Dilemmas in Forensic Care of
Vulnerable Victims of SA
Dr Rosemary Isaacs
FRACGP MForensMed (Monash)
Medical Director Sexua...
People most vulnerable to assault
may find it hard to …..
Get help
Give history
Provide consent
Give evidence in Court
Challenges
• Gauging capacity to consent for victims who are
currently suffering with psychiatric illness
• History and Ex...
2005 ABS
Vulnerable to assault
•
•
•
•

Easy targets
Poor witnesses… less chance of prosecution
Lacking support
Cannot speak out
• ...
Gauging Consent
•
•
•
•

What does an adult need to understand?
Examination may help the police/Law
She has a choice wheth...
Technique
• If possible find out from a carer the patient’s
general level of functioning e.g. what they can do
for self ca...
Records
• What you said to the patient
• How you gauged they understood
Mental Ill-health
• What are the dilemmas?
– Past history or current history of ill-health, may
inappropriately prejudice ...
Mental Health
Care of patient
• Safety, decision making
• Suicidality, self harm
Acute trauma mimicking mental illness
– Emotion
• Affect, Mood
• Agitation, Anxiety
• Psychomotor retardation

– Thinking
...
Useful signs of Mental Illness
• Delusion
– Fixed, unable to reason

• Grandiosity
• Hallucinations
• Flight of ideas
Documenting the functioning brain
•
•
•
•
•
•

Orientation
Clear history of matters not related to assault
Answered genera...
Matters disclosed not
related to the assault
Declining part of the examination
Substitute consent
• Consent supported by another adult
• Consent provided by another adult or
guardianship board
http://www.telegraph.co.uk/health/8960195/Ambulance-crews-stretched-tonight-byoffice-Christmas-parties-on-Mad-Friday.html
“Coming to”
• May remember events up to a certain time and
then “go blank”
• May “come to” in the middle of a conversation...
Amnesia
• Deficit in declarative memory: unable to recall past
experience
• Anterograde: in reference to events occurring ...
“Alcoholic blackouts”
• Dense anterograde amnesia
• During the blackout
– Individual appears outwardly unchanged
– Events ...
Drugs combined with alcohol to cause amnesia
• Benzodiazepines, Other hypnotics
• Zolpidem: (Stilnox )
Zopiclone (Imovane ...
During the blackout
• Observers may suspect nothing
• Continue to act “in character”
• Short term memory negligible but lo...
Cognitive function after D & A
• Orientation
• Return of Memory and simple cognition
Photography

https://theconversation.com/over-60-australian-adults-now-overweight-or-obese-1924
Pressures on our patients
Trust and Safety

My future
My judgment
Who will go to jail?
My community pulled apart
What details of the consenting sex may be
relevant ?
Sex Workers

http://www.news.com.au/national/foreign-prostitutes-wanted-on-457-skilled-workvisas/story-fncynjr2-1226660651...
Bulldog witnessed alleged gang
rape: police
A Bulldogs rugby league player has been caught between police and his teammate...
Degradation and War

Sydney Morning Herald
Time alone
Rosemary Isaacs - Australian Association of Forensic Physicians - Dilemmas in Providing Forensic Care for Vulnerable Victi...
Rosemary Isaacs - Australian Association of Forensic Physicians - Dilemmas in Providing Forensic Care for Vulnerable Victi...
Rosemary Isaacs - Australian Association of Forensic Physicians - Dilemmas in Providing Forensic Care for Vulnerable Victi...
Rosemary Isaacs - Australian Association of Forensic Physicians - Dilemmas in Providing Forensic Care for Vulnerable Victi...
Rosemary Isaacs - Australian Association of Forensic Physicians - Dilemmas in Providing Forensic Care for Vulnerable Victi...
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Rosemary Isaacs - Australian Association of Forensic Physicians - Dilemmas in Providing Forensic Care for Vulnerable Victims of Sexual Assault

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Dr Rosemary Isaacs, Medical Director Sexual Assault and Clinical Forensic Medicine, Sydney & South West Sydney LHDs, Royal Prince Alfred & Liverpool Hospitals, Secretary, Australasian Association of Forensic Physicians presented this at the 2nd Annual Forensic Nursing Conference.

This is the only national even of its kind promoting research and leadership for Australia's Forensic Nursing Community. The program addresses future training of forensic nursing examiners, forensic mental health consmers, homicide and its aftermath, ethical dilemmas in clinical forensic medicine, child sexual abuse, providing health care to indigenous patients in the forensic arena and more.

