ABSTRACT

Aim

It was aimed to investigate the characteristics of forensic cases admitted to the emergency department of Tekirdağ Namık Kemal University Hospital (TNKUH), the qualities of forensic reports and the prognosis of the cases.

Materials and Methods

All forensic cases for which a forensic report was written in the TNKUH emergency department between 01.01.2021 and 31.12.2021 were included in the study. Case records, hospital information management system and clinical patient forms and judicial notification files in the emergency department archive were examined retrospectively one by one.

Results

Analyzes were made on 1136 cases for which forensic reports were prepared in the TNKUH emergency department. While 71.8% of the patients were male, the overall average age was 33.4±15.7 years. It was observed that the highest number of patients was in the 21-30 age group with a rate of 31.3%. Among the reasons for application, traffic accidents ranked first (33.3%), followed by assault-force cases (24.1%) and work accidents (21.5%). It was determined that 89.1% of the assault-algebra cases occurred with blunt traumatic-impact action. In the conclusions of the forensic reports, no life-threatening situation was mentioned in 175 cases (15.4%), it was stated that there was a life-threatening situation in 84 patients (7.4%), and that there was no life-threatening situation in 877 (77.2%) patients. It was observed that 957 patients (84.2%) were discharged from the emergency department after their examination and treatment, 112 patients were admitted to the ward (7.5%) and intensive care units (2.4%), and 8 (0.7%) patients died in the emergency department during their examination and treatment. Most of the patients admitted to clinical wards were admitted to surgical branch wards.

Conclusion

A significant portion of forensic cases are caused by trauma. Having complete and orderly records in forensic cases is important in terms of physician safety and preventing patient victimization in the legal process that may occur afterwards.

INTRODUCTION

Many emergency cases are admitted to emergency departments every day and some of these cases are forensic cases. A forensic case can be defined as any event that causes a person’s physical or mental health to deteriorate, injury or death as a result of the intent, negligence, recklessness or carelessness of oneself or another person. On the basis of this definition, it is a situation where the intent, negligence, recklessness or carelessness of another person or persons is a factor in a situation where people may be physically or mentally harmed^1-6. Forensic cases include not only applications to health service providers due to criminal incidents, but also those who frequently apply to the departments of forensic medicine in cases that will be subject to a trial, such as examinations of detainees and prisoners, entrance and exit examinations of detention, age determination, detection of illegal substance use, safe driving examinations depending on alcohol intake level, forgery of writing-signatures-documents, as well as those who frequently apply to the departments of emergency services, and those who generally apply to the Departments of Psychiatry and Neurology for reasons such as legal capacity, criminal capacity, guardianship, annulment of marriage⁷. The procedures carried out by healthcare professionals in order to determine the incident, to find evidence and traces, and to organize the treatment and prophylaxis stage in the necessary processes in order to document it in a report are called “forensic examination”⁸.

Traffic accidents, firearm and explosive injuries, sharp-piercing-crushing tool injuries, battery and force (blunt traumatic-effective action) cases, occupational accidents, physical, emotional, sexual abuse and neglect of vulnerable risk groups (such as women-elderly-children-disabled and those with sexual orientation differences), poisoning, suicide attempts, falls, illegal substance use, entry and exit from detention, allegations of torture, animal scratches and bites, mechanical or chemical asphyxia, burns, exposure to electric current, suspected domestic accidents, allegations of medical malpractice and all kinds of suspicious deaths are considered forensic cases^{3, 4, 6, 9, 10}.

Legal Basis

Within the scope of the duties and responsibilities imposed on all physicians by national and international health legislation, emergency physicians have the responsibility to examine patients and perform the necessary medical intervention, as well as the duties of forensic medicine and official referee^11-13.

Physicians have an obligation to report forensic cases to the judicial authorities in accordance with article 280 of the Turkish Criminal Code (TCC) no. 5237¹⁴. In addition, Article 86 of the Regulation on the Operation of Inpatient Treatment Institutions, which includes the articles amended in 2015, states that “In cases examined and treated in inpatient treatment institutions, if there is an indication that a crime has been committed, it is obligatory to inform the public prosecutor’s office or judicial police without delay in accordance with the relevant article of the Turkish Criminal Code. The items that have the quality of evidence removed from the wounded and the corpse must be delivered to the judicial authorities in the same manner and without delay”¹⁵.

Within the framework of Law No. 1219 on the Practice of Medicine and Medical Sciences, all physicians who have the right to practice medicine in our country are responsible for taking part in forensic incidents, making forensic notifications and issuing forensic reports, as well as fulfilling the official referee duties imposed on them by law¹⁶.

