FORENSICSFORENSICSInIn

NursingNursing

““Current Trends in Forensic Current Trends in Forensic Science”Science”

Medical Examiners Sixth Annual Conference Medical Examiners Sixth Annual Conference December 14, 2005December 14, 2005

Eva Murray, RN, SANE-AEva Murray, RN, SANE-AJPS Health Network’s SANE/DV Program JPS Health Network’s SANE/DV Program

ManagerManager

Forensics: Pertaining to Forensics: Pertaining to the Lawthe Law

Forensic Nursing: Forensic Nursing: Application of Application of Nursing to the Nursing to the

LawLaw

What is Forensic Nursing?What is Forensic Nursing?

The application of forensic science, The application of forensic science, combined with clinical nursing practice as combined with clinical nursing practice as they are applied to public or legal they are applied to public or legal proceedings in the law enforcement arena. proceedings in the law enforcement arena.

It is the application of forensic aspects of It is the application of forensic aspects of health care combined with biopsychosocial health care combined with biopsychosocial education of the registered nurse in the education of the registered nurse in the scientific investigation and treatment of scientific investigation and treatment of trauma, death, violent or criminal activity, trauma, death, violent or criminal activity, and traumatic accidents within the clinical and traumatic accidents within the clinical or community institution (Lynch, 1991). or community institution (Lynch, 1991).

Forensic NursesForensic Nurses

Trauma/ERTrauma/ER SANE/FNE/SARTSANE/FNE/SART Nurse Coroners/Forensic Nurse Death Nurse Coroners/Forensic Nurse Death

InvestigatorsInvestigators Nurse Attorneys/Legal Nurse Nurse Attorneys/Legal Nurse

Consultants Consultants Psychiatric & Mental HealthPsychiatric & Mental Health Correctional HealthCorrectional Health Domestic ViolenceDomestic Violence

ER/TraumaER/Trauma

ER/TraumaER/Trauma

Why are they neededWhy are they needed IdentificationIdentification Care for the SurvivorCare for the Survivor Care for the Perpetrator Care for the Perpetrator Identification & Collection of Identification & Collection of

evidenceevidence ClothesClothes Injury and patterns of injuryInjury and patterns of injury

ER/TraumaER/Trauma

DocumentationDocumentation What we do v. the crime committedWhat we do v. the crime committed Chain of custodyChain of custody Measurements in centimetersMeasurements in centimeters LocationLocation DescriptionDescription PhotographyPhotography

SANE/FNE/SARTSANE/FNE/SART

SANESANE

A A registered nurseregistered nurse who has been who has been specially trained to provide specially trained to provide comprehensive carecomprehensive care to sexual to sexual assault patients, who demonstrates assault patients, who demonstrates competency in conducting a competency in conducting a forensic forensic examexam and the and the ability to be an expert ability to be an expert witnesswitness..

Benefits of a SANE TEAMBenefits of a SANE TEAM

WillingnessWillingness Specialty trainingSpecialty training Comprehensive careComprehensive care Fact based documentation (drop all Fact based documentation (drop all

opinions)opinions) Forensic issueForensic issue

evidence collectionevidence collection chain of custodychain of custody courtroom testimonycourtroom testimony

SART-Sexual Assault Response TeamSART-Sexual Assault Response Team

Law EnforcementLaw Enforcement Rape CrisisRape Crisis Medical ResponseMedical Response

SANE/RNSANE/RN PhysicianPhysician ANPANP PAPA

Crime LabCrime Lab Counseling Counseling

ServicesServices Forensic ScientistForensic Scientist CPS/APSCPS/APS ProsecutionProsecution

Together Everyone Together Everyone Accomplishes MoreAccomplishes More

Don’t tell other members of Don’t tell other members of the TEAM how to do their the TEAM how to do their

jobs.jobs.

Together we can make Together we can make offenders want to relocate.offenders want to relocate.

SARTSART

Provide victim Provide victim centered servicescentered services

Provide Provide compassionate compassionate carecare

Provide community Provide community awarenessawareness Where to comeWhere to come How we will treat How we will treat

youyou

Encourage reporting Encourage reporting of Sexual Assaultsof Sexual Assaults

Encourage Encourage successful successful apprehension and apprehension and prosecution of guilty prosecution of guilty offendersoffenders

Aid in the Aid in the identifying of false identifying of false reportingreporting

Sexual AssaultSexual Assault

Every 45 seconds a women is Sexual Every 45 seconds a women is Sexual Assaulted.Assaulted.

