Infant health – a 20 year anniversary Sweden: Editorial Denmark: Nordic Cooperation
39 40 41
Assessment of bite marks on human skin – occlusal variations in the dentition of criminal offenders deserve special attention
Implementation of Evidence-based Practices in Forensic Psychiatric Clinical Practice in Denmark: Are We There?
Chronic posttraumatic stress in victims of sexual violence
Deaths by drowning in coastal and inland areas
If you look for it, you will ﬁnd it - contributions from advanced post-mortem histological analysis of cervical spine traumas
Cranial fractures caused by blunt trauma to the skull
IAFS 18. møde, New Orleans, Louisiana, USA, den 21-25. juli 2008
Subject: Human sufferings
NRF: Referat fra årsmøte og generalforsamling 2008
PUBLISHED BY th ordicce ic 7 1ConnNferenoren ine o F dic e M BE
Dansk Selskab for Retsmedicin Norsk Rettsmedisinsk Forening Svensk Rättsmedicinsk Förening VOLUME 14 - NO. 2 - 2008 - PAGE 37 - 80
Scandinavian Journal of
The “This side up while I am asleep” has been given to 500.000 newborn babies in Norway. The campaign has probably saved 2000 lives.
SCANDINAVIAN JOURNAL OF FORENSIC SCIENCE Ofﬁcial journal of the Danish, the Norwegian and the Swedish societies for forensic medicine. The journal will publish original articles, review articles, preliminary communications, letters to the editor and case reports in the different disciplines of forensic sciences: forensic pathology, clinical forensic medicine, forensic genetics, forensic toxicology, forensic anthropology, forensic odontology, forensic psychiatry and forensic science. Submission of articles Manuscripts prepared in accordance with Guide for authors should be sent to the editor-in-chief or to one of the national editors. Editor in chief:
Torleiv Ole Rognum, Oslo
Editorial secretary: Editorial address:
Anne Gunn Winge firstname.lastname@example.org Rettsmedisinsk institutt, Rikshospitalet, N-0027 Oslo, Norway
National editor, Denmark:
Jørgen Lange Thomsen, Odense
National editor, Norway:
Torleiv Ole Rognum, Oslo
National editor, Sweden:
Håkan Sandler, Uppsala
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Sigrid I Kvaal Vallegaten 17 A, N-0454 Oslo 7874.06.45012
Clinical forensic medicine:
Markil Gregersen, Århus Kari Ormstad, Oslo Annie Vesterby, Århus
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Per Holck, Oslo
Marie Allen, Uppsala Bertil Lindblom, Linköping Niels Morling, Copenhagen Bjørnar Olaisen, Lovund Antti Sajantilla, Helsinki
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Sigrid I Kvaal, Oslo Sven Richter, Reykjavik
Thomas Bajanowski, Münster Roger W Byard, Adelaide Anders Eriksson, Umeå Gunnlaugur Geirsson, Reykjavik Jorma Hirvonen, Oulu Hans Petter Hougen, Copenhagen Pekka Karhunen, Tampereen Inge Morild, Bergen Lennart Rammer, Lindköping Pekka Saukko, Turku Jørn Simonsen, Copenhagen Michael Thali, Bern Ingemar Thiblin, Uppsala
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Peter Kramp, Copenhagen Randi Rosenqvist, Oslo
Bjarni Bogason, Reykjavik Frank Jensen, Vanløse Reidar Nilsen, Oslo
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Johan Ahlner, Linköping Jørg Mørland, Oslo
Lay out: Holstad Graﬁsk, Oslo - Print: prograﬁa, Oslo - ISSN 1503-9552
Infant health – a 20 year anniversary
nowledge about the risk factors for SIDS has in Norway alone saved more than 2000 lives since 1990. For the Nordic countries as a whole the ﬁgure is probably approximately. 6000, and for all industrialized countries in which prone sleeping position had unfortunately become popular, we are dealing with more than a hundred thousand lives. 1989 was the annus horibilis in Norway with a SIDS rate of 2.4 per 1000 live births. By the end of 1989 the paediatrician Trond Markestad - picked up the hypothesis that prone sleeping position might be dangerous – and started to tell parents not to put their infants to sleep on their fronts. It soon became a national campaign and by 2009 more than half a million newborns have received a baby suit with the message in the front: “This side up while I am asleep” as a gift from The Norwegian SIDS Society (see front page). The “This side up-campaign” reduced the number of SIDS victims by 75 %, to a rate of 0.5, in 3 years. Since 2002 Norway has experienced a further 50 % reduction, bringing the SIDS rate down to 0.2 per 1000 live births. The reason for this last development is not yet clear, but in the same period there has been a signiﬁcant reduction in the proportion of pregnant women who smoke. In spite of the knowledge about environmental risk factors, the lethal mechanism in SIDS is not yet clariﬁed. Genetic studies have reduced our ignorance: fatty acid oxidation defects (e.g. MCAD), heart arrhythmias (LQTS) and other rare conditions may explain 10 % of the deaths previously classiﬁed as unexplained. Other syndromes and conditions may be disclosed as cause of sudden death in the future. However, there will probably remain a core of cases that cannot be explained by one simple factor. These cases may be the result of an interplay between genetic disposition, a vulnerable developmental period of life and environmental factors that in coinciding cause dysregulation of essential regulating systems in the brain stem. Certain genetic variations (polymorphisms) in the serotonergic system and the cytokine network or elsewhere may, during a certain stage of brain development, be triggered by for example CO2 accumulation, starting a vicious circle, resulting in hypoxia and death. The SIDS epidemic in the 1970’es and the 1980’es, and the knowledge about environmental risk factors offered SIDS researchers a historic chance to solve the SIDS enigma. The unlucky experiment of prone sleeping position may help us understand fatal mechanisms. The release of information from research efforts is a meaningful way of honouring the many SIDS victims and their families. Another challenge for forensic pathologists, paediatricians and other health personnel engaged in infant care and health is to focus on the increasing proportion of sudden infant death due to explained causes. While SIDS made up 80 % of all sudden infant deaths 20 years ago, the proportion is now around 60 %. In fact, in south-eastern Norway, SIDS after 2002 constitutes less than half of all sudden infant deaths (40 %). The remaining causes of sudden infant death are sudden fatal disease (33 %), home accidents (11 %) and neglect, abuse and homicide (14 %). Some cases of sudden infant death are very difﬁcult to classify. In some countries these cases are classiﬁed as “undetermined”, “unascertained” or in the Scandinavian countries “borderline SIDS”. Both for epidemiological surveillance and for comparison of research results it will be necessary to reach agreement in classifying these deaths. During the last 19 years SIDS researchers have met at Soria Moria in Oslo to exchange experiences and research results. One of the goals has been to reach agreement on common diagnostic criteria. A draft based on the discussions during the last Soria Moria meeting has been on hearing and will be presented in the spring issue of Scand J Forens Sci. An internationally accepted classiﬁcation of sudden infant death is an assumption for solving the SIDS enigma and to reach the ultimate goal – the prevention of these deaths. Torleiv Ole Rognum
Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Editorial I was quite recently adressed by Anne Gunn Winge who told me that I was to write an editorial. Scince this task takes some consideration, I immediately tried to come up with some clever subject.- No response.- Looking into my computer I found some real old ones. In 1998 my editorial was dealing with.: The necessity of: - quality assessment - conditions for increased recruitment - research and development - ﬁnancial issues Something unfamiliar? Thus it seems out of date to pick up some of these subjects in this editorial, - Or? In the meantime the Danes have succeded in establishing Forensic Medicine as a separate medical speciality, - quite an achievement, and probably important not only in Denmark, but for the discipline on an international basis as well. Remains to be seen what happens in Norway. As to Sweden: A revision of our National Recuirements for Specialisation in Forensic Medicine is taking place, lead by Prof Anders Eriksson. A small country like ours can not make distinctions between Forensic Pathology or Clinical Forensic Medicine. And when there is a ﬁxed time schedule of 5 years, then the interrelationship between the constituents have to be considered. By tradition Pathology has been the dominant “external“ subject (e.g. Denmark 2 ½ year). Somewhere in the range between 0.5 – 1.5 years will be most likely. Clinical Forensic Medicine becoming progressively quantativly more important, paired with evolving new techniques, seem to attract more interest from the medical students, than “classical” Pathology itself (reduced from 80p to 20p at medical school in Sweden). The solution to the problem may be to have a “market sensitive and adaptive“ ﬂexible educational system, based on lifelong learning. At our Department in Uppsala, Sweden we are in the happy situation of receiving two forensic specialists from Hungary and Iran. Each one of them, educated differently. It will be interesting to share their speciﬁc experiences. About exchangeing experiences: Attending the Soria Moria course on SIDS 2008, one important discussion point was: Is there a need for a panel or a network to discuss difﬁcult cases? Judging from the intensive debate around some cases, I would absolutely say YES. Wether it is organized according to “The Delphi-method“ or “A network aimed at systemiatic research”, is of minor importance. A very interesting initiative, to good to be just dropped. *** About the current issue: Jakobsen and Reippen present an interesting paper on “ Assesment of bite marks - - -“, conﬁrming the complex nature in the evaluation of these ﬁndings, especially when we in general meet with so few cases. A separation of forensic pathology from clinical forensic medicine, further enhances this problem. Uhrenholt,Hauge and Vesterby Charles and their advanced postmortem histological analysis of cervical spine traumata, can render important feed-back to the clinical situation, and indicate the shortcomings of contemporary diagnostic imaging. Bengtson and Pedersen are pushing for implementation of evidence-based practices in Forensic Psychiatric Clinical Practice in Denmark. One important result is the fact that most risk assessments in Denmark are made on empirical basis. This could probably apply to many assessments made in other Forensic areas, not only in Denmark. Ole Ingermann-Hansen et al. present a study of posttraumatic stress disorder (PTSD) in victims of sexual violence ranging over a 5 year period. Although a layman in this ﬁeld, it is easy to realize the ordeals they met with concerning, sample demograﬁcs, prevalence and bivariate analyses, regression analyses, etc. The results suggest, that many victims are suffering from severe health outcomes several years after a sexual assault, and that pre-assault health factors may inﬂuence. Schmeling, Geserick, Lignitz and Wirth have studied deaths by drowning in one costal vs one inland area in Germany. The ﬁndings were not so easily interpreted as may be expected, eg – acess to the
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sea, did not result in more suicides. Regional differences in drinking habits was suspected to be a risk factor.One interesting ﬁnding: Although the rate of drowning victims in the costal area was 3 times higher, only 1/3 of the cases drowned in the sea. Geirsson: Lectures in forensic medicine: Human sufferings/self inﬂicted injury A higly interesting document that deﬁnes, autovictimization and its participants, the role of media and motives. *** Synopsis from: IAFS meeting, New Orleans USA 21-25 July 2008. Hansen et al: To sum up: Not overly impressing. Annual meeting of NRF: (Norsk Rettsmedisinsk Forening - Norwegian Forensic Society) - Discusion about a register from the former 14 years of Scand J of Forensic Sciences - NRF will, at the next annual meeting, present a documentary proposal, concerning “ requirements” for obtaining forensic specialist competence. *** Finally, I will take the opportunity to thank you all, for your contributions, to our Journal, making it progressively better in every way. Uppsala, Sweden, 21 Januaey 2009 Håkan Sandler
Nordic Cooperation JØRGEN L.THOMSEN
The politicians are downgrading the signiﬁcance of the Nordic Council, while we become more and more oriented towards the South and the European community. The forensic community, however, seems to give high priority to the Nordic coexistence. We beneﬁt mutually from the development in each individual country. Recently we had the satisfaction of being recognized as a medical specialty in Denmark. The number of specialists is low but the impact on society of a formalized specialty may be high. It will probably increase the number of applicants to forensic medicine and increase the professional level. On 1. January 2009 the ﬁrst three postgraduate students commenced their education, and already at the time of writing, three comprehensive courses are planned in detail. We look forward to the participation of forensic staff from the other Nordic countries. In October 2008 the second edition of “Nordic Textbook of Forensic Medicine” was published. It has been a pleasure in the process to beneﬁt from the skills of colleagues from each country. The text book is so far included in the syllabus for medical students in Denmark and Sweden. Though recently ﬁnished we are already considering the content of the next edition. There may be different views on the best suited content but I hope that you will share your thoughts on this in order to have a truly “Nordic” textbook. As we will soon meet in Bergen, there seems to be an excellent opportunity for fruitful discussions. I look forward to seeing you all in beautiful, rainy Bergen in June.
Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Assessment of bite marks on human skin – occlusal variations in the dentition of criminal offenders deserve special attention Examples from two murder cases and an assault case Jan Jakobsen* and Kirsa Reppien** * DDS, former chairman of the Forensic Dental Unit. ** DDS, research fellow Institute of Forensic Medicine, University of Copenhagen
ABSTRACT The article focuses on the analysis of bite marks that present uneven markings because of occlusal variations in the dentition that inﬂicted the bite mark. Various parameters that inﬂuence the appearance of a bite mark on the skin are described, as well as the conditions at the time of and after the crime that may determine whether the bite mark can serve as evidence in a criminal case. Bite marks found on two murder victims and an assault victim imply a link between special occlusal conditions and the nature of individual tooth marks. Key words: forensic odontology; bite mark investigation; dental occlusion
INTRODUCTION The specialist literature describing bite marks as evidence is extensive and has grown over the last 15 years. Published in 2005, Bitemark Evidence provides a general overview of the topic . The book’s editor, Robert B.J. Dorion, and his co-authors have written sections describing the chief methods of analysing and documenting bite marks in skin and of comparing characteristics in the bite mark with the dentition of the presumed offender. The book refers to the guidelines issued by the American Board of Forensic Odontology (ABFO) to ensure the quality of odontological evidence produced during criminal cases when bitemarks make up part of the evidence . Since the early 1900s, many authors have identiﬁed factors that can affect the appearance of bite marks on skin, depending on the conditions at the time of the crime and on the length of time elapsing before the forensic odontological examination [3 – 26]: 1. Vital reactions in the skin of a surviving assault victim will change details in and around the bite mark. 2. The bite mark and the individual tooth marks on the skin of a murder victim can be preserved for several days if the body is kept in cold storage. 3. Bite marks will present differently because of the varying nature of the CORRESPONDENING ADDRESS Jan Jakobsen, Forensic Odontologist, Department of Forensic Pathology, Institute of Forensic Medicine, University of Copenhagen, DK-2100 Copenhagen
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soft tissue covering bone and muscle in the different anatomical regions of the body. The bite orientation relative to the surface of the skin will determine the extent to which the perpetrator’s tooth marks will be found on either side of the bitemark. The force exerted during occlusion determines the degree of skin injury in the individual tooth markings of the bitemark. Sharp edges on active teeth, combined with variations in the occlusion of the dental arches, cause special injuries and unevenly distributed tooth marks in the bite mark. Missing or partially missing teeth leave no corresponding traces in the bite mark. The overall shape of the bite mark may be distorted if the victim’s position is changed before or during bite registration and examination.
The importance of these factors varies from case to case. Occasionally the poor quality of a bite mark may prevent analysis establishing its orientation relative to the teeth that inﬂicted the bite. There is a need for the forensic dental literature to provide examples of decisions by odontological experts, who concluded that a bite mark was inadmissible as evidence because of its poor quality; it would be a valuable addition to the discussion about the evidentiary importance of bite marks in skin. In some instances, national courts have questioned the evidentiary value of bite marks, referring particularly to the various factors that affect the marks left by bites to the skin [27 – 28]. Experienced forensic odontologists are aware of the limitations of bite
mark evidence, agreeing, for example, that dentition measurements and bite mark measurements cannot be compared directly, when signs of distortion or shrinkage of the skin are present in the bitten area. Changes which may explain why a calculation of a likelihood ratio between details in a bite mark and characteristics in the dentition from an offender sometimes has been of limited value. An improved use of the likelihood ratio has recently been published  recommending a weighing of traits calculated on the basis of relevant population data. It should be emphasized however, that generally, it is possible to prepare an assessment of bite marks in skin that can be included in the evidence of a criminal case. Odontological assessments should take into account the biomechanical factors that affect the creation of a bite mark: all bite marks showing a semi-circular or elliptical mark from two opposing dental arches are made at the moment the active teeth grasp a fold of skin over ﬁrm subcutaneous tissue such as muscle and bone. Individual tooth marks occur when the teeth bite the fold of skin, and the entire bite mark gains its ﬁnal shape once the bite has returned to a position of neutral tension relative to the surrounding tissue in the given area . The illustrations in ﬁgures 1 and 2 show marks from opposing dental arches where the shape and details of the marks were determined by the jaw’s degree of opening, the orientation of the bite and the amount of soft tissue in the anatomical region concerned. Figure 1 shows a bite mark (located in the pubic region) made by maximum opening before biting. The result was a regularly shaped mark, with the outlines
Figure 1: A regular shaped bite mark with the outlines of opposing dental arches. The arrow points to the trace after the palatal cusp of an upper left premolar.
Figure 2: Photograph of an assault victim showed upturned according to the orientation of a series of bite marks inﬂicted by the same offender. The lowest mark on the phototograph (dot) shows scrab marks made before a skin fold was created. In the upper mark the teeth have penetrated the skin caused by a very thin skin fold between the biting teeth (cross). The orientation and analysis of the marks were based on the insert photo (arrow) illustrating the traces of single teeth from the upper and lower jaw. Crowding of the lower incisors from the right side of the lower jaw can be recognized in the mark and on the insert photo (quardrant 4).
of the opposing dental arches and marks from all incisors and premolars in the four jaw quadrants. The photograph is from a murder case in which the offender, who was undergoing sentence, agreed to bite a dummy, allowing a closer examination of his dentition and of the biomechanical factors in play. The bite mark orientation could be established from the ﬁrst premolar in the upper left jaw. In the
occlusal plane, this tooth had a sharp, hanging palatinal cusp – the only dental structure to penetrate the epidermis. Figure 2 is an example of the bite mark variations when the same offender inﬂicted bites on the back of an assault victim. Corresponding to the skin over spina scapulae the bone is only covered by a thin layer of soft tissue, scrape marks were made by the lower incisors before a proper grasp was gained on a fold of skin (marked with a dot). The same phenomenon is often seen in bites to the face, which characteristically show scrapes and overlapping marks because of the difﬁculty of getting a ﬁrm bite on facial skin. The upper bite mark (marked with a cross) show that the skin was almost completely bitten through because the teeth only grabbed a thin skin fold during occlusion. The analytical results regarding the position of the individual tooth marks are shown on the black-and-white photo insert. The photo indicates single teeth responsible for the tooth marks related to the four jaw quadrants. Quadrant number 1 corresponds to the upper right part of the maxilla. The dotted line shows the approximate centre line of the offender´s upper and lower jaw. The occlusal signiﬁcance of the individual tooth marks in bitemarks: Very few authors have referred to the importance of the details of dental occlusion for the appearance of individual tooth marks in bite marks. This is surprising, since the occlusal registration of suspects’ dentition is a normal part of cases involving bitemark investigation. The fact that only few authors have focused on these details prompted the following three case descriptions, in which the intercuspidation between certain teeth or groups of teeth was critical for the odontological evidence produced in two murder cases and one assault case. The international system adopted by the FDI World Dental Federation in 1971 is used to identify the teeth in these accounts . The ﬁrst ﬁgure indicates the jaw quadrant in which the tooth is located while the second indicates the tooth’s position relative to the centre line:
CASE 1 (Fig. 3, 4, 5, 6, 7) Two murder victims were found in a ﬂat in the Copenhagen suburb of Amager. The police had been called following reports of domestic violence the previous evening. When the police arrived, the ﬂat had overturned and broken furniture as well as numerous traces of blood in the sitting room. A dead man (A) was found in the bathroom and on closer inspection, the body of a woman (B) was seen partly hidden behind the man. The case suspect was the woman’s husband (C), whom she had left about one month earlier. The suspect was arrested at his relatives’ house in Sweden. In addition to stab wounds, the forensic examination of the young woman revealed a mark consistent with biting. The mark, on the inside of the right wrist, was uneven with random marks from speciﬁc teeth that had inﬂicted skin injuries of varying depth. Several individual marks on the bite site were covered with scabs, and the entire area showed signs of subcutaneous bleeding, but without clearly deﬁned teeth marks (Fig. 3). The location of the bitemark means the bite could have been self-inﬂicted, so the teeth of all three persons involved – A, B and C – were compared with the mark on the woman’s wrist. Figure 4 illustrates the dental status of the three persons. The image of B’s teeth (centre photo) immediately rules out the possibility of the bite being self-inﬂicted because in normal occlusion, B’s closeset, regularly positioned central incisors would be expected to leave a regular bite mark, with the teeth leaving evenly distributed traces, as in the bite mark shown in Fig. 1. The teeth of suspect C (Fig. 4, bottom photo) showed traits consistent with the bite mark because of the diastemata between the incisors of the upper and lower jaws. Six months before his arrest, a note had been made in his dental record that he had no lateral incisor in the upper right jaw (tooth number 12 – see the FDI Two-Digit Notation #). An odontological examination following the suspect’s arrest showed that this tooth had been
FDI Two-Digit Notation Upper right
18 17 16 15 14 13 12 11
21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41
31 32 33 34 35 36 37 38
Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Figure 3: Case 1, bite mark located on the inside of the right wrist.
ﬁtted with a crown three months prior to the time of the crime (the pale incisor in the bottom photo, Fig. 4). This fact ruled out the otherwise reasonable assumption that C had inﬂicted the bitemark. Attention then turned to the teeth of the murder victim A, whose dentition and dental status differed signiﬁcantly from those of B and C. A’s front teeth had been severely affected by caries, which had destroyed the upper lateral incisors almost to gum level. Caries in the approximal surfaces of the central incisor in the upper left jaw (21) meant this tooth was distinctly narrower than the corresponding tooth on the opposite side. The lower left canine (33) had caries in the mesial and cervical surfaces. The canine tooth on the opposite side (43) was missing, with no diastema between the ﬁrst premolar (44) and the lateral incisor (42). There was a noticeable difference in the occlusal curve of the dental arches of both jaws as a result of the uneven attrition of the upper canines, a fractured incisal edge on the lower right central incisor (41) and elongation of the lower left lateral incisor (32) (Fig. 5). The occlusion of A’s dentition was evaluated from a cast (Fig. 6), which displayed several characteristic details that could be compared with the bite mark (Fig. 3): the upper right canine tooth (13) occluded in a deep bite with the moderately worn cusp only 2 mm from the gingival edge in the opposite dental arch. The upper central incisors (11, 21)
were close set and had relatively sharp incisal edges due to enamel fractures on the palatal surface, easily veriﬁed by a magnifying glass (the fractures are not visible on the ﬁgures 4- 7). The occlusion was notable in that it was particularly close, with the lower left lateral incisor (32) occluding in a deep bite under the narrow carious central incisor of the opposite dental arch (21), and almost in contact with the carious remains of the lateral incisor (22) (Fig. 7). These factors might explain the scabcovered teeth marks in the bite mark: the canine tooth (13) could have left the isolated mark on the right of the bite mark (Fig. 3). Two distinctly close-set wounds were observed after the space before the next mark, the left wound smaller and narrower than the other. A faint mark could be discerned next to the narrow one. It is highly probable that these three details from the upper teeth in the bite mark were generated when the central incisors made contact with the remains of the lateral incisor during occlusion with the incisors of the lower jaw. The isolated and also best-deﬁned mark on the left side of the bite mark could be attributed to the elongated lateral incisor of the lower left jaw (32). This tooth occupied the highest position in the occlusal curve and the closest part of the occlusion between the dental arches of the upper and lower jaws (Fig. 6-7). The conclusion of the odontological opinion on the case ruled out the possibility of B and C inﬂicting the bite mark on B. However, it was assessed that the interrelation of the tooth marks in the bite mark, along with their relative proportions and the skin injury, were compatible with A’s dentition. No evidence was found to rule out A inﬂicting the bite mark. The bite mark could have been formed if B had grabbed A’s face during the apparently violent struggle at the crime scene. It was established that A had most likely bitten B’s wrist.
