to the LNC that several breaches It was also necessary to discover level of psychiatric care, if any, provided of communication and supervision whether the parent company provided during the program, the credentials of occurred in this case and that multiple adequate resources for patients whose care providers, their education, and their and distinct treatment provider types residential stay was funded via a capitat- expertise disclosed further deficiencies.

| 28 | THE JOURNAL OF LEGAL NURSE CONSULTING As in the hospital and halfway house, • The staffing, training, expertise, and • The IOP was also not licensed to case management communication was psychiatric care was insufficient for provide care for dual diagnosis cli- virtually nonexistent. For example, the the care of such a complex case. ents, nor was the staff education and probation department thought random • The parent company of the sub- expertise adequate. drug screens were being conducted at stance abuse treatment facility • The IOP did not have appropriate the halfway house. The halfway house demonstrated a pattern of pre- psychiatric evaluation, consultation, thought the IOP was doing them cipitous discharge planning when or staff supervision to care for such a and sending results to the probation insurance benefits ceased. complex case. department. The IOP staff thought that • The discharge planning activities • The IOP did not communicate the local probation department and the delineated in internal policies and with the referring substance abuse halfway house were both doing them. procedures, including appointment treatment facility, the probation And finally, IOP staff did not think setting, were frequently disregard- department, the halfway house, or there was a problem because they were ed due to inadequate staffing and Ms. S.’s family. never received any positive results. resources. • The insurance company had provided A review of autopsy and post-mortem • The halfway house was not licensed several days of notice (as revealed by toxicology records (vitreous humor for the care of dually diagnosed clients. utilization review records obtained concentrations) revealed that Ms. S. • The staff at the halfway house were from the insurance company) that died from a massive overdose of heroin inadequately educated and supervised. Ms. S. needed to be stepped down to a lower level of care based upon cut with strychnine. Further, the post • Policies and procedures at the discussions with the substance abuse mortem physical exam showed multiple halfway house did not allow the facility’s utilization review agent. cuts on her inside thighs and vagi- transportation of unlicensed cli- nal area in various stages of healing, ents to offsite activities despite the • The insurance company failed to pro- indicating that Ms. S. had returned to house’s positioning in an area where vide appropriate case management self-cutting. Further, her stomach and drug dealing was occurring (failure services for Ms. S., a case or care intestines were devoid of foods, her to protect). manager that would coordinate all of these various agencies and providers. • The medical examiner’s autopsy and post-mortem toxicology demonstrat- The ability of the forensic psychiatric nurse ed that Ms. S. had injected drugs to review a multitude of critical records can several times before her death and that she died from heroin overdose provide the depth and breadth of a case and strychnine poisoning. for either the plaintiff or the defense team. This case settled out of court after suit was filed against all three levels of care and the parent companies. The probation department was not part of the suit due to governmental immunity in tooth enamel was eroded, and inflam- • Policies and procedures at the half- the jurisdiction. mation was noted in her esophagus. way house requiring random drug Last, she had several fresh needle punc- screening. were ignored and commu- SUMMARY ture wounds characteristic of IV drug nication with outside agencies (IOP, The role of the forensic psychiatric Probation) did not occur. use between her toes. nurse can be critical in review of cases • Halfway house staff did not veri- with elements similar to those described The expert forensic psychiatric nurse fy the adequacy of medication for above. The forensic psychiatric nurse concluded and opined during deposi- Ms. S. and did not facilitate refills navigates easily within and across tion as follows: either by setting an appointment for domains, knowing the laws govern- psychiatric follow-up or by contact- ing care of psychiatrically ill patients, • The substance abuse treatment facil- ing the sending facility for another substance abusing patients, and patients ity was not licensed for the care of prescription while Ms. S. waited for with co-existing disorders. Knowing dually diagnosed individuals. an appointment with a provider. typical routines on psychiatric units is

critical to understanding a case. The • Utilization review records (hospital Rachel Regan Boersma, ability of the forensic psychiatric nurse and payor/insurance company) Ph.D., R.N. is a forensic to review a multitude of critical records Psychiatric issues can be confound- psychiatric nurse and owner can provide the depth and breadth of ing and fascinating. Many cases could of Forensic Nursing a case for either the plaintiff or the benefit by review by psychiatric forensic Consultation. She has defense team. These include but are not nurses, such as nursing home patient- provided expert review and limited to: on-patient violence, allegations of testimony in a variety of psychiatric and • Unit layout dangerous behavior in a community, or substance abuse cases throughout the United States. Additionally, she is • Architectural schematics cases involving incarceration, to name a few. Consider consulting a forensic recognized as an expert in federal courts • Maintenance reports testifying about the consequences of psychiatric nurse to highlight and illu- • Unit staffing patterns torture and persecution on individuals minate their nuances to strengthen • Police reports seeking asylum in the United States. She your case. 4 is on the faculty of Indiana Wesleyan • Sentinel event documents University, teaching in the Graduate • Risk management records REFERENCE School of Nursing, and she is the Director • Toxicology and autopsy reports Center for Behavioral Health Statistics and of Nursing for Aware Recovery Care in • Federal and state statutes (across Quality. (2015). Behavioral health trends in the New Hampshire. She can be contacted at state lines) United States: Results from the 2014 National [email protected]. Survey on Drug Use and Health. (HHS • Nurse practice acts Publication No. SMA 15-4927, NSDUH • Professional standards of nursing Series H-50). Retrieved 9/29/2016 from practice www.samhsa.gov/data/.

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A Legal Nurse Consultant as Death Examiner

Melissa Becker RN, BA, CFN

n 1999 I stumbled across an ad for a The history of forensic medicine and certificate, provided the death does seminar sponsored by the local cor- death investigation has a very long not fall under the jurisdiction of the Ioner’s office. After several eight-hour history as outlined in Fourth Edition of coroner/medical examiner, Again, each training sessions dealing with topics Spitz and Fisher’s Medicolegal Investi- state determines its criteria (Centers such as blunt and sharp force injuries, gation of Death. The purpose of a death for Disease Control and Prevention strangulations, overdoses, suicides, investigation is to determine the cause (CDC), 2013). In general, a treating homicides and motor vehicle accidents, and manner of death, primarily, but not physician usually only signs death certif- including all the guts and gore you solely for the death certificate. icates for natural deaths. The National can imagine, I was hooked. I casually Association of Medical Examiners has slipped my business card to the pre- All deaths require a death certificate. guidelines and teaching tools for provid- senter stating if they needed any other While death certificates are modeled ers to fill out death certificates regarding investigators I was interested. Much after the “US Standard Certificate of cause and manner of death. Death to my surprise, they did call, and thus Death,” each state has their own form; investigations vary throughout the Unit- began my career into death investigation many can be completed on line. A ed States, and thus, the quality of the as a deputy coroner. treating physician can sign the death investigation varies as well. (Fig. 1)

A death certificate requires a cause of death statement, the opinion of the “certi- fier of death” that to the best of his or her knowledge the person died from the cause listed. It is not legally binding and can be amended later. However, many other entities rely on these opinions. A cause of death statement has two parts; with Part I being the primary medical condition/disease resulting in death or any disease or injury that initiated the events leading to the death. Part II allows the addition of significant contributing conditions, or preexisting or coexisting medical conditions that contributed in some say to the death (CDC, 2015). For example:

Part 1 Immediate cause: Chronic ischemic Fig. 1: Death Investigation Systems, http://www.cdc.gov/phlp/publications/coroner/death.html heart disease Due to or as a consequence of: atherosclerotic coronary artery disease County coroners are usually elected lay between the determination a medical individuals, such as funeral directors, professional may make regarding the Part 2 law enforcement, nurses, or physicians, cause and manner of death and what Other significant conditions: who serve a specific term. Medical the coroner may independently decide Hypertension, diabetes mellitus examiners are usually physicians, and certify as the cause and manner of and may be pathologists or forensic death remains the weakest link in the A legal nurse consultant can see how pathologists. Not all physicians are process.” (National Criminal Justice important an accurate cause and man- created equal; some physician coroners Reference System, 2009) ner of death statement are because they have specialities such as obstetrics or can provide the direct link between the family practice. Many states do not Reportable deaths are those deaths that medical condition causing the death regulate or require coroner education fall under the jurisdiction of the Coroner/ and litigation. Sometimes criminal or specialized training in death Medical Examiners to investigate and charges many years after the original investigation. The National Academy determine the cause and manner of death. injury occur because the cause of death of Sciences (NAS) report in 2009 Each state has different requirements is linked to earlier circumstances, e.g., stated the current process of death outlining which types of deaths require death from sepsis due to a pressure inju- investigation was a “fragmented,” investigation and or autopsy (CDC, ry in a person paralyzed from a gunshot “deficient,” and “hodgepodge” system 2013b). Some of the more common types wound 25 years ago, or a young person and recommended eliminating of deaths that require investigations are in a permanent vegetative state after an coroner-based systems nationwide. violent deaths, deaths under unusual or assault who dies of pneumonia eight months later. According to Strengthening Forensic mysterious circumstances, deaths caused Science in the United States: A Path by fire, deaths of inmates of public insti- “Manner of death” usually falls into Forward (2009), assessing the dead tutions, motor vehicle accidents. Sudden one of 5 common categories: natural, is a medical decision, and therefore a or unexpected deaths, deaths during or accident, homicide, suicide and pending/ medical professional — not “a layperson in associations with or as the result of undetermined/not classified. Because with investigative and some medical a diagnostic, therapeutic or anesthetic manner of death is circumstance-depen- training” — should make this decision. procedure and deaths outside a licensed dent, not autopsy-dependent, the quality The report concludes, “The disconnect health care facility. of the death investigation very important.

