Medico-Legal Investigation Introduction PDF

Introduction: Medico-legal Investigation ======================================== Exam = no negative marking Introduction: - Definitions - Overview of disciplines in Forensic Medicine. - The objectives of the course - Medico-legal investigation of a death. Definitions - [Forensice...

Introduction: Medico-legal Investigation ======================================== Exam = no negative marking Introduction: - Definitions - Overview of disciplines in Forensic Medicine. - The objectives of the course - Medico-legal investigation of a death. Definitions - [Forensice medicine]: is the medical knowledge applied to situations where legal issues arise (generally applied in relation to criminal law) and which provides assistance to the courts in legal proceedings. - [Legal medicine]: has been mainly used in relation to civil law issues, and it also relates to legal issues in relation to provision of health care. - [Medical jurisprudence] (used by legal practitioners): the science of the law as applied to the practice of medicine. Forensic medicine a. [Clinical forensic medicine] investigation of trauma to living patients. Regards medicolegal aspects related to patient care (diagnosis, treatment, management) b. [Pathological forensic medicine] examination of traumas to the deceased. Post-mortem to determine the cause of death. c. [Forensic psychiatry] branch of psychiatry related to criminology. d. [Forensic odontology] application of dental science (bite marks on the victim, identification based on dental records). **[Forensic Science ]** Any science used for the purposes of the law. - [Fingerprints] obtaining and comparing prints. - [Toxicology] study of blood/ body fluids to detect drugs/ chemicals (poisons). - [Serology] study of blood/ body fluids/ stains on materials to characterise the samples and identify the individual. - [Molecular biology/ DNA] study of blood/ body fluids/ stains to isolate DNA. - [Trace evidence] study of biological/ chemical in minute amounts. - Hair (human, non-human), natural fibres, pollen, soil. - Glass, paint, drugs, firearm powder residues. - [Ballistics] study of weapons and ammunition. - [Fire and explosions] study of accelerants/ explosive residues. - [Marks and scratches] tools and their impressions. - [Forgeries] paintings, documents, cassettes, videos. - [Computer/ electronic crime (cybercrime)] machines using electronic technology. - [Photography] stills, videos, special techniques. - [Forensic anthropology] science of skeletal remains. Course description ------------------ Forensic pathology: - Wounds (including firearm wounds) - Complication of wounds - Pathophysiology of death (ex: manner of death). - Changes after death - Medico-legal investigation of unnatural deaths (asphyxia, thermal injuries, deaths in water, death in custody, drug abuse, violent deaths, abortion, torture). - Physical and sexual abuse in children and the elderly. Medical law: - Regulation of medical practice. - Legal duties of doctors - Regulation of medicines, poisons and drugs of abuse. Criminalistics - Scene of crime investigation (including crimes at sea) - Evidence collection - DNA technology - Identification of victims - Aspects of toxicology - IT technology and cybercrime. Corrections and security - Alternative corrections (probation, community service) - Terrorism and criminal justice, Maltese security forces, IT security. [Reading list ] [Recommeded textbook: ] Simpson's Forensic Medicine, J. Payne-James Reading list - Knight\'s Forensic Pathology, 4th Ed., P. Saukko and B. Knight, CRC Press, 2015 - Clinical Forensic Medicine, W. McLay, 3rd Ed., Cambridge University Press, 2009 - Crime Scene to Court. The Essentials of Forensic Science by P.C. White, 4th Ed., RSC Publishing, 2016 - Medical law in Malta, by D. Bianchi, Kluwer Law International, 2023 Websites: - Maltese legislation - Forensic website : - Various internet resources available for pathology/ forensic pathology: Assessment: - Multiple choice questions - Single best answer - No negative marking. Medico-legal investigation ========================== **[Investigation of death: principles]** **[Investigation of death: aims ]** - To provide proper and accurate certification of death/ bodily harm. - Full and accurate statistics -- to identify the most common cause of death. - [Criminal justice]: discovery/ prosecution of crime and protection of innocent from scientific evidence. - [Civil justice]: information for settling estates/ resolution of disputes (ex: insurance conflicts). - [Public safety]: information to relevant bodies (ex: car safety) - [Education]: related to preventable deaths and dangers to health and safety. - [Information to public, particulalry next of kin]: explaining the cause and circumstances of death (ex deceased has a condition, this can be inherited and the next of kin is informed) **[Medico-legal systems for investigating deaths]** If a death is natural and a doctor can sign the death certificate, the relatives can proceed with burial or cremation of the body. However, if the death is not natural, or if no doctor can complete a death certificate, the need for death investigation systems arises. Death investigation systems: - These are arranged to identify and investigate deaths that are (or might be): unnatural, overtly criminal, suspicious, traumatic, caused by poisoning, unexpected or unexplained. - These deaths are examined by a variety of legal officers in different countries: coroners, medical examiners, magistrates, judges, police officers\... The different medico-legal systems for investigating deaths: 1. Coroner system (inquiry into the death and completion of the death certificate by the coroner) a. UK, Australia, New Zealand -- legally qualified. b. Canada -- many are medical, some law officers. c. US -- variable, sometimes neither qualification. 2. Medical examiner system d. US e. Canada 3. Police system f. Some European countries (Scandinavia, Czech Republic) 4. Magistrate system g. Many European states (Malta, Scotland's Procurator Fiscal) Magistrate system in Malta -------------------------- Magistrates - Appointed by the President of Malta, from candidates proposed by the Judicial Appointments Committee. - They qualify to be appointed as magistrates after practising as lawyers in Malta for not less than 7 years. - They sit in inferior courts. Magisterial inquiry - Technically called 'inquiry relating to the in genere' - Launched after receiving a request from the Police, or rarely from a private citizen. - Inquiring Magistrate (on call rota) conducts preliminary inquiry -- to collect evidence of the crime, in order to determine whether any person should be charged with an offence (whether there is sufficient evidence to proceed with a criminal trial). - In a magisterial inquiry, no person is as yet charged by the police before the court, although there may be suspects. - Magistrates carry out an inquiry into suspicious deaths to establish the manner of death. - Magistrate may hold an inquest on site (or direct a Police officer not below the rank of an Inspector). - Magistrate appoints experts (ex medical experts) to assist in the collection of evidence. **[Maltese courts ]** Superior courts: 1. Constitutional Court 2. Court of Appeal 3. Court of Criminal Appeal 4. Civil Court 5. Criminal Court Inferior Courts: 1. Juvenile court 2. Court of magistrates a. Civil jurisdiction b. Criminal jurisdiction i. Court of Criminal Judicature ii. Court of Criminal Inquiry Magisterial inquiry -- compilation of evidence (kumpilazzjoni) Following the inquiry, the case moves to the Criminal Court (which is a superior court) **[Court experts ]** Experts at the scene: 1. Doctor to examine the scene of death (clinical forensic physician or pathologist) 2. SOCOs (Scene of Crime Officers, members of the Malta Police Force with specific training) 3. Photographer 4. Architect to document the scene 5. Expert to hear evidence on oath from witnesses on site (can be a medical expert). 6. Others as required (ballistics, toxicologist, DNA, etc.) Court experts are - Independent and funded by the judicial system - Appointed by the court -- following the continental inquisitorial system (independent establishment of the truth) - Appointed in uneven number - Their report is submitted only to the Magistrate, is confirmed on oath, and becomes part of the procès verbal -- includes photographs, articles, documents relevant to the investigation. - The experts can see each other's reports once presented to the Magistrate. - The only persons entitled to information derived from the results of the investigation are the Magistrate, the AG and the investigating police officers. What different Medical experts can contribute: - clinical forensic physician attends scene of death/ interviews witnesses/ advises court - pathologists (often 2) carry out autopsy, identification (and occasionally attend scene) - toxicologist, if necessary - specialist medical experts - for instance if a dead body is found, police can call a doctor from health centre to certify death -- not an expert witness **[Deaths reported to the Magistrate ]** Art. 551(1) Criminal Code "In cases of sudden or violent or suspicious death or of death whereof the cause is unknown, a report thereof shall be made by the Executive Police to a magistrate; the magistrate shall hold an inquest on the body for the purpose of ascertaining the cause of death and shall, for that object, take all such evidence as may be possible for him to procure; after taking all the evidence, the magistrate shall draw up and sign a procès-verbal stating his finding as to the cause of death." Deaths to be investigated: Art. 551(2) and (3) Criminal Code \(2) Whenever a person dies while he is imprisoned or detained in any place of confinement contemplated in the Prisons Act, or while he is in Police custody, an inquest shall be held and a procès-verbal shall be drawn up for the purposes of and in accordance with the provisions of sub-article (1). \(3) The provision of the last preceding sub-article shall also apply whenever a person dies in Mount Carmel Hospital while he is kept there under an order of a court made pursuant to sub-article (3) of article 525 or to article 623(1) or for the purpose of his being examined by experts appointed by the court to report on the plea of insanity. **[Deaths reported to the Magistrate: guidelines]** (typical exam question: which 5 deaths need to be reported to the magistrate?) - uncertified (no medical history, foreigner) - deaths due to violent, suspicious or unexplained cause - death in legal custody - in mental hospital if under custody - accident - use of vehicle, car, ship, aircraft - accident in public, including hospital, institution, home - by drowning - in fire or explosion - unexplained death in a child - possible suicide - at work, including industrial disease - due to poisoning - due to fault of another or to neglect - following an abortion - death under medical care - possible negligence by medical carers - therapeutic/ diagnostic hazard - under anaesthetic **[Deaths reported to the Magistrate: manner of death ]** - Manner or mode refers to the circumstantial events (legal categorization). - In the investigation of a crime, Magistrate must establish the manner or mode of death. - 5 manners of death: 1. Natural 2. Unnatural a. Accident b. Suicide c. Homicide 3. Following the investigation, it remains unascertained or undetermined **[Death: manner vs cause vs mechanism ]** 1. ***Manner or mode of death***: legal categorisation (natural, accident etc.) 2. ***Cause of death***: medical condition, listed on the death certificate (ex: stroke, cancer). 