Figure 6: Case 1, mounted casts of the dentition from victim A.
Figure 7: Case 1, victim A , position of the lower left lateral incisor (tooth 32) in occlusion to the remains of the upper left lateral incisor (tooth 22) marked with an arrow.
Figure 4: Case 1, illustration of the dental status of A, B and C (from the top).
Figure 5: Case 1, details of the front teeth, canines and premolars of the victim A.
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It was concluded that with a high degree of certainty victim A inﬂicted the bite mark on B. The odontological examination was conducted approximately 48 hours after the time the crime was committed. No attempts were made during the forensic examination to collect DNA samples from B’s wrist. CASE 2 (Fig. 8, 9) A young man was found stabbed to death with a knife in a ﬂat in the western suburbs of Copenhagen. During the forensic examination, several skin injuries observed on the victim’s back were found to be consistent with biting. One mark near his right shoulder on the lateral scapular
Figure 8: Case 2, preservation of the bite mark. Arrows point to the traces after prominating mesial corners of the upper lateral incisors (12,22).
Figure 9: Case 2, study casts of the dentition from the suspect. Arrows point to the prominating mesial corners of the upper lateral incisors (12,22). On the lower cast the occlusal curves raises in the right side (marked with a curved line) producing a deep bite in occlusion of the front teeth in the right side of the offenders dentition.
region could be used for odontological examination. It was decided to excise skin tissue from the area and ﬁxate the specimen (Fig. 8). Best suited for plane anatomical regions, the method has been recommended as a technique for preserving bite mark dimensions . The bite mark showed marks from separate teeth, both as subcutaneous bleeding and as scab-covered injuries. The outline of the dental arch in the lowest part of the bitemark was most prominent on the right side of the wound where the teeth marks showed most clearly. A large area of blue-coloured bleeding (ecchymosis) was seen subcutaneously in the middle of the bitemark. This change, which normally occurs in the centre of bite marks, is caused by blood vessels bursting when a fold of skin becomes trapped between the dental arches during forceful occlusion. In some cases this bleeding can be assumed to result from sucking or tongue thrusting during sexually motivated biting . The bite mark orientation was established by the marks from the upper ﬁrst premolars, whose facial and palatinal cusps had left traces on both sides of the bite mark (14, 24), (Fig. 8). This meant that the outline of the upper arch had been created by the teeth in the upper jaw, and it was also assessed that the mesial corners of both lateral incisors (12, 22) would be more prominent than the central incisors ( arrows ). The police traced a case suspect to Italy, where he had been arrested for not possessing a residence permit. At the request of the Danish police, he was transferred to Denmark where he was submitted to an odontological examination that included making a study cast of his dentition (Fig. 9). The plaster casts conﬁrmed that the suspect’s lateral incisors in the upper incisal arch had prominent mesial corners. His teeth were otherwise positioned regularly in the dental arches, with a single molar missing from the left lower jaw. The occlusion was interesting: the incisors occluded in a close, relatively deep bite, and the occlusal curve of the lower jaw was highest on the right side, corresponding to the canine (43) and the two incisors (42, 41) (Fig. 9, bottom photo). This feature was consistent with the uneven marks left by the lower incisors and might explain the more pronounced skin injury on the right side of the bite mark (Fig. 8). The conclusion of the odontological opinion emphasized the irregular position of the upper lateral incisors which had been established, as well as the special bite traits, that had produced more pronounced marks from the incisors on
the right side of the bite mark. It was concluded that the ﬁndings supported the identiﬁcation of the suspect as the offender. The forensic examination did not attempt to acquire material for DNA testing. CASE 3 (Fig. 10, 11) A young woman living in Copenhagen who had survived a domestic violence incident identiﬁed her former husband as the offender. He admitted having been in the ﬂat on the day of the incident, but denied having attacked his former wife. In addition to injuries from blows to the face, the forensic examination found signs of bites on the skin of the upper and lateral areas of the cheekbones. Partially overlapping scab-covered scratches were observed. A mark comprising of two opposing U-shaped arches consistent with a bite mark was found
Figure 10: Case 3, bite mark located to the outer side of the victims lower left arm. Traces from the cusps of the upper left premolar (24) set the orientation of the mark.
Figure 11: Case 3, characteristics of the offenders teeth: diastemata between the upper front teeth, the upper right lateral incisor is missing, an open bite occlusion, crowding of the lower incisors and preservation of mamelons (arrow) on these incisors. Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
on the outer side of her lower left arm. The mark showed signs of distortion and it was located across the lower arm with the diagonal between the two arch markings positioned vertically, when the arm was bent (Fig. 10). The mark could have been made if the arm had been held up to protect the face when warding off an attacker. The bite mark on the arm was most clearly deﬁned on the left side of the mark, and no mark had been made by the right lateral incisor of the upper front dental arch. The upper teeth had left fainter traces than the opposing teeth in the lower jaw. The clearest marks were covered in scabs. Study casts of the ex-husband’s dentition were made and photographs taken to supplement the odontological examination of the suspect. The most characteristic features of the dental arches were the wide-set positions of the upper incisors and the missing upper right lateral incisor (12). The gaps presented as 1-2 mm diastemata, which were widest between the central incisors (11, 21) and most narrow between the right central incisor and the canine on the same side (13), where the lateral incisor should have been (Fig. 11). The lateral incisor ( 22) was rotated standing in a ninety degree angle towards the central incisor (21 ). The lower incisors were slightly crooked because of crowding. The four lower incisors were not worn. The occlusion deviated from the norm, with the lower incisal arch occluding in an open bite from the canine (13) to the second premolar on the left (25). Signs of compensation for the open bite could be seen on the lower incisors, which were slightly elongated, although the teeth did not come into contact in occlusion. This could explain the preservation of the development structure from the initial stages of tooth formation (‘mamelons’) in the lower incisors (Fig. 11, arrow). The mamelons could have contributed to the pronounced marks from the teeth in the lower jaw (Fig. 11). The conclusion of the odontological opinion pointed out the match between the missing upper incisor and the lack of a mark from this tooth in the bite mark. Diastemata between the suspect’s upper incisors could be identiﬁed in the bite mark. The angle between the upper incisors (21, 22) could be seen in the upper arch of the bite mark; and the pronounced marks left by the lower incisors in the bite mark were consistent with the undamaged incisal edges on the four lower incisors, which, despite the open bite, had left clear traces in the
46 Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
bite mark. No evidence was found that ruled out the possibility of the suspect inﬂicting the mark on the victim’s lower arm. It was concluded, that the comparison of the teeth of the former husband and the bite mark supported the identiﬁcation of the suspect as the offender. Presented with this and other evidence, the suspect confessed to the violent attack. The odontological examination took place about two weeks after the crime and no attempts were made to acquire material for DNA testing. Discussion The basis of the bite mark analysis in the three cases was knowledge of some of the biomechanical conditions that come into play when a bite to the skin produces a bite mark consisting of two opposing dental arches. A number of authors have carried out bite simulations using mounted casts (Fig. 6). They have used various pliable materials to show the marks made by teeth in occlusion by having the mounted casts simulate a bite [33 – 36]. These simulations have helped to show variations in bite mark appearance and different types of distortion. Test volunteers have also submitted themselves to bites from mounted casts. In this way, the traces of bite marks on skin on various parts of the body have been demonstrated, although it was difﬁcult to reproduce the variations of injury within a bite mark . On the basis of a guilty plea in a murder case in the late 1970s, the Department of Forensic Odontology of the Royal Dental College of Copenhagen instigated a series of investigations into the biomechanical factors associated with human skin bites. The certainty that a known offender had inﬂicted a bite mark on a murdered woman provided a good opportunity for closer analysis of the odontological evidence in the case. The convicted man, who was undergoing sentence, agreed to a complete registration of his dentition at the Royal Dental College. Part of the examination involved using a dummy made of a foam rubber roll covered with rubber dam to simulate the elasticity of the skin during biting . The active tooth surfaces on plaster casts from the offender were stained so they would leave imprints after biting the dummy. It was proved that the bite marks ﬁnal form was created when the rubber dam returned to its original pre-bite position. The principle of the printing method had already been used in 1924 .
The highly irregular traces of the three bite mark cases made it hard to use the normal method of comparison, which relies on transparent overlays to compare bite marks with the offender’s dentition. This method can usually be used to trace the tooth marks of the bite mark by placing a transparent plastic sheet over the active teeth in the plaster cast. Transparencies produced by this technique normally reveal points of similarity between the mark and the suspect’s teeth, but can also be an effective way of ruling out a suspect [35,36,37,39,40]. With bite marks gradually being used as evidence in criminal cases all over the world, prosecutors have sometimes overestimated the value of the evidence, and courts have questioned the acceptability of bite marks as evidence [41 – 45]. Defence counsels have drawn attention to the variable factors affecting the appearance of bite marks: effects that can prevent a direct comparison of the bite mark and the teeth claimed to have made the mark. In some instances, disagreement among odontological experts on the origins of speciﬁc tooth marks have undermined conﬁdence in this type of evidence. The well-known Torgersen murder case from Norway in 1957 is an example of 50 years ongoing criticism of the technical and forensic evidence taken to court. A criticism also including the dental evidence based on analysis of bite marks found on the victim [46-50]. The debate on the legal acceptability of this evidence has led to more stringent demands on case handling, and it is recommended that at least two forensic odontologists assess bite marks inﬂicted on the skin of homicide and assault victims. The number of criminal cases in which bite marks are produced as evidence is relatively small. For example, forensic institutes in Scandinavia rarely deal with more than one case a year. Forensic odontologists in the Nordic countries have kept each other informed about such cases at annual meetings, but the stricter requirements for expert case handling may generate a need for greater international cooperation. A number of examination prerequisites must be met to ensure the validity of bite mark analysis: ■
■ ■ ■
The odontological expert must be involved in the forensic examination as early as possible. Assessment of individual tooth marks made by human teeth. DNA sampling should be attempted. Police technicians should be in charge of photographic bite mark
documentation to make sure the images are suitable for presentation in court (forensic odontologists will supplement the photographic documentation as part of their assessment). The evidence should be additionally preserved by impressions and possibly by excising the area of skin concerned. A complete odontological examination of a suspect should include clinical registration, photographs and impressions of the dentition and bite registrations. Attention should be turned to discrepancies in the material, which could exclude suspects in a case.
9. 10. 11. 12.
CONCLUSION This review of the odontological evidence from two murder cases and one assault case highlights the value of more detailed registration of the occlusal conditions of dentition, particularly when bite marks present uneven injury patterns and marks from speciﬁc teeth. If the details of the suspects’ occlusal conditions in these three cases had been ignored, it would have been difﬁcult to account for the origin of marks deriving from speciﬁc teeth, and therefore the possibility that the offenders had inﬂicted the bite marks. The three cases also show that teamwork between forensic pathologists and the police is essential to the preparation of odontological evidence. Two odontologists assisted in evaluating the material before the ﬁnal statement to the police was prepared.
15. 16. 17. 18.
19. 20. 21. 22. 23.
3. 4. 5. 6. 7.
’Dorion RJB (ed). Bitemark Evidence. 21 contributors, Marcel Dekker, New York 2005. Forensic Science Series no.1; (ISBN 0-8247-5414X): 1-629. American Board of Forensic Odontology, Inc. ABFO Bitemark Analysis Guidelines, in Bowers CM, Bell GL ( eds) Manual of Forensic Odontology 3rd ed. Saratoga Springs: American Society of Forensic Odontology, 1997; 299-357. Amoedo O, Morsure. In L. Art Dentaire en Medicine Legale. Massou et Cie, Paris 1898; 319-338. Gross H. Zahn-Kriminalistik. Arch Kriminalanthropol 1900; 53: 16-17. Keyes FA. Teeth marks on the skin as evidence in establishing identity. Dent Cosmos 1925; 67: 1165-67. Claps A. Les dents et la criminalistique. Sem Dent 1932; 14: 1319-22. Buhtz und Erhardt. Die identiﬁcation von Bissspuren. Experimentelle Untersuchingen. Dtsch Z Gesamte Gerchtl Med 1938; 29: 453-468. Hoppe und Ballhause. Zur Kriminalistik der Bissspuren – identiﬁzierung bei Mord-
fallen. Arch Kriminol 1956; 110: 163-169. Euler H. Bissspuren und Bissverletzungen. In Euler & Venter, Forensicher Zahnheilkunde. JA Bart Muenchen 1956; 185-194. Furness J. A new method for the identiﬁcation of teeth marks in cases of assault and homicide. Br Dent J 1968; 124: 261-267. Furness J. Teeth marks and their signiﬁcance in cases of homicide. J Forensic Sci Soc 1969; 9: 169-175. Harvey W, Millington PF, Evans JH, Barbenel JC, Butler O, Graham V, & T Gibson. Bite marks – the clinical picture. Physical features of the skin and tongue. Standard and scanning electron microscopy. Abstr 6th Int Meet Forensic Sci Edinburgh 1972; 64. MacDonald DG. Bite mark recognition and interpretation. J Forensic Sci Soc 1974; 14: 229-234. MacDonald DG, MacFarlane TW, & DA Sutherland. The characteristics of individual teeth and identiﬁcation from bite marks. Preliminary statistical data. In Harvey W. Dental Identiﬁcation & Forensic Odontology, Henry Rimton Publ., London 1976; 136-140. Gibson T, Stark and Evans JH. Directional variation in extensibility of human skin in vivo. J Biomech 1969; 2: 201-204. Barbenel JC, Evans JH. Bite marks in the skin – mechanical factors. J Forensic Sci Soc 1974; 14: 235-238. DeVore DT. Bite mark for identiﬁcation? - A preliminary report. Med Sci & Law 1971; 144-145. Vale GL, Sognnaes RF, Felando GN & Noguchi T. Unusual three dimensional bite mark evidence in a homicide case. J Forensic Sci 1976; 21: 642-652. Vale GL, Noguchi T. Anatomical distribution of human bite marks in series of 67 cases. J Forensic Sci 1983; 28: 61-69. Dailey JC, Brown CM. Aging of bite marks: A literature review. J Forensic Sci 1997; 42: 792-795. Sebata N. Medico-legal studies on the tooth mark. J Tokyo Med Coll 1961; 9:275292. Sheasby DR, MacDonald DG. A forensic classiﬁcation of distribution in human bite marks. Foren Sci Int 2001; 122: 75-78. Dorion RBJ. Human bite marks: Factors affecting bite mark dynamics. In Bitemark Evidence. Robert B.J. Dorion (ed), Marcel Dekker, New York 2005; chapt. 17: 323387. Kieser JA, Bernal V, Waddell JN, Raju S. The uniqueness of the human anterior dentition: A geometric morphometric analysis. J Forensic Sci 2007; 52: 671-677. Hennis J, Scienbein H. Menschliche Bissspuren bei Stellungsanomalien der Zähne und ihre forensische ververtbarkeit. In Kriminalistik Rechtsmedizin, Heidelberg – Hamburg 1981; 4: 176-180. Suzuki K, Hashimoto M, Minaguchi K, Shirotani T. A murder Case – Personal identiﬁcation by means of bite marks on the body. Bull Tokyo Dent Coll 1979; 20: 93-100. Mincer A, Mincer HH. The court-appointed expert: A solution to all the problems? In Bitemark Evidence Dorion RBV (ed). Marcel Dekker, New York, 2005: chapt 23. Science and the law; 465-475. Pretty I A, Sweet DJ. The judicial view of bite marks within the United States criminal justice system. J Forensic Odontostomatol 2006; 24: 1-10. Bernitz H, Owen JH, Heerden van FP, Solheim T. An integrated technique for the
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analysis of skin bite marks. J Forensic Sci 2008; 53: 194-198. Jakobsen JR, Keiser-Nielsen S. Bite mark lesions in human skin. Forensic Sci Int 1981; 18: 41-66. Federation Dentaire Internationale.TWODIGET SYSTEM of designating teeth. Internat Dent J 1971; 21: 104-106. Dorion RBJ. Preservation and ﬁxation of skin for ulterior scientiﬁc evaluation and courtroom presentation. J Can Dent Assoc 1984; 50: 129-130. Harvey W, Millington P, Barbanel JC, Evans JH. Experimental human bite marks. In Harvey W. Dental Identiﬁcation & Forensic Odontology, Henry Rimton Publ., London 1976; 124. Whittaker DK. Some laboratory studies on the accuracy of bite mark comparison. Int Dent J 1975; 25: 166-171. Dailey JC. The Comparison in bite mark evidence. In Bitemark Evidence, Robert B.J.Dorion, (ed). Marcel Dekker. New York 2005; chapt 2: 423-451. Drinnan JC, Melton MJ. Court presentation of bite mark evidence. Int Dent J 1985; 35: 316-321. James H. Good bite mark evidence, a case report. J Forens Odonto-Stomatol 2006; 24: 12-13. Soerup A. Odontoskopie, ein Zahnaerztlicher Beitrag Zur gerichtlichen Medizin. Vierteljahresschr Zahnheilkd 1924; 40: 385-393. Berndt T. Bite mark science. Florida Dent J 1982; 53: 22-24, 42. Velden van der A, Spiessens M, Willems G. Bite mark analysis and comparison using image perception technology. J Forensic Odonto-Stomatol 2006; 24: 14-17. Keiser-Nielsen S. Comment on the Hay Murder Case. Scand Soc Forens Odontol Newsl 1969; 3: 4. Keiser-Nielsen S. A bite mark Case. Some forensic dental reﬂections. Tandlaegebladet 1970; 74: 651-661. Pretty JA. Unresolved issues in bite mark analysis. In Bitemark Evidence, Robert B.J. Dorion, (ed). Marcel Dekker, New York 2005; chapt. 28: 547-563. Harvey WG. The Hay murder Case (The Biggar Murder). More facts, fantasies and phantasmagoria. Int Microform J Leg Med 1973; 8 (4): card 1, D1-D8. Kittelson JM, Kieser JA, Buckingham DM & Herbison GP. Weighing evidence: Quantitative measures of the importance of bite mark evidence. J Forensic Odontostomatol 2002; 20: 31-37. Stroem F. Investigation of bite marks. J Dent Res 1963; 42: 312-316. Stroem F. Identiﬁcation of bite marks. A murdercase. Abr Proc Excerpta Med Int Congr Ser no 80, Amsterdam 1964; 3940. Bang G. Analysis of tooth marks in a homicide case. Observations by means of visual description, stereo-photography, scanning electron microscopy and stereometric graphic plotting. Acta Odontol Scand 1976; 34: 1-11. Kommisjonen for gjenopptakelse av straffesaker Torgersen-saken: Sluttinnlegg etter høringen. Oslo 2006; http://www.torgersensaken.no/sluttinnlegg.pdf Brandzæg P, Eskeland S. Sakkjyndig uttalelser i Torgersen saken ble ikke kvalitetssikret. Tidsskr Nor Legeforen 2008; 128: 947-948.
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Implementation of Evidence-based Practices in Forensic Psychiatric Clinical Practice in Denmark: Are We There? Susanne Bengtson, MSc, PhD1 and Liselotte Pedersen, MSc2 1 2
Department of Forensic Psychiatry, Aarhus University Hospital, Risskov, Denmar Department of Forensic Psychiatry, Psychiatric Center Sct. Hans, Roskilde, Denmark
ABSTRACT The future is inherently non-cognizable and assessing violence risk is, accordingly, a difﬁcult, uncertain and complex task. Empirical studies suggest that using formalized risk assessment methods may improve the predictive validity of professionals’ predictions of risk of future violence. The aim of this study was to determine the utilization of formalized risk assessment scales among Danish psychiatrists and psychologists in relation to forensic psychiatric evaluations and risk management. Overall, the results from a survey, based on 41 respondents, showed that risk assessments typically are done in an unstructured manner without utilization of formalised risk assessment instruments, although the majority of the sample was familiar with a number of risk assessment scales. The most frequent reasons for not using risk assessment instruments was insufﬁcient knowledge of such instruments, insufﬁcient training in applying the instruments, preference of unstructured clinical judgment and mistrust to the reliability and validity of risk assessment instruments. The current ﬁndings suggest a need for implementing formalized risk assessment methods to a higher degree in clinical practice in Denmark. Key words: risk assessment instruments, unstructured clinical judgment, and clinical practice.
