April Stanley-Banks

Clinical Nurse / Clinical Practice

Consultant

Emergency / Acute Assessment Unit

Education Link Nurse

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• Substance abuse

• Domestic violence

• Poverty and unemployment

• Access to weapons

• Gang formation

• Drug and alcohol abuse

• Interpersonal violence

• Criminal activity

• Medical conditions which affect

cognitive abilities.

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Forensic Nursing: Application of

Nursing to the Law

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An intersection where Nursing and the Law meet creating a cross-road where a new perspective to nursing exists.

The application of Forensic Science, combined with clinical Nursing practice as they are applied to the Criminal Justice System, civil litigation and public or legal proceedings in the law enforcement arena.

The application of Forensic aspects of health care combined with bio-psychosocial education of the Registered Nurse in the scientific investigation and treatment of trauma, violent or criminal activity, and traumatic accidents within the clinical or community institution.

A developing role involving the identification, collection and preservation of evidence in a chain-of-custody process from living Forensic patients.

An opportunity for Nurses to communicate with Law enforcement personnel, protective agencies, defence attorneys and prosecutors.

An opportunity for Nurses to uphold the principles of objectivity in public inquiry and human rights.

The facilitation of deterrence of criminal activity and violent assault.

(Lynch 2006)

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• Nurse Coroners

• Nurse Attorneys/Legal Nurse Consultants

• Forensic Psychiatric & Mental Health Nurse

• Domestic Violence Nurse

• Sexual Assault Nurse Examiner (SANE)

• Pediatric Forensic Nurse

• Correctional Nurse

• Clinical Forensic Nurse

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• Identification

•Care for the Survivor

•Care for the Perpetrator

• Identification & Collection of evidence :

Circumstances surrounding injury

Type of weapon(s)

Length of time between injury and treatment

Nature and their pattern of injury

Witnesses

Care of clothing

Chain-of-custody for evidence

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Emergency nurses are often exposed to extreme human behaviour such as:

• 1. Abuse of the disabled

• 2. Assault and battery

• 3. Burns > 5% body surface area

• 4. Child abuse and neglect

• 5. Clients in police custody

• 6. Domestic Violence

• 7. Elder abuse and neglect

• 8. Firearm injuries

• 9. Food and drug tampering

• 10. Forensic psychiatric clients

• 11. Gang violence

• 12. Human and animal bites

• 13. Malpractice and/or negligence

• 14. Motor vehicle trauma

• 15. Occupation-related injuries

• 16. Organ and tissue donation

• 17. Personal injury

• 18. Product liability

• 19. Questioned death cases

• 20. Sexual assault

• 21. Sharp force injuries

• 22. Substance abuse

• 23. Transcultural medical practices

• 24. Toxic exposure

• 25. Victims of mass destruction/terrorism

• 26. End of life decisions: Do Not Resuscitate (NFR)

• 27. Control of communicable diseases

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• Removal of hair from a person’s

body.

• Removal of material from

beneath a finger or toe nail.

• Removal of biological or other

material from the external part

of the body.

• The taking of a DNA sample by

buccal swab.

• The taking of a finger print.

• The taking of an impression or

cast of a wound.

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and preservation

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Things to note:

Circumstances surrounding injury

Type of weapon(s)

Length of time between injury and treatment

Nature and pattern of injury

Witnesses

Care of clothing

Chain of custody

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Besides emergency care, attention should also be focused on the responsibilities to preserve and protect as much evidence as possible.

Maintain an index of suspicion

Identify sustained patterns and patterned injury

Distinguish between intentional or accidental injury

Distinguish between blunt and sharp force injury

Documentation must be objective

Facts, not assumptions, opinions nor allegations are recorded

Care must be taken in any interpretation of any alleged explanation of injuries by patients

Patient behaviour and statements or utterances must be documented

• Domestic Violence, abuse or neglect

• Trauma (non accidental or suspicious)

• Vehicular/automobile vs. pedestrian accidents

• Substance abuse

• Attempted suicide/homicide

• Occupational injuries

• Environmental hazard incidents

• Terrorism/violent crime victims

• Illegal abortion practices

• Supervised care injuries

• Public health hazards

• Involvement of firearms/weapons

• Prominent individuals/celebrities

• Unidentified individuals

• Damaged/improperly used equipment

• Poisonings, illegal drugs, overdose

• Anyone in police custody

• Sudden, unexplained, suspicious deaths

• Sexual assault or abuse

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Physical evidence can:

Identify whether a crime has been committed

Identify the offender or exonerate a suspect

Link a person with another person or a scene

Link an object to another object or a scene

Verify or contradict specified statements by person(s)

Physical evidence is classified as any matter such as:

clothing,

hair,

fibres,

bullets,

body fluids,

DNA, debris,

contusions,

Lacerations

Marks on the skin such as bruises or bite marks,

Foreign bodies.

Physical evidence can be defined as any matter

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The forensic nurse looks for

deposits

of:

gun powder residue,

soot,

fire accelerant,

particle patterns,

imprints,

defining cuts from

penetrating

weapons,

bullets.

Extreme care must be taken

to preserve these findings

when removing clothing

from victims or offenders.

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A white sheet or

paper is placed under

the victim or offender

while

undressing to catch

such

evidence.

These sheets and

papers are then

folded and placed in

paper bags and

sealed.

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Care must be taken so as not to make folds through specific

evidentiary areas in clothing.

Clothing cut away is preserved

and reconstructed to reflect

circumstances of trauma.