3. ***Mechanism of death***: physiological derangement that results in death (ex: cardiac arrest, respiratory arrest, coma) Exam: which of the following is a cause of death? Etc. Identification ============== Learning objectives 1. Cases discussion 2. Identification procedures: a. General characteristics b. Specific characteristics c. Special techniques 3. Dead body 4. Age of living individual Who? - skeletal remains, mutilation, burning, decomposition, mass disasters - Visual identification possible but there is no ready clue - Usually: visual identification not possible but there is a match to a missing person - Rarely: visual identification not possible and there is no indication as to name WHY? - Identification of a body is necessary for the following reasons: - Ethical and humanitarian need to know who has died, especially for the relatives - Criminal investigation - Civil field - inheritance, remarriage, presumed death after 7 years (death in absentia) - Legal claims and obligations (property and debts) - Death Certificates: Final & Provisional - Social - religious, burial (permit, death certificate) - Statistical and legal purposes **[Scene information (case 1: derelict factory caught on fire)]** - position of body - in relation to fire origin / exit - collect all human remains, clothing, personal effects - fingers, teeth may fall off - assess if trauma to deceased - ascertain how fire started - ascertain use of accelerants - document architectural features of site (ex: fire exit) - document weather changes Personal effects - not part of body, therefore not specific - direct line of enquiry - identification by weight of evidence - degree of association with body as in mass disasters in confined spaces υ keys, papers, personalised effects (ID, letters, credit cards), clothing, jewellery **[General characteristics ]** 1. **[Height, Weight, Build ]** - **[Height]** (if bones are found): errors due to a. loss of water and shrinkage of body b. body may lengthen up in the first stage of flaccidity c. body may shorten when rigor mortis - **[Weight, build]**: unreliable in decomposition - weight increases in early decomposition - weight decreases in late decomposition 2. **[Age ]** - Babies: - examination of fontanelles (anterior fontanelle + posterior fontanelle) - measurements and tables  - children - ossification centres & epiphyses till 20-25 years \[+teeth\] - accuracy possible to within 1-2 yrs in foetus and infant - fusion of epiphyses earlier in females and in tropics - teeth eruption till 20-25 yrs but earlier in girls and in tropics - after 25 yrs, there are no dramatic events such as tooth eruption or the appearance of ossification centres A diagram of bones with red labels Description automatically generated - adults: - more difficult to determine age - obliteration of cranial sutures (wide range of ages) - full ossification of the thin connective tissue ligaments separating the bones at the suture lines begins in the late 20s, and is normally completed in the 5th decade of life - elderly - degenerative bone diseases (especially pubic symphysis, 4th rib, ilium -- equally stressed in all individuals regardless of activity, proportional to age only) - edentulous, wear and tear of teeth 3. **[Sex ]** - obvious in all but severely burnt bodies - elderly may have ambiguous facial features - uterus, prostate resist decomposition - teeth - teeth are the hardest and most resistant tissues in the body - can survive total decomposition and even severe fire - combination of morphological and morphometric features 4. **[Race ]** - some differences in facial skeleton and teeth, but this is usually not possible except for colour of skin 5. **[Hair ]** - distinguish from animal hair & fibres (microscopy) - distribution - colour: - grey changes to brassy blonde at 120°C - brown changes to slightly reddish at 200°C - black does not change - hair peels in water 6. **[Eyes]** - colour difficult after a few days - with decomposition: tend to darken to brown - pupil size and shape (?operation) **[Body recovered from fire ]** **[Victim was alive when fire started: ]** - Carboxyhaemoglobin saturation - Carbon monoxide (CO) toxicity → cherry pink discolouration of skin / internal tissues - Carboxyhaemoglobin (HbCO) is the complex formed when haemoglobin is exposed to carbon monoxide - Soot below the level of the vocal cords indicates the victim was alive and breathing **[Case 2]** - Two children were walking a dog on the beach in November. The dog ran ahead and started digging in the sand. - The children realised the dog had found some bones. When they got to the site, they saw the dog was holding a long bone. - They took the bone home and the parents decided it looked like a human thigh bone. - Police were informed. No other bones were found at the scene. Questions for Discussion: 1. What information can be obtained from bone(s)? 2. What investigations are necessary / can be done? Bone identification? - Is it human? - What is the age? - What is the sex? - What is the stature? - How long have they been dead and/or concealed? - What was the cause of death (e.g. trauma)? - Am I dealing with one or more bodies? - Can a personal identity be discovered (body implants -e.g. pacemakers, joint replacements- bear a unique reference number of the maker)? General characteristics 1. Height, Weight, Build - tables for heights from long bones 2. Age υ exclude archaeological remains - carbon dating - aspartic amino acid racemization dating - ossification centres, closure of epiphyses - see above 3. Sex   A diagram of the pelvis Description automatically generated Female pelvis is larger than the male pelvis.  Investigations - anatomical examination with measurements - examination of teeth υ X-ray (e.g. ossification centres) - DNA - archaeological remains -- carbon dating, protein studies **[Dental evidence ]** **[Sex ]** - Male teeth usually larger - mandible large with a square chin - angle of body with ramus is more straight, less than 125° - Female jaw - chin rounded with a point in midline - jaw differences less marked in Indians - measurements compared to published tables for populations - DNA from tooth pulp **[Race ]** - cannot really be determined from teeth though there are certain racial characteristics - Whites have canines with long pointed roots - Negroid races have large teeth and more cusps on molars - Mongoloid races (Chinese, Mongols, Eskimos, Japanese) have shovel shaped upper central incisors -- not exclusive **[Age ]** - Criteria for age - biochemical tests for acid in dentine - special morphological dental and skeletal methods to assess development and/or deterioration - Adults - wear and colour deteriorate with age - marked occlusal attrition indicates age - unless rough diet has accelerated process - edentulous jaws indicate age - beware of skeletons where conservative dentistry not available - alveolar margins (mandible) atrophy when teeth are lost - Children - easiest up to second decade - sequence of deciduous teeth well known - modified by sex (earlier in females), race and climate - after third molars erupt, age determination more difficult - third molar may be congenitally absent A diagram of teeth showing different types of teeth Description automatically generated  Dental evidence: Charting - The following should be noted: - dentures - pressure marks on gums or palate - dental prosthesis - bridgework, braces - extractions - recent or old - fillings - number, position, composition - artificial teeth - composition - crowned teeth - broken teeth - The following should be noted: - pathology of teeth, gums, jaw - congenital defects - pearls, ectopic teeth - malpositioned teeth -- rotated or tilted - hygiene - caries, plaque, tobacco staining, gingivitis - racial pointers Neither a living individual nor a body can be identified simply by taking a dental chart -- that chart has to be compared with, and found to match, a chart whose origins are known Dental evidence: Radiography - X-rays before removal of the skull - for superimposition, frontal sinuses, broken roots, dental work, congenital anomalies and other foreign bodies A close-up of a person\'s arm Description automatically generated  **[Identification: Case 3 ]** - A partly decomposed male body was recovered from a field, 3 days after the report of a person missing from a home for the mentally disabled. - The body was found within an hour's walk of the home. Question for Discussion 1. What information should be available to the pathologists? Medical information - tattoos - dermal pigment, scarred skin, skin lesions - amputations - not unique - healed fractures - unique plates and pins - prostheses - glass eyes, contact lenses, artificial joints - surgical scars and sutures - occupational scars - normal variance - frontal sinuses, sacroiliac joints - skeletal disease - degenerative disorders - congenital abnormalities - cervical ribs, extra digits - pregnancy - dental records Investigations PROCEDURES to confirm or exclude identity - Document features & general characteristics (full body autopsy) - Dental examination of teeth and jaws (forensic odontology) - Comparative methods for identification - Medical Records - Photography - Charting - Fingerprints - Radiography (full body x-ray) - DNA - Blood grouping - Facial Reconstruction **[Specific features ]** 1. **[Fingerprints ]** - Unique: each person has a particular pattern of finger and thumb prints specific to that person - no two individuals have identical fingerprints - Formed \~12 weeks gestation and remain unchanged during life unless scarred - chances of identical match \~1 in 64 billion - identical twins do not have completely identical fingerprints - a genuine match: 16 different characteristics match - initial computer match but then visual - useful as long as records of prints exist - physiological function: increase in grip? enhanced sensitivity? - identification based on the classification of the finger ridge pattern - the overall appearance of the ridges can be described as arches, loops and whorls - oil/debris on ridge and sides of furrow + dead squamous cells, found on touched surfaces - specific nomenclature with numerical values to specific patterns 2. **[Full body X-Rays ]** - fractures, deformities, degenerative diseases - prostheses, metal sutures - dental fillings - metallic objects (clothing, jewellery) 3. **[Blood grouping ]** - ABO, Rhesus grouping from blood - ABO secretors: people who secrete blood group antigens in their body fluids (e.g. saliva, sweat, tears, semen...) 4. **[DNA Fingerprinting ]** - any sample with nucleated cells - commonly blood and semen - in forensic practice: - saliva, hair - bone marrow - tooth pulp - tissue at scene of a crime Specific features - An individual\'s DNA pattern is unique - Match based on a number of tests - Probability of having the same DNA is remote (approx. 