Transcript Slide 1

Medical Reports
for Children’s Court
Anne Smith
Medical Director VFPMS
(images of children removed)
When writing medico-legal report
Ask yourself
What is the purpose?
How should it be structured?
What information must be in it
What information might be in it?
How should it be worded?
What are the important “do”s
and “don’t”s?
Types of medico-legal reports
Child Abuse
•
•
•
•
•
•
(perhaps not?) Letter to colleague
Child Protection - for information
Child Protection – Court Report
Criminal justice system (for criminal court)
Victims of Crime Compensation
Expert Opinion
Information in medico-legal report
Should enable you to comment on
• Cause of injury
– Accident or assault ……& neglect
– Mechanism (nature of insult & forces)
– Certainty / probability
• Timing of injury
• Circumstances surrounding injury
• Treatment required
• Outcomes (potentially life-threatening?)
And make Recommendations
Objectivity
An expert witness does not compromise objectivity by defending,
forcefully if necessary, an opinion based on the experts
specialised knowledge which is genuinely held
but may do so if the expert is, for example, unwilling to give
consideration to alternative factual premises
or is unwilling, where appropriate, to acknowledge recognised
differences of opinion or approach between experts in the
relevant discipline.
guidelines from the Federal Court of Australia
Impartiality
Stick to the facts
Eliminate bias
This is NOT time to go out on a limb
Focus on the TRUTH
(the whole truth, and nothing but the truth…..)
Ask yourself: Is your evidence (legally) able to be presented?
History of prior criminal behaviour +/_ sentencing
In accordance with local reporting requirements /
legislation in relation to notifications to statutory
authorities (Child protection)
Hearsay (depends on the court)
Ask yourself: Is your evidence (legally) able to be presented?
Daubert: whether the theory or technique in question can be (and has
been) tested, whether it has been subjected to peer review and
publication, its known or potential error rate, and the existence and
maintenance of standards controlling its operation, and whether it has
attracted widespread acceptance within a relevant scientific community
Daubert v. Merrell Dow Pharmaceuticals (92-102), 509 U.S. 579 (1993)
Hard vs soft sciences
• Eg DNA fingerprinting vs social sciences / psychology (opinion
about witness reliability, state of mind, interpreting behaviour)
Attending
court without
first having
prepared a
good medical
report is
like……..
http://www.worth1000.com/cache/contest/
contestcache.asp?contest_id=2455&start
=51&end=60&display=photoshop#entries
Ensure that the Medical Report
(a) is clearly expressed and not
argumentative in tone;
(d) explains the process of reasoning
by which the expert reached the
opinion expressed in the report;
(b) is centrally concerned to express
an opinion, upon a clearly defined
question or questions, based on
the expert’s specialised
knowledge;
(e) is confined to the area or areas of
the experts specialised
knowledge; and
(c) identifies with precision the
factual premises upon which the
opinion is based;
(f) identifies any pre-existing
relationship between the author
of the report, or his or her
company etc, and a party to the
litigation (eg a treating medical
practitioner).
guidelines from the Federal Court of Australia
Separate the following:
Facts
– Those things that are known
to be true
Circumstantial evidence
– Those things that might
influence opinion about the
likelihood that a proposition
is true
Speculation
– Imagine a scenario (Probably
best avoided)
Opinion
– Evaluation of likelihood that a
proposition is true
References
– evidence base
Writing a medical report
Differing format for
For whom?
How will it be used?
Who owns it?
What qualifiers and protection is
required?
1. Criminal justice
(police report)
2 . Expert opinion
3. Child Protection
4. Victims of Crime Comp
5. Family Court
6. Coroners Court
7. Medical Board hearing
Reprinted from Australian Family Physician Vol. 33, No.
11, November 2004
Helen Louise Parker. Writing a Police Statement
Smithtown Family Clinic
1 Parkside Way
Smithtown 3006
Ph 9684 4480
Fax 9684 4481
3rd February 2004
Detective Senior Constable Plodd
Smithtown Criminal Investigation Unit
122 Smith’s Road
Smithtown 3006
Re: Mr John Smith DOB: 13th January 1970
I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way Smithtown
Hereby state that:
I am a medical practitioner registered in the state of Victoria.
