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Humanitarian forensic action is the application of the knowledge and skills of forensic medicine and science to humanitarian action, especially following conflicts or disasters. It has its early roots in the experience of the Argentine Forensic Anthropology Team and that of the Grandmothers of Plaza de Mayo in Argentina, is moulded by International Humanitarian and Human Rights Law and was developed by the International Committee of the Red Cross. Having demonstrated its worth, this new field of application of forensic medicine and science needs further development, integration and research.

Forensic pathology is a specialty that involves death investigation while clinical forensic medicine is the application of the practice of medicine to the requests of the law in relation to the living. Around the world, there is diverse practice for these two disciplines. The forensic physician or forensic doctor (sometimes, called a forensic pathologist but not a forensic histopathologist) in parts of the world such as continental Europe, the Middle East and India, practice both clinical forensic medicine and forensic pathology. This is the specialty, for the purposes of this paper, we will call forensic medicine. The forensic doctor will usually receive training in autopsy dissection, perhaps with a short training of a few months in anatomical pathology or surgical histopathology. When undertaking autopsies (involving internal as well as external examination), if it is thought histological assessment is required, the forensic doctor will sample the organs and tissues required and refer the specimens to the hospital histopathologist for microscopic examination. This division of responsibility could compromise the quality of the autopsy unless handled correctly.Where the histological assessment of the autopsy specimen is undertaken by a pathologist other than the one who dissected the body and collected the samples, standard operating procedures need to be developed to minimize the risk to the overall quality of the autopsy. We are not aware that any such procedures have been published, hence we offer an outline of what a set of such procedures might contain.

Atlanto-occipital dissociation injury is an important injury in forensic pathology practice. Radiological diagnosis of atlanto-occipital dissociation clinically is assessed by direct measurement of occipito-vertebral skeletal relationships. Different measurements may be used to diagnose atlanto-occipital dissociation, including the basion-dens interval (BDI) and basion-axial interval (BAI). It is not known whether the normal ante-mortem measurements of BDI and BAI described in the literature are applicable to post-mortem CT images of the occipito-cervical junction (OCJ) or whether these measurements could be affected by early post-mortem changes. This study aims to compare post-mortem BDI and BAI measurements with ante-mortem values. Post-mortem CT scans of the cervical spines of 100 deceased adults were reviewed, and the BDI and BAI were measured. Different parameters were recorded in each case. The results from this study suggest that there are no effects of post-mortem changes on the measurement of BAI as relied upon clinically. There appear to be some effects of fully established rigor mortis on BDI measurement, shortening it. This may have consequences for the post mortem diagnosis of atlanto-occipital dissociation.

The proper and dignified management of the dead is one of the three pillars of the humanitarian response to disasters, along with the rescue and care of survivors and the provision of essential services. First launched in 2006, the widely used publication Management of Dead Bodies after Disasters: A Field Manual for First Responders offers practical and easy-to-follow guidelines. It has become the go-to guide not only for non-experts confronted with dead bodies in the aftermath of a catastrophe, but also for those responsible for disaster planning and preparedness in countries with well-developed forensic services. Ten years after the publication of the 2006 Manual, a revised edition has been released. The inclusion of a decade of experience in its field implementation, as well as the incorporation of recent scientific developments in mass fatality management, makes the revised Manual an invaluable resource for first responders confronted with the realities of dead body management following a disaster.

The management of the recent Ebola virus disease (EVD) epidemic continues to pose currently insuperable challenges to health care providers in the resource-deprived countries of West Africa. In an age where air travel facilitates rapid movement of people between countries and continents, there is an urgent requirement for health systems around the globe to develop management strategies and protocols in the event that EVD cases are suspected or confirmed. Departments of forensic pathology play an important, and underestimated, role in public health service delivery, particularly at times of novel infectious disease emergence. This role can include disease identification, characterization, and notification, as well as close engagement with agencies responsible for disease surveillance and treatment provision. A mass outbreak of EVD in the Western world is considered highly unlikely; however, there is clear responsibility on departments of forensic pathology to develop protocols for rapid assessment of sporadic or suspected cases while ensuring the health and safety of mortuary and pathology personnel. The Ontario Forensic Pathology Service and the Victorian Institute of Forensic Medicine have collaborated on the development of a protocol for management of EVD cases presenting at a scene or in the mortuary. It is hoped that this trans-national, inter-departmental exercise will serve as a model for future co-operative endeavors. The protocol has been distributed to forensic pathology departments around Australia and may be modified to accommodate local resource capabilities.