1 in a billion) Specific features: special techniques - Photo superimposition - alignment of photo with radiograph of the skull with optical precision - superimposed bony facial features, frontal sinuses A collage of images of a skull Description automatically generated Facial recognition - Scan features on photo or acquire from video - Compared with a database of facial images Computer-enhanced ageing - Aging the images of missing children - Photograph family members  Legal implications of wounding & head injuries ============================================== **[Learning objectives]** - Criminal law in relation to: - Bodily harm (grievous vs. slight) - Collection of evidence (including medical samples) - Torture - Head injuries - Scalp - Skull - Brain damage - Intracranial haemorrhage **[Bodily harm: criminal law ]** [The Criminal Code] **Title VIII Of Crimes Against The Person** - **Sub-title I - Wilful Homicide** - **Sub-title II - Wilful Offences Against the Person** - **Grievous Bodily Harm** - **Slight Bodily Harm** - **Sub-title III - Justifiable Homicide or Bodily Harm** - **Sub-title IV - Involuntary Homicide or Bodily Harm** [Grievous Bodily Harm (GBH)] **Criminal Code, Article 216(1):** A bodily harm is deemed to be **grievous** **bodily harm** and is punishable with **1-7 years prison** if a. it can give rise to **danger of**: i. loss of **life** or ii. **permanent debility** of health or permanent functional debility of iii. any organ of the body or iv. **permanent defect** in any part of the body or v. **permanent mental infirmity** a. it causes **deformity or disfigurement in face, neck, or hands** b. is caused by **a wound penetrating body cavities** without producing the effects mentioned in **Article 218** (*no permanent debility or defect*) c. it causes **mental or physical infirmity for** **30 days** or more or if the injured **cannot work for 30 days** or more d. committed on a woman with child, it **hastens delivery** **Criminal Code, Article 218:** A grievous bodily harm is punishable with imprisonment for **5-10 years** if a. it causes **permanent debility** of health or permanent functional debility of any organ of the body or **permanent defect or permanent mental infirmity** b. it causes **serious** and **permanent disfigurement in face, neck, or hands** c. being committed on a woman with child, it causes **miscarriage** **Criminal Code, Article 217:** A grievous bodily harm is punishable with - imprisonment for **2-10 years** if **arms, cutting or pointed instruments, explosives, burning or corrosive substance** - imprisonment for a **minimum 4 years** if the offence is committed by means of explosives (& no probation) **Criminal Code, Article 220:** after **grievous bodily harm** **(1) death** as a result of **the nature or natural consequences of the harm** and not of a supervening accidental cause: - within **40 days** → **6-20 years prison** - **\>40 days but \60yr) - disability (amended in 2021, before it was physical or mental infirmity) Slight bodily harm - Art. 221 Criminal Code - Bodily harm is slight if it doesn't cause the above effects prison for not more than 2 years, or a fine - If bodily harm is of small consequence to the injured, the punishment is reduced, but still more severe with use of arms etc. Bodily harm: forensic evidence ------------------------------ [The law ] Criminal Code, Article 357: Where the officer of the Executive Police discovers any weapon/document/trace/vestige or any other thing relating to an offence, he shall take steps to establish and ensure the existence and the preservation thereof in the state in which it was found until he shall have reported the matter to the Court of Magistrates, and, if unable to establish and ensure such existence or preservation, he shall observe the same procedure provided for the drawing up of a "repertus" intimate/ non-intimate samples - Intimate sample: a. Sample of blood b. Semen c. Other tissue fluid d. Pubic hair e. Swab from a person's body orifice other than the mouth. - Non-intimate sample d. Sample of hair (other than pubic hair) e. Sample from a nail or from under a nail f. Swab from any part of a person's body (including mouth, no other orifices) g. Urine h. Saliva i. Footprint or similar impression of any part of a person's body (not hand) - Fingerprints have their own regulations **[Samples -- arrested person: ]** - Art. 355BA(1): The investigating officer (Police) may, with the appropriate consent in writing of the person arrested, cause to be taken: - Fingerprints - Non-intimate photographs - Non-intimate samples - If the person objects, the police officer must request (Art. 355V) the magistrate's authorisation, which is then possible under Art. 554(2) - Art. 355AV Cap 9: The investigating officer (police) may request a magistrate to authorise the taking, from arrested person, of - Intimate samples - Photos of intimate body parts - Fingerprints, non-intimate samples, non-intimate photos if person has refused consent. - Art. 355AX (1) Cap 9: upon a request from police for an intimate sample, the magistrate decides if justified or not. - Art. 355AX(2) Cap 9: where the magistrate decides that the request is justified, he shall visit the person arrested to request his consent and before asking for his consent he shall explain to him a. The nature of the request and reasons thereof b. The consequences of giving his consent and of refusing consent as provided in article 355AZ; and c. The arrested person may request to consult his lawyer before deciding to consent or not. - Art. 355AZ: if he refuses 'without a good cause', the judge or magistrate may draw such inferences from the refusal as appear proper and the refusal may, on the basis of such inferences, be treated as, or as capable of amounting to corroboration of any evidence against the person in relation to which the refusal is material. - Art. 355BA (2): The person arrested may request in writing that: - Non intimate samples/ photos, fingerprints be taken and any such request shall be complied with by the investigating officer with the assistance of any competent person as may be necessary. - Art. 355BA (3): the person arrested may also request in writing the taking of intimate samples but this request must be directed to a magistrate. **[Samples -- non-arrested person]** - Art. 355BB Cap 9: samples from a person other than a person arrested may only be taken with that person's prior consent in writing: - Provided that for the taking of an intimate sample a magistrate's authorisation must also be obtained upon application. - Art. 355BC: a non-arrested person may also request samples to be taken if s/he suspects that otherwise s/he may be arrested, again requiring magistrate's authorisation for intimate samples. Intimate Search -- Arrested person - **Intimate search:** physical examination of a person's body orifices other than the mouth - **Criminal Code, Article 355AP:** Where the **arresting/custody officer** has a reasonable suspicion that the person **arrested** may have **concealed on his person** any **drug** (the unlawful possession of which would constitute a criminal offence), or any other item (which a custody officer is authorised by this Code or by any other law to seize from the possession of an arrested person), the said officer **may request** a **Magistrate** to order an **intimate search** of the person arrested - **Article 355AQ(2):** A person shall not be appointed an **expert** for the purpose of carrying out an intimate search on a person of the opposite sex unless the expert is a **medical practitioner** and the person to be searched **consents thereto in writing**  Fingerprints ------------ - **Criminal Code, Article 397(3):** The **court** may, moreover, at the request of the **Police**, **order** that any **accused person** be photographed or measured or that his **fingerprints** be taken: Provided that when an accused person, who has not been previously convicted of crime, is acquitted, all photographs (both negatives and prints), fingerprint impressions, and records of measurements so taken, shall be **destroyed** or handed over to the person acquitted - Apply **Article 355BA(1)** which allows the **investigating officer** with **appropriate** **consent in writing** of the **person arrested**, to take **fingerprints** (as well as non-intimate samples and photographs) If the arrested person **objects**, the police officer must request the **Magistrate's** authorisation **Fingerprints, Photographs and Measurements of the Accused Persons Regulations (SL 9.04)** - **Reg 2.** Where, at the request of the Police, the **Court of Magistrates (Malta) or the Court of Magistrates (Gozo),** as the case may be, thinks fit to **order**, under the provisions of **sub-article (3) of article 397 of the Criminal Code**, that the fingerprints, photographs or measurements of an accused person be taken, such **fingerprints, photographs or measurements** shall be **taken by a member of the Police Force**. - **Reg 3.** The fingerprints, photographs or measurements referred to in **regulation 2** shall be taken either at the place where the court is sitting or at such other place as the court may think fit Torture ------- **1975 Tokyo Declaration of the World Medical Association (updated 2005 and** **2006)** defines **torture** as: \"the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.\" - As far as the **forensic doctor** is concerned, torture is seen in two main contexts: - perpetrated by criminal and terrorist groups - carried out, or allegedly carried out, by the police or other security forces\' personnel, during the detention and interrogation of prisoners and suspects - Methodical and detailed \'head to toe\' examination - all injuries and marks must be accurately recorded and photographed A **forensic doctor** may be asked to investigate allegation of torture / abuses of human rights in: - persons who claim refugee status because of torture - examination not very fruitful, especially if considerable time has elapsed from the time of torture - less likely to see fresh injuries - all type of mechanisms are used, preferably those that do not scar - prisoners in custody - properly treated during detention and interrogation - actual physical abuse less frequently seen - more subtle use of threats and intimidations - hooding, prolonged standing, continuous high-pitched sounds - disorientation - food at erratic times, frequently waking person after short intervals of sleep, light in cell all day long... **Police Act, Chapter 164** **Third Schedule: Code of Practice for Interrogation of Arrested Persons** **Section 16** - Any inhuman or degrading treatment, or any form of physical or mental torture is prohibited and an offence under **article 139A, Criminal Code** → **max 9 years imprisonment** - guidelines regarding interrogation: - person being interrogated should all times be seated - no foul language, threats, deprecatory laughter, menacing gestures - firearms, weapons not to be exhibited unless part of investigation - person questioned must not be bound by rope, chain, shackle, but may be handcuffed for safety or to prevent escape **Section 17** - **intellectual disability:** interviewed only in presence of parent/ tutor/ carer/ social worker of same sex as interviewee - documents signed by the person with disability and by parent / accompanying person at interview - persons under **influence** of **drugs, alcohol, medicine, or in shock**, should only give statements when able to appreciate significance of questions and their answers - certification by doctor of any sick person before interrogation Head injuries -------------  Open vs closed head injuries: - Open head injury: - Penetrating head injury - Includes a fractured skull - Closed head injury - Intact skull - But intracranial injury Types of injury: outline - **Scalp - abrasions, bruises, lacerations** - **Skull - fracture** - **Brain damage -- traumatic brain injury (TBI)** - **Intracranial haemorrhage**  Skull fractures: 1. **[Linear fracture ]** - straight line fractures of the vault - skull collides with an object - due to blunt trauma over a wide surface area of the skull - fracture may occur away from point of impact - skull bends inwards at impact - both minor and severe trauma can cause fractures - not serious unless other brain injury/haemorrhage - Heal with minimal intervention 2. **[Depressed fracture ]** - fractures of the vault - occur at a focussed point of impact with a heavy but small object (e.g. hammer or a rock) - a piece of skull is pushed inwards for a few millimetres - May cause brain injury - May require surgery 3. **[Base of skull fracture:]** - involve base of skull - due to severe blunt force - generally involve sinuses with risk of infection - acceleration-deceleration fractures  4. **[Facial fracture: ]** - Results from a direct injury to the face (e.g. road traffic accidents, sports...) - Might cause damage to surrounding tissue (e.g. eye, nose, jaw..) **[Traumatic brain injury (TBI)]** Mechanisms: - The head is struck with an object - The head strikes an object - The brain moves within the skull Types of brain damage: - Concussion - Contusion - Brain oedema - Diffuse Axonal Injury - Intracranial haemorrhage **[Brain damage: types ]** 1. **[Concussion ]** - Mild form of TBI - Caused by a bump/ blow/ jolt to the head cause the brain to move rapidly back and forth - Temporary disruption of brain functions, without structural damage.  **[Coup vs contrecoup ]** - Coup injury head struck at one point - Contrecoup injury but brain in skull is free to move brain is damaged, diametrically opposite the impact point. - Brain movement restricted by brainstem, tentorium, falx, leaving frontal and temporal lubes prone to injury. 2. **[Contusion ]** - areas of focal brain damage (bruises, small haemorrhages) - **coup contusion** occurs at the site of impact - **contrecoup contusion** at a point diametrically opposite to the point of impact - heal with formation of orange brown scars over the cortical surface (plaques jaunes), which remain for a long time - common in alcoholics 3. **[Brain oedema ]** - Swelling of the brain tissue - Can be delayed (clinical deterioration 24-48 h after injury) - Can increase the intracranial pressure - Diffuse oedema may occur in the absence of focal lesions (particularly in children) 4. **[Diffuse axonal injury]** - Stretching of the nerve fibres (axons) axonal injury. - Due to rapid head movement inside skull - Associated with severe TBI (unconscious patients)  5. **[Intracranial haemorrhages ]** - Extradural (epidural) haemorrhage - Subdural haemorrhage (Subacute / Chronic) - Subarachnoid haemorrhage - Intracerebral haemorrhage 1. **[Epidural haemorrhage (extradural haemorrhage)]** - Least common - Typically, due to **fracture of temporal bone** - Tearing of **artery** crossing extradural space - 15% with closed head injury - 1/3 also have brain injuries - Initial concussion → **lucid interval** (hours) → rapid deterioration into coma as more bleeding occurs - Treatable - Beware of alcohol intoxication with head injury - patients have died in custody  2. **[Subdural haemorrhage ]** - Results from **bleeding** due to **rupture of the bridging** **veins in the subdural space** - Diffuse and bilateral - Due to accelerational force on the brain - Can occur with any injury, also fractures - Common in young and old - Usually, no lucid interval **Subacute subdural haematoma** - Gradual pooling of blood in the subdural space - Symptoms within 10-14 days of the injury **Chronic subdural haematoma** - Symptoms weeks/months after initial injury, which could be trivial - A slow ooze of blood starts to organise at the edges after 2 weeks → this displaces the brain → may take months to produce clinical effects → eventually severe compression occurs - Histologically, it can be very difficult to date a subdural haematoma, but an approximation may be possible 3. **[Subarachnoid haemorrhage ]** - commonest type - any damage to cortex, is accompanied by some degree of subarachnoid haemorrhage - aetiology is most variable - natural disease (eg. rupture of aneurysms) - all penetrating injuries - many blunt injuries - complication of cerebral contusion - injuries to the upper neck region - damage to vertebral arteries  4. **[Intracerebral haemorrhage ]** - Intraparenchymal haemorrhage (within the brain parenchyma) - Can be due to head injury (may be delayed for 2 weeks or more) - Can be due to hypertension, AV malformations or aneurysm rupture - Most common type in patients on anticoagulant drugs  Pregnancy, abortion, assisted reproduction, deaths in infancy ============================================================== Learning objectives - Proving pregnancy - Abortion - Assisted reproduction - Deaths in infancy - Stillbirths - SIDS - Infanticide Pregnancy --------- Legally important to prove pregnancy: - abortion is alleged - infanticide - disposition of property after death (inheritance) - excusing a witness from appearing in court - deferment of capital punishment - pretence of being pregnant Diagnosis generally straightforward - Early pregnancy - Physiological changes (breast swelling and tenderness, amenorrhoea, leucorrhoea...) - Biochemistry (hCG in urine/blood) + US - Late pregnancy - Uterine enlargement over the pelvic brim - Palpation foetus, foetal movement - Recent pregnancy - Perineal damage or evidence of an episiotomy - Uterus palpable up to 2 weeks after delivery, endometrial histology - Vaginal discharge (lochia) - Lactation Abortion -------- Abortion = termination of pregnancy - Spontaneous abortion (miscarriage → stillbirth) - 20% of pregnancies, higher % in first trimester - Foetal chromosomal abnormalities incompatible with life (50%) - Maternal or paternal problems - Induced abortion - ends a pregnancy through a medical procedure (usually up to 2nd trimester) - termination of pregnancy to save mother (therapeutic abortion) - doctors with strong religious/moral objections can refuse - in Malta allowed by law only in very strict situations **[Criminal abortion ]** - incidence has fallen in Western countries - deliberate ending of a pregnancy, outside the legal provisions of the state - against ethics of medical profession, disciplinary action by Medical Council - by mother / health worker / lay person - When a doctor learns that a criminal abortion has taken place, his obligations depend on circumstances - Performed by woman herself: give all necessary medical care, duty of confidentiality to the patient, no obligation to report the fact (unless woman death occurs) - Performed by professional abortionist: the name, if known, could be disclosed without any breach of confidentiality **[Methods ]** drugs, toxins: - vegetable compounds/chemicals/purgatives (?effect) - Medical abortion: progesterone receptor antagonist (e.g. mifepristone) + prostaglandins (e.g. misoprostol) to start contractions (up to 12w) instrumentation: - tears vagina/cervix or perforate uterus/intestines - haemorrhage - shock -- infection - air embolism general violence: self-inflicted or not - deaths of woman from trauma, often no foetal death local interference: - chemicals to cervix/uterus cause burns/irritation - maternal death from toxic absorption or embolism syringe aspiration: - Surgical abortion (vacuum aspiration, dilation and evacuation) - rupture of early gestational sac (used also by legal abortionists) Illegal abortion: complications - Perforation of vagina, uterus, adjacent organs - Haemorrhage (due to local genital trauma) - Sepsis (due to non-sterile instruments and lack of antibiotic prophylaxis) - Air embolism (due to injection of fluid into the uterus) - Shock - Cardiac arrest - Deep pelvic vein thromboses (late) - Sterility Abortion ***Criminal Code: Title VIII - Crimes against the person*** ***Subtitle VII - Of Abortion, of the Administration or Supplying of Substances Poisonous or Injurious to Health, and of the Spreading of Disease.*** Art. 241(1) Whosoever, by any food, drink, medicine or by violence, or by any other means whatsoever, shall cause the miscarriage of any woman with child, whether the woman be consenting or not, shall on conviction, be liable to imprisonment for a term from 18 months to 3 years. \(2) The same punishment shall be awarded against any woman who shall procure her own miscarriage, or who shall have consented to the use of the means by which the miscarriage is procured. - Maltese law only applies to the territory of Malta. Art. 242 if woman dies or is severely injured, whether miscarriage actually took place or not, offender liable to punishment applicable to wilful homicide or wilful bodily harm, diminished by one to three degrees Art. 243 deals with any physician, surgeon, obstetrician or apothecary who knowingly prescribes or administers means whereby the miscarriage is procured, punishment includes imprisonment (from 18 months to 4 years) as well as perpetual interdiction from the practice of the medical profession (that is permanent erasure from the medical register) Art. 243A whosoever, through imprudence, carelessness, unskilfulness in his art or profession, or non-observance of regulations, cause the miscarriage of a woman with child, shall be liable to imprisonment for a term not exceeding 6 months  Added in 2023: Art. 243B it is not considered a criminal offence if the cessation of pregnancy results from a medical intervention carried out to save the life and protect the health of a pregnant woman suffering from a medical complication which may put her life at immediate risk or her health in grave jeopardy which may lead to death - after having considered the medical practices current in Malta (all other treatments have been exhausted) - decision taken by 3 specialists: 1\) obstetrician/gynaecologist who carries out the intervention; 2\) another obs/gyne; 3\) a specialist in the condition she is suffering (except in emergency cases: only the first) - reasonable opinion that the foetus has not reached the period of viability and cannot be delivered - the medical intervention is carried out in a licensed hospital. Assisted reproduction --------------------- Infertility is defined as the inability to conceive after at least one year of engaging in sexual intercourse without contraception Medically assisted procreation (MAP): - Artificial or intrauterine insemination (IUI) - In vitro fertilization (IVF) + embryo transfer (ET) - Intracytoplasmic sperm injection (ICSI) + embryo transfer (ET) - Egg / sperm / embryo donation The ART clinic (assisted-reproductive-technology-clinic) at MDH offers two types of services: 1. Medically assisted reproduction services to prospective parents facing infertility issues 2. Fertility preservation to patients undergoing chemotherapy **[Embryo Protection Act Cap 524]** Aims to provide for the protection of human embryos Article 3: Establishes and specifies the composition of the Embryo Protection Authority (EPA): 1. Chairman (a person in possession of a warrant to exercise the profession of Advocate and who has exercised that profession for at least twelve years or a retired Judge or a retired Magistrate) 2. Not less than 4 other members appointed by the Minister responsible for health SL 524.01 Embryo Protection Authority Regulations **[Donor]** = a third party who donates germ line cells to be used in medically assisted procreation: Provided