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The Innocence Project has enabled, amongst many other things, quantification of contributors to wrongful convictions in the United States. There, individual cases of wrongful conviction have multip...

Over two afternoons in Melbourne in early(This editorial was submitted by the Victorian Chapter Committee of the Australian Academy of Forensic Sciences) November 2019, the Australian Academy of Fo...

Although melanoma is initiated by acquisition of point mutations and limited focal copy number alterations in melanocytes-of-origin, the nature of genetic changes that characterise lethal metastatic disease is poorly understood. Here, we analyze the evolution of human melanoma progressing from early to late disease in 13 patients by sampling their tumours at multiple sites and times. Whole exome and genome sequencing data from 88 tumour samples reveals only limited gain of point mutations generally, with net mutational loss in some metastases. In contrast, melanoma evolution is dominated by whole genome doubling and large-scale aneuploidy, in which widespread loss of heterozygosity sculpts the burden of point mutations, neoantigens and structural variants even in treatment-naïve and primary cutaneous melanomas in some patients. These results imply that dysregulation of genomic integrity is a key driver of selective clonal advantage during melanoma progression., The genetic changes that occur in late stage metastatic melanoma are not well delineated. Here, the authors use rapid autopsy samples from metastatic melanoma patients and show that the late stage in the disease is characterised by whole genome doubling and aneuploidy.

Introduction: Most findings of forensic pathology examinations are presented as written reports. There are currently no internationally accepted recommendations for writing forensic pathology reports. Existing recommendations are also varied and reflect the differences in the scope and role of forensic medical services and local settings in which they are to be implemented. The legal fact-finder thus faces wide variation in the quality of forensic pathology reports, which poses a threat to the reliability of legal decision-making. To address this issue, the development of the "PERFORM-P (Principles of Evidence-based Reporting in FORensic Medicine Pathology version)" was undertaken. The goal of the PERFORM-P is to provide common practice recommendations adaptable to local requirements to promote evidence-based practice (EBP) in forensic pathology. Methods: An international consensus study was conducted in three phases by (1) developing a long-list of items to be considered in the reporting recommendations, (2) conducting a Delphi process (an iterative survey method to transform individual opinions into group consensus) with international forensic pathologists, and (3) designing the PERFORM-P prototype and its accompanying manual. Results: With assistance from 106 forensic pathologists/forensic medical practitioners from 41 countries, the PERFORM-P was developed. The PERFORM-P consists of a list of 61 items to be included in a forensic pathology report, which is accompanied by its Explanation and Elaboration (E&E) document. Discussion: To prepare forensic pathology (postmortem) reports that incorporate principles of evidence based practice, internationally accepted recommendations might be helpful. The PERFORM-P identifies recommendations for necessary elements to include in a forensic pathology report. PERFORM-P can be applied to a wide range of matters requiring forensic pathological analysis, acceptable to forensic pathologists from a representative selection of jurisdictions and medico-legal systems. (c) 2021 The Author(s). Published by Elsevier B.V. CC_BY_4.0

Humanitarian forensic science is the application of the knowledge and skills of forensic medicine and science to humanitarian action, especially following conflicts or disasters. It sprouted from t...

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.

In September 2016, the President’s Council of Advisors on Science and Technology (PCAST) in the United States published its report to the President entitled Forensic Science in Criminal Courts: Ensuring Scientific Validity of Feature-Comparison Methods. The need for this report arose out of the highly critical 2009 National Research Council report on the state of forensic sciences in the United States. The report had noted that there were particular problems in feature-comparison disciplines where the science underpinning the validity of the discipline was poor. The PCAST report has developed the National Research Council’s thinking further. It looked at the foundational validity of a number of forensic disciplines, including, for example, bite mark interpretation in forensic odontology. PCAST concluded that bite mark analysis does not meet the scientific standards for foundational validity. In addition, it felt that the prospects of developing bite mark analysis into a scientifically valid method were poor, and they advised against government investment in research to try to establish such validity. The principles discussed in this report, focused as they are on forensic science, will need to be digested by forensic medicine. Forensic medicine will be increasingly called upon to justify the validity of the various areas in which its practitioners provide expert evidence.

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.

