Denis A Cusack

Ireland: breakdown of trust between doctor and patient

By European standards Ireland experiences a very high level of medical litigation. The possible reasons for this are numerous but not yet determined with any certainty. The consequences are quite clear with negative effects on medical practice, on the psychological health of doctors and patients alike, and on finances of the state. There are different patterns of medical litigation throughout Europe. Ireland may be merely anticipating the emerging increase in such actions elsewhere in the region. The present adversarial basis for medical litigation is not wholly without merit and has contributed to professional accountability. Nevertheless, a change in the present system ensuring accountability and fair compensation is required, together with a striving to ensure that trust is rebuilt between doctors and patients.

European Council of Legal Medicine (ECLM) accreditation of forensic pathology services in Europe

Forensic experts play a major role in the legal process as they offer professional expert opinion and evidence within the criminal justice system adjudicating on the innocence or alleged guilt of an accused person. In this respect, medico-legal examination is an essential part of the investigation process, determining in a scientific way the cause(s) and manner of unexpected and/or unnatural death or bringing clinical evidence in case of physical, psychological, or sexual abuse in living people. From a legal perspective, these types of investigation must meet international standards, i.e., it should be independent, effective, and prompt. Ideally, the investigations should be conducted by board-certified experts in forensic medicine, endowed with a solid experience in this field, without any hierarchical relationship with the prosecuting authorities and having access to appropriate facilities in order to provide forensic reports of high quality. In this respect, there is a need for any private or public national or international authority including non-governmental organizations seeking experts qualified in forensic medicine to have at disposal a list of specialists working in accordance with high standards of professional performance within forensic pathology services that have been successfully submitted to an official accreditation/certification process using valid and acceptable criteria. To reach this goal, the National Association of Medical Examiners (NAME) has elaborated an accreditation/certification checklist which should be served as decision-making support to assist inspectors appointed to evaluate applicants. In the same spirit than NAME Accreditation Standards, European Council of Legal Medicine (ECLM) board decided to set up an ad hoc working group with the mission to elaborate an accreditation/certification procedure similar to the NAME’s one but taking into account the realities of forensic medicine practices in Europe and restricted to post-mortem investigations. This accreditation process applies to services and not to individual practitioners by emphasizing policies and procedures rather than professional performance. In addition, the standards to be complied with should be considered as the minimum standards needed to get the recognition of performing and reliable forensic pathology service.

Repatriation of human remains following death in international travellers

Background: Death during international travel and the repatriation of human remains to one’s home country is a distressing and expensive process. Much organization is required involving close liaison between various agencies. Methods: A review of the literature was conducted using the PubMed database. Search terms included: ‘repatriation of remains’, ‘death’, ‘abroad’, ‘tourism’, ‘travel’, ‘travellers’, ‘travelling’ and ‘repatriation’. Additional articles were obtained from grey literature sources and reference lists. Results: The local national embassy, travel insurance broker and tour operator are important sources of information to facilitate the repatriation of the deceased traveller. Formal identification of the deceased’s remains is required and a funeral director must be appointed. Following this, the coroner in the country or jurisdiction receiving the repatriated remains will require a number of documents prior to providing clearance for burial. Costs involved in repatriating remains must be borne by the family of the deceased although travel insurance may help defray some of the costs. If the death is secondary to an infectious disease, cremation at the site of death is preferred. No standardized procedure is in place to deal with the remains of a migrant’s body at present and these remains are often not repatriated to their country of origin. Conclusions: Repatriation of human remains is a difficult task which is emotionally challenging for the bereaving family and friends. As a travel medicine practitioner, it is prudent to discuss all eventualities, including the risk of death, during the pre-travel consultation. Awareness of the procedures involved in this process may ease the burden on the grieving family at a difficult time.