that donations by an ascendant to a descendant; descendant to an ascendant; or between siblings, shall not be permissible **[Embryo]** = the human organism that results from the fertilisation of a human egg cell by a human sperm cell, which is capable of developing **[Medically Assisted Procreation]** = includes in vitro handling of human oocytes, spermatozoa or embryos for establishing a pregnancy (e.g. intra-uterine insemination, in vitro fertilisation, intracytoplasmic sperm injection, embryo transfer, gamete / germinal tissue / embryo cryopreservation, oocyte / embryo donation) Art. 4(2) the Authority may give for adoption the embryos to a third party who qualifies for medically assisted procreation procedures, in those cases where: a\) after the fertilization of the egg cells but before the implantation of the embryos into the womb has taken place, death of the woman ensues; or b\) for any other reason the implantation of the embryos into the womb of the prospective parent cannot take place including those cases where the prospective parent refuses said implantation or has reached the maximum permissible age for the implantation thereof or fails to renew the contract with the licensee where the cryo-preserved embryos are being stored for future use. - Women up to 48 years old. Art. 4(3) The adoption of an embryo may only take place if the Authority so decides - the prospective parent or prospective parents need to be declared as physically fit by a medical practitioner for the transfer of an embryo and following a favourable recommendation issued by the Adoption Board in accordance with the Adoption Administration Act determining the eligibility and suitability or otherwise of the prospective parent or prospective parents: - the identity of the adopter(s) and the persons from whom the germ line cells originated shall in all cases remain anonymous - the simultaneous implantation of embryos originating from different persons in a prospective parent during the same cycle is prohibited. Art. 4(5) When the decision of the Authority or the court giving an embryo for adoption becomes final, that embryo shall be considered as the embryo of the adopter(s), and the persons from whom the embryo originated shall lose all rights and shall be freed from all obligations with respect thereto. Art. 5(1) Any prospective parent shall have access to medically assisted procreation procedures: Provided that these procedures may only be resorted to where there is a reasonable chance of success and the procedures do not entail any known undue risk to the health of the woman or the child - any person over 18 years old (also single people) Art. 6 Unlawful procedures: whoever a. artificially fertilizes any egg cell for any purpose other than that of bringing about the pregnancy of the prospective parent; b. intentionally fertilizes more than 5 egg cells from one woman in one cycle of treatment; Provided further that where the prospective parents do not expressly give their consent to the cryopreservation of embryos and to the donation of fertilized eggs if necessary, it shall not be lawful to fertilize more than 2 eggs within each treatment cycle c. transfers more than 2 embryos into the prospective parent within each treatment cycle; d. removes an embryo from a woman before the completion of implantation in the womb in order to transfer the embryo to another woman; e. selects or discards an embryo for eugenic purposes; f. carries out artificial fertilization or transfers a human embryo into a woman who is prepared to give up her child after birth (surrogate mother) shall be guilty of an offence and liable to a fine (multa) (€5,000-15,000) or to imprisonment (max 3 years) or both. Art. 7 Cryo-preservation of germ line cells and embryos: - Sperm cells may be cryo-preserved up to the lifetime of the donor - Oocytes may be cryo-preserved up to the maximum permissible age for fertilization - Embryos which cannot be transferred into the prospective parent within a treatment cycle shall be cryo-preserved in licensed tissue establishments for future use by that prospective parent Art. 9 Donation and use of germ line cells: \(2) A donor must be over 18 years of age, have the legal capacity to contract and good mental and physical health \(3) A donor must not have attained the age of 36 years \(4) Except in cases of a direct donation, the prospective parent(s) shall only be entitled to obtain generic information about the donor (whose identity shall in all cases remain confidential) Provided that the medical records that may affect the health of the child and the identity of the donor or of the person from whom an adopted embryo originated shall be accessible to the child upon reaching 18 years of age or, subject to the consent of the Authority, at any earlier stage in exceptional circumstances in which the life or health of the child is at risk \(5) The donation of germ line cells shall be limited to one donation only and such donation shall be used in one prospective parent only. \(8) No person shall pay consideration to a donor or to any other person to arrange for the services of a donor or offer to pay such consideration: Provided that oocytes donors may be compensated for the costs and expenses of the stimulation treatments. Art. 10 Prohibition of selection of sex \(1) Whosoever artificially fertilizes a human egg cell with a sperm cell that is selected for the sex chromosome contained in it, shall be guilty of an offence and, on conviction, shall and liable to the punishment of a fine (multa) of not less than four thousand euro (€4,000) and not exceeding ten thousand euro (€10,000). \(2) Nothing contained in sub-article (1) shall be understood as preventing the selection of a sperm cell by a medical practitioner in order to prevent the child from falling ill with a sex-linked genetic illness. Art. 11 Prohibition of cloning 1\) Any intervention seeking to create a human being genetically identical to another embryo, foetus, or human being, whether living or dead, is prohibited and for the purpose of this article, the term \"genetically identical\" means a human being sharing with another the same nuclear gene set. \(2) Whosoever intervenes or participates in any artificial intervention as referred to in sub-article (1) shall be guilty of an offence and, on conviction, shall liable to the punishment of a fine (multa) of not less than ten thousand euro (€10,000) and not exceeding twenty-three thousand euro (€23,000) or to imprisonment not exceeding five years or to both such fine and imprisonment. \(3) Whosoever transfers into a woman an embryo as referred to in sub-article (1) shall be liable to the same punishment laid down in sub-article (2). Art. 13 Prohibition of artificial alteration of human germ line cells 1\) Subject to the provisions of sub-article (3), whosoever shall willfully alter in an artificial way the genetic information of a human germ line cell shall be guilty of an offence and, on conviction, shall liable to the punishment of a fine (multa) of not less than ten thousand euro (€10,000) and not exceeding twenty-three thousand euro (€23,000) or to imprisonment not exceeding five years or to both such fine and imprisonment. \(2) Whosoever knowingly uses a human germ line cell with artificially altered genetic information for fertilization shall be guilty of an offence and shall be liable to the same punishment laid down in sub-article (1). \(3) No offence shall arise, against the medical practitioner carrying out the medically assisted procedure, under sub-article (1) where the alteration of the genetic information of a germ line cell is the unintended consequence of inoculation, radiation or chemotherapeutic or treatment. Art. 15 Prohibition of experimentation on human embryos \(1) Any **experimentation on human embryos** is prohibited and whosoever contravenes this sub-article shall be guilty of an offence and, on conviction, shall liable to the punishment of a fine (multa) not exceeding seventy thousand euro (€70,000) and to imprisonment not exceeding seven years. \(2) The creation of human embryos for the purpose of research or experimentation or for any other purpose not permitted under this Act is prohibited and whosoever contravenes this sub-article shall be guilty of an offence and shall be liable to the same punishment laid down in sub-article (1). \(3) **Clinical interventions on a human embryo are allowed** on condition that said interventions pursue an **exclusively diagnostic and, or therapeutic purpose related to the embryo and are in the interests of the health and development of the embryo itself**: Provided that nothing in this sub-article shall in any way be construed as prohibiting clinical interventions deemed permissible in terms of the Protocol, nor prohibiting the prospective parent and, or prospective parents from opting for the cryopreservation of the human embryo after the carrying out of any such intervention wherever such an option is deemed permissible in terms of the Protocol. ***[Leave For Medically Assisted Procreation National Standard Order SL 452. 114]*** Art. 3(1) The prospective parents who undergo the process of medically assisted procreation, whether in or outside Malta, shall be entitled to 100 hrs of leave with full pay. Art. 3(2) Leave for medically assisted procreation shall be utilised at any time during the process of medically assisted procreation: - the prospective parent acting as the receiving person shall be entitled to 60 hours of leave; whereas the other prospective parent shall be entitled to 40 hours of leave - they can be used in a non-continuous manner: - up to a maximum of 3 processes of medically assisted procreation. Deaths in infancy ----------------- Terminology 1. Foetal death prior to the complete expulsion or extraction from its mother (irrespective of the duration of the pregnancy) 2. Perinatal from 22 completed weeks of gestation, up to 7 days after birth (includes stillbirths & foetal deaths) 3. Neonatal from birth up to 28 days of age a. Early during first 7 days of life b. Late after 7th day but before 28 completed days of life 4. Infant under 1 year ### Stillbirths Stillbirth foetal death at/ after 22 completed weeks of gestation (in Malta -- NOIS) Miscarriage pregnancy loss before this cut-off Other countries or international medical classifications: different timing (20-24th weeks of gestation) or birth weight - Definition of stillbirth in England and Wales: "a child which has issued from the mother after the 24th week of pregnancy and which did not in the meantime, after being completely expelled from the mother, breathe or show any other sign of life" (Births and Deaths Registration Act 1953) "Signs of life" include: - Respiration - Heartbeat - Movement - Crying - Pulsation of the umbilical cord most stillbirths have an autopsy - often no ascertainable cause of death, even after autopsy - to bury a stillbirth, a death certificate is required Possible causes of stillbirth are varied and include: - Intrauterine infection (viral, bacterial, fungal) - Maternal medical conditions - Congenital defects (especially in the cardiovascular or nervous system) - Placental insufficiency - Problems during labour or delivery (intrapartum stillbirth) Based on the pathological features alone, it may be impossible to determine if the death occurred before, during or after birth If death occurs more than a couple of days before birth, the foetus shows evidence of maceration because of the effects