| 32 | THE JOURNAL OF LEGAL NURSE CONSULTING Circumstances are surrounding events that may or may not have an affect on what happened: relationships (divorce, marriage, fight, child custody issues, break-ups, abusive relationships), SCENE financial issues (loss of employment, bankruptcy, foreclosure, inheritance, gambling issues), medical issues (chronic medical conditions, mental health issues, change in medications, recent surgeries or procedures, recent hospital- AUTOPSY CIRCUMSTANCES izations, or falls), drugs/alcohol (recent prescriptions, rehab visits, driving under the influence, court issues, drug interac- tions, or doctor shopping), and recent events (long plane ride, death of close friend, loss of business, or legal issues). Fig. 6. Circumstances Components of a death investigation involves three equally importantcomponents; scene, autopsy and circumstances. Body/autopsy The coroner/medical examiner orders an autopsy not for criminal/civil reasons but to determine There are important civil, criminal, of property/room cleanliness etc. It cause and manner of death. If this can reliably be determined otherwise financial, public and epidemiological may also involve the temperature of implications for listing cause and man- then an autopsy might not be done. surroundings, who had access, who has For example, if the decedent had been ner of death. A death certificate is the been in or around the scene, how did the hospitalized, had diagnostic testing or primary basis for criminal charges, the body come to be found, how was access surgeries, or a prolonged hospital stay, legal proof of death for Social Security, gained to find the body, and so forth. the ME/coroner may sign the death and required to resolve estate issues and (Figs. 2-5, Scene photos next page) certificate based on reviewing medical death benefits. It also is important for records. Sometimes autopsy would be statistical data supporting decisions on In a motor vehicle accident (MVA), limited, such as to only the brain or research and public funding programs. issues such as type of roadway, type chest. If the death appears to be related of surface, curves in the road, visual to homicide, then a full autopsy would COMPONENTS OF THE obstructions and aerial views can become be done. In many civil cases an autopsy INVESTIGATION very important. The death examiner will is not done, so the death certificate is issued based on opinions/presumptions. A death investigation involves three look at the event time, and if the fatal equally important components; the The LNC should know that in this case, accident occurred at night, will obtain important vital issues can be missed. scene, circumstances and body/autopsy. pictures during day and night. Injuries Fig. 6. Gunshot wounds, with shot Each component by itself is important found in autopsy and be related to other pellets visible on x-ray and each component could have limited factors, e.g., whether seatbelts were used, or expansive details but it is the com- The quality of the death certificate is whether the person was ejected, whether bination of these three that impact the based upon the quality of the death the vehicle rolled over the person, or quality of the investigation and outcome. investigation. Death investigations cost whether a foreign body intruded into the money; more rural jurisdictions may Scene The scene is where the death passenger compartment. not have the same financial resources as occurred. Depending on type of case more urban jurisdictions. In addition, For deaths in a home, factors at the involved (e.g., motor vehicle accident, the level of training, experience and homicide, suicide, child abuse) various scene to consider include ancillary associations matter. If the local coroner scene details become important, such as items, such as blankets in a crib, unkept is also the local clinic physician investi- type of building, surroundings, indoors house or an unmowed lawn, or old food gating the death of a colleague’s patient, or outdoors, associated objects, upkeep sitting on counter. important issues may be overlooked or

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 33 | the scene , how the did scene the body , how come did the to body found, be come how to found, be was how access was gained access to gained , find the body and to so forth. , find the body and so forth. Figs. 2-‐5. Scene Figs. otos ph 2-‐5. Scene otos ph

In a motor In a vehicle motor accident (MVA), vehicle issues accident such (MVA), as issues type such of roadway, as type type of roadway, of surface, type of curves surface, in the road, curves in the road, visual obstructions visual obstructions and aerial views and aerial can views become can very important. become The death very important. The examiner death will examiner look at the will look at the event time, event and time, if the and fatal if accident occurred the at fatal night, accident occurred will at obtain pictures night, during will obtain pictures day during and . night Injuries day and . night Injuries found in found autopsy in and autopsy be related and be to related other factors, e.g., whether to seatbelts other were factors, e.g., whether seatbelts used, whether were used, the person whether the person was ejected, whether was ejected, the vehicle whether rollthe ed over vehicle the person rolled over , or the whether person , or a whether foreign i body ntru a ded foreign into the i body ntru ded into the passenger compartmentpassenger . compartment.

For deaths For in deaths a home, in factors a home, at factors the scene at to consider include ancillary the items, scene to consider include ancillary such as items, blankets such in a crib, as blankets in a crib, the the scene scene , , how how did did the body come come to to found, be found, be how how was was access access gained gained to , find the body to and , find the body so and forth. so forth. unkept house or an unmowed , lawn or old food sitting on . counter Figs. Figs. 2-‐5. 2-‐5. Scene Scene otos ph otos ph unkept house or an unmowed , lawn or old food sitting on . counter FEATURE

Fig. 2-5: Scene photos In a motor vehicle accident (MVA), issues such as type of roadway, type of surface, curves in the road, not addressed. Once I evaluated a drug visual obstructions and aerial views can become very important. The death examiner will look at the In a motor vehicle accident (MVA), issues such as type of roadway, type of surface, curves overdose in the road, case in which the coroner event time, and if the fatal accident occurred at night, will obtain pictures during day and . night Injuries visual obstructions and aerial views can become very important. The death examiner will who look at the investigated the death was the found in autopsy and be related to other factors, e.g., whether seatbelts were used, whether the person prescribing physician; he filled out the event time, and if the fatal accident occurred at night, will obtain pictures during day and . night Injuries was ejected, whether the vehicle rolled over the person , or whether a foreign i body ntruded into the death certificate citing the manner of RELATIONSHIPS found passenger in compartment autopsy . and be related to other factors, e.g., whether seatbelts were used, whether the person death as “natural.” was ejected, whether the vehicle rolled over the person , or whether a foreign i body ntruded into the The person performing the autopsy For deaths RECENT in a home, factors at the scene to consider include ancillary items, FINANCIAL such as blankets in a crib, passenger compartment. needs information about the scene and unkept EVENTS house or an unmowed , lawn or old food sitting on . counter ISSUES circumstances. Incomplete information For deaths in a home, factors at the scene to consider include ancillary items, such as blankets in a fromcrib, a poor investigation will affect unkept house or an unmowed , lawn or old food sitting on . counter the final determinations on cause and manner of death. Preconceived notions impact death investigation. One case involved a per- DRUGS/ MEDICAL son with a gunshot wound to the head; ALCOHOL ISSUE the gun was found at the scene, and the emergency medical services personnel Fig. 6. Gunshot wounds, with shot pellets visible on x-‐ray report documented “suicide, exit wound at the top of the head.” However, autopsy indicated the wound at the top of the Fig. 6: Circumstances head was in fact an entrance wound, leading to an investigation for murder.

CASE EXAMPLE #1 Driver of vehicle involved in a single vehicle motor vehicle accident in which the vehicle went off the road and the driver died at the scene.

Scene: • Rural county road • No witnesses • Police report: highway speeds, small right turn • Vehicle kept going straight over Fig. 6: Gunshot wounds, with shot pellets visible on x-ray guardrail, down steep incline, landed on driver’s side of vehicle

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The quality of the death certificate is based upon the quality of the Death death investigation. investigations cost money; more rural jurisdictions may not financial have the same resources as more urban jurisdictions. In addition, the level of training, associations experience and matter. If the local coroner is the also local clinic physician investigating the death of a colleague’s patient, important issues may be overlooked not or addressed. Once I evaluated a drug dose over case in which the coroner who investigated the death prescribing was the physician; he filled out the death certificate citing the manner of death “ as natural.”

The person performing the needs autopsy information about the scene and circumstances. Incomplete information rom f a poor investigation will affect the final determinations on cause and manner of death.

Preconceived notions impact death investigation. One case involved person a with a gunshot wound to the head; the gun was found at the ical scene, and the emergency med services personnel report documented “suicide, exit wound at the top of the head.” However, autopsy indicated the wound at the top of the head was in fact an entrance wound, leading to an investigation for murder.

Case Example #1

Driver of vehicle involved in a single vehicle motor in vehicle accident which the vehicle went off the road and the driver died . at the scene

Fig. 7: Case #2 Scene:

Circumstances: Summary: • Winding rural road, no street-  Late at night, heavy snowfall lights, no shoulder, deep ditches • Issue was “Act of God” vs. insurance • Driver talking to wife at time of acci- on both sides dent, told her to “Hold on!” coverage  Winding ural r road, streetlights, no no shoulder, deep ditches • Vehicle stopped on both sides in middle of road • Accident occurred at this time • Suffered event from medical issue • No braking, skid marks, unusual – sudden cardiac arrest R/T under- • Body under vehicle, face down, marks, Vehicle curve in road stopped in middle lying of road cardiac condition hand and foot sticking out from • Medical responders were EMTs, • However, argument made that underneath delayed Body arrival under vehicle, face circumstances down, prevented hand medical and foot • Massive sticking blood out from underneath loss under body • Prolonged extrication due to vehicle attention from reaching him timely, • Obvious blood, bone and tissue trail location thus causing his death; cardiac arrest of 416 feet • Unable Massive to get to driver blood to render loss under was body possibly survivable without • Tire tracks from vehicle appear to be medical care prolonged extrication and delay in getting to driver in opposite traffics path (wrong side Autopsy: Obvious blood, bone tissue and trail of 416 feet of road) • Lack of higher level training of first • Atherosclerotic heart disease responders was also important, as no Circumstances: • Left anteriorTire descending tracks and from vehicle defibrillator appear was available. to be in opposite traffics path (wrong side of road) right coronary artery with • Driver did not see anything prior to CASE EXAMPLE #2 running over “something” Circumstances:75-90% blockages • Cardiomegaly with biventricular Driver of small vehicle runs over some- • Passenger yelled “Watch out!” and hypertrophy thing in the middle of the road, stops said, “I think you ran over someone.” • Pulmonary Driver congestion did not see the anything vehicle to find prior a body under to the car. running over “something” • Driver did not stop right away, did • History DM (Fig. 7) not believe it was a person • Thoracic vertebra fx, left lateral rib fx, • Driver had been drinking, previous Passenger yelled W “ atch outScene:!” and said, “I think you ran over . someone ” minimal associated hemorrhage DUI • Toxicology negative • Late at night, heavy snowfall • Driver and passenger switched places  Driver did not stop right away, did not believe it was a person ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 35 | FEATURE

