The Medical Report Beta Ahlam Gizela Bagian Ilmu Kedokteran Forensik dan Medikolegal FK UGM
The Medical Report What is it ???
In every country in the world, there are crimes and its victims. In another side there are tortures and ill treatments to the detainee who did a crime. To seek justice for both of cases above, it is needed medical proofing
The Medical Report Documenting the medical consequences and the case history including the methods used for attack, ill treatment and torture
Expert Witness
Evidence
Cross matching
Judge Decision To be continued to the next page
Continue
Re-trial
Proof Evidence Tool Evidence (Court) Forensic Science
Forensic science Forensic medicine Dermatogliphy Forensic chemistry Forensic physics Forensic biology Ballistic etc
Medical Evidence Human: living or dead Human remain: bone, teeth, body part Biological substances: blood, saliva, sperm, epithelia, hair, other tissue
Medical Report Court Judge need consideration for punishment. Judge ask about: Is there a victim? How severe is the disease/injury? Is it related to the accused?
The Medical Report Can be used as a proof in the court Projusticia Without projusticia
The Medical Report Using projusticia Person being examined is an evidence tool Request by the police/attorney/judge Called Visum et Repertum in Indonesia Doctor as a police doctor, only give his/her report to the police/attorney/judge
The Medical Report Without projusticia Person being examined is a patient who makes a contract of examination Request by the patient Called Surat Keterangan Medis in Indonesia Doctor as a treaty doctor, only give his report to the patient (medical confidentiality)
Late Request Letter In some case, the request letter from the police/attorney/judge come later. First contract come from the patient Law Criminal Procedure (KUHAP): the doctor need Informed Consent from the patient to write the medical report for the police/attorney/judge Medical Practice Act (Act no 29/2004): didn’t need Informed Consent
The Medical Report of a living person 1. Preamble (Projusticia, only for MR request by police/attorney/judge) 2. Introduction (Identity of requester, doctor, person/patient, incident) 3. Content (history, physic diagnostic, advance examination, treatment) 4. Conclusion (Identity, diagnosis: include severity/qualification, whether or not there is any contradiction between the trauma/diagnosis and the history - possibility cause of trauma) 5. Closing (jurisdiction base, doctor’s signature) Adapted from Istanbul Protocol
INTRODUCTION Personal data of client Circumstances of the report Phrasing of questions by requesting party Medical records / Relevant document Indicate to whom a copy of the report will be sent
HISTORY An important part of the case history is a description of the torture; this should be detailed, as it is important for the interpretation of the findings during the medical examination. The recording of current symptomology should be painstakingly accurate and, if possible, its relationship to the torture should be described.
PHYSICAL EXAMINATION and PSYCHIATRIC EXAMINATION This section is therefore of great importance and will be examined in detail. It must be accurate and easily understandable.
PHYSICAL EXAMINATION and PSYCHIATRIC EXAMINATION The manner in which the wounds/scars are described is vital. The description should be extensive and detailed. However it should only cover those abnormalities and symptoms that can be ascertained objectively. Constructing a report to include personal interpretations or subjective observations is to be avoided as it will undermine its own objectivity and directly affect its credibility.
For example: Do not write: “there is a perforation of the ear drum that was caused by a blow to the client’s ear” (own interpretation) but rather: “a perforation of the ear drum was found. An explanation of its cause could be a trauma, e.g. a blow to the ear, such as the client told me he had received”.
Summary, discussion and conclusion This is the crux of the matter. You should concentrate on constructing a balanced and logical report, providing insight into the argument that lead to a conclusion that flows naturally from the preceding objective information. All that has been written on objectivity in earlier paragraphs is of course to be taken into consideration here.
CONCLUSION In the Conclusion, a statement may be included underlining the probability of a connection between the torture suffered by the victim and the medical findings - if, of course, the medical findings support this objectively.
Warning ! In practice it proves to be difficult for many people not to include personal interpretations and subjective descriptions in a report. The feelings, emotions and anger that people naturally feel when listening to these stories and on seeing the results of torture can have a profound influence. However it is important to remember the aim and the legal character of the report in order to understand the importance of the signs of torture.
The Autopsy Report 1. Preamble (Projusticia, only for MR request by police/attorney/judge) 2. Introduction (Identity of requester, doctor, corpse, incident) 3. Content (external examination, internal examination, advance examination) 4. Conclusion (Identity, cause of death, manner of death, time of death) 5. Closing (jurisdiction base, doctor’s signature) Adapted from Minnesota Protocol
INTRODUCTION Personal data of the victim Circumstances of the report Indicate to whom a copy of the report will be sent Official Statement of the case
EXTERNAL EXAMINATION General: external abnormalities Specific: consequences of torture: + Scars: localization, size (in mm), shape, limitation, colour, mutual arrangement, hypertrophy, include a diagram of the body and possibly photographs on which the scars are indicated Describe the abnormality systematically, in detail, each part of the body.
INTERNAL EXAMINATION Describe all the result internal examination in detail, each part of the body: Fracture Corpus alienum Haematoma Internal bleeding Organ damage or rupture Organ congestion or swelling Secretion, and any abnormalities found in autopsy
LABORATORY EXAMINATION Note the result of laboratory examination supporting an autopsy
SUMMARY AND DISCUSSION Note summary of the examination, make a scientific explanation and interpretation to construct a conclusion.
CONCLUSION Identity Cause of death Time of death Manner of death
Another Simply Medical Report DDeath certificate BBorn certificate HHealth certificate IImmunization certificate eetc
References Istanbul Protocol Minnesota Protocol David Owen, Hidden Evidence Indonesia Regulation