With some of their economies, communities and health systems weakened by decades of war and poor governance, it was no accident that an epidemic of Ebola virus disease broke out in west Africa. Being spread in part by contact with body fluids of those who had died from the disease, funerary rites and the way dead bodies were managed were important modes of transmission. The Liberian Red Cross, supported by the International Federation of Red Cross and Red Crescent Societies and the International Committee of the Red Cross, undertook the challenging task of managing the dead bodies in Monrovia during the epidemic. The work was undertaken by volunteers, not health care workers, who were trained and equipped for this task. The authors observed their work and were impressed. Valuable lessons were learned for mortuaries generally, and for Humanitarian Forensic Action involving the management of highly infectious human remains.

An autopsy is a significant event and should not be undertaken for simply narrow purposes. Forensic pathology institutions, whether in coronial or medical examiner jurisdictions, should be actively engaged in research, either directly or by facilitating access to bodies, tissues and data. The challenge, assuming that resources are available, is to do this lawfully, ethically, and in accordance with community expectations. Failure in the challenge will be wrong and cause damage to the reputation of the institution. The risks associated with such research therefore need to be managed. An approach which is transparent and based on respect for the deceased and consent for the activity, while no guarantee of success, is likely to engender community confidence in the activity and in those undertaking it.

The contribution from Pollanen [1] in this issue of the Journal is not only rare in that it is a report of fatal torture, it is the first time that the fatal potential and pathology of reverse hanging have been published. Aside from its appearance in the peer reviewed academic literature, the contribution is extremely important on a number of other counts. Firstly, it reminds us of torture. Article 5 of the Universal Declaration of Human Rights states that ‘‘no one shall be subject to torture or to cruel, inhuman or degrading treatment or punishment’’ [2]. Article 1 of the UN Convention against Torture defines torture as: ‘‘... any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions’’ [3]. As Pollanen points out, the bodies of those who die from or with torture are seldom presented for autopsy. The authorities in such contexts aggravate their reign of terror by hiding these things in the dark. The people know by word of mouth that it is happening, their family members are taken away and cannot be found, the family receive no news of their fate, and they fear the worst. It is likely however, that for some of our colleagues on the forensic frontline, dealing with the aftermath of torture is probably a regular experience. We really do not know, and are never likely to know how often this might occur. If and when the bodies are presented for autopsy, there is no framework of independence for the pathologist; worse, there is real danger. This is in complete breach of one of the fundamental precepts of medical practice, expressed as follows by the World Medical Association in its International Code of Medical Ethics: ‘‘A physician shall be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity’’ [4]. In the circumstances of Pollanen’s case, such an ethic is no more than imaginary. It should not be forgotten that it is States which have the obligation to create the circumstances where such independence can be exercised. It would take a remarkable pathologist (a heroic one actually) in a repressive regime to inform the system of the existence of a case such as this one. The pathologist would be running the personal risk of serious reprisals, as well as putting their family and perhaps work friends and colleagues at risk. The case might be signed out as acute renal failure, and while this would be incomplete, it is probable that no one would ask any questions; most would think death was from some form of natural disease. The risk faced by the pathologist in such a case is a particular example of a more general phenomenon: health care workers around the world are working under increasingly threatening circumstances [5]. Hospitals in Somalia, Sri Lanka, Afghanistan and, recently on 15 & Stephen Cordner stephen.cordner@vifm.org

Although this is a chapter on the medicolegal aspects of the autopsy, the starting point is ethical: The autopsy is a procedure of considerable ethical significance because it interferes with the body. This significance means that the autopsy should not be undertaken for insignificant reasons or purposes. There are substantial potential benefits to the autopsy, within ethical, legal, and resource constraints, and if an autopsy is to be performed, these should be maximized. These are discussed, along with the role of the pathologist: to whom she/he owes a duty, and what is the content of this duty? Managing the mortuary, and issues around the removal and retention of organs and tissues for diagnostic purposes are canvassed.

