THE EUROPEAN NPM PROJECT
THE ROLES AND COMPETENCES FOR DOCTORS
ASSOCIATED WITH THE EUROPEAN NPMs
INJURIES IN DETENTION
7th Thematic NPM Workshop
Warsaw, Poland, 14-15 December 2011
INJURIES
I Mechanical
II Asphyxial
III Physical (thermal, electrical)
IV Chemical
V
Psychical
I MECHANICAL INJURIES
1. Blunt force injuries
2. Sharp force injuries
3. Others
mechanism: movement of object
movement of body
mutual movement (collision)
MECHANICAL INJURIES
1. BLUNT FORCE INJURIES
conditions: amount of force, time, region,
extent of body surface, nature of object
MECHANICAL INJURIES
3. OTHERS
- gunshot /explosive wounds
- ruptures
- penetrations
- detractions, conquasations
- bite injuries:
ASPHYXIAL INJURIES
MECHANICAL ASPHYXIA
- “lack of oxygen”
- characteristics:
congestion of the face,
oedema,
cyanosis,
petechial hemorrhages in the skin of the
face and eyes, as well in conjunctivae and
sclerae
Common methods of ill-treatment and consequences
- physical effects of ill- treatment: immediate, short-term and
long-term anatomical/functional effects
- may be specific or have a very strong association with a
known method of ill-treatment
- many forms of ill-treatment do not leave physical evidence
- no medical classification of methods of ill-treatment
- methods are extremely diverse with a considerable regional
variability, are commonly applied in different combinations and
sequences, and result in all forms of injury known to medicine
Some Common Methods of Physical Torture
Beating: hitting, clubbing, kicking - whole body or specific parts
(head, genitalia) with fists, clubs, rifles (telefono, falanga),
Stabbings or razor cuts
Electric shock: cattle prod, multiple electrodes, electrically
charged bedspring (to breasts, genitals, anus)
Burning: cigarettes, cigars, other hot implements,
Asphyxiation: wet and dry submarino,
Stretching: suspension by limbs, forced abduction of the legs
Genital torture: blunt or penetrating trauma, electrical, vaginal
or anal rape, animal rape
Other trauma: planton, fingernail and toenail removal, removal
of teeth or dental fractures, prolonged exposure to heat or cold
Some Common form of Psychological Torture
Threats: pain, torture, execution
Isolation and uncertainty about release
Mock executions
Sleep deprivation
Interrogation for hours
Excessive noise
Sensorial deprivation
Detention in very small and
possibly overcrowded rooms
Detention in unhygienic
conditions – forbidding access to a toilet
Threats of torturing relatives or
forcing the detained person to
witness others being tortured
Pseudo-executions (mock e.)
HOW TO FIND AND DOCUMENT INJURIES?
TERMS AND CATEGORIES
Documented allegations - cannot be referred to
as “allegations”
What can “document” an allegation of illtreatment?
1. Medical criteria
2. Non-medical criteria
TERMS AND CATEGORIES
credible allegations = they are not contradicted
by other indirect information but are not supported
by documents or medical observations
unverified/unverifiable allegations = the events
took place too long ago and the injuries (if real)
have disappeared, they cannot be crossreferenced, there are no documents or medical
observations to support them
ASSESSMENT OF ILL-TREATMENT
Total number of allegations of ill-treatment received
by the delegation is important,
but
make a clear distinction between allegations and
evidence of ill-treatment.
The number of allegations should be related to the
number of persons interviewed by the members of the
delegation.
ASSESSMENT OF ILL-TREATMENT
be aware of “statistical illusion”!
1. visit – 20 allegations
2. visit – 40 allegations
conclusion = ill-treatment dramatically
1. visit – 100 interviews and 20 allegations (20%)
2. visit – 400 interviews and 40 allegations (10%)
conclusion = ill-treatment significantly
ASSESSMENT OF ILL-TREATMENT
- calculate (at least roughly) the proportion of
allegations out of the total of persons interviewed
- consider the proportion of allegations that could
be verified and documented as facts out of the total
number of allegations verified by the delegation
EXAMINATION PROCEDURE
Principles of examination
1. Examine a complete body
2. Pay attention to all injuries
3. Describe in detail every injury. Description should
include:
a) type of lesion
b) localization
c) shape margins
d) size
e) color
f) texture
EXAMINATION PROCEDURE
Principles of examination
4) Injuries should be numbered and related to the
written notes.
