Evaluation of forensic reports issued in emergency departments and comparison with reports issued by the Council of Forensic Medicine

ABSTRACT

BACKGROUND:

Identify the deficiencies in the forensic reports prepared by the emergency physicians and to identify the frequent mistakes in these reports by comparing the forensic reports issued by the emergency physicians in the context of offences against physical integrity and the forensic reports issued by the Second Forensic Medicine Specialization Board for the same forensic cases.

METHODS:

Existence of the information that should be included in the standard forensic report (name, surname, address, event date, etc.) of 241 cases prepared by emergency physicians who were sent to the Forensic Medicine Second Forensic Medicine Second Specialization Board due to various reasons between February 1, 2019, and May 1, 2019, were reviewed retrospectively. Besides, whether the trauma causing the forensic event stated in these reports is life threatening or not and whether it can be eliminated with simple medical intervention or not were compared with the reports prepared by the Council of Forensic Medicine Forensic Medicine Second Specialization Board for the same events and certain mistakes were determined.

RESULTS:

Address, examination time, and incident date were not specified in forensic reports issued by emergency physicians with a ratio of 95.5%, 63.9%, and 75.9%, respectively. About 23.2% of forensic reports written by hand were not legible. When the reports prepared by the Council of Forensic Medicine and the emergency physicians for the same forensic events were compared in terms of the presence of life threat and treatment with simple medical intervention, it was shown that the emergency physicians were insufficient in determining the life hazard and the simple medical intervention to resolve the trauma causing the forensic event. It was found that the forensic reports issued in tertiary hospitals (education and research hospitals and university hospitals) were more accurate in determining the life hazard and treatment with simple medical intervention status of trauma which caused the forensic event when compared with forensic reports which were issued in primary and secondary line hospitals.

CONCLUSION:

Regardless of whether the physicians working in the emergency departments are general practitioners or emergency specialists, their sensitivity and knowledge level regarding the preparation of a forensic report was found to be insufficient. We believe that with the increase of coordinated planned multidisciplinary trainings that include emergency medicine and forensic medicine, the forensic reports that are arranged incorrectly will decrease and the awareness of physicians about the results of forensic reports will increase.

INTRODUCTION

As a result of a person’s will, indisposition or negligence; an active or passive affected person is considered a judicial event when a condition that we can call illness physically or mentally occurs. In this context; traffic accidents, falls, battery cases, work accidents, poisonings, burns, electrical and lightning strikes, all kinds of asphyxia cases, sharp object injuries and firearm injuries, abuse cases or presence of suspected abuse, and suicide attempts should be considered as forensic cases.[1] In 280^th article of the Turkish Penal Code (TPC), it is obligatory for physicians/health personnel to report the forensic events encountered. Physicians report these situations to the relevant authorities through the forensic report, which indicates the strength of the trauma experienced in the affected person as a result of the forensic event.[2] Since the most common places where forensic cases are seen are emergency services, forensic reports are most frequently prepared by the emergency physicians.[3]

Criminal and judicial situations in judicial events vary according to the reports prepared by physicians. Therefore, emergency physicians who prepare forensic reports should show the necessary care and attention. Unfortunately, many studies have found that forensic reports prepared by physicians other than forensic medicine specialists are inaccurate and/or incomplete.[4,5] It should not be forgotten that physicians may face accusations such as “false expertise” and “judicial liability negligence” in case of incomplete or incorrect judicial reports.[6]

The Council of Forensic Medicine is tasked with providing scientific and technical opinions on forensic medicine issues sent by courts, judges, and prosecutors. This institution contains eight specialized boards and seven specialized departments with different distribution of duties. The Second Forensic Medicine Specialization Board, one of the specialization boards, is also tasked with organizing expert opinion on acts involving crimes against body immunity and acts related to torture and torture by courts or prosecutors. The Second Forensic Medicine Specialization Board, one of the specialization boards, is tasked with organizing expert opinion about actions related to crimes sent by courts or prosecutors and committed against physical integrity, and acts related to torture and torture crimes.[7]

In this study, we aimed to identify the deficiencies in the forensic reports prepared by the emergency physicians and to identify the common mistakes in these reports by comparing the forensic reports issued by the emergency physicians within the scope of crimes against body integrity and the forensic reports issued by the Second Forensic Medicine Specialization Board for the same forensic cases.