This chapter provides a brief overview of some international forensic medical and scientific organizations. There is an impressive number of organizations, many of which have a long history of publishing, hosting congresses, and contributing to the development of a field which underpins civil society and the rule of law.

Murder, medicine and motherhood, by Emma Cunliffe, Oxford, Hart Publishing, 2011, 232 pp., hardback This book explores how we deal with a small subset of supposed child homicides in our criminal ju...

The 2009 Victorian Bushfires Disaster started on a record hot day in February 2009 and resulted in over 300 separate fires with a death toll of 173 and over 400 presentations to hospital emergency departments. This occurred a little over a week after a heat wave in which over 400 people were thought to have died prematurely in southeastern Australia. The Victorian Institute of Forensic Medicine in collaboration with the police force and the State Coroner's Office and over 100 colleagues from all over Australia, Indonesia, New Zealand and Japan implemented a DVI process based on Interpol guidelines to identify the deceased persons. CT scanning was conducted on all remains collected and played a pivotal role in the identification processes in conjunction with experts in pathology, anthropology, forensic odontology and molecular biology. This paper outlines the scale of the disaster and the work, from a forensic medical perspective, to identify the deceased.

This article is a subject review summarizing and interpreting the existing knowledge on the question "Can a simple short fall cause fatal head injury in an infant?" It also reflects on the challenges of undertaking a review in the contentious area of pediatric forensic pathology. The authors identified and considered 1055 publications for inclusion. Using explicit selection criteria 27 publications were included in the subject review. The literature suggests that it is rare, but possible, for fatal head injury to occur from a simple short fall. Large population studies of childhood injuries indicate that severe head injury from a short fall is extremely rare. This is counter pointed by a single documented case report that demonstrates it can happen. The question of whether it is a credible claim in a particular case is inextricable from the circumstances of that case.To strengthen the evidence based on fatal potential of simple short falls in infants, future studies addressing this question would ideally be prospective in design and include the key elements of: (1) a large sample size, (2) clearly defined comparison groups, (3) clear and verifiable criteria for causation, (4) specified fall height, (5) specified fall type: vertical free fall or the presence of additional forces, (6) composition of contact surface, and (7) nature of contact point: concentrated to one point or onto a flat surface.We believe subject reviews for forensic pathology require a specific approach because the application of information differs between clinical and courtroom settings.

Victoria's new trauma care system has been followed by reductions in preventable and potentially preventable deaths and in deficiencies contributing to death. This improvement has followed triaging more patients to expanded major trauma services where mortality was already lower rather than to improved results within the major trauma services, metropolitan or rural trauma services or ambulance services, Victoria. The objective of the present study was to identify continuing inadequacies within the individual trauma services and in association with representatives of these services to develop appropriate countermeasures. Initially, presentations were made to each trauma service of their fatalities evaluated after introduction of the new trauma system. At separate working party meetings with each service consensus recommendations were finalized and these disseminated to stakeholders. Recommendations related to the need for Trauma Director/Coordinator appointments at all designated hospitals receiving major trauma, improved facilities and equipment, the trauma team, referral, communications, protocols, a prompting system, education, audit and feedback, infrastructure, staffing, documentation and inter-hospital patient transfer. Interaction between the Consultative Committee on Road Traffic Fatalities and Victorian trauma services identified continuing deficiencies in the new trauma care system and developed consensus recommendations to target these problems. These require implementation through the State Trauma Committee.