prior to PD arrival, gave story that than just the circumstances. Each of passenger had been driving these components is vital to under- Autopsy: standing what happened. The overall quality of the investigation directly • Multiple traumatic injuries asso- reflects the quality of the details. Check Your Answers ciated with motor vehicle vs. After several hundred investigations pedestrian accident over two years, I left the coroner’s office, Test Your Case • Head trauma – scalp laceration, but I continue to apply what I learned Screening Skills comminuted calvarial and basilar to each case I review that involves a skull fractures, cerebral laceration death. This experience was very valuable 1. Investigate and destruction in helping me to hone my investigation • Thoracic trauma – multiple rib frac- and critical thinking skills, of vital value • Pedicle screw into sacral tures, pulmonary contusions for a legal nurse consultant. 4 nerve probably malpractice • Abdominal trauma – spleen and liver • 5 month delay in diagnosis lacerations, retroperitoneal hemorrhage REFERENCES and treatment of injured Centers for Disease Control and Prevention nerve • Toxicology (victim) – blood alcohol Office for State, Tribal, Local, and Territorial .20, drug screen negative • Significant pain & suffering Support (2013a) Selected characteristics for death - permanent Summary: requiring investigation by state www.cdc.gov/ phlp/docs/coroner/table1-investigation.pdf • Permanently disabled from working • At issue here was whether the victim Centers for Disease Control and Prevention was dead before he was hit by the car Public Health Law Program (2013b). Select- • Possible conflict between surgeon and hospital, cul- • What was the victim’s body position ed characteristics of deaths requiring autopsy by state www.cdc.gov/phlp/docs/coroner/ minating in his departure. before being hit? Why was he in the table2-autopsy.pdf middle of road? Disposition: $1.4 million Centers for Disease Control and Prevention settlement at mediation • Further investigation revealed that National Center for Health Statistics (2015). victim had been drinking heavily and Where to write for vital records. www.cdc.gov/ probably passed out in road prior to nchs/w2w.htm 2. Reject being struck National Criminal Justice Reference Service (2009) Strengthening forensic science in the • Heavy snowfall and lack of lighting United States: A path forward. NCJ National • Delay in cutting cord is not made victim difficult to see until it Research Council www.ncjrs.gov/pdffiles1/nij/ malpractice and does not was too late grants/228091.pdf Retrieved September 2016 cause apnea • Driver might not have been charged • According to literature, may had he stopped immediately and not be difficult to pick up BWS Melissa Becker RN, BA, on prenatal ultrasounds and lied about who was driving CFN, is a Certified Forensic no established guidelines • Details of the investigation, however, Nurse and former death exist for the prenatal diag- was a mitigating factor in sentencing investigator with extensive nosis of this condition experience in performing • Earlier diagnosis of con- • Opinion that victim’s face was facing both civil and criminal genital condition would not away from the vehicle at the time he investigations. She complet- have changed the outcome. was struck and was alive at time of ed her bachelor’s degree with a focus on Thus, no harm. being struck, given length of blood trail the study of crime and crime victims. She • Clients declined amnio- and large pool of blood 416 feet later has been in private practice since 1997 and works on cases such as; wrongful centesis, which may have • Opinion that whether victim might death, personal injury, medical malprac- detected disorder. have survived if driver stopped right tice and the full array of criminal cases. away was unknown, but possible She has lectured to attorneys, judges, law enforcement, nurses and other groups on Death investigations are about more a variety of topics related to forensic than just the autopsy report, more than investigations. She can be contacted at just the scene investigation, and more [email protected]

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The Continuing Enigma of Sudden Unexpected Infant Death

Thomas Andrew, MD, FCAP, FAAP

Keywords: SIDS, SUID, triple risk model, sleep environment, diagnostic shift, autopsy

Sudden unexpected infant death (SUID), even in 2016, more often than not remains incompletely explained, even after a meticulous scene investigation, complete autopsy, and thorough review of the medical record. This article discusses the evolving understanding of SUID, the dramatic decline in the diagnosis of sudden infant death syndrome (SIDS) by forensic pathologists, and the critical importance of detailed investigation of the scene and circumstances of the infant’s death, including doll re-enactments of the fatal episode. It also discusses scope and limitations of autopsy and ongoing difficulty in characterizing different types of SUID accurately for epidemiological purposes.

he tragedy of the sudden, unexpected death of a previ- During a critical period of abnormal T ously healthy infant has been neurodevelopment, multiple stressors described since antiquity. One of the first recorded cases can be found in such as subclinical infection, thermal the Old Testament Book of I Kings 3: 16-28, a case of asphyxia by overlaying. stress, rebreathing exhaled carbon dioxide, Similar incidents without apparent and others can converge to produce explanation continued to haunt human- kind. This phenomenon was eventually sudden death. dubbed sudden infant death syndrome (SIDS) by a conference of experts in the field in 1969 (Beckwith, 1970). Etio- logical theories ranging from infectious published by Dr. Alfred Steinschneider. investigation, including performance of to immunological reactions to vaccines The theory came crashing down with a complete autopsy, examination of the to environmental exposures such as the revelation in 1995 that a center- death scene, and review of the clinical lead and black mold were advanced, but piece of Steinschneider’s work was, in history.” (Williger, et al., 1991) What none have been definitively proven and actuality, the serial homicide of five constitutes a complete autopsy and many are now known to be invalid. children in the same family perpetrated adequate scene examination remains by their mother. This dramatic episode a subject of debate even today, but the For example, in one novel hypothesis, is chronicled in The Death of Innocents basic definition itself has stood the test so-called auto-brewery syndrome had by Richard Firstman and Jaimie Talan, of time. once been implicated as an etiolo- published in 1997. gy of sudden infant death. Candida The 1980s also saw the refinement of albicans can produce alcohol from Other theories as to the root cause of Wedgwood’s 1972 “triple risk model” of glucose, and dominated intestinal flora the phenomenon have emerged, but SIDS by Filiano and Kinney, eventually in some SIDS cases. Thus the theo- the medical and scientific communities, published in 1994. According to this ry was ethanol production in the gut and more importantly, families faced model, sudden death in SIDS results (auto-brewery) led to intoxication with with the seemingly instantaneous loss from the intersection of three overlap- enough respiratory depression as to of a child still face more unanswered ping factors: (1) a vulnerable infant; induce prolonged apnea and death. questions than evidence-based expla- (2) a critical developmental period nations. In 1974 Congress passed the in homeostatic control, and (3) an A paper in the German literature Sudden Infant Death Syndrome Act, exogenous stressor(s). Death will ensue published in 1982 showed ethanol was which recognized SIDS as a significant only if the infant possesses all three produced at a maximum rate of 1 mg public health issue. This Act directed factors; the infant’s latent vulnerability per gram of intestinal content per hour. the National Institute of Child Health is exposed by entrance into the critical The authors concluded that the intesti- and Development (NICHD) to take period and is subject to an exogenous nal production of alcohol in vivo from the lead on SIDS research within the cases with Candida albicans-dominated U.S. Public Health Service. stressor (Filiano and Kinney, 1994). intestinal flora does not surpass the The basic concept can be illustrated in liver’s normal capacity to metabolize EVOLVING CONCEPTS Figure 1. alcohol. Furthermore, measurable con- OF SUID Research suggests that there are likely centrations of alcohol in the blood from one or more specific neurodevelop- such cases cannot be expected from this While a single unifying theory remained mental disorders that can make an mechanism in these kinds of deaths. elusive, the NICHD convened another infant vulnerable. During a critical (Geertinger et al., 1982) consensus conference of experts in the field in 1989 for the purpose of estab- period of abnormal neurodevelopment, Throughout the 1970s the wider med- lishing a standard definition of what multiple stressors such as subclinical ical community accepted the etiological was then referred to as SIDS. Their infection, thermal stress, rebreathing theory of sustained apnea during sleep proposed definition, published in 1991 exhaled carbon dioxide, and others leading to a hypoxia-mediated cardiac was, “the sudden death of an infant can converge to produce sudden death. arrhythmia. This belief stemmed in no younger than 1 year of age that remains Among the proposed neurodevelop- small part from a series of sleep studies unexplained after a thorough case mental abnormalities proposed as

| 38 | THE JOURNAL OF LEGAL NURSE CONSULTING prone sleeping as a risk factor. Based on research findings, AAP formally rec- INFANT ommended that U.S. babies be placed on their backs or sides to sleep in 1992 VULNERABILITY (AAP, 1992). In 1994 the NICHD launched the Back to Sleep® campaign in collaboration with the AAP and other entities. Conferences, informational mailings and thousands of public service S announcements spread the Back to Sleep message, now called “Safe to Sleep.” I D Based on additional research, in 1996 S the AAP sharpened their recommenda- DEVELOPMENT ENVIRONMENT tion, stating that U.S. babies should be placed to sleep solely on their backs, as this is associated with the lowest SIDS risk. The AAP further recommended using firm sleep surfaces and avoiding the use of soft bedding in cribs. Fig. 1: Triple risk model for SIDS A heretofore unconsidered target for sleep safety education was revealed by causative or contributory to sudden • a mouse model, suggesting abnormal Rachel Moon’s important retrospective infant death, the one that has shown development and loss of cerebellar study of 1,916 SIDS cases (Moon, Patel the most promise involves the concept Purkinje cells adversely affecting the and McDermott-Shaefer, 2000). Moon of a medullary serotonergic network ability to recover from hypercarbia found that 20.4% of deaths studied deficiency. Published in 2001, the (Calton et al., 2016) occurred in child care settings versus an hypothesis focused on examination of • laryngeal reflex apnea potentiated by anticipated 7% rate. The anticipated rate serotonergic neurons in specific regions upper airway infection (Scadding et was calculated as a function of overall of the infant brain (ventral medulla and al., 2014), infant death rates against the back- the medullary reticular formation). The • failure of brainstem-mediated autore- ground of time spent by infants in and authors suggest observed developmental suscitation (Randall et al., 2013) out of home child care. Sixty percent of anomalies of this network results in a deaths in child care were in non-com- failure of protective responses to various BACK TO SLEEP/BACK TO mercial settings. Infants in child care life-threatening stressors, particularly THE FUTURE were more likely to be placed prone for during sleep as the infant passes through The 1990s ushered in a new era of sleep or found prone and unresponsive. a critical period of homeostatic control. prevention efforts focused on initially This was particularly important when (Kinney, Filiano and White, 2001) sleep position and evolving to today’s the infant’s usual sleep position was lateral or supine. There are other hypotheses. Neural, emphasis on sleep environment. Studies cardiac, metabolic, genetic, immunolog- published in Australia (Dwyer et al., The authors opined that infants sent ical, infectious and physiologic research 1995), New Zealand (Mitchell et al., home with parents who were given remains ongoing. A survey of recent 1994), and the United Kingdom (Mark- instructions to put their infants in the published work suggests research con- stead et al., 1995) showed a significant supine position for sleep were unaccus- tinues on a broad front, including: link between SIDS and prone sleeping. tomed to prone sleep. When mothers This was the genesis of public educa- went back to work and made child care • identification of developmental tion campaigns recommending that arrangements with family or friends who defects of specific brainstem centers infants be placed to sleep on their sides had not been educated as to the risk, involved in hearing pathways, suggest- or backs. The newly formed American they tended to place infants in the prone ing a possible influence of the acoustic Academy of Pediatrics (AAP) Task position. Today, training in safe sleep system on respiratory activity (Lavez- Force on Infant Sleep Position and environments is a requirement for com- zi, Ottaviani, and Matturi, 2015) SIDS began to evaluate studies on mercial childcare providers most states.

