Examination of Maltreatment Victims

Essentials

• In the examination of maltreatment victims, a physician's role consists in providing treatment and writing a statement for any court proceedings.
• Treatment should be provided according to medical assessment.
• All findings suggestive of maltreatment must be accurately and systematically recorded.
• The statement should be written in plain language (avoid medical jargon), objective and impartial.

Observations

• Patient interview and recording of any injuries
  • Interview the victim, recording the data on a body diagram.
  • Record the injuries carefully, with the help of drawings and measurements, for example.
  • Take photographs of the injuries, as far as possible. Always include a ruler or tape measure in photographs, and take photographs from various angles.
• A nurse should provide material on psychological support, as necessary.
• Always examine the whole body, systematically from head to toe, for instance. Have the patient take off their clothes from one part of the body at a time (first the upper and then the lower body, for instance).
• Record essential general and normal findings and the examinee's behaviour.
• Record all injuries carefully (location, size, form, colour, and other indications of the timing and mechanism of injury).
  • Recording absence of injury may also be essential; compare the patient history to the findings.
  • Record any intoxication from alcohol or other intoxicants. Take samples as requested by the police or as directed by your institution.
• The description should enable a statement to be written to provide an impression of the injuries.
  • Check the local legal practice concerning statements and the obligation to maintain secrecy.

The concept of causality and the degree of severity of injury in the statement

• Please note that the concept of causality may be understood differently in a court from how it is understood in natural science (medicine).
• Terms used to describe levels of probability (such as "likely" or "possibly") and their exact definition in a legal context may differ between countries.
• In a legal context, words describing severity (e.g. severe and mild) can have specific meanings affecting legal consequences, such as, in the case of maltreatment, the level of the penalty.

Structure of certificate

1. Name and purpose of the medical certificate
   • For which authority, for whom?
   • In what matter?
   • For what purpose?
   • Is the certificate based on an examination performed by the author or on patient records?
2. Introduction
   • Party requesting the examination (e.g. the patient, an authority)
   • Reason for the examination (e.g. injuries from maltreatment)
   • Personal data of the person being examined, and how these were ascertained
3. History
   • How did the patient arrive (by themselves, by ambulance, escorted by the police, etc.)?
   • The events as described by the examinee (time and place, mechanism of injury)
   • Data on the incident presented in the statement request given by the police, if available
   • How the examinee reacts to the incident
4. Observations made in the examination
   • Time (date, time)
   • General condition and behaviour of the examinee
   • All injuries and abnormal findings, as well as normal findings that are essential for the examination
   • Location, size, form, and colour of injuries, and any other observations concerning the origin of the injuries, systematically and accurately (drawings, photographs, official forms)
     • For example: Medially on the right upper arm, a 3-cm long sharp-edged wound / lacerated, partly crusty wound, etc.
   • Age of the injuries (colour of bruising, scarring of wounds, etc.)
5. Conclusions
   • The physician's opinion on whether the findings are consistent with the history
     • Consistency of the findings with the examinee's report or with the data provided by the party requesting the examination, and any incompatibility between the injuries and the suggested mechanism of injury and/or the examinee's behaviour
     • An excessively accurate estimate of how the injuries occurred should not be given (it is, for instance, hard to assess exactly what blunt weapon was used to produce the injury).
     • Probability of causal connection
     • Any evident conflict between the history and the findings should be mentioned.
   • Severity and possibly life-threatening nature of the injuries (such as a large wound on the neck close to a large blood vessel)
     • Any threat to life should only be assessed based on concrete findings: a contusion causing unconsciousness for more than 24 hours, intracranial haemorrhage, any perforating brain injury and most penetrating brain injuries, flail chest, serial rib fractures (> 7), severe haemopneumothorax, diaphragmatic rupture, cardiac tamponade, severe liver and spleen rupture, or simultaneous injury to two or more abdominal organs.
     • Any abstract danger to life should be assessed by a court (accurate description of the event helps in this process).
   • A brief account of therapeutic procedures and further treatment
     • Length of hospital treatment, period of incapacity for work
     • Assessment of pain, medication given
   • Prognosis of healing / permanent disability / invalidity (bruising, for example, will heal in a couple of weeks without permanent disability, and the final assessment of any sequelae of fractures can only be given after 6 months)
   • Conclusions are important for the court because laymen (such as lawyers) often lack medical knowledge.
6. Certification, date and signature
   • Local requirements may apply regarding the format.