The Consultative Committee's findings that preventable or potentially preventable (P/PP) death rates (survival prospectsor =25%) of road crash fatalities who received treatment were unaltered between 1992 and 1998 led to a Ministerial Taskforce on Trauma and the gradual introduction of a new Victorian trauma care system. The present study compares outcomes before (1997-1998) and after (2002-2004) the new system.The emergency and clinical management and death preventability of 245 consecutive fatalities in the 'before' period and 193 in the 'after' period was assessed by the committee's multidisciplinary panels using the complete hospital, ambulance, and autopsy findings.Emergency department admissions to expanded Major Trauma Services (MTS) increased from 34% to 62% (p0.05). More patients were attended by Advanced Trauma Life Support paramedics (p0.05) and scene times increased (p0.05). Patients admitted within 1 hour decreased from 70% to 45% (p0.05). The mean number of deficiencies per patient including those contributing to death was decreased (p0.05). The combined P/PP death rates decreased from 36% to 28% (22% relative risk reduction). The P/PP death rates for MTS, Metropolitan Trauma Services, Rural Trauma Services, and Urgent Care Centers for 2002 to 2004 were 25%, 33%, 50%, and 83%, respectively, and did not differ significantly from those of 1997 to 1998 (23%, 49%, 36%, 75%, respectively). The P/PP death rates in MTS were less than those of the other hospital groups.The new Victorian trauma care system has resulted in a significant decrease in deficiencies including those contributing to death and a decrease in P/PP deaths rates. The improvement has been largely consequent to a marked increase in admissions to MTS.

The subject of missing persons is of great concern to the community with numerous associated emotional, financial, and health costs. This paper examines the forensic medical issues raised by the delayed identification of individuals classified as "missing" and highlights the importance of including dental data in the investigation of missing persons. Focusing on Australia, the current approaches employed in missing persons investigations are outlined. Of particular significance is the fact that each of the eight Australian states and territories has its own Missing Persons Unit that operates within distinct state and territory legislation. Consequently, there is a lack of uniformity within Australia about the legal and procedural framework within which investigations of missing persons are conducted, and the interaction of that framework with coronial law procedures. One of the main investigative problems in missing persons investigations is the lack of forensic medical, particularly, odontological input. Forensic odontology has been employed in numerous cases in Australia where identity is unknown or uncertain because of remains being skeletonized, incinerated, or partly burnt. The routine employment of the forensic odontologist to assist in missing person inquiries, has however, been ignored. The failure to routinely employ forensic odontology in missing persons inquiries has resulted in numerous delays in identification. Three Australian cases are presented where the investigation of individuals whose identity was uncertain or unknown was prolonged due to the failure to utilize the appropriate (and available) dental resources. In light of the outcomes of these cases, we suggest that a national missing persons dental records database be established for future missing persons investigations. Such a database could be easily managed between a coronial system and a forensic medical institute. In Australia, a national missing persons dental records database could be incorporated into the National Coroners Information System (NCIS) managed, on behalf of Australia's Coroners, by the Victorian Institute of Forensic Medicine. The existence of the NCIS would ensure operational collaboration in the implementation of the system and cost savings to Australian policing agencies involved in missing person inquiries. The implementation of such a database would facilitate timely and efficient reconciliation of clinical and postmortem dental records and have subsequent social and financial benefits.

Introduction:This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes.Methods:The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion.Results:One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable.Conclusion:The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.