1.6 SIDS vs Cosleeeping

1.4 Buenos Aires

1.2 New Zealand 1 Germany Australia 0.8 Manitoba, Canada 2 cities, Austria 0.6 Scotland Ireland Ukraine 0.4 Japan Sudden infant deaths per 1000 Graz, Austria Copenhagen Sweden 0.2 Hungary Hong Kong Beijing, China

0 10 20 30 40 50 60

Percent cosleeping over 5 hours

Fig. 2: Comparison of international rates of co-sleeping and sudden infant death. After Palmer in Baby Matters

Regarding the issue of firm sleep more and longer breast feeding, “safe” 2015, a Swedish study group of SIDS surfaces and soft bedding, there have bed-sharing is “protective” against SIDS reported a significantly higher prevalence been declines in potentially hazardous because of increased infant arousability, of bed sharing than in explained infant bedding use since the 1990s, but this and that bed-sharing is common in “low deaths and that prone sleeping was still trend has slowed since 2000. SIDS cultures.” (Palmer, 2007, Mile- overrepresented. (Möllborg et al., 2015) va-Seitz, et al., 2016) Approximately 50% of US parents, and DECLINE IN THE DIAGNOSIS two-thirds of black and Latino parents, Safe sleep advocates point to the risk of continue to use thick blankets, cushions, falls, overlaying, wedging, entrapment, OF (SIDS) BY FORENSIC pillows, and other potentially hazardous and thermal stress combined with the PATHOLOGISTS soft bedding, either under or covering factors of maternal fatigue, obesity, and The 1990s was also the era of “diagnos- the infant for a variety of stated reasons, impairment by drugs and/or alcohol, tic shift” when, against the backdrop of including perceived increased comfort creating conditions that make the family declining SIDS rates and the apparent and warmth (Salm and Ngui, 2015). bed untenable when it comes to very success of the Back to Sleep campaign, young infants. (Moon and Hauk, 2015, there were increased numbers of cases In 1997, research that continues to be Shapiro-Mendoza et al., 2014) Further- certified as of undetermined cause and controversial suggested that bed-shar- more, potentially hazardous bedding manner of death and more frequent ing between adults and infants, use is more common among infants diagnoses of accidental asphyxia due to especially under certain conditions, may sleeping in adult beds (71.5%), and unsafe sleeping environments (Byard increase SIDS risk. Notwithstanding, when sharing a sleep surface (70.0%) and Beal, 1995, Mitchell, et al., 2000, bed-sharing increased among new par- (McBride, 2015). Perrizo and Pustilnik, 2006). This was ents from 5.5 to 12.8% between 1993 attributed to better and more compre- and 2000. Bed-sharing also frequently The debate continues to rage today, but hensive scene investigation (Images 1-3). means soft bedding and bed-sharing even the most ardent of shared sleep infants are twice as likely to be covered advocates will agree there are factors As early as 1977 Jones and Weston pro- by a quilt or comforter as crib sleepers. such as maternal drug and/or alcohol posed specific investigative and autopsy Proponents of the “family bed” hold use, sofa sleeping, unsafe space between protocols for infant deaths (Jones and that bed-sharing is a normative human mattresses and/or headboards, overly Weston, 1977). Their recommendations pattern altered by modern furniture, heavy or fluffy bedding, and others that went largely unheeded, but nine years behavior, etc., bed-sharing promotes make bed-sharing unsafe. As recently as later a controversial paper suggested

| 40 | THE JOURNAL OF LEGAL NURSE CONSULTING Image 1 & 2: Inflatable bed in which a 10-month-old was found wedged between a soft headboard Image 3: Pulmonary edema foam observed in and mattress scene investigation

that every sudden unexpected infant the 1996 document. It was, and still is SUIDI INVESTIGATIVE TOP 25 death case they investigated yielded believed that improved data collection a critical environmental feature that enhances diagnostic accuracy and a explained the death, usually caused by more standardized approach to death • Case information asphyxia. (Bass et al., 1986) This ush- investigation and certification much • Asphyxia ered in a period of renewed interest in better informs prevention strategies. • Sharing sleep surfaces the scene of death as critical for complete investigation. The new working group was larger • Change in sleep conditions and more multidisciplinary than was • Hyperthermia/hypothermia IMPORTANCE OF A involved in the prior document; their • Environmental hazards (CO, DETAILED SCENE charge included developing a training chemicals, etc.) curriculum to accompany the new and INVESTIGATION • Unsafe sleeping condition improved SUIDIRF. (Andrew et al., • Diet It is axiomatic in virtually every field of 2006). This effort culminated in five • Recent hospitalizations medicine that patient history carries 75 separate training academies involv- • Previous medical diagnoses to 90% of the diagnostic weight; foren- ing representatives from ten states at • History of “acute life threatening sic medicine is no different. It is likewise each to introduce the new SUIDIRF, events” axiomatic that the forensic autopsy its goals, and objectives and train the • History of medical care without begins at the scene. The diagnostic shift representatives to disseminate the diagnosis of the 1990s prompted a major initia- information in their own states. An • Recent fall or other injury tive by the Centers for Disease Control enduring legacy of that effort is the • History of religious, cultural or and Prevention (CDC) to bring some Sudden Unexplained Infant Death ethnic remedies degree of standardization to the process Investigation Investigative Top 25 (Fig. • Potential known natural causes of infant death scene investigation. 3). Forensic pathologists in the United • Prior sibling deaths The basic data-gathering tool devel- States generally agree that this core • Previous encounters with police or information is critical to the accurate social service agencies oped by the CDC was the Sudden Unexpected Infant Death Investigation determination of cause and manner of • Request for tissue or organ donation Reporting Form (SUIDIRF). Spurred death in infants who die suddenly, and • Objection to autopsy by Congress, the CDC embarked on that this information should be made • Resuscitative treatment an effort to improve infant death scene available to the forensic pathologist • History of trauma, poisoning or investigation nationally and rolled out before autopsy as it may guide autopsy intoxication their guidelines and the first iteration of technique and ancillary testing. • Any suspicious circumstances SUIDIRF in 1996 (Iyasu, et al. 1996). • Other alerts for pathologist’s attention Item 24 is now routinely augmented in • Detailed description of circumstances Forensic pathologists resisted this, many jurisdictions by a re-enactment of • Pathologist information perceiving it as a top-down edict with the circumstances of death using a doll. (name/agency/phone) little to no input from the community When suggested by Bass in the 1980s specifically charged to investigate such the concept was considered scandal- deaths. The CDC responded by conven- ous, and was vigorously resisted by Fig. 3: SUIDI Investigative Top 25. ing a working group to review and revise many pediatricians who perceived this

Image 5: Position of mother and seven-day-old Image 6: Mother woke with infant’s head infant when breast fed wedged between her breast and right arm

Image 4: SUID scene investigation doll. Image 7: Position when napping on sofa with Image 8: Father awoke with infant wedged 22-day-old in couch as a gratuitous intrusion on caregiv- While the National Association of Medi- rhythm or structural abnormalities may ers’ intense guilt at a highly charged cal Examiners (NAME) has promulgated become routine. moment. Time has taught us otherwise. forensic autopsy performance standards, It has become clear that parents’ need the document is silent on the specifics of POSTMORTEM an infant autopsy (NAME, 2006). to understand what happened to their EXAMINATION baby much more frequently trumps At a minimum you should expect the any resentment at providing a sensi- COMPONENTS following from the medical legal author- tive, professional investigator critical External examination ity performing autopsies on infants in information about the circumstances The gross examination of the autopsy these kinds of cases in your jurisdiction: of death. The preference in my juris- should begin with a detailed inspec- diction in New Hampshire is using a • thorough external and systematic tion of all external surfaces. Artifacts rather featureless, simple doll (Image 4) internal examination of resuscitation are resolved. Subtle with printed signs for the “placed” and • skeletal survey external features, such as contusions “found” position of the infant. on a non-ambulatory infant, cutaneous • tissue sampling for microscopical vesicles or pustules, petechiae, a sunken evaluation Results of these re-enactments have fontanelle, unusual livor mortis pat- provided information that meant the dif- • cultures of blood, spinal fluid and terns, particularly those inconsistent ference between an etiologically specific other sites as indicated with the proffered history and others cause of death versus certification of the • a toxicological screens may be harbingers of a diagnosis other death as “undetermined,” as illustrated by • screen for inborn errors of metabolism than SIDS (Images 9-12). There may the images above (Images 5-8). Formal consultation with a neuro- be an attempt to visualize the retinae using direct or indirect ophthalmoscopy. SCOPE AND LIMITATIONS pathologist experienced with infant brains and/or a pediatric cardiologist The presence of retinal hemorrhages OF AUTOPSY as indicated may be considered. When will dramatically shift the focus of the What constitutes a “complete” infant the cost of such testing falls into a range autopsy. Cultures of blood, cerebrospi- autopsy is still subject to debate and that is not prohibitive for public sector nal fluid and perhaps a nasopharyngeal largely a function of resources available to agencies like coroner and medical exam- swab for viral pathogens are obtained the agency carrying out the examination. iner offices, routine screening for cardiac during the external examination.

| 42 | THE JOURNAL OF LEGAL NURSE CONSULTING At some point during the external survey and before any internal examination takes place a radio- logical skeletal survey should be conducted. Note the term used here is not random or non-specific. A so-called “babygram,” in which the deceased infant is simply placed on a large radiology cassette and radiographed, Image 9: Infant as found by the investigator. Image 10: Distinct parallel linear marks over the is diagnostically insufficient. Livor pattern inconsistent with the position of occiput The approach should mirror the the body. radiography of suspected abuse in that there are individual, tightly collimated, coned down views of specific anatomical regions. At a minimum this should include AP and lateral views of the head, chest and abdomen, including the spine, pelvis and extremities, with separate images of the hands and feet.

Internal examination Image 11: Specific questioning determined Image 12: Livor pattern consistent with elec- This will consist of a systematic that infant was found wedged between broken tronic equipment where wedging occurred inspection of all internal organs crib rail and wall with specific attention paid to critical anatomic relationships and structural normalcy of major organs. There are a number of diagnostically, nonspecific findings that are commonly seen in sudden infant death but must be interpreted holistically in the context of the entire investigation and circumstances surrounding the death. Such findings include Image 13: Thymic petechiae Image 14: Pleural petechiae pulmonary congestion, edema or even overt hemorrhage, petechiae on the thymus, epicardial surface and/or visceral pleura (Images 13, 14), minimal to moderate termi- nal aspiration and small, focal, perivascular CNS hemorrhages. Previously undiagnosed congenital anomalies may be revealed, particularly those of the cardiovas- cular system that may fully explain sudden death (Images 15, 16). Image 15: Left ventricular hypertrophy in a Image 16: Previously undiagnosed coarctation The internal examination includes 6-month-old who died suddenly during a of aorta in infant from image 15 respiratory illness obtaining various tissue and fluid samples for ancillary studies such