1:5 Women1:5 Women 1:10-20 Men1:10-20 Men Screen ALL Trauma Patients (LOC, Screen ALL Trauma Patients (LOC,

clothing)clothing)

Sexual Assault ExamSexual Assault Exam

Sexual Assault is rarely suspected Sexual Assault is rarely suspected unless an outcry is made.unless an outcry is made.

History from Patient (to diagnosis & History from Patient (to diagnosis & treat)treat)

Head-to-toe Assessment Head-to-toe Assessment Detailed Genital ExamDetailed Genital Exam Collection of forensic evidenceCollection of forensic evidence Treatment for injuries, STD’s & Treatment for injuries, STD’s &

pregnancypregnancy

DFSADFSA 1/3 offenders convicted-alcohol1/3 offenders convicted-alcohol 40% of 2,366 survivors urine-alcohol40% of 2,366 survivors urine-alcohol Multiple drugs: Ethanol, Benzo’s (valium, Multiple drugs: Ethanol, Benzo’s (valium,

xanax, restoril, klonopin, rohypnol) xanax, restoril, klonopin, rohypnol) Barbiturates, GHB, Ketamine, Chloral Barbiturates, GHB, Ketamine, Chloral Hydrate, Muscle Relaxants, Opiates, Hydrate, Muscle Relaxants, Opiates, Sedative AntidepressantsSedative Antidepressants

Challenges:Challenges: Drugs usesDrugs uses ReportingReporting Collection of evidenceCollection of evidence Lab methodologiesLab methodologies Dosages Dosages

JPS Health Network StatisticsJPS Health Network StatisticsNo. of Exams

050

100150200250300350400450500

1996

1997

1998

1999

2000

2001

2002

2003

2004

No. of Exams

Nurse Coroners/Nurse Coroners/Forensic Nurse Death Forensic Nurse Death

InvestigatorsInvestigators

Nurse Coroner/Death InvestigationNurse Coroner/Death Investigation

The coroner is a public official who is The coroner is a public official who is primarily charged with the duty of primarily charged with the duty of determining how and why people determining how and why people under the coroner’s jurisdiction die under the coroner’s jurisdiction die (these jurisdictions vary form state to (these jurisdictions vary form state to state, but typically include sudden, state, but typically include sudden, unexpected, unexplained, or unexpected, unexplained, or traumatic death).traumatic death).

Nurse Coroner/Death InvestigationNurse Coroner/Death Investigation

A licensed nurse who carries out the A licensed nurse who carries out the duties of a death investigator in duties of a death investigator in accordance with the performance accordance with the performance standards and procedures standards and procedures established under the medical established under the medical examiner or coroner’s system of examiner or coroner’s system of death investigating and the death investigating and the jurisdictional standards of practice.jurisdictional standards of practice.

Nurse Coroner/Death InvestigationNurse Coroner/Death Investigation

Nurses have the educational background Nurses have the educational background to understand exactly what causes death to understand exactly what causes death and what happens to a body after death and what happens to a body after death occurs. Death may be a criminal event, occurs. Death may be a criminal event, but it is always a medical event. Unlike but it is always a medical event. Unlike law enforcement who look at the deceased law enforcement who look at the deceased and want to know, “Who killed you?” and want to know, “Who killed you?” nurses look at a dead body and ask, “Why nurses look at a dead body and ask, “Why are you dead?” If it is determined that the are you dead?” If it is determined that the death was due to criminal cause then it is death was due to criminal cause then it is law enforcement’s job to determine who. law enforcement’s job to determine who. Who better to determine the manner of Who better to determine the manner of death than medical personnel?death than medical personnel?