BACKGROUND Victoria recently established a new trauma care system following the Consultative Committee's findings on frequent preventable deaths after road crash injury. This study investigates the contribution to neurologic disability of preventable deficiencies in health care in survivors of road crashes occurring from 1998 to 1999. METHODS The emergency and clinical management of 60 road crash survivors with head Abbreviated Injury Scale score > or = 3 and residual neurologic disability were evaluated by analysis and multidisciplinary discussion of their complete prehospital, hospital, and rehabilitation records. RESULTS The mean number of potentially preventable errors or inadequacies per patient was 19.2 +/- 7.5, with 10.5 +/- 7.2 contributing to neurologic disability. The mean number contributing to neurologic disability was greatest in the emergency room (3.5 +/- 3.2), followed by the intensive care unit (2.2 +/- 2.7) and the prehospital setting (1.8 +/- 2.0). Eighty-four percent of the deficiencies were management errors/inadequacies and 7% were system inadequacies. Fifty-five percent of deficiencies contributed to neurologic disability. In patients with a systolic blood pressure less than 90 mm Hg with hypovolemia consequent to inadequate resuscitation, the frequency of severe neurologic disability was increased almost twofold (p < 0.05). Deficiencies contributing to neurologic disability were significantly less frequent in university teaching hospitals with neurosurgical units. CONCLUSION Improvement in neurologic outcomes can be achieved through appropriate triage and increased attention to basic principles of trauma and head injury care.

It is not unusual for laypersons to object on the conduct of an autopsy of a loved one for fear of disfigurement or burial delays. In this paper, we discuss a new possible reason for objection among Arabic speaking communities related to the language. The Arabic word for autopsy is “al-tashreeh” which, when examining its other linguistic uses, might result in wrong inferences among laypersons.

Background The aim was to identify organizational and clinical errors in the management of road traffic fatalities and to use this information to improve Victoria's trauma care system. Methods A multidisciplinary committee evaluated the complete ambulance, hospital and autopsy records of 559 consecutive road traffic fatalities, who were alive on arrival of ambulance services, in five substantial time periods between 1992 and 1998. Patients who survived more than 30 days were excluded. Errors or inadequacies in each phase of management, including those contributing to death, were identified and an assessment was made of the potential preventability of death. Results Findings between 1992 and 1998 were similar. In 1998, 1672 problems were identified in 110 deaths with 1024 (61 per cent) contributing to death. Eight hundred and forty-two (50 per cent) of the total problems occurred in the emergency department. There were frequent problems in initial patient reception and medical consultation, resuscitation, investigation and assessment (especially of the abdomen and head), and in transfer to the operating theatre or to a higher-level hospital. Victoria's combined preventable and potentially preventable death rate has been unchanged between 1992 and 1998 (34–38 per cent). Conclusion The problems identified led to a Ministerial Taskforce on Trauma and Emergency Services in Victoria as a consequence of which a new trauma system is now being implemented.

Medical disaster response: a survival guide for hospitals in mass casualty events, by David Goldschmitt and Robert Bonvino, CRC Press, 2009, 836 pp, AUS $175, ISBN: 9781420061222 The two authors (t...

Since 1992 the Consultative Committee on Road Traffic Fatalities in Victoria (CCRTF) has examined the medical management of patients who died following motor vehicle accidents. Three hundred and fifty-five fatalities with head injury occurring between 1 July, 1992 and 31 December 1997 were assessed by the CCRTF. They represented 79% of the total 449 fatalities examined by the Committee. Following examination of the complete medical records and multidisciplinary discussion, the Committee considered 237 (67%) of the 355 neurotrauma deaths to be non-preventable, 105 (30%) potentially preventable and 13 (4%) preventable. The present analysis excludes the non-preventable deaths in order to focus on preventable factors. Problems identified in the 118 patients pre-hospital included: no intubation; prolonged scene time; and no intravenous access; in 139 emergency room attendances: inappropriate reception including delay in arrival of a consultant, no neurosurgical consultation, no CT scan of the head, inadequate blood gases and oxygen monitoring, inadequate fluid resuscitation, delayed respiratory resuscitation and delayed despatch to the operating room; in 111 operating room visits: no ICP monitoring, inadequate fluid administration and inappropriate anaesthetic technique; and in 90 intensive care unit admissions: no ICP monitoring. Overall, 1745 individual problems in the various areas of care were identified, of which 1104 (63%) were judged to have contributed to death. Improved delivery and quality of trauma care could reduce the identified problems in emergency services and clinical management. Basic principles of trauma management remain the most important means of reducing morbidity and death following road trauma. The leadership role of the neurosurgeon in neurotrauma care is emphasised.