MATERIALS AND METHODS

Our study was done with the permission of the Council of Forensic Medicine Education and Scientific Research Commission. This study was conducted after examination of forensic reports and reports issued by the Council of Forensic Medicine Forensic Medicine Second Specialization Board on total number of 241 cases which were sent to the Council of Forensic Medicine Forensic Medicine Second Specialization Board between February 1, 2019, and May 1, 2019, with the request of a report to be prepared within the scope of crimes against body integrity by judicial authorities due to various reasons (such as contradiction between reports, requesting a final report). The report issued by the Second Specialization Board was answered according to different questions of the judicial authorities such as causality and mechanism. Cases where there is no opinion about whether trauma is life-threatening or not, can be resolved by simple medical intervention or not and whether it causes bone fracture or not were excluded from the study. In addition to that cases with forensic reports not prepared by emergency physicians were also not included into this study. In reports prepared by emergency physicians; name, surname, place of birth, date of birth, father’s name, address, date of incident, time of admission to the hospital, reason for arrival, complaint, general condition, state of consciousness, radiological findings, laboratory findings, lesion feature, whether or not the examination time was written, whether the name and surname of the physician who issued the report is available, whether the report is written in computer environment, the condition of life hazard, the condition of simple medical intervention, the hospital in which the reports are prepared, the academic title of the physician who prepared the report and the readability of the reports were all retrospectively reviewed.

Statistical Analysis

Statistical analyses were done using SPSS 20 statistical analysis program (IBM). Data are given as percentage and number. Shapiro–Wilk and Kolmogorov–Smirnov tests were used to evaluate whether the data were suitable for normal distribution or not. Independent sample t-test was used to compare normally distributed data between the two independent groups, and the Mann–Whitney U test was used if the data were not normally distributed. Categorical variables were compared using Chi-square and Fisher’s exact tests. P<0.05 value was considered statistically significant.

RESULTS

In our study, 241 cases that meet the criteria were included in the study. Cases that do not indicate whether trauma is life-threatening or not, whether it can be resolved with simple medical intervention or not and whether it causes bone fracture or not were not included into this study. In addition to that cases with forensic reports not prepared by emergency physicians were not included in the study. Examination of forensic reports from the outer center is summarized in Table 1.

Table 1.

Analysis of information that should be included in forensic reports of cases

	Yes		No
	n	%	n	%
Name surname	240	99.6	1	0.4
Place of birth	169	70.1	72	29.9
Date of birth	196	81.3	45	18.7
Father name	145	60.2	96	39.8
Address	18	7.5	223	92.5
Event date	58	24.1	183	75.9
Application time to the hospital	113	55.2	108	44.8
Reason of arrival	221	91.7	20	8.3
Complaint	194	80.5	47	19.5
General status	142	58.9	99	41.1
Awareness status	128	53.1	113	46.9
Radiological findings	134	55.6	107	44.4
Laboratory findings	89	36.9	152	63.1
Defining lesion feature	230	95.4	11	4.6
Indicating the life-threating status	162	67.2	79	32.8
Indicating the simple medical	127	52.7	114	47.3
intervention status
Specifying an inspection time	87	36.1	154	63.9
Physician name and surname	231	95.9	10	4.1
Writing the report in computer	73	30.3	168	69.7
environment
Readability of written reports	202	83.8	39	16.2
Presence of information that the report was delivered	28	11.6	213	88.4

About 7.1% (17) of the 241 forensic reports issued by the emergency physicians were arranged as strict (69) and 69.3% (167) of them were temporary. The accuracy of the report is not specified in 23.7% (57) of these reports.

Accordingly, 37.8% (91) of the 241 forensic reports included in the study were issued in district state hospitals, 19.1% (46) in provincial state hospitals, 24.1% (58) in education and research hospitals, 10.8% (26) were organized in university hospitals, and 8.3% (20) were issued in private hospitals.

