Surgical wounds, consent and rape samples

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Describe the main differences between homicidal and suicidal incised wounds.

Incised wounds are cause by sharp-force trauma most frequently by a sharp edged cutting object such as a razor, knife or glass shard. The distinction between suicide and homicide can be a major issue in forensic pathology and it is essential to determine the cause of death. The pattern of injury of incised wounds found at autopsy can help give the answers as to the nature of the death however this distinction may be difficult if not sometimes impossible.

There are certain features in the character and distribution incised wound that assist the pathologist in making the distinction between self inflicted or assailant inflicted wounds.

Neck incised wounds can be found in suicide, homicide and accidental injury such as motor vehicle accidents. Self inflicted neck wounds when made by a right handed person often begin higher on the left side of the neck and are deeper at their origin however may occasionally be horizontal. They are generally linear and clean cut as the skin is sliced under tension. As a rule, suicidal wounds can have separate shallower wounds and linear abrasions, known as tentative or hesitation wounds, which strongly indicate self inflicted injury. Suicide incised wounds can be very deep on the neck and can often leave score marks on the larynx or vertebrae of the neck.

Tentative cuts are generally adjacent to the main wound that caused the death of the victim. They are usually caused by the same item that was used in the suicide and can be small, repetitive puncture type wounds near the ‘target area’. Tentative wounds can vary in depth and could be due to the victim progressing and preparing mentally until the final incision, which causes their demise. Suicidal injuries tend to be directed towards the non-dominant side of the victim and there may be associated injuries of self mutilation found on the victim which can assist the forensic pathologist in their diagnosis.

Homicidal wounds to the neck are more indiscriminate and less planned. The wounds usually have more irregular edges and may be very deep. They are without tentative injury. There are often defensive injuries visible on the victim where they attempted to defend themselves from the attacker, most commonly on the palms of the hands or back of the arms. There may also be accompanying stab wounds.

Defensive injuries are not usually the cause the death of the victim and can be classified as passive (back of hand when protecting their face) or active (palm of hand when gripping assailant’s blade).

Suicide by cutting the wrists is often unsuccessful however self inflicted wrist wounds present most commonly with multiple parallel incised wounds to the ventral aspect of the wrist. Less frequently incised wounds can be seen on the dorsal aspect of the wrist in self inflicted injury however it is important to distinguish these from defensive injuries.

What samples should be taken from the suspect in an alleged case of rape and how should they be stored?

Rape is an abhorrent crime and an extremely traumatic experience for any victim. It is essential that rape evidence is processed timely and accurately in order to identify and convict the person responsible.

In an alleged case of rape there are many samples that must be obtained with the victim's consent. It is paramount that the victim is treated with respect at all times and must not be coerced into any investigation against their will. At any point in the examination, the victim can withdraw their consent and cease any further investigations.

A sterile technique for collection is used by the operator at all times in order to avoid any contamination of the samples. All the swabs collected will have an additional control swab to ensure no contamination has occurred.

Photographs will often be taken to document any injury sustained by the victim in the course of the rape. Small samples of clothing may be collected including both unstained and stained samples. Hair samples including any loose hairs, semen encrusted pubic hair should be collected. Scalp and pubic hair from the victim is collected for comparison and at least ten of each type is needed.

Blood is collected from the victim of the rape and any dried samples of the perpetrators blood are collected. Saliva, urine and smears from the victims’ buccal mucosa are collected as well as fingernail clippings and scrapings.

Samples from the victim’s mouth must be taken within 48 hours of oral penetration. Two mouth swabs are taken using cotton swabs and a mouth rinse using 10mls of sterile water should be collected following rinsing by the victim for 60 seconds. The mouth rinse is collected in a sterile container and the complainant must wear gloves whilst holding the container. Any spillage onto the gloves will also be collected and analysed.

Hair samples will be taken depending on the alleged circumstances. Hair samples are usually required if the perpetrator is not known to the victim. During the analysis of the hair the forensic physician would be looking for foreign hair types and/or semen. It is important to respect the victim at all times and obtain the hair sample without further traumatising the victim by removing large sections of hair.

Skin samples, as with hair sample are taken if they are going to aid the investigation. If the alleged rape involves a perpetrator who is known to the complainant (e.g. husband/long term partner) then skin samples would not be beneficial, as the victim will most likely have their partners DNA present on their body. If the alleged rape involves a stranger then skin samples would be taken from whatever part of the body has been touched. A moist and a dry swab must be taken from each site. Additional swabs can be taken if the skin has semen or saliva present.

The following swabs are required and must be taken under certain circumstances if consent allows.