Sudden unexpected death in epilepsy (SUDEP) refers to sudden unexpected death in patients with epilepsy in whom autopsy fails to reveal an anatomic or toxicological cause of death. The purpose of this study was to examine associated factors and mechanisms relating to SUDEP in Victoria. The study was a retrospective study based on data from questionnaires completed by treating doctors and coronial files including police reports of death, autopsy and toxicology reports. The deaths were of people with epilepsy in Victoria that were referred to the coroner between 1991 and 1997. There were 15,751 coronial autopsies of which 357 had epilepsy and 50 (14%) were SUDEPs. The SUDEP rate was approximately 1 per 3000 epileptics per year. This study suggested the following associations: young age, tonic-clonic seizures, seizure frequency greater than 10/year, duration of epilepsy greater than 10 years, mental retardation, psychiatric disease and alcohol abuse. Antiepileptic drug (AED) compliance was rated by treating doctors as good in 24 cases. One or more postmortem AED drug levels was subtherapeutic in 30 of 50 cases. Only 5 were receiving psychotropic drugs; only 1 of these was receiving more than one of these drugs. A history of recent unusually stressful life event was present in only 4 cases. At least 11 showed evidence of terminal seizure, and the majority of events occurred in sleep. These observations support the hypothesis that seizures are the mechanism of many cases of SUDEP. The associations observed were largely in agreement with previous studies. However, seizure frequency was greater and duration of epilepsy greater than most previous studies. The role of factors such as AED compliance, psychotropic drug prescription and recent unusually stressful life event is less clear. This highlights the need for case-control studies of risk factors for SUDEP.

Progressive reduction in trauma mortality and morbidity demands both peer-group and state registry evaluations, with ensuing recommendations implemented by a responsive state government trauma committee.

The absence of a formal postgraduate course has had a significant impact on the development of clinical forensic medicine. Increasing scrutiny by the criminal justice system and recognition of the specialized nature of the work have led to the need for an academic basis for the discipline. Monash University in Victoria, has developed a course leading to a Graduate Diploma in Forensic Medicine. Combining principles and practice taught largely by distance education methods, the programme will enhance practitioners' knowledge and skills in clinical forensic medicine.

Objectives: Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria, Australia, has identified problems including those contributing to death and the potential preventability of deaths in road fatalities who survived until at least the arrival of ambulance services. The present analysis examines the outcomes at a Level I trauma center compared with other hospital groups in Victoria. Methods: Between 1992 and 1994, 257 consecutive eligible fatalities were evaluated. Problems in management and preventable deaths were identified at the trauma center (TC) and in pooled data from other hospital groups, i.e., specialist teaching (Level II), other metropolitan (Level III), large regional (Level III), and small regional hospitals. Results: Mean problems identified and those contributing to death (controlled for the number of areas of care), were less frequent at TC (1.7 and 0.6) than at other hospital groups (specialist teaching, 1.9 and 1.1 * ; metropolitan, 3.1 * and 1.6 * ; large regional, 3.8 * and 1.8 * ; small regional, 5.1 * and 2.6 * ) ( * p < 0.05 compared with TC). Preventable and potentially preventable deaths were also less common at TC (20%) than at the other hospital groups (specialist teaching, 40% * ; metropolitan, 41% * ; large regional, 53% * ; small regional, 62% * ) ( * p < 0.05 compared with TC). When a Trauma and Injury Severity Score of 75% or more was used to define preventable death, a similar trend was identified. Conclusion: Management of patients with major trauma at a Level I trauma center was associated with fewer problems contributing to death and fewer preventable and potentially preventable deaths than at the different hospital groups. A trauma system in Victoria, including bypass of major trauma patients to designated hospitals with 24-hour trauma services, is likely to decrease the frequency of problems, including the preventable death rates.

