Forensic Medicine Notes PDF

Forensic Medicine Notes ======================= Identification -------------- For identification to take place: there can be general characteristics, specific characteristics and special techniques. [Identification is important:] 1. Humanitarian aspect: for the relatives to know that a family m...

Forensic Medicine Notes ======================= Identification -------------- For identification to take place: there can be general characteristics, specific characteristics and special techniques. [Identification is important:] 1. Humanitarian aspect: for the relatives to know that a family member has died 2. Criminal aspect: for investigation to take place 3. Civil aspect: for remarriage, inheritance purposes 4. Social aspect: for a burial, death certificate 5. Statistical and legal purposes [What information should be collected from a scene?: ] 1. The position of the body 2. Collect all human remains, personal effects (these are items which are not a part of the body making them less specific for identification for examples keys, documents, ID's, clothing and jewellery). What features should one look for in an external examination?: 1. The height/weight/build : the height can change due to water loss and body shrinkage, there may also be shortening during rigor mortis. The weight may increase earlier on in decomposition and then decreases at a later stage. 2. Age: in the case of babies, there is the examination of the fontanelles (soft spots). Posterior closes within 3 months, while the interior closes between 18-24 months. In the case of children: bones grow and fuse until the ages of 20-25 years (ossification), the teeth are also helpful for identifying the age. Ossification and fusion and teeth growth happen earlier in girls and in warmer climates. After 25 years there are no major changes that occur in bones or teeth. In the case of adults cranial sutures (in the head)close gradually starting in the late 20's and are usually finished by the 40s or 50s. In the case of the elderly, their bones show signs of wear, along with the teeth. 3. Sex: this is obvious except in the case of severely burnt bodies. 4. Race: there are some difference in the facial skeleton and teeth, but usually this isn't possible except for colour of skin. 5. Hair: Can be distinguished from animal hair or fibres under a microscope. **Colour changes with heat:** Grey → blonde at 120°C.,Brown → reddish at 200°C, Black stays the same. Hair peels off in water. 6. **Eyes:** Colour becomes hard to identify after a few days. With decomposition, eye colour darkens to brown. How can you establish that a victim was alive when fire started?: - **Carbon Monoxide (CO) Poisoning:** - Skin and internal tissues turn cherry pink. - Caused by haemoglobin binding to CO (forming carboxyhaemoglobin). - **Soot in Airways:** - Soot found below vocal cords shows the victim was alive and breathing during the fire. Case 2: a human bone was found at the beach: Bone identification:  **Height:** - Estimated using tables for long bones.  **Age:** - Ensure remains are not ancient (use carbon dating or amino acid tests). - Check bone growth and fusion.  **Sex:** - **Skull differences:** - **Male:** Larger skull, square eye sockets, big mastoid process, prominent brow ridges, larger palate. - **Female:** Smaller skull, round eye sockets, small mastoid process, less prominent brow ridges, smaller palate. Even the pelvis is different in males and females. Investigations which must be carried out: - Measure and examine the body. - [Check teeth]:**Sex**: a male jaw has larger teeth, and a more square chin. The angle where the jaw meets the side part is more straight. The female jaw is rounded with a point in the middle. Teeth can also be a criteria for age: in the case of **adults**, the teeth ear down and change the colour with age. Missing teeth and heavy wear on the teeth may indicate the age but not necessarily. - Use X-rays (e.g., to see bone growth). - Test DNA. - For ancient remains, use carbon dating and protein analysis. Case 3: a body was found partly decomposed in a filed Medical information υ tattoos - dermal pigment, scarred skin, skin lesions υ amputations - not unique υ healed fractures - unique plates and pins υ prostheses - glass eyes, contact lenses, artificial joints υ surgical scars and sutures υ occupational scars υ normal variance - frontal sinuses, sacroiliac joints υ skeletal disease - degenerative disorders υ congenital abnormalities - cervical ribs, extra digits υ pregnancy υ dental records Specific features ================= 1. **Fingerprints:** - Unique to each person, even identical twins. - Formed around 12 weeks of pregnancy and stay the same for life (unless scarred). - Chance of identical fingerprints: 1 in 64 billion. - A genuine match needs 16 matching points. - Computer gives initial match; confirmed visually. - Useful if fingerprint records are available. Fingerprints are identified by **ridge patterns**: such as arches, loops and whorls. They leave marks on surfaces due to oil/debris/dead skin cells. 2. Full-body X-Rays - Bone fractures, deformities, and degenerative diseases - Prostheses and metal sutures - Dental restorations (fillings) - Metal items like clothing accessories or jewellery 3. Blood grouping- this is also useful for identification 4. DNA Fingerprinting - Any sample with nucleated cells can be used (e.g., blood, semen, saliva, hair, bone marrow, tooth pulp, or tissue). - Each person's DNA is unique. - Identification relies on multiple tests. - The chance of two people having the same DNA is extremely rare (about 1 in a billion). **[Identification summary: ]** 1. **Height, Weight, Build:** - Basic physical attributes to estimate general size and structure. 2. **Age:** - Determined using teeth, bones, and signs of wear or development. 3. **Sex:** - Assessed using skeletal features (e.g., pelvis, skull) and DNA. 4. **Race:** - Inferred from skull shape, facial features, and bone structure. 5. **Hair:** - Color, texture, length, and whether dyed or natural. 6. **Eyes:** - Eye color, shape, or abnormalities (if preserved or recorded). **Specific Characteristics (Individual Identification):** 1. **Fingerprints:** - Unique patterns used for positive identification if records are available. 2. **Dental Comparison:** - Matching teeth with dental records, fillings, or other treatments. 3. **Medical Information:** - Includes healed fractures, prostheses, scars, implants, or surgical history. 4. **X-rays:** - Comparing skeletal features or previous medical images for unique identifiers. 5. **Personal Effects:** - Clothing, jewelry, watches, or other items found with the remains. 6. **Photo Superimposition:** - Comparing skull features with known photos of the person. 7. **3D Sculpture:** - Reconstructing a face from a skull to aid in visual identification. 8. **Computer-Enhanced Age Progression:** - Estimating how a person's face might look with age changes. 9. **Serology:** - Blood analysis to determine group type or biological material origins. 10. **DNA Fingerprinting:** - Matching DNA from remains with records or relatives for precise identification. Legal implications of wounding and head injuries ================================================ Crimes against the person: - Wilful homicide - Wilful offences against the person: Grievous Bodily Harm and slight bodily harm - Justifiable homicide or bodily harm - Involuntary homicide or bodily harm **[Grievous bodily harm (GBH):]** Article 216: BH is deemed to be grievous and is punishable with 1-7 years of imprisonment if: 1. If it can give rise to the danger of: the loss of life, permanent debility of health, permanent defect, permanent mental infirmity 2. Causes deformity/disfigurement in the face/neck/hands 3. Caused by wound penetrating body cavities (without producing any permanent debility/defect) 4. Causes mental/physical infirmity for 30 days or more (person cannot work for 30 days or more) 5. Committed on a woman with child, it hastens delivery Article 218: GBH is punishable with imprisonment for 5-10 years if: 3. Causes permanent debility or permanent defect/permanent mental infirmity 4. Causes serious and permanent disfigurement in face/neck/hands 5. Being committed on a woman with child and causes miscarriage Article 217: GBH is punishable with 2-10 years if arms, cutting, pointed instruments, burning, explosives or corrosive substance is used. Imprisonment is a minimum of 4 years if the offence is committed by means of explosives. Article 220: if after GBH, death ensues: 1. If the death is a result of the nature/natural consequences of the harm and not a supervening accidental cause: - Within 40 days: 6-20 years imprisonment - After 40 days but within one year: 6-12 years imprisonment 2. If the death is a result of a supervening accidental cause and not solely due to natural consequences of harm: 5-10 years imprisonment. 3. If the bodily harm is inflicted in Malta (even if the death is abroad), then the suspect is still tried in Malta. When punishments are decreased and increased by 1-2 degrees: 1. Article 219: punishments are **[decreased]** by 1-2 degrees is a supervening accidental cause contributes to harmful effects 2. Article 222 and 222A (2): punishment **[increases]** by 1-2 degrees if victims are close relatives, witnesses, under 9 years old, public officers, local wardens 3. If the crime if motivated by: gender, gender identity, sexual orientation, race, colour, language, citizenship, religion, political or any other opinion. 