The problem of the sexual abuse and exploitation of children is global and thousands of children are sexually abused every day around the world. Sexual abuse has come to prominence more recently than
physical abuse, although sexual contact between adults and children has been recorded in many situ- ations and many countries for centuries. The modern definition of child sexual abuse may be expressed as ‘the involvement of dependent, developmentally immature children and adolescents in sexual activi- ties they do not truly comprehend, to which they are unable to give informed consent or which violate social taboos or family roles’.
The diagnosis and management of child sexual abuse are multidisciplinary, involving not only doctors but also social agencies and sometimes law enforcement agencies.
■ Further information sources
A Local Authority v S [2009] EWHC 2115 (Fam) (08 May 2009).
http://www.familylawweek.co.uk/site.aspx?i=ed53850 (accessed 22 November 2010).
Anon. Unexplained deaths in infancy, England and Wales, 2007.
Offi ce for National Statistics Statistical Bulletin, August 2009; http://www.statistics.gov.uk/pdfdir/uinfmort0809.pdf (accessed 11 February 2011).
Barbet JP, Houette A, Barres D, Durigon M. Histological assessment of gestational age in human embryos and fetuses. American Journal of Forensic Medicine and Pathology 1988; 9: 40–4.
Births and Deaths Registration Act 1953. http://
www.legislation.gov.uk/ukpga/1953/20/pdfs/ukpga_
19530020_en.pdf (accessed 22 November 2010).
Berry PJ. Pathological fi ndings in SIDS. Journal of Clinical Pathology 1992; 45: 11–16.
Bilo RAC, Robben SGF, van Rijn. Forensic Aspects of Paediatric Fractures – Differentiating Accidental Trauma from Child Abuse. Berlin: Springer-Verlag, 2010.
British Society of Paediatric Radiology. Standard for skeletal surveys in suspected non-accidental injury (NAI) in children.
http://www.bspr.org.uk/nai.htm (accessed 17 April 2010).
Busuttil A, Keeling JW. Paediatric Forensic Medicine and Pathology. London: Hodder Arnold, 2009.
Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. AJR American Journal of Roentgenology 1946; 56: 163–73.
Case ME, Graham MA, Handy TC et al. Position paper on fatal abusive head injuries in infants and young children.
American Journal of Forensic Medicine and Pathology 2001; 22: 112–22.
Cooper N, Dattani N. Trends in cot deaths. Health Statistics Quarterly 2000; 5: 10–16. (http://www.statistics.gov.uk/
articles/hsq/HSQ5SIDs.pdf).
Domestic Violence, Crime and Victims Act 2004 C.28.
http://www.legislation.gov.uk/ukpga/2004/28/contents (accessed 22 November 2010).
Figure 7.12 Non-accidental, blunt force, intra-abdominal visceral injury (same infant as in Figure 7.5). Note the liver laceration leading to intra-abdominal haemorrhage.
F urther information sourc es
Gilliland MG, Luthert P. Why do histology on retinal haemorrhages in suspected non-accidental injury?
Histopathology2003;43: 592–602.
Goudge ST. Inquiry into paediatric forensic pathology in ontario Report 2008. www.attorneygeneral.jus.gov.
on.ca/inquiries/goudge/policy_research/pdf/Limits_and_
Controversies-CORDNER.pdf
Infant Life (Preservation) Act 1929 C.34. http:// legislation.
data.gov.uk/ukpga/Geo5/19-20/34/enacted/data.htm (accessed 22 November 2010).
Infanticide Act 1938 C.36. http://www.statutelaw.gov.uk/
content.aspx?activeTextDocId=1085464 (accessed 22 November 2010).
Kellogg ND; American Academy of Pediatrics Committee on Child Abuse and Neglect. 2007. Evaluation of suspected child physical abuse.Pediatrics119: 1232–41.
Kemp AM, Dunstan F, Harrison S et al. Patterns of skeletal fractures in child abuse: systematic review. British Medical Journal 2008; 337: a1518.
Kemp AM, Butler A, Morris S et al. Which radiological investigations should be performed to identify fractures in suspected child abuse? Clinical Radiology 2006;
61: 723–36.
Kleinman PK. Diagnostic imaging in infant abuse. AJR American Journal of Roentgenology 1990; 155:703–12.