INTRODUCTION Psychiatrists’ and psychologists’ conclusions on offenders’ risk of future violence are often central in reaching decisions on sentencing, risk management and release of offenders (1). Given the impact of such evaluations, the potential admissibility of risk evaluations is related to the scientiﬁc basis of the evaluators’ conclusions regarding future risk. In general, a distinction is made between three broad approaches of risk assessment: unstructured clinical, actuarial and structured clinical judgment (2). The unstructured clinical approach implies unguided and subjective decision-making on an offender’s risk reached by intuitive human judgment. In contrast, the actuarial and the structured clinical procedure involves using an a priori research-supported list of risk factors to be considered and given weight in the risk assessment (risk assessment instruments/scales). While the clinician makes the ﬁnal decision on the offender’s future risk in the structured clinical approach, the ﬁnal evaluation of the offender’s future risk is reached using a formal, algorithmic and objective procedure, when an actuarial approach is applied. Although more recent studies have suggested an above chance level accuracy of unstructured CORRESPONDING ADDRESS: Susanne Bengtson, Department of Forensic Psychiatry Aarhus University Hospital Skovagervej 2 8240 Risskov, Denmark Email: firstname.lastname@example.org
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clinical predictions of violence, the empirical evidence is unequivocal that unstructured clinical judgment generally has been a rather poor predictor of future violence risk with predictive validity at chance level (3-8). In contrast, several studies suggest moderate predictive validity of a number of actuarial and structured clinical risk assessment scales, both for the construction samples and out-ofconstruction samples (9-12). Assessing violence risk is a difﬁcult, uncertain and complex task. However, the best available evidence suggests that the actuarial and the structured clinical approach at present show the greatest promise for the assessment of an individual’s re-offending risk. Thus, in order to identify potential violent individuals with at least some predictive validity formalised risk assessment instruments should be part of risk assessments in clinical practice. The literature suggests that risk assessment instruments have been implemented as standard in a number of forensic settings in North America and across Europe as well as in other Nordic countries in relation to risk assessments of criminal offenders (13-17). However, there are no clear explicated set of national or international standards for “best practice” and there is as yet only one published peer-reviewed study exploring to which degree formalized risk assessment instruments are utilized in today’s clinical practice (18). The study evaluated psychological test usage among psychologists who perform forensic evaluations, herein the utilization of risk assessment instruments developed to predict criminal re-offence among sexual
offenders. Results showed that only 41% of 62 respondents reported to use formalized risk instruments. Due to this lack of knowledge regarding the usage of risk assessment instruments in clinical practice, we sought to explore whether today’s professionals in Denmark apply formalized risk assessment instruments for forensic purposes. Reasons for using or not using risk assessment instruments were examined as well. METHODS Setting In Denmark forensic psychiatry is part of general psychiatry and not a speciality in itself (19). At present there are seven established departments of forensic psychiatry inside general psychiatric facilities (Glostrup, Middelfart, Ribe, Roskilde, Viborg, Aalborg and Aarhus) and four other separate units evaluating and/or treating defendants or convicted offenders (the Herstedvester Institution, the Clinic of Forensic Psychiatry in Copenhagen, Clinical Sexology at Rigshospitalet, and the maximum-security psychiatric facility in Nykøbing Sj.). Forensic psychiatric tasks are mainly carried out in relation to psychiatric evaluations and treatment/risk management of mentally ill or otherwise mentally disturbed defendants and convicted offenders. Psychiatric evaluations are primarily conducted in relation to forensic psychiatric evaluations (FPE) of defendants for the courts to decide whether special measures or indeterminate sentences should be applied. Psychiatrists carry out FPEs, while psychological
evaluations form only a smaller part of an FPE. Evaluations of risk are also conducted for treated/admitted patients in relation to treatment, discharge, and release on parole or other legal decisions for forensic patients. In sum, assessment of future risk of violence is generally an implicit part of the task for psychiatrists and psychologists completing forensic psychiatric evaluations or treatment/risk management. Participants The survey sample consisted of psychiatrists and psychologists employed at forensic psychiatric departments/units in Denmark: the departments of forensic psychiatry in Glostrup, Middelfart, Ribe, Roskilde (including department of clinical psychology), Viborg, Aalborg and Aarhus as well as the Herstedvester Institution, the Clinic of Forensic Psychiatry in Copenhagen, Clinical Sexology at Rigshospitalet, Copenhagen, and the high-security psychiatric facility in Nykøbing Sj.. A telephonic survey found that approximately 85 psychiatrists, psychologists and registrars were working at the forensic departments/units at the time of sending out the questionnaires. A total of 41 individuals completed and returned the questionnaire, leaving a response rate of 48%. Of the respondents, 56.5% were female and 42.5% were male. The mean age of the respondents was 47.7 years (SD = 10.4, range = 27-66). Female respondents (mean age = 43 years, SD = 9.5, range = 2756) were signiﬁcantly younger than male respondents (mean age = 53.7 years, SD = 8.8, range = 31-66) (t = 3.6, df = 37, p < 0.01). Of the respondents, 55% were psychiatrists (50% female, 50% male), 42.5% psychologists (65% female, 35% male) and 2.5% registrars (one female). Psychiatrists (mean age = 50.9 years, SD = 8.3, range = 38-66) were signiﬁcantly older than psychologists (mean age = 44.7, SD = 11.2, range = 29-56) (t = 3.6, df = 37, p < 0.01). Procedure The invitation to participate in the current study was sent to the managing consultants at the forensic psychiatric departments and other units together with questionnaires and postage prepaid envelopes. The managing consultants were asked to distribute the questionnaires and the envelopes to psychiatrists and psychologists employed at the department/unit. The questionnaire pack contained information to the participants regarding the aim of the study and instructions on how to complete and return the questionnaire. After approximately 6 weeks a letter was mailed to
the managing consultant asking them to distribute reminders to the psychiatrists and psychologists, requesting them to complete and return the questionnaire as soon as possible, if they wanted to participate. To improve the response rate the answering of the questionnaire was anonymous. The questionnaire included 39 questions spread out on four sections. Section 1 requested information on demographics, data concerning professional background and place of work (one of three possibilities: forensic psychiatric department, other similar units or others). Section 2 presented 11 formalised risk assessment scales and the participants was asked to indicate whether they had knowledge of the mentioned risk assessment instruments and if the participants had received any training in using the risk instruments. Furthermore, the participants were asked to indicate if they knew or were trained in using other risk assessment instruments than the referred ones. In section 3 the respondents were asked to indicate: a) their frequency of forensic psychiatric evaluations, b) their frequency of and reason for making risk assessment as part of the FPE, c) their frequency of and reason for utilizing formalised risk assessment instrument in relation to FPE risk assessments and d) if formalised risk assessment instruments were not applied, the reason(s) for not using the instruments. Questions on frequency related to a scale ranging from 1-25% (infrequently), 26-50% (now and then), 51-75% (regulary), to 76-100% (frequently). Questions similar to those in section 3 were asked in section 4 with focus on risk assessment in relation to treatment purposes/risk management: a) number of patients in treatment/risk management, b) frequency of and reason for making risk assessment as part of treatment/risk management, c) frequency of and reason for utilizing formalised risk assessment instrument in relation to treatment/risk management and d) if formalised risk assessment instruments were not applied, the reason(s) for not using the instruments. In section 3 and 4 space was provided for the respondents to include up to four additional instruments not mentioned in the survey. Questions concerning the knowledge and implementation of risk instruments considered 11 speciﬁed risk instruments. Two of these instruments were instruments commonly used in relation to making risk assessments rather than being speciﬁc risk assessment instruments (i.e., PCL-R and PCL-SV). The 11 risk instruments were selected after computer searches of PsychInfo and PubMed as well as a search in relevant
peer-reviewed articles, selecting the most widely cited and/or validated risk instruments (including both actuarial and structured clinical risk assessments), but also more recent risk instruments, developed to predict an individual’s relative risk of violence across various settings (general risk [LSI-R], violent recidivism among mentally ill/incarcerated offenders [VRAG, HCR-20], and sexual re-offending among sexual offenders [RRASOR, Static-99, Static2002, SORAG and SVR-20], and spousal violence risk [SARA]) (see Table 2 for a list over the instruments). Of all 39 questions, 21 included an open reply option. While the majority of the openended questions did not include qualitative material that required additional analysis, eight questions implied qualitative answers that needed to be analyzed and coded. Speciﬁcally, we analyzed the answers (N = 98) to eight questions concerning reasons for conducting/not conducting risk assessment and reasons for using/not using risk assessment instruments. After reading the answers and discussing the underlying themes of these, the authors established conceptual categories of answers. To test the reliability of the authors’ coding of answers, a third rater independently rated a random selection of the answers, a total of 20% of the answers (every ﬁfth). There was a good and signiﬁcant agreement between ratings from the independent rater and the authors’ joint ratings (Pearson’s r coefﬁcient = 0.74). Statistical analyses Categorical data were analyzed with 2test or Fisher’s Exact Test if necessary, while continuous data were compared with t-test (parametric data) or MannWhitney test (nonparametric data). A two-tailed signiﬁcance level was used (p < 0.05). All statistical analyses were conducted in SPSS 14.0. RESULTS Figure 1 illustrates the proportions of clinicians being familiar with risk assessment instruments and the proportion of those, who had received instruction in using risk assessment instruments. On average, the respondents knew 4.7 risk assessment instruments (SD = 2.9, range = 0-11). The most known risk instruments were VRAG (45%), HCR-20 (85%), PCL-R (93%), PCL-SV (78%) and SVR-20 (55%), while the remainder instruments (LSI-R, SORAG, RRASOR, STATIC-99, STATIC-2002 and SARA) were recognised by few respondents (5%-35%). On average, the respondents had received training or Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Figure 1. The proportion of clinicians with knowledge of risk assessment instruments, who were not instructed in using the instruments (black bars), and those who were instructed in using risk assessment instruments (grey bars).
instruction in using 1.7 risk assessment instruments (SD = 2.0, range = 0-9). The respondents were most likely to be trained in using HCR-20 (56%), PCLR (44%) or PLC-SV (39%), while few respondents (0%-12%) were trained in using the remainder instruments. Implementation of risk instruments in clinical practice The rate and frequency of risk assessment and application of risk instruments in relation to FPE and treatment/risk management purposes is shown in Table 1. The majority of clinicians reported that risk assessment was a part of conducting FPEs (87%, N = 26) and treatment/risk management (94%, N = 29).
Only a smaller proportion of those clinicians, who conducted risk assessments in relation to FPE (19%, 5/26) or treatment/risk management purposes (38%, 11/29), applied risk assessments instruments. Clinicians using risk assessment instruments applied on average 3.8 risk assessment instruments (SD = 2.6, range = 2-8) for risk assessments conducted in relation to FPE and 3.4 instruments (SD = 1.9, range = 2-8) for treatment/risk management purposes. Table 2 provides information on the most frequently used risk assessment instruments. PCL-R and PCL-SV were the most commonly used instruments for FPEs, while HCR20, PCL-R, PCL-SV and SVR-20 were
the most applied instruments for treatment tasks (Table 2). Fisher’s Exact Test showed that each risk instrument was applied to the same extent for FPE tasks and treatment/risk management purposes (p > 0.05). The respondents registered to use only few other instruments (N = 5) in clinical practice than the 11 pre-scribed instruments. The registered instruments were, however, not speciﬁcally developed to predict violence risk but were rather instruments developed to uncover underlying psychological constructs or sexual attitudes of an individual (e.g., Rorschach, Hanson Sex Attitude Questionnaire). A somewhat larger proportion of psychiatrists (95% and 100%, respectively) reported conducting risk assessments in relation to FPEs and treatment than psychologists (70% and 83%, respectively), while psychologists (43% and 60%, respectively) were more likely to apply risk assessment instruments in relation to FPEs and treatment than psychiatrists (11% and 24%, respectively). Out of the proportion using risk instruments, the psychologists generally used the instruments more frequently than the psychiatrists. However, none of the found differences between psychiatrists and psychologists were statistically signiﬁcant (p > 0.05). Arguments for using and not using risk instruments As seen in Table 3, the most frequent argument for using risk assessment instruments was the desire for evidence-based risk assessments. The most frequent arguments for not using risk assessment instruments was insufﬁcient instruction
Table 1. Rate and frequency of risk assessments and application of risk assessment instruments in clinical practice among psychiatrists and psychologists conducting forensic psychiatric evaluation (FPE) (N = 30) and/or treatment (N = 31) at forensic psychiatric departments/units in Denmark.
Rate and frequency of risk assessments in clinical practice Mean number of FPEs/treatment sequences (patients) per month (S.D.) Clinicians conducting risk assessment as part of FPE/treatment (%) Frequency of clinicians’ risk assessments Infrequently (1%-25% of the cases) Now and then (26%-50% of the cases) Regularly (51%-75% of the cases) Frequently (76%-100% of the cases) Rate and frequency of implementation of risk assessment instruments in clinical practice Clinicians applying risk instruments in relation to risk assessment (%) Frequency of clinicians’ application of risk assessment instruments Infrequently (1%-25% of the cases) Now and then (26%-50% of the cases) Regularly (51%-75% of the cases) Frequently (76%-100% of the cases) * Includes psychological evaluations included in FPE. Ns: Statistical insigniﬁcant difference (p > 0.05)
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2 (1.9) 87%
14.8 (8.3) 94%
23% 4% 8% 65%
25% 11% 7% 57%
Ns Ns Ns Ns
20% 60% 0% 20%
64% 0% 9% 27%
Ns Ns Ns Ns
or training in using risk assessment instruments and that unstructured clinical judgment was applied or preferred over risk assessment instruments (Table 4). As seen in Table 3-4, some respondents recorded more than one argument
for using or not using risk assessment instruments. No statistically signiﬁcant differences were found in the distribution of the remainder arguments of psychiatrists and psychologists for using and not using risk assessment instruments.
Table 2. Percent applied risk assessment instruments among psychiatrists and psychologists applying risk assessment instruments at forensic psychiatric departments/units in Denmark. FPE General crime Level of Service Inventory (LSI-R)1
40% 40% 100% 60%
18% 91% 73% 64%
Ns Ns Ns Ns
Violence (sexual and any violence) Rapid Risk Assessment for Sex Offence Recidivism (RRASOR)6 STATIC-997 STATIC-20028 Sex Offender Risk Appraisal Guide (SORAG)9 Sexual Violence Risk – 20 (SVR-20)10
20% 40% 0% 20% 40%
9% 18% 0% 9% 46%
Ns Ns Ns Ns Ns
Spousal violence risk Spousal Assault Risk Assessment Guide (SARA)11
Additional risk instruments Others
Violence (nonsexual) Violence Risk Appraisal Guide (VRAG)2 Historical Clinical Risk – 20 (HCR-20)3 Psychopathy Checklist – Revised (PCL-R)4 Psychopathy Checklist – Screening Version (PCL-SV)5
Andrews & Bonta (37), 2Harris, Rice, & Quinsey (38), 3Webster, Douglas, Eaves, & Hart (39), Hare (40), 5Hart, Cox, & Hare (41), 6Hanson & Thornton (42), 7Hanson & Thornton (43), 8 Hanson & Thornton (44), 9Quinsey, Harris, Rice, & Cormier (45), 10Boer, Hart, Kropp, & Webster (46), 11Kropp, Hart, Webster, & Eaves (47). 1 4
Table 3. Psychiatrists’ and psychologists’ arguments for using risk assessment instruments (RAI) in relation to forensic psychiatric evaluation (FPE) or treatment and risk management purposes in forensic clinical practice in Denmark. Clinicians using RAI in FPE (N = 5)
Clinicians using RAI in treatment (N = 11)
0% 80% 20%
27% 67% 9%
Standard at the department/unit Desire for evidence-based risk assessments Desire for transparent risk assessments
Table 4. Psychiatrists’ and psychologists’ arguments for not using risk assessment instruments (RAI) in relation to forensic psychiatric evaluation (FPE) or treatment and risk management purposes in forensic clinical practice in Denmark. Clinicians not using Clinicians not using RAI RAI in FPE (N = 22) in treatment (N = 18) Insufﬁcient knowledge of, instruction or training in using RAI Apply or prefer unstructured clinical judgment General mistrust to RAI* Not expected or requested to use RAI
41% 41% 23% 18%
56% 28% 22% 22%
* General mistrust reﬂected mistrust in the validity and reliability of risk assessment instruments or because the instruments have not been validated on Danish samples.
DISCUSSION The current study presents the results of the ﬁrst Nordic survey of the implementation of risk assessment instruments in forensic psychiatric clinical practice. Our results showed that clinicians usually conduct risk assessment as part of forensic psychiatric evaluations and treatment/risk management in clinical forensic psychiatry in Denmark. In line with previous literature, the results suggest that unstructured clinical judgment continues to be the standard in forensic psychiatric clinical practice (5;20). Only few implemented risk assessment instruments in clinical practice and generally on an irregular basis. In the present study it was evidently lack of knowledge of or instruction in using risk assessment instruments that was the main reason for not applying risk assessment instruments. Thus, a proactive administration securing appropriate and reasoned training for clinicians involved in risk assessment appears to be a central element in the work to achieve evidence-based practice for predictions of violence risk. The study further illustrated that the majority of clinicians using risk instruments did in fact so to base their clinical practice on empirical evidence. This may suggest that more clinicians would have implemented risk assessment instruments, had they possessed the necessary knowledge and training to do so. Considering the international literature on risk assessment it was remarkable that more than every third clinician reported that they applied or preferred unstructured clinical judgment instead of risk assessment instruments and every fourth reported mistrust to the validity and reliability of risk assessment instruments. There may be several reasons for the reluctance to apply risk assessment instruments and the general mistrust to such instruments (21). First, it may seem contra-intuitive that a simple tool consisting of few (and sometimes a-theoretical) risk items may be superior to human judgment. Clinicians access much more information and are able to detect rare facts and use this information accordingly. Secondly, others are unaware of the empirical research on risk assessment. Further, some dismiss this kind of research principally as dehumanizing the client, while some dismiss the research arguing that group statistics do not apply to single individuals. Other may plainly put their conﬁdence in the accuracy of their own clinical judgments. In the current study, the mistrust in risk assessment instruments appeared to be due to the less than perfect preScand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
dictive accuracy reported for formalised risk assessment instruments. International research suggests that there is no basis for predictive over-enthusiasm for any existing risk assessment instrument. The reported predictive accuracy of risk assessment instruments is generally far from perfect and is associated with a number of false positive and false negative prediction errors (22). Still, the predictive accuracy of formalised and well-validated risk assessment scales implies a degree of accuracy that is similar to the accuracy we achieve in other important human decision (e.g., the likelihood of cardiac bypass surgery improving mortality rates) (23). Further, the mistrust in formalised risk assessment instruments is noteworthy in the light of a vast number of comparative reviews and meta-analyses suggesting a relatively lower predictive validity of unstructured clinical prediction judgment across a wide range of settings and problems (8;20;24-25). The aim to protect society from harm is advanced by accurate decisions by preventing further criminal acts and in reducing the high social and ﬁnancial costs of unnecessary detentions and imprisonments (26). The scientiﬁc evidence suggests that a crucial element in “best-practice” in risk assessment is to apply risk assessment instruments that have proved to fare well in predicting violence (27). Furthermore, the empirical literature does not provide support for the continued used of unstructured clinical judgment. In line with international empirical studies a recent Danish study showed that the predictive accuracy of unguided clinical judgment did not exceed chance for the prediction of any sexual, severe sexual or any violent (sexual or non-sexual) reconviction among 121 sexual offenders (AUCs of the ROC curve=0.50-0.57) (28). Overall, the current ﬁndings support the recommendations in two recent Danish reports, that systematic risk assessment procedures should be implemented in the mental health system, herein forensic psychiatric practice, in Denmark (29-30). A central element in using research on risk assessment procedures from other countries as basis for evidence-based practice is, however, that the risk assessment instruments in question have been cross-validated in the country concerned. Also in the current study, many clinicians refrained from using risk assessment instruments due to a general mistrust in using instruments developed and validated in other countries. It seems important to clinicians that certain steps are undertaken before relying on research from other
52 Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
countries as a basis for their evidencebased practice. An important step is to test for reliability and validity. While a number of cross-validation studies have been conducted in the other Nordic countries (10;17;31-32), Danish crossvalidation studies have only started to be established (33-34). It is important to establish further studies in terms of validity of risk assessment instruments in regards to provide clinicians with the needed empirical literature to guide their clinical practice. Finally, some limitations of the current study should be noted. The sample size was rather small and the response rate was smaller than the average response rate for traditional paper-andpencil surveys at 56% as reported by Baruch (35). Given that the sample only represents approximately half of the clinicians employed in forensic psychiatric clinical practice in Denmark at the time of the study, the generalisability of the results awaits to be compared to future surveys on this matter. Moreover, the construction of the questionnaire could have been improved by including more comprehensible deﬁnitions of risk assessment and risk assessment instruments, since some respondents appeared to think risk assessment as equivalent with using risk assessment instruments. Despite these limitations, it is clear that the results show that research on clinical versus systematic assessment procedures have had only a smaller effect in clinical practice. Evidently, there is a need to bridge the gap between clinical practice and empirical knowledge on assessment of violence risk (36).
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18. Archer RP, Bufﬁngton-Vollum JK, Stredny RV, Handel RW. A survey of psychological test use patterns among forensic psychologists. Jn of Pers Assess 2006;87;84-94. 19. Kramp P. Concepts and procedures in the member states - Denmark. In: Salize HJ, Dressing H, editors. Placement and treatment of mentally disordered offenders - legislation and practice in the European Union.Lengerich: Pabst Science Publishers; 2005. p. 152-77. 20. Hanson RK, Morton-Bourgon K. The accuracy of recidivism risk assessments for sexual offenders: A meta-analysis. Ottawa, ON: Public Safety and Emergency Preparedness Canada; 2007. Report No.: 2007-01. 21. Dawes RM, Faust D, Meehl PE. Clinical versus Actuarial Judgment. In: Gilovich T, Grifﬁn D, Kahneman D, editors. Heuristics and Biases. The Psychology of Intuitive Judgment. 1 ed. New York: Cambridge University Press; 2002. p. 716-30. 22. Sjöstedt G & Grann M. Risk assessment: What is being predicted by actuarial prediction instruments? International Journal of Forensic Mental Health 2002;1,179-183. 23. Meyer GJ, Finn SE, Eyde LD, Kay GG, Moreland KL, Dies RR, Eisman EJ, Kubiszyn TW, Reed GM. Psychological testing and psychological assessment. A review of Evidence and issues. Am Psyc 2001;56;128-165. 24. Grove WM, Zald DH, Lebow BS et al. Clinical versus mechanical prediction: A meta-analysis. Psychol Assess 2000 March;12:19-30. 25. Ægisdóttir S, White MJ, Spengler PM, Maugherman AS, Anderson LA, Cook RS et al..The meta-analysis of clinical judgment project: Fifty-six years of accumulated research on clinical versus statistical prediction. The Couns Psychol 2006;34:341-82. 26. Wakeﬁeld H, Underwager R. Assessing Violent Recidivism in Sexual Offenders. Issues Child Abuse Accu 1998;10:9298.
27. Janus ES, Prentky RA. Forensic use of actuarial risk assessment with sex offenders: Accuracy, admissibility and accountability. Am Crim Law Rev 2003;40:1443-99. 28. Bengtson S, Långström N. Unguided clinical and actuarial assessment of reoffending risk: A direct comparison with sex offenders in Denmark. Sex Abuse 2007;19:135-153. 29. Bratbo J, Kyvsgaard B, Sestoft D. Psykisk sygdom og kriminalitet. København: Indenrigs- og Sundhedsministeriet; 2006. 30. Toft L, Kjelsgaard T. Retspsykiatri - status og udfordringer. København: Amtsrådsforeningen; 2004. 31. Belfrage H. Implementing the HCR-20 scheme for risk assessment in a forensic psychiatric hospital: Integrating research and clinical practice. J Forensic Psychiatry 1998;9:328-38. 32. Grann M, Belfrage H, Tengström A. Actuarial assessment of risk for violence: Predictive validity of the VRAG and the historical part of the HCR-20. Crim Jus Beh 2000;27:97-114. 33. Pedersen L, Rasmussen K. Reliability of the Danish version of the HCR-20 risk assessment scheme. Scand J Forensic Sci 2006;2:54-7. 34. Bengtson, S. Is newer better? A crossvalidation of the Static-2002 and the Risk Matrix 2000 in a Danish sample of sexual offenders. Psychology, Crime Law (in press). 35. Baruch Y. Response rates in academic studies – A comparative analysis. Hum Rel 1999;52;421-434. 36. Elbogen EB, Calkins C, Tomkins AJ, Scalora M. Clinical practice and violence risk assessment: Availability of MacArthur risk cues in psychiatric settings (pp. 38-55). In D.Farrington, C. Hollins, & M. McMurran (Eds.). Sex and violence: The psychology of crime and risk assessment. Routledge: London; 2001. 37. Andrews, D. A. and Bonta, James L. LSIR:SV Level of Service Inventory Revi-
sed: Screening Version User’s Manual. Toronto: Multi-Health Systems; 1999. Quinsey V, Harris GT, Rice ME, & Cormier MA Violent Offenders, Appraising and Managing Risk. Washington: APA Webster CD, Douglas KS, Eaves D, Hart SD. HCR-20. Assessing the risk of violence. Version 2. Burnaby, British Columbia, Canada: Simon Fraser University and Forensic Psychiatric Services Commission of British Columbia; 1997. Hare RD. Manual for the Hare Psychopathy Checklist - Revised. Toronto, Canada: Multi-Health Systems; 1991. Hart SD, Cox D, Hare RD. Manual for the Screening Version of the Hare Psychopathy Checklist - Revised (PCL: SV). Toronto, Canada: Multi-Health Systems; 1995. Hanson RK. The development of a brief actuarial risk scale for sexual offense recidivism. Ottawa, Canada: Public Safety and Emergency Preparedness Canada; 1997. Report No.: 1997-04. Hanson RK, Thornton D. Static-99: Improving actuarial risk assessments for sex offenders. Ottawa, Canada: Public Safety and Emergency Preparedness Canada; 1999. Report No.: 1999-02. Hanson RK, Thornton D. Notes on the development of Static-2002. Ottawa, Canada: Public Safety and Emergency Preparedness Canada; 2003. Report No.: 2003-01. Quinsey VL, Harris GT, Rice ME, Cormier CA. Violent offenders: Appraising and managing risk. Washington: American Psychological Association; 1998. Boer DP, Hart SD, Kropp PR, Webster CD. Manual for the Sexual Violence Risk - 20: Professional guidelines for assessing risk of sexual violence. Burnaby, BC: Simon Fraser University, Mental Health, Law, and Policy Institute; 1997. Kropp PR, Hart SD, Webster CD, Eaves D. Manual of the Spousal Assault Risk Assessment Guide (2nd ed). Vancouver, Canada: British Columbia Institute on Family Violence; 1994.