4. If its motivated by age ' 5. Disability Slight bodily harm: Article 221: BH is [slight] if it does not cause the above effects. It results in imprisonment for not more than 2 years or a fine. If the bodily harm is of small consequence to the injured then the punishment is reduced, but still more severe with the use of arms etc. The law and forensic evidence: ============================== Article 357: If a police officer finds any weapon, document, trace, or item related to a crime, they must: - Preserve it in its original state until reporting it to the Court of Magistrates. - If preservation isn't possible, follow the procedure for recording and documenting evidence (\"repertus\"). **Criminal Code, Article 554 (2):**\ A Magistrate can order that a suspect be photographed, measured, fingerprinted, or have their body or clothing examined by appointed experts. - If the Magistrate decides these items (photos, fingerprints, measurements, or anything taken from the body or clothing) are no longer needed for the investigation, they must be destroyed or returned to the person they belong to. Intimate and non-intimate samples: ================================== Intimate samples: 1. Sample of blood 2. Semen 3. Other tissue fluid 4. Pubic hair 5. Swab from a person's body orifice other than the mouth Non-intimate samples: 1. Sample of hair (other than pubic hair) 2. Sample from a nail or from under a nail 3. Swab from any part of a person's body (including the mouth and no other orifices) 4. Urine 5. Saliva 6. Footprint or similar impression of a person\'s body (except the hands)- the fingerprint have their own regulations. Samples of an arrested person ============================= Article 335BA (1) of the Criminal Code: The police can take fingerprints, non-intimate photos, or non-intimate samples from an arrested person if they give written consent. - If the person refuses, the police must ask a Magistrate for authorization, as allowed under Article 554(2). Article 335AV: The police can ask a Magistrate to authorize the following from an arrested person: - Intimate samples - Photos of intimate body parts - Fingerprints, non-intimate samples, or non-intimate photos if the person refused consent. **Article 355AX (1):**\ The Magistrate decides if a police request for an intimate sample is justified. **Article 355AX (2):**\ If the Magistrate approves the request, they must visit the arrested person to: - Explain the nature and reasons for the request. - Ask for the person's consent, which must be given directly to the Magistrate. **Criminal Code, Article 355AX(2)(c):**\ An arrested person can ask to consult their lawyer before deciding whether to give consent. **Article 355AZ:**\ If the person refuses without a valid reason, the Judge or Magistrate may interpret the refusal as supporting evidence against them, depending on the circumstances. **Article 355BA (2):**\ An arrested person can ask in writing to have non-intimate samples (like photos or fingerprints) taken. The investigating officer must arrange this with help from qualified people if needed. **Article 355BA (3):**\ An arrested person can also ask in writing to have intimate samples taken, but this request must go through a Magistrate. **Article 355BB:**\ Samples from someone who is not arrested can only be taken with their written consent. For intimate samples, a Magistrate's approval is also needed. **Article 355BC:**\ A non-arrested person can ask for samples to be taken if they think they might otherwise be arrested. For intimate samples, a Magistrate's approval is required. **Therefore for intimate searches, the approval of the Magistrate is always needed.** **Intimate Search:** A physical examination of body openings other than the mouth. ================================================================================== **Article 355AP:**\ If the arresting officer reasonably suspects someone has hidden drugs or other items that could be seized under the law, they can ask a Magistrate to approve an intimate search of the arrested person. **Article 355AQ(2):**\ An expert cannot perform an intimate search on someone of the opposite sex unless the expert is a doctor, and the person being searched agrees in writing. Fingerprints ============ **Article 397(3):**\ The court can order that an accused person be photographed, measured, or have their fingerprints taken if requested by the Police. - If the accused has no prior convictions and is later acquitted, all photos, fingerprints, and measurements must be destroyed or returned to them. **Article 355BA(1):**\ An investigating officer can take fingerprints, photos, and non-intimate samples with the written consent of the arrested person. - If the person objects, the police must get approval from a Magistrate. **Fingerprints, Photographs, and Measurements of Accused Persons Regulations (SL 9.04):** - **Regulation 2:** If the Court of Magistrates in Malta or Gozo agrees to a Police request under Article 397(3) of the Criminal Code, an accused person's fingerprints, photos, or measurements will be taken by a Police officer. - **Regulation 3:** These fingerprints, photos, or measurements can be taken at the court or any other location the court decides. **[Torture]**: For forensic doctors, torture is mainly seen in two situations: - Done by criminal or terrorist groups - Done, or claimed to be done, by police or security forces during detention and questioning of suspects. The examination should be thorough, covering the entire body. All injuries and marks must be carefully recorded and photographed. A forensic doctor may be asked to look into torture or human rights abuse claims in: - **Refugees claiming torture:** - The examination might not be helpful, especially if a lot of time has passed since the torture. - Fresh injuries are less likely to be seen. - Various methods are used, often ones that don't leave scars. - **Prisoners in custody:** - If they were treated properly during detention and questioning, physical abuse is less likely to be seen. - More subtle methods like threats and intimidation are common, such as: - Hooding - Forced standing for long periods - Continuous loud noises - Disorientation from irregular meals, interrupted sleep, and constant light in the cell. **Section 16:** - Any inhuman or degrading treatment, or physical or mental torture, is banned and considered a crime under Article 139A of the Criminal Code, punishable by up to 9 years in prison. **Guidelines for interrogation:** - The person being questioned must always be seated. - No bad language, threats, mocking laughter, or threatening gestures. - Firearms or weapons should not be shown unless necessary for the investigation. - The person being questioned should not be tied up but can be handcuffed for safety or to prevent escape. **Section 17:** - **Intellectual disability:** The person should only be interviewed in the presence of a parent, tutor, carer, or social worker of the same sex. - Documents should be signed by both the person with a disability and the accompanying person. - **Persons under the influence of drugs, alcohol, or medicine, or in shock:** They should only give statements when they are able to understand the questions and their answers. - A doctor must certify that any sick person is fit to be interrogated. Head injuries ============= Meninges are the covering of the brain. They are made of dura mater, arachnoid and pia mater. Then there is the skull on top and then there is the skin. **Head injuries can be open head injuries or closed head injuries**. **Open head injuries**: This is a penetrating head injury, and includes a fractured skull. **Closed head injury:** The skull is still intact in this case, but there is **intracranial** injury. **[Different types of injury]**: 1. Scalp: There can be abrasions, bruises od lacerations. 2. Skull fractures **1) Linear Fracture:** - A straight-line crack in the skull. - Happens when the skull hits an object. - Caused by blunt force over a large area of the skull. - The fracture can be away from the impact point. - The skull bends inward at the point of impact. - Can be caused by both minor and severe trauma. - Not serious unless there's additional brain injury or bleeding. - Usually heals with little treatment. **2) Depressed Fracture:** - A crack in the skull. - Happens when a heavy, small object (like a hammer or rock) hits a specific spot. - A part of the skull is pushed inward by a few millimetres. - Can cause brain injury. - May need surgery. **3) Base of Skull Fracture:** - A fracture at the base of the skull. - Caused by strong blunt force. - Often affects the sinuses, which can lead to infection. - Caused by rapid movement (acceleration-deceleration). **4) Facial Fracture:** - Caused by a direct injury to the face (e.g. from accidents or sports). - Can damage nearby tissues (like the eyes, nose, or jaw). Traumatic brain injury (TBI) ============================ **Mechanisms:** - The head is hit with an object. - The head hits an object. - The brain moves inside the skull. **Types of Brain Damage:** - **Concussion** - **Contusion** (bruising of the brain) - **Brain Swelling** (Oedema) - **Diffuse Axonal Injury** (damage to brain nerve fibers) - **Intracranial Bleeding** (haemorrhage) [Concussion: ] - A mild type of brain injury (TBI). - Caused by a bump, blow, or jolt to the head, making the brain move quickly back and forth. - Causes temporary brain function disruption, but no structural damage. Top of Form [Coup vs countrecoup:] - The head is hit at one point (coup injury). - The brain, however, moves inside the skull, causing damage on the opposite side of the impact (contrecoup injury). - The brain\'s movement is limited by parts like the brainstem, tentorium, and falx, making the frontal and temporal lobes more likely to get injured. [Contusion:] - Localized brain damage (bruises or small bleeding). - **Coup contusion** happens at the impact site. - **Contrecoup contusion** occurs on the opposite side of the impact. - Heals with orange-brown scars on the brain's surface (plaques jaunes), which can last a long time. - Common in alcoholics. [Brain Oedema:] - Swelling of the brain tissue. - Can be delayed, with symptoms worsening 24-48 hours after the injury. - Can increase pressure inside the skull. - Diffuse swelling may happen even without specific injuries, especially in children. [Diffuse Axonal Injury:] - Stretching of the nerve fibers (axons), causing damage. - Caused by rapid head movement inside the skull. - Often linked to severe brain injuries (in unconscious patients). [Intracranial Haemorrhages] - **Extradural (Epidural) Haemorrhage**: Bleeding between the skull and brain. - **Subdural Haemorrhage (Subacute/Chronic)**: Bleeding between the brain and its outer covering. - **Subarachnoid Haemorrhage**: Bleeding in the space between the brain and the thin tissues covering it. - **Intracerebral Haemorrhage**: Bleeding inside the brain itself. Bottom of Form 1. **Epidural Haemorrhage:** - The least common type of bleeding. - Usually caused by a fracture in the temporal bone. - Occurs when an artery in the space outside the brain is torn. - Happens in 15% of closed head injuries. - About 1 in 3 cases also have brain injuries. - After an initial concussion, there may be a brief period of clear thinking (lucid interval), followed by rapid worsening into a coma as bleeding increases. - It can be treated. - Be cautious of alcohol intoxication with head injuries, as some patients have died in custody. 2. [Subdural haemorrhage ] - Caused by bleeding from ruptured veins in the space between the brain and its outer covering. - The bleeding is diffuse (spread out) and usually affects both sides of the brain. - Happens due to rapid movement (acceleration) of the brain. - Can occur with any kind of injury, including fractures. - More common in the very young and the elderly. - There is usually no lucid interval (clear period) after the injury. **2.1 Subacute Subdural Haematoma:** - Blood slowly collects in the space between the brain and its covering. - Symptoms appear 10-14 days after the injury. **2.2 Chronic Subdural Haematoma:** - Symptoms appear weeks or months after the injury, sometimes starting with minor symptoms. - A slow leak of blood starts to form a clot after 2 weeks, pushing the brain. - This process can take months and may eventually cause severe pressure on the brain. - It's hard to determine exactly when the haematoma occurred, but an estimate can be made. 3. Subarachnoid Haemorrhage - The most common type. - Any damage to the brain\'s outer layer (cortex) usually comes with some subarachnoid bleeding. - The cause (aetiology) can vary widely. 