Background: Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria has identified problems in the management of traffic fatalities. Its two evaluative committees have additionally assessed the potential preventability of death. Previous studies have shown only poor to fair reproducibility of death judgments. Methods: Problems in the management of 60 consecutive road traffic fatalities and the potential preventability of death were independently evaluated by the two committees. Inter-rater and inter-committee concordance were analyzed using the κ statistic. Results: Reproducibility was high. Inter-committee agreement on nonpreventable, potentially preventable, and preventable death judgments was high (κ = 0.73, 95% confidence interval = 0.57-0.89). Agreement within the two evaluative committees was also high (average weighted κ = 0.73 and 0.74). There was good agreement between committees on problems identified, including those contributing to death. Conclusion: The high κ concordance on preventable death judgments and the agreement on problem identification supports the reproducibility of the methodology used.

BACKGROUND: In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: survival probability between 25 and 75%). METHODS: For 1993-94, 120 consecutive fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete pre-hospital, hospital and autopsy records. RESULTS: A total of 1175 problems were identified in 455 admission to the various areas of care. A total of 949 problems (81%) were found to be management errors and 123 (11%) were found to be system inadequacies. Technique errors (35 (3%)), diagnosis delays (27 (2%)) and diagnosis errors (41 (4%)) were less frequent. The emergency department (ED) accounted for 662 (56%) problems, followed by 191 (16%) pre-hospital problems and 140 (12%) intensive care unit (ICU) problems. There were 598 (51%) problems that were assessed as contributing to death. A total of 308 (52%) problems occurred in the ED, 106 (18%) were pre-hospital problems and 71 (12%) occurred in ICU. Management errors comprised 465 (78%) problems contributing to death, and system inadequacies comprised 76 (13%) problems. Resuscitation problems accounted for 101 (40%) of the 254 ED management errors contributing to death. A total of 79 (66%) deaths were assessed as non-preventable, five (4%) were assessed as preventable and 36 (30%) were assessed as potentially preventable. CONCLUSIONS: Organization and educational countermeasures are required to reduce the high frequency of problems in emergency services and clinical management.

OBJECTIVES: In 1992 a multidisciplinary committee was established to identify problems in the management of road fatalities in Victoria, Australia, to assess their contribution to death, and to identify preventable deaths (preventable: survival probability more than 75%; potentially preventable: 25 to 75%). METHODS: For 1992 and 1993 all 137 fatality cases surviving until arrival of ambulance services were evaluated by analysis and discussion of their complete prehospital, hospital, and autopsy records. RESULTS: 1,012 problems were identified in 509 admissions to the various areas of care. Six hundred eighty-five (68%) were management errors and 217 (21%) were system inadequacies. Technique errors (45 (4%)), diagnosis delays (25 (2%)), and diagnosis errors (40 (4%)) were less frequent. The emergency department (ED) accounted for 537 (53%) problems, followed by prehospital (200 (20%)) and intensive care unit (118 (12%)). Four hundred seventy (46%) problems were assessed as contributing to death. Two hundred twenty-eight (49%) occurred in the ED, 90 (19%) were prehospital problems, and 63 (13%) occurred in the intensive care unit. Management errors comprised 326 (69%) problems contributing to death, and system inadequacies 88 (19%). Resuscitation problems accounted for 82 (49%) of the 167 ED management errors contributing to death. Eighty-five (62%) deaths were assessed as nonpreventable, 7 (5%) as preventable, and 45 (33%) as potentially preventable. CONCLUSION: Organizational and educational counter measures are required to reduce the high frequency of problems in emergency services and clinical management. Language: en