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Chronic posttraumatic stress in victims of sexual violence Ole Ingemann-Hansen1,2, Ask Elklit3, Svend Sabroe4, Annie Vesterbye Charles1, Ole Brink1 Institute of Forensic Medicine, Section of Clinical Forensic Medicine, University of Aarhus The Western Danish Sexual Assault Center, Aarhus University Hospital 3 Institute of Psychology, University of Aarhus 4 Institute of Public Health, University of Aarhus 1 2
ABSTRACT The purpose of this paper was to estimate the prevalence of Post-Traumatic Stress Disorder (PTSD) in sexual assault victims attending a rape crisis centre, and to examine the interrelationships among victim and assault characteristics, forensic ﬁndings, and PTSD. Eighty victims completed a questionnaire 2 to 5 years after the assault. Measures included the Harvard Trauma Questionnaire. Forty-ﬁve percent met the full PTSD diagnosis. Completed sexual intercourse was identiﬁed as a predictor for PTSD development. The results suggest that many victims are suffering from severe health outcomes several years after a sexual assault, indicating a need for follow-up monitoring and intervention. Key words: Sexual assault, posttraumatic stress disorder, prospective
INTRODUCTION Sexual assault is not an uncommon lifetime event with a prevalence of 7% to 33% in both of adolescents and adults (depending on the deﬁnition of a sexual assault, study design, sampling, and setting) [1-4]. Prior research has concluded that PTSD is a rather common consequence of sexual violence [5-9]. U.S. national samples have indicated that victims of sexual assault report lifetime PTSD prevalence rates of between 32% and 46% [7, 10]. A short term followup study, which was conducted in a rape crisis centre setting, revealed that 94% of rape victims suffered from PTSD (apart from the time criterion) 2 weeks after the sexual assault, 65% after 1 month, and 47% after 3 months . In order to prevent or at least reduce the deleterious post-assault sequelae it is imperative to conduct research aimed at identifying both speciﬁc and immediate predictors of PTSD post-assault. An identiﬁcation of such could alert, for example, rape crisis centre employees who are ideally placed to offer the help and assistance many sexual assault victims require. Preassault factors, assault-related factors, and/or postassault attributions may lead to PTSD. Several studies from non rape crisis centre settings have examined possible predictors of PTSD using
CORRESPONDING ADDRESS Ole Ingemann-Hansen Institute of Forensic Medicine, Section of Clinical Forensic Medicine, University of Aarhus, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark Telephone: +45 42 98 00 Fax: +45 86 12 59 95 E-mail: email@example.com
54 Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
different kinds of analyses in order to identify which victims are most likely to develop the disorder. Prior research has identiﬁed multiple factors, such as young age, complete intercourse, and physical injury, which are individually associated with the development of PTSD [12, 13]. Exposure to moderate/severe coercion and physical injury during the assault were also found to be associated with PTSD in multivariate analysis [1, 14, 15]. The perpetrator’s relationship to the victim as partner or unknown was also reported as indicative of PTSD [16-18]. However, the media-recruited sample by Ullman & Filipas  concluded no signiﬁcant associations of either the victim’s injury or the victims relationship with the perpetrator with PTSD development after multivariate analysis. Kilpatrick et al.  conducted a study, which employed socioeconomic information such as occupational status, this study concluded that such had no association with the development of PTSD following sexual assault. Contradictorily however, Kimerling et al. showed that the development of PTSD was linked to unemployment . More recent sexual assault studies, with a focus on the victims educational level as a correlate to PTSD, have reported inconsistent ﬁndings regarding the association between PTSD and victims reporting low levels of education [1, 18, 19]. The only study examining the relationship of PTSD with the legal outcome of the case concluded no associations with PTSD . Apparently, a number of studies have examined the prevalence of PTSD and associations with victim and crime factors, however few have focused solely on victims attending a rape crisis centre in a year long prospective way. Additionally,
the study regarding the association with legal outcome decided not to employ a multivariate analysis instead opting to conduct a univariate test. In the present study, which employs a sample of sexual assault victims visiting a rape crisis centre, the aims were to describe the prevalence of PTSD, and to determine the victim- and assault-related predictors of PTSD. It was hypothesised that completed intercourse, unknown perpetrator, physical coercion, young victim age, unemployment, and injury would predict PTSD. Ideally, the victims’ exposure to a rape crisis centre (forensic examination and psychologist treatment) or to police authorities should cause positive social reactions and was therefore expected to be unrelated to PTSD [19, 22]. In the case of police notiﬁcation a common legal outcome is that the perpetrator fails to be convicted of the sexual assault . Hypothetically, this could leave the victim with a feeling of non-believing and mistrust expected to be related to PTSD. Finally, we expected that there would be no decrease in the prevalence of PTSD during the study period due to the chronicity of PTSD . METHODS Participants Within this study sexual assault (or violence) is deﬁned as the unwanted attempted or achieved penile, ﬁnger, or object penetration of the vagina, anus, or mouth. Survey and register data were collected from a sample of adolescents/adults more than 12 years of age. The sample represented the entire caseload of victims at the Western Danish Center for
prevention, treatment, and research of Sexual Assault (WeDSAC) during a ﬁve-year period from November 1, 1999 to October 31, 2004 . Every referral to the WeDSAC was interpreted as a case of sexual assault. About 2/3 of all rape victims received psychological counselling based on crisis intervention principles; for treatment details see Elklit & Knudsen . Four hundred and nineteen victims (8 males and 411 females) were identiﬁed retrospectively in the WeDSAC ﬁles. Twenty-seven false allegations were excluded. A referral was considered false if the victim later admitted he/she lied or if the police pressed charges for false report/accusation. In cases where the victim had more than one referral during the study period only the latest referral counted. Thirteen cases were excluded for this reason. Victims with unknown mail addresses (24), deceased victims (4), victims mentally disabled or unable to answer the questionnaire due to reading difﬁculties (4), or unwilling to have further contact with the WeDSAC (14) were also excluded. This leaves 333 victims who were eligible to receive the questionnaire at 2, 3, 4, or 5 years postassault. Two hundred and forty victims failed to return the questionnaire resulting in the end sample consisting of 93 victims (28%). The total response rate for PTSD was 24% due to incomplete data. For the 2year sample, 169 victims were available and 33% returned the questionnaire, for the 3-year sample, 10% (5) of 52 responded, 56 received the questionnaire in the 4-year sample with a 13% response rate, and ﬁnally 64 had been at the centre 5 years ago and were reachable with a 45% response rate. The 240 victims who failed to complete the questionnaire did not differ (i.e. p > 0.2) from the participants with regard to sociodemographics, assault histories, or forensic ﬁndings and legal outcomes. Measures Basic background information (baseline variables) collected in the ﬁles comprised of the victim’s age (1), gender, ethnicity, and occupation (employed/under education or unemployed) (2). Assault characteristics such as the place of assault, use of coercion by the assailant (3), the sexual act (4), and the victim and the alleged assailant’s relationship (5) were also noted in the ﬁles. Postassault measures, such as the time from the assault to WeDSAC referral, bodily (6) and/or genital injuries (7) identiﬁed at the medical examination, having an examination (8), treatment by the psychologist (9), police notiﬁcation (10),
and the legal disposition in case of notiﬁcation (11) were also included. The victim’s relationship to the assailant was classiﬁed as known (partner, family, acquaintance, contact) or unknown (stranger). The sexual act during the assault was regarded as complete in the case of vaginal, anal, or mouth penetration. Use of coercion was categorised as none/verbal threats or physical coercion. Bodily injury was deﬁned as redness, bruising, abrasion, swellings, lacerations, and fractures of the body surface or bones. Genital lesions were abrasion, swelling, and lacerations interfemoral, anogenital, vaginal, or anal. The legal outcome according to the Danish Administration of Justice Act was dichotomised (conviction yes = suspect guilty of charge, conviction no = no suspect, setting incompatible with rape (no charge or charge dropped due to baseless charge), or suspect free (acquittal or charge dropped due to insufﬁcient evidence)). The Harvard Trauma Questionnaire Part IV (HTQ) measures the occurrence of psychological symptoms associated with trauma and was used to provide a reliable diagnosis of current PTSD corresponding to the DSM-IV [26, 27]. The answers were scored on a 4-point Likert scale (0 = not at all, 3 = very often). Scale items 2 were counted toward PTSD. The a-values for the dimensions and scale in the present study were as follows: intrusion (a = 0.81), avoidance (a = 0.82) and arousal (a = 0.85). Total HTQ scale a was 0.96. The Danish version has been validated using data from 4311 respondents from 15 trauma samples . The A1 PTSD stressor criterion was considered present due to the rape or the attempted rape, which is the reason for coming to the centre. The A2 PTSD stressor criterion was directly assessed at the ﬁrst interview. Procedure During the primary visit all victims were asked if they would accept possible future requests for their participation in research and/or follow-up research from the WeDSAC either direct or via their general practitioner. The questionnaire which covered cross-sectional PTSD outcome was send by mail to the victim’s home address with a stamped return envelope at one of four distinct occasions postassault: 2, 3, 4, or 5 years after the primary referral to WeDSAC. The rationale behind this method of data collection is two-fold, ﬁrstly to include as many victims as possible during a limited period of time, and secondly to test the chronicity issue hypothesised. However despite the passage of time,
no signiﬁcant differences (2-test) were identiﬁed for PTSD outcome, therefore, the year factor was not taken into consideration in further analysis. Permission to go through police reports was obtained from The Danish Ministry of Justice. The Danish Data Protection Agency allowed the collection of data. No compensation was offered. Statistical analysis was conducted through the use of STATA 8.2. Tests applied to categorical data (bivariate analyses) were Pearson’s 2-test and Fisher’s exact test, and statistical signiﬁcance was assumed if p < 0.05. Tests were conducted with all the numbered predictor variables. Signiﬁcant predictor variables in the bivariate analyses were included in the multivariate logistic regression analysis and used to estimate the strength of the association with PTSD by crude and adjusted odds ratios (OR) and their adjoining 95% conﬁdence intervals (95% CI). When testing for effect measure modiﬁcation, the introduction of an interaction term between forensic examination and completed intercourse removed the signiﬁcance of completed intercourse for PTSD development, however the interaction term itself was deemed non-signiﬁcant. Thus, no effect measure modiﬁcation could be revealed and the forensic examination variable was kept in the regression. RESULTS Sample demographics In total, 95% of the participants were ethnical Danes. Thirty-ﬁve percent were students, 30% employed, 10 % unemployed, and 8 % on social welfare occupation unknown in 18%. The most common type of sexual assault among the respondents was completed intercourse (61%) by vaginal penetration (86% of completed). Seventy-four percent knew their assailant (partners/family and acquaintances each making up 22%, and 30% were contact). A private residence was the place of assault in 61% of the cases. The perpetrator used physical coercion of some kind in 71% - weapons and strangling attempts composed 13%. Among the victims, 74% had a forensic medical examination within a median time of 11 hours (range: ½ to 140 hours) after the assault, whereas the victims treated only by psychologists received this after a median of 6 days (range: 0 to 180 days). Prevalence and bivariate analyses Table 1 shows the prevalence of PTSD. Fully, 45% of the assault victims met the PTSD criteria; 24% missed a PTSD Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Table 1: The distribution and prevalence of PTSD 2-5 years after referral to a sexual assault centre Criteria
Re-experiencing (n=85) Avoidance (n=85) Arousal (n=87) No. of PTSD symptom clusters 0 1 2 (subclinical PTSD) 3 (full PTSD) Total
Respondents fulﬁlling requirements Number
63 47 52
74 55 70
15 10 19 36
19 12 24 45
diagnosis by one criterion (classiﬁed as subclinical PTSD). In Table 2, an overview of possible predictors of the ﬁnal outcome is presented at the bivariate level. Unknown perpetrator, physical coercion, injuries, and neither treatment by a psychologist nor the legal disposition in case of police notiﬁcation were associated with PTSD. Regression analysis Table 3 summarises the results of the logistic regression analysis with PTSD as the dependent variable together with the predictors signiﬁcant at the bivariate level. Completion of the intercourse was associated with PTSD (OR 4.6) whereas forensic examination was wiped out after adjustment. DISCUSSION This study examined the prevalence and correlates of PTSD with measures of victim, assault situation, and postassault attribution in a sample of sexual assault victims disclosing to a rape crisis centre two to ﬁve years postassault. Forty ﬁve percent of the respondents fulﬁlled the diagnostic criteria for PTSD. Completed intercourse was concluded as a predictor for PTSD development. The study has a number of limitations susceptible to biases. Unfortunately, it is not known whether PTSD preceded or followed the assault because mental and physical states at the initial referral could not be judged without taking into account the inﬂuence of the sexual assault incident. Additionally, there was no consideration with regards to information on or control of prior health symptoms. This should be acknowledged as an information bias, which could have contributed to decreased associations
56 Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Table 2: Distribution of victim sociodemographics, assault characteristics, and forensic medical ﬁndings collected right after the assault by PTSD estimated after 2-5 years follow-up Predictors
Unemployment Employment Unknown assailant Known Completed Attempt No coercion/threats Physical coercion Alcohol victim No Genital lesion No Bodily lesions No Forensic exam No Psychologist No Police ﬁling No Conviction** No
13 53 22 56 44 29 16 44 32 28 13 47 43 13 60 20 55 25 57 23 10 28
4 30 14 28 17 21 7 23 17 14 8 21 21 6 29 15 30 14 30 14 5 15
9 23 8 28 27 8 9 21 15 14 5 26 22 7 31 5 25 11 27 9 5 13
0.10 0.28 0.005 0.56 0.81 0.28 0.86 0.04 0.90 0.50 0.57
*N=80 but n=60 for forensic examination, thus n=60 for lesions, alcohol, coercion. Missing values for occupation, relationship, legal outcome. ** Fisher’s exact test.
Table 3: Multivariate logistic regression analysis showing the association (odds ratio – OR) between predicting variables and PTSD Crude OR Predictors Age 12-17 18-24 25-56 Attempt Completed Forensic exam No Yes
Outcome: PTSD (n=73) 1 1.1 1.2 1 4.2 1 3.2
0.3-3.3 0.4-3.5 1.5-11.3 1.1-9.6
1 0.6 0.6 1 4.6 1 1.9
0.1-3.2 0.1-3.1 1.1-19.8 0.4-8.6
Note: model 2=9.3, df=4, p<.05
with PTSD. The victims were sampled from a distinct sub-population of sexual assault victims, and whether generalisation is possible to any victim of sexual assault is unclear. The response rate is low limiting internal validity, which is no surprise keeping in mind the vulnerability of the group in focus. However, no signiﬁcant differences between respondents and nonrespondents occurred. Thus, it is expected that selection bias did not affect the outcome of associa-
tions, which occurred. In support, it has been argued that the women who came forward and participated in interviews or questionnaires were women more able to cope , likewise nonparticipants in questionnaires have been demonstrated to be mentally more affected than participants [29-31]. With regard to the speciﬁc subsample, this may in fact lead to an underestimation of the prevalence of PTSD. Furthermore, provided that the sexual assault is the releasing trauma, the
design of the present study with detailed information of the assault circumstances contributes signiﬁcantly to predict the chronicity of the victim’s stress level. By using this exact knowledge of assault onset the response rate is compromised. Contrariwise, Ullman et al. (2006) reported a very high response rate of 90% but with regards to women recalling sexual violence by their own. Such a high response rate is said to be attributable to both recruitment through the media and the monetary compensation of $20 per respondent. The practice of monetary compensation is controversial with regards to obtaining reliable data regarding both assault and victim characteristics. The high prevalence of PTSD in this study is very similar to the results obtained by Rothbaum and colleagues (47 % after 3 months), who examined a similar sized sample from a rape crisis centre, however they did obtain a somewhat higher response rate (67%). Research regarding legally decided rape victims concluded that 95% met the criteria for PTSD after 9 months post rape . Research conducted in non rape crisis centre settings, with samples recruited or examined several years after a sexual assault, concluded that PTSD was shown to persist in 70% of the community cross-sectional sample . Likewise, PTSD was shown to be persistent in 65% of a convenient sample of women seeking treatment for premenstrual syndrome and reporting former episodes of sexual assault . In concordance with the latter two studies, our ﬁndings suggest that PTSD is persistent several years after the index trauma and that there are no differences 2 to 5 years postassault, however it must be acknowledged that a more recent trauma than the sexual assault could have attributed to the psychological health in our study. The latter suggestion is in agreement with Kessler and colleagues, who concluded from a population study that the remission of symptoms occurred with a median time of 3 years, and that 35% of victims were not expected to remit after an initial PTSD diagnosis. Additionally, one should be aware of the considerable number of victims belonging to a subclinical group. The identiﬁcation of predictors of PTSD may permit early intervention for victims who are at greatest risk of developing postassault psychopathology. One such predictor of the development of PTSD postassault, is that of completed intercourse, shown both within the current study and in prior research . Nevertheless, forensic examination as an independent variable is thought to
interact with completed intercourse. An interaction term explainable by victims exposed to completed intercourse is whether or not victims believe in the justiﬁcation and necessity of police involvement and a subsequent examination. No effect measure modiﬁcation could be revealed, however the PTSD risk should be interpreted carefully. It is remarkable that neither the degree of coercion nor injuries sustained seem to be of special importance as several prior research studies are ambiguous on that point [1, 7, 13, 14]. It is not entirely clear why the legal outcome in the cases notiﬁed to the police did not affect posttraumatic outcome, however the ﬁndings are consistent with the only other study to date . We argued that acquittal or charges dropped by the defendant might increase posttraumatic symptoms. Apparently, the legal outcome is not decided until after a period of inquiry, a period preceding the chronicity of symptoms possibly obtained by the assault. We mainly employed the use of forensic information, but other factors such as preceding depression or PTSD from other traumas, coping strategies, or social reactions from formal as well as informal caregivers, could explain a greater variance in the posttraumatic psychopathology. Acknowledging the limitations of this study, the high and prolonged presence of PTSD in victims of sexual assault is underlined. It is known that victims suffering from PTSD use community service resources like medical consultations and sick leave . This combined with the ﬁndings that not all victims attending the WeDSAC accept the offer of psychological treatment, and the non-signiﬁcant effect when they do, calls for further follow-up monitoring and intervention. In addition, future studies should endeavour to employ increased response rates and to address preassault health factors. REFERENCES 1.
Acierno R, Resnick H, Kilpatrick DG, Saunders B, Best CL. Risk factors for rape, physical assault, and posttraumatic stress disorder in women: examination of differential multivariate relationships. J Anxiety Disord 1999;13:541-63. Resnick HS, Holmes MM, Kilpatrick DG, et al. Predictors of post-rape medical care in a national sample of women. Am J Prev Med 2000;19:214-9. Wijma B, Schei B, Swahnberg K, et al. Emotional, physical, and sexual abuse in patients visiting gynaecology clinics: a Nordic cross-sectional study. Lancet 2003;361:2107-13. Olshen E, McVeigh KH, Wunsch-Hitzig RA, Rickert VI. Dating violence, sexual
assault, and suicide attempts among urban teenagers. Arch Pediatr Adolesc Med 2007;161:539-45. Helzer JE, Robins LN, McEvoy L. Posttraumatic stress disorder in the general population. Findings of the epidemiologic catchment area survey. N Engl J Med 1987;317:1630-4. Frans O, Rimmo PA, Aberg L, Fredrikson M. Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatr Scand 2005;111:291-9. Resnick HS, Kilpatrick DG, Dansky BS, Saunders BE, Best CL. Prevalence of civilian trauma and posttraumatic stress disorder in a representative national sample of women. J Consult Clin Psychol 1993;61:984-91. Perkonigg A, Kessler RC, Storz S, Wittchen HU. Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatr Scand 2000;101:46-59. Elklit A. Victimization and PTSD in a Danish national youth probability sample. J Am Acad Child Adolesc Psychiatry 2002;41:174-81. Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995;52:1048-60. Rothbaum BO, Foa EB, Riggs D, Murdock T, Walsh W. A prospective examination of post-traumatic stress disorder in rape victims. J Trauma Stress 1992;5:455-75. Kilpatrick DG, Saunders BE, AmickMcMullan A, Best CL, Veronen LJ, Resnick H. Victim and crime factors associated with the development of crime-related post-traumatic stress disorder. Behav Ther 1989;20:199-214. Bownes IT, O’Gorman EC, Sayers A. Assault characteristics and posttraumatic stress disorder in rape victims. Acta Psychiatr Scand 1991;83:27-30. Stein MB, Walker JR, Forde DR. Gender differences in susceptibility to posttraumatic stress disorder. Behav Res Ther 2000;38:619-28. Cortina LM, Kubiak SP. Gender and posttraumatic stress: sexual violence as an explanation for women’s increased risk. J Abnorm Psychol 2006;115:753-9. Koss MP, Dinero TE, Seibel CA, Cox SL. Stranger and acquaintance rape. Psychol Women Quart 1988;12:1-24. Campbell R, Seﬂ T, Barnes HE, Ahrens CE, Wasco SM, Zaragoza-Diesfeld Y. Community services for rape survivors: enhancing psychological well-being or increasing trauma? J Consult Clin Psychol 1999;67:847-58. Ullman SE, Filipas HH, Townsend SM, Starzynski LL. The role of victim-offender relationship in women’s sexual assault experiences. J Interpers Violence 2006;21:798-819. Ullman SE, Filipas HH. Predictors of PTSD symptom severity and social reactions in sexual assault victims. J Trauma Stress 2001;14:369-89.
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20. Kimerling R, Alvarez J, Pavao J, Mack KP, Smith MW, Baumrind N. Unemployment Among Women: Examining the Relationship of Physical and Psychological Intimate Partner Violence and Posttraumatic Stress Disorder. J Interpers Violence 2008. 21. Frazier PA, Haney B. Sexual assault cases in the legal system: police, prosecutor, and victim perspektives. Law Hum Behav 1996;20:607-28. 22. Ullman SE, Filipas HH, Townsend SM, Starzynski LL. Psychosocial correlates of PTSD symptom severity in sexual assault survivors. J Trauma Stress 2007;20:82131. 23. Ingemann-Hansen O, Brink O, Sabroe S, Sorensen V, Charles AV. Legal aspects of sexual violence-Does forensic evidence make a difference? Forensic Sci Int 2008;180:98-104. 24. Ingemann-Hansen O. The Western Danish Center for Prevention, Treatment and Research of Sexual Assault. Scand J Forensic Sci 2006;12:25-9.