4. Intracerebral haemorrhage - Bleeding within the brain tissue itself. - Can be caused by a head injury, with symptoms possibly delayed for up to 2 weeks or more. - Can also result from high blood pressure, blood vessel malformations, or an aneurysm rupture. - Most common in patients taking blood-thinning (anticoagulant) medication. Pregnancy, infanticide, Abortion, Assisted reproduction ======================================================= Pregnancy: it is very important to prove pregnancy. **Early Pregnancy:** - **Physical signs:** Breast swelling, tenderness, missed period, vaginal discharge (leucorrhoea). - **Tests:** Positive hCG (urine/blood) and ultrasound. **Late Pregnancy:** - **Physical signs:** Enlarged uterus above the pelvic brim, can feel the baby or detect fetal movements. **Recent Pregnancy:** - **Physical signs:** Perineal damage or episiotomy scar. - **Tests:** Uterus felt up to 2 weeks postpartum, endometrial analysis. - **Other signs:** Vaginal discharge (lochia), breastfeeding. Abortion ======== **1. Spontaneous Abortion (Miscarriage → Stillbirth):** - Occurs in 20% of pregnancies, most common in the first trimester. - **Causes:** - 50% due to fetal chromosomal abnormalities incompatible with life. - Maternal or paternal health issues. **2. Induced Abortion:** - Medical procedure to end a pregnancy (usually up to the second trimester). - **Types:** - **Therapeutic abortion:** Done to save the mother's life. - Doctors may refuse on religious/moral grounds. - **In Malta:** Permitted only under very strict legal conditions [Top of Form] [Criminal Abortion ] **Illegal Abortion** - Incidence has decreased in Western countries. - **Definition:** Intentional termination of pregnancy outside the state\'s legal framework. - **Ethical Implications:** Violates medical ethics, may lead to disciplinary action by the Medical Council. - **Participants:** Can involve the mother, a health worker, or a layperson. **Doctor\'s Obligations When Aware of Criminal Abortion:** - **If self-performed by the woman:** - Provide necessary medical care. - Maintain patient confidentiality. - No obligation to report unless the woman dies. - **If performed by a professional abortionist:** - The doctor may disclose the abortionist\'s name without breaching confidentiality. Methods of abortion **1. Drugs/Toxins:** - **Substances:** Herbal compounds, chemicals, purgatives (often unreliable). - **Medical Abortion:** - Uses mifepristone (blocks pregnancy hormones) and misoprostol (causes contractions, effective up to 12 weeks). **2. Instruments:** - **Risks:** Tears to the vagina/cervix, uterus or intestines perforated. - **Complications:** Heavy bleeding, shock, infection, air embolism. **3. Physical Violence:** - Self-inflicted or external trauma. - May cause maternal death without ending the pregnancy. **4. Chemical Interference:** - Applying chemicals to the cervix/uterus causes burns or irritation. - **Risks:** Toxic absorption or embolism leading to death. **5. Syringe Aspiration (Vacuum/Surgical):** - Breaks the early pregnancy sac. - Used in both illegal and legal abortion procedures. Abortion and the criminal code ============================== **Key Articles:** - **Article 241 (1):** - Anyone causing a miscarriage, by any method (e.g., food, drink, medicine, violence, or other means), with or without the woman's consent, faces **18 months to 3 years imprisonment** upon conviction. - **Article 241 (2):** - The same penalty applies to a woman who induces her own miscarriage or consents to methods used to cause the miscarriage. - **Article 242:** - If the woman dies or is seriously injured (even if no miscarriage occurs): - The offender faces penalties for **willful homicide** or **bodily harm**, reduced by **1 to 3 degrees**. - **Article 243:** - Applies to **medical professionals** (physicians, surgeons, obstetricians, or pharmacists) who knowingly cause a miscarriage. - Punishment: **18 months to 4 years imprisonment** and **permanent disqualification from medical practice**. - **Article 243A:** - Applies to cases of **negligence** (e.g., carelessness, lack of skill, or failure to follow regulations) causing miscarriage. - Punishment: **Up to 6 months imprisonment**. **[Article 243B: Imp.]** Abortion is **not a criminal offence** if it is the result of a medical intervention meeting the following conditions: 1. **Purpose:** - To save the life or protect the health of a pregnant woman facing a **medical complication** that puts her life at immediate risk or her health in grave danger that could lead to death. 2. **Requirements:** - Current **medical practices in Malta** are followed, and **all other treatments** have been exhausted. - The decision is made by **three specialists**: 1. An obstetrician/gynecologist performing the intervention. 2. Another obstetrician/gynecologist. 3. A specialist in the condition affecting the woman. - **Exception for emergencies:** Only the first specialist\'s decision is required. 3. **Fetal Viability:** - A **reasonable opinion** that the fetus is not viable (cannot survive outside the womb). 4. **Location:** - The procedure must be performed in a **licensed hospital**. Assisted reproduction ===================== - **Infertility:** Unable to conceive after 1 year of unprotected sex. - **Medically Assisted Procreation (MAP):** - **Methods:** - Artificial or intrauterine insemination (IUI). - In vitro fertilization (IVF) with embryo transfer (ET). - Intracytoplasmic sperm injection (ICSI) with embryo transfer (ET). - Egg, sperm, or embryo donation. - **ART Clinic at MDH:** - **Services Offered:** - Help for couples with infertility. - Fertility preservation for patients undergoing chemotherapy. Embryo Protection Act (Ch. 524) =============================== - **Purpose:** Ensures the protection of human embryos. - **Article 3:** - Establishes the **Embryo Protection Authority (EPA)** and its structure: - **Chairperson:** Must be: - A qualified Advocate with at least 12 years of experience, OR - A retired Judge or Magistrate. - **Other Members:** At least **4 members**, appointed by the Minister of Health - **Donor:** A third party who donates reproductive cells (eggs or sperm) for medically assisted procreation. - Donations **between family members** (e.g., parent to child, sibling to sibling) are **not allowed**. - **Embryo:** A human organism formed when an egg and sperm fertilize and has the potential to develop into a fetus. - **Medically Assisted Procreation (MAP):** Techniques that involve handling human eggs, sperm, or embryos to help achieve pregnancy. - Includes methods like intrauterine insemination, in vitro fertilization, sperm injection, embryo transfer, cryopreservation of gametes or embryos, and egg/embryo donation. The **Embryo Protection Authority** can allow embryos to be given to another person who can use them for medically assisted reproduction if: 1. **The woman who originally had performed IVF etc dies** after the egg was fertilized, but **before the embryos are implanted** into her womb. Therefore in this case the stored embryo can be donated to another woman. 2. **For other reasons**, the embryos can\'t be implanted into the woman\'s womb, such as: - She refuses to have the embryos implanted. In this case she may choose to donate the embryo to someone else. - She is too old for the procedure. - She doesn\'t renew the agreement to store the embryos for future use. In these cases, the embryos can be adopted by another person who is eligible for medically assisted reproduction. **Article 4(3): Conditions for Embryo Adoption** For an embryo to be adopted, the **Embryo Protection Authority** must approve the process. The conditions are as follows: 1. **Physical Fitness:** - The **prospective parent(s)** must be declared physically fit by a doctor to receive the embryo transfer. 2. **Adoption Board Approval:** - The **Adoption Board** must give a positive recommendation, assessing the eligibility and suitability of the prospective parent(s) according to the **Adoption Administration Act**. 3. **Anonymity:** - The **identity of the donor(s)** (the person who provided the egg and sperm) and the **adopter(s)** must remain **anonymous**. 4. **No Mixed Embryo Implantation:** - It is **prohibited** to implant embryos from different donors (egg or sperm) into the same prospective parent during the same cycle. **Article 4(5): Adoption of an Embryo** - Once the decision to adopt the embryo is final (either by the **Embryo Protection Authority** or a **court**), the **adopter(s)** are considered the legal parents of the embryo. - The **donors** (the people from whom the embryo originated) **lose all rights** and **obligations** concerning the embryo. **Article 5(1): Access to Medically Assisted Procreation** - Any **prospective parent** has the right to access **medically assisted procreation** procedures. - However, these procedures can only be used if there is a **reasonable chance of success** and if the procedures do not involve any **known significant risks** to the woman\'s or child\'s health. **Article 6: Unlawful Procedures** The following actions are **illegal** under the Embryo Protection Act: 1. **Artificial fertilization for other purposes:** - **Artificially fertilizing** an egg cell for any reason other than to bring about a pregnancy for the **prospective parent**. 2. **Excessive fertilization of eggs:** - **Fertilizing more than 5 egg cells** from one woman in a single treatment cycle. - **Exception:** If the prospective parents do not consent to **cryopreserving embryos** or **donating fertilized eggs**, then it is illegal to fertilize more than **2 eggs** in one treatment cycle. 3. **Excessive embryo transfers:** - **Transferring more than 2 embryos** into the prospective parent within the same treatment cycle. **Article 6: Unlawful Procedures (Continued)** The following actions are **illegal** under the Embryo Protection Act, and those who perform them are subject to a **fine (€5,000--15,000)**, **imprisonment (up to 3 years)**, or both: 1. **Removing an embryo before implantation:** - **Removing an embryo** from a woman before it has fully implanted in her womb with the intent to **transfer it to another woman**. 2. **Eugenic selection or discarding of embryos:** - **Selecting or discarding an embryo** for **eugenic purposes** (choosing embryos based on genetic traits). 