According to the Turkish Criminal Code No. 5237, which entered into force in June 2005, emergency room physicians are expected to clarify two main issues in forensic cases in which they examine and issue a report: whether the damage has caused a situation that endangers the life of the person and whether it is mild enough to be eliminated by a simple medical intervention. In this context, a standard guideline for “Evaluation of Injury Crimes Defined in the Turkish Criminal Code from the Perspective of Forensic Medicine”, which was first created in September 2005 and published in June 2019 with the joint work of the Presidency of the Council of Forensic Medicine (ATK), the Association of Forensic Medicine Specialists (ATUD) and the Forensic Medicine Association, has been prepared for nationwide use⁴. Following the enactment of the Criminal Procedure Code No. 5271, the 2019 guideline was added to the circular dated 22.09.2005 and numbered 13292, regulating the “Principles to be followed in the Execution of Forensic Medicine Services” published by the Ministry of Health General Directorate of Primary Health Care Services. It was also sent to governorships by the Ministry of Health and announced to health units by provincial health directorates^17-22. Feedback received along with community and human-based needs is being evaluated and updates are currently underway for the 2019 guidelines.

In this cross-sectional study, we aimed to analyze the epidemiological and demographic characteristics of forensic cases, which have an important place among the admissions to the emergency department of Tekirdağ Namık Kemal University Hospital (TNKÜH), the qualities of forensic reports, their relations with other clinics, their prognosis and other related factors, and to make a comparison with basic sources of information and literature studies. In addition, according to the results, it is aimed to determine the needs for in-service trainings between clinics and to review our status of good medicine on the basis of law.

MATERIALS AND METHODS

This study was planned as a retrospective, cross-sectional, one-year archival data review, which was initiated with the approval of Tekirdağ Namık Kemal University Non-Interventional Clinical Research Ethics Committee (protocol number: 2023.75.04.11, date: 25.04.2023).

Study Population and Data Collection

All forensic cases for which a forensic report was written in the emergency department of TNKÜH between 01.01.2021 and 31.12.2021 were included in the study. The case list was obtained from the hospital information management system. The records of the cases were retrospectively reviewed one by one in the hospital information management system and the clinical patient forms and forensic report files in the emergency department archive. Cases with missing data and cases that could not be reached were not included in the study. The files were analyzed in terms of age, gender, nature of the forensic event, mechanism of trauma, presence and level of ethanol, outcome of the forensic report, presence of life threat, outcome of the case in the emergency department and if the case was hospitalized in a clinic, its nature.

Statistical Analysis

Statistical Package for the Social Sciences 16.0 package program was used to analyze all data obtained from the study. The findings were analyzed statistically in terms of frequency distribution. Descriptive numerical variables were expressed as mean±standard deviation, categorical variables were expressed as number (n), and proportions were given as percentage (%).

RESULTS

Between 01.01.2021 and 31.12.2021, it was determined that a general forensic examination form was filled out and a forensic report was prepared for 1186 cases in the emergency department of TNKÜH. Statistical analyses were performed on 1136 files, since 50 cases with incomplete or inaccessible file information were excluded from the study.

The gender distribution was male with a rate of 71.8% (n=816) and female with a rate of 28.2% (n=320). The mean age was 33.4±15.7 years, the oldest case was 92 years old and the youngest case was in the zero age group. The median age of the cases was 33.4±15.7 years (minimum: 0 - maximum: 92). The highest number of cases was in the age range of 21-30 years with the rate of 31.3% (n=355). While 6.6% (n=75) of the oldest group were 61 years old and older, 3.3% (n=38) of the youngest group were in the age group of 0-10 years (Table 1).

When we analyzed the cases according to event types, traffic accidents ranked first with the rate of 33.3% (n=378), followed by assault and battery cases with 24.1% (n=274) and occupational accidents with 21.5% (n=244). In terms of the trauma mechanisms of the incidents, we see that 89.1% (n=244) of the cases of assault and battery (n=274) were caused by blunt traumatic-effective action, most of the cases of occupational accidents (n=244) were caused by blunt-crushing trauma (43.9%, n=107) and sharps injuries (42.2%, n=103), most of the suicide cases (n=65) were caused by oral drug intake (73.9%, n=48), followed by sharps injuries (21.5%, n=14), poisoning cases (n=60) were mostly caused by food intake (65%, n=39), 20% (n=12) by smoke-gas inhalation and 6.7% (n=4) by alcohol use (Table 2).

Blood alcohol level was requested from 26.1% (n=297) of the 1136 cases included in the study, and blood alcohol level was below the detection value (<10 mg/dL) in 223 of the cases. Most of the alcohol level requests were made for traffic accidents with 208 (70%) cases, 178 cases had blood alcohol levels below the detection value and 30 cases were found to be alcoholic. The highest blood ethanol level was not due to a traffic accident, but belonged to a patient admitted for suicide attempt with a blood level of 582 mg/dL (Table 2).

