19.2 Forensic paediatrics and the law

Introduction

The emergency department (ED) is the initial point of contact for many children presenting with acute injuries. While the majority of injuries are accidental, within this large group will be a number of children with inflicted injury or with findings resulting from abuse or neglect, on whose behalf legal proceedings may be initiated in a variety of legal jurisdictions. Hence ED staff require some expertise in forensic medicine or medicine as it relates to the law.

The role of medical staff in the ED is to carefully assess and treat children with such injuries. A number will present with a clear history or findings to indicate that injury or abuse has been inflicted. Many others will present with non-specific injuries or findings that will not be flagged as abusive, but at a later date may evolve to require legal involvement. It is therefore essential that doctors in the front line adopt high standards of history, examination and documentation for all cases of injury, both to allow detection of abuse and also to meet the standards required should a matter progress into the legal system.

Medical staff have a number of legal obligations in such matters. These include mandatory notification of suspected abuse or neglect, a need to advise the police of a potential criminal matter and to assist police in their investigation of such an event. There are also obligations with regard to the management and notification of deaths to the state coroner.

By virtue of this front-line contact, emergency physicians will at times be required to provide evidence in a variety of legal jurisdictions. Familiarity with these systems, good preparation, and a neutral unbiased approach will allow doctors to discharge their duty to provide the courts with accurate representation of facts and balanced expert opinion.

Forensic medical assessment

Forensic medicine, also known as medical jurisprudence, deals with the interaction of medicine and the law. All specialities or areas of medicine will have overlap with forensic matters at some time, and this is particularly so in paediatric emergency medicine. The aims of a forensic medical assessment are diagnosis and management that incorporates the requirements of the legal system. The qualities required include precision and thoroughness, objectivity, neutrality, clarity of thought and expression, and logical formulation of opinion.

Forensic paediatric medicine largely revolves around the assessment of trauma to develop an understanding of the mechanism of an injury, and the nature of the forces required. This then allows consideration and evaluation of the provided history to determine whether it adequately and plausibly accounts for the injuries seen. An opinion can then be formulated that an injury is truly accidental, resulting from an unpredictable or unavoidable event; that it has been inflicted or imposed on the child; or that it is accidental but involves caregiver neglect, or failure to protect from harm.

As in all areas of medicine, a forensic medical opinion must be based on the information available to the clinician. This is obtained using standard clinical tools of history, examination and investigation, but also incorporates additional standards and procedures and may require more expansive investigations to consider all differential diagnoses.

Accurate history and examination and appropriate investigation

The following points may assist in forensic matters.

Physical injuries

It is important to document from whom each part of the history is obtained and any differing accounts. Any explanation that the child gives for the injury should be recorded.

A child’s developmental abilities should be evaluated to ensure that any actions the child has allegedly taken are within their developmental ability, e.g. standing and turning on hot-water taps.

Any injury must be accurately described including site, colour, size and pattern.

Accurate terminology for injuries should be used e.g.:

• Abrasion – superficial denuding of the skin confined to the epidermis, often called a graze or scratch

• Bruise or contusion – extravasation of blood into surrounding tissue caused by blunt trauma

• Laceration – tearing wound through the full thickness of the skin, or through other tissues and organs caused by blunt trauma

• Incised wounds – sharply cut injuries from any object with a cutting edge, e.g. stab or slash wounds.

If an injury or injuries are present, there must be careful examination for other abnormalities that might not be immediately obvious, e.g. a child with facial bruising should have careful examination of mouth and ears.

In addition to a child’s injuries, notice should also be taken of their general presentation, appearance and demeanour, and of any non-concerning injuries or skin markings.

When ED medical staff encounter injuries or findings that are suspicious of abuse or neglect they should, in the first instance, involve more senior staff, either a senior paediatric emergency physician, or a child protection paediatrician, for guidance.

In consultation with senior staff, further testing for occult injury may be required when injuries or findings are suspicious for abuse or neglect e.g. skeletal survey in infants with bruising to look for occult fractures, or funduscopy with dilated pupils in infants with rib fractures, looking for retinal haemorrhages (see Table 19.2.1).

Additional testing may also be indicated to exclude differential diagnoses and to assess for other factors that may impact on the extent of any injuries for a given history e.g. testing for bleeding tendency (Table 19.2.1).

Specific forensic sampling may be required in some instances, e.g. toxicology, swabbing for DNA in suspected bites, or specimen collection in sexual abuse. Child protection or forensic physicians should be involved, and a clear ‘chain of evidence’ must be maintained from clinician to police to forensic pathologist.

Table 19.2.1 Further investigations
I. For occult injury
Skeletal survey: to examine for occult fractures. Generally indicated in any child under 2 years of age where inflicted physical injury is suspected. This may be done at older ages in specific cases. A second skeletal survey, 11–14 days after the original, may be helpful in detecting healing fractures not easily visible in the very acute phase.
Funduscopy with dilated pupils: to examine for retinal haemorrhage and define nature and extent. Generally indicated if suspected shaking, or concerns for inflicted head and neck trauma.
Neuroimaging: CT is generally indicated in the acute and hyperacute settings, with MRI preferred in the subacute and chronic phases, after suspected injury. MRI is increasingly sensitive for intraparenchymal injury and often allows more accurate delineation of subacute and chronic haemorrhage.
Bone scan: may be indicated to examine for acute fractures (prior to callus formation). Any positive findings still require confirmatory X-rays at a later date.
II. For underlying medical conditions:
Full blood count and film, coagulation screen
Extended coagulation screen: may include von Willebrand’s factor testing, factor assays, platelet function tests. These tests should be discussed with a haematologist prior to collection.
Further testing as advised and according to injury e.g. calcium, phosphate, PTH, vitamin D, urine metabolic screen including organic acids, copper, ceruloplasmin, bone mineral density imaging, skull X-ray for wormian bones.