3. **Surrogate motherhood:** - **Performing artificial fertilization** or **transferring an embryo** into a woman who intends to **give up the child after birth** (acting as a surrogate mother). **Article 7: Cryo-preservation of Germ Line Cells and Embryos** - **Sperm cells** can be frozen (cryo-preserved) for the **lifetime of the donor**. - **Egg cells (oocytes)** can be frozen until the woman reaches the **maximum age** for fertilization. - **Embryos** that cannot be transferred during a treatment cycle will be frozen in **licensed facilities** for future use by the **same prospective parent**. **Donor Requirements:** - Must be **over 18 years old**. - Must have the **legal capacity** to contract. - Must be in **good mental and physical health**. - Must be **under 36 years old**. - **Donor Information:** - Except in cases of **direct donation**, prospective parents will only receive **generic information** about the donor. - The **identity of the donor** remains confidential, but medical records that could affect the health of the child are available to the child once they reach **18 years old**. - In exceptional cases, the child may access these records earlier if their **health or life is at risk**, with the Authority\'s consent. - **Limitations on Donations:** - **Each donor can only donate once**, and their donation will be used for only **one prospective parent**. **Article 9(8): Payment for Donors** - No one is allowed to **pay a donor** or anyone else to arrange for the donor\'s services. - However, **oocyte (egg) donors** may be compensated for the **costs and expenses** of the treatment to stimulate egg production. **Article 10: Prohibition of Sex Selection** - It is **illegal** to select the **sex of a baby** using sperm cells, unless it\'s to avoid a **sex-linked genetic illness**. **Article 11: Prohibition of Cloning** - **Cloning** (creating a human being genetically identical to another) is **prohibited**. **Article 13: Prohibition of Genetic Alteration** - It is **illegal** to artificially change **human germ line cells** (cells that pass on genetic material to offspring). **Article 15: Prohibition of Embryo Experimentation** - **Experimentation on human embryos** is **prohibited**.Top of Form **Leave For Medically Assisted Procreation National Standard Order (SL 452.114)** 1. **Leave Entitlement:** - Prospective parents undergoing **medically assisted procreation** (MAP) in Malta or abroad are entitled to **100 hours of leave** with **full pay**. 2. **Distribution of Leave:** - The **receiving parent** (the one who will carry the child) is entitled to **60 hours** of leave. - The **other parent** is entitled to **40 hours** of leave. 3. **Leave Usage:** - The leave can be used **non-continuously**. - It applies to a **maximum of 3 MAP processes** Deaths in Infancy ================= Bottom of Form Top of Form - **Foetal Death:** Death of the fetes before it is completely expelled or extracted from the mother, regardless of how far along the pregnancy is. - **Perinatal:** Refers to the time from **22 weeks of gestation** up to **7 days after birth**. This includes both **stillbirths** and **foetal deaths**. - **Neonatal:** Refers to the period from **birth up to 28 days** of age. - **Early Neonatal:** The first **7 days** of life. - **Late Neonatal:** From the **7th day** to the **28th day** of life. - **Infant:** A child under **1 year** of age. [Definitions]: - **Stillbirth:** Foetal death occurring at or after **22 completed weeks of gestation** (in Malta, as per **NOIS**). - **Miscarriage:** Pregnancy loss occurring **before 22 weeks** of gestation. - **Other Countries/International Classifications:** Some places use different timing (typically **20-24 weeks of gestation**) or criteria based on **birth weight** to define stillbirth. - **Definition in England and Wales:** A **stillbirth** is defined as \"a child that is born after the **24th week** of pregnancy but did not breathe or show any other sign of life after being completely expelled from the mother.\" Stillbirths: ============ **Signs of life\" include:** - Breathing - Heartbeat - Movement - Crying - Pulsation of the umbilical cord - Most stillbirths undergo an **autopsy**. - Often, there is **no clear cause** of death, even after the autopsy. - A **death certificate** is needed to bury a stillbirth. **Possible causes of stillbirth include:** - **Intrauterine infection** (viral, bacterial, or fungal) - **Maternal medical conditions** (such as diabetes, hypertension, etc.) - **Congenital defects** (especially in the cardiovascular or nervous system) - **Placental insufficiency** (when the placenta doesn\'t supply enough nutrients/oxygen to the fetus) - **Problems during labor or delivery** (known as intrapartum stillbirth) - From **pathological features alone**, it may not be possible to tell whether the death happened **before, during, or after birth**. - If the death occurred **more than a few days before birth**, the fetus may show signs of **maceration** (softening and breakdown of tissues) due to **early decomposition** combined with exposure to amniotic fluid. **Causes of Infant Deaths: Examination Steps** - Take a detailed history of the circumstances. - Gather information about the **pregnancy** and **birth**. - Review the baby\'s **feeding routine**. - Check the baby\'s **sleeping arrangements**. - Examine the **bedding** for signs of possible suffocation. - Perform **bacteriological** and **toxicological tests**. - Provide **counseling** for grieving parents. - Offer **genetic counseling** if needed. Sudden infant death syndrome ============================ This is the sudden and unexpected death of an infant (below the year of 1 age). They are usually found dead in their cot during their sleep, often between midnight and 9am in winter. There is no explanation for their death even after an autopsy and reviewing the circumstances. **Unknown Cause of Death - Main Theories:** 1. **Overheating:** - Infants have **poor thermal control** due to immature systems. - A possible link to the **serotonin transporter gene** in the brainstem of affected babies. 2. **Prone Sleeping Position (sleeping on the stomach):** - Increases risk of **hypercapnia** (excess CO₂) and **hypoxia** (low oxygen). - Leads to **reduced brain oxygen levels**. - Raises chances of **overheating**. - Alters the **autonomic control** of the heart and blood circulation. - Makes it harder for the baby to **wake up** (higher arousal threshold). **Key Points About Infant Death During Sleep:** - **Cause:** Breathing stops during sleep, leading to circulatory failure, possibly due to **unstable body control mechanisms**. - **Suffocation:** Only suspected if there is clear evidence (e.g., **soft bedding** or **pillows** in the history). **Findings at Autopsy:** - Infant appears **well-nourished** and **hydrated**. - No visible or hidden **trauma**. - No **congenital abnormalities**. - No clear cause of death identified. - Negative **bacteriological tests**. - Small **petechiae** (tiny blood spots) on thymus, pleurae, and epicardium, which may indicate airway failure like **apnea**. Infanticide =========== **Criminal Code, Article 245:** If a mother causes the death of her child (under 12 months old) due to mental disturbance caused by childbirth or lactation, this is considered **infanticide** instead of murder. The maximum penalty is **20 years in prison**. The killing is done shortly after birth by the mother due to postnatal depression. To prove infanticide, it must be shown that: 1. **The woman was recently pregnant.** 2. **The child\'s death was caused by a deliberate action (either by commission or omission).** 3. **The child had a separate existence, meaning it was completely expelled from the mother.** 4. **The child lived, showing signs of life after birth.** Evidence to support this includes: - **Eyewitness testimony** that the child showed signs of life. - **Autopsy findings**, such as: - Expanded lungs - The position of the diaphragm - Air in the stomach or middle ear - Milk in the stomach - Lack of meconium in the intestines. The floatation test is no longer used in modern practice: The floatation test (hydrostatic test) was once used to tell if a baby was born alive by checking if the lungs floated in water. It is now considered unreliable because: 1. If a lung sinks, it could mean the baby didn't breathe enough to expand the lung. 2. Stillborn lungs can sometimes float due to resuscitation attempts, decomposition, or other factors. Road Traffic Incidents and Drink Driving Legislation ==================================================== Fractures: ---------- There are: 4. Open/compound fracture: a fragment of bone breaks through the skin. This is an open wound. 5. A closed/simple fracture: the fracture is not exposed to the environment There is also: - A displaced fracture the bone ends are no longer straight - Non-displaced fracture: the bones are still straight Other kinds of fractures: 3. Linear fracture: parallel to the long axis of the bone 4. Transverse fracture: this is perpendicular to the long axis of the bone 5. Avulsion fracture: a fragment of the bone is pulled away 6. Comminuted fracture: the bone is broken into multiple fractures 7. Greenstick fracture: this is an incomplete break; broken on one side and bent on the other side. This is very typical in children. 8. There is also a compression fracture: the vertebrae collapse on each other. - Bottom of Form Driving and Alcohol Legislation: Traffic Regulation Ordinance ------------------------------------------------------------- - Breathalyser: 22/100ml - Blood: 50/100ML - Urine: 67/100ML **[Commercial vehicles/probationary drivers]**: - Breathalyser: 9/100ml - Blood: 20/100ml - 27/100 ml **[Bus/Coach/Minivan drivers:]** - Breathalyzer: 0/100 ML - Blood: 0/100ML - Urine: 0/100ml Who does one need to perform a surgery in RTA?: - Confirm if the collision was the main cause of death. - Check if the injuries match the reported events. - Examine injury patterns to determine the seating position. - Compare the collision and car damage to the car's design. - Address legal matters like insurance, inheritance, or alcohol use. Case 2 : 50 year old man with heart problems died in a motorcycle incident (hit the pavement and died):\ **Head Injuries Found:** - A 5 cm cut on the upper right eyelid. - Bruising (black eye) and scrapes at the outer corner of the right eye. - A 4x3 cm scrape on the right cheek, below and beside the right eye. - Small scrapes and bruises (1.5x1.5 cm) on the bridge of the nose and left nostril. - Blood coming from the right nostril and left ear. [Acceleration-deceleration injuries:] **Hinge Fracture of the Base of the Skull**: This is called the motorcyclist fracture. - Caused by a sudden stop or change in speed (acceleration-deceleration injury). - Suggests the injury happened at high speed. - The helmet didn't protect the person because it wasn't worn properly. Top of Form Bottom of Form Other injuries due to acceleration-deceleration: 1. Ruptured aorta 2. Neck injuries Top of Form **Primary Injuries:** - Head injury from the first impact. **Secondary Injuries:** - When thrown off and landing on the ground or an object, injuries can include: - Head injury - Scrapes and bruises - Neck (cervical spine) fractures - Leg injuries - Ruptured aorta (a serious blood vessel injury) **Why Motorcyclists Are Vulnerable:** - They can reach high speeds, causing serious injuries in sudden stops (acceleration-deceleration). - They have little protection, making them easy to be thrown off the bike. - Motorcycles are harder to see since they present a small, narrow profile. **Primary Injuries:** - Head injury from the first impact. **Secondary Injuries:** - When thrown off and landing on the ground or an object, injuries can include: - Head injury - Scrapes and bruises - Neck (cervical spine) fractures - Leg injuries - Ruptured aorta (a serious blood vessel injury) **Why Motorcyclists Are Vulnerable:** - They can reach high speeds, causing serious injuries in sudden stops (acceleration-deceleration). - They have little protection, making them