An atmospheric pressure chemical ionisation liquid chromatographic–tandem mass spectrometry method for the analysis of benzodiazepines in urine

The objective of this work was to establish an analytical method for the analysis of 7 Benzodiazepines (diazepam, oxazepam, temazepam, nordiazepam, desalkylflurazepam, alprazolam and α-hydroxyalprazolam) in urine specimens taken from drivers suspected of driving under the influence of drugs. The specimen, calibrator and control preparation involved hydrolysis of conjugated benzodiazepines using β-glucuronidase in sodium acetate buffer, with incubation at 60°C for 2h. Specimens were then centrifuged, before being diluted 1 in 5 (total dilution 1 in 10), with 10% acetonitrile in water. Specimens were analysed using a Shimadzu Prominence UPLC coupled to an AB Sciex 4000 QTrap LC-MS-MS. The chromatographic column was a Shim-pack XR ODS 2.2μm. 3.0×50mm column and the mobile phase was a binary gradient system comprising of mobile phase A which was an ammonium formate/formic acid buffer dissolved in water and mobile phase B which was an ammonium formate/formic acid buffer dissolved in Acetonitrile. APCI was selected as the ionisation technique and the MS was operated in MRM mode, monitoring 2 transitions per analyte. The validation of the method is described. The method was found to be linear, accurate and precise (within day and between day) for diazepam, oxazepam, temazepam, nordiazepam, desalkylflurazepam, alprazolam and α-hydroxyalprazolam. The results of 480 cases are reviewed and show that alprazolam use was found in 35% of cases. Use of benzodiazepines resulting in oxazepam, nordiazepam or temazepam were found ca. 70% of cases analysed.

'Near PVS': a new medico-legal syndrome?

This paper addresses the current medico-legal issues surrounding PVS (Permanent Vegetative State), including: the lack of a unified definition of the acronym PVS, the varying criteria for diagnosis of PVS, and the issue of patients who maintain a minimal degree of consciousness and cannot be categorized as PVS patients. First, we analyse the differing medical definitions and criteria for diagnosis in vegetative conditions. We also ask what part ‘consciousness’ plays in treatment decisions made by the family, the healthcare team, and the courts, by analysing a unique Irish case of a patient in a state deemed by the courts as ‘near PVS’. The paper demonstrates that there is now a legal dichotomy in vegetative patients. However, the manner in which the court treated these patients is the same. Underlying this discussion we hope to demonstrate how medical practice is subject to legal decisions and thus the importance of establishing uniform medical guidelines to assist the nonmedical professional.

European Council of Legal Medicine (ECLM) principles for on-site forensic and medico-legal scene and corpse investigation

Forensic medical practitioners need to define the general principles governing procedures to be used for the on-site examination of a body where the death has occurred in unnatural, violent or suspicious circumstances. These principles should be followed whenever a medical expert is required to perform an on-site corpse inspection and should be utilised as a set of general guidelines to be adapted to the specific situation in hand and interpreted using common sense and scientific knowledge of the relevant procedures and facts of the case. The aim of these principles is to ensure that forensic evidence at the scene of a death is properly observed and assessed and all necessary relevant evidence gathered in order to ensure that a comprehensive report is available to the judicial authority (investigating judge or coroner) in the justice system. The on-site corpse inspection by a forensic practitioner is a mandatory and essential stage of the forensic and medico-legal autopsy, as it may provide important information for subsequent investigation stages.

Guidelines examination of victims of sexual assault harmonization of forensic and medico-legal examination of persons

Sexual assault is a complex situation with medical, psychological, and legal aspects. Forensic experts play a major role in terms of forensic and gynecological medical examination and evidence collection in order to maintain the chain of custody. Victims should be examined by a specially trained medico-legal examiner in order to avoid multiple examinations in the surroundings that do not meet minimum health standards. The evolution and treatment of sexual assault victims are time-intensive and should optimally be provided by a team that includes a forensic medical doctor. These guidelines will be of interest to forensic medical doctors who will have responsibility for the examination and assessment of victims of sexual violence and can be used as a day-to-day service document and/or a guide to develop health service for victims of sexual violence.

European council of legal medicine (ECLM) guidelines for the examination of suspected elder abuse

Article 25 of the Charter of Fundamental Rights of the European Union (adopted in Nice on 7 December 2000) recognizes and respects the rights of older people to lead a life of dignity and independence and to participate in social and cultural life. It also highlights the importance of prevention and recognition of elder abuse, especially since exposure to violence is likely as the population ages, either in familial or in institutional settings. Elder abuse has some issues in common with child abuse but in spite of this fact currently is less recognized. Health professionals have a major role to play in early detection and management of cases of elder abuse. This protocol summarizes some key concepts and approaches to assist in the timely detection and investigation of elder abuse cases by healthcare professionals and forensic practitioners.