of early decomposition combined with exposure to fluid ### Infant mortality Infant mortality rate: the ratio of 1. The number of deaths of children under 1 year of age 2. To the number of live births in that same year 3. Expressed per 1000 live births ### Causes of infant deaths 1. Malformations 2. Extreme prematurity and complications (\< 27 weeks ) 3. Birth asphyxia and trauma 4. Congenital heart disease 5. Infection 6. Trauma 7. SIDS 8. Infanticide Causes of infant deaths: examination - careful history of circumstances - information about pregnancy and birth - infant feeding regime - infant sleeping arrangements - bedding examined to consider possibility of suffocation - bacteriological and toxicological tests - counselling of bereaved parents important - genetic counselling if indicated ### Sudden Infant Death Syndrome (SIDS) - sudden and unexpected death of an infant \< 1 year of age - majority 2-4 months - M:F ratio slightly more males - onset of the lethal episode apparently occurring during sleep - found dead in cot, after being asleep, often between midnight and 9.00am in winter (also known as "cot death") - remains unexplained after a thorough investigation including performance of a complete autopsy and review of the circumstances of death Incidence - The incidence has declined in many developed countries. This decline coincided with social and housing improvements as well as 'back to sleep' campaign which promoted supine position (in early 90s). - UK, 2017: 0.27 deaths / 1000 live births - USA, 2016: 0.4 deaths / 1000 live births - Malta - about 1 death every two years Cause of death not known: main theories: 1. overheating because the infant has poor thermal control as system is immature a. Serotonin transporter gene promoter in the brainstems of affected babies has been implicated 2. prone sleep position is associated with: b. Increased risk of hypercapnia and hypoxia c. Depressed cerebral oxygenation d. Increased rates of overheating e. Altered autonomic control of the infant cardiovascular system f. Increased arousal threshold 3. Cessation of respiration during sleep with circulatory arrest -- unstable control mechanisms 4. Possibility of suffocation -- consider only if sufficient evidence from history (soft-bedding, pillows) At autopsy: - Signs of normal hydration and nutrition - No signs of obvious/occult trauma - No evidence of congenital abnormalities - No evident cause of death - All bacteriological tests are negative - Few petechiae -- thymus, pleurae, epicardium (suggesting centrally mediated airway failure, such as in apnea) Risk factors: - genetic factors - prematurity - low birth weight (small for dates) - immature immunity - smoking - drug and alcohol exposure in utero - sleeping prone - sharing a bed with parents/ siblings - soft bedding (loose blankets, pillows, bumpers...) - young mother (\< 20y) - poor antenatal care - second twin - near miss SIDS - sibling with SIDS or near miss (x 5 risk) Protective factors: 1. breastfeeding 2. use of pacifiers 3. immunizations 4. smoking cessation 5. back to sleep In the US, the Safe Sleep for Babies Act of 2021 was signed into law on May 16, 2022. - It bans crib bumpers and inclined sleep products since they increase the risk of suffocation and SIDS. ### Infanticide Art. 245 Cap 9 "Where a woman by any wilful act or omission causes the death of her child, being a child under the age of twelve months, but at the time of the act or omission the balance of her mind was disturbed by reason of her not having fully recovered from the effects of giving birth to the child or by reason of the effects of lactation consequent upon the birth of the child, then, notwithstanding that the circumstances were such that but for this article the offence would have amounted to wilful homicide, she shall be guilty of infanticide and shall be liable to the punishment of imprisonment for a term not exceeding 20 years." 1. Killing a child under 1 year by the mother, shortly after birth (generally within a few hours), when she is suffering from postnatal depression. 2. Before a charge of infanticide is proven, it must be shown that: a. The woman was recently pregnant b. Death was caused by a wilful act of commission or omission c. Child had a separate existence = completely expelled from the mother d. The child lived = signs of life, i.e. born alive. i. Eyewitness: the child had signs of life ii. Autopsy: expanded lungs, position diaphragm, air in the GIT or middle ear, milk in the stomach, lack meconium... iii. Floatation test not used anymore nowadays. The floatation test (or hydrostatic test) was used to differentiate expanded lungs of a live-born from collapsed lung of a stillborn however the test is now considered to be unreliable: 1. If a (piece of) lung sinks in water, the baby had not breathed sufficiently to expand that lung 2. However, lungs of stillborn babies sometimes float (due to resuscitation, decomposition, etc) Often dead infants are concealed or abandoned, and so when discovered, a degree of decomposition makes examination difficult Most commonly, death by smothering: few signs are present at post-mortem, may be confusion with a cot death Traumatic methods (strangulation, head injuries and drowning) Genuine accidents may occur / circumstantial evidence is important Road traffic accidents & drink driving legislation ================================================== Learning objectives: 1. Road traffic accidents a. Cases b. Patterns of injury c. Prevention/ reduction of injuries 2. Alcohol d. Alcohol metabolism e. Drink driving legislation Road traffic accidents ---------------------- Case 1 - A previously healthy 37-year-old man was crossing a dual carriageway when he collided with a vehicle. - He was admitted to hospital, where bilateral chest drains were introduced due to collapsed lungs. - He died 2 hours after admission to hospital. - At autopsy, the external examination revealed: - oblique parallel abrasions across anterior chest wall, overall covering an area 50.0 cm in length, extending onto the abdomen; - a vertical laceration, 4.0 cm in length, on the right arm, overlying a fracture of the right humerus (upper arm bone); - multiple abrasions, including glass abrasions, and bruising on the forearms; - abrasions and bruising on the lateral aspect of the left lower leg, overlying a closed fracture of the left tibia and fibula. - At autopsy, the internal examination revealed: - chest drains for pneumothorax and collapsed lungs; - multiple rib fractures; - bruising of the intact scalp with underlying linear skull fracture of the left parietal region, intact meninges and subarachnoid haemorrhage, covering the cerebral hemispheres, particularly the left side. - Toxicological analysis of blood revealed 100 mg of alcohol / 100 ml of blood. Blood was negative for drugs. Questions: 1. ***[Relate the head, chest and limb injuries to the mechanism of the accident. Can you confirm how the accident occurred and what type of vehicle was involved? ]*** Autopsy findings: 1. Head: "bruising of the intact scalp with underlying linear skull fracture of the left parietal region, intact meninges and subarachnoid haemorrhage" sustained on hitting the car or the ground - Linear skull fractures: - resembling a thin line, without splintering, depression, or distortion of bone - most common skull fractures at all ages - caused by broad-based forces striking the head over a wide area - common in vehicular collisions and falls 2. Chest "oblique parallel abrasions across the anterior chest wall, overall covering an area 50.0 cm in length, extending onto the abdomen" indicate being thrown across the road "chest drains for pneumothorax and collapsed lungs; multiple rib fractures" fractures have caused tears of the lungs which have allowed air into the pleural cavities and then the lungs collapsed 3. Upper limbs "a vertical laceration, 4.0 cm in length, on the right arm, overlying a fracture of the right humerus" indeterminate mechanism of trauma "multiple abrasions, including glass abrasions, and bruising on the forearms" contact with vehicle 4. Left lower leg "abrasions and bruising on the lateral aspect of the left lower leg, overlying a closed fracture of the left tibia and fibula" contact of legs with bumper (primary injury) - therefore, deceased had been standing up at impact - height of injuries from sole is equal to height of bumper from ground  A diagram of bones and bones Description automatically generated  Patterns of injury: the pedestrian 1. primary injuries on impact with vehicle a. lower leg injuries at height of bumper b. measure height from sole c. injuries at hip/ shoulder/ head from larger vehicles 2. secondary injuries on hitting road d. fracture of the skull, ribs, pelvis, arm, leg e. thrown onto bonnet and back onto road or f. thrown forward and then run over by same/ another car - can be struck by motorcycles, cars, trucks - older people and children more at risk A person jumping in the air Description automatically generated A diagram of a car crash Description automatically generated  ***[2. What is the significance of the toxicology result? ]*** ***[What is the legal limit for alcohol when driving?]*** Toxicology result: "Toxicological analysis of blood revealed 100 mg of alcohol / 100 ml of blood. Blood was negative for drugs." high - above legal limit allowed for drivers - of course, not an offence for a pedestrian - would be unsteady and suffering from incoordination, slurred speech - so may be partly responsible for accident - victim/family may not be eligible for insurance benefits Driving and Alcohol Legislation ------------------------------- Traffic Regulation Ordinance Cap 65 Art. 15I (1) Prescribed limits of alcohol A table with text and images Description automatically generated with medium confidence Effects of alcohol  3. ***[What other evidence may be collected at the autopsy? ]*** - Clothing -- damage compatible with injuries - Trace evidence -- glass, paint, metal from car - Photographs for court case - Features that lead to identification **[Road Traffic Accidents (RTA)]** **[Why is an autopsy necessary? ]** 1. to verify whether primary cause of death was collision 2. to confirm injuries compatible with alleged circumstances 3. to assess pattern of injury in relation to seating position 4. to assess pattern of collision and car damage with regard to car design 5. for legal considerations (e.g. insurance, inheritance, alcohol) **[Case 2: ]** A 50-year-old man was riding a motorcycle uphill on a busy two-lane two-way road, when he apparently hit the pavement and died on site. He was wearing a crash helmet. His medical history included heart problems for 10 years. υ Valium tablets were found on the motorbike. At autopsy, the external examination revealed mainly injuries to the **[head]** as follows: - a horizontal laceration, 5.0 cm in length, on the right upper eyelid; - a right periorbital haematoma and abrasions and bruises at the outer angle of the right eye; - an abrasion, 4.0 x 3.0 cm, on the right cheek lateral to and below the right eye; - abrasions and bruises, overall 1.5 x 1.5 cm, on the bridge of the nose and left nostril; - blood issuing from the right nostril and left ear. At autopsy, the internal examination revealed: - intact scalp but extensive haemorrhage at the front, on the right side and on the vertex; - depressed fracture of the right frontal bone with radiation onto the vault of the skull; - a hinge fracture of the base of the skull due to an acceleration--deceleration injury; - disrupted meninges and brain laceration of the right frontal lobe and the right temporal lobe, with bone fragments embedded in the brain. - There was also an enlarged heart with focal fibrosis and severe coronary artery disease, evidence of ischaemic heart disease. Questions for Discussion 1. ***[What is the significance of the hinge fracture? What other injuries can be caused by the same mechanism?]