I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery conferred in
1988, and Fellowship of the Royal Australian College of General Practitioners
conferred in 1996. I have worked in the capacity of a general practitioner in both
rural and metropolitan practice since 1992.
Reprinted from Australian Family Physician Vol. 33, No.
11, November 2004
Helen Louise Parker. Writing a Police Statement
Smithtown Family Clinic
1 Parkside Way
Smithtown 3006
Ph 9684 4480
Fax 9684 4481
3rd February 2004
Detective Senior Constable Plodd
Smithtown Criminal Investigation Unit
122 Smith’s Road
Smithtown 3006
Re: Mr John Smith DOB: 13th January 1970
I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way Smithtown
Hereby state that:
I am a medical practitioner registered in the state of Victoria.
I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery conferred in
1988, and Fellowship of the Royal Australian College of General Practitioners
conferred in 1996. I have worked in the capacity of a general practitioner in both
rural and metropolitan practice since 1992.
Reprinted from Australian Family Physician Vol. 33, No.
11, November 2004
Helen Louise Parker. Writing a Police Statement
Smithtown Family Clinic
1 Parkside Way
Smithtown 3006
Ph 9684 4480
Fax 9684 4481
3rd February 2004
Detective Senior Constable Plodd
Smithtown Criminal Investigation Unit
122 Smith’s Road
Smithtown 3006
Re: Mr John Smith DOB: 13th January 1970
I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way Smithtown
Hereby state that:
I am a medical practitioner registered in the state of Victoria.
I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery conferred in
1988, and Fellowship of the Royal Australian College of General Practitioners
conferred in 1996. I have worked in the capacity of a general practitioner in both
rural and metropolitan practice since 1992.
Reprinted from Australian Family Physician Vol. 33, No.
11, November 2004
Helen Louise Parker. Writing a Police Statement
Smithtown Family Clinic
1 Parkside Way
Smithtown 3006
Ph 9684 4480
Fax 9684 4481
3rd February 2004
Detective Senior Constable Plodd
Smithtown Criminal Investigation Unit
122 Smith’s Road
Smithtown 3006
Re: Mr John Smith DOB: 13th January 1970
I, Mary Nicole Brown of the Smithtown Family Clinic, 1 Parkside Way Smithtown
Hereby state that:
I am a medical practitioner registered in the state of Victoria.
I hold the qualifications of Bachelor of Medicine and Bachelor of Surgery conferred in
1988, and Fellowship of the Royal Australian College of General Practitioners
conferred in 1996. I have worked in the capacity of a general practitioner in both
rural and metropolitan practice since 1992.
Background
I have received a request from Detective Plodd to detail the
injuries received by Mr Smith as a result of an alleged assault
on him on Saturday 12th January 2004. In particular he has
asked whether Mr Smith’s head wound could have ‘resulted
from being struck with a baseball bat or could have occurred
when he fell to the pavement’. I examined Mr Smith at this
clinic on Tuesday 15th January 2004, 3 days after he was
allegedly assaulted, and again on Monday 21st January 2004
to remove his sutures. I have been provided with a signed
consent form from Mr Smith for the release of this report to
police.
This report has been prepared from:
• my clinical notes made at the time of the examination
• a letter from the Smithtown Hospital Emergency
Department.
Background
I have received a request from Detective Plodd to detail the
injuries received by Mr Smith as a result of an alleged assault
on him on Saturday 12th January 2004. In particular he has
asked whether Mr Smith’s head wound could have ‘resulted
from being struck with a baseball bat or could have occurred
when he fell to the pavement’. I examined Mr Smith at this
clinic on Tuesday 15th January 2004, 3 days after he was
allegedly assaulted, and again on Monday 21st January 2004
to remove his sutures. I have been provided with a signed
consent form from Mr Smith for the release of this report to
police.
This report has been prepared from:
• my clinical notes made at the time of the examination
• a letter from the Smithtown Hospital Emergency
Department.
