rosemary isaacs - australian association of forensic physicians - dilemmas in providing forensic...

Dilemmas in Forensic Care of Vulnerable Victims of SA

Dr Rosemary Isaacs

FRACGP MForensMed (Monash) Medical Director Sexual Assault and Clinical Forensic Medicine

RPA and Liverpool Hospitals

rosemary.isaacs@sswahs.nsw.gov.au

People most vulnerable to assault

may find it hard to …..

Get help

Give history Provide consent

Give evidence in Court

Challenges

• Gauging capacity to consent for victims who are currently suffering with psychiatric illness

• History and Examination of cognitively impaired

• Patients who decline part of the examination

• Personal matters that may cause further stress in court

• Trauma response

• Mental illness

• Pressures on the victim

2005 ABS

Vulnerable to assault

• Easy targets

• Poor witnesses… less chance of prosecution

• Lacking support

• Cannot speak out • Too much to loose

• Not safe to speak

• Don’t understand their rights

Gauging Consent

• What does an adult need to understand?

• Examination may help the police/Law

• She has a choice whether to proceed

• Forensic Examiner will speak to Police about them

• General understanding of a genital examination

Technique

• If possible find out from a carer the patient’s general level of functioning e.g. what they can do for self care

• Simple sentence structure

• Match your language and syntax to the patient’s

• Gauge the patient’s understanding of health care

• Substitute consent if required. Do not proceed if the patient is objecting

Records

• What you said to the patient

• How you gauged they understood

Mental Ill-health

• What are the dilemmas?

– Past history or current history of ill-health, may inappropriately prejudice their evidence

– Multiple diagnoses on history

– Unwell to your observation

• Forensic history may be real or doubtful

– Trauma response masquerading as mental illness so that formal mental health exam is not reliable

Mental Health

Care of patient

• Safety, decision making

• Suicidality, self harm

Acute trauma mimicking mental illness

– Emotion • Affect, Mood • Agitation, Anxiety • Psychomotor retardation

– Thinking • Difficulty organising history into sequential events • Some or partial : overvalued ideas, confusion, disorientation,

denial, Derealisation

– Speech • Paucity of speech, Rapid seems pressured

Useful signs of Mental Illness

• Delusion

– Fixed, unable to reason

• Grandiosity

• Hallucinations

• Flight of ideas

Documenting the functioning brain

• Orientation

• Clear history of matters not related to assault

• Answered general questions appropriately

• Could consider various possibilities

• Behaviour to health staff

• Future plans

Matters disclosed not related to the assault

Declining part of the examination

Substitute consent

• Consent supported by another adult

• Consent provided by another adult or guardianship board

http://www.telegraph.co.uk/health/8960195/Ambulance-crews-stretched-tonight-by-office-Christmas-parties-on-Mad-Friday.html

“Coming to”

• May remember events up to a certain time and then “go blank”

• May “come to” in the middle of a conversation with no idea of what they were talking about

• May go to sleep and wonder how they got home to bed

• May worry about what happened

Amnesia

• Deficit in declarative memory: unable to recall past experience

• Anterograde: in reference to events occurring after the drug or trauma:

• Retrograde to those event before it

• If Pure “no other cognitive defect”. The defect is in short term memory, not maths etc

• Hours

• Anticholinergics, antihistamines

“Alcoholic blackouts”

• Dense anterograde amnesia

• During the blackout

– Individual appears outwardly unchanged

– Events fail to enter their memory

After “coming to” the individual has no recall of events during the blackout

Alcohol +/- Sedative Hypnotics

Drugs combined with alcohol to cause amnesia

• Benzodiazepines, Other hypnotics

• Zolpidem: (Stilnox )

Zopiclone (Imovane )

• Chloral hydrate (Mickey Flynn)

• GBH

• Ketamine

• Barbiturates

• Opioids

• Anticholinergics, Antihistamines, Dextromethorphan

During the blackout

• Observers may suspect nothing

• Continue to act “in character”

• Short term memory negligible but long term and intermediate memory good.

• Clinicians or Forensic examiners, taking a history, need to assess short-term memory

Cognitive function after D & A

• Orientation

• Return of Memory and simple cognition

Photography

https://theconversation.com/over-60-australian-adults-now-overweight-or-obese-1924

Pressures on our patients

Trust and Safety

My future My judgment

Who will go to jail? My community pulled apart

What details of the consenting sex may be relevant ?

Sex Workers

http://www.news.com.au/national/foreign-prostitutes-wanted-on-457-skilled-work-visas/story-fncynjr2-1226660651907

The Age

Bulldog witnessed alleged gang rape: police

A Bulldogs rugby league player has been caught between police and his teammates, with detectives revealing he is a key witness to the alleged pack rape of a 20-year-old woman. The player was one of 23 who had given only "scant" written statements about the incident to police, Detective Chief Inspector Jason Breton said yesterday. Taskforce McGuigon yesterday revealed that it believed six players were involved in a poolside rape at the Pacific Bay Resort at Coffs Harbour on February 22. While most Bulldogs players had co-operated by providing statements and DNA samples, the details provided were "brief", Mr Breton said. However, one other player was believed to have witnessed the incident, and the information he could provide was crucial to investigations

Degradation and War

Sydney Morning Herald

Time alone