When we analyzed the conclusions of the forensic reports, it was observed that in 175 cases (15.4%), there was no mention of any life-threatening situation; 18 of these were reports that reported only lesions and complaints for the purpose of detention-entry-exit examination; 84 cases (7.4%) were found to be life-threatening; and in 877 cases (77.2%), it was written that there was no life-threatening situation. Of the 84 life-threatening cases, 31 were traffic accidents and 13 were high-energy traumas such as falling from a height (Tables 2 and 3).

Again, when the final decisions of forensic reports were analyzed, it was found that 4.6% (n=52) were finalized as “definitive physician’s report”, 59.6% (n=677) as “physician’s report expressing opinion”, and 27.2% (n=309) as “provisional physician’s report” (Table 3).

When the outcomes of forensic cases in the physical environment of the emergency department were analyzed, it was detected that 957 cases (84.2%) were discharged from the emergency department after examination and treatment, 112 cases (n=85 + n=27) were hospitalized in the ward and intensive care units (7.5% + 2.4%), and 8 cases (0.7%) died in the emergency department during their examination and treatment. When the forensic events of the 8 patients who died were analyzed, it was determined that two cases were traffic accidents, two cases were suicide, one case was a fall from a height, one case was firearm injury, one case was drowning in water and one case was suspected arrest.

It was observed that most of the patients (n=85) hospitalized in clinical service beds were hospitalized in surgical unit beds (35 cases in orthopedics and traumatology clinic, 20 cases in neurosurgery clinic, 8 cases in ophthalmology unit and 7 cases in thoracic surgery unit). Of the 27 cases hospitalized in the intensive care unit, 25 were hospitalized in the intensive care unit of the anesthesiology and reanimation clinic and the other two cases were hospitalized in the intensive care units of the internal medicine clinic and pediatrics clinic (Table 3).

DISCUSSION

Forensic incidents constitute a considerable portion of emergency department visits. Between the dates of the study, the number of patients admitted to the emergency department for all reasons was 60,403 and the number of forensic cases was 1186 (2%). Demircan et al.²³ reported a rate of 3.66% and Yavuz et al.²⁴ a rate of 6% in their study. In our study, we found that the majority of forensic cases admitted to our hospital were male and the male/female ratio was 2.5. Although this ratio varies in similar studies in the literature, it has been observed that there are many studies in which the number of men is higher²⁵. The difference in male density was thought to be due to the fact that men were more involved in the social and business environment of our country than women, and it was understood that similar opinions prevailed in other studies^26-29.

The mean age was 33.4 years (±15.7) and approximately half of the cases (49.4%) were between 21 and 40 years of age. The high number of forensic cases in this age group, which plays a greater role in the active period of the life process, was found to be consistent with similar studies in the literature^25-30.

Considering the nature of forensic events, we see that traffic accidents ranked first with 33.3%, followed by assault and battery cases with 24.1% and occupational accidents with 21.5%. In our study, it was found that physicians kept forensic reports mostly related to traffic accidents, which was consistent with similar studies in the literature^{2, 25, 26, 29, 31-33}. In addition to the fact that traffic accidents and related injuries are still a major problem in our country, it was associated with the fact that our hospital was located close to the city center and intercity road junction.

In Turkey, the number of occupational accidents within the scope of Article 4-1/a of Law no. 5510 was reported as 384,262 in 2020 and 511,084 in 2021³⁴. As can be seen in Table 2, Table our data, such as the second highest rate of forensic reports on occupational accidents, the nature of the forensic event and the mechanism of trauma, are consistent with the SSI statistics as well as the study conducted in a university hospital in the metropolitan city of İstanbul^{34, 35}. We are of the opinion that in large cities where industrialization and migration are increasing, there will be more occupational accident applications to emergency departments in the coming years.

When we analyzed the emergency department outcomes of the cases, it was seen that the majority (84.2%) were discharged from the emergency department after follow-up and treatment. Of the hospitalized patients, 7.5% were hospitalized in clinical wards, 2.4% were hospitalized in intensive care units, and 8 (0.7%) patients died. It was understood that the intra- and/or inter-clinical outcomes we determined were compatible with the rates of similar studies in the literature²⁹.

