Forensic toxicology

Deborah Blum has written an entertaining book (The Poisoner's Handbook) on the development of forensic medicine at the newly created Office of Chief Medical Examiner, New York City - under the guiding steer of Dr Charles Norris - and of forensic toxicology during Prohibition in the 1920s.

Alexander Gettler, the toxicologist at Norris' right-hand, worked tirelessly to identify poisonous substances in cadavers at a time when the techniques necessary to do so were either non-existent or unreliable.


The 'Father of Toxicology' - Mathieu Joseph Bonaventure Orfila (1787–1853) - attempted to bring chemistry into forensic medicine as often as possible and, on the matter of the detection of arsenic at exhumation he argued that arsenic in the soil around graves could be drawn in to the body and be mistaken for poisoning.

Orfila-related resources available online include:

• Chemistry, Medicine and Crime. Bertomen-Sanchez JR, Nielo-Galan A (Eds) 2006
• On the detection of poisons. Orfila M The Lancet 1831; 16(398):72-76
  
• National Library of Medicine - Visible Proofs exhibition website
  

Additional resources regarding early forensic science pioneers, autopsy practice and forensic pathologists are available here. (http://forensicpathologist.webnode.com/autopsies-at-the-turn-of-the-20th-century/)

New website - forensic pathologists in history

A new website is currently under construction by me, providing resources on famous forensic pathologists in history, and their notorious cases.

The website will cover Sir Bernard Spilsbury, Professor Keith Simpson, and Dr Francis Camps initially, but will expand in due course to include Professor Bernard Knight, Sir Sydney Smith and others.

Forensic pathologists old and new revisited

A recent BBC4 programme - Watching the dead - considered how the portrayal of forensic scientists and pathologists in 'crime dramas' had changed over the past 30 or so years, and in doing so presented a clip of Professor Keith Simpson teaching some students at Guy's Hospital, and being interviewed for the Horizon programme in the 1970s. The programme also featured Professor Bernard Knight explaining how he had tried to inject some realism into those forensic dramas on which he acted as advisor, with little success!

With one nostalgic eye on the past, a read of Andrew Rose's book on Sir Bernard Spilsbury - Lethal Witness - starts one thinking about how one's own work will be judged in the future. As forensic pathological evidence and theory changes over time, it is inevitable that opinion given decades ago will now seem untenable, but that is the nature of 'scientific evidence'. Perhaps we shouldn't view the 'old guard' of forensic pathology so harshly?

Coroners and Justice Bill

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The long-awaited Coroners and Justice Bill has been published, having finally been included in the Queen's speach in December.

The Bill repeals the Coroners Act 1988, and Part 1 sets out the duty on Coroners to investigate certain deaths (where the Coroner has reason to suspect that the deceased died a violent or unnatural death, or where the cause of death is unknown, or where the deceased died in custody/ state detention).

Of great interest in the UK is the introduction of reforms of the death certification process, and the Bill sets out a new duty on Primary Care Trusts (England) and Local Health Boards (Wales) to appoint 'medical examiners' to scrutinise, and enquire into, deaths in which doctors have issued Medical Certificates of Cause of Death - a function proposed in a Department of Health consultation last year.

A new duty on medical practitioners to notify the Coroner of a death 'of which they are aware' is also included in the Bill, following a consultation last year by the Ministry of Justice. Regulations detailing the circumstances in which such a death should be reported will apparently follow after enactment of the Bill.

The Bill creates a new Chief Coroner (to be a judge of the High Court or a Circuit judge) who will lead a new national Coroner Service.

The Bill's progress through Parliament will be eagerly followed by practitioners in the UK, and a new post will follow when the Bill receives Royal Assent.

Paediatric forensic pathology

The death of a child or infant in suspicious circumstances is one type of case that has the potential for being particularly contentious for forensic pathologists, and the evidence base upon which opinions are based is weak in certain instances, not least those involving alleged 'shaken baby syndrome' or 'short distance falls'.

The Goudge Inquiry into paediatric forensic pathology services in Ontario, Canada demonstrates how 'bad things can get'. Aspiring forensic pathologists are recommended to visit the website for this Inquiry, which provides a unique insight into current thinking on the contentious issues, with transcripts of witnesses called to give evidence at the Inquiry, as well as some extremely interesting documents prepared by forensic pathology and legal experts for the Inquiry.

Of particular note are 'Paediatric forensic pathology: Limits and controversies', by the Victorian Institute of Forensic Medicine, Australia, 'Medical mistakes and miscarriages of Justice' in the UK, 'Paediatric forensic pathology as forensic science', and 'Demonstrable reliability and expert forensic pathology evidence'. In addition, there is an excellent paper, again from the Victorian Institute, on 'A model Forensic Pathology Service', which gives more general guidance on how a modern forensic pathology service should operate.