*** Dynamics of vehicular injury - Tissue injury is caused by a change of rate of movement - Acceleration or deceleration - F=ma - Tissue damage produced will depend upon the force applied per unit area Acceleration--deceleration injuries 1. Hinge fracture of base - an acceleration--deceleration injury - implies speed - In this case, the helmet did not help prevent fracture because it was not worn correctly A diagram of a skull Description automatically generated Other injuries caused by speed & acceleration/deceleration 2. ruptured aorta  3. neck injuries - Whiplash injury C5/C6 (no head restraint, more likely with rear impact) - Fracture cervical vertebrae - Spinal cord injury  Patterns of injury: the Motorcyclist - Primary injuries - head injury on initial contact - Secondary injuries -- thrown off and landing on ground/ object: head injury, abrasions, cervical spine fractures, leg injuries, ruptured aorta - Motorcyclists are vulnerable since: - reach high speeds (acceleration -- deceleration injury at high speed) - no solid protection for rider, easily thrown about - poorly seen as presents a narrow profile - Tailgating accidents - The rider drives into the back of a truck, the motorcycle passes underneath, but the head of the motorcyclist impacts upon the tailboard - Severe head and neck injuries, up to decapitation Reconstruction - position of cars, skid marks, car damage and patient\'s injuries - casualty officer describes injuries if death is delayed or if surgery - medical records - photographs of the injuries are advisable - car and scene examined by police - car material - windscreen glass at scene - important to identify car in a hit-and-run accident - at autopsy, retain for police & scientific examination - foreign bodies, glass, paint on body/clothing - clothing 2. ***[Can you explain the significance of the depressed fracture?]*** Depressed Frontal Fracture "depressed fracture of right frontal bone with radiation onto the vault of the skull" "right periorbital haematoma and abrasions" "laceration on right upper eyelid" "abrasions and bruises on bridge of nose" - impact at this point - blood oozes into right orbit, with black eye - injury to nose also may lead to bleeding into tissues around the eye - fractures of the vault - occur at point of impact with a heavy but small object (eg. hammer or a rock) - a piece of skull is pushed inwards for a few millimetres 3. ***[Is the heart disease of any importance in this case? ]*** Heart "enlarged heart with focal fibrosis and severe coronary artery disease, evidence of ischaemic heart disease" - heart disease may have been responsible for the accident, if the victim suddenly suffered from chest pain - there was no evidence of acute injury (coronary thrombosis or myocardial infarction) but this does not exclude a cardiac event, because changes in the heart in infarction can only be identified after a few hours ***[4. Is a toxicology examination necessary?]*** Toxicology examination - yes - although no other victim was involved, it is needed for insurance purposes, especially since he was carrying Valium - toxicology was negative in this case PATTERNS OF INJURY ------------------ 1. The driver 2. The passenger 3. Children 4. Motorcyclist 5. Pedestrian 6. Pedal cyclist 1. ***[The driver ]*** Primary injuries: - Head injury -- hitting windscreen, side pillars, dashboard - Fracture legs, pelvis -- force transmitted through pedals - Fracture ribs, wrists, arms -- steering wheel injuries - Injuries abdomen, chest -- steering wheel injuries - Ruptured aorta (more common in motorcyclists) Secondary injuries - Ejection onto roadway - Contact with road surface or struck by other vehicles - Usually fatal  - In a frontal impact: severe deceleration - In a rear impact: initially violent acceleration, then deceleration when the car hits another vehicle or obstruction - In a side impact: structures (door, side panels) easily burst into car - Roll over: multiple injuries from contact with mirrors/door handles... 2. ***[Passengers ]*** Front-seat passenger - pattern of injuries similar to driver, but no steering wheel - this position is even more dangerous Rear-seat occupants - The rear-seat position fairly safe, compared with the front seats - During violent deceleration, if unrestrained projected forward (injuries to front-seat passengers, ejected through the windscreen...) - Use of seatbelt became mandatory as well Seatbelts - extremely effective in reducing mortality and morbidity in low-medium speed collisions - little influence on outcome in high-speed collision - Functions of seatbelts: - restrain against severe deceleration and keep away from windscreen - prevent ejection onto road, so minimise more serious secondary injuries - reduce forces by reducing deceleration due to stretch of strap (by increasing stopping distance) - spread deceleration over broad area of strap Seatbelts injuries - An impact that causes seatbelt injuries would have caused even worse injuries or death if no seatbelt had been worn - The three-point adult harness rests on the shoulder, chest, and abdomen - Bruising is the most common - abdominal or chest wall (under the diagonal or the transverse part) - Rarely causes internal injuries Prevention/Reduction of injuries 1. Airbags - Supplemental to seat belts, - Airbags alone may cause severe facial injuries, fractures arms or cervical spine, eye injuries, amputation fingers 2. Head restraints - Reduce the risk of neck injury 3. Helmets - prevent severe head injury, but damage is transferred to the neck (cervical spine injury) 4. Leather gear - protects from severe abrasions, lacerations and friction burns, as ensures sliding (reduces friction) 3. ***[Children ]*** Unrestrained in the front seat → facial/eye damage even in minor accidents - The child can fly out of the arms of a belt-restrained mother - Adult seat belts can pass across the throat - Thrown about lethally (heavy head leading) **[Seatbelts law ]** Children - Children defined by law as under 12 years and \< 135 cm in height - Correct child restraint system (Groups 0-1-2-3) - Rear-facing position up to 15 months - High-back booster - Car seat alarms A baby carrier with a baby seat Description automatically generated with medium confidence 4. ***[Pedal cyclist ]*** - very vulnerable - same instability as motorcyclists, but speeds are low - profile is low, thus easily overlooked by other road users - usual fatal injury when vehicle strikes cyclist - **Primary injuries** to legs (unique injury: entrapment of the leg between wheel spokes, with compression of the soft tissues of the calf) - **Secondary injuries** impact to head, shoulder, trunk - Helmets offer considerable protection Alcohol metabolism and drink driving legislation ------------------------------------------------ **Alcohol metabolism: absorption** - Absorbed in stomach (20%) and first part of the small intestine (80%) - over a period of 2-6 hours in the normal individual - Rate of absorption depends on: - Ethanol concentration - Carbonated drinks → faster absorption - Presence of food in the stomach → slower absorption **Alcohol metabolism: distribution** - Alcohol is distributed throughout the water in the body - Heart, brain, muscles, lungs are exposed to the same concentration as the blood - Liver greater exposure (receives alcohol directly via portal vein) - Distribution depends on: - Amount of water (more water, more diluted) - Amount of fat (does not absorb alcohol, women more fat) **Blood alcohol concentration vs. time curve** - As soon as alcohol enters the bloodstream, mechanisms for its removal come into action - Elimination rate is less than rate of absorption - Thus, the blood alcohol concentration (BAC) will rise - Peak of BAC obtained at about 30--45 minutes for one drink (varies from 20-180 minutes depending on amount and speed of drinking) - Followed by linear curve where average rate of elimination is 15 mg/100ml/hour (1 unit of alcohol/hour in a 70Kg male) - Blood and urine samples checked for alcohol and difference between gives indication as to time elapsed since drinking **Alcohol metabolism: elimination** - 90% of absorbed alcohol is metabolised in the liver - ethanol → acetaldehyde → acetic acid → CO2 + H2O - 2-10% excreted unchanged in urine, sweat, breath - The first reaction can occur very rapidly (alcohol dehydrogenase is an inducible enzyme) - The second reaction is rate-limiting - Acetaldehyde can cause headache, nausea, flushing, tachycardia, hangover **[Alcohol and the Law ]** Criminal Code article 338(ff) - drunkenness alone is not a criminal offence - but if drunk and incapable of taking care of himself, becomes a contravention Art. 338 Every person is guilty of a contravention against public order, who -- (ff) in any public place or place open to the public, is found drunk and incapable of taking care of himself; or in any public place or place open to the public, being in charge of a child under the age of seven years, or of any horse, mule or ox, or steam engine, or of any vehicle, is manifestly in a state of intoxication, or, being in such a state, causes any annoyance or disturbance, or is in possession of firearms, or refuses to quit any wine and spirit shop, inn, tavern or lodging-house, or attempts to enter any passenger boat or vessel or other vehicle, or refuses to quit such boat, vessel or other vehicle notwithstanding the warning of the person in charge thereof not to enter into or to quit such boat, vessel or other vehicle Title II -- Of the will and age of the offender Art. 34 Cap 9 - intoxication does not absolve from any criminal charge - unless caused by malicious or negligent act of another person without consent of individual \(1) Save as provided in this article, intoxication shall not constitute a defence to any criminal charge. \(2) Intoxication shall be a defence to any criminal charge if -- \(a) by reason thereof the person charged at the time of the act or omission complained of was incapable of understanding or volition and the state of intoxication was caused without his consent by the malicious or negligent act of another person; or \(b) the person charged was by reason of the intoxication insane, temporarily or otherwise, at the time of such act or omission. ***[Traffic Regulation Ordinance Cap 65]*** Driving under the influence of alcohol or drugs Article 15A. \(1) No person shall drive or attempt to drive or be in charge of a motor vehicle or other vehicle on a road or other public place if he is unfit to drive through drink or drugs Article 15B. \(1) No person shall drive or attempt to drive or be in charge of a motor vehicle or other vehicle on a road or other public place after consuming so much alcohol that the proportion of it in his breath, blood or urine exceeds the prescribed limit A table with a chart of alcohol Description automatically generated with medium confidence **Three Types of Blood-Alcohol Concentration (BAC) Testing** 1. BAC Urine Test - Cannot be performed at time of road accident - Does not correlate with blood alcohol