A study of eight deaths involving the benzodiazepine flunitrazepam was performed to assess the contribution of this drug to the fatalities. Coronial deaths in Victoria in the 2-year period to mid-1991 were selected in which either flunitrazepam or flunitrazepam and ethanol were the principal toxicological findings. All bodies were subject to a full autopsy by forensic pathologists, and a full toxicological examination. No significant pathology was found at autopsy in any case. Very high concentrations of 7-aminoflunitrazepam, a metabolite of flunitrazepam, were present in all cases. In four cases no other significant drug was detected, whereas in the other four cases there were significant concentrations of ethanol (mean 1.6 g/L). In these two groups of cases the concentrations of 7-aminoflunitrazepam were 0.45 mg/L and 0.16 mg/L, respectively. Only moderate levels of flunitrazepam were detected, suggesting that 7-aminoflunitrazepam is produced postmortem and may be an important marker of flunitrazepam usage. The causes of death in these eight cases were probably either flunitrazepam toxicity or a combination of flunitrazepam and ethanol toxicity. Only one case appeared likely to have been a suicide. Our observations in these cases suggest that flunitrazepam may cause death in the absence of other drugs or significant disease. The presence of ethanol reduces the amount of flunitrazepam needed to cause death.

1. Ethical principles for the medical profession 2. Ethical and legal responsibilities of medical students 3. Communication skills 4. Consent and informed decision making 5. Confidentiality, privacy and disclosure 6. Medical records, reports and certificates 7. Negligence, professional liability and adverse events 8. The regulation of the medical profession 9. Health care complaints systems 10. The doctor and sexual boundaries 11. Personal health of the doctor: illness and impairment 12. Maintenance of professional competence 13. Ethics and the allocation of health care resources 14. The Australian health care system 15. The doctor and interprofessional relationships 16. Entering and leaving practice and practice management 17. Clinical research 18. Prescribing and administering drugs 19. Diagnosing and certifying death and the role of the coroner 20. Births, reproductive technology, family law and child protection 21. Termination of pregnancy and related issues 22. Withholding or withdrawing treatment in the seriously or terminally ill 23. The law and the mentally ill 24. The law and courts of law in Australia 25. Medico-legal examinations and reports, court procedures and expert evidence 26. Other legislation relevant to medical practice.

Fundamental to a proper doctor–patient relationship is the assurance that information provided by the patient to the treating doctor will remain strictly confidential. Doctors must be free to ask their patients any questions necessary for diagnosis and treatment, and patients must be willing to trust doctors by giving full answers. Maintaining such trust has a wider social benefit of ensuring that medical practice serves to promote and maintain the health of the community. The basis of this trust lies in one of the oldest ethical principles of medical practice stated in the Hippocratic Oath as: whatsoever I shall see or hear in the course of my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets. This same obligation has since been repeated in the World Medical Association Declaration of Geneva as ‘I will respect the secrets confided in me, even after the patient has died’. This ethical requirement for confidentiality, well understood by doctors, has been overlaid in Australia in recent years by the progressive introduction of privacy legislation at the federal level and in some states, which for doctors covers very much the same territory as this ethical requirement. As a result, doctors now need to understand the ethical and legal bases of their professional obligations in this regard. In this chapter, both bases are described and explained.

No doctor will deny an ethical obligation to provide competent clinical care to patients, but many have been reluctant to embrace compulsory continuing medical education (CME) or compulsory recertification of their professional competence. Such reluctance in regard to making this obligation compulsory relates to factors including scepticism that recertification will necessarily improve standards of patient care or prevent the problems created by incompetent members of the profession; awareness that the medical profession is generally very committed to CME, and to evaluation of care through clinical research and its dissemination and publication; and, lastly, sensitivity by many doctors to the accountability already required of them by the courts, health complaints mechanisms and medical boards. There has, however, emerged a more positive approach to the need to document maintenance of professional competence in the profession with formal initiatives taken by all the medical colleges. These initiatives, while eschewing examinations, are designed to reflect the realities of everyday professional life and are consistent with education and learning theory, itself still evolving. A small proportion of doctors still resent this perceived bureaucratic intrusion, but the benefits for the medical profession and the community outweigh any additional effort involved in documenting what most doctors already do. Apart from the ethical dimension there are other influences at work in the move to document the maintenance of professional learning and competence of doctors.