easy to be thrown off the bike. - Motorcycles are harder to see since they present a small, narrow profile. **Reconstruction:** ------------------- - Look at the position of the cars, skid marks, car damage, and the person's injuries. **Injury Description:** - A casualty officer explains injuries if the person is still alive or undergoing surgery. **Evidence Collection:** - Keep medical records. - Take photos of the injuries. **Police Examination:** - Police check the car and the scene. - Look for car parts (like windscreen glass) at the scene. - Identify the car in a hit-and-run. **At Autopsy:** - Keep items for police and scientific tests, like: - Foreign objects, glass, or paint on the body or clothes. - The clothing itself. [Seatbelts]**:** - Very effective in reducing death and injury in low to medium-speed crashes. - Have less effect in high-speed crashes. **Functions of Seatbelts:** - Keep you in place during sudden stops and prevent hitting the windshield. - Prevent you from being thrown out of the car, reducing serious injuries. - Reduce impact forces by stretching the strap, which increases stopping distance. - Spread the force of the crash across a larger area of the strap. **Prevention/Reduction of Injuries:** **Airbags**: - Work with seatbelts to protect you. - Airbags alone can cause facial injuries, arm fractures, neck injuries, eye injuries, or even finger amputation. **Head Restraints**: - Help reduce the risk of neck injuries. **Helmets**: - Prevent severe head injuries, but can transfer damage to the neck (cervical spine). **Leather Gear**: - Protects from severe scrapes, cuts, and friction burns, as it helps you slide in case of a fall, reducing friction. **Seatbelt Laws for Children:** - Children are considered those under 12 years old and shorter than 135 cm. - They must use the correct child restraint system (Groups 0-1-2-3). - Rear-facing car seats should be used until 15 months old. - Use a high-back booster seat after that. - Some cars have alarms to remind you to secure the child seat properly **Cyclists Are Very Vulnerable:** - Like motorcyclists, they are unstable but travel at lower speeds. - Low profile makes them hard to see for other road users. - Fatal injuries often occur when a vehicle hits the cyclist. **Common Injuries:** - **Primary injuries**: Legs, including a unique injury where the leg gets trapped in wheel spokes, compressing the calf. - **Secondary injuries**: Head, shoulder, and body impacts. **Protection:** - Helmets provide significant protection against head injuries. Alcohol metabolism and drink driving legislation ================================================ **Alcohol Absorption:** - **Where**: 20% in the stomach, 80% in the first part of the small intestine. - **Time**: Takes 2-6 hours in a normal person. **What Affects Absorption:** 1. **Ethanol concentration**: Higher levels absorb faster. 2. **Carbonated drinks**: Speed up absorption. 3. **Food in the stomach**: Slows down absorption. **Alcohol Metabolism: Distribution** - Alcohol spreads through the water in the body. - Heart, brain, muscles, and lungs get the same alcohol level as the blood. - The liver gets more exposure because it receives alcohol directly from the portal vein. **What Affects Distribution:** - **Water**: More water dilutes alcohol. - **Fat**: Fat doesn't absorb alcohol. Women, with more body fat, may have higher blood alcohol levels. **Alcohol in the Bloodstream:** - Once alcohol enters the bloodstream, the body starts removing it. - However, alcohol is absorbed faster than it is eliminated. - This causes the blood alcohol concentration (BAC) to rise. - **Peak BAC**: Reached 30--45 minutes after one drink (can vary from 20--180 minutes depending on amount and speed of drinking). - **Elimination**: Alcohol is removed at an average rate of 15 mg/100ml/hour (about 1 unit per hour for a 70 kg male). **Testing:** - Blood and urine samples are used to check alcohol levels. - The difference between blood and urine alcohol levels can indicate how much time has passed since drinking. **Alcohol Metabolism:** - **Liver Breakdown**: - 90% of alcohol is processed in the liver: - **Alcohol → Acetaldehyde → Acetic Acid → Carbon Dioxide + Water** - **Small Amount Excreted**: - 2-10% leaves the body unchanged in urine, sweat, or breath. **Key Steps:** 1. **First Step (Fast)**: - Alcohol is quickly turned into acetaldehyde by an enzyme (alcohol dehydrogenase). 2. **Second Step (Slow)**: - Acetaldehyde breaks down more slowly into acetic acid. **Why You Feel Bad:** - Acetaldehyde builds up and can cause headaches, nausea, flushing, fast heart rate, and hangovers. **Article 338 (ff): Drunkenness** - **Being drunk is not a crime** on its own. - However, if someone is **drunk and unable to take care of themselves**, it is considered a minor offense (contravention). **Article 34: Intoxication** - Being intoxicated does **not excuse someone from criminal charges**. - Exception: If intoxication was caused by another person's malicious or negligent act and without the individual\'s consent. **Driving Under the Influence (DUI)** **Article 15A(1)**: - It is illegal to drive, attempt to drive, or take charge of a vehicle in a public place if you are unfit to drive due to alcohol or drugs. **Article 15B(1)**: - It is illegal to drive, attempt to drive, or take charge of a vehicle in a public place after consuming alcohol above the legal limit in your breath, blood, or urine. Car drivers: 22/100ml in breath, 50/100ml in blood and 67/100ml in urine Probation/commercial vehicles: 9/100ml in breath, 20/100ml in blood, 27/100ml in urine Bus drivers/coach drivers: 0/100ml in breath, urine and blood. Blood-alcohol-concentration testing (BAC): ------------------------------------------ **Urine Test**: - Cannot be done immediately after a road accident. - Does not show alcohol level in real-time (it can take 2 hours to appear in urine and may stay for 6-24 hours). **Blood Test**: - Most accurate for determining BAC because it directly measures alcohol in the bloodstream, which affects behaviour. **Breath Test**: - Measures the alcohol in your breath as it passes through the lungs and is then exhaled. - **Police can stop a driver** if they suspect driving under the influence of alcohol. - **Tests can be conducted** after an accident or if the driver violates traffic regulations. - If the test is positive or the driver refuses to provide a breath sample, the **police may arrest the driver**. - **No spot checks** are allowed; tests are done based on suspicion. - The law defines **who is authorized** to take samples. **Article 15E(1): Police and Alcohol Testing** - A police officer can ask a person to provide: 1. **Breath sample** for an approved device. 2. **Blood or urine samples** for lab analysis (e.g., Malta National Laboratory). - The police can ask for **both breath and blood** or **two urine samples** (with a 1-hour gap between them). The later sample will be used for analysis. - If the **breath alcohol level is under 50 µg/100 ml**, the person can request a **blood or urine sample** instead of a breath test. - **Specimens** can be taken at a police station, health centre, or hospital, while **breath samples** can also be taken at the scene. **Article 15GA(1): Local Wardens and Breath Tests** - **Local wardens** can now ask for a breath test from anyone suspected of driving under the influence of alcohol. - If the breath test is **positive**, the person can be **detained until the police arrive**. - **Refusing to provide a breath specimen** is an offense: - The person may be **detained until the police arrive**. - If the person **drives off**, it's considered an offense, as if the police had given the order to wait. **Article 15E(4): Refusal to Provide Specimen** - **Refusing or failing** to provide a required specimen (breath, blood, or urine) is an offense. - **Presumed guilt**: If someone refuses, it\'s assumed their alcohol level exceeds the legal limit, unless proven otherwise. - **Defense**: The person can defend themselves by proving they couldn\'t provide a specimen due to **physical or mental incapacity** or if it would cause serious health risks. **Article 15D: Arrest for DUI** - A person can be arrested if: 1. **Breath test is positive**, or 2. They **fail to provide a breath test**, after being warned about the consequences. **Article 15H: Penalties for Driving Under the Influence** **First Conviction**: - **Fine**: At least 1800 euros, plus up to **6 months in prison**. - **Licence Suspension**: Minimum **6 months**. **Second or Subsequent Conviction**: - **Fine**: At least 3000 euros, plus up to **12 months in prison**. - **Licence Suspension**: Minimum **12 months**. - **Additional Orders**: The court may also order a **Probation Order** to attend a **rehabilitation program** at the person\'s expense, or a **Community Service Order**. - A **probation order** (such as attending a rehabilitation program or community service) only applies if the alcohol levels exceed the prescribed limit by a certain amount. These levels are: - **30 μg/100 mL** of breath or more. - **70 mg/100 mL** of blood or more. - **90 mg/100 mL** of urine or more. **Criminal Charges in a Road Traffic Accident** **Death**: - **Penalty**: Up to **4 years in prison** or a fine of up to **11,646.87 euros**. - **Licence Suspension**: As decided by the court. - **Article 225(2)**: If the accident causes **multiple deaths** or if **bodily harm** is also caused, the penalty increases to **up to 10 years in prison**. **Grievous Bodily Harm (GBH)**: - **Articles 226 & 218**: Maximum **1 year in prison** or a fine up to **4,658.75 euros**. - **Article 226**: For **less serious GBH**, the penalty is **up to 6 months in prison** or a fine up to **2,329.37 euros**. - **Licence Suspension**: As decided by the court. Health legislation ================== [The Health Act: Chapter 528] This law aims to manage who gets access to healthcare services in Malta and ensure the quality of those services. It also works on improving and organizing the government bodies responsible for health and protects the rights of patients. **Health Policy and Strategy Board** - This group discusses and evaluates the direction and development of healthcare policies and strategies. - They also track the progress of implementing these healthcare policies. **Council of Health** - Advises the Government on all matters related to health in Malta. **Advisory Committee on Healthcare Benefits** - This committee provides advice on healthcare benefits. **Subsidiary Legislation** - **Indemnity Insurance for Healthcare Professionals Regulations (SL 528.02)**: Rules about insurance for healthcare professionals. - **Cross-border Healthcare Regulations (SL 528.03)**: Rules regarding healthcare services between different countries. - **Functions and Responsibilities of the Three Departments (SL 528.01, SL 528.04, SL 528.05)**: Details the responsibilities of three departments involved in healthcare. **Patients\' Rights and Safety** - **Right to privacy**: Your medical data must be handled according to the Data Protection Act. - **Right to refuse treatment**: You can refuse any treatment offered to you, as