Knight B. The history of child abuse. Forensic Science International 1986; 30: 135–41.
Krous HF, Beckwith JB, Byard RW et al. Sudden infant death syndrome and unclassifi ed sudden infant deaths:
a defi nitional and diagnostic approach. Pediatrics 2004;
114: 234–8.
Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Archives of Disease in Childhood 2005; 90: 182–6.
Maguire S, Mann MK, Sibert J, Kemp A. Can you age bruises accurately in children? A systematic review. Archives of Disease in Childhood 2005; 90: 187–9.
Maguire S, Mann M, John N et al. Does cardio pulmonary resuscitation cause rib fractures in children? A systematic review. Child Abuse & Neglect 2006; 30: 739–51.
Maguire S, Hunter B, Hunter L et al. Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries.Archives of Disease in Childhood 2007; 92:
1113–17.
Maguire S, Pickerd N, Farewell D et al. Which clinical features distinguish infl icted from non-infl icted brain injury? A systematic review. Archives of Disease in Childhood 2009;
94: 860–7.
Malcolm AJ. Examination of fractures at autopsy. Chapter 2. In: Rutty GN (ed), Essentials of autopsy practice.
New advances, trends and developments. London:
Springer-Verlag, 2008; p. 23–44.
Meservey CJ, Towbin R, McLaurin RL et al. Radiographic characteristics of skull fractures resulting from child abuse.
AJR American Journal of Roentgenology 1987; 149:
173–5.
Piercecchi-Marti MD, Adalian P, Liprandi A et al. Fetal visceral maturation: a useful contribution to gestational age estimation in human fetuses.Journal of Forensic Sciences 2004;49: 1–6.
Prosser I, Maguire S, Harrison SK et al. How old is this fracture? Radiological dating of fractures in children:
a systematic review. AJR American Journal of Roentgenology 2005; 184: 1282–6.
R v Harris, Rock, Cherry and Foulder (2005) EWCA Crim 1980.
http://www.bailii.org/ew/cases/EWCA/Crim/2005/1980.html (accessed 22 November 2010).
Saukko P, Knight B. ‘Infanticide and stillbirth (Chapter 20). In:
Saukko P, Knight B. Knight’s Forensic Pathology, 3rd edn.
London: Hodder Arnold, 2004; p. 439–50.
Saukko P, Knight B. ‘Sudden death in infancy (Chapter 21). In:
Saukko P, Knight B. Knight’s Forensic Pathology, 3rd edn.
London: Hodder Arnold, 2004, p. 451–60.
Saukko P, Knight B. Fatal child abuse (Chapter 22) In: Saukko P, Knight B. Knight’s Forensic Pathology, 3rd edn. London: Hodder Arnold, 2004, p. 461–79.
Scheuer JL, Musgrave JH, Evans SP. The estimation of late fetal and perinatal age from limb bone length by linear and logarithmic regression. Annals of Human Biology 1980;
7: 257–65.
Still-Birth (Defi nition) Act 1992 C.29. http://www. legislation.
gov.uk/ukpga/1992/29/contents (accessed 22 November 2010).
World Health Organization. Child maltreatment. Geneva, Switzerland: WHO, 2010; http://www.who.int/topics/
child_abuse/en (accessed 9 April 2010).
Weber MA, Risdon RA, Offi ah AC et al. Rib fractures identifi ed at post-mortem examination in sudden unexpected deaths in infancy (SUDI). Forensic Science International 2009;
189: 75–81.
Weber W. [Experimental studies of skull fractures in infants].
Zeitschrift für Rechtsmedizin 1984; 92: 87–94 (in German).
Worn MJ, Jones MD. Rib fractures in infancy: establishing the mechanisms of cause from the injuries – a literature review. Medicine, Science, and the Law 2007; 47:
200–12.
Chapter
■ Introduction
One of the most important aspects of forensic medicine – both clinical and pathological – is the assessment, classification and documentation of injury. Any healthcare professional should be able to appropriately document injury in a way that can be understood and interpreted by others.
Most non-forensic healthcare professionals will not be trained in the interpretation of injuries and wound causation, but accurate documenta- tion can greatly assist the legal process at a later stage.