All authors highlight the lack of 'evidence-based forensic pathology', particularly in those areas of paediatric practice that are commonly in dispute at trial. The Welsh Child Protection Systematic Review Group is attempting to address this need, and have performed systematic reviews of the literature for abusive bruising, fractures, burns and oral injuries/bites, as well as currently finalising a review of non-accidental head injury, and undertaking a review of retinal haemorrhages. It remains to be seen whether such evidence makes its way into expert opinions and court proceedings.

Fire deaths

One category of death that often causes interpretative problems for forensic pathologists is the fire death.

A useful summary of the issues raised by such deaths has been recently published, highlighting the need to establish the deceased's identity and, in the pathological assessment of the body, to determine whether the deceased was alive at the time of the conflagration, why they could not extract themselves from the fire, and what the cause (and manner) of death appears to be.

In England and Wales, fire deaths are often investigated by coroner's pathologists with little (or no) training in forensic pathology; the approach taken in some cases rests on the assumption that there are no attendant suspicious circumstances, and it is only when the post mortem blood carboxyhaemoglobin level is returned from the laboratory as zero % that a review of the post mortem findings indicates some other cause of death than 'exposure to fire smoke and fumes'.

Whether this situation would occur in jurisdictions in which forensic pathologists perform all such post mortem examinations is unclear, but it behoves the autopsy-performing pathologist to consider the possibility that their 'fire death' is not related to exposure to the products of fire but is, in fact, a concealed homicide, and that the pathological assessment - and documentation of the findings - is capable of scrutiny should the 'worst-case scenario' unfold later in the course of the investigation.

Medicolegal misconceptions

The public is exposed to a wealth of forensic pathology in the media, particularly in TV programmes such as Silent Witness (UK) and CSI. However, these representations are rarely accurate.

Dr Charles Petty identified popular medicolegal misconceptions (the 'devil's dozen') in an article in 1971;

• that the time of death can be precisely determined by the examination of the body
• that the autopsy always yields the cause of death
• that the autopsy can properly be carried out without a 'history'
• that the autopsy is over when the body leaves the autopsy room
• that embalming will not obscure the effects of trauma and disease
• that only true and suspected homicide victims need examination
• that the cause and manner of death are the only results of the autopsy
• that any pathologist is qualified
• that the autopsy must be immediate
• that the poison is always detected by the toxicologists
• that all physicians are good death investigators
• that the medicolegal autopsy is criminally or prosecution oriented

These are still valid misconceptions today, again illustrating the fact that 'nothing is new under the sun', and that forensic practitioners will always be struggling to disabuse the police and others involved in the administration of justice that forensic pathology does not provide all of the answers in any investigation.

Classical mistakes in forensic pathology

Public scrutiny of forensic pathology is frequently intensive, particularly where a 'miscarriage of justice' is perceived, and the case is 'taken on by the media' as a cause celebre. Dr Alan Moritz identified several 'mistakes' to avoid in forensic pathology, in his 'classic paper' of 1956;

• not being aware of the objective of the medicolegal autopsy
• performing an incomplete autopsy
• permitting the body to be embalmed before performing a medicolegal autopsy
• mistakes resulting from non-recognition or misinterpretation of postmortem changes
• failure to make an adequate examination and description of external abnormalities
• confusing the objective with the subjective sections of an autopsy protocol (report)
• not examining the body at the scene of the crime
• not making adequate photographs of the evidence
• not exercising good judgment in the taking or handling of specimens for toxicologic examination
• permitting the value of the protocol (report) to be jeopardised by minor errors

The recognition of these potential pitfalls are as valid today as they were 50 years ago, and should be learnt by all aspiring forensic practitioners!

Forensic pathologists old and new

Autobiographies of forensic pathologists give an insight into the recent history of forensic pathology, and how the 'craft' has been practiced over the years.

Sir Bernard Spilsbury has often been thought of as the 'father' of modern forensic medicine, and a recent book by Colin Evans, 'The father of forensics: The groundbreaking cases of Sir Bernard Spilsbury and the beginnings of modern CSI', provides an interesting overview of forensic pathology at the turn of the 20th Century.

Professor Keith Simpson, of Guy's Hospital, London is another 'household name' in the field, and his book, 'Forty Years of Murder' illustrates the investigation of suspicious death in the 'war years' in England, and makes for fascinating reading.

The National Clearing House for Science, Technology and the Law at Stetson University College of Law, USA, has several webcasts and audio files of 'modern' forensic pathologists talking about their careers and provides insight into the practice of forensic pathology in more recent times. Dr Michael Baden provides a 'complete history of murder and science in one hour', whilst Dr Cyril Wecht runs through a 'forensic medicine odyssey'.

A recent edition of the Student BMJ contains an interview with Dr Rob Chapman, a forensic pathologist in the UK, describing his work, and the BBC series 'Horizon' aired a programme 'How to commit the perfect murder', containing interviews with Dr Richard Shephard, another UK forensic pathologist.

An excellent web resource, the 'Visible Proofs' exhibition website, contains further interviews with forensic pathologists (and others) on their work, including video clips of the autopsy.