long as you sign a form agreeing to it. - **Right to timely care**: You have the right to be seen and treated without unnecessary delay. - **Right to file a complaint**: You can file a complaint about the service you received and should be informed about the outcome of the investigation. - **Right to appeal**: You can appeal any decision made under this law to the Administrative Review Tribunal. **Article 27(2)** - A person who is 14 years or older has the right to accept or refuse medical treatment if the doctor believes the person is mature enough to make that decision. - If the doctor thinks the person isn\'t mature enough, the consent of a parent or legal guardian is required. - Even if a mature person refuses treatment, the doctor can still provide treatment if it's urgent and in the person's best interest. - Once a doctor confirms that someone is mature enough, other healthcare professionals can treat that person without needing further permission. **Article 27(2)** - A person who is 14 years or older has the right to accept or refuse medical treatment if the doctor believes the person is mature enough to make that decision. - If the doctor thinks the person isn\'t mature enough, the consent of a parent or legal guardian is required. - Even if a mature person refuses treatment, the doctor can still provide treatment if it's urgent and in the person's best interest. - Once a doctor confirms that someone is mature enough, other healthcare professionals can treat that person without needing further permission. **Article 28** - Healthcare providers must offer services with respect for human dignity. - Patients are expected to use services responsibly and show respect for healthcare professionals, staff, and property. **Article 29(1)** - The Minister must create a \"Charter of Patient Rights and Responsibilities\" within two years. **Article 29(2)** - This Charter will outline the rights and responsibilities of patients and others involved in healthcare at the time of its publication. **Article 29(3)** - The Charter will be updated regularly to keep up with new trends and issues. **[Article 3 (1) : ]** - Every healthcare professional in Malta must have professional indemnity insurance. This insurance should cover the risks related to their work when providing healthcare services. - **Professional indemnity insurance** protects against any professional liability that may arise from their work. Medical and kindred professions ordinance ----------------------------------------- The law governing medical and related professions was first created in 1901 and has been changed many times since. Some parts of it were removed and included in new laws, like the **Health Care Professions Act (HCPA)** and the **Medicines Act**. Currently, the law mainly covers: - Rules about **psychotropic drugs** and **khat**. - Regulations on **advertisements** for healthcare services or treatments. - The requirement for **healthcare facilities** to have a license. **Article 40A**: The Minister has the power to create rules for controlling the production, export, import, possession, distribution, and sale of **psychotropic drugs** (mainly psychiatric prescription drugs listed in the 3rd Schedule). This includes regulations on **prescriptions**, **dispensing**, **labeling**, and **advertising** of these drugs. Inspections are required for anyone involved in their manufacture, export, import, sale, or distribution. Offences and penalties apply for violations. **Article 90A**: No one is allowed to advertise medical or health services or treatments (except those provided by the government) without approval from the **Council of Health**. **Articles 96 and 98**: These articles state that a **license** is required to set up a **chemical laboratory**, **clinic**, **hospital**, or **medical diagnostic laboratory**. Health Care Professions Act --------------------------- The law in Malta regulates healthcare professions by replacing most of the **Medical and Kindred Professions Ordinance (MKPO)** and parts of the **Department of Health Constitution Ordinance (DHCO)**. It applies a common legislative and regulatory framework for all healthcare professions, including: doctors, nurses, midwives, dentists professions complimentary to medicine as listed in the third schedule like acupuncture, diet, nutrition, chiropractic etc.  **Practice Conditions**: - **Article 3(1)**: Only those meeting the legal requirements can practice a healthcare profession in Malta. - **Article 3(2)**: Professional titles can only be used if the individual fulfills the legal requirements. - **Article 4**: Concurrent practice of multiple healthcare professions is prohibited unless exceptions are prescribed by the Minister on the recommendation of the relevant Council.  **Licensing and Regulation**: - **Medical Doctors and Dentists**: Licenses recommended by the **Medical Council** to the President of Malta. - **Pharmacists**: Licenses recommended by the **Pharmacy Council**. - **Nurses and Midwives**: Licenses recommended by the **Council for Nurses and Midwives**. - **Professions Complementary to Medicine**: No licensing required, but professionals must register with the **Council for Professions Complementary to Medicine**. - Councils also recommend **withdrawal of licenses** to the President.  **Councils**: - Each council oversees its respective profession: - **Medical Council**: Doctors and Dentists. - **Pharmacy Council**: Pharmacists. - **Council for Nurses and Midwives**: Nurses and midwives. - **Council for Professions Complementary to Medicine**: Allied health professions. - Councils consist of a mix of elected representatives and **two laypersons**. - The President of each council is a **legal practitioner** appointed by the Prime Minister. - Elections for council members can be conducted by postal ballot.  **Registers**: - Councils maintain **professional registers**. - Specialist registers currently exist only for **medical and dental specialists**. In order to practice as a medical practitioner, one must be qualified and have a Doctor Of Medicine and Surgery of UOM, and must have a licence.Top of Form Specialists have a separate register and his name must be listed in this register. These professionals are bound by the code of ethics and may face charges when necessary. They are also bound by professional secrecy, along with other professionals such as social workers and lawyers. Medical practitioners can only be compelled to reveal these secrets to a public authority and if revealed to any one else shall be liable to a fine not exceeding 46,000 euro and a prison term not exceeding 2 years. **The public health act**: notification to the superintendent of public health regarding circumstances touching public health such as suspected food poisoning. There is a **notification of cancer act: healthcare practitioners are to notify cancer** to the superintendent of public health. Notification of drug addicts as well The Medicines Act ================= This act deals with the manufacture, preparation. Storage and destruction of medicinal products. The superintendent of public health has delegated authority to the Medicines Authority and the functions include inspections, monitoring of medicines, authorizing advertising of medicinal products. A pharmacy requires a licence and must be managed by a pharmacist. No person shall be qualified for a licence is he is a medical practitioner, vet or dentist. It is unlawful for the pharmacist to be in a partnership with any medical practitioner, dental surgeon or veterinary surgeon and to enter into any agreement for a share in the profits of a pharmacy. 1. Prescription drugs: Article 80- pharmacist must only dispense medicines on prescription, unless (Article 80) it does not require a prescription 2. Over the Counter Drugs: pharmacist shall assume full responsibility for dispensing of medicinal products, which do not need a prescription Apart from this, the pharmacy is inspected usually once a year and the act also regulates the storage of medicine and poisonous substances as well. Dangerous Drug Ordinance ======================== Where a licensed/warranted person is dealing drugs, the court may order the revocation of such licence or warrant. **Summary of Drug Possession Regulations:** **Possession of Prohibited Drugs:** - **Small quantities** for personal use (Article 4): - Less than **2g of drugs other than cannabis**, **2 ecstasy pills**, or **2 other prohibited pills**. - Penalty: Fine of €75--€125, no jail time. - Second/subsequent offenses within 2 years lead to stricter consequences. **Possession of Cannabis:** - **Adults (over 18 years)** (Article 4A, updated in 2021): - Possession of **up to 7g** of cannabis: **Not an offense** if clearly for personal use. - Possession of **7g--28g** for personal use: Fine of €50--€100. - **Cultivation** of up to **4 cannabis plants** and possession of **up to 50g of dried cannabis** for personal use within one\'s residence: **Not an offense**, provided cultivation is not visible to the public. - **Minors (under 18 years)**: - Possession of cannabis requires appearing before the Commissioner for Justice. **Trafficking or Dealing:** - **Reasonable suspicion** of trafficking or dealing leads to arrest and custody. **Rehabilitation:** - Offenders may appear before the **Drug Offenders Rehabilitation Board**, which recommends rehabilitation procedures. - Non-compliance results in prosecution in the Court of Magistrates, with penalties: Fine (€100--€500), imprisonment (up to 3 months), or both Prescribing: Standard Prescriptions ----------------------------------- - Prescriptions cannot be dispensed after **6 months** from the date of issue unless it is a **repeat prescription**. - Antibiotics: Must be dispensed within **10 days** of prescription issuance. - Narcotics and psychotropics: Require a **special prescription form** retained by the pharmacist, as per the **Dangerous Drugs Ordinance (DDO).