Offences against individuals of a physical nature that may result in criminal prosecutions have a great variety of types and origins, not all of which may cause visible evidence (e.g. poisoning, infection).
The role of the forensic pathologist and forensic physician is to ensure that the medical relevance of findings, or lack of them, is understood by the investigating authority.
■ Terminology of injury
Words to describe injury or harm are used non- specifically by lay persons and non-forensic healthcare professionals. In a legal setting the use of the word may have a specific meaning that can influence the nature of the charge and the penalties related to an offence.
Perhaps the most frequent error is the use of the word ‘laceration’ used in the context of a cut to the skin. In the forensic setting – as discussed below – a laceration is a split or tear in the skin caused by blunt impact. If the word laceration is used wrongly to described a cut caused by a knife (an incised wound) this may have implications with regard to the credibility of the witnesses.
Every jurisdiction will have its own legal classi- fication of injury or wounding, and again the use of such terms may have specific relevance. Forensic practitioners must be familiar with such classifica- tions in order to assist the courts in determining the seriousness of an injury.
■ Introduction
8
■ Terminology of injury
■ Law of injury
■ Types of injury
■ Other types of injury pattern
■ Survival after injury
■ Self-inflicted injury
■ Torture
■ Documentation of injury or marks of injury
■ Further information sources
Assessment, classification and
documentation
of injury
Types of injur y
Most harm or injury can be embraced by one of the following broad groups, using terms used within the England and Wales jurisdiction:
■ Those with a fatal outcome
• Murder
• Manslaughter
■ Those without a fatal outcome
• Assault, assault occasioning actual bodily harm
• Common assault
• Battery, or common battery
• Wounding or wounding with intent
• Poisoning
• Inflicting grievous bodily harm or causing grievous bodily harm with intent
■ Sexual offences (see Chapter 12)
• Penetrative
• Non-penetrative (both with or without extra- genital injury).
■ Law of injury
In the England and Wales setting a ‘wound’ (used by most people interchangeably with ‘injury’) can have a specific legal meaning. In the legal context, a wound is an injury that breaks the continuity of the skin. There must be a division of the whole skin structure and not merely a division of the cuticle or upper layer. As the skin is not broken, a bruise or internal rupturing of blood vessels is not a wound. A broken bone is not considered a wound, unless it is a comminuted fracture.
The Offences against the Person Act 1861 (‘the Act’), which has been amended over the years, sets out a range of offences for which an individual, in England and Wales, can be prosecuted when that individual is alleged to have caused injury to another person. This statute excludes homicide and sexual offences (which are covered by the Sexual Offences Act 2003).
As may be expected the terminology used in a law whose origins go back almost one and half cen- turies can sometimes be a little unclear. The main offences relevant to injury assessment by forensic practitioners are found in the following sections of the Offences Against the Person Act.
Section 18
This section creates the offences of wounding and causing grievous bodily harm, with intent to cause grievous bodily harm, or to resist arrest. It is
punishable with life imprisonment, the specific wording being
Whosoever shall unlawfully and maliciously by any means whatsoever wound or cause any grievous bodily harm to any person ...
with intent ... to do some ... grievous bodily harm to any person, or with intent to resist or prevent the lawful apprehension or detainer of any person, shall be guilty of felony, and being convicted thereof shall be liable ... to be kept in penal servitude for life ... .
The key element of this offence is intent. Types of injury would include stabbings or shootings.
Section 20
This section creates the offences of wounding and inflicting grievous bodily harm. They are less serious than the offences created by Section 18 and carry a maximum prison sentence of 5 years. The key ele- ment of this offence is the causing of grievous bodily harm, but without the intent to do so.
Section 47
This section creates the offence of assault occa- sioning actual bodily harm. It encompasses those assaults that result in substantial injuries, typically requiring a degree of medical treatment for the vic- tim and provides the penalty to which a person is liable on conviction of that offence on indictment. A periorbital haematoma with a superficial laceration after a punch, or a broken tooth, are the types of injury that may be considered a Section 47 assault.
■ Types of injury
Injury caused by the application of physical force can be divided into two main groups: blunt force and sharp force. There are a number of other types of injury caused by non-physical forces, which can be thermal, chemical, electrical or electromagnetic which are referred to in other Chapters.