Image 17: Respiratory syncytial virus (RSV) Image 18: Viral myocarditis. Note inflammation Image 19: Confluent bronchopneumonia bronchiolitis about conduction fiber at lower right as toxicological analysis, screen for ing evidence that such disorders may histology, and 97%, including toxicolo- inborn errors of metabolism, serology, account for up to 10% of sudden unex- gy. (Lambert et al., 2016) genetic studies and, of course, histologi- pected death in otherwise previously cal examination. healthy infants. (Arnestad et al., 2007; Difficulty in accurately characterizing Rhodes et al., 2007; Morris, 2015) SUID for epidemiological purposes Microscopic Other than the scene investigation, At present, the cost of such screening In years past, when SIDS was recog- the microscope is the tool with the studies prevents most medicolegal juris- nized as a distinct entity, most infants highest diagnostic yield when it comes dictions from routinely pursuing them dying suddenly and unexpectedly were to specific diagnoses responsible for except in very selective circumstanc- assigned this cause of death. Unfortu- sudden, natural infant death. It is this es. Anticipated price reductions for nately, though, an unknown percentage instrument that will yield diagnoses developing technology, CDC funding of these cases were classified improperly not definitively discernable to the for studies, and the epidemiological because there was never a thorough naked eye such as infectious processes data on sudden unexpected death in death scene investigation, or autopsy (Images 17-19), metabolic disorders infants and young children will enhance was inadequate or never occurred at all. (e.g. microvesicular fatty change of the the evidence base and encourage more Nevertheless vital records nosologists liver associated with medium-chain widespread testing. dutifully assigned the International acyl-CoA dehydrogenase deficiency and Classification of Diseases code, R95, for other inborn errors of metabolism), Looking even farther into the future, SIDS (Table 1.) Epidemiological data cardiomyopathies (e.g., histiocytosis whole-exome sequencing may yield developed from such death certificates cardiomyopathy, endocardial fibroblast diagnoses explaining sudden unex- and inferences therefrom are suspect, stenosis) and even occult neoplasms pected infant death that currently given these serious shortcomings. (e.g., endocardial rhabdomyoma). routinely escape us. A recent case report described a 15 day old infant The era of diagnostic shift introduced Other studies who was posthumously found to have 2 a new set of epidemiological issues. Ancillary studies such as bacterial mutations in the CLCNKB gene, lead- In some jurisdictions, the diagnosis and viral cultures, toxicology, vitreous ing to a molecular diagnosis of Bartter of SIDS was abandoned altogether. electrolytes and screens for inborn syndrome type III, the likely cause of Overall, diagnoses of asphyxia errors of metabolism can more clearly death. (Lopez et al., 2015) increased, as did certifications define diagnoses suggested by the gross of cause and manner of death as and microscopical examination and in Progress is being made on the inves- “undetermined.” Certificates of death some instances may provide the diag- tigative and autopsy front. A recent were fashioned in a more descriptive nosis in and of themselves. The issue study analyzing 770 cases of sudden manner, sometimes including the sleep of screening for genes encoding ion unexpected infant death showed that environment in which the infant died channels responsible for prolonged QT 98% had a death scene investigation. if deemed to be unsafe. Ironically, syndrome (LQTS) and other rhythm Critical information about 10 infant the nuances of this approach to disturbances as well as structural pro- sleep environment components was certification of death was lost on the teins such as desmosomal genes looms available for 85%. All 770 cases had an nosologists who, when encountering especially large in the face of increas- autopsy performed with 98% including any combination of the words,

| 44 | THE JOURNAL OF LEGAL NURSE CONSULTING ILL-DEFINED AND UNKNOWN CAUSES OF MORTALITY (R95-R99) Excludes: fetal death of unspecified cause (95), obstetric death NOS (O95)

R95 Sudden infant death syndrome R98 Unattended death Death in circumstances where the body of the deceased was found and no cause could be discovered R96 Other sudden death, cause unknown Found dead Excludes: sudden: • cardiac death, so described (I46.1) • infant death syndrome (R95) R99 Other ill-defined and unspecified R96.0 Instantaneous death causes of mortality R96.1 Death occuring less than 24 Death NOS hours from onset of symptoms, Unknown cause of mortality not otherwise explained Death known not to be violent or instantaneous for which no cause can be discovered Death without sign of disease

Table 1

“sudden,” “infant” and “death” often such deaths have been published. Krous or mechanical asphyxia or autopsy continue to assign the R95 code. Thus, et al. published what they termed a abnormalities not sufficient to be interpretation of death certificate data “definitional and diagnostic approach” to unequivocal causes of death, the classification of sudden, unexpected remains problematic. • Unclassified Sudden Infant Death: infant death in an effort to systematical- does not meet category I or II criteria This conundrum extends to the inter- ly stratify the kinds of deaths forensic and alternative diagnoses of natural national level where there remains pathologists evaluate evaluated every or unnatural conditions are equivo- substantial variation in how different day (Krous et al., 2004). Their proposed cal, including cases in which autopsy countries code sudden unexpected classification system was as follows: infant death. The proportion coded is not performed. as R95 ranges from 32.6% in Japan to • Category IA SIDS: classic features The thought was that with widespread of a previously healthy infant in a 72.5% in Germany. The proportion of use of this classification system, the safe sleep environment and complete deaths coded as accidental suffocation coding system for such deaths would be documentation of the scene and and strangulation in bed (W75) ranged more precise, for example, R95 for cate- circumstances of death from 1.1% in Germany to 31.7% in gory IA, R95.1 for category 1B, etc. The New Zealand. (Taylor et al., 2015) • Category IB SIDS: classic features classification never gained wide accep- but incomplete documentation Clearly, a standardized approach to tance, however, and the coding, statistical, classification and vital records coding • Category II SIDS: meets category I and epidemiological problems remained. remains elusive. criteria with specific exceptions such as similar deaths among so siblings Shapiro-Mendoza et al. captured Two relatively recent attempts at devel- or other relatives, the inability to 436 sudden unexpected infant deaths oping a stratified classification system of rule out the possibility of suffocation reported to a case registry created by

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 45 | FEATURE the CDC in 2009 and published a proposed classification system based on Curious, that in this age of ever increasing analysis of these cases in 2014. (Shap- technical wizardry, the most critical iro-Mendoza et al., 2014) This group categorized unexplained infant death by element in the evaluation of these deaths accompanying factors: is simply asking the right questions of the • No autopsy or death scene investigation right people in the right way. • Incomplete case information • No unsafe sleep factors • Presence of unsafe sleep factors • Possible suffocation due to unsafe sleep factors and explained with suf- right people in the right way. A forensic Sudden Death in Infants, University of Washing- focation due to unsafe sleep factors, pathologist armed with the “Top 25,” ton Press, Seattle, WA i.e., asphyxia. or as many as can be identified prior to Byard, RW, Beal, SM. (1995) Has changing As of this writing, there does not appear autopsy, is more solidly positioned to diagnostic preference been responsible for the to be widespread usage of this classifica- deploy autopsy and ancillary assets to recent fall in incidence of sudden infant death tion system by those certifying sudden provide a devastated family the infor- syndrome in South Australia? J Pediatr Child unexpected infant death. Thus, it mation they need to process their loss, Health, 3:197-99 appears the road ahead remains some- and perhaps even affect future family Calton MA, Howard JR, Harper RM, Goldow- what uncharted. planning. The investigative team owes itz D, Mittleman G. (2016) The Cerebellum the families of these infants nothing less and SIDS: Disordered Breathing in a Mouse SUMMARY than our very best effort on every case. Model of Developmental Cerebellar Purkinje Investigation, autopsy protocols, and This is the essence of our public health Cell Loss during Recovery from Hypercarbia. classification of sudden, unexpect- and safety mission. 4 Front Neurol.May 13;7:78. doi: 10.3389/ ed infant death continue to evolve. fneur.2016.00078. eCollection 2016. Informed by advances made by their REFERENCES Dwyer, T, Ponsonby, AL, Blizzard, L, Newman, basic and clinical research colleagues, AAP Task Force on Infant Positioning and NM, Cochrane, JA. (1995) The contribution forensic pathologists will continue to SIDS. (1992) Positioning and SIDS. Pediatrics, of changes in the prevalence of prone sleeping tease away diagnostic layers, assigning 89(6); 1120-26 position to the decline in sudden infant death etiologically-specific causes of death syndrome in Tasmania. JAMA, 273:783-89 Andrew, TA, Blanding, S, Bronheim, S, Bur- in more cases and leaving a smaller brink, D, Clark, S, Corey, T, Covington, T, et Lambert AB, Parks SE, Camperlengo L, percentage of those remaining truly al. (2006) Sudden Unexplained Infant Death Cottengim C, Anderson RL, Covington TM, unexplained and awaiting a unifying Investigation: A Systematic Training Program Shapiro-Mendoza CK. (2016) Death Scene Investigation and Autopsy Practices in Sudden diagnosis, whether it be anomalies of for the Professional Infant Death Investigation Unexpected Infant Deaths. J Pediatr. Jul;174:84- this medullary serotonergic network or Specialist. CDC Press, Atlanta, GA other neurodevelopmental abnormality. 90.e1. doi: 10.1016/j.jpeds.2016.03.057. Epub Arnestad M, Crotti L, Rognum TO, Insolia R, The forensic pathology community may 2016 Apr 22. Pedrazzini M, Ferrandi C, Vege A, Wang DW, come to accept a standard classification, Filiano JJ, Kinney HC. (1994) A perspective on Rhodes TE, George AL Jr, Schwartz PJ. (2007) neuropathologic findings in victims of the sud- leading to more rational coding and Prevalence of long-QT syndrome gene variants den infant death syndrome: the triple-risk model. cleaner epidemiological data for pub- in sudden infant death syndrome. Circulation. Biol Neonate. 65(3-4):194-7 lic health experts to mine in search of Jan 23;115(3):361-7 prevention strategies. Firstman, R, Talan, J. (2011) The Death of Inno- Bass, M, Kravath, RE, Glass, L. (1986) Death cents. Bantam Books, New York, New York. The one constant is the primacy of a scene investigation in sudden infant death. thorough, systematic death scene inves- NEJM, 315:100-105. Geertinger P, Bodenhoff J, Helweg-Larsen K, Lund AZ. (1982) Endogenous alcohol produc- tigation with doll reenactment. Curious, Beckwith, JB. (1970) Discussion of terminology tion by intestinal fermentation in sudden infant that in this age of ever increasing techni- and definition of sudden infant death syndrome. death. Rechtsmed. 89(3):167-72 cal wizardry, the most critical element In: Bergman, AB, Beckwith, JB, Ray CG, eds. in the evaluation of these deaths is Sudden Infant Death Syndrome: Proceedings of Iyasu, S, Rowley, DL, Hanzlick, RL, Willinger, simply asking the right questions of the the Second International Conference on Cases of M. (1996) Guidelines for death scene investi-