History
Mr Smith told me that he had been assaulted on the previous
Saturday night (ie. 3 days before the consultation). He said he was
unable to recall much of what had occurred as he had consumed a
considerable amount of alcohol. He stated the following to me:
• he was in a queue outside a nightclub and was shoved from behind
• he turned around and verbally abused the male standing behind him
and that male punched him in the face
• he recalled being on the ground and thinks he was struck on the
head with a baseball bat
• he was taken to hospital by ambulance.
The letter from the hospital indicated a wound on his scalp was
sutured.
Mr Smith attended here requesting review and documentation of his
injuries, and a medical certificate for work.
There is no past medical history of relevance to this allegation.
Symptoms of recent injury
Mr Smith complained of headaches and indicated his injuries to me.
Opinion
In summary, Mr Smith is a 34 year old man whom I examined 3
days following an incident in which he was allegedly punched
to the face and possibly struck with a baseball bat. He had
evidence of a black eye and a sutured wound on the back of
his scalp. With respect to the findings I am of the opinion that:
1. The bruise around the eye is the result of blunt trauma:
• blunt trauma may result from a blow or forceful contact with
an object
• it is impossible to accurately age a bruise, however that
observed could have occurred within the time frame of the
alleged incident
• it is not possible to state more precisely the cause of this
bruising around the eye. It may have resulted from a punch,
however other mechanisms are possible
• this injury should fully resolve leaving no permanent
sequelae, however, a blow to the eye has the potential to
result in permanent serious visual impairment.
Opinion
2. The sutured wound had the appearance of a laceration, due to
the application of blunt trauma to the region causing the skin
to split:
• it had the appearance of a relatively recent wound and could
have occurred within the time frame of the incident
• it is not possible to state more precisely the exact cause of
this wound, and in particular I am unable to differentiate
between a fall onto the pavement versus a blow with a
baseball bat as the cause. The doctor who initially treated Mr
Smith and sutured his wound may be able to assist you
further with this inquiry
• this wound should heal, leaving a scar that will be barely
visible under the hair.
Dr Mary Nicole Brown
MBBS, FRACGP
I hereby acknowledge that this statement is true and correct and I make
it in the belief that a person making a false statement in the
circumstances is liable to the penalties of perjury.
Mary N Brown
Acknowledgement taken and signature witnessed by me at 3 pm,
On 6th February 2004 at Smithtown
Signature P Plodd _____________________________________
Name Peter Plodd______________________________________
Rank/No D/S/C 31268 ________________________________
Medical Report
(for Child Protection)
Letterhead +/- logo
Date
For whom
Title
Re
–
–
–
–
Name
Date of birth
Identifier
(NOT ADDRESS)
Who you are
–
–
–
–
–
full name,
qualifications
professional address
current position/title
experience in the field
When and where you had contact
with the child
Who else was there
Who provided consent and what
consent was for
All sources of information
Medical Report - Children
Who said what
– Verbatim**
– New paragraph per person
– Allegations
Headings optional
Number paragraphs optional
Content
– Allegation 1st
– Concerning features
• Delay in presentation
• History changes over time
• Differing histories by
individuals
– Paediatric medical history
Allegations
–
–
–
–
What?
Who?
Where?
When?
History
– Specific
• related to allegation
• chronology
– Nonspecific
• past medical and developmental
concerns
• child care practices
• genogram
Medical Report - Children
Examination - general
–
–
–
–
Demeanour, affect
Cooperation
Clothing
Measurements and
percentiles
– Skin
– Orifices
• Mouth, ears, eyes
– Systems
– Pattern recognition
Examination - specific
– Injuries
• Obvious
• Search
– Documentation
•
•
•
•
•
•
•
•
•
Site
Size
Shape
Surrounds
Colour
Contour
Contents
Edge
(pain, discharge,
movement)
Medical Report - Children
Investigations
–
–
–
–
–
What?
When?
Who interpreted findings?
Implication(s) of findings?
+/- sensitivity and specificity of the test (rarely)
Consultations: Quote
– Who ?