On May 24, 2010, 800 soldiers and 370 police officers stormed into Tivoli Gardens, an impoverished district in the capital of Jamaica. Their aim was to restore state authority in this part of Kingston and to arrest Christopher “Dudus” Coke, who was wanted for extradition to the United States on drug and arms trafficking charges. The incursion was the culmination of nine months of national political turmoil. The first aim was achieved, but the second was not, and only at great cost. Around 70 civilians and three members of the security forces were killed. The authors constituted a small group of international forensic pathologists who, at the request of the Public Defender and over a four-week period from mid-June, observed the autopsies of the civilians. This paper describes some of the outcomes of this work, set within the evaluation of the incursion by the Commission of Enquiry. The Enquiry concluded there was evidence of at least 15 extrajudicial killings and was highly critical of many other aspects of the operation and its aftermath.

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.

Catastrophic natural disasters are a regular global issue claiming thousands of lives and having severe and long lasting consequences for communities. Along with the rescue and care of survivors and the provision of basic services, managing the dead in a proper and dignified manner is one of the three pillars of disaster response. Since the 2004 Indian Ocean Tsunami, progress to facilitate better coordination in the management of the dead has been made. Two guidelines contributing to this positive trend are the Interpol DVI Guide, and the "Management of the Dead after Disasters - A Field Manual for First Responders". The former is aimed at forensic specialists and emergency services, the latter at untrained first responders confronted with the management of the dead when specialist forensic services are not available. This paper sets out the complementarity of the two publications, illustrating that ideally, both first responders and experts are needed to properly manage and identify the dead following large disasters.

This is a critical review to discuss the best practice approaches to mortuary operations in preparation for and the response to natural, mass fatality, disaster events, as identified by a review of published articles. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) Statement guided the identification of potential articles to use in this critical review. Subsequent searches were also conducted to identify articles relating to heat wave, and flood mortality. All identified peer-reviewed studies published in English which discussed the preparation and response of mortuaries to mass fatality natural disasters occurring in developed countries were included. Using the PRISMA-P method of identifying articles, 18 articles were selected for inclusion in this review. Although there are numerous articles which describe the mortuary response to mass fatality incidents, few articles analyzed the response, or discussed the roles which supported and enabled the organization to undertake the task of identifying disaster victims. It is thus difficult to determine objectively if the actions and activities outlined in the articles represent best-practice.

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 father of a 28-day-old deceased was convicted of manslaughter in the Supreme Court of Victoria and imprisoned for 5 years. The conviction was overturned by the Court of Appeal essentially because, in the view of the author, it understood the significance of the pathology evidence given at the trial. The evidence issues in this case are set in the context of problems generally in cases where the conviction is later overturned. In addition to other improvements, a specific proposal is raised to require more structure in expert forensic pathology opinions to address issues which commonly arise in cases of particular types.

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.

Patients with high-grade serous ovarian cancer (HGSC) have experienced little improvement in overall survival, and standard treatment has not advanced beyond platinum-based combination chemotherapy, during the past 30 years. To understand the drivers of clinical phenotypes better, here we use whole-genome sequencing of tumour and germline DNA samples from 92 patients with primary refractory, resistant, sensitive and matched acquired resistant disease. We show that gene breakage commonly inactivates the tumour suppressors RB1, NF1, RAD51B and PTEN in HGSC, and contributes to acquired chemotherapy resistance. CCNE1 amplification was common in primary resistant and refractory disease. We observed several molecular events associated with acquired resistance, including multiple independent reversions of germline BRCA1 or BRCA2 mutations in individual patients, loss of BRCA1 promoter methylation, an alteration in molecular subtype, and recurrent promoter fusion associated with overexpression of the drug efflux pump MDR1.

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.

BackgroundAn increased risk of choking associated with antipsychotic medication has been repeatedly postulated.AimsTo examine this association in a large number of cases of choking deaths.MethodCases of individuals who had died because of choking were linked with a case register recording contacts with public mental health services. The actual and expected rates of psychiatric disorder and the presence of psychotropic medication in post-mortem blood samples were compared.ResultsThe 70 people who had choked to death were over 20 times more likely to have been treated previously for schizophrenia. They were also more likely to have had a prior organic psychiatric syndrome. The risk for those receiving thioridazine or lithium was, respectively, 92 times and 30 times greater than expected. Other antipsychotic and psychotropic drugs were not over-represented.ConclusionsThe increased risk of death in people with schizophrenia may be a combination of inherent predispositions and the use of specific antipsychotic drugs. The increased risk of choking in those with organic psychiatric syndromes is consistent with the consequences of compromised neurological competence.

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.