| 46 | THE JOURNAL OF LEGAL NURSE CONSULTING gation of sudden, unexplained infant deaths: Mitchell, E, Krous, HF, Donald, T, Byard, RW. Infant Death Syndrome. Current Pediatric recommendations of the interagency panel on (2000) Changing Trends in the diagnosis of Reviews, 10:309-313 sudden infant death syndrome. MMWR, 45 sudden infant death. Am J. Forensic Med Pathol, Shapiro-Mendoza CK, Colson ER, Willinger M, (RR-10) 21(4):311-14 Rybin DV, Camperlengo L, Corwin MJ. (2015) Jones, AM, Weston, JT. (1977) The examination Möllborg P, Wennergren G, Almqvist P, Alm B Trends in infant bedding use: National Infant of the sudden infant death syndrome infant: (2015) Bed sharing is more common in sudden Sleep Position study, 1993-2010. Pediatrics. investigative and autopsy protocols. J Forensic infant death syndrome than in explained sudden Jan;135(1):10-7. unexpected deaths in infancy. Acta Paediatr. Sci, 22:833-41 Shapiro-Mendoza, CK, Camperlengo, L, Aug;104(8):777-83 Kinney, HC, Filiano, JJ, White, WF. (2001) Ludvigsen, R, Cottengim, C, Anderson, RN, Meduillary serotonergic network deficiency in Moon, RY, Patel, KM, McDermott-Shaefer, SJ. Andrew, T, Covington,T, Hauck, FR, Kemp, J, the sudden infant death syndrome: review of a (2000) Sudden infant death syndrome in child MacDorman, M. (2014) Classification System 15-year study of a single dataset. J Neuropathol care settings. Pediatrics, 106(2):295-300 for the Sudden Unexpected Infant Death Case Registry and its Application. Pediatrics; original- Exp Neurol, 60:228-47 Moon RY, Hauck FR. (2015) Hazardous ly published online June 9, 2014 DOI: 10.1542/ bedding in infants’ sleep environment is still Krous HF, Beckwith JB, Byard RW, Rognum peds.2014-0180. TO, Bajanowski T, Corey T, Cutz E, Hanzlick R, common and a cause for concern. Pediatrics. Taylor BJ, Garstang J, Engelberts A, Obonai T, Keens TG, Mitchell EA. (2004) Sudden infant Jan;135(1):178-9 Cote A, Freemantle J, Vennemann M, Healey M, death syndrome and unclassified sudden infant Morris, JA. (2015) The genomic load of deleteri- Sidebotham P, Mitchell EA, Moon RY. (2015) deaths: a definitional and diagnostic approach. ous mutations: relevance to death in infancy and International comparison of sudden unexpected Pediatrics. Jul;114(1):234-8 childhood. Frontiers in Immunology, 6:1-8 death in infancy rates using a newly proposed Lavezzi AM, Ottaviani G, Matturri L. (2015) N.A.M.E. Standards Committee. Forensic set of cause-of-death codes. See comment in Developmental alterations of the auditory Autopsy Performance Standards. (2006) National PubMed Commons belowArch Dis Child. brainstem centers--pathogenetic implications Association of Medical Examiners, Atlanta, GA Nov;100(11):1018-23. in Sudden Infant Death Syndrome. J Neurol Palmer, LF. (2007) Baby Matters : What Your Williger, M, James, LS, Catz, C. (1991) Defining Sci. Oct 15;357(1-2):257-63. doi: 10.1016/j. Doctor May Not Tell You about Caring for Your the sudden infant death syndromw (SIDS): jns.2015.07.050. Epub 2015 Aug 1. Baby. Baby Reference, San Diego, CA deliberations of an expert panel convened by the Lopez HU, Haverfield E, Chung WK. National Institute on Child Health and Human Perrizo K1, Pustilnik S. (2006) Associa- (2015) Whole-Exome Sequencing Reveals Development. Pediatr Pathol,11:677-84 tion between sudden death in infancy and CLCNKB Mutations in a Case of Sudden co-sleeping: a look at investigative methods for Unexpected Infant Death. Pediatr Dev Pathol. Galveston County Medical Examiners Office Jul-Aug;18(4):324-6. doi: 10.2350/14-08-1543- Thomas Andrew, MD, from 1978-2002. Am J Forensic Med Pathol. CR.1. Epub 2015 Apr 29. FCAP, FAAP is currently Jun;27(2):169-72 Chief Medical Examiner for Markstead, T, Skadberg, B, Hordvick, E, Morlid, Randall, BB, Paterson, DS, Haas, EA, Broad- the State of New Hamp- I, Irgens, LM. (1995) Sleeping position and sud- belt, KG, Duncan, JR, Mena, OJ, Krous, HF, shire. Before being named den infant death syndrome (SIDS): effect of an Trachtenberg, FL, Kinney, HC (2013) Potential to this post, he served in intervention programme to avoid prone sleeping. Asphyxia and Brainstem Abnormalities in Sud- the Office of Chief Medical Examiner in Acta Paediatr, 84:375-78 den and Unexpected Death in Infants Pediatrics; New York City, boroughs of Manhattan and Brooklyn, before being named See comment in PubMed Commons below- originally published online November 11, DOI: Acting Deputy Chief Medical Examiner of McBride DL. (2015) Over half of U.S. infants 10.1542/peds.2013-0700 Richmond County (Staten Island). He is sleep in potentially hazardous bedding. J Pediatr Rhodes TE, Abraham RL, Welch RC, Vanoye board certified in pediatrics, anatomic Nurs. May-Jun;30(3):519-20. doi: 10.1016/j. CG, Crotti L, Arnestad M, Insolia R, Pedrazzini pathology and forensic pathology, and pedn.2015.02.001. Epub 2015 Feb 16. M, Ferrandi C, Vege A, Rognum T, Roden DM, has performed over 5000 autopsies for Mileva-Seitz VR, Bakermans-Kranenburg Schwartz PJ, George AL Jr. (2008) Cardiac purposes of investigating sudden, MJ, Battaini C, Luijk MP. (2016) Parent-child potassium channel dysfunction in sudden unexpected or violent death. He is a bed-sharing: The good, the bad, and the infant death syndrome. J Mol Cell Cardiol. member of the National Association of Mar;44(3):571-81 burden of evidence. Sleep Med Rev. Mar 15. Medical Examiners, the American Academy of Forensic Sciences, the pii: S1087-0792(16)00026-5. doi: 10.1016/j. Salm Ward TC, Ngui EM. (2015) Factors asso- American Academy of Pediatrics, the smrv.2016.03.003. [Epub ahead of print] ciated with bed-sharing for African American Association of SIDS and Infant Mortality and White mothers in Wisconsin. Matern Child Mitchell, EA, Brunt, JM, Evard, C. (1994) Programs and the College of American Health J. Apr;19(4):720-32 Reduction in mortality from sudden infant death Pathologists. He can be contacted syndrome in New Zealand. Arch Dis Child, Scadding, GK, Brock, C, Chouiali, F, Hamid, Q. at [email protected] or 70:291-94 (2014) Laryngeal Inflammation in the Sudden www.whitemountainforensic.com.

Death Investigation in Maryland

Bruce Goldfarb, BS

he history of death investigation inquest. On Jan. 31, 1637, a jury of a decedent’s material possessions to in Maryland dates nearly to its twelve freemen tobacco planters was settle his debts. T founding in 1634. Under the called to view the body of John Bryant, One of the first death investigations authority of King Charles I, provincial who met an untimely death while felling to include the participation of a med- Governor Leonard Calvert appointed a tree. According to a witness who ical person occurred in 1642. A jury Thomas Baldridge, a tobacco planter testified under oath to the jury, Bryant of twelve St. Mary’s County men was in St. Mary’s County, as sheriff and stepped back five or six paces as the tree empaneled to consider the death of an coroner in 1637. The coroner was toppled. The falling timber glanced off infant named Anne Thompson. One authorized to “[d]oe all and every- another nearby tree and rebounded onto member of the inquest was Robert thing…the office of sheriff or coroner of Bryant. “[T]he said John Bryant spake Ellyson, who is described in records as any county in England doe.” not one word after,” the jury noted. a “Barber-Chirurgeon.” After viewing The coroner was instructed how to Examination of Bryant’s body showed the body of the infant and hearing from determine the cause of death: “two scratches under his chinne on the witnesses, the panel concluded “that “Upon notice or suspicion of any person left side.” The jury concluded that Bryant they do not find anything, but that the that hath or shall come to his or her death died because “his bloud bulke broke.” said Anne came to a naturall death.” entirely within the limits of that hundred The tree responsible for Bryant’s death The earliest known forensic autopsy in as you conveniently may to view the dead was forfeited to the Lord Proprietor of America was performed in St. Mary’s body and to charge the said persons with the Province of Maryland --the earliest County on Feb. 25, 1642. It was likely per- an oath truly to inquire and true verdict to example of a deodand in the New formed by George Binx, a “Licentiate in grant how the person viewed came upon World. It was the coroner’s responsi- Physicke” serving as foreman on the coro- his or her death according to the evidence.” bility to ensure a proper disposition of ner’s inquest investigating the homicide of Two days after his appointment as the deodand. Acting as a sort of execu- a Native American youth, who was shot to coroner, Baldridge conducted his first tor at large, the coroner also liquidated death by John Dandy, a blacksmith.

| 48 | THE JOURNAL OF LEGAL NURSE CONSULTING FEATURE

“[W]e find that this Indian ladd GRIEVOUS AND grave and buried the body. Although (named Edward) came to his death by a OPPRESSIVE coroners throughout the State faced a bullet shott by John dandy, which bullet Noting that “the prevailing practices steep penalty up to $100 for overcharg- entered the epigastrium neare the navel of coroners are improper, grievous ing for their services, additional sums of on the right side, obliquely descending, and oppressive,” a law enacted in 1821 money were allowed “for any business & piercing the guts, glancing on the last established a fee schedule for coroners done” by coroners in Baltimore County. vertebra of the back, and was lodged in The law compensated each juror serving the side of Ano,” the inquest reported. and inquest jurors. No coroner was to be paid more than $4.17 for his services, on a coroner’s inquest 50 cents, and The coroner system existed in Mary- plus an additional $2.50 if he provided 12.5 cents per juror for the constable or land for more than 300 years. For most a coffin and another $2.50 if he dug the coroner who summoned them. of this time, coroners were untrained laypeople who lacked any qualification other than being an adult male. Initially, the office of coroner was combined with that of the sheriff, constable, or justice of the peace. Due to the potential for abuse, in 1666 the provincial Assem- bly passed an act prohibiting the same person from holding both offices, and directed the Governor to appoint coroners for each of Maryland’s counties. Unlike Massachusetts, where coroners were chosen by popular vote, Mary- land’s tradition of appointing death investigators continues to this day.

In 1671, the Assembly set a fee for coroners – about 250 pounds of tobacco per case -- which was on a scale slightly higher than the amount paid to their counterparts in England. Although they were state officials, coroners were paid by local governments.

The 1671 act limited the duties of coroner to “the holding of inquests over the bodies of those dead by misadven- ture, murder, suicide, or other forms of violence, as well as the serving of writs or subpoenas upon a sheriff in any suit to which he is a party, or for the arrest of a sheriff.” The coroner was authorized to make arrests in cases of homicide.

The term of service for coroners varied by jurisdiction until the Maryland Constitution of 1777, which authorized the Governor to appoint coroners to two-year terms.