– What opinion ?
Medical Report - Children
Opinion – clear heading
Summarise allegations
Summarise examination findings
How the 2 relate to each other
What you believe is the most likely cause for the child’s condition
WHY?
Other conditions to consider
– Why they are or are not likely to be the cause of the child’s condition
– References
Medical Report - Children
Limitations of your opinion
Qualifiers
Jurat
Evidence on which your
opinion is based
– References
Limit / permit the use or
distribution of the report?
(court documents = public
records)
CHECK IT for
– Typing errors
– Grammatical errors, sloppy
language, imprecise language,
misleading language
– Errors of fact
– Errors of judgement
– Opinion = accurate and
complete
Sign it
Send it (cc to all the relevant
professionals)
Record in child’s record when report
sent to whom
Courtroom Quotes
Lawyer: "What happened then?"
Witness: "He told me, he says, 'I
have to kill you because you can
identify me.'"
Lawyer: "Did he kill you?"
Witness: "No."
Lawyer: "I show you Exhibit 3
and ask you if you recognize
that picture."
Witness: "That's me."
Lawyer: "Were you present
when that picture was taken?"
Lawyer: "Now, Mrs. Johnson, how
was your first marriage
terminated?"
Witness: "By death."
Lawyer: "And by whose death
Lawyer: "How far apart
were the vehicles at the
time of the collision?"
was it terminated?"
http://rinkworks.com/said/courtroom.shtml
OPINIONS: where do they come from?
Values
Bias (+/- motivational error)
+ Knowledge
+ Reasoning (+/- cognitive error)
-> Conclusions
= Opinion (+/- judgement error)
Opinion in medico-legal report
Should address matters related to
• Cause of injury
– Accident or assault ……& neglect
– Mechanism (nature of insult & forces)
– Certainty / probability
•
•
•
•
•
•
Timing of injury
Circumstances surrounding injury
Evidence base for your conclusions
Confidence in diagnosis /probability /likelihood
Treatment required
Outcomes (note if potentially life-threatening)
Cause of injury
Possible phrases to use
• Indicative of.. Indicates that… Has been caused by …
• Suggestive of… suggests that…
– Is likely to have been caused by…
– Probably has…
•
•
•
•
•
•
•
Raises concern about …
Could have been caused by .. It is possible that..
Not able to determine the cause based on the appearance alone
Is unlikely to have been caused by…
Is highly unlikely to have been caused by …
Almost certainly has not been caused by…
Cannot have been caused by…
Unpopular phrases (not wrong)
•
•
•
•
Consistent with…
In keeping with …
As she alleged….
Within the alleged time frame….
• Could have been caused by A.. or B.. or C..
• Nonspecific (both an accidental cause and assault
is possible )
Time of injury
•
•
•
•
•
Minutes to hours
Hours to days
Days to weeks
Weeks to months
Months to years
CAUTION: Few doctors understand
statistics!
Single event probabilities
Eg Prozac has a 30-50% chance of sexual dysfunction
Many doctors do NOT understand risk for their patient
Solution to improve understanding of relative risk : Reference
class or only use frequency statement
Conditional probabilities
• Sensitivity
• Specificity
• Positive predictive value
Relative risks
BMJ 2003;327:741-744 (27 September), doi:10.1136/bmj.327.7417.741
Education and debate: Simple tools for understanding risks: from innumeracy to
insight Gerd Gigerenzer, director1, Adrian Edwards, reader2
Statistics in Court
Appropriately reference
current knowledge and
explain consensus
Must understand Baysian
probability
Always apply statistics
appropriately
An Intuitive Explanation of Bayes'
Theorem Eliezer S. Yudkowsky
http://yudkowsky.net/rational/bayes
Sally Clark case
• Sir Roy Meadow -2 children in 1 family dying of
SIDS = 1 in 73,000,000
– Probability of 1 in…X probability of 1 in…
• Assumed independence
• Other medical causes of multiple deaths not
considered
• Ignored conditional probability /probability of
multiple homicides not considered
• He was possession of manuscript about research
on 2 or more deaths in one family (probability
much less than 1 in 73 million)
BEWARE
• Prosecutor’s fallacy
• Defense Attorney’s fallacy
• Conditional probability
fallacy / confusion of the
inverse
• Base rate fallacy
GET IT RIGHT
OR DON’T GO THERE……
Prosecutors fallacy
A piece of evidence that would implicate a
random person in the population = probability
that it implicates the defendant.