Holes, rips and tears often

reveal mechanism of

injury.

Consider if bodies have been

washed down before

arrival.

• Minimise handling of

evidence

• Prevent cross-

contamination

• Maintain evidentiary

integrity

• Maintain evidentiary

probative value

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Apart from physical evidence, early

collection of biological specimens are

invaluable for prosecutorial outcome.

Positive blood toxicology can be used to

corroborate the involvement of a drug in

sexual assault.

This is crucial as recent legislative efforts

are issuing higher penalties for those who

use controlled substances with the intent to

commit sexual assault or other violent

crime.

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• Hair indicates drug use over months

• Saliva indicates the present parent

drug

• Sweat indicates drug use over

weeks

• Nails demonstrates drug use over

months

• Blood determines drug use over

hours or days

• Urine carries a high potential for

donor if contamination of collection

is unsupervised.

• Buccal, vaginal and genital swabs

yield information for DNA

profiling. These swabs are dried

before storing.

• Mitochondrial DNA is harvested

from hair plucking’s including hair

roots.

• In cases of sexual assault, pubic

hair combings and fingernail

scrapings are collected.

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• Research reveals that

knowledge of type,

location and severity of

injuries and wounds in

both male and female

victims and offenders is

extremely useful for the

identification of

mechanism of injury.

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Research demonstrates:

most head lesions occur on the left side of the victim’s head/face

males generally sustain wounds to their nose and mouth

females sustain abrasions to their neck through strangulation

most offender upper limb injuries occur at the dorsal right hand

involving fourth and fifth metacarpal bone fracture.

• u-shaped arches not

touching at the base

• central contusion or

erythema

• sucking marks

• some shallow

puncture marks

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• v-shaped and deep

puncture marks

• associated parallel

linear lacerations and

abrasions

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• age, race, skin

thickness/elasticity

• location/underlying

support of body

structure

• strength/movement of

biter

• temperature/humidity

• contamination

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• Multiple bruises of different ages

• Any wound showing the shape of the object causing it

• Flow of hot liquid not consistent with burned areas of skin and body position at time of burning

• Scalds to buttocks, perineum, genitalia

• Splash or immersion burns

• Dislocations/sprains not fitting with age or mobility of a child

• Facial, head/neck bruising, choke

marks

• Unexplained abdominal injury,

bleeding/rupture

• Unexplained unconsciousness

• Evidence of skull fracture

• Bleeding in back of eye

• Any fracture in infant too young to

walk

• Fractured ribs (especially

posterior)

• Multiple fractures of different

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Preservation of

Evidence

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• all evidence collected

• all treatment and procedures

implemented

• all wounds and their location, severity,

size, colour and characteristics

• any statements, utterances and

behaviours expressed

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• Who handled the evidence

• What was handled

• Why it was handled

• Where it was located at all times

• Recognize: Does the patient fit into a Forensic category?

• Assessment: Does the patient have specific Forensic needs?

• Collection & Preservation: Does your patient require you to

collect evidence?

• Documentation: Patient history in quotes, measure injuries,

maintain Chain-of-Custody, lock up all evidence collected,

discharge referrals, (does the patient require specific referral

agency upon discharge?

• Report: Do you need to call the Police and/or inter-agencies?

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Chain of Custody Form Patient Label

List of Evidence/Items:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

___________________________________________________________________

Total Number of Items/Evidence Bags Collected __________________________

Agency receiving

evidence:____________________________________________________________

Person given

evidence:____________________________________________________________

Signature of person receiving

evidence:____________________________________________________________

Date Evidence was

Released:____________________________________________________________

Time Evidence was

Released:____________________________________________________________

Hospital Staff

Collector:____________________________________________________________

Hospital Staff

Signature:___________________________________

A = Airway

B = Breathing

C = Circulation

+

E = Evidence

F = Forensics

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• Ballistics

• Legal standards

• Deposition and courtroom testimony

• Crime scene processing

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As well as contemporary and social justice issues

such as:

• Human rights/reconciliation and justice

• International Humanitarian Law

• Terrorism and torture

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The objectives of Forensic Nursing intervention remain largely

unaddressed even though…

‘Every individual who works in a health care facility should receive

basic Forensic education. This is essential to meet the standards and

limit liability in the event of a failure to recognise indications of

injuries associated with;

• sexual assault

• child or elder abuse

• domestic violence

• other Forensic trauma”

Lynch 2006 p10.

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• A patient’s evaluation must be adequately documented,

narratively, diagrammatically and photographically in the

patient’s chart for possible use in future legal actions.

• The failure to do so may have far ranging consequences for

the hospital, the patient and potentially for the treating

physician.

Facilitating the legal and ethical obligations of forensic clients

Preventing miscarriages of justice in the community

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• Training in interviewing forensic clients

• Supply of camera to capture photographic evidence

• Supply of appropriate kits for evidence collection

• Provision of side room privacy for victims of abuse and sexual assault

• Raising awareness of inter-agency membership for protection of human

rights

• Training in documenting evidence according to judicial requirement

• Raising awareness for various classifications of forensic populations

• Training in identification of physical, trace and biological evidence

• Raising knowledge of levels of court proceedings

• Preparation of testimony Supply of appropriate documentation and

anatomical charts

• Training in communication with law enforcement personnel

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• Department of Health South Australian Government 2002, Mental Health- the Case

for Change, submission 506, chapter 2, pp. 16, accessed 11th May 2009,

http://www.aph.gov.au/senate.committee/mentalhealth_ctte/report/co2.pdf

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