To find out more about this conference, please visit http://www.healthcareconferences.com.au/forensicnursing

Published in: Health & Medicine
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Rosemary Isaacs - Australian Association of Forensic Physicians - Dilemmas in Providing Forensic Care for Vulnerable Victims of Sexual Assault

  1. 1. Dilemmas in Forensic Care of Vulnerable Victims of SA Dr Rosemary Isaacs FRACGP MForensMed (Monash) Medical Director Sexual Assault and Clinical Forensic Medicine RPA and Liverpool Hospitals rosemary.isaacs@sswahs.nsw.gov.au
  2. 2. People most vulnerable to assault may find it hard to ….. Get help Give history Provide consent Give evidence in Court
  3. 3. Challenges • Gauging capacity to consent for victims who are currently suffering with psychiatric illness • History and Examination of cognitively impaired • Patients who decline part of the examination • Personal matters that may cause further stress in court • Trauma response • Mental illness • Pressures on the victim
  4. 4. 2005 ABS
  5. 5. Vulnerable to assault • • • • Easy targets Poor witnesses… less chance of prosecution Lacking support Cannot speak out • Too much to loose • Not safe to speak • Don’t understand their rights
  6. 6. Gauging Consent • • • • What does an adult need to understand? Examination may help the police/Law She has a choice whether to proceed Forensic Examiner will speak to Police about them • General understanding of a genital examination
  7. 7. Technique • If possible find out from a carer the patient’s general level of functioning e.g. what they can do for self care • Simple sentence structure • Match your language and syntax to the patient’s • Gauge the patient’s understanding of health care • Substitute consent if required. Do not proceed if the patient is objecting
  8. 8. Records • What you said to the patient • How you gauged they understood
  9. 9. Mental Ill-health • What are the dilemmas? – Past history or current history of ill-health, may inappropriately prejudice their evidence – Multiple diagnoses on history – Unwell to your observation • Forensic history may be real or doubtful – Trauma response masquerading as mental illness so that formal mental health exam is not reliable
  10. 10. Mental Health Care of patient • Safety, decision making • Suicidality, self harm
  11. 11. Acute trauma mimicking mental illness – Emotion • Affect, Mood • Agitation, Anxiety • Psychomotor retardation – Thinking • Difficulty organising history into sequential events • Some or partial : overvalued ideas, confusion, disorientation, denial, Derealisation – Speech • Paucity of speech, Rapid seems pressured
  12. 12. Useful signs of Mental Illness • Delusion – Fixed, unable to reason • Grandiosity • Hallucinations • Flight of ideas
  13. 13. Documenting the functioning brain • • • • • • Orientation Clear history of matters not related to assault Answered general questions appropriately Could consider various possibilities Behaviour to health staff Future plans
  14. 14. Matters disclosed not related to the assault
  15. 15. Declining part of the examination
  16. 16. Substitute consent • Consent supported by another adult • Consent provided by another adult or guardianship board
  17. 17. http://www.telegraph.co.uk/health/8960195/Ambulance-crews-stretched-tonight-byoffice-Christmas-parties-on-Mad-Friday.html
  18. 18. “Coming to” • May remember events up to a certain time and then “go blank” • May “come to” in the middle of a conversation with no idea of what they were talking about • May go to sleep and wonder how they got home to bed • May worry about what happened
  19. 19. Amnesia • Deficit in declarative memory: unable to recall past experience • Anterograde: in reference to events occurring after the drug or trauma: • Retrograde to those event before it • If Pure “no other cognitive defect”. The defect is in short term memory, not maths etc • Hours • Anticholinergics, antihistamines
  20. 20. “Alcoholic blackouts” • Dense anterograde amnesia • During the blackout – Individual appears outwardly unchanged – Events fail to enter their memory After “coming to” the individual has no recall of events during the blackout Alcohol +/- Sedative Hypnotics
  21. 21. Drugs combined with alcohol to cause amnesia • Benzodiazepines, Other hypnotics • Zolpidem: (Stilnox ) Zopiclone (Imovane ) • Chloral hydrate (Mickey Flynn) • GBH • Ketamine • Barbiturates • Opioids • Anticholinergics, Antihistamines, Dextromethorphan
  22. 22. During the blackout • Observers may suspect nothing • Continue to act “in character” • Short term memory negligible but long term and intermediate memory good. • Clinicians or Forensic examiners, taking a history, need to assess short-term memory
  23. 23. Cognitive function after D & A • Orientation • Return of Memory and simple cognition
  24. 24. Photography https://theconversation.com/over-60-australian-adults-now-overweight-or-obese-1924
  25. 25. Pressures on our patients
  26. 26. Trust and Safety My future My judgment
  27. 27. Who will go to jail? My community pulled apart
  28. 28. What details of the consenting sex may be relevant ?
  29. 29. Sex Workers http://www.news.com.au/national/foreign-prostitutes-wanted-on-457-skilled-workvisas/story-fncynjr2-1226660651907
  30. 30. Bulldog witnessed alleged gang rape: police A Bulldogs rugby league player has been caught between police and his teammates, with detectives revealing he is a key witness to the alleged pack rape of a 20-year-old woman. The player was one of 23 who had given only "scant" written statements about the incident to police, Detective Chief Inspector Jason Breton said yesterday. Taskforce McGuigon yesterday revealed that it believed six players were involved in a poolside rape at the Pacific Bay Resort at Coffs Harbour on February 22. While most Bulldogs players had co-operated by providing statements and DNA samples, the details provided were "brief", Mr Breton said. However, one other player was believed to have witnessed the incident, and the information he could provide was crucial to investigations The Age
  31. 31. Degradation and War Sydney Morning Herald
  32. 32. Time alone

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