** **Free Medicinal Provision:** - **Chronic conditions**: Free medications for all citizens under **Schedule V (yellow card)**. - **Social benefits**: Free acute and chronic medications for individuals on social benefits with a **pink card** (Article 23). - The **Health Department** provides doctors with: - Government formulary lists for hospital and outpatient use. - Lists of medicines that GPs and consultants can prescribe. **Narcotic Drugs:** - **Controlled under DDO**: Includes heroin, morphine, methadone, pethidine, codeine, cannabis, and cocaine. - Doctors, dentists, and pharmacists may prescribe, possess, and dispense for therapeutic purposes. - Requires **control cards**, regulated by the **Drugs (Control) Regulations (DCR)**. **Psychotropic Drugs:** - **Restricted drugs**: Highly controlled, requiring special authorization (e.g., LSD, mescaline, ecstasy). - **Specified drugs**: Prescribable with a license (e.g., amphetamines, barbiturates, benzodiazepines). - Transactions for both types must be recorded in specific registers. **Drug Control Card Process:** - **Doctor applies** to the Superintendent of Public Health for a **Drug Control Card (white card)** for a named patient. - In emergencies, a **1-week supply** may be prescribed, with notification to the Superintendent within **48 hours**. - Superintendent issues the card for **1 year**. - Special prescription form (green form) and white card: - **Doctor** fills Part A, signs the green form, and updates the white card. - **Patient** takes both to the pharmacist. - **Pharmacist** fills Part C of the green form (retains it) and updates the white card, which is returned to the patient. - All transactions are recorded in a special register retained for **2 years**. **Additional Pharmacist Responsibilities:** - Maintain registers for all transactions of controlled drugs. - Ensure proper labeling of drug containers. - Retain prescriptions for verification by the Department of Health to prevent abuse. Summary: NARCOTICS - Dangerous Drugs Ordinance (DDO) - Drugs (Control) Regulations (DCR) - Methadone Rules Narcotics: heroin, methadone, morphine, pethidine, codeine and dextropropoxyphene υ Others: cannabis, cocaine Wounds and Injuries =================== Classification of Injuries: ---------------------------- There are Kinetic Injuries: Bruises/abrasions/lacerations (these are blunt force injuries) and there are also sharp force injuries (incised wounds/cut/slash/stab wound). Non-Kinetic Injuries: 3. Thermal :due to the heat or the cold 4. Chemical 5. Electrical due to high or low voltage 6. Electromagnetic radiation: radio wave, microwave, UV etc An injury can be simple or grievous. [A blunt weapon/force]: This causes abrasions, contusions (bruises) and lacerations. [Bruises/Contusions: ] - Caused by blood leaking into tissues from ruptured capillaries. - **Key Features:** - Skin is not broken. - May appear a day after injury. - Color changes over 7--12 days:\ **Red → Blue → Purple → Green → Yellow → Brown.** - Helps estimate age of the bruise (fresh = red/blue; old = yellow/brown). - Often in loose tissues (e.g., around the eyes). - Shape can indicate the weapon used. - **Examples:** - **Periorbital Hematoma:** Trauma to the eye (e.g., punch, forehead wound). - **Skull Base Fracture:** Bruising around both eyes. **Abrasions (Scratches/Grazes):** - Involve only the outer skin layers, caused by tangential force (e.g., brush or crush injuries). - **Key Features:** - Often superficial and shaped by the object (e.g., rope weave, tyre marks). - \"Skin tags\" at edges indicate the direction of impact (e.g., biker falls and scrapes knee). - Can be caused by fingernails, seatbelts, or road rash. - Post-mortem abrasions lack scab formation and color changes. **Timing of Abrasions:** 1. **Fresh (0--24 hours):** Oozing lymph/blood, no scab yet. 2. **2--3 Days:** Reddish-brown scab forms. 3. **4--7 Days:** Epithelium grows under scab. 4. **After 7 Days:** Scab dries, shrinks, and falls off. - Typically heal without scarring unless deeper layers are involved. **Pattern and Site Examples:** - **Patterns:** Tyre marks, whip marks, muzzle imprints, etc. - **Sites:** Fingernails (neck), road rash (exposed skin), abrasions over bony areas. Lacerations -----------  Caused by **blunt injury** (e.g., blows, falls, road accidents, assaults).  Involve **tearing through the full thickness of the skin**, sometimes affecting deeper tissues.  **Key Features:** - Irregular, jagged edges. - Tissue bridges visible in the wound. - Often accompanied by bruises or abrasions. - May contain **trace evidence** (e.g., dirt, hair).  **Internal Injuries:** - Can occur in organs like the spleen or liver from indirect force. Cuts/Slashes: ------------- - **Longer than they are deep.** - Clean, linear wounds (e.g., surgical cuts). - Caused by knives, scissors, or glass. 1. **Stabs:** - **Deeper than they are wide.** - Caused by sharp-pointed objects (e.g., knives, screwdrivers). 2. **Chops:** - Combine sharp and blunt trauma. - Severe, deep wounds caused by heavy tools (e.g., cleavers, swords, axes). **Cuts/Slashes in Suicide vs. Homicide:** - **Suicide:** - Tentative, shallow, and repetitive. - Often on **wrists, neck, elbows, groins, or abdomen.** - Parallel and close, showing hesitation. - **Homicide:** - Forceful, not tentative or repetitive. - Target vital spots like **neck or face.** - Often show **defense wounds** on forearms (from blocking attacks). **Other Details:** - **Common Weapons:**\ Knives, scissors, pens, screwdrivers, or other sharp/pointed tools. - **Defense Wounds:**\ Found on **ulnar borders of forearms** (protective gesture). Stab Wounds **Causes and Characteristics:** - Caused by **sharp or pointed instruments**, such as: - Knives, scissors, screwdrivers, pens, or pencils. - Blunt tools with a sharp point (e.g., iron bars). - **Wound Shapes:** - **Slit Shape:** Straight or curved depending on angle or motion. - **Double-edged knife:** Slit with two sharp points. - **Single-edged knife:** Triangle-shaped wound. **Track Depth:** - **Knife fully inserted:** Track depth equals blade length. - **Knife partially inserted:** Track depth is less than blade length. - **Soft tissue (e.g., abdomen):** Track depth can exceed blade length due to compression. - **Hilt mark:** Imprint of knife handle when fully inserted. **Handling and Measurement:** - **Never insert a weapon** into the wound to check if it fits. - **Leave the weapon in the body** until reaching a hospital. - Measure the wound's **length, depth, and track** for forensic analysis. **Forensic Clues:** - **Patterns** of wounds can link the injury to the weapon. - Dirt, dust, or debris in wounds may connect the victim to the crime scene. - **Defensive wounds** (e.g., on forearms) indicate the victim tried to block the attack. **Common in Homicides:** - Most stab wounds occur in **homicides.** - Death usually results from **severe bleeding (hemorrhage).** **Associated Abrasions:** - May reveal the **manner of injury:** - **Struggles:** Abrasions on the assailant or victim. - **Smothering:** Around the mouth and nose. - **Sexual assault:** On sensitive areas like breasts or genitals. Gunshot Injuries ================ **Factors Affecting Injury:** 1. **Projectile Features:** - **Caliber and shape** affect how the bullet moves through tissue and loses kinetic energy (KE). - Bullets that deform or break up cause more damage by losing more KE. 2. **Velocity:** - **High-velocity bullets** are more likely to break apart, increasing injury. 3. **Wound Track:** - Longer tracks cause the bullet to lose stability and deform more. - Denser tissues slow the bullet, increasing KE loss and damage. **Extent of Injury:** 1. **Mechanical Damage:** - Tissue is shredded and crushed by the bullet as it moves through the body (like a drill). 2. **Cavity Formation:** - Bullets create a temporary cavity that stretches and compresses surrounding tissue, causing additional damage. 3. **Bullet Breakup:** - Fragments of the bullet can cause secondary injuries. In short, the **bullet's design, speed, and the type of tissue it hits** all influence the extent of injury. GSW can be **penetrating or perforating**. Penetrating occurs when the bullet enters an object but does not exit. Perforating occurs when the bullet passes through and exits the object. The different types of weapons: **Shotguns:** - Common in **sports** and **agriculture** (most common weapon in Malta). - **Barrel:** Long, smooth bore (66--81 cm). May have **two barrels** or a tapered end called a **choke** for better accuracy. - **Ammunition:** Fires **multiple pellets** (lead shot). **Gauge (Size):** - Determined by the bore's diameter. - **Gauge Definition:** Number of solid lead balls (of bore diameter) that make up **1lb of lead**. - Example: A **12-gauge** shotgun has a bore diameter of 19mm (12 lead balls of this size weigh 1lb). **Cartridge Components:** 1. **Case:** Made of plastic or cardboard. 2. **Lead Shot:** Multiple small pellets. 3. **Wad:** Plastic/cardboard layer, may have markings for gauge or manufacturer. 4. **Propellant:** Explosive (gunpowder) containing nitrocellulose and chemicals like barium, antimony, and nitrites. 5. **Primer:** Metal base that ignites when struck by the firing pin. **Rifled Barrel (Different from Shotguns):** - Grooves inside the barrel create a **spin on bullets** for accuracy. - Leaves identifiable marks (lands and grooves) on bullets. - **Caliber:** Diameter of the barrel measured between opposite lands. In summary, shotguns fire multiple pellets with smooth-bore barrels, while rifled barrels are designed for precision using spinning bullets. [Rifled Weapons ] - Revolver - Pistol - Rifle The range of fire: ------------------ **Close-Range Wounds:** - **Muzzle in contact with skin at discharge.** - **Hard contact:** All gas, soot, metallic particles, and bullet are forced deep into the wound. - **Loose contact:** Skin is not indented; soot forms a ring around the entry wound. **Near-Contact Wounds:** - **Muzzle close but not touching skin.** - Powder grains create **powder tattooing** on skin (small marks). - Soot deposits around the wound, blackening and searing the skin. **Intermediate Range:** - Muzzle is farther from the skin. - **Powder tattooing** occurs but soot is less dense. - Blackening from soot may appear around the wound, but soot can be wiped away (tattooing cannot). - Pattern varies with weapon type, caliber, and distance. **Distant Range:** - **No soot or powder tattooing.** - Entrance wounds are clean but may be **irregular or stellate** depending on the bullet's impact and location. - Range varies based on weapon and ammunition. **Smooth Bore Weapon (e.g., Shotguns):** - **Entry wounds:** - Lead shot exits as a **solid mass**, with pellets, unburnt powder, flame, smoke, gases, and wadding diverging in a **cone shape**. - Dispersal increases with distance. - **Exit wounds:** - Rare, except for severe injuries like **head wounds** where pellets may exit. - Inside the body, pellets spread, causing extensive internal damage. **Key Point: Range Impacts Injury Severity** - **Closer range = more severe injuries** due to gases, soot, and concentrated energy at the entry site. - **Farther range = less direct damage, more dispersed impact.** **Near Contact to Intermediate Range:** - **Close Contact:** - Skin burns or singed hair from heat. - Blackening from smoke up to **40 cm**. - **Tattooing:** Marks from unburnt powder embedded in skin, found up to **1--2 meters**. - **Intermediate Range:** - **Rat Hole (Scalloped Wound):** Caused by separating pellets, starts around **1 meter**. - **Satellite Pellets:** Appear around the main wound at **1.5--2 meters**. **Distant Range:** - Only **individual pellets** are found beyond **8--10 meters**. - **Long Range Shots:** Pellets spread widely, causing less concentrated damage. **Modifiers:** - Clothing can alter the pattern of burns, blackening, and tattooing. - X-rays can show the **spread of pellets** inside the body for forensic analysis. **Example Case:** - **Near Contact Shot:** Entry wound in the **right lower chest/upper abdomen**, with visible spread of pellets on X-ray. Rifled weapons -------------- **Loose Contact Entry Wound:** - **Characteristics:** - **Circular wound**, slightly smaller than the bullet due to skin stretching and recoil. - **Inverted edges** (the skin is turned inwards) and an **abrasion collar** caused by the bullet\'s friction. - **Muzzle imprint**, soot, burning, and hair singeing may be present. - **Pink stain** from carbon monoxide (CO). - **Bone Contact:** - Wounds over bone may appear as **stellate (star-shaped)** or **cruciform (cross-shaped)** due to ragged tearing. **Tattooing and Long-Range Wounds:** - **Tattooing (powder marks):** Seen at distances beyond soot range. - At **long range:** - Entry wounds are **round with abraded margins** and **inverted skin.