level at the same time (can take up to 2 h to appear in the urine, and can remain for 6-24 h) 2. BAC Blood Test - Most relevant, it is the concentration of alcohol passing through the brain that affects the behaviour 3. BAC Breath Test - Measure the alcohol that passes through alveoli as blood flows through small lung vessels, and is then expelled with a breath Cap 65 Traffic Regulation Ordinance - police can stop driver on suspicion of driving or attempting to drive under influence of alcohol - tests also after an accident / if the driver commits any contravention of traffic regulations - if positive or if the driver fails to provide a breath specimen, police may arrest the driver - no spot checks - law stipulates who is authorised to take samples Article 15E \(1) A Police officer may require a person to provide: a. a **breath** specimen or specimens for use by the approved device (SL 65.16) b. a specimen or specimens of **blood** and **urine** for lab analysis at lab mentioned in law (SL 65.16) - Malta National Laboratory - police may in addition to breath specimens also require a specimen of blood or two specimens of urine (with an interval of **one hour** between them and the later specimen shall be used for analysis) - if \< 50ug of alcohol/100 ml in breath, person may ask for blood or urine sample to be used instead (SL 65.16 Reg 5) - all specimens can be obtained at police station, health centre or hospital, while breath can also be obtained on site. Article 15GA (1) - local wardens are now empowered to ask for **breath tests** from anyone driving (or attempting to drive) and suspected of being under the influence of alcohol - if positive detains till police arrive - refusal to provide a specimen is an offence - may be detained till police arrive - if they drive off, it is an offence as if the order to wait was given by police Article 15E.(4) - A person who refuses or fails to provide the requisite specimen.... shall be guilty of an offence and unless the contrary is proved, it shall be presumed that the proportion of alcohol in that person's blood exceeds the prescribed limit: - Provided that it shall be a defence for such person to prove that his failure to provide a specimen was due to physical or mental incapacity to provide it or because its provision would entail a substantial risk to his health Article 15D. A person may be arrested if g. breath test is positive or h. fails to provide a breath test provided he has been warned of consequences Article 15H: Driving under influence First conviction - not less than 1800 euro fine +/- prison up to 6 months - driving licence suspension minimum 6 months Second or subsequent conviction - not less than 3000 euro fine +/- prison up to 12 months - driving licence suspension minimum 12 months - Court may also impose a Probation Order - to attend a rehabilitation programme, at own expense or a Community Service Order There is a proviso that sub-article 3 (probation order) only applies if levels exceed the prescribed limit by a certain amount and are: - 30 μg/100 mL of breath or more - 70 mg/100 mL in blood or more - 90 mg/100 mL in the urine or more **[Cap 9 Criminal Code ]** Criminal Charges in a Road Traffic Accident Death - prison maximum 4 years or fine of maximum 11,646.87 euro - and suspension of licence as established by court - Article 225 (2): Where the offender has caused the death of more than one person or where in addition to causing the death of a person the offender has also caused bodily harm to another person or other persons the punishment shall be that of imprisonment of a term of up to ten years. Grievous Bodily Harm - Articles 226 & 218: - Art. 218 1\) A grievous bodily harm is punishable with imprisonment for a term from five to ten years -- \(a) if it causes any permanent debility of the health or any permanent functional debility of any organ of the body, or any permanent defect in any part of the physical structure of the body, or any permanent mental infirmity; \(b) if it causes any serious and permanent disfigurement of the face, neck, or either of the hands of the person injured; \(c) if, being committed on a woman with child, it causes miscarriage. \(2) Any debility of the health or any functional debility of any organ of the body, and any mental infirmity, serious disfigurement, or defect shall be deemed to be permanent even when it is probably so. \(3) The punishment for the offences referred to in sub-article (1) shall be that established in article 312(2) if the bodily harm is committed by means of any explosive fluid or substance - Art. 226: \(1) Where from any of the causes referred to in the last preceding article a bodily harm shall ensue, the offender shall, on conviction, be liable -- \(a) if the harm is grievous and produces the effects mentioned in article 218, to imprisonment for a term not exceeding one year or to a fine (multa) not exceeding four thousand and six hundred and fifty-eight euro and seventy-five cents (€4,658.75); \(b) if the harm is grievous without the effects mentioned in article 218, to imprisonment for a term not exceeding six months or to a fine (multa) not exceeding two thousand and three hundred and twenty-nine euro and thirty-seven cents (€2,329.37); \(c) if the harm is slight, to the punishments established for contraventions. \(2) In the cases referred to in sub-article (1)(c), proceedings may only be taken on the complaint of the injured party - suspension of licence as established by court Breath Test Regulations SL 65.16 Regulation of Health Care I =========================== **[Regulation of Health Services and Staff ]** **[Health regulation ]** **[Main Legislation:]** g. MEDICAL AND KINDRED PROFESSIONS ORDINANCE Ch31 h. HEALTH CARE PROFESSIONS ACT Ch464 i. HEALTH ACT Ch528 Others: a. PREVENTION OF DISEASE ORDINANCE Ch36 b. PUBLIC HEALTH ACT Ch465 c. HUMAN BLOOD AND TRANSPLANTS ACT Ch483 d. EMBRYO PROTECTION ACT Ch524 e. MENTAL HEALTH ACT Ch525 f. HUMAN ORGANS, TISSUES AND CELL DONATION ACT Ch558 Subsidiary legislation: a. ETHICS OF THE MEDICAL PROFESSION REGULATIONS 464.17 b. CERTIFICATE OF DEATH AND CAUSE OF DEATH REGULATIONS 465.06 c. INDEMNITY INSURANCE FOR HEALTHCARE PROFESSIONALS REGULATIONS 528.02 d. CROSS-BORDER HEALTHCARE REGULATIONS 528.03 Others: a. DANGEROUS DRUGS (INTERNAL CONTROL) RULES 101.02 b. LICENSING OF PRIVATE MEDICAL CLINICS REGULATIONS 458.23 c. LIST OF POISONOUS SUBSTANCES ORDER 458.10 d. MEDICINAL PRODUCTS (ADVERTISING) REGULATIONS 458.32 e. CLINICAL TRIALS REGULATIONS 458.43 f. TISSUES AND CELLS (QUALITY AND SAFETY) REGULATIONS 483.01 g. ORGAN TRANSPLANTS (QUALITY AND SAFETY) REGULATIONS 483.06 h. EMBRYO PROTECTION AUTHORITY REGULATIONS 524.01 Health Act Cap 528 ------------------ 1. Department for Policy in Health Head: Chief Medical Officer, Mr. Walter Busuttil matters related to the Government's health policies 2. Department for Health Services Head: Director General, Mr. Clarence Pace effective and efficient operation and delivery of healthcare services 3. Department for Health Regulation Head: Superintendent of Public Health, Prof. Charmaine Gauci to safeguard public health, license, monitor and inspect the provision of healthcare services and to recommend the standards to be met by healthcare providers Health Policy and Strategy Board - to discuss and evaluate policy, strategy developments and direction in the health sector - to monitor and follow the implementation of the health policy Council of Health - advise Government on any matter affecting all matters related to health in Malta Advisory Committee on Healthcare Benefits Subsidiary Legislation: - Indemnity Insurance for Healthcare Professionals Regulations (SL 528.02) - Cross-border Healthcare Regulations (SL 528.03) - Functions and Responsibilities of the three Departments (SL 528.01, SL 528.04, SL 528.05) **[Part VIII - Patients' Rights and Safety ]** Article 27: It shall be the right of every patient: a\) to receive healthcare in accordance with the provisions of this Act; b\) to receive information concerning the state of his health and the health services and treatments available; c\) to be provided in advance with clear information on the treatment options available and to be involved in discussions and decisions about the treatment to be given; d\) to access his medical records in accordance with the Data Protection Act (Ch. 586) provided this is not to the detriment of his overall wellbeing; e\) to have his medical data processed in conformity with the Data Protection Act; f\) to refuse treatment that is offered to him, provided such refusal is endorsed by his signature; g\) to be seen and treated without excessive or undue delay; h\) to file a complaint about services received and be informed of the outcome of the investigation of his complaint in a timely manner; i\) to appeal in respect of any decision taken under this Act to the Administrative Review Tribunal in accordance with the provisions of the Administrative Justice Act (Ch. 490) and any applicable regulations made thereunder. Article 27(2): A person aged 14 years old and over shall 'have the right to consent to, or refuse, medical attention, care or treatment if the medical practitioner is of the opinion that such person has sufficient maturity and understanding to so consent or refuse' - if medical practitioner is of the opinion that the young person lacks of maturity and understanding, the consent of the parent / legal guardian is required - if a mature person refuses, treatment may still be given if the doctor considers that treatment to be urgently required in the best interest of the person \(3) once a medical practitioner has certified someone as mature, this allows all other healthcare professionals to treat young person without need for further authorisation Article 28: Without prejudice to anything provided in this Act and, or any other law, whilst health care providers are expected to provide services based on the respect for human dignity, users are expected to make use of the services available in a responsible manner and to show respect to professionals, employees and also for the property. Article 29(1): The Minister shall, within two years of the coming into force of this Part, publish a document to be known as the Charter of Patient Rights and Responsibilities. \(2) The Charter shall set out a summary of the rights and responsibilities of patients and other relevant persons as existing at the time of publication. \(3) The Charter shall be updated on a regular basis to reflect contemporary trends and issues. **[Patient's Charter ]** Launched 21 November 2016 8 principles for a safe equitable healthcare service delivery: 1. Health Protection 2. Access 3. Information -- right to be informed 4. Participation & Informed Consent 5. Privacy and Confidentiality 6. Dignity and Respect 7. Safe healthcare 8. Right of Comments and Complaints Indemnity Insurance for Healthcare Professionals Regulations (SL 528.02) ------------------------------------------------------------------------ Article 3(1) It shall be the duty and responsibility of every healthcare professional providing healthcare to patients in Malta to ensure that he is covered by a professional indemnity insurance policy, which is appropriate to the nature and extent of the risk which he undertakes when providing healthcare services to patients. professional indemnity insurance policy = a policy against all risks of professional liability arising from the exercise of one's profession MEDICAL AND KI