Nurse Coroner/Death InvestigationNurse Coroner/Death Investigation

Manner of death is the circumstances in Manner of death is the circumstances in which the cause of death arose, i.e. natural, which the cause of death arose, i.e. natural, accident, homicide, suicide, and accident, homicide, suicide, and undetermined. In some cases manner of undetermined. In some cases manner of death may be difficult to determine and may death may be difficult to determine and may appear accidental (i.e. in a suicide without a appear accidental (i.e. in a suicide without a note). Forensic nurses possess the skills note). Forensic nurses possess the skills necessary to complete a psychological necessary to complete a psychological autopsy and interpret the subtle nuances of autopsy and interpret the subtle nuances of medications, health history and medications, health history and circumstances surrounding suspicious deaths.circumstances surrounding suspicious deaths.

Nurse Coroner/Death InvestigationNurse Coroner/Death Investigation

Mechanism of death is the physiologic Mechanism of death is the physiologic derangement or biochemical derangement or biochemical disturbance incompatible with life, disturbance incompatible with life, which is initiated by the cause of death, which is initiated by the cause of death, e.g. cardiac arrest. Forensic nurses are e.g. cardiac arrest. Forensic nurses are well educated in physiology and are well educated in physiology and are therefore prepared to accurately therefore prepared to accurately distinguish between the cause and the distinguish between the cause and the physiologic mechanism of death.physiologic mechanism of death.

Nurse Attorneys/Nurse Attorneys/Legal Nurse ConsultantsLegal Nurse Consultants

GoalsGoals

To establish a leadership role in health care To establish a leadership role in health care policy making.policy making.

To influence health care social policy, health To influence health care social policy, health care legislation and nursing practice acts.care legislation and nursing practice acts.

To educate the public about health law issues.To educate the public about health law issues. To educate the public about nurse attorneys.To educate the public about nurse attorneys. To educate nurses about the legal system.To educate nurses about the legal system. To represent the public; client advocate.To represent the public; client advocate.

Nurse Attorneys/Legal Nurse Nurse Attorneys/Legal Nurse ConsultantsConsultants

Nurses want to make fundamental change Nurses want to make fundamental change in the way healthcare is delivered, and in the way healthcare is delivered, and recognizing that it needs to occur through recognizing that it needs to occur through legislation and political process is a big legislation and political process is a big piece of it.piece of it.

Like nurses, attorneys must interact with Like nurses, attorneys must interact with people who are vulnerable, who have been people who are vulnerable, who have been injured or traumatized, and who need injured or traumatized, and who need assistance to regain their wholeness.assistance to regain their wholeness.

Client advocacy is the skill nurses bring to Client advocacy is the skill nurses bring to the profession.the profession.

Psychiatric and Mental Psychiatric and Mental HealthHealth

Issues and GoalsIssues and Goals

The enhancement of appropriate care for The enhancement of appropriate care for the severe and persistently mentally ill.the severe and persistently mentally ill.

The integration of psychiatric and The integration of psychiatric and addictions treatment.addictions treatment.

Strategies for promotion of mental health Strategies for promotion of mental health and prevention of psychiatric disorders.and prevention of psychiatric disorders.

The provision of appropriate care within The provision of appropriate care within the criminal justice system.the criminal justice system.

The equitable provision of care for children The equitable provision of care for children and adolescents.and adolescents.

Issues and GoalsIssues and Goals

Ensuring access to care for older adults Ensuring access to care for older adults and members of minority groups.and members of minority groups.

Advocacy for access to psychiatric-mental Advocacy for access to psychiatric-mental health services as readily as access to health services as readily as access to medical services.medical services.

The development of an evidence-based The development of an evidence-based approach to teaching nursing students approach to teaching nursing students about psychiatric-mental health nursing, about psychiatric-mental health nursing, at both the undergraduate and the at both the undergraduate and the graduate levels of education.graduate levels of education.

Correctional HealthCorrectional Health

Correctional Health NursesCorrectional Health Nurses

Correctional healthcare is a unique Correctional healthcare is a unique specialty area.specialty area.

Goals:Goals: Facilitate an improved working Facilitate an improved working

relationship between the private sector relationship between the private sector and the correctional staff in jails, adult and the correctional staff in jails, adult and juvenile detention centers, prisons and juvenile detention centers, prisons to meet the needs of the inmate patient.to meet the needs of the inmate patient.

Promote correctional healthcare as part Promote correctional healthcare as part of the public health continuum. of the public health continuum.