** **Exit Wounds:** - **Larger and irregular** compared to entry wounds. - Bullet spin becomes ineffective in tissue. - Bullets may deform while passing through the body. - **Everted edges** (turned outward). - **Multiple exit wounds** if bone fragments are expelled. - **Re-entry wounds** can occur if the bullet re-enters the body. **Bullet Marks:** - **Marks on bullets and cartridges** are unique to the weapon that fired them. - Forensics compares bullets using **microscopy** or **test-firing** similar ammunition to determine: - If the bullet matches a suspect weapon. - The range of fire. **Gunshot Residue (GSR):** - GSR includes **residues from the primer**, **metal from the barrel/bullet**, and **unburnt gunpowder.** - GSR can land on: - **Victim\'s skin/clothing** (near entry wound). - **Assailant\'s firing hand, clothing, or hair.** - GSR is collected using a solvent swab. - Helps identify the shooter and confirm proximity. **Gunshot Suicides:** - **Characteristics:** - Weapon is usually found at the scene, but not always in the victim\'s hand (only 20% of cases). - The gun is typically fired at **arm's length**, unless a special mechanism is used. - Rare in females and rarely involves multiple gunshots. - Suicide notes are uncommon but may coexist with other suicide attempts. - **Forensic Check:** - GSR on the **firing hand, clothing, or hair** confirms self-infliction if in doubt. **Keyhole Skull Wound:** - When a bullet **grazes the skull tangentially** (this means at an angle) it creates a **keyhole-shaped defect**: - Circular damage at one end (where the bullet originally impacts) with radiating fractures, causing a piece of bone to lift outward. Thermal Injuries ================ **Normal Body Temperature:** - Average: **36.8°C (98.2°F)**. - Normal range: **36.4°C--37.3°C (97.5°F--99.1°F)**. - Controlled by the **hypothalamus** through the **autonomic nervous system.** - Heat is lost by: - **Radiation:** Blood vessels dilate, causing redness. - **Evaporation:** Sweat cools the body. **Hyperthermia (Heat Injury):** - Core temperature reaches **40.6°C (105°F)** or higher. - Brain's heat regulation fails, leading to **heat stroke.** **Causes of Hyperthermia:** 1. **Environmental Factors:** - High temperatures, physical exertion, obesity, alcoholism. 2. **Drugs:** - Certain medications or illegal drugs can disrupt heat regulation. 3. **Genetics:** - Some people are predisposed (e.g., reactions to certain anesthetics). 4. **Specific Drugs:** - **Ecstasy:** Increases heat production and impairs heat loss by narrowing blood vessels. **Heat Exhaustion vs. Heat Stroke:** 1. **Heat Exhaustion:** - **Normal temperature.** - Loss of fluids and salt. - **Symptoms:** Sweating (wet, cool skin), fatigue, dizziness, nausea, and possible collapse. 2. **Heat Stroke:** - **Temperature 40.5°C (105°F) or higher.** - Sweating stops (hot, dry skin). - **Symptoms:** Dizziness, fainting, confusion, unconsciousness. - **Often fatal**; children, elderly, and obese are most at risk. Types of Thermal Injuries: -------------------------- 1. **Moist Heat (Scalds):** Hot liquids or steam. 2. **Dry Heat:** Burns from flames or hot surfaces. 3. **Cold Injuries:** Frostbite or hypothermia. 4. **Chemical Burns:** Corrosive substances. 5. **Electric Contact:** Electric shock burns. 6. **Radiation Burns:** X-rays, ultraviolet rays. **Scalds (Moist Heat):** - **Causes:** Hot liquids or steam, causing redness and blisters. - Clothing can worsen injuries by trapping hot liquids against the skin. - Common in domestic settings, especially with children and the elderly. **Scalds and Abuse Indicators:** - **Accidental Scalds:** Irregular patterns from liquid flow. - **Abuse Scalds:** - **\"Glove and stocking\" pattern:** Burns around hands or feet. - **Regular margins:** Indicate deliberate immersion in hot liquid. Burns ===== **Causes and Severity:** - Caused by **dry heat** (e.g., flames, hot surfaces) above **50°C**. - Severity depends on **temperature** and **duration of exposure.** - **Three Degrees of Burns:** 1. **1st Degree:** - Redness (erythema), superficial blisters. - No loss of dermis, heals easily. 2. **2nd Degree:** - Full thickness of **epidermis destroyed**, exposing dermis. - Can regenerate with proper care. 3. **3rd Degree:** - Entire skin layer and some subcutaneous tissue destroyed. - May expose muscle or bone, heals with scarring. **Extent of Burns:** - Measured by **% of body surface area** using the **Rule of Nine.** - **Patterns:** Indicate the victim's position or clothing at the time of injury. - **Clothing:** Can reduce burn severity. **Prognosis:** - **Poor outcomes** if: - Over **1/3 of body** is burned. - Elderly: Can die from just **10--20% burns.** - Burns on **face or hands** are more serious than on legs. - Children recover better from extensive burns. **Complications:** - **Immediate Risks:** - Fluid and electrolyte loss. - Infection. - Airway or lung damage. - Blood clotting issues. **Delayed Risks:** Death weeks later due to complications like **electrolyte imbalances.** Fires Fires require Magisterial Inquires. To establish the origin of the fire. **ole of the Pathologist:** 1. **Identity:** Determine who the victim is. 2. **Timing of Death:** Establish if the victim died **before or during the fire** (alive in the fire?). 3. **Cause of Death:** Determine if death was directly caused by the fire or related to other factors. 4. **Preceding Events:** Investigate why the victim was in the fire (e.g., accidental, suicidal, or criminal circumstances). 5. **Escape Inability:** Assess factors preventing escape, including medical, social, or environmental reasons. **Common Scenarios of Fire Deaths:** 1. **Accidents (most common):** - Young, elderly, or intoxicated individuals are at higher risk. - Causes: - Carelessness (e.g., clothes catching fire, throwing lit matches). - Faulty appliances. - Physical inability to escape (e.g., medical events like strokes or seizures). 2. **Suicide:** - Rare in Western cultures, more common in Eastern cultures. 3. **Homicide:** - Rare but may involve fire to **conceal the crime.** **Body Examination After a Fire:** 1. **General Appearance:** - **Height/weight** reduced due to water loss (up to 60%). - **Pugilistic stance:** Body appears in a "boxer pose" due to muscle contraction from heat. 2. **Skin:** - Brittle with long or wide splits caused by heat. - Cherry pink color indicates carbon monoxide poisoning (victim was alive during the fire). 3. **Hair:** - Changes colour due to heat: - Grey → blond. - Brown → reddish. 4. **Fractures:** - **Skull and long bones** may crack due to dehydration of collagen. 5. **Organs:** - Often preserved, even in a charred body. 6. **Accelerants:** - Flammable liquids (e.g., gasoline) may be detected on clothing, suggesting intentional fire. 7. **Burn Severity:** - Most burns on a fire victim are **post-mortem** (after death). **Key Forensic Notes:** - **House Fires:** An adult's body cannot be completely destroyed, even at **780°C.** - **Child's Body:** May burn completely in a confined oven-like environment. **Key Indicators:** - **Soot in Airways:** - Soot below the **vocal cords** shows the victim was alive and breathing during the fire. - **Full Body X-Rays:** - Used to detect fractures (caused by heat or trauma) and pre-existing bone or joint diseases. **Causes of Death in Fires:** 1. **Hypoxia (Low Oxygen):** - Main cause of death, resulting from: - Breathing in low oxygen and high levels of carbon monoxide. - Inhaling smoke, particulate matter, and noxious gases. - Victims often lose consciousness quickly, before severe burns occur. 2. **Heat-Related Injuries:** - Burns to the **larynx** or inhaling superheated air can cause laryngeal spasm or cardiac arrest. 3. **Smoke Poisoning:** - Caused by toxic gases released during the fire, including: - **Carbon monoxide (CO):** Major contributor. - **Hydrogen cyanide (HCN):** Produced by burning plastics and synthetic materials. - **Hydrogen sulphide, nitrogen dioxide, hydrochloric acid:** Additional toxic gases. - **Synergistic Effect:** CO and HCN together increase toxicity. **Carbon Monoxide (CO) Poisoning:** - **Source:** - Created by incomplete combustion of carbon-containing materials (e.g., fires, gas appliances, car engines, tobacco smoke). - **Danger:** - CO binds to hemoglobin **200x more strongly than oxygen**, reducing oxygen in the blood. - **Levels in the Environment:** - Normal air: **\ - Corpus delicti -- To develop information to determine whether a crime has been committed, or whether negligence contributed to an accident - Association -- To connect an individual as proximate cause of crime/accident, or to connect victim with incident - Jurisdiction -- To locate events to determine whether they occurred within the territorial jurisdiction of the court, or within the time period of the statute of limitations - Reconstruction -- To help narrow the frame of suspects by establishing feasibility, pattern and motive 11. **Short Tandem Repeats (STR'S**): These are present in the non coding part of the human genom 12. **A Laceration**: irregular and jagged wound edges are indicative of a laceration caused by a blunt force trauma. Using a sharp object eliminates it straight away. 13. **Bite Marks**: Bite marks typically show a mirror-image alignment of upper and lower dental arches. Thw wound is secondary to the imprint of the arches. 14. **If there is a bullt with spiral grooves on its surface**: this is a rifled weapon. 15. **The forensic expert examines a gunshot wound characterized by a small entrance hole with a surrounding ring of abrasion. ** 16. **The wound is relatively clean with no tearing of the skin.** 17. **Decomposition**: The rate of decomposition is slower in a submerged environment due to the lack of oxygen. 18. **Post-mortem cooling**: The rate of body cooling after death is faster in children than in adults. Children and elderly have different cooling. If the ambient temperature is more than the body temperature, its going to increase. 19. **In a body recovered from the cold sea**: Decomposition is hastened in cold water 20. **During an autopsy, the forensic pathologist notes petechiae in the conjunctiva, facial congestion, and facial oedema**: the most likely cause of death is asphyxia death. 21. **Manual Strangulation**: - There are marked internal injuries in the soft tissues of the neck - May be associated with sexual abuse - The victim is usually a female - There may be fracture of the thyroid cartilage (larynx) 22. Carbon monoxide poisoning: Victims of carbon monoxide poisoning often display cherry-red discoloration of the skin, particularly in the face and extremities. Top of Form Bottom of Form