Eg DNA evidence (and Meadow’s law)
1 in 3 million chance that a random person has
this particular DNA profile is (wrongly)
attributed / equated to a 1 in 3 million chance
that this person is innocent
Defense attorney’s fallacy
1 in a million chance of a match.
Test 10 million, ->10 matches.
The defendant is merely one of the 10.
Thus my client has 90% chance of innocence!
• Eg OJ Simpsons blood at crime scene matched 1
in 400 other LA citizens. In a LA football stadium
a number of other “matches” possible
Conditional probability
• P(I|E) = P(E|I ) x P(I) / P(E)
• P (I |E) = probability of innocence given the
evidence
• = P (E|I) probability of false positive
• TIMES
• Probability of Innocence independent of test
result
• Divided by Probability that evidence would be
observed regardless of innocence
Base rate fallacy
Prior probability = base rate probability
CIA example: Vietnam war
• US pilot identifies strafing aircraft as Cambodian
• Under experimental conditions (50% Cambodian 50% Vietnamese) pilot
correct 80% erred 20%
• BUT field conditions : 85% of aircraft are Vietnamese, only 15% are
Cambodian
• Thus 68 of 85 Vietnamese aircraft (80%) correctly identified, and 17
incorrectly identified as Cambodian
• And 12 of 15 Cambodian aircraft correctly identified ( 3 incorrectly
identified as Vietnamese
• 17 incorrectly identified as Cambodian (actually Vietnamese) + 12
correctly identified as Cambodian = 29
• Therefore probability he is correct is actually 12 / 29 = 41%
www.cia.gov/library/center-for-the-study of intelligence/csi-publications/book
Examples of Cognitive Bias
People apply a high evidential standard ("Must I believe
this?") to unpalatable ideas & a low standard ("Can I
believe this?") to preferred ideas
Excessive drive for consistency is another potential source
of bias because it may prevent people from neutrally
evaluating new, surprising information
People can only focus on one thought at a time, so find it
difficult to test alternative hypotheses in parallel.
People can overlook challenges to their existing beliefs
Hidden assumptions assume shared values
and beliefs, therefore AVOID these words
Disclosure
Assumes the statements are factual
“He disclosed that she hurt him”
Victim
Assumes something bad happened to this person
“The victim wept after the alleged assault”
Offence
Assumes crime has been committed
“She said that the perpetrator raped her”
Assumptions and ‘medical truisms’
•
If you hear hoof-beats think of horses not zebras
– Common things occur commonly (and conversely…)
•
Occham’s razor
•
•
•
•
•
The rule of parsimony (all symptoms are due to one complaint)
If a test result surprises you, repeat the test before taking action
If a test result is unlikely to change the management of a patient, don’t do the test.
Rare manifestations of common diseases > common manifestations of rare diseases
1st priority in DDX = diseases you cannot afford to miss
•
Values and bias – eg, People are inherently ‘good’
sometimes poverty makes people do bad things…
How useful are these things when evaluating a particular child’s situation?
Dos and don’ts for doctors
Do be quiet and listen
Do diligently record verbatim comments
Do explore all possible scenarios
Do seek detail about injury mechanism
Do demonstrate your reasoning
Don’t close your mind to any possibility
Don’t hide anything
Don’t ever suggest to caregivers /others a possible
explanation for an injury (Don’t speculate)
Tips
Don’t say or write ANYTHING that you would not
defend under cross-examination in court.
Don’t hesitate to seek advice (early)
Don’t allow yourself to be bullied or influenced to
provide a biased opinion in a report
Always question your own judgement and review the
evidence on which your opinion is based
If in doubt, perhaps more particularly when you are in
NO doubt…have a colleague review & edit report