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25. Elklit A, Knudsen M. Psykiske følger af voldtægt. In: Brink O, ed. Håndbog for fagpersoner i kontakt med voldtægtsofre. Århus: Center for Voldtægtsofre, 2000. 26. Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Harvard Trauma Questionnaire. Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. J Nerv Ment Dis 1992;180:111-6. 27. American Psychiatric Association. Diagnostic and statistical manual of mental disorders IV (4th ed.). Washington DC: 1994. 28. Bach ME. En empirisk belysning og analyse af ‘’Emotional Numbing’’ som eventuel selvstændig faktor i PTSD. Psykologisk Studieskriftserie 2003;6:1199. 29. Elklit A, Brink O. Acute Stress Disorder in physical assault victims visiting a Danish emergency ward. Violence Vict 2003;18:461-72. 30. Holen A. A long-term outcome study of
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Deaths by drowning in coastal and inland areas Andreas Schmeling, Gunther Geserick, Eberhard Lignitz, Ingo Wirth A. Schmeling. Institut für Rechtsmedizin des Universitätsklinikums Münster, Röntgenstraße 23, 48149 Münster, Germany G. Geserick. Zähringerstraße 34, 10707 Berlin, Germany E. Lignitz. Wolgaster Straße 20, 17489 Greifswald, Germany I. Wirth. Fachhochschule der Polizei des Landes Brandenburg, Bernauer Straße 146, 16515 Oranienburg, Germany
ABSTRACT The present paper is based on the comparative analysis of all deaths by drowning autopsied at the Institutes of Legal Medicine Greifswald and Berlin (Charité) in the ten-year period from 1991 to 2000. In Greifswald (coastal area) drowning was determined to be the cause of death in 191 of 2,825 autopsies. In Berlin (inland) 117 of 5,837 autopsied deaths were caused by drowning. The locations of drowning, manners of death, sex distribution, age distribution as well as the blood alcohol concentrations were evaluated for the deaths by drowning in Greifswald and Berlin. It was determined that the rate of drowning victims was higher for the examined coastal area than for the inland area with a higher percentage of male bodies and a slightly higher age peak. The thesis of an increased number of suicides by drowning due to the access to the sea could not be conﬁrmed. The fact that the study population in Greifswald contained more victims under the inﬂuence of alcohol, in addition to higher alcohol levels, is related to regional differences in the people’s drinking behaviour. Key words: drowning, coast, inland, manner of death, alcohol
INTRODUCTION World-wide more than half a million people die each year due to drowning (www.drowning.nl). In many countries, drowning ranks second to trafﬁc injuries as a cause of unintentional injuries, especially among young and adult males (Smith 2006). The rates of drowning vary widely from a high of 12.5 per 100,000 population in Russia to as low as 0.4 per 100,000 population in the UK. Scandinavia and Germany are in the low range of the global rates. The rate of drownings amounts to 0.9 per 100,000 population in Denmark, 1.3 in Sweden, 1.5 in Norway and 0.6 in Germany (www. who.int/healthinfo/statistics/bodgbddeathdalyestimates.xls). Research indicates that age, sex, alcohol use and socioeconomic status are key risk factors for drowning. Also the location of a drowning plays an important role. For example, in Japan, bathtubs are the major source of accidental drownings, especially among young children and older adults. This is probably due to a combination of sociocultural factors, including the design of the Japanese baths, which are very deep, the Japanese habit of taking frequent baths of long duration, and their habit of using very hot water (Mizuta et al. 1993, Branche and van Beeck 2006).
CORRESPONDING ADDRESS: A. Schmeling. Institut für Rechtsmedizin des Universitätsklinikums Münster, Röntgenstraße 23, 48149 Münster, Germany
The present paper is based on the analysis of deaths by drowning autopsied at the Institutes of Legal Medicine Greifswald and Berlin (Charité). The focus is to ﬁnd out to what extent access to the sea inﬂuences the phenomenology of drowning. The catchment area of the Institute of Legal Medicine of the University of Greifswald contains the Eastern part of the Federal State of MecklenburgWestern Pomerania, which is bounded on north by the Baltic Sea and has a length of coastline of about 1,700 km. The Western Pomeranian lagoon coast occupies the larger part of this coastline. The population density in MecklenburgWestern Pomerania is 72.7 inhabitants per km2. The rivers Spree and Havel run through the city area of inland Berlin. There are several lakes in the course of these rivers. The water area amounts to 6.7 % of the total area of Berlin. The population density in Berlin is 3,820 inhabitants per km2. MATERIAL AND METHODS This study is based on the autopsy protocols including ﬁndings from the toxicological-chemical analyses of the Institutes of Legal Medicine Greifswald and Berlin (Charité). The study covers the ten-year period from 1991 to 2000. All cases in which the cause of death was drowning were taken into account. Due to a uniform legal basis in Germany for the order of medico-legal autopsies, a comparability of the study populations can be assumed. Those cases in which the place of death was outside of the
institutes‘ catchment areas were excluded. The data compiled for each case include autopsy year, sex and age of the deceased, manner of death, location of drowning as well as the results of the blood alcohol determination. Regarding the manner of death we distinguished between homicide, suicide, accident and undetermined. All cases which could not doubtlessly be classiﬁed as homicides, suicides or accidents on the basis of the present documents were classiﬁed “undetermined”. RESULTS At the Institute of Legal Medicine Greifswald 2,825 autopsies had been performed in the period from 1991 to 2000. In 191 cases drowning was determined to be the cause of death. Thus, deaths by drowning amount to 6.8 % of the Greifswald autopsy material. In the same period 5,837 autopsies had been performed at the Institute of Legal Medicine Berlin (Charité), including 117 cases of death by drowning. Thus, deaths by drowning account for 2.0 % of the Berlin autopsy material. Tables 1 to 5 show the locations of drowning, manners of death, sex distribution, age distribution as well as the blood alcohol concentrations of the drownings in Greifswald und Berlin. DISCUSSION The examination of drowning victims is a central ﬁeld in legal medicine. Thus, there are numerous analyses on the forensic autopsy material from cases of drowning. In several papers, however, Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
only selected age groups and/or manners of death have been analysed (Cairns et al. 1984, Copeland 1987, Patetta and Biddinger 1988, Smith et al. 1991, Byard et al. 2001, Lunetta et al. 2003). Ewald (1986) analysed the autopsy material from the Institute of Legal Table 1: Locations of drowning Greifswald
Sea Inland waters Bathtub Others N/A
66 (35 %)
0 (0 %)
81 (42 %) 12 (6 %) 24 (13 %) 8 (4 %)
75 (64 %) 35 (30 %) 6 (5 %) 1 (1 %)
191 (100 %)
117 (100 %)
Table 2: Manners of death of the drownings Greifswald
Homicide Suicide Accident Undeter mined
3 (2 %) 22 (11 %) 69 (36 %)
1 (1 %) 52 (44 %) 45 (39 %)
97 (51 %)
19 (16 %)
191 (100 %)
117 (100 %)
Table 3: Sex distribution of the drownings Greifswald
148 (78 %) 43 (22 %)
68 (58 %) 49 (42 %)
191 (100 %)
117 (100 %)
Table 4: Age distribution of the drownings Age (years) Greifswald
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80
15 (8 %) 12 (6 %) 28 (15 %) 31 (16 %) 41 (21 %) 30 (16 %) 21 (11 %) 8 (4 %) 5 (3 %)
3 (3 %) 3 (3 %) 5 (4 %) 12 (10 %) 24 (21 %) 31 (26 %) 16 (14 %) 12 (10 %) 11 (9 %)
191 (100 %)
117 (100 %)
Table 5: Blood alcohol concentrations BAC (‰) Greifswald
0-0.49 0.5-1.49 1.5 N/A
91 (48 %) 20 (11 %) 62 (32 %) 18 (9 %)
75 (64 %) 5 (4 %) 31 (27 %) 6 (5 %)
191 (100 %)
117 (100 %)
60 Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Medicine Hamburg for the period from 1971 to 1983. Among the about 15,000 autopsied bodies there were 722 bodies found in the water, representing about 5 % of the autopsy material. 73 % of the bodies found in the water were male and 27 % were female. There is no information on the distribution of the manners of death. Among the 219 cases of drowning autopsied in all Institutes of Legal Medicine in Denmark in the period from 1987 to 1989 there were 105 accidents, 73 suicides and 3 homicides (Kringsholm et al. 1991). In 38 cases the manner of death remained undetermined. 70 % of the bodies were male and 30 % were female. Lunetta et al. (2002) analysed 1,590 bodies found in the water who had been autopsied at the Institute of Legal Medicine Helsinki. They involved 893 accidents, 379 suicides, 13 homicides, 49 natural and 256 undetermined deaths. Bodies found in the water accounted for 3.4 % of the overall autopsy material. In 1,499 cases drowning was determined to be the cause of death. Thus, the share of drowning victims amounts to 94.3 % of all bodies found in the water. There is no information on the sex distribution of the drowned bodies. On account of various modalities in ordering forensic autopsies in different countries this demographic information can hardly be compared with each other nor with our ﬁndings. The result of the present analysis is that in the ten-year period from 1991 to 2000 drowning was determined to be the cause of death in 6.8 % of all cases in Greifswald. In Berlin, however, deaths by drowning accounted for 2.0 %. Thus, the rate of drowning victims in the coastal area was three times higher than in the inland area. About one third of the cases in Greifswald drowned in the sea. Drowning victims who drowned in the sea and in inland waters accounted for 77 % of the cases in Greifswald and 64 % of the cases in Berlin for inland waters. Thus, in Greifswald the share of drowning victims who drowned in the bathtub is relatively low. While in Berlin the manner of death remained undetermined in 20 % of the cases, in Greifswald in about half of the cases the manner of death could not be determined – mostly due to putrefaction. The higher rate of undetermined deaths in the coastal area is referable to the high rate of bodies who drowned in the sea and the related later landing. Furthermore the considerably lower population density may have contributed to longer post mortem intervals of drowning victims who drowned outdoors.
Due to the high rate of undetermined deaths in Greifswald a comparison of the respective proportion of deaths by homicide, suicide or accident in the coastal area and the inland area is difﬁcult. With 1 % and 2 % respectively of all cases of drowning homicides were rare in both areas. The share of accidents amounted to about one third for both areas. However, it can be assumed that a share of the undetermined cases in Greifswald were accidents. With 11 % the share of suicides in the study collective in Greifswald is considerably lower than in the collective in Berlin with 44 %. The thesis has been established repeatedly that the access to the sea would lead to an increase of suicides by drowning (Clarke and Lester 1989, Auer 1990, Byard et al. 2001). While Lester (1989) was able to demonstrate that the rate of suicides by drowning was higher in US states bordering on the oceans and the Great Lakes than in inland areas, the suicide rates in 27 countries were not related to the length of their coastline (Lester 1993). La Harpe and Mahnert (1998) evaluated 850 suicides that had been committed from 1980 to 1989 in the Cantone of Geneva. Among them were 123 suicides by drowning. They determined the distance between the home address and the nearest shore of a natural body of water for each suicide. In this process no correlation with the decision for drowning as the suicide method was determined. Even though a share of the undetermined deaths in Greifswald was probably caused by suicide, it cannot be assumed that it would reach the Berlin share of 44 %. Thus, even our own ﬁndings are opposed to the thesis of an increase of suicides by drowning caused by access to the sea. In line with the current literature (Cairns et al. 1984, Ewald 1986, Copeland 1987, Patetta and Biddinger 1988, Kringsholm et al. 1991, Pachar and Cameron. 1992, Avis 1993, Davis et al. 1999, Lucas et al. 2002, Lunetta et al. 2004) the male rate in our study material was higher. Male drowning victims accounted for 78 % in Greifswald and 58 % in Berlin. The higher percentage of male bodies in Greifswald is probably referable to the fact that in a coastal area more men have direct professional contact with water, leading to a relatively high risk of work-related accidents. Almost all sailors, dock workers and divers are men. In addition numerous, predominantly male, water sports enthusiasts spend their free time at and on the water and are therefore exposed to a higher accident risk (Lustig 2004).
In the Greifswald study collective the twenty-, thirty-, forty-, ﬁfty- and sixtyyear-olds accounted for at least 10 % each of all cases of drowning. The 4049-year-olds showed the highest share with 21 %. In the Berlin collective the share of thirty-, forty-, ﬁfty-, sixty- and seventy-year-olds amounted to 10 % each of all cases of drowning. Here, the 50-59-year-olds showed the highest rate with 26 %. The slightly higher age peak in Berlin may be related to the fact that in the coastal area work-related accidents and sports accidents prevail in the working age group and that in inland areas suicides are more often committed at a higher age. The impact of the risk factor alcohol in connection with deaths by drowning has been highlighted in several papers (Giertsen 1970, Dietz and Baker 1974, Cairns et al. 1984, Plueckhahn 1984, Howland and Hingson 1988, Patetta and Biddinger 1988, Wintemute et al. 1990, Warner et al. 2000, Byard et al. 2001, Smith et al. 2001, Driscoll et al. 2004). The analysis of the blood alcohol levels in the present study shows that in the Greifswald collective considerably more drowning victims were under the inﬂuence of alcohol and that the percentage of bodies under the inﬂuence of very high amounts of alcohol in Greifswald was higher than in Berlin. These differences are related to a regionally varied drinking behaviour. A recent regional comparison of alcohol related mortality in Germany shows that MecklenburgWestern Pomerania has the highest death rate with 34.3 deaths per 100,000 population. The alcohol related mortality in Berlin, however, was at the rate of 22.3 deaths per 100,000 population (Rübenach 2007). In summary it can be established that the rate of drowning victims of the overall autopsy material is higher in the studied coastal area than in the inland area with a higher percentage of male bodies and a slightly higher age peak. The thesis of an increase in suicides by drowning caused by access to the sea could not be conﬁrmed. The fact that in the Greifswald study collective more
victims were under the inﬂuence of alcohol, in addition to higher alcohol levels, is related to regional differences in the people’s drinking behaviour. Acknowledgement: The authors wish to thank Dr. Jan M. Laturnus for his preparations for this study. REFERENCES Auer A. Suicide by drowning in Uusimaa province in Southern Finland. Med Sci Law 1990;30:175-179. Avis SP. Suicidal drowning. J Forensic Sci 1993;38:1422-1426. Branche C, van Beeck E. Overview. In: Bierens JJ, ed. Handbook on drowning. Berlin: Springer, 2006, pp. 41-43. Byard RW, Houldsworth G, James RA, Gilbert JD. Characteristic features of suicidal drownings. A 20-year study. Am J Forensic Med Pathol 2001;22:134-138. Cairns F, Koelmeyer TD, Smeeton WM. Deaths from drowning. N Z Med J 1984;97:65-67. Clarke RV, Lester D. Suicide: closing the exits. New York: Springer, 1989. Copeland AR. Suicide by drowning. Am J Forensic Med Pathol. 1987;8:18-22. Davis LG. Suicidal drowning in South Florida. J Forensic Sci 1999;44:902-905. Dietz PE, Baker SP. Drowning: epidemiology and prevention. Am J Public Health 1974;64:303-312. Driscoll TR, Harrison JE, Steenkamp M. Alcohol and drowning in Australia. Inj Control Saf Promot 2004;11:175-181. Ewald D. Ertrinken – Tod im Wasser. Med. Diss. Universität Hamburg, 1986. Giertsen JC. Drowning while under the inﬂuence of alcohol. Med Sci Law 1970;10:216.219. Howland J, Hingson R. Alcohol as a risk factor for drowning: a review of the literature (1950-1985). Accid Anal Prev 1988;20:19-25. Kringsholm B, Filskov A, Kock K. Autopsied cases of drowning in Denmark 19871989. Forensic Sci Int 1991;52:85-92. La Harpe R, Mahnert J. Gibt es räumliche Einﬂußfaktoren bei der Wahl des Ertrinkungstodes als Suizidmittel in Genf? Arch Kriminol 1998;202:152-156. Lester D. The suicide rate by drowning and the presence of oceans. Percept Mot Skills 1989;69:338. Lester D. Suicide by drowning and the extent
of the nation’s coastline. Percept Mot Skills 1993;77:1118. Lucas J, Goldfeder LB, Gill JR. Bodies found in the waterways of New York City. J Forensic Sci 2002;47:137-141. Lunetta P, Penttilä A, Sajantila A. Circumstances and macropathologic ﬁndings in 1590 consecutive cases of bodies found in water. Am J Forensic Med Pathol 2002;23:371-376. Lunetta P, Smith GS, Penttilä A, Sajantila A. Undetermined drowning. Med Sci Law 2003;43:207-214. Lunetta P, Smith GS, Penttilä A, Sajantila A. Unintentional drowning in Finland 1970-2000: a population-based study. Int J Epidemiol 2004; 33:1053-1063. Lustig MJ. Sportboottodesfälle – eine kasuistische Studie. Med. Diss. Universität Greifswald, 2004. Mizuta R, Fujita H, Osamura T, Kidowaki T, Kiyosawa N. Childhood drownings and near-drownings in Japan. Acta Paediatr Jpn 1993;35:186-192. Pachar JV, Cameron JM. Submersion cases: a retrospective study - 1988-1990. Med Sci Law 1992;32:15-17. Patetta MJ, Biddinger PW. Characteristics of drowning deaths in North Carolina. Public Health Rep 1988;103:406-411. Plueckhahn VD. Alcohol and accidental drowning: a 25-year study. Med J Aust 1984;141:22-25. Rübenach SP. Die Erfassung alkoholbedingter Sterbefälle in der Todesursachenstatistik 1980 bis 2005. Wirtsch Statist 2007;59:278-290. Smith G. The global burden of drowning. In: Bierens JJ, ed. Handbook on drowning. Berlin: Springer, 2006, pp. 56-61. Smith GS, Keyl PM, Hadley JA, Bartley CL, Foss RD, Tolbert WG, McKnight J. Drinking and recreational boating fatalities: a population-based case-control study. JAMA 2001;286:2974-2980. Smith NM, Byard RW, Bourne AJ. Death during immersion in water in childhood. Am J Forensic Med Pathol 1991;12:219221. Warner M, Smith GS, Langley JD. Drowning and alcohol in New Zealand: What do the coroner’s ﬁles tell us? Aust N Z J Public Health 2000;24:387-390. Wintemute GJ, Teret SP, Kraus JF, Wright M. Alcohol and drowning: an analysis of contributing factors and a discussion of criteria for case selection. Accid Anal Prev 1990;22:291-296.
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If you look for it, you will ﬁnd it - contributions from advanced post-mortem histological analysis of cervical spine traumas Lars Uhrenholt1,2, Ellen M. Hauge2,3, Annie Vesterby Charles1,2 Institute of Forensic Medicine, University of Aarhus Research unit of Rheumatology and Bone Biology, Aarhus Sygehus, Aarhus University Hospital 3 Department of Rheumatology, Aarhus Sygehus, Aarhus University Hospital 1 2
SUMMARY Injuries to the spinal column are commonly encountered following trauma, however not all injuries are readily identiﬁable. Using post-mortem materials, investigations of bones and joints not being possible in vivo can be performed, and lead to the identiﬁcation of injuries occult to imaging procedures. An example of such an advanced examination is presented, in which the cervical spine facet joints were evaluated following fatal motor vehicle trauma. Injuries detected were correlated to imaging ﬁndings, and showed that the contributions from post-mortem scientiﬁc investigations are important to improve differential diagnostics methods to better understand conditions encountered in surviving trauma patients. Keywords Post-mortem investigation, autopsy, medicolegal, cervical spine, pathology
INTRODUCTION Injuries to the spinal column often occur following sport activities, violent assaults, and road trafﬁc crashes. In clinical settings some types of injury are difﬁcult to identify, calling for supplemental diagnostic investigations, e.g. single photon emission computed tomography (SPECT), CT-scanning and MRI. However, diagnostic imaging procedures have been found insensitive towards identiﬁcation of discrete lesions(1-4). In traumatic orthopaedic diagnostics it is generally not feasible to take biopsies from the spinal column as the location and risk of the intervention outweighs the beneﬁts. In order to improve scientiﬁc knowledge of pathological lesions in the spinal column, several studies have investigated post-mortem tissue samples of the human skeleton in experimental conditions, including for example compression loading of vertebrae, fracture analysis of the femoral neck, and numerous studies of spondylosis and osteoarthritis. Hence, examination of
tissue samples from deceased allows detailed investigations, that are not possible in clinical settings, thereby offering an alternative approach to investigation of clinical conditions(5). Fatal road trafﬁc trauma In the search of a pathoanatomical explanation of neck pain following road trafﬁc crashes it has been found difﬁcult to conduct both sensitive and at the same time non-invasive examinations of the casualties. The underlying aetiology of the painful conditions is often assumed to be a conglomerate of neurological, clinical biomechanical/physiological, and psychological conditions, with strict pathological lesions being rare(4;6). Clinical studies have pointed to the cervical spine facet joints as culprits involved in pain production, and several studies using post-mortem human subjects (PMHS), animals, and mathematical Finite Elements models have investigated these structures(7-9). Cervical spine lesions, similar to those identiﬁed in road trafﬁc crash fatalities, have
been identiﬁed in PMHS’s exposed to experimental loading(8). Many of these lesions have no inﬂuence on the cause of death, making the ﬁndings trivial in the perspective of the medicolegal report. However, as the lesions are extremely difﬁcult to identify by methods other than microscopy, the contributions from the forensic investigations are unique and of great value. During medicolegal autopsy it is possible to examine for acute injuries in human subjects exposed to non-experimental trauma. This allows identiﬁcation of vital injuries which can be incorporated into injury pattern analyses (IPA)(10;11), whereby the circumstances leading to the death can be evaluated. Furthermore, histological methods can be applied in order to improve portrayal of more discrete pathological lesions. Advanced histological examination of injuries to the cervical spine facet joints As a part of a large-scale investigation, approved by the local Scientiﬁc Ethics
Figure 1: Identiﬁcation of injuries in the cervical spine facet joints using different methods. Fracture of the right superior articular process of C6 visualised by; MR-scanning (A), CT-scanning (B), and microscopy (10 µm Safranin Fast Green)(C).
62 Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Figure 2: Soft tissue injuries of a cervical spine facet joint. Close-up of an intra-articular free ﬂoating fragment of articular cartilage (A), surrounded by blood (B), with erythrocytes identiﬁed as pale ghost-cells in a honeycomb pattern, devoid of stained cellular matrix due to prolonged ethanol ﬁxation and embedding in methylmethacrylate (haemarthrosis). There is also disruption and bleeding in the synovial fold (C)(original magniﬁcation x 4, 10 µm Masson-Goldner trichrome).
Committee, of people killed in road trafﬁc crashes, pathological lesions of the cervical spine facet joints were examined using a post-mortem model described in detail elsewhere(12). The lower cervical spine was systematically collected from 19 people killed in a passenger car crash and 21 people who had died due to non-traumatic causes (age range 20-49 years). Microscopical analysis of randomly sectioned parasaggital 10 µm thick tissue sections at 3 millimetre increments revealed a number of traumatic lesions that correlated signiﬁcantly with the exposure to fatal trauma. These included microfractures of the articular facets (Figure 1), cartilage damage, haemarthrosis and bleeding within the synovial folds(12). None of the microscopical injuries, particularly the soft tissue injuries (Figure 2), could be reliably identiﬁed using diagnostic imaging procedures, including conventional radiology, CT- and MRI-scanning. The CT-scanning was the most sensitive, identifying approximately half of the discrete fractures(1;12). The results were in agreement with previous publications ﬁnding discrete non-fatal lesions in the cervical spine to be very common following fatal road trafﬁc crashes and difﬁcult to identify radiologically(2;3;1315). Overall, these ﬁndings raise the possibility that discrete lesions can be present in survivors from road trafﬁc crashes thereby inﬂuencing clinical conditions(8), and that there are some limitations to forensic diagnostic imaging with regard to identiﬁcation of discrete injuries. CORRESPONDING ADDRESS: Lars Uhrenholt, Institute of Forensic Medicine, University of Aarhus, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark e-mail: firstname.lastname@example.org
CONCLUSION For the purpose of improving clinical management of conditions associated with large health care expenditures and personal morbidity, such as trafﬁc related injuries, forensic research studies can contribute with detailed pathoanatomical investigations. This study showed that post-mortem scientiﬁc investigations are important in order to improve differential diagnostic methods that may inﬂuence clinical decision strategies. As diagnostic imaging procedures failed to produce ﬁndings that were identiﬁed during microscopy, the role hereof remains unproven, and future studies examining the reliability and validity of forensic diagnostic imaging should be encouraged(1;16;17).