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 49 | The unceremonious treatment of ty and security of people in his custody missioner was also authorized to order Baltimore’s deceased, particularly and, when required, burying the dead. an autopsy. the unknown dead, was fueled by a “Whenever it shall be necessary for a burgeoning demand for cadavers for coroner to bury any deceased person, he The medical examiners primarily per- medical education. University of Mary- shall provide a coffin and decently bury formed autopsies on cases of homicide, land was one of America’s first medical him,” the law stated. and occasionally on cases of suspected schools to require human dissection, in poisoning. Upon completion of their 1833. The need for cadavers for ana- In 1868, a State law was enacted investigation, the medical examiners tomical study increased substantially as authorizing the Governor to appoint were directed to furnish the evidence Baltimore became home to a growing “a competent member of the medical and a formal written report to the Board number of medical schools, with at least profession” as sole coroner for the City of of Health and the State’s Attorney. seven institutions in business during the Baltimore, who served a two-year term at Baltimore’s first Medical Examiner was 19th Century. an annual salary of $2,000. The coroner Nathan G. Keirle, M.D., who served in was instructed to hold inquests over any that capacity for 29 years. Grave-robbing was frequently employed person found dead in the city when the to acquire bodies for medical schools cause and manner of death were not FUMIGATION AND BURIAL in Baltimore and elsewhere. Baltimore’s already known to be accidental or natu- reputation as a reliable source of cadav- ral. He was responsible for the interment Within the Baltimore City Health ers for anatomical study during the of unclaimed and unidentified bodies, Department, the morgue was organized 1800s earned it the nickname “the Paris and was required to provide monthly in the Division of Fumigation and Burial, which was also responsible for of America.” reports of his activities to the police. the control of tuberculosis, diphtheria, The earliest statute in the U.S. related Postmortem examinations, when scarlet fever and other communicable to the participation of a physician in an they were done at all, were performed diseases. Thousands of blankets, pillows inquest is an 1847 Baltimore City ordi- at police stations, funeral parlors, and miscellaneous goods were sterilized nance enacted by the Maryland General hospitals, private homes and other or incinerated at the morgue each year. Assembly. The ordinance allowed the places of convenience. During the year of 1914, the morgue coroner to require the attendance of a Baltimore made major strides in the received 394 bodies, primarily uniden- physician from the same jurisdiction to care for its dead during the last decade tified persons. Keirle, the city’s medical examine the body and provide testi- of the 19th Century. On March 9, 1890, examiner, performed autopsies in 67 mony if a decedent was suspected to Mayor Robert Davidson approved an cases (17 percent), the vast majority of have met a violent death. A doctor who ordinance passed by the City Council to which were at the request of a coroner. declined to cooperate with an inquest appoint two physicians to serve as med- That same year, 880 bodies had been faced a fine from the coroner or justice ical examiners for the city. Four months received by the Anatomical Board and of the peace. Otherwise he was compen- later, city leaders appropriated $4,000 to distributed to ten medical teaching sated $5-10 for his services. select “a suitable site on the water front, facilities in the city. or easy access from the harbor, and Many local governments believed that In 1914, Baltimore had coroners in each cause to be erected thereon a building to coroners were lining their pockets by of the police districts, and one serving at be used as a morgue or dead-house.” calling for inquests in cases when it large throughout the city. Coroners were wasn’t necessary. A law similar to the appointed to two-year terms and paid a Baltimore ordinance, enacted statewide MEDICAL EXAMINERS $1,000 annual salary. They were respon- in 1860, contained the same provision Organized within the city’s Board of sible for holding inquests for deaths that for physician participation in suspected Health, the 1890 ordinance authorized occurred within their district. Cases violent deaths. The law also featured a the appointment of a Medical Examiner requiring an autopsy were sent to the key limitation on coroners, prohibiting and an Assistant Medical Examiner. The morgue for Keirle’s examination. inquests “where it is known that the physicians were appointed by the Board deceased came to his death by accident, A 1914 study by the U.S. Public of Health to two-year terms, at an annual mischance or any other manner” except Health Service was critical of Balti- salary of $1,000 and $500 respectively. if the person died in jail or as the result more’s coroner system: The law directed the medical examiners of a felony. to make post-mortem examinations The coroners lack organization, inas- Other duties assigned to coroners by whenever called upon by coroners or the much as each works independently of the 1860 law included assuring the safe- State’s Attorney. The city’s health com- the other and confines his particular

| 50 | THE JOURNAL OF LEGAL NURSE CONSULTING work to his own district; he does not could be reformed. In April of 1937, MedChi struck while the iron was care even in an emergency to accept a surgeon Richard T. Shackelford, M.D., hot. Within a month of the election, case which may be just over the border a member of MedChi’s Medical-Legal MedChi formed a committee, chaired line. To get the most efficient service Committee, presented a paper about the by Shackelford, to study the issue and from such an important office as the problems posed by doctors testifying as draft legislation for a radically different coroner’s office there should be one witnesses in the coroner system. approach to death investigation. coroner appointed for the city, who Shackelford noted that a growth in During a series of meetings, members of would be responsible and who should insurance was among the factors con- MedChi discussed the shortcomings of be given as many assistants as would tributing to an increase in court cases the coroner system. Shackelford pointed be necessary to perform the work. involving medical testimony. Accord- out that appointments to coroner are He should have his office in police ing to Shackelford, medical witnesses strictly political, with no qualifications headquarters, and there should be a appeared in about half of all cases that necessary to hold the office. With a two- coroner on duty at all times. come to court. Doctors, he said, were year term, coroners had no incentive to poorly equipped to be thrust into the increase their efficiency or expertise. The GUESSES AND HEARSAY adversarial arena of the courtroom and coroners had no supervision or account- ability, and were slow and unreliable to By the 1930s, the coroner-based death are often unaware of their rights on the witness stand. Physicians felt they were submit reports to the Health Depart- investigation system in Baltimore – and ment and the State’s Attorney. As they throughout the State of Maryland – had being exploited, losing income while testifying in court, and browbeaten had since colonial days, coroners were evolved into one that was unreliable, dis- authorized to bring charges – or not – in satisfactory, and vulnerable to corruption into providing expert opinions for the payment of $1 per day allotted for fact cases of homicide; a situation that was and abuse. “It’s a known fact that the old vulnerable for abuse and corruption. system of ‘coroner’s’ diagnosis is replete witnesses. “The average physician views with guesses, snapshot diagnoses based this contingency with great distaste, and By 1939 there were ten physicians often on hearsay and without personal often goes to ridiculous extremes in his serving as coroners in Baltimore City. investigation,” said Howard James Mal- efforts to avoid it,” Shackelford said. Eight were assigned to police districts, deis, M.D., who served as Chief Medical one served at-large throughout the city, Examiner from 1939 until 1949. A NEW APPROACH and one was assigned specifically to automotive fatalities. Death investiga- Discrepancies and inaccuracies were so The general election of 1938 opened tion was uneven elsewhere in Maryland. common on death certificates, he said, a door to the possibility of reforming Physician coroners served in only six of that “in a large proportion of cases they death investigation in Maryland. Med- the state’s 23 counties, with magistrates were worthless for giving immediate Chi had a sympathetic ear in Herbert acting as coroners in the remainder. causes of death with accuracy.” O’Conor, a Democrat who served as Baltimore City State’s Attorney for ten The coroner system was held in low The MedChi committee sought to years before being elected as Attorney abolish the coroner system and replace regard by the public. The Baltimore Sun General of Maryland in 1932. More editorial page said that the “antiquated it with a state-wide medical examiner than almost anybody, newly elected system modeled after some of the best coroner system…has long provided Governor O’Conor understood the features of the laws governing medical lucrative jobs for politically minded deficiencies of the coroner system. examiner offices in New York City and physicians,” and that “[t]he system is a Newark, N.J., combined with some relic of the past and fails utterly to meet The 1938 election also brought a original and innovative provisions. the present-day demand for immediate, General Assembly determined to competent inquiry into all deaths result- undertake a sweeping restructuring of Among key features of the draft leg- ing from other than natural causes.” state government, in which numerous islation, which became known as the commissions and departments were Coroner Bill: Among the harshest critics of the system eliminated or reorganized. For example, was the Medical and Chirurgical Fac- lawmakers merged the Conserva- • The abolition of the office of coroner ulty of Maryland (MedChi), the state tion Commission, the State Forestry throughout the State of Maryland, medical society, which characterized the Department, the Geologic Survey, and and a prohibition on inquests practice of coroners as racketeering. the State Weather Bureau into a new • Separation of the medical and legal Department of Natural Resources. Starting in the mid-1930s, MedChi duties of the coroner, with the latter members began meeting to discuss the Tackling the coroner system fit well assigned to the State’s Attorney coroner system and ways in which it into the reform movement, and • Appointment of a Chief Medical

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 51 | Examiner with the authority to con- schools, the director of the State Depart- Despite an attempt to defeat the Cor- duct forensic investigations without ment of Health, the commissioner of the oner Bill by an amendment that would the need for permission of the State’s Baltimore City Health Department and render it impractical, the legislation was Attorney or law enforcement agencies the Attorney General of Maryland. The passed on April 3, 1939 – the last day MedChi member were of the consensus unpaid commission would be nonpartisan of the General Assembly – and signed that two years of pathology training was and nonpolitical, have expertise to appoint into law by Gov. O’Conor on May 3., an adequate minimum qualification for and supervise qualified medical examiners, All but one of Maryland’s 23 counties appointment as Chief Medical Examin- and provide a link to university and state were covered by the new law. Cecil er. The Chief Medical Examiner would laboratories for assistance when needed. County, the lone holdout, joined the be based at the Baltimore morgue, system in 1941. which would serve as the primary site As in New York City, authority to con- of autopsies for Baltimore City and the duct a forensic investigation was vested Once the legislation was signed, events five counties in closest proximity – Anne in the medical examiner, and not done moved very quickly. The law was slated Arundel, Carroll, Howard, Harford, and at the behest of the coroner or State’s to go into effect on June 1, 1939. A Baltimore County – and provide labo- Attorney. “The medical examiner need new system had to be operational in ratory services and expertise throughout not obtain permission….Therefore, they less than a month. In the meantime, the state. The central Baltimore office are not handicapped and make their own a citizen petition was filed with the would also be the permanent repository decisions regarding autopsies. There are Secretary of State requiring the new of forensic investigation records. no interfering influences and the respon- law held in abeyance until the matter sibility is on the examiner,” Maldeis said. In Maryland’s 18 outlying counties, could be decided by voters in the 1940 Deputy Medical Examiners would be Under the proposed model, the Chief election. Attorney General William C. appointed for each jurisdiction based Medical Examiner did not work for Walsh determined that the petition was on the recommendation of the coun- the coroner, the police, or the State’s invalid because half of the names must ty medical society. Deputy Medical Attorney. His primary responsibility be residents of Baltimore City and half Examiners, under the supervision of the was to look after the interests of the from the counties, and ruled that the Chief, could conduct an autopsy at a citizens of Maryland, divorced from law could take effect as planned. local hospital or have the body trans- politics, the criminal justice system, ported to Baltimore. Almost immediately, the newly minted and other considerations. Post Mortem Examiners Commission A considerable amount of discussion Baltimore Morgue/Medical Examiner set to work developing guidelines – among MedChi committee members Office, center, 1930s later formalized into regulations – to centered around governance, how med- govern forensic investigations. The ical examiners would be appointed and The Coroner Bill was among the first Commission established guides for supervised. Initially, the medical examin- pieces of legislation introduced during defining sudden death and determined er’s office was envisioned under the State the 1939 session of the Maryland Gen- which deaths were medical examiner Health Department, with appointments eral Assembly, sponsored by Emanuel cases. Certain medical examiner cases by the State Board of Health. Another Gorfine, a Senator representing Balti- that occurred during hospitalization suggestion was for medical examiners to more City. Initially, the bill languished could be released without a forensic be appointed by county medical soci- in the Senate Judicial Proceedings autopsy subject to the approval of the eties or county health commissioners. Committee. When presented to the full None of these options were acceptable medical examiner. The Commission Assembly, the bill was the subject of to MedChi members, who were “quite eliminated the requirement that any contentious debate. Some lawmakers determined to keep the job out of poli- deaths that occur during the first 24 were skeptical of financial aspects of the tics if possible.” hours of hospitalization are automati- legislation, while others were opposed cally coroner’s cases. They also issued a to having the state meddle in what requirement that hospitals designate a AN INDEPENDENT had traditionally been a local activity. COMMISSION person responsible for providing reports Reporters suspected the real objection and records to the medical examiner in A proposal that the committee considered was something more tangible; “poli- forensic investigations. most favorably called for the establishment ticians do not look with much favor of an independent commission, comprised upon the removal of these lucrative The framework established by the of the chairman of pathology at University appointments from the political sphere,” Commission in 1939 remains in effect of Maryland and Johns Hopkins medical one noted. today with very little change. One minor