When the finalization provisions of the forensic reports were examined, it was seen that 77.2% of the cases had no life-threatening situation, but 7.4% of the cases were stated to have a life-threatening situation; 15.4% of the cases did not mention any life-threatening situation, therefore an important information was missing in some part of the investigation; 59.6% of all forensic reports were concluded as “physician’s report expressing opinion”, the second highest rate was “provisional physician’s report” with 27.2%, 4.6% were concluded with “final report (definitive physician’s report)”, but 8.6% did not contain any termination statement; therefore, 98 reports in this group and 309 reports closed as “provisional physician’s report” were not binding for the judicial authorities and remained open. Forensic reports are one of the important elements of the dynamics of “time in judicial proceedings” and the orderly execution of judicial workflow processes, which are important in the judicial systems of legal states. The most common problem with forensic reports is that physicians issue temporary reports without justification. There are sufficient opportunities to prepare a definitive report, but instead of stating as “it is a forensic report expressing the opinion” or “it is a definitive forensic report”, the statements such as “it is a provisional report” or “it is a provisional report and a definitive report will be issued by the ‘.... ‘ clinic”, “there is no danger to life for the time being, but it is a temporary report issued for the life danger that may arise in the future” unnecessarily prolong the judicial process, sometimes unnecessarily prolong the detention periods of persons who would be suspects in the incident, delay justice, and as a result, may lead to the deprivation of the rights of victims and suspects.

At the same time, it causes a defensive approach in clinics within different specialties and causes unnecessary labor and time loss^{28, 36}. In a study conducted by Serinken et al.³² in Denizli, they reported that 20% of the reports were issued as “final reports“. In a prospective study of forensic reports issued in the emergency departments of two different state hospitals in Mersin and Iskenderun, they reported the rates of issuing provisional reports as 58.5% and 99.6%.²⁸

In many studies, it has been emphasized that physicians are reluctant to prepare forensic reports due to reasons such as lack of knowledge and experience, desire to avoid taking responsibility and not knowing the legal legislation for which they are responsible^{27, 36, 37}. In our study, 309 of the forensic reports were “temporary physician’s report” and 98 of them were “without any termination statement”, which constituted a high rate of 35.8% (27.2% + 8.6%) in total, and which we think is due to the concern of being held responsible for future legal problems that might develop in the future, which are listed in the justifications mentioned in the studies, At the root of the problem is the fact that physicians’ knowledge of forensic duties is limited within their general medical knowledge, and some physicians who have knowledge prefer to abstain in processes related to forensic procedures, thus suggesting that they remain in negative defensive medical practice. There are other clinical studies that are consistent with this data of our study, as well as basic sources of information that support our conclusion^{27, 28, 32, 36-43}.

In the Emergency Department of our hospital, it was observed that in the last one year, the rate of reports on the examination of entry-exit from detention was 1.6% of all forensic reports. In some literature reviews in which the İstanbul Protocol and the Regulation on Arrest, Detention and Statement Taking are emphasized in examinations and reports, it is seen that compliance with national and international legislation is emphasized^{9, 10}. Although the physical conditions and manpower adequacy of our hospital comply with the legislation, the relatively low rate is associated with the fact that especially in recent years, detention entry-exit examinations and reports have been made in the emergency departments of the Ministry of Health hospitals. In this context, it is thought that support is received from the city hospital, which has a campus in the central district of our province, and provincial-district state hospitals.

The number of applications to the emergency department with suspicion of sexual abuse is limited to one case. In our health institution, which is a university hospital, it is known that the applications are made to the units where forensic medicine specialist physicians are present in order to carry out the process more professionally, since there are at least 4 or more forensic medicine specialist physicians in the child follow-up centers affiliated to the nearby provinces, the Ministry of Health hospitals within the provincial-district borders and the units affiliated to the ATK organization.

Study Limitations

Since our study was a single-center retrospective file review study, the generalizability of the findings may have been limited, and problems related to the lack of data to reflect the complete population were also encountered.

CONCLUSION

The data we obtained in this study, which aimed to reveal the profile of forensic cases, are generally consistent with the results of similar studies in the literature.

Health professionals should approach forensic cases in a team-based framework and provide comprehensive treatment and care by adhering to the relevant legal processes. More regulations are needed to develop standards, protocols and training programs regarding the approach and precautions for forensic cases, which constitute an important group among emergency department visits. Since medical records are important data sources for determining the trends in the incidence of forensic cases, it is important to have complete and regular records in forensic cases, as in all medical cases, in order to prevent physician safety and patient victimization in the legal process that may occur afterwards. In many studies, it has been reported that providing regular training to emergency physicians, who frequently encounter forensic cases and have a high risk of professional errors, is important in terms of physician rights as well as the protection of patient rights. However, forensic medicine specialists have as much responsibility as emergency physicians in the management of forensic cases affecting the judicial process. In addition, we strongly recommend the establishment and expansion of forensic bureau units working with a professional team within health institutions and organizations, and the integration of a training on the workflow processes of forensic cases in health service providers into the undergraduate and graduate education curricula of medical, nursing, legal and law enforcement organizations.

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