REFERENCE LIST (1)
Uhrenholt L, Nielsen E, Vesterby Charles A, Hauge E, Gregersen M. Imaging occult lesions in the cervical spine facet joints. Am J Forensic Med Pathol (in press) 2007. Uhrenholt L, Grunnet-Nilsson N, Hartvigsen J. Cervical spine lesions after road trafﬁc accidents: a systematic review. Spine 2002;27:1934-41. Stäbler A, Eck J, Penning R, Milz SP, Bartl R, Resnick D, et al. Cervical spine: postmortem assessment of accident injuries--comparison of radiographic, MR imaging, anatomic, and pathologic ﬁndings. Radiology 2001;221(2):3406. Taylor J, Twomey L. Whiplash injury and neck sprain: a review of their prevalence, mechanisms, risk factors, and pathology. Crit Rev Phys Rehab Med 2005;17(4):285-99. Charles AV, Baandrup U, Melsen F. [Research on the dead]. Ugeskr Laeger 2004;166(24):2356-9. Kongsted A, Sorensen JS, Andersen H, Keseler B, Jensen TS, Bendix T. Are early MRI ﬁndings correlated with long-lasting symptoms following
whiplash injury? A prospective trial with 1-year follow-up. Eur Spine J 2008;17(8):996-1005. Yoganandan N, Pintar FA, Kleinberger M. Whiplash injury. Biomechanical experimentation. Spine 1999;24(1):835. Yoganandan N, Cusick JF, Pintar FA, Rao RD. Whiplash injury determination with conventional spine imaging and cryomicrotomy. Spine 2001;26(22):2443-8. Liebschner MA. Biomechanical considerations of animal models used in tissue engineering of bone. Biomaterials 2004;25(9):1697-714. Freeman MD, Nelson C. Injury pattern analysis as a means of driver identiﬁcation in a vehicular homicide; a case study. Forensic Examiner 2004;13(1):24-8. Freeman MD, Rossignol AM, Hand ML. Forensic Epidemiology: a systematic approach to probabilistic determinations in disputed matters. J Forensic Leg Med 2008;15(5):281-90. Uhrenholt L. Morphology and pathoanatomy of the cervical spine facet joints in road trafﬁc crash fatalities with emphasis on whiplash - a pathoanatomical and diagnostic imaging study. Thesis, Faculty of Health Sciences, University of Aarhus, Denmark, 2007. Schonstrom N, Twomey L, Taylor J. The lateral atlanto-axial joints and their synovial folds: an in vitro study of soft tissue injuries and fractures. J Trauma 1993;35(6):886-92. Taylor JR, Twomey LT. Acute injuries to cervical joints. An autopsy study of neck sprain. Spine 1993;18(9):111522. Jonsson H, Jr., Bring G, Rauschning W, Sahlstedt B. Hidden cervical spine injuries in trafﬁc accident victims with skull fractures. J Spinal Disord 1991;4(3):251-63. Leth P. The use of CT scanning in forensic Autopsy. Forensic Sci Med Pathol 2007;3(1):65-9. Poulsen K, Simonsen J. Computed tomography as routine in connection with medico-legal autopsies. Forensic Sci Int 2007;171(2-3):190-7.
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Cranial fractures caused by blunt trauma to the skull A retrospective analysis of medico-legal autopsies in Denmark from 1999-2004 Christina Jacobsen1* and Niels Lynnerup1 1 Section of Forensic Pathology, Department of Forensic Medicine, University of Copenhagen, Frederik V Vej 11, DK-2100 Copenhagen Ø, Denmark
ABSTRACT Blunt trauma to the head with subsequent cranial, external cranial and intracranial lesions occurs in many types of trauma. The aim of this study was to focus on the cranial fractures caused by blunt trauma in a medico-legal material. In the years 1999-2004 428 cases with cranial fractures caused by blunt trauma were autopsied at the medico-legal institutes in Denmark. In order to report the summary statistics of the cases with cranial fracture, we retrospectively registered basic data from the autopsy and toxicology report, including the manner of death, the circumstances regarding the trauma, the autopsy ﬁndings regarding the cranial fractures, external lesions and intracranial lesions. The male:female ratio was 3:1. Accidents were the most common manner of death (n=372), mainly comprising trafﬁc accidents (n=242) and falls (n=109). Trafﬁc related deaths with cranial fracture comprised ~37% of all the medico-legally autopsied trafﬁc related deaths in this period, while deaths with cranial fractures caused by homicides and suicides constituted less than 5% of the cases. Approximately 40% of the cases tested positive in the blood alcohol analyses and toxicology analyses for various substances. The external lesions were mostly sugillations and subgaleal hematomas (n=502). Linear fractures of the cranium constituted ~60% of the total material, while comminute fractures constituted 14.5%. The most common intracranial lesions were subarachnoid haemorrhages and contusions (~70%). Subdural haemorrhages occurred in ~23% and epidural haemorrhages in ~5% of the cases. The epidural haemorrhages were mainly located on the right side of the head. Keywords: Cranial fracture, Trauma type, Blunt trauma
INTRODUCTION Injury is a leading cause of death in the young and middle aged in the western world  and blunt trauma to the head occurs in many trauma types. In most western countries head injuries are mainly caused by trafﬁc related injuries . In the years 1991-1993 the Danish incidence rate for cranial fractures was 7.1/100.000, while the annual incidence rate for patients hospitalized for brain injuries is approximately 157/100.000 with an annual mortality rate for brain injuries of approximately 10.7/100.000 . A number of studies regarding head and brain injury exist [1,3-12,12-16], but to our knowledge there are only very few recent studies regarding cranial fractures caused by blunt trauma to the head and the corresponding trauma type [17,18]. The aim of this retrospective study was to provide the summary statistics and an up-to-date overview of all cases with cranial fracture regardless of cause of death as encountered in a Danish medicolegal material. The focus was on basic case data, including basic pathological description of the lesions and fractures. MATERIAL AND METHODS The study is based upon medico-legal autopsies performed at the forensic insti* CORRESPONDING AUTHOR: Christina Jacobsen Frederik V Vej 11 DK-2100 Copenhagen Ø, Denmark Telephone: +4535326167 Fax: +4535325160 E-mail: Christina.Jacobsen@forensic.ku.dk
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tutes in Denmark at Copenhagen, Århus and Odense, in the period 1999-2004. In this 6-year period a total of 8682 forensic autopsies were performed at the institutes; 4805 in Copenhagen, 2714 in Århus and 1163 in Odense (overall male/female ratio 2.5:1). The cases were selected by using databases at the institutes. Cases with fractures of only the facial skeleton, intracranial lesions without cranial fractures, and cases involving sharp trauma or cranial gun-shot wounds were excluded. This resulted in a total of 428 cases (Copenhagen 170/Odense 92/ Århus 166), equivalent to ~5% of all the autopsies in the period. By reviewing the autopsy reports, including the forensic toxicology report, we registered basic data, including the circumstances regarding the trauma, the autopsy ﬁndings regarding fractures in the neurocranium, the associated scalp lesions and the macroscopic intracranial lesions. If a microscopic examination of intracranial lesions was performed the results were not registered. The results of a forensic toxicology analysis (400 acid, neutral and basic drugs, tetrahydrocannabinol, cocaine, benzoylecgonine, methadone, amphetamines, opiates, benzodiazepines, buprenorphine and norbuprenorphine) and/or analysis of blood alcohol concentration (BAC) were registered. Results of a possible hospital analyses were registered in the autopsy reports and in these cases a forensic toxicology analyses had not been performed. All analyses were included for the general overview. For the detailed description of the results only the forensic analyses was included.
The cases were grouped by the manner of death into accident, homicide, suicide, natural and undetermined. These groups were sub-grouped into different types of trauma: Trafﬁc related deaths, falls and the related height, hit/struck/crushed by blunt object and other trauma type.
RESULTS Sex and age distribution The material comprised 330 males (age span: below 1 year of age to 93 years; median: 40 years) and 98 females (age span: below 1 year of age to 89 years; median: 59 years) with a male:female ratio of 3:1 (see table 1). This disparity between the sexes was evident throughout all the age groups until the seventh decade, with a relatively larger male proportion killed in accidents and homicides. From 71 years of age the disparity between the sexes diminished. Manner and cause of death The largest group of cases were accidents (see ﬁgure and table 1), which comprised trafﬁc accidents (n=242), falls (n=109), trauma by blunt object (n=14) and other accidents (n=7). A cranial fracture was sustained by 37.5% of all the medicolegally autopsied trafﬁc related deaths (n=651) in this period, while the other accidents, including falls caused cranial fractures in 4.5% of all the medicolegally autopsied falls and other accidents. The share of trafﬁc accidents was proportionally greatest in the age ranges 18-40 years. Among cases above 40 years of age, trafﬁc accidents and the other
Table 1. Characteristics of the included cases: manner of death, cause of death and trauma type. Characteristics Manner of death: Accidents Homicides Suicides Natural death Undetermined Cause of death: Craniocerebral lesion Craniocerebral lesion and other lesions Undetermined Trauma type: Trafﬁc: Car occupant Pedestrian Bicycle riders Motorcycle riders Other trafﬁc situations
n=428 372 26 20 3 7 233 190 5
103 53 39 32 26
Falls/jumps from heights: Ground level 2 - 3 metres 3 - 5 metres above 5 metres No height known
48 32 16 19 15
Hit/struck by blunt object and/or interpersonal violence: Hit/struck by blunt object Blows and kicks
Figure 1. The manner of death distributed by age range and sex. “Others” include natural deaths and undetermined manner of death. The included groups are: Accident - trafﬁc (vertical hatching); Accident - Fall (white); Accident - other (left-to-right oblique hatching); Suicide (horizontal hatching); Homicide (black); Others (rightto-left oblique hatching)
Figure 2. Number of cases with a positive test for alcohol, illicit drugs, and prescription drugs distributed by age range and sex. The included groups are: alcohol (horizontal hatching); illicit drugs (white); prescription drugs (black); combination (vertical hatching).
accident types were represented evenly. In the age group 81-90 the role in trafﬁc changed, especially for females, from using motorised vehicles and bicycles to being a pedestrian with an increase in falls and being hit by motorised vehicles. Falls occurred throughout the age ranges; there were a few falls below the age of 12 years and a peak of falls at the age of 51-60 years. The homicide cases with cranial fracture comprised 4.5% of the total material (n=26/428) and in most cases the head had been hit/struck with a blunt object, jumped upon or kicked (73%). Another mechanism was falls (~15%) in the course of interpersonal violence and three cases had been registered as “other mechanisms”. Roughly one third of the homicide cases were female (n=7), which were distributed evenly through the age ranges, unlike the males in which a higher number of homicides occurred in the age range of 0-12 years and 41-50 years. Of the 20 suicide cases (3.5% of the total material), half committed suicide by jumping from heights and half occurred in a trafﬁc setting (four were car drivers,
ﬁve were hit by train, one was hit by a truck). This occurred in the age ranges of 18-60 years for males and 31-60 years for females. There were three cases of natural death which all comprised sudden deaths due to a natural disease. In these cases the cranial fractures were the result of falls in relation to death and the cause of death was nonviolent. There were seven cases in which a manner of death was not determined; in three of the seven cases there was a suspicion of homicide versus accident, in one case suicide vs. accident and in three cases natural death vs. accident. Overall, craniocerebral lesions were
the sole cause of death given in approximately half the material (see table 1) and in nearly all the remaining cases polytrauma, e.g. the craniocerebral lesions were combined with substantial lesions of other organsystems. There was no difference in the cranial fracture characteristics of these two groups. Alcohol and substance abuse Forensic toxicology, including BAC analysis was performed in 207 cases. Furthermore in 107 cases a BAC analysis only was performed. In additional eighteen cases, hospitals had performed a BAC and toxicologic analysis. Based upon hosScand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Figure 3. The activity during trafﬁc accident distributed by age range and sex. The included groups are: car occupant (white); pedestrian (right-to-left oblique hatching), cyclist (vertical hatching); motorcyclist (black); other (horizontal hatching).
pital and forensic analyses it was found that about half of the tested individuals (n=18/134, 48.8%) tested positive for various substances (see ﬁgure 2), with an overall male:female ratio of 6.5:1. For males there was a fairly even distribution throughout the age ranges until 60 years, whereas the number of females testing positive increased throughout the age range of 41-60 years. The BAC was above the legal driving limit of 0.05% in 40% of the cases (n=122/314). Overall 116 individuals had a known history of alcohol abuse (n=83), illicit drugs (n=17), or a combination thereof (n=12), or of alcohol in combination with prescribed drugs (n=4). Half of the alcohol abusers tested positive for alcohol and/or illicit or prescription drugs at the time of death. Likewise most of the illicit drug abusers (82.4%) and half (56.3%) of the mixed substance abusers tested positive for various substances. Trauma type: Trafﬁc In our material most cranial fractures were caused in trafﬁc (n = 252 cases) (see ﬁgure 3). Car accidents formed the largest group with a declining frequency after the 31-40 year group. The car drivers were the car occupants which most often underwent a medico-legal autopsy. The second largest group were pedestrians (n=53), mostly hit by motorised vehicles, with a peak at the age of 18 to 30 (n=11) and 81 to 90 (n=11). Motor cyclists and bicycle riders (n=32/39) sustained cranial fractures most often by being hit or hitting other vehicles (n=23/30). They were distributed nearly evenly throughout the age ranges. There was seldom information whether cycle riders had used protective helmets. The group of other trafﬁc related deaths con-
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sisted amongst others of plane (8 accidents) and train crashes (3 accidents/5 suicides). A BAC above the legal driving limit was found in 25 car drivers and 9 motor cyclists. Also 19 pedestrians and 7 cyclists tested positive for alcohol. Seven of the road users tested positive for illicit drugs. Trauma type: Falls Most falls had been classiﬁed as accidents (n=109/129). There were also ten suicides, ﬁve homicides, three natural deaths and three cases in which the manner of death was undetermined. In 116 cases there was a height speciﬁcation (see table 1). Ground level falls and falls down stairs constituted 67.5% of all the falls and occurred mostly in domestic settings. Falls from buildings (n=10), ladders (n=4) and outdoors (n=1) were also represented. The suicidal jumps from heights were mostly from buildings, but also bridges and, in one case, a staircase. The fall height varied between 3 m to above 20 m. The individuals tested positive for alcohol in 38 of the fall cases (34 male, 4 female) and this was especially seen in ground level falls and falls involving stairs. Of these individuals 63% were known alcohol and/or illicit drug abusers (n=21 alcohol, n=3 alcohol and illicit drugs). Trauma type: Blunt interpersonal violence or violence by/with blunt object This group (n=38, male=29, female=9) comprised 16 accidents and 22 homicides. The accidents were characterised by several different trauma mechanisms resulting in crushing of the head by heavy objects (e.g., a television, tree-branches)
and other mechanism. Five of these accidents were work-related and ﬁve happened during leisure activities outdoors. Interpersonal violence (blows and kicks) or a blunt object was the mechanism in 22 homicides. Five of the cases were female adults and ten were male adults while the remaining cases were under the age of 14 years. A blunt object was used in 10 of the homicides. The type of object used varied greatly (e.g., a mannequin arm, a wooden log) and in ﬁve cases no information about the object used was available. Ten cases were with interpersonal violence, of which three cases were with witnessed jumping on/punching/ trampling or kicking to the head. Three children under the age of 14 died in the course of an extended suicide in which their father induced blunt trauma to their heads and afterwards caused an explosion of their home. (The cause of death could not be established in these cases.) Seven individuals tested positive for alcohol and three of the seven also for illicit drugs. The group also comprised six infants under the age of 12 months (two accidents and four homicides). Two sustained accidental cranial fractures by manual or instrumental force on the head during child birth. Four infants were killed in homicides and sustained their head injuries by being hit against an object, with an object or by being punched/kicked by primary and secondary caretakers. Trauma type: Other In eight cases there was no information about how the cases had sustained the craniocerebral injuries. External cranial lesions Almost all cases (398/428) had one or several scalp lesions. A total of 946 lesions were registered (see table 2). The most common lesions were sugillations or subgaleal hematomas, but severe burns (e.g. car occupants) and partial amputations also occurred. Bleeding from the auditory canal was in nearly all the cases (n=94) associated with a basilar cranial fracture. The mono- or biocular hematomas were associated with fracture of the
Table 2. The number of external lesions and signs of fracture. External lesions and signs of fracture Contusion wounds Excoriations Sugillations/subgaleal hematomas Other lesions (e.g. burns) Bleeding from auditory canal Mono- or biocular hematomas
n 244 162 502 38 96 68
Table 3. The classiﬁcation and number of cranial fractures. Fractures of the neurocranium
Linear fractures Anterior-posterior orientation Side-to-side orientation Oblique orientation or combination Subtotal
84 107 60 251
Other fracture types Depressed Multiple Spider web Ring fracture Comminute Combination Inconclusive Subtotal
22 22 3 15 62 42 11 177
bones comprising the anterior fossa in approximately 80% of the cases. In 30 of the cases (19 trafﬁc related/10 falls/1 accident by blunt object) external lesions were not reported in the autopsy reports. Eleven of these cases had been hospitalized and treated prior to death and six survived for more than three days, which could have resulted in healing of minor external lesions prior to the autopsy. This means that in 19 cases no external lesions were registered, but it is possible that they were not correctly identiﬁed and registered by the pathologist. Fractures of the neurocranium Blunt trauma to the neurocranium had
resulted in 428 fracture systems which consisted of a variety of different fracture types divided into linear fractures and other fracture types  (see table 3). The linear fractures comprised ~60% of the total material. The other fracture types ranged from involving small areas of the theca, e.g. depressed fracture to massive comminute fractures. Some of the other fracture types were combinations of the fracture groups, e.g., depressed fractures combined with multiple fractures or linear fractures and were therefore grouped separately (table 3). The linear fractures were anatomically generally located equally in the base or both the base and the theca, while only a few fractures were located solely in the theca (see table 4). The other fracture types mostly involved both the base and the theca. The comminute fractures always involved both, while especially the ring fractures involved only the base. The so-called inconclusive fractures (in table 3) were cases in which the fracture description from the autopsy report did not allow a certain classiﬁcation. Intracranial lesions In 371 cases 998 intracranial lesions were registered macroscopically during the autopsy (see table 5). Contusions and subarachnoid haemorrhages were found in approximately 70% of the cases while epidural haemorrhages occurred in only 5% of the cases. The frontal lobes sustained one-third of the contusions, while the temporal lobes and the cerebellum were affected in approximately 25% and 14% of the cases respectively.
Table 4. The anatomical localisation of linear fractures and other fracture types. Base and theca
Linear fractures Other fracture types
All fracture systems
Table 5. The anatomical localisation of the registered intracranial lesions. SAH
Frontal lobes Temporal lobes Parietal lobes Occipital lobes Cerebellum Right hemisphere Left hemisphere
56 55 34 14 69 86 81
0 0 0 0 0 16 4
0 0 0 0 0 46 52
119 74 22 37 45 16 7
30 23 14 11 19 7 9
12 6 6 1 15 6 6
217 158 76 63 148 177 159
SAH - subarachnoid haemorrhage, EDH - extradural haemorrhage, SDH - subdural haemorrhage
Subarachnoid haemorrhage involving the hemispheres was seen in 42% of the cases, while localised subarachnoid haemorrhages involved the frontal and temporal cerebral lobes in approximately 14% of the cases respectively and the cerebellum in approximately 17% of the cases. The subdural haemorrhages were distributed evenly over both hemispheres, while epidural haemorrhages were more common over the right hemisphere. Approximately 80% of the epidural haemorrhages were located over the right hemisphere and were associated with mainly linear fractures of the right temporal and/or parietal bone and lesion of the middle meningeal artery. Cerebral haemorrhages occurred especially in the frontal lobes and the cerebellum.