Briefly, 53.1% (128) of the physicians who prepared the forensic reports were practitioners, 23.2% (56) were emergency resident physicians, 22.4% (54) were emergency specialists, and in 1.2% (3) of these cases, the condition physician could not be determined. The judicial characteristics of the cases included in the study are summarized in Table 2.

Table 2.

Causes of forensic cases

	n	%
In-vehicle traffic accident	23	9.5
Non-vehicle traffic accident	34	14.1
Sharp object injury	46	19.1
Firearm injuries	9	3.7
Battery	105	43.6
Occupational accident	9	3.7
Electric shock	7	2.9
Falling down from height	1	0.4
Not specified	7	2.9

Comparison of the reports given by the Council of Forensic Medicine and emergency physicians with regard to life-threating condition (vital hazard) is shown in Table 3. The comparison between two groups in terms of the presence of life-threatening condition was statistically different (p<0.05).

Table 3.

Comparison of reports given by Council of Forensic Medicine and emergency physicians in terms of life threat (vital danger) (LT)

	Report of the Council of Forensic Medicine
	LT is present	LT is not present	Total
Report of the emergency
physician
LT is present	33	26	59
LT is not present	16	87	103
Not specified	35	44	79
Total	84	157	241

LT: Life threat.

Comparison of the reports given by the Council of Forensic Medicine and emergency physicians in terms of treatment with simple medical intervention status is shown in Table 4. Difference for treatment with simple medical intervention was found to be statistically significant between two groups (p<0.05).

Table 4.

Comparison of reports given by Council of Forensic Medicine and emergency physicians in terms of treatment with SMI

	Report of the Council of Forensic Medicine
	Can be treated with SMI	Cannot be treated with SMI	Total
Report of the emergency physician
Can be treated with SMI	19	20	39
Cannot be treated with SMI	8	83	91
Not specified	28	83	111
Total	55	186	241

SMI: Simple medical intervention.

Comparison of the reports issued by the Council of Forensic Medicine and emergency physicians in terms presence of a fracture is given in Table 5. Difference for the presence of fracture was found to be statistically significant between two groups (p<0.05).

Table 5.

Comparison of the reports issued by the Council of Forensic Medicine and emergency physicians in terms presence of a fracture

	Report of the Council of Forensic Medicine
	Fracture is present	Fracture is not present	Total
Report of the emergency physician
Fracture is present	66	2	68
Fracture is not present	7	72	79
Not specified	28	66	94
Total	101	140	241

The physicians who prepared the report were classified as general practitioners, assistants or specialists and unspecified. The reports given by these physicians were compared with the reports issued by the Council of Forensic Medicine.

• There was no statistically significant difference between these two groups (general practitioner and emergency assistant or specialist) in terms of reporting life-threatening condition (p=0.302).

• There was no statistically significant difference between these two groups when treatment with simple medical intervention were compared (p=0.439).

• When the presence of a fracture was compared; there was no statistically significant difference between these two groups (p=0.787).

When the hospitals where the report is prepared are classified as 1^st (primary care) and 2^nd (secondary care) line hospitals (provincial, district hospitals), 3^rd line (tertiary health care) hospitals (education research and university) and private hospitals;

• In the determination of the life-threatening situation, 3^rd line hospitals have been more successful. This situation is statistically significant (p<0.05).

• It was detected that third line hospitals are more successful in determining the treatment status with a simple medical intervention. This situation is statistically significant (p<0.05).

• It was detected that third line hospitals are more successful in determining the fracture status. This situation is statistically significant (p<0.05).

DISCUSSION

As with all physicians, physicians working in emergency departments also have forensic medicine duties. This task is much more important for the physicians working in the emergency departments, as they often face judicial events.[8] The physician who encounters the forensic event should report the situation caused by the trauma to the judicial authorities with an appropriate report. Procedures and principles in the preparation of a forensic report in the circular titled “Principles to be followed in the execution of forensic medical services” published by the Ministry of Health on September 22, 2005, with the number of 13292 was based on the Turkish Criminal Code (TCK) and the Criminal Procedure Law (52K) numbered 5271.[9] As a result of filling the information in the standard forms prepared in accordance with this circular, judicial reports will be processed faster and more effectively with duly prepared forensic reports.