Domestic ViolenceDomestic Violence

Intimate Intimate Partner Partner ViolenceViolence

is an Epidemicis an Epidemic

The Surgeon General The Surgeon General of the United States of the United States recently declared:recently declared:

““Domestic ViolenceDomestic Violence is the number one is the number one

health issue facing the health issue facing the country today”country today”

Domestic Violence Domestic Violence

DV is the leading cause of injury to DV is the leading cause of injury to women in the world.women in the world.

DV is the leading nonobstetric cause DV is the leading nonobstetric cause of death to pregnant women.of death to pregnant women.

Every 9 seconds a women is Every 9 seconds a women is battered.battered.

1:3 women are a victim of domestic 1:3 women are a victim of domestic violenceviolence

Cycle of ViolenceCycle of Violence

Eva’s Top 5 Domestic Violence Eva’s Top 5 Domestic Violence Myths/FactsMyths/Facts

MYTHSMYTHS Poor/unemployedPoor/unemployed The victim spends a lot The victim spends a lot

of time running to the of time running to the doctordoctor

He would never hurt the He would never hurt the childrenchildren

He only does this when He only does this when he drinkshe drinks

He wouldn’t kill herHe wouldn’t kill her

FACTSFACTS <15% unemployed <15% unemployed Only 2/3 will seek Only 2/3 will seek

medical assistance medical assistance

There is an increased There is an increased incidence of child abuse incidence of child abuse

67% report alcohol 67% report alcohol abuse only 1/5 drinking abuse only 1/5 drinking at the time of abuse at the time of abuse

2 women die each week 2 women die each week at the hands of their at the hands of their husbands/Texas husbands/Texas

3-10 Million Children Witness DV 3-10 Million Children Witness DV Violence in Their Homes Each YearViolence in Their Homes Each Year

63% of Young Men Ages 11 to 20 Who 63% of Young Men Ages 11 to 20 Who Are Serving Time for Homicide Have Are Serving Time for Homicide Have

Killed Their Mothers’ AbusersKilled Their Mothers’ Abusers

The Leading Cause of Injury to 14 Year The Leading Cause of Injury to 14 Year Old BoysOld Boys

More Facts.. More Facts..

DV kills as many women every 5 DV kills as many women every 5 years as the total number of years as the total number of Americans killed in the Vietnam Americans killed in the Vietnam War…54,000War…54,000

Approximately 50% of all homeless Approximately 50% of all homeless women and children in the U.S. are women and children in the U.S. are fleeing DV.fleeing DV.

There are 7 animal shelters for every There are 7 animal shelters for every 1 DV shelter. 1 DV shelter.

DV & Healthcare Costs DV & Healthcare Costs 3-5 billion dollars in health care claims3-5 billion dollars in health care claims 100 million dollars in absenteeism, high turnover 100 million dollars in absenteeism, high turnover

and lost productivityand lost productivity Employee’s miss 1,175,000 days of work per year Employee’s miss 1,175,000 days of work per year

because of DV alonebecause of DV alone DV in the US costs an estimated $67 billion/yearDV in the US costs an estimated $67 billion/year 13,000 acts of DV against women occur in the 13,000 acts of DV against women occur in the

workplace every yearworkplace every year Up to 52% of victims of DV have lost their jobs Up to 52% of victims of DV have lost their jobs

because batterers typically engage in behavior because batterers typically engage in behavior that makes it difficult to workthat makes it difficult to work

Types of AbuseTypes of Abuse

PhysicalPhysical Hitting, kicking, strangulation, weaponsHitting, kicking, strangulation, weapons

Emotional/psychological Emotional/psychological Threats, destruction of self worth, Threats, destruction of self worth,

isolationisolation FinancialFinancial

Work, advancement, access to finances, Work, advancement, access to finances, credit, credit,

Lack of identifying victims of Lack of identifying victims of Domestic Violence is Domestic Violence is

consistent in community consistent in community hospitals and trauma hospitals and trauma

centers.centers.

““Justice will only be Justice will only be achieved when those achieved when those

who are not injured are who are not injured are just as indignant as just as indignant as

those who are.”those who are.”

King Solomon King Solomon