DISCUSSION While there are many epidemiological studies about head trauma and traumatic brain injury [1-16], we have found only few recent studies about cranial fractures [17,18]. Indeed, most of the extant knowledge about the pathology of cranial fracture arises from studies carried out in the beginning and the middle of the last century [19-23]. The epidemiological data from our medico-legal material was compared to studies based both on clinical data and death certiﬁcates regarding head injuries and traumatic brain injuries [1-16], and studies on cranial fractures [17,18,20-24]. Validity Our study was intended to provide an overview of cranial fractures caused by blunt force in a medico-legal material. We focused only on cranial fractures regardless of cause of death and the results naturally have to be interpreted with this in mind. The medico-legal autopsies in Denmark are performed on request of the police in cases of interest according to the legislation. This material is therefore characterized by comprising only a fraction of the deaths by accident or suicide, namely when there is doubt about the manner or cause of death. As a consequence of this the material reﬂects only a portion of the deaths with cranial fracture by blunt force in Denmark which, amongst others, is reﬂected in the distribution of the trauma type and age, e.g. there were only a few elderly in our material. BAC analysis was performed in most cases (75%), of which 40% were positive, while forensic toxicology analysis was performed in half of the cases, of which 20% tested positive. A selection bias is thus introduced by the police not requesting analysis in all cases. Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
Manner of death and trauma type In some aspects our material reﬂects the sex and age distribution of head injuries in Denmark and other countries [4,612,18]. As others, we also found a proportional peak in case numbers in the young children, the young adults and middle aged, while an otherwise reported increase in the total number of elderly [4,6-11,18] was not seen. This is most likely explained by a decrease in deaths were medico-legal autopsy was deemed necessary for this age group. The sex ratio is in line with other studies, with a preponderance of males compared to females [1,2,4-16,18]. We noticed, however, a levelling out of the sex difference in old age which has been mentioned only in a few other studies [1,8]. This probably reﬂects the composition of the population in general at that age. Our study shows a peak of cranial fractures caused by trafﬁc accidents in the young adults which coincides with the incidence rate of head injury in other studies [5,6,8,10,11,15,25]. In our study the number of cranial fractures caused by accidental falls is noticeable in the very young and increases through the age ranges, peaking in the age range of 51- 60 years. This is partly comparable to some studies [3,18], although in other studies the incidence progresses further throughout the older age ranges (75+ years) [6-12,14,15], together with an increasing mortality rate for falls . In the mentioned studies the increase in falls substitutes trafﬁc accidents as the prominent trauma type for head injuries, which is not the case in our study reﬂecting the medico-legal material. Compared to other European countries and the US, a high share of head injuries in Scandinavia were caused by falls [6,9,13,14,16], but head injuries in Denmark are predominantly caused in trafﬁc . In studies about the methods used in homicides [26-30] and interpersonal violence in assaults, blunt force was used in 16-36% of the homicides and in most of the assaults . The blunt violence was mostly aimed at the head, including the face both in adults [27,30-32] and children , mainly by blows and kicks [27,28], although some studies found [26,32], similar to our ﬁndings, that a variety of blunt objects were used in approximately half of the homicides. The age and sex distribution of the homicide cases in our study matched the distribution found in other studies with a comparable population [28,33], although we found a preponderance of male cases in the age range <12 years, a tendency which Myhre et al.  also found. Only a few suicide cases are represented in our material, but even so the age and
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sex distribution corresponded to other studies [34-36], although no elderly cases were found in our material. Blunt force as a suicide method (e.g. jumping from heights/in front of motorised vehicles/trains, trafﬁc accident) is not very common internationally [34-36] and has been described as a “hard suicide method” . The number of car driver suicides in our material suggests that this method might be more common than expected . Alcohol and substance abuse One third of the fall cases, 25% of the trafﬁc cases and some of the homicide cases tested positive for alcohol. This has also been found in similar studies of traumatic deaths [25,39,40] and in studies on drugged driving . A few of the cases in our study tested positive for illicit drugs which also corresponds to other studies [42,43]. Others [39,44] found that head injury severity for blunt trauma did not increase depending on alcohol abuse, while Ingebrigtsen et al.  found a tendency towards greater severity. A positive alcohol test is common in fall cases, but regarding ground level falls no increasing injury severity was found even though half the cases tested positive for alcohol . Preuss et al.  found that nearly 70% of cases with falls down stairs tested positive for alcohol, which in our study was true for 50% of the cases. External lesions The greatest part of the cases sustained external lesions in the course of the trauma to the head, and often there were several lesions per case. It has been found by Yartsev et al.  that external lesions of the head may be fairly predictable of cranial fracture or intracranial injury with a positive predictive value of ~80%. In the same study  it was also found that bleeding from the auditory canal was highly predictive (95%) for basilar cranial fracture which is in concordance with our material. In our study also mono- or biocular hematomas seemed to be associated with fracture of the frontal cranial base. We also found several cases, distributed evenly across the age ranges, with no external lesions yet cranial fractures of varying severity. Lack of registration by the pathologist or healing of injuries in cases which initially survived could explain some of the absent injuries and instant death the absence of e.g., sugillations . Also the biomechanical trauma circumstances, e.g., the size of impact area, the nature and surface of the impacting material/object are of signiﬁcance for the causation of external injuries. We are not aware of studies that explicitly have focused on an absence
of external injuries on the head despite the application of a substantial amount of force. Kremer et al.  found that over half of the included fall cases did not sustain lacerations, in a retrospective study systematically analysing the relation of skull fractures to the Hat Brim Line. However, in their study there was no mention of other external injuries. Hartshorne et al.  noted that internal head injuries often were more severe than predicted from the relatively minor external injuries, in an analysis about ground-level falls,. Fractures of the neurocranium Linear fractures of the neurocranium caused by blunt force are reported to be the most common cranial fracture in population studies , clinical studies [3,50], medico-legal studies  and experimental studies , which is in line with our study. Also the share of comminute fractures in our study corresponds to other studies [17,21], while there are fewer depressed fractures in our and LeCounts  material than in other studies [17,50]. This might be explained by the selected medico-legal material and possibly an increased chance of survival with a sustained localised depressed fracture compared to the other fracture types. Ring fractures are known to occur seldom [51,52]. Fractures of only the base are often the result of severe trauma [20,53]. In our material the fractures involved only the base in a third of the cases which is similar to other studies which found that this occurred in approximately 20% of the cases [17,54]. In contrast to this, Bauer  refers to several medico-legal studies which report fractures involving only the base in 60-70% of the cases. Others have found the combination of both basilar and vault involvement to be common, while involvement of only the vault occurs less often [21-23]. Jennett et al.  report in a clinical study that radiologically detected vault fractures occurred in 62% of the cases and found less common involvement of both the base and the vault (27%). This might be explained by radiologic difﬁculties in diagnosing fractures located in the cranial base, especially by traditional Xraying, which can result in minor cranial basal fractures not being diagnosed. Intracranial lesions The most frequent intracranial lesion was the subarachnoid haemorrhage followed by cerebral contusions. Similar results were found in a study based on emergency department admissions in which both subarachnoid haemorrhages and contusions were found in approximately
30% of the patients, with increasing incidence with increasing injury severity . Kleiven et al.  basically reported the same proportions in a Swedish study, but it should be noted that cranial fractures occurred in only 14% of the overall head injury material in Sweden. In contrast, in an American study Freytag  found that 12% of the cases in a medico-legal material had suffered severe subarachnoid haemorrhages and nearly 89% lacerations and contusions. Freytag  also found a high frequency (63%) of subdural haemorrhages. Other studies [6,15,50,56] have also reported a higher frequency than we ﬁnd, which amongst other things could be due to difﬁculties diagnosing the haemorrhages at the autopsy and also due to the selected medico-legal material in this study focusing only on cases with cranial fracture and not all head injuries. The frequency of the epidural haemorrhages is the same as in Kleiven et al.’s study , but less frequent than in the other studies [15,50,55]. Epidural haemorrhage is generally considered to be seldom , probably because fracture of the parietotemporal bones with subsequent rupture of the middle meningeal artery does not occur very often. To our knowledge no studies have reported an increased occurrence of epidural haemorrhages on either side of the head, although Kremer et al.  reported a side lateralization in cranial fractures induced by falls, which were mainly on the right side of the head, as opposed to fractures induced by blows, which were mainly located on the left side of the head. Such a lateralization of cranial fractures was not found in our study.
small excoriations to severe burns and comminution of the head. Mono- or biocular hematomas and bleeding from the auditory canal corresponded well to ﬁnd of cranial fractures. The linear fractures were the most common cranial fractures and most of the fractures were, reﬂecting the medico-legal material, accompanied by moderate to severe intracranial injuries or/ and severe injuries of other organsystems resulting in the fatal outcome. Localised intracranial lesions: subarachnoid haemorrhages, contusions and cerebral haemorrhages were often found corresponding to the frontal, temporal and occipital lobe and the cerebellum. In half of the cases a uniform distribution over the cerebral hemispheres was found. The frequency of subdural and epidural haemorrhages was as expected in a medico-legal material, but the primarily right sided distribution of the epidural haemorrhages was surprising and needs further investigation. Future studies will especially focus on the causative relationship between trauma type, the resulting head impact and both cranial fracture and brain injuries.
  
REFERENCE LIST  
CONCLUSION We report the summary statistics for cases with cranial fractures in a medicolegal material over the course of a 6-year period in Denmark. Our comprehensive data provide baseline characteristics of this forensically important group. Head injuries with cranial fracture are mainly seen in trafﬁc related deaths, especially affecting the young adults (18-31 years). Trafﬁc related deaths with cranial fracture constitute 37.5% of the medicolegally autopsied trafﬁc related deaths in this period. Falls were also a prominent trauma type throughout every age range. A positive test for alcohol was common in ground level falls and falls down stairs, especially in the group of chronic alcohol abusers. This stresses the known vulnerabilities of this group and also the fatal consequences a fall from a limited height may have. Nearly every victim sustained external injuries varying from
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 Schmidt P, Müller R, Dettmeyer R, Madea B. Suicide in children, adolescents and young adults. Forensic Sci Int 2002; 127(3): 161-7.  Murray D, de Leo D. Suicidal Behavior by Motor Vehicle Collision. Trafﬁc Inj Prev 2007; 8(3): 244-7.  Demetriades D, Gkiokas G, Velmahos GC, Brown C, Murray J, Noguchi T. Alcohol and illicit drugs in traumatic deaths: Prevalence and association with type and severity of injuries. J Am Coll Surg 2004; 199(5): 687-92.  Tsai V, Anderson C, Vaca F. Young Female Drivers in Fatal Crashes: Recent Trends, 1995-2004. Trafﬁc Inj Prev 2008; 9: 65-9.  Christophersen AS, Ceder G, Kristinsson J, Lillsunde P, Steentoft A. Drugged driving in the Nordic countries-: a comparative study between ﬁve countries. Forensic Sci Int 1999; 106(3): 173-90.  Bernhoft IM, Steentoft A, Johansen SS, Klitgaard NA, Larsen LB, Hansen LB. Drugs in injured drivers in Denmark. Forensic Sci Int 2005; 150(2-3): 181-9.  Behrensdorff I, Steentoft A. Medicinal and illegal drugs among Danish car drivers. Acc Anal Prev 2003; 35(6): 85160.  Edna T. Alcohol inﬂuence and head injury. Acta Chir Scand 1982; 148: 209.  Hartshorne N, Harruff R, Alvord EJr. Fatal Head Injuries in Ground-Level Falls. Am J Forensic Med Pathol 1997; 18(3): 258-64.  Preuß J, Padosch SA, Dettmeyer R, Driever F, Lignitz E, Madea B. Injuries in fatal cases of falls downstairs. Forensic Sci Int 2004; 141(2-3): 121-6.  Yartsev A, Langlois NEI. A comparison
of external and internal injuries within an autopsy series. Med Sci Law 2008; 48(1): 51-6. Vanezis P. Interpreting bruises at necropsy. J Clin Pathol 2001; 54(5): 348-55. Kremer C, Racette S, Dionne C-A, Sauvageau A. Discrimination of Falls and Blows in Blunt Head Trauma: Systematic Study of the Hat Brim Line Rule in Relation to Skull Fractures. J Forensic Sci 2008; 53(3): 716-9. Macpherson B, Macpherson P, Jennett B. CT Evidence of Intracranial Contusion and Haematoma in Relation to the Presence, Site and Type of Skull Fracture. Clin Radiol 1990; 42: 321-6. Voigt GE, Skold G. Ring fractures of the base of the skull. J Trauma 1974; 14(6): 494-505.  Gan YC, Charkravarty D, Flint G. Ring fracture of the skull base: case report and review of the literature. Bri J Neurosurg 2002; 16(3): 300-3. Rowbotham GF. The mechanisms of injuries of the head. Acute Injuries Of The Head. Edinburgh and London: E.& S.Livingstone Ltd. 1964; 56-69. Jennett B, Teasdale G, Galbraith S, Pickard J, Grant H, Braakman R et al. Severe head injuries in three countries. J Neurol Neurosurg and Psychiatry 1977; 40: 291-8. Freytag E. Autopsy Findings in Head Injuries from Blunt Forces - Statistical Evaluation of 1367 Cases. Arch Pathol 1963; 75: 402-13. Tallon J, Ackroyd-Stolarz S, Karim S, Clarke D. The epidemiology of surgically treated acute subdural and epidural hematomas in patients with head injuries: a population-based study. Can J Surg 2008; 51(5): 339-45.
IAFS 18. møde, New Orleans, Louisiana, USA, den 21-25. juli 2008 Steen Holger Hansen1, Christina Jacobsen1, Birgitte Kringsholm1, Niels Lynnerup1, Marianne Rohde2 1 2
Retsmedicinsk Institut, Københavns Universitet Retsmedicinsk Institut, Århus Universitet
“First, we must kill all subversives; then their sympathizers; then those who are indifferent; and ﬁnally, we must kill all those who are timid”. Ovenstående citat af den argentinske junta-general, Saint Jean, blev vist af Clyde Snow, der åbnede den 18. kongres for International Association of Forensic Sciences. Hans foredrag omhandlede retsantropologi og hans undersøgelser verden over omkring overtrædelse af menneskerettigheder og ekshumering i massegrave. Han fortalte, hvordan han var kommet ind i det retsantropologiske arbejde; om de første udgravninger i Argentina og om hvordan det havde udviklet sig til et stort netværk af retsmedicinere og retspatologer, der er engageret i humanitært arbejde. Clyde Snows foredrag var et stærkt indlæg om hvorledes retspatologi og retsantropologi kan anvendes, ikke mindst da han afsluttede sit foredrag med at sige, at grunden til at han var gået ind i dette arbejde var, at han selv havde ﬁre døtre som kunne være ”forsvundet” og dræbt, sådan som det var sket for dem han havde været med til at grave op og identiﬁcere. Det næste foredrag ved åbningen var af Henry Lee. På sin karakteristiske, farverige facon fortalte han om sig selv, illustreret ved en række af de meget omtalte sager han har været involveret i, ikke mindst som ekspertvidne i de amerikanske retter. Han fremdrog også et par gode punkter, f.eks. at retsmedicinere altid skal være rationelle og betjene sig af almindelig logik, herunder at det ikke er altid, at meget avancerede statistiske argumenter nødvendigvis er vigtige, selvom nogle forsvarere og anklagere så gerne vil have ”procenter” på udsagn.
KORRESPONDERENDE FORFATTER: Niels Lynnerup Retspatologisk Afd., Retsmedicinsk Institut Frederik d. 5´s Vej 11 DK-2900 København Ø Danmark tlf: +45 35327239 fax: +45 35327215
Desværre var disse to foredrag nok højdepunktet for hele kongressen. De efterfølgende, almindelige, videnskabelige indlæg, serveret løbende over de følgende to dage, var generelt middelmådige, og hvad næsten værre var; meget få. Det viste sig, at en pæn del af de tilmeldte foredragsholdere ikke viste sig, så der var ofte pause eller tomt i de forskellige foredragssale, og det samme gjaldt for postersessionerne. Baggrunden for dette store og iøjnefaldende frafald kunne vi ikke helt få opklaret. Vi ﬁk oplyst, at der var ca. 850 deltagere. Der var tilmeldt en lang række posters og foredrag fra Kina og ikke mindst fraværet herfra var markant, hvilket måske skyldtes visum problemer. Det virkede også som om spændvidden generelt var mindre end den havde været før, f.eks. i Hong Kong og Montpellier. Alt i alt synes ingen af os, at vi kom hjem med spændende nye teknikker eller resultater. En lille undtagelse var måske en session om Forensic Science og medier og rekruttering. Flere talere bemærkede hvorledes alt hvor ordet forensic indgår, pludselig blev meget interessant for unge studerende. Der var ingen tvivl om, at denne bevågenhed i høj grad skyldtes de mange TV-serier (CSI, Bones, etc). Ud over at ironisere over deciderede ﬁlmiske fejl (fx et skelet lagt forkert op), blev det dog også påpeget, at situationen kunne anskues positivt: at det kan bedre rekrutteringsgrundlaget blandt unge. Det føles nærliggende, at udnytte den samme situation i Danmark, dels over for yngre læger, der er nysgerrige for faget, dels også andre faggrupper, fx molekylærbiologer og farmakologer.
Vi havde fra Danmark 3 påosters med omhandlende hhv. traumatisk subarachnoidal blødning opstået efter stump vold mod halsen, resultater fra et funktionelt studie på ﬁbroblaster af cellulært stressrespons hos spædbørn samt et dødsfald efter stump vold mod halsen muligt betinget af sinus caroticus reﬂeks, ligesom vi afholdt 2 foredrag om hhv. undersøgelse af drab i Rwanda samt aldersbestemmelse ud fra øjenlinser. Flere af disse resultater har desuden været fremlagt ved hjemlige møder.De øvrige nordiske lande var sparsomt repræsenteret ved kongressen. Mest bemærket gjorde vores kollega, Andreas Marnerides fra Stockholm sig, med et interessant indlæg om ”An unusual Case of Multiple Gunshot Suicide”. Til gengæld, og måske også sat i relief af det lettere pauvre videnskabelige program, var udstillingsområdet spændende med mange udstillere, der fremviste mindre aggregater, herunder f.eks. meget præcise laseropmålere (som
Artiklens forfattere Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
kunne bruges på crime-scenes og automatisk kobler dette sammen med digitalbilleder, så der dannes et fuldstændigt målbart virtuelt 3D-billede af en crimescene), mikroskopi samt billedbehandling og prøvesikring. Dertil ﬂere forlag, med nye udgivelser inden for feltet (og med kongres-rabat). I dagene forud for det videnskabelige program var der workshops: de ﬂeste af os deltog i “Mass Dissaster handling”. Workshoppen var sat op som en sceance med fokus på planlægning, organisation og fordeling af ressoucer der bør sættes ind med i forbindelse med en massekatastrofe. Der blev bl.a. arbejdet i teams med hver deres funktion; vi var i gruppen, der organiserede støtte til pårørende, så vi opererede lidt uden for vores vante arbejdsområde. Overordnet var der nogle øjenåbnere, men selve workshoppen var dårligt planlagt, og vi nåede derfor kun halvvejs gennem programmet, hvilket for nogle af os efterlod et lidt uorganiseret indtryk af en workshop, der paradoksalt nok skulle handle om organisering. Vi savnede en workshop eller nogle inviterede indlæg om orkanen Katrina og de følger det har haft for byen. Man kommer jo ikke udenom at New Orleans´ indbyggere for 3 år siden var hovedpersoner i USAs måske største naturkatastrofe, hvor der i kølvandet blev rejst umådelig megen kritik af både staten Louisiana
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og regeringens manglende, eller i hvert fald, alt for langsomme indgriben og tilførsel af hjælp. Man kunne mistænke, at det unævnelige opfattedes som en skamplet, der skulle udviskes. Der var kun et indlæg der handlede lidt om Katrina: En lokal odontolog fortalte om hvor vanskeligt arbejdet havde været, idet hele deres grundlag for arbejdet med identiﬁkation, nemlig journaler og universitetsklinikken, hvor han var ansat, var destrueret af stormen. Det gør katastrofen så meget større og kaotisk, at også organisationen der skal hjælpe og de faciliteter de har til rådighed er ramt. Han viste desuden nogle rystende billeder af hvordan man de første dage, på grund af manglede ressourcer, ikke kunne gøre andet end sejle rundt til husene, der stod i vand næsten op til taget, og forsøge at redde folk ud. Der blev sat et kryds på taget for at markere, at man havde været der, og et nummer, der angav hvor mange døde kroppe, der skulle bjærges fra huset. Det sociale program afspejlede for så vidt det videnskabelige. Det var ikke specielt spændende og ikke særligt omfattende. Der var en kongresmiddag, hvor formentlig under halvdelen af alle delegerede deltog, og hvor det sceniske islæt alene var lidt kedelig musik. Vi var ikke imponerede. Til gengæld var alle imponerede over mødet med byen. New Orleans må siges stadig at være på listen over byer i USA, der absolut er et besøg
værd. Vi fandt vores yndlingsrestaurant ved bredden af Mississippi ﬂoden “The crazy Lobster”, hvor man, når man bestilte skaldyr, ﬁk en stor spand sat på bordet, med alt muligt godt i rigelige mængder, serveret med New Orleans` berømte drink “The Hurricane” som man naturligvis kunne få i kategori 1-5, refererende til alkoholkoncentrationen! Vi ﬁk også udforsket sumpene i Mississippi-deltaet i de såkaldte “Airboats”, der med stor fart over vand og land tog os på en succesfuld oplevelsestur gennem de menneskeskabte kanaler. Vi ﬁk bl.a. set, fodret, holdt og ﬁlmet alligatorer, fra stor til lille. Guiden forsikrede os om at de var helt uskadelige og at han selv havde alligatorer hjemme som kæledyr, så vi var ganske trygge. Få dage efter vores hjemkomst til Danmark, kunne vi så læse om en 11-årig dreng, der netop i det samme område havde overlevet et voldsomt alligatorangreb, dog kun med èn arm i behold. Vi fulgte også alle med da orkanen Gustav gik i land i august, og tænkte på, hvorledes vi havde gået rundt i de gader, hvor man nu så forblæste TVreportere fortælle om evakueringerne og læren fra Katrina. *** Næste IAFS, den 19., vil ﬁnde sted i 2011 i Portugal på Madeira. Man må håbe på et bedre program og større fremmøde.
LECTURES IN FORENSIC MEDICINE:
Subject: Human sufferings (Torture / Self inﬂicted injury) Auto victimization/pseudo-martyrdom (fragments from english version).
Av Gunnlaugur Geirsson, Island
INTRODUCTION In lecturing to students who are going to specialise in the care of human suffering it behoves to classify the subject in order to try to bring order to the chaos. It is a matter of universal knowledge that human suffering is far from being evenly distributed among the population of the earth. Many will enjoy life practically from the cradle onwards till death does call, but most of us will meet with sufferings at some time or other during our lifetime --- be it for a brief period, or a long time. The mass media are selectively directing the attention of the general public to rare diseases, accidents or other sufferings especially if the persons involved are famous (Princess Diana) , a great havoc with a number of people perishing (e.g.air crash) or a nationwide disaster ( e.g.Darfour). The attention of the media is shortlived and rarely offers relief to the grieving survivors. In other words , the general public is well informed about human sufferings as chosen by the media but vast areas of human misery are not covered by the press and unknown by most people. Normal persons will naturally respond to strain in a “negative” fashion when meeting with severely adverse conditions.Such responses may be classifed in psychiatry as exogenous depression and may have a varied spectrum of expression. Endogeous depressions are probably more common and follow a more uniform symptomatology. A mixture of exogenous and endogenous depression may of course exist. Physical injury and/ or mental choc may create the posttraumatic stress syndrome with sleep disturbances , anxiety , nightmares, tiredness and depression—(this being the subject of psychiatry and will be cut off here.) AUTOVICTIMIZATION – DEFINITION It may be called autovictimization or pseudo-martyrdom when a person tells an altogether ﬁctious story or blows up
minor happening to a major adversity with the result that he or she will appear as a sufferer and gain the sympathy of people and often at the same time incriminate an innocent person. It seems far fetched that people may go to extremes such as to fabricate maltreatment (such as rape or harrasment) and wilfully put the blame on innocent persons but such episodes are well known e.g. in forensic cases. People commit such things at times with planned intention but in other cases more or less by blurred instinct for personal gain, hate or passion. The circumstances are extremely varied and in the following some examples are given (The Kain and Abel complex serves as a classic: Let us assume that I am a boy and my younger brother is pestering me by his brilliance.Let us assume that I lie to our parents that my brother has thrown my toothbrush into the toilet . As a result I may gain the attention of my parents and a new toothbrush as well as enjoying having had the chance to be nasty to my brother which I felt was totally merited by him for being such a pest.) The above would be a simple example of auto-victimization but in real life the circumstances are more complicated. The key to a successful double crossing with auto victimization is to concoct a believable story to sound genuine and then to disseminate in the media to reach far and wide (journalism) and to garnish the story with a tinge of spice to attract attention (sensationalism). AUTO-VICTIMIZATION: THE PARTICIPANTS: The primary role in the auto-victimization episode is of course that of the person who fabricates the history of maltreatment. Secondly are the media very signiﬁcant and does play a role in most successful episodes of this nature and ﬁnally the target population who is expected to believe the lies. In most
cases the greater number of people that believe the lie the better. The more important the people are the better and especially to politicians who have access to money and power to pull strings if necessary and whose shallow knowledge makes them an easy prey to all sorts of lies. a.) Who set the stage for auto-victimization ? We are all tempted to exaggerate to maximize our story of loss if e.g. we are robbed our car broken into or vandalized.We have a tendency to try to arouse sympahty for our situation when we have to excuse something that we have done or something that we have neglected.The line of separation between a small white lie and a pitch black one for personal gain is quite indistinct. In medicine there is a long time experience with the chronic complainer who ﬁnally ﬁnds a surgeon to operate.The surgeon may ﬁnd that the patient states that he is no better even worse after the operation and even if the patient has signed a consent he may well refuse having received intelligible explanation of possible complications. It is of paramount importance for the surgeon -,maybe in particular the plastic surgeon – to evaluate the patient carefully with respect to this. Patients with genuine psychoses rarely use autovictimization(as they may lack the shrewdness) but obviously a psychotic patient may fabulate a story of rape etc.all of which requires scrutinization. The genuinely handicapped person may understandably emphasize his or her physical condition but does not generally use this to fabricate and thus promote his cause. However insurance fraud is a problem , such as the whiplash injury where the evaluation of the patient rests on the verbal statement of the subject and not any physical signs. ---Auto victimization is a common game in politics where truth is only measured by credibility and nobody looks behind the potemkinian curtains but this will not be discussed here.-Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
b. Which is the part in “the autovictimization game” played by the media? With the increased number of printed and broadcasting media there is an ever growing need for material--ﬁt or not ---for publishing The ties beween the autovictimizer and the press are getting stronger since the so called research journalist became fashionable. These journalists are ready to accept fully prepared stories, true or false .The mythe goes that a false story printed can be recalled and corrected but the truth is that the press rarely admits erroneous articles and litigation is very costly.It is a fact that many a person has been falsely accused and suffered irreparably as a result of sloppy journalism. The press is a boon to the autovictimizers. c.The target group of autovictimization is most often the public at large and is meant to stir the general public e.g. to get a response in the form of monetary contibutions , or to create a sentiment among sufﬁcient number of people have a support from politicians who are willing to play with in quest of popularity. The target group may be more limited such as the police , judges in fact any one who may be able to affect the fate of auto-victimizer.(In criminal cases the auto-victimizer will illustrate his or her difﬁcult childhood etc, etc.
late evening the young woman became severely intoxicated and fell asleep while a live candle burned down and set the house on ﬁre. The old couple woke up and were able to arouse the young woman and get her out before the ﬁre brigade arrived but the house and furniture were destroyed.The young woman owned practically no furniture but the following day the afternoon yellow press had her pictured over the entire frontispiece /ﬁrst page holding in one hand a burned piece of visibly precious carved wood from a cabinet owned by the old couple . The text accompanying the picture described the great loss of the entire posessions of the young woman and urged all to donate money through a certain bankaccount. Such manipulation of people to show misericordia is quite commonly being utilized
A-v with a deﬁned motive such as money (e.g. insurance fraud.) A-v with a blurred intent –(“slande or just anything to hurt“) A-v with deﬁned motive ( revenge) A-v to attract attention e.g. a-v with self inﬂicted wounds Examples to illustrate autovictimization
2. example A known homosexual man was found murdered with numerous stab wounds of exceptionally violent nature aimed at thorax, abdomen ,sexual organs and head , leaving the lethal weapon, a pair of scissors. in the victims head. A young man was arrested and admitting his crime. He stated that the victim had started to approach him sexually at whic point he had become irate and ﬁlled with disgust , caught the scissors which were lying on a table and had assaulted the victim and then ﬂed. It had taken him some time to come to his senses at which point he gave himself in.to the police The jury did mollify the sentence as if sexual approaches had been accepted as proven although the possiblity of a passion crime e.g.jealosy seem no less credible and the sexual proclivity of the perpetraitor was not known for sure. In the years to follow a certain leniency was offered to violence offenders if the crime was committed in the wake of alledged homosexual approach.