| 52 | THE JOURNAL OF LEGAL NURSE CONSULTING revision was made by lawmakers subse- pressure, media, and other external acquired property in the University of quent to passage of the bill; the Director forces. No consideration is factored into Maryland BioPark, a 10-acre community of the Maryland State Police was sub- a forensic investigation other than the of life science companies and translation- stituted for the Attorney General on the medical and scientific evidence. al research centers west of the UMAB/ Post Mortem Examiner’s Commission. Maldeis died on January 15, 1949, after medical center campus. Working with a The composition of the Post Mortem a brief illness. A search to find a suitable team of architects and designers, Fowler Examiner’s Commission has remained replacement commenced immediately. and other State officials developed plans the same ever since. for a 120,000-square-foot six-story The Commission appointed Russell building occupying an entire block. Maldeis, who had served as post-mortem Fisher, M.D., Chief Medical Examin- When completed, the facility would be er in 1949, a position he held for the physician at the Baltimore Morgue since one of the largest freestanding forensic next 35 years. Fisher transformed the 1919, was appointed as the first Chief medical centers in the U.S., rivaling the Medical Examiner by the Commission. Baltimore Morgue into a leading center of research, education, and training in military’s largest mortuary at Dover Air Maldeis deserves credit for forging a forensic pathology. Barely a year into Force Base. his tenure, Fisher began conducting state-wide medical examiner system Ground was broken on the site on Oct. seminars on homicide investigation for from a patchwork of jurisdictions, and 22, 2008, and the Forensic Medical officers at law enforcement agencies for transforming the Baltimore Morgue Center of Maryland officially opened into a centralized facility. He improved throughout the state, which included practice with Lee’s celebrated crime on Sept. 21, 2010, under budget with a and expanded the morgue’s laboratory scene dioramas, the Nutshell Studies of final cost of $43.6 million. capabilities, adding a part-time toxicol- Unexplained Death., ogist and a laboratory technician to the The Forensic Medical Center staff, and introduced photography as a Fisher made lasting contributions to the of Maryland routine part of forensic investigation. State of Maryland and his profession. The textbook he co-edited with Spitz, Among the noteworthy elements of The medical examiner system proved Medicolegal Investigation of Death, the building: is regarded as the bible of forensic superior to the coroner system, ulti- • Energy-saving features including a pathology. Much of what is consid- mately winning over even its most vocal curtain wall system with argon gas ered standards of practice in forensic critics. Death investigations were more low E glass that is up to three times thorough and completed sooner, and pathology has its origins in Maryland. more energy efficient than standard records available more promptly. From modest beginnings, Fisher created a world-renown center of research and single glazed glass; sensors to turn “The law definitely separates the legal training that conducted thorough, sci- off lights in unoccupied spaces; water and medical duties and yet creates a ence-based investigations at a cost to the conservation measures on all plumb- close cooperation between the legal public that was less than the State spent ing fixtures; variable speed controllers agencies and the police departments,” on stocking fish in recreational waters. on all fans and pumps; night set back operations on all HVAC systems; Maldeis said. “This system, through Fisher worked until illness forced his separate investigation of a death, is much retirement in 1984. Three weeks later, use of high-efficiency air cooled more satisfactory. If the case is turned he died at age 67. chillers; a system to cool the com- over to a grand jury, it is much better puter rooms via outdoor air in the prepared for prosecution. The evidence The person appointed by the Post Mor- winter time to minimize the load is more direct and trustworthy. A great tem Examiners Commission to continue on chillers. improvement likewise has been brought Fisher’s legacy was John E. Smialek, • A radio frequency identification about in the accuracy of the causes of M.D. Smialek served as Chief Medical (RFID) system for case files so they death as placed on the death certificates Examiner until he died suddenly while can be located at any time anywhere for medical examiner cases. This results at work on May 9, 2001. In his place, the in the building. from the more careful and efficient Commission appointed David R. Fowler, MB.ChB. M.Med. Path (forens). FCAP. • An enclosed 15,000-square-foot investigations of the deaths as compared ground-floor receiving and mass with the coroner system.” FAAFS, who had been at the OCME since his residency in 1993. fatality triage area that permits The Post Mortem Examiners Commis- smooth, bottleneck-free access for sion served to insulate the Chief Medical Planning for a new Forensic Medi- transport vehicles and deliveries. Examiner from political influence, public cal Center began in 2002. The State Columns in the ground floor area are

ISSN 2470-6248 | VOLUME 27 | ISSUE 4 | WINTER 2016 | 53 | fully equipped with water, electrical, much like a studio apartment, the Today, the OCME investigates more data lines and other utilities neces- facility is used to stage a variety than 9,000 deaths and conducts about sary to set up a temporary morgue or of crime scenes. Aside from being 4,400 autopsies annually. The OCME’s autopsy stations in event of a mass used to train the OCME’s forensic 12 Assistant Medical Examiners are fatality incident. The space is scaled investigators, Scarpetta House has supplemented by three fellows and a to allow access for tractor trailers, a been employed to train members dozen full-time forensic investigators. decontamination tent, or anything of the Disaster Mortuary Opera- The OCME has a strong institutional else that may be required. tions Response Team (D-MORT), lineage of excellence, following policies and best practices enacted by Smialek, • In-house histology, toxicology, and Baltimore City Police Department Fisher and Maldeis. Maryland’s forensic neuropathology laboratories. The homicide detectives, attendees of the Frances Glessner Lee Homicide investigation system is tightly integrat- toxicology lab can provide STAT Seminar, and other groups. ed, with one centralized facility for results within an hour, negative autopsies, laboratories, records, training, results in three days, and quantified THE OCME TODAY and supervision. The OCME is one of final results within five days. Suffi- The Forensic Medicine Center of Mary- the few forensic medical centers with cient space is provided for specimen land is considered a model in the U.S. quality assurance practices-- multiple preparation and storage. layers of peer review with morning and internationally. OCME has hosted • A biosafety level (BSL) III suite rounds and afternoon conferences -- to visits from U.S. and foreign medicolegal for handling decomposed or infec- ensure that findings are as close to the death investigation agencies to observe tious decedents. The suite has three truth as humanly possible. the building for their own design pro- rooms equipped with two stations cess, including representatives from San The work at the OCME is done with each, and includes a gowning room Francisco, Houston, Singapore, Turkey, remarkable efficiency, mindful of costs and shower, a pass-through steril- to the public. Among peer accredited izer, and a dedicated elevator to the Japan, United Arab Emirates, and the People’s Republic of China. forensic medical centers, the average ground-floor receiving area. Two cost is about $3 per taxpayer per additional rooms are ready to be The OCME maintains a role in resident year, while the OCME operates at finished for use as BSL-III autopsy training for the two medical schools approximately $1.97. The OCME’s $10 rooms in the future. in Baltimore, three in the District of million annual budget is still less than • Two spacious main autopsy rooms Columbia, and the Uniformed Services the State’s Fisheries Service. with eight stations each. The rooms University. Students have been hosted These are among the reasons why the have abundant natural light, bright, from China, Japan, Ireland, South Africa, OCME is regarded as the gold standard shadow-free artificial lighting, Malaysia, and numerous other countries. to which other forensic investigation and an extremely efficient laminar systems are compared. After the most ventilation system. At present, the The OCME has established educational recent site visit and assessment for OCME has a total of 22 autopsy relationships in China, largely through accreditation by the National Associa- stations; 16 in the main autopsy the efforts of Assistant Medical Exam- tion of Medical Examiners, evaluators rooms and six in the BSL-III suite. iner Ling Li, M.D. In 2012, OCME called the OCME “a stellar example of The autopsy suite also has a viewing formed an international study agree- modern and professional medicolegal room and an operating room for ment with Ningbo University medical death investigation.” 4 harvesting tissues. school and hosted two visiting scholars • A radiology suite with computed from Fudan University. Two years later, tomography and a Lodox low-dose the OCME launched the U.S.-China Bruce Goldfarb is executive X-ray machine that produces a crisp, Forensic Science Research Center, assistant and public full-body digital image in less than which includes a new forensic science information officer for the 15 seconds. master’s program in conjunction with Office of the Chief Medical Examiner for the State of the University of Maryland Graduate • Scarpetta House, a training facil- Maryland. A former EMT/ ity donated by novelist Patricia School and the China University of paramedic, Goldfarb received his B.S. in Cornwell, who based the futuristic Political Science and Law. Li and Fowler emergency health services from Universi- space-age forensic medical center in also produced the first English language ty of Maryland, Baltimore County. He can her books on the OCME. Designed forensic pathology textbook in China. be contacted at [email protected]

| 54 | THE JOURNAL OF LEGAL NURSE CONSULTING THEegal JOURNAL OF Nurse Consulting

Looking Ahead…

XXVIII.1, March 2017 — Niche Roles in LNC XXVIII.2, June 2017 — Interventional Radiology XXVIII.3, September 2017 — Brain Injury XXVIII.4, December 2017 — Employment Law and New Author Supplement