  • Two vulval swabs are taken under the following circumstances:

Vaginal penetration within the past 7 days

Digital penetration within the past 48 hours

Anal penetration within the past 72 hours

Ejaculation onto the vulva/perineum

  • Two low vaginal swabs are taken under the following circumstances:

Vaginal penetration within the past 7 days

Digital penetration within the past 48 hours

Anal penetration within the past 72 hours

The victim must be post-pubertal and it is possible to pass a swab

  • Two high vaginal swabs are taken under direct view through a speculum under the following circumstances:

Vaginal penetration within the past 7 days

Digital penetration within the past 48 hours

Anal penetration within the past 3 days

  • Two endocervical swabs are taken under the following circumstances:

Vaginal penetration within the past 7 days

Anal penetration within the past 3 days

  • Two peri-anal swabs are taken under the following circumstances:

Anal penetration within the past 3 days

Digital penetration within the past 12 hours

  • Two anal swabs are taken under the following circumstances:

Anal penetration within the past 3 days

Digital penetration within the past 12 hours

  • Two rectal swabs are taken using a lubricated proctoscope under the following circumstances:

Anal penetration within the past 3 days

Digital penetration within the past 12 hours

All samples are taken with care to maintain forensic integrity and placed in suitable containers, in tamper-proof bags. All samples must be correctly labeled. Preserving DNA evidence is paramount in any sexual assault case.

Dry items such as clothing should be placed in a brown paper bag, folded twice at the top, sealed with adhesive tape and stored in a cool dry environment. Damp or wet clothing must be frozen in the brown sealed paper bag if DNA analysis is required.

Urine and blood are stored in the appropriate container with preservatives depending on the test to be undertaken, the samples are refrigerated.

Hair is collected from the victim with a sterile comb or scissors and stored in a poly bag in a cool dry environment. Finger nail clippings are collected with sterile instruments and placed in a folded and sealed paper bag and frozen. DNA swabs from the mouth, vulva, vagina or anal-rectal region are packaged as per the kit instructions and frozen.

All samples should be packaged and sealed as soon as collected to avoid contamination. It is essential that victim samples are kept entirely separately from suspect samples and a different team collect samples from each individual to prevent cross contamination.

Any items which are required for DNA analysis, once sealed can only be opened within an accredited laboratory.

Write short notes on consent with reference to minors

In English Law, any person under the age of 18 is a classed as a minor. The legal age of majority has become progressively irrelevant in determining when a young person may consent. The law on consent, including the reliance on maturity in assessing a young person’s capacity to consent or refuse medical treatment is complex and can often appear contradictory.

The Family Law Reform Act 1969 s8 concerns minors aged 16 and 17 years of age and provides that a minors’ consent is effective as if he were an adult;

‘The consent of a minor who has attained the age of 16 to any surgical, medical or dental treatment which in the absence of consent would constitute a trespass to his person, shall be as effective as it would be if he were of full age; and where the minor has by the virtue of this section given an effective consent to any treatment it shall not be necessary to obtain any consent for it from his parents’.

Minors under the age of 16 can consent to treatment by virtue of common law. In the House of Lords case Gillick v West Norfolk and Wisbech AHA & DHSS [1985] the test for maturity was developed and the term ‘Gillick competent’ was coined. The case specifically looked at whether doctors should be able to give contraceptive advice to girls under 16 years of age without parental consent and the court held that there is no fixed age at which a child can be said to have the capacity to consent.

The term ‘Gillick competent’ is now used more widely to define whether a minor under 16 years of age has ‘sufficient maturity and intelligence to understand and appraise the nature and implications of the proposed treatment, including risks and alternative courses of action’ with relation to medical, surgical and dental treatments. Gillick competency is a well known principle of law and medical professionals may assume that a mature minor can give effective legally binding consent however legally, as is seen in case law over the past two decades, they do not always have complete autonomy and self determination as proposed in the Gillick case.

In Gillick, Lord Scarman established that as a matter of law the ‘parental right to determine whether or not a minor below the age of 16 receives medical treatment terminates when the child has sufficient understanding and intelligence so they are able to comprehend what is proposed’. However, the ruling led to ambiguity and uncertainty on what exactly the child must understand to be considered competent. As per Lord Scarman, the minor must ‘fully understand what is proposed’ or ‘understand the doctors’ advice’ as per Lord Fraser. Whichever the interpretation, this essentially means that a minor has to go beyond their natural comprehension to meet the required threshold.

English law pursuant of the Family Law Reform Act 1969 and common law may recognise that the minor, in accordance with the law and being sufficiently mature may act for himself and that consent as expressed by that minor should be legally valid without the need for parental agreement. However, the law becomes more cautious when it deals with the minors right to refuse consent for medical treatment. If a minor refuses to consent the courts have made it clear that the person with parental responsibility can override this refusal and give consent.

The parents can act for their child’s benefit, however the courts have made it clear that if they seek to make a decision that is not in the best interest of their child and may do harm their decision will be repealed by the courts.

The prerogative power of the Crown to act as parens patriae, to act as the ‘parent’ to any individual in need of protection, gives the courts more power than that of both the minor and their parents. The power of the courts to override the minors’ refusal to consent is derived from inherent jurisdiction, wardship and statute.