1.example A classic example of autovictimization with the aim to make money may be illustrated by the story of a young alcoholic woman. She had recently rented a small basement ﬂat from elderly couple í the old section in Reykjavík when one
3. example An employee in a hospital laboratory had been engaged in routine work for fourteen years when new techniques had been developed. Having no education to master the new technique the job that she had held was discontinued. The
EXAMPLES OF MOTIVES
74 Scand J of FORENSIC SCIENCES - No. 2 - 2008 - Page 37-72
employee had taken time off to work abroad but became furious when the laboratory work was discontinued and threatened the supervisor in the laboratory but not the hospital management who was responsible for discontinuing the job and not offered relocation. She spread the rumour that she had been dismissed on the basis of jealosy by the supervisor and in doing so she published a sheet from the diary of her superiour in the laboratory where the dismissed person was said to have forgotten to close a refrigerator door.By this she disclosed that she had invaded (violated ) the privacy of her former superior by reading his diaries which were kept in a locked room. The press and the authorities seemed to accept this as a normal behaviour and the employee was able to pull her strings of auto victimization and was able to receive sympathy and ﬁnancial support from public funds based on her unique talent for fraudulence. This is an example of a very successful autovictimization getting ﬁnancial boon and revenge by lies and double crossing thanks to the shallow intelligence of politicians. 4.example A painter with a history of being a “ difﬁcult” child decided when in his middle age to blame his mother for neglecting him in the upbringing and blaming her for his alcoholism, violence against his several wifes and ﬁnancial difﬁculties. In the retroscopic view of those who knew him he was considered hyperactive psychopath whose behaviour was very bizarre at times. He concocted stories of his maltreatment and in his auto-victimized state he sought inspiration in painting his family and surroundings as a child in a very –to say the least--- degrading manner In other words he seemed to ﬁnd a source of inspiration to paint a series of canvases where he painted his next of kin as ugly, sad group . *** These are but few examples of autovictimization -- a ubiquitous phenomenon in human behaviour !!!!.
REFERAT FRA ÅRSMØTE OG GENERALFORSAMLING 2008 Siden det viste seg å bli umulig å få de foredragsholderne som styret ønsket til et eget årsmøte i NRF, ble det av styret besluttet å legge generalforsamlingen i tilknytning til høstens kurs Dødsstedsundersøkelser ved barnedødsfall (Lægeforeningens kurs nr. L-24003), som ble holdt på Soria Moria fra 26/1108. Kurset som ble arrangert i samarbeid med Norsk Barnelegeforening og Rettsmedisinsk institutt (RH), gikk over tre dager, og ble åpnet av barneombud Reidar Hjermann. Foredragsholdere under den generelle delen var: rettsmedisiner professor dr. Torleiv Rognum, riksadvokat Knut Kallerud, rettsmedisiner dr. Arne Stray-Pedersen, generalsekretær i Landsforeningen uventet barnedød Trond Mathiesen, politibetjent ved Kripos Kjærsti Helland, klinikksjef dr. Jens Grøgaard, Toril M. Kristoffersen, krisepsykolog Magne Raundalen samt professor dr. Roger Byard fra Australia. Etter kurset var det som vanlig få gjenværende medlemmer til generalforsamlingen. Revisjonsrapporten ble lest opp og regnskapet for 2007 godkjent. Revisors rapport (datert 19/11-08) ga uttrykk for misforholdet mellom medlemsregisteret og innbetalt kontingent. Styret tok dette til etterretning og lovet at rutinene ville bli skjerpet. Formannen redegjorde for årets virksomhet. Det har på alle måter vært et travelt år. Det resulterte i at årsmøtet, som opprinnelig var planlagt avholdt før sommerferien, dessverre måtte forskyves til den mørke årstid, hvilket ble meddelt medlemmene allerede i brev av 8/4-08. En vesentlig årsak til denne forskyvningen var som nevnt problemene med å få tak i de foredragsholderne som vi opprinnelig hadde ønsket oss, da de
dessverre var opptatt på annet hold. Vi håper imidlertid at vi lykkes ved en senere anledning. Av samme grunn var antall formelle styremøter avholdt i løpet av 2008 redusert til tre, men det har i tillegg vært ganske mange telefoniske og personlige kontakter av foreningsmessig art mellom styremedlemmene i denne tiden. Tidsskriftet Scandinavian Journal of Forensic Science er nå inne i sin 14. årgang. Av tidsmessige årsaker har bare ett nummer utkommet i år, neste utgivelse vil se dagens lys like etter jul. Det ble ytret ønske om et registerbind for de 15 første årganger. Svar på et høringsnotat (”Forslag til endringer i forskrift av 21. desember 2000 nr. 1378 om legers melding til politiet om unaturlig dødsfall og lignende – Obligatorisk tilbud om dødsstedsundersøkelse i regi av helsetjenesten der barn i alderen 0 til 3 år dør plutselig og uventet”) ble sendt Den norske Lægeforening 8/6-08. Her konkluderte styret med at NRF anså det for positivt at det nå skal lages et system for dødsstedsundersøkelse, fortrinnsvis etter modell foreslått av barnedødsårsaksprosjektet. Et tilsvarende brev ble sendt Helse- og omsorgsdepartementet 29/8-08, hvor dødsstedsundersøkelsene nettopp blir anbefalt knyttet til ekspertise ved de rettsmedisinske sentrene ved universitetene i Oslo, Bergen, Trondheim og Tromsø. Arbeidet med å gjøre rettsmedisin til en formell spesialitet, slik man nå har fått til i Danmark, pågår fortsatt. Under landsstyremøtet i Lægeforeningen i mai 2008 ble ingen ting vedtatt (det eneste forslaget var ny spesialitet i rus- og avhengighetsmedisin), og det kunne se ut som om man der ikke var
klar over at ”rettsmedisin” ennå ikke var en spesialitet. Styret i NRF vil derfor utarbeide forslag til kompetansekrav for Norge og fremme dette på neste årsmøte. På forhånd vil foreningens medlemmer få utkastet tilsendt, med anledning til å gi kommentarer/tilbakemelding. Åshild Vege redegjorde for den rettsmedisinske virksomheten i landet (dvs. i Oslo, Bergen, Trondheim og Tromsø). Det ble foreslått et møte med representanter for de aktuelle universitetene etter at medlemmene har fått anledning til å uttale seg om spesialitetsspørsmålet; utgiftene til møtet vil belastes foreningens kasse (som nå viser et lite overskudd). Det sittende styre ble foreslått gjenvalgt, men samtidig ble det påpekt uklarheter ved vedtektene, idet det heter seg at ”halvparten skiftes ut hvert år” – noe som kan bli problematisk for de tre styrerepresentantene Torleiv Rognum (formann), Kjærsti Helland (kasserer) og Per Holck (sekretær). Styret vil imidlertid se nærmere på dette. Rådets tre medlemmer (Andreas Hamnes, Anne Christine Johannessen og Tarjei Rygnestad) ble gjenvalgt. Rådet foreslo Rune Andreassen som et 4. rådsmedlem (innvelges formelt ved neste årsmøte, som legges til konferansen i Bergen 17.-20. juni 2009). Revisor Christian Lycke-Ellingsen ble gjenvalgt. Den sittende valgkomité ønsket ikke å stille til gjenvalg; til ny valgkomité ble foreslått Sigrid Kvaal og Åshild Vege. Foreningen teller pr. idag 152 medlemmer. Det er imidlertid sendt ut brev om purring på kontingenten, som nå er kr. 200.-, og vi kan av den grunn ikke utelukke en viss fremtidig reduksjon av medlemsmassen.
Oslo 18/12-08 Per Holck Sekretær.
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17 Nordic Conference on Foren ic Medicine th
BERGEN – NORWAY – 17–20 JUNE 2009
INVITATION REGISTRATION CALL FOR ABSTRACTS The 17th. Nordic Conference on Forensic Medicine will take place in June 2009, and it is a pleasure for the organizing committee to welcome you to beautiful Bergen this summer For detailed information of the program, please visit: «17th. Nordic Conference on Forensic Medicine» at: www.kongress.no Deadline for registration is April 1st. 2009, and you will be able to register online at the above website, from February 1st. Deadline for abstracts is April 1st. 2009, and you will also ﬁnd detailed information for submitting abstracts online at the above website, from February 1st. Don’t miss the chance of experiencing Bergen in June 2009! Chairman of the organizing committee: Inge Morild email@example.com Technical organizer/Secretariat: Bergen Kongress og Kultur AS ofﬁce@kongress.no
WELCOME TO BERGEN IN 2009 It is a pleasure to welcome all potential delegates to the 17th Nordic Conference on Forensic Medicine in Bergen 2009, June 17 - 20. The conference will be a forum where delegates can discuss science, current challenges and opportunities in forensic medicine. It is also the hope of the organizing committee that the conference can promote the delegates to make connections, both professional and personal, in order to improve nordic forensic medicine, on all levels. The 17th Nordic Conference will be held at the Radisson SAS Hotel Norge, right in the middle of the city centre of Bergen, Norway. The social events will be in walking distance from this hotel. We promise to present an interesting scientiﬁc programme, however, Bergen in early summer is always worthy of a visit. The organizing committee welcomes you to Bergen in June 2009. Inge Morild President
Peer Kåre Lilleng Vice president
PROGRAMME All scientiﬁc sessions are held at the Conference venue, Radisson SAS Hotel Norge. Wednesday 17. June 18:00-20:00 Get Together Party / Registration at the Conference venue: Radisson SAS Hotel Norge Thursday 18. June 08:00-09:30 Registration 09:30-09:35 Opening of conference 09:35-10:15 Clinical forensic medicine: Prof. Kari Ormstad, University of Oslo 10:15-11:00 Clinical forensic medicine 11:00-11:30 Coffee and posters 11:30-13:00 Forensic toxicology 13:00-14:00 Lunch 14:00-16:00 Forensic toxicology / Forensic odontology 16:00-16:15 Coffee and posters 16:15-17:30 Forensic odontology / Forensic anthropology 19:00-21:00 Reception (Details will follow) Friday 19. June 09:00-09:45 Terrorism and forensic science: Prof. Jack Crane, University of Belfast 09:45-10:45 Forensic pathology 10:45-11:15 Coffee and posters 11:15-13:00 Forensic pathology 13:00-14:00 Lunch 14:00-15:30 Forensic pathology / Forensic science 15:30-16:00 Coffee and posters 16:00-17:30 Forensic pathology / Forensic science 19:00-01:00 Congress Banquet at Mount Fløien Saturday 20. June 09:00-10:30 Forensic pathology / Forensic medicine / Forensic science 10:30-11:00 Coffee and posters 11:00-12:30 Forensic medicine / Forensic science / Closing of conference The program, is preliminary and changes will be made. The time schedule will, however, only be subject to minor changes.
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General information for submitting abstracts We welcome presentations from all areas of forensic medicine: forensic pathology, toxicology, genetics, odontology, osteology and anthropology, psychiatry as well as clinical forensic medicine. The abstract deadline is April 1st 2009. Abstracts should be sent electronically as an attachment in MS-Word XP, using your surname as the ﬁle name, to the abstract secretariat at firstname.lastname@example.org Please specify in your email whether you would prefer an oral or a poster presentation. We aim to conﬁrm the receipt of an abstract within relatively short time. Kindly contact us using the same e-mail address as above if you have not received any conﬁrmation of receipt or for any other abstract enquiries. Abstracts sent by ordinary mail or telefax cannot be accepted. ABSTRACT SELECTION Abstracts are selected by the Scientiﬁc Committee on the basis of their scientiﬁc merit. Notiﬁcation of acceptance for oral or poster presentation will be made in the end of April, 2009. INSTRUCTIONS ● Abstract must be written in English ● Start with a brief introductory paragraph, give the results in sufﬁcient detail to justify the conclusions, and keep the discussion as brief as possible. ● Write the title of the abstract in CAPITAL LETTERS ● Write the last names of all the authors below the title in the following format: Lilleng PK (1), Morild I (2), and write the author afﬁliations in the following format: (1) Haukeland University Hospital , (2) University of Bergen ● Font: Times New Roman ● Font size: 11 points ● Line spacing: single ● Maximum length: 2000 characters (with spaces) ● Equalize left and right margins ● All abbreviations should be spelled out when used for the ﬁrst time in the abstract Do not use any formatting like subscripts or any special symbols
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KURSUSPROGRAM - KLINISK RETSMEDICIN Mandag d. 30. marts - torsdag 2. april 2009 (26 timer) - Retsmedicinsk Institut, Skejby Sygehus Formål:
At give kursusdeltagerne kendskab til relevante aspekter af den kliniske retsmedicin både hos børn og voksne. Der er lagt vægt på samarbejdsparternes funktioner fra anmeldelse over socialvæsenet til de psykologiske konsekvenser af overgreb samt centerfunktionerne omkring visse typer ofre. At gøre kursusdeltagerne i stand til at udføre klinisk retsmedicinsk undersøgelse med maksimalt efterforskningsmæssig udbytte samtidig med at hensynet til den undersøgte, herunder behandlingsbehov og behov for opfølgningen tilgodeses. Undervisningen vil være både teoretisk og case-baseret. Der vil være forberedelse for kursisterne, som også opfordres til at medbringe cases til evt. diskussion indenfor de programsatte emner, dog bør evt., materiale til diskussion være delkursuslederen i hænde senest 3 uger før kursus start m.h.b. På orientering til underviserne og de øvrige kursister. Alt undervisningsmateriale udsendes i rimelig tid inden kursus start.
Deltagere: Kurset er rettet mod personer i hoveduddannelsesstillinger i Retsmedicin, personer med meritoverførsel i retsmedicin og speciallæger i retsmedicin, som ønsker at deltage i kurset, personer i tilsvarende forløb fra de øvrige Nordiske lande. Tilmelding: Via selskabets hjemmeside, senest 02.03.09. MANDAG D. 30 MARTS 2009 Pauser lægges ind i programmet efter behov Kl. 10.45-11.15 Kl. 11.15-13.00
Velkomst og præsentation. Delkursusleder, Jytte Banner Efterforskning af personfarlig kriminalitet (vold og voldtægt). v/ ka. Gitte Christensen, Østjyllands Politi
Efterforskning af seksuelle overgreb og vold mod børn – videoafhøring, straffe- og retsplejelov, vejledninger mv. v/ ka. Gitte Christensen, Østjyllands Politi og Rigsadvokatassesor, Torben Borregaard, Rigsadvokaten Efterforskning - “Tøndersagen”. v/ka Tom Christensen, NEC- Rejseholdet
TIRSDAG D. 31. MARTS 2009 Pauser lægges ind i programmet efter behov Kl. 09.00-11.00 Kl. 11.00-12.00
Undersøgelse af volds-, voldtægtsofre og sigtede - systematisk gennemgang af undersøgelsesforløb og udformning af erklæringen.v/vicestatsobducent Ingrid Bayer Kristensen Erfaringer for voldtægtsundersøgelser - praktisk og videnskabelig. v/læge, ph.d. Ole Ingemann Hansen og cand. psych. Rikke Bramsen
Tortur og undersøgelser i tortursager. v/professor Jørgen Thomsen, Inge Genefke, og Professor Bent Sørensen, Rehabiliteringsråd for Torturofre (IRCT). Legemsindgreb v/professor Jørgen Thomsen Reaktionsmønstre og psykologiske aspekter ved voldtægts- og voldsofre. v/Anja Hareskov Madsen, Center for Voldtægtsofre, Århus Sygehus
Kl. 15.30-16.00 Kl. 16.00-17.00
ONSDAG D. 1. APRIL 2009 Pauser lægges ind i programmet efter behov Kl. 09.00-12.30
Den objektive undersøgelse og fund ved børn udsat for seksuelle overgreb Undersøgelsens brugbarhed - Hvad ved vi? v/vicestatsobducent Jytte Banner Center for Børn udsat for Overgreb. v/overlæge Hanne Nødgaard, CBO, Skejby Sygehus
Seksuelle overgreb mod børn - på Internettet (børnepornograﬁ,grooming mv. ). v/konsulent Søren Christensen, NITEC og vicestatsobducent Ingrid Bayer Kristensen (case-gennemgang) Kommunikation med børn og unge i alderen 12 - ca. 17 år. v/cand.psych. Inge Stage, Sct. Stefans Rådgivningscenter
TORSDAG D. 2. APRIL 2009 Pauser lægges ind i programmet efter behov Kl. 09.00-12.00 Kl. 12.00-14.00 Kl. 14.00-16.00
Undersøgelse af børn og unge under 18 år, hvordan forholderman sig til det, i henhold til lov om social service? v/lektor, cand.jur. Lars Horskær Madsen Mødet med andre etniske kulturer. v/cand.psych. Mansour Esfandiari, Tværkulturel Psykologisk Rådgivning Gerningsmanden - psykologisk belyst forskellige typer gerningsmænd - Behandlingen. v/psykiater Henrik Day Poulsen
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DELKURSUS RETSGENETIK OG KRIMINALTEKNIK Formål: ● At give kursusdeltagerne kendskab til relevante aspekter af retsgenetikken, specielt de praktiske konsekvenser heraf, især i forbindelse med prøvetagning ved personundersøgelser, ﬁndstedsundersøgelser og obduktioner samt en basis for fremtræden i retten. ● At give kursusdeltagerne en sådan forståelse for samvirke mellem kriminalteknik og retspatologi at de kan gennemføre ﬁndesteds/gerningsstedsundersøgelse, obduktion og personundersøgelser med maksimalt efterforskningsmæssigt udbytte. Deltagere:
Målgruppen for kurset er uddannelsessøgende i hovedforløb i speciallægeuddannelsen i Retsmedicin, personer med meritoverførsel og speciallæger i retsmedicin . Tid: Onsdag den 13. Maj kl. 10.00 til 17.00 og torsdag den 14. maj 2009 fra kl. 0800 til 1600. Sted: Onsdag: Retsgenetisk afdeling, Retsmedicinsk Institut, Københavns Universitet, Fr. den V’s vej 11, 2100 København Ø Torsdag: Kriminalteknisk Center, Slotsherrensvej 113, 2720 Vanløse. Kursusledelse: Vicestatsobducent Peter Thiis Knudsen, Retsmedicinsk Institut, Syddansk Universitet (Del-kursusleder), Retsgenetiker Bo Simonsen (RGA) og vicepolitiinspektør Bent Hytholm (KTC). Tilmelding: Via selskabets hjemmeside, aktiveres senest en måned før kursus start. PROGRAM: Onsdag den 13. maj 2009: 1000 Velkomst og praktiske oplysninger 1015 RGA – Opbygning og arbejdsområder. 1100 Det videnskabelige grundlag for retsgenetiske undersøgelser 1200 Frokost 1300 Praktisk retsgenetik - Personundersøgelser 1400 Praktisk retsgenetik - Obduktioner 1500 Pause 1530 Praktisk retsgenetik - Identiﬁkation 1630 Diverse 1700 Afslutning
PROGRAM: Torsdag den 14. maj 2009: 0800 Introduktion 0815 Samarbejde på gerningssteder i forbindelse med ﬁndestedsundersøgelser, bl. a.: o Krav og forventninger indbyrdes o Gerningsstedsdisciplin o Kvalitetskrav og kontamineringsproblematikken o Sportyper, sportolkning og sporsikring o Dokumentation o Erklæringsindhold RI og KTC 0945 Pause 1005 Samarbejde på gerningsstederne – fortsat. 1130 Frokost 1215 - 1255 Sporsektionen – diverse sportyper og deres identiﬁkationsværdi 1300 - 1340 ID-sektionen 1345 Obduktioner og personundersøgelser 1415 Pause 1435 - 1515 Fingeraftrykssektionen 1520 - 1600 Våbensektionen 1600 Evaluering og afslutning Med venlig hilsen
Bo Simonsen Retsgenetiker
Peter Thiis Knudsen Vicestatsobducent
Bent Hytholm Vicepolitiinpsektør
DELKURSUS JURA OG RETSMEDICINSKE ERKLÆRINGER Formål: ● At give kursusdeltagerne kendskab til relevante juridiske principper og de praktiske konsekvenser heraf, især i forbindelse med fremtræden i retten. ● At give kurusudeltagerne kendskab til principperne for udfærdigelse af retsmedicinske erklæringer og disses anvendelse i praksis Deltagere: Målgruppen for kurset er uddannelsessøgende i speciallægeuddannelsen i Retsmedicin. Personer på meritoverførsel inden for specialet og speciallæger i retsmedicin Tid: Onsdag den 09. september 2009 fra kl. 0900 – 1600. Sted: Retsmedicinsk Institut, Syddansk Universitet, Lokale 19.11, J. B. Winsløwsvej 19 5000 Odense C. Kursusledelse: Vicestatsobducent Peter Thiis Knudsen Undervisere: Politiadvokat Henrik Andersen, Fyns Politi og vicestatsobducent Peter Thiis Knudsen Tilmelding: Via selskabets hjemmeside som aktiveres senest en måned før kursusstart
PROGRAM: Onsdag den 09. september 2008: 0900 Velkomst og praktiske oplysninger 0915 Juridiske krav til erklæringer, specielt retsmedicinske erklæringer 1045 Pause 1100 Den praktiske anvendelse af retsmedicinske erklæringer i retten 12.30 Frokost 13.15 De retsmedicinske erklæringers udformning 14.15 Pause 14.30 De retsmedicinske erklæringers udformning, fortsat 15.15 Diskussion 16.00 Afslutning
Med venlig hilsen Peter Thiis Knudsen Vicestatsobducent
Henrik Andersen Politiadvokat
Leica FS M New Forensic Comparison Macroscope The new Leica FS M forensic comparison macroscope provides superior optical and mechanical performance to forensic scientists. Offering ďŹ‚exibility, convenience, and user comfort, the Leica FS M is the universal instrument for high-precision ďŹ rearm and toolmark examinations. The highly stable comparison bridge, the ergononmic design and the highest optical performance combined with versatile illumination options makes this system ideal for the simultaneous observation of evidence during training and consultation.
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