It has been determined that the most frequent forensic events in emergency departments are traffic accidents.[10,11] However, it was found from the files, sent to the 2^nd Forensic Medicine Specialization Board, that forensic reports are most frequently given (43.6%) to battery cases in emergency services. Traffic accidents were the second with 23.6%. Most traffic accidents are considered within the scope of negligent injury except in some cases.[12] Considering that only cases from judicial authorities have been sent to the Second Specialization Board, According to the TPC, investigating and prosecuting the crime of injury by negligence, except for some cases, is subject to complaint but most of battery cases are reflected to judicial authorities and this seems to explain the difference.

In the forensic reports prepared by the emergency physicians in our study, we found that the address of the cases, the date of the incident, the application time, the examination time and the delivery status of the report were not generally written. In a study of Turla et al.,[5] it was determined that 71.8% of forensic reports did not include the inspection time, and the status of report delivery was not specified in any of the reports. In another study, it was stated that in half of the forensic reports, the time of the incident and the examination time were not written.[11] In a study of Çetin et al.,[13] contrary to our study, it was found that reporting the time of incident and examination time to be high in forensic reports. They linked this situation to the fact that learning and recording of the date and examination time of the forensic cases by trained administrative personnel. In another study, it was determined that 61.5% of the forensic reports issued in the emergency departments did not state the general condition and, on the other hand, the state of consciousness was not specified in 58.7% of these reports.[5] In our study, we found that the general condition was not written in 41.1% of the cases, and the state of consciousness was not written in 46.9% of the cases in the forensic reports. In the same study, it was determined that the physician’s name and surname were not written in 8% of the cases. In 4.1%[10] of the forensic reports we examined, the physician name and surname were not written. Unfortunately, the absence of a physician’s name and surname is a difficult situation to explain. Bozkurt et al.[14] stated that 96.4% of the forensic reports issued in the emergency department did not have laboratory results, and 61.7% did not have the radiological results. In our study, similarly to this study, we found that laboratory results were not recorded in 63.1% of the forensic reports prepared in emergency departments and radiological results were not recorded in 44.4% of these reports. Incomplete forensic reports may lead to prolonged judgment and increase of victimization, and physicians who issue these reports may also face legal sanctions.

It is one of the most common problems that forensic reports are written illegibly and irregularly.[15] In a study, it was detected that 10.3% of pharmacists and 11.5% of physicians had problems reading hand-written prescriptions.[16] In a study of Serinken et al.[11] it was stated that 26% of the forensic reports issued were not understandable. In our study, 30.3% of the forensic reports prepared in emergency departments were prepared in computer environment. In 23.2% of the forensic reports written by hand there was difficulty in reading. It should not be forgotten that if the report is written illegibly, the report can be sent again to make the report understandable or the physician can be called to the judicial authorities for the correction of the report. These situations will delay the manifestation of justice and cause loss of material/moral rights.

İn forensic reports, it is important to indicate whether trauma causes life-threatening conditions in that individual and whether it can be treated or not with simple medical intervention.[5] Taking into account the TCK numbered 5237 and the Criminal Procedure Code numbered 5271 (CMK), the Forensic Medicine Institution, the Forensic Medical Experts Association and the Forensic Medicine Association were published a guideline named as “Guidelines for Forensic Reports to be issued within the framework of the New Turkish Criminal Law” in 2005. This guide has been updated in 2013 and 2019 to overcome the deficiencies in the implementation process. Forensically, this guide explains whether traumatic changes can be treated or not by simple medical intervention or if they can cause a life-threatening condition or not in detail.[17] The fact that the physicians who prepare forensic reports prepare their reports in line with this guide will enable the judicial process to progress more healthily. In our study, we found that the presence of a life threating condition was not indicated in 32.8% of the reports and in 47.3% of the reports in our study, we found that it was not stated whether this could be resolved by simple medical intervention. In another study evaluating the forensic reports prepared in the emergency departments, the treatment status by a simple medical intervention was given in all of the reports and the concept of life-threating condition was included in only 56.8% of these reports.[18] In our study, a significant difference was found in comparing the forensic reports issued by the 2nd Forensic Medicine Board and emergency physicians for the same forensic cases in terms of “treatment with simple medical intervention” and presence “life-threatening” situations. In a study in which forensic reports prepared in the emergency department were examined, only 6% of 21 cases who were given to have a life-threatening condition by their emergency physicians were identified as life-threatening injuries.[19] The meaningful difference we found in our study made us think that emergency physicians do not fully understand the concepts of “being able to be treated with a simple medical intervention” and “life threatening situation” and cannot evaluate these two concepts clearly.