Forensic imaging

The effective documentation (and subsequent visual presentation) of wounds relies on the skills of the individual photographing those wounds, and the quality of illustrations prepared from those images.

There have been huge advances in the field of forensic photography, forensic imaging and postmortem imaging (using multi-slice CT and MRI) - pioneered by the Virtopsy group in Switzerland.

A new forensic imaging blog has recently been set up by a professional forensic imaging specialist, which aims to provide those in the field with up-to-date resources in this important area, and a chapter on postmortem imaging can be found in the new edition of Progress in Pathology (edited by Dr Nigel Kirkham).

New forensic medicine wiki

In the spirit of collaboration in forensic medicine, a new forensic wiki has been launched. Anybody can contribute to the development of this resource - the aim of which is to provide peer reviewed (and so far as is possible) evidence-based forensic medicine and pathology educational materials.

In the first instance, content is requested on general topics such as;

• What is forensic medicine/ pathology?
• Post mortem changes
• Post mortem interval assessment
• Wounds and injuries, and
• Head injury
  

Pages can be created and edited without log-in in to the wiki, although it would be helpful for the administration of the wiki for editors to create an account.

In order to provide the most up-to-date and accurate content, practitioners of forensic medicine/pathology are especially invited to contribute to the development of this wiki.

Images of deceased persons should not include any 'identifiable features' (images of faces/ heads with the eyes 'blacked out' is not considered ethically acceptable in this regard), and the use of alternative illustrations (including body mannequins) is to be encouraged.

Autopsy

In October 2006. the National Confidential Enquiry into Patient Outcome and Death (still called NCEPOD) produced a report into the quality of autopsies carried out on behalf of the Coroner (in England and Wales). 25% of autopsies were considered to be poor or unnacceptable - a lamentable situation.

The Royal College of Pathologists have produced guidelines for autopsy, and a series of guidelines for various autopsy scenarios.

These scenarios cover such situations as a suspected sudden cardiac death, but it should be noted that these are only a guide, and that each case should be considered on its merits, and that the autopsy should be guided to address the issues relevant to each individual case.

Wikipedia also gives an overview of autopsy, whilst an excellent website produced by the University of Leicester (UK) creates case studies to work through, under the guise of a 'Virtual autopsy'. There is also a section on 'death', and a list of 'causes of death by rate', providing further links to specific causes of death.

The National Library of Health (USA) 'Visible Proofs' exhibition website has some good autopsy related resources, with interviews with Medical Examiners and autopsy movie clips.

Some excellent new anatomy and anthropology resources ...

Anatomy

Anatomy teaching has changed over the years, from extensive cadaver-based sessions, to the study of prosections, and more recently, computer-based learning etc.

There are many excellent web based anatomy resources, and some of the best include movie clips and examples of dissected specimens.

Wikipedia provides a useful starting point for general and regional anatomy, with a description of, for example, the anatomy of the neck (of vital importance when considering a 'diagnosis' of strangulation).

The University of Wyoming has an excellent skeletal anatomy resource, with Quick Time movie clips of bones, whilst the Wright School of Medicine, Dayton (USA) has an excellent Quick Time resource including selected dissections.

The Lumen dissector illustrates human dissection, and has an online 'quiz' on anatomical structures (Learn'em) and an excellent cross sectional anatomy resource.

The University of Colorado (USA) has a selection of animated 3D sequences of structures, whilst the University of Michigan has video clips of regional dissections, including that of the anterior neck. An animated illustration of the structures of the larynx can also be found on the 'Anatomia' site (University of Toronto, Canada).

For the 'old school' anatomy students, the 'antique' Gray's anatomy has also been re-produced online, whilst the excellent 39th Edition can also be accessed online to those who have bought the book.


Forensic Anthropology

Several sites provide clear and well illustrated resources for forensic anthropology, including 'Osteointeractive', from the University of Utah (USA) which has a forensic anthropology section.

Paleopathology, including clear images of bone injuries (with movable images of skulls with gunshot wounds) is presented by the University of Wyoming (USA).


Forensic Dentistry

For those interested in dental anatomy and forensic dentistry, Forensic Dentistry Online is the best resource on the web.

Welcome to forensic medicine resources ...

Having hosted an educational website (www.forensicmed.co.uk) for medical students and pathology trainees on forensic medicine and pathology for several years, I thought it was about time to enter the world of bloggers ...

As I discover interesting resources on the web, I will post them on this blog, and would encourage visitors to comment on them, and share their own sites or items of interest!

With so much information available, I will try to be selective, and provide links to the most accurate and 'evidence based' sources (as far as is possible!), and would urge visitors to do the same.

Forensic medicine and pathology are fascinating subjects, and encompas every conceivable branch of medicine, where there are attending legal issues, and so the scope of this blog will necessarily be wide ranging. I hope that you will find these posts of use ... happy reading!

An excellent introduction to forensic science and medicine can be found at the National Library of Medicine (USA) 'Visible Proofs' exhibition website, which includes galleries of images and many educational resources including radio broadcasts and interviews with practitioners.