In a study of Hakkoymaz et al.[20] which was examining forensic reports in a university hospital emergency room; it was determined that only 2.3% of the reports were prepared definitely. In another study examining forensic reports prepared in a university hospital emergency room, it was stated that 0.7% of the reports prepared were definite and 93.4% were temporarily prepared.[14] In accordance with the literature, we found that 7.1% of forensic reports given in our study were prepared with precise features. The fact that the rate of exact reports in forensic reports is so low can be explained by the fact that physicians do not have sufficient information about the preparation of forensic reports or that they are shy about legal matters.

In the articles 87 and 89 of the TPC, an increase in penal sanctions is foreseen in cases where trauma causes bone fracture. In the reports issued by the emergency physicians, it is also important to specify the bone fracture and its grade although reporting whether the trauma causes life-threatening situations or not and these situations can be treated with simple medical intervention or not are prioritized. In the guide prepared for the forensic reports to be prepared within the framework of the TPC, the international abbreviated Injury Scale has been determined and explained in detail, including the grading of bone fractures and its effect on life functions (mild/moderate/severe).[17] In a study of Karbeyaz et al.[21] in which forensic reports with nasal bone fractures were examined; nasal bone fracture was not reported in the forensic reports in 7.8% of cases. In our study, we found that fracture was reported in forensic reports that were issued in emergency service only in 68 of 101 cases, in whom presence of a fracture was reported by Second Forensic Medicine Specialization Board. This situation made us think that emergency physicians do not have enough information about the 87^th and 89^th articles of TPC and the importance of bone fractures in forensic reports.

The level of knowledge of the emergency medicine assistants and specialists working in the emergency departments in the preparation of the forensic report is not related to the graduation year of the doctor who prepared the report or the working duration in the emergency departments.[3] In a study of Çolak et al.[22] it was also found that general practitioners were inadequate in preparing judicial reports. In our study, when the forensic reports given by general practitioners, emergency assistants or emergency specialists and the forensic reports given by the Council of Forensic Medicine were compared; it was found that the life-threatening condition of the trauma, the ability to treat with simple medical intervention, and the state of bone fracture did not differ significantly between general practitioners, emergency assistants, and emergency specialists. For this reason, we think that it would be appropriate to give more places to the issue of forensic report in emergency specialty training.

In our study, it was found that detection of life-threating conditions and treatment with simple medical intervention is more accurate in forensic reports that were prepared in the 3^rd line hospitals when compared with other health institutions (provincial and district state hospitals and private hospitals). We believe that providing academic training in university and education research hospital emergency departments, presence of academic staff and the ability to obtain opinions from forensic medicine departments, especially in university hospitals, contribute to more accurate identification of life threating conditions and ability of treatment with simple medical intervention in forensic reports which were prepared by the 3^rd line hospitals.

Limitations

There were some limitations in our study. Some of the reports issued in the emergency departments could not be evaluated. These unevaluated sections were considered as unwritten. Our study could be expanded by increasing the number of cases.

Conclusion

As in similar studies in the literature, it has been determined that the physicians working in emergency departments have insufficient sensitivity and knowledge level regarding forensic report preparation regardless of whether they are general practitioners or emergency specialists. Considering that nearly half of the physicians who prepare forensic reports in emergency departments are general practitioners and the other half are emergency medicine specialists and assistants; We believe that with the increase of coordinated planned multidisciplinary trainings that include emergency medicine and forensic medicine, the forensic reports that are arranged incorrectly will decrease and the awareness of physicians about the results of forensic reports will increase.