5) Description of injuries must be accurate and the
correct terminology used in the notes.
6) Positioning of lesions must be unequivocal, so use
body diagrams or sketches
EXAMINATION PROCEDURE
Topographic examination
1. The head and neck
Scalp
- inspect the surface of the scalp
- palpate the scalp
Face
- asymmetries, swelling, redness or surface marking
Eyes
- asymmetric eye movements, pupillary abnormalities
- subconjunctival hemorrhages, bilateral petechial
hemorrhages
Ears
- traces of blood/blood crusts inside the external acoustic
meatus
Nose
- asymmetry or deformation
- crackling noise on palpation
- evidence of recent nose bleeds
Mouth
- examine the lips for asymmetry due to swelling or injuries
- examine the inner surface of the lips and the internal surface
of the cheeks
- check the jaw and teeth for pain, loose or damaged
Neck
- check for subcutaneous bruises and semilunar abrasions
- neck holds or locks by police or assailants may imprint
overlapping red marks or intradermal bruising in a “linen fold”
pattern of marks
- check the neck for tenderness and swelling by palpation
2. The limbs
- check for shoulder, elbow, forearm and hand ranges of
movement
- look for specific type of injuries:
bruising, handcuff injuries,
circumferential areas of alopecia (loss of hair),
round/oval scars
3. The trunk
- bruising, abrasions, lacerations and other injuries can occur
anywhere (be aware of non-existing marks)
- specific way of punishment, e.g. flogging
4. The genitalia
- any vulvo-vaginal/anorectal injuries must trigger an
examination made by a trained medical doctor
General topographical assessment
- When assessing wounds of any kind, the doctor may consider
self-infliction
/may occur in para-suicide, in mental illness or with a deliberate
intention to mislead/
characteristics!
- The examiner should be aware of injuries which could be
“defense injuries”
/self-protection/
DOCUMENTING INJURIES
- a multi stage and multi-disciplinary task
- producing medical documentation:
at different stage
- the principle reference: Istanbul protocol
- a principle 6 b): the medical expert, after examination been
conducted, shall prepare a written report which shall include:
history, physical and psychological examination, opinion
- IP speaks about the role of medical expert as it speaks about
medical evaluation for legal purposes
Medical Investigation and Documentation of Torture,
Human Rights Centre, University of Essex
- any health professional should be able to document injuries
and other physical and psychological findings
- where possible there should be also an opinion on the
consistency between these findings and the allegation of illtreatment
- it is important that the health professional does not exceed his
capabilities
- recommended terms to describe lesions attributed to torture:
non consistent, consistent with, highly consistent, typical off,
diagnostic of
MEDICAL REPORTS
- medical records
- medical reports
- medico-legal reports
MEDICAL RECORD
- any record made by a medical or other health
practitioner during or after consultation,
examination or medical procedure
- potentially be required in court as medical
evidence
MEDICAL REPORT
- requested by different individuals or groups
- am I entitled to write such report?
(limitation by confidentiality, secrecy or lack of
knowledge)
- basis: notes
MEDICAL REPORT
- content:
details of patient and doctor, date and place,
detailed history of event,
physical examination and treatment,
identification and description of injuries,
other information from medical records,
conclusion indicating degree of support to alleged
history
MEDICO-LEGAL REPORT
- report on condition of patient, solicited for legal
purpose (gives medical expert’s findings, diagnosis,
prognosis, opinion and conclusion)
- content
- need to be structured, detailed and accurate
- include only, but all, relevant details
- good report will give relevant facts clearly, concisely
and completely and will be understandable
GUIDELINES:
• Have good notes
(complete, concise, consistent)
• Write in standardized format
• Avoid complicated medical/technical jargon
• Avoid comments,
describe facts
DOCUMENTING/REPORTING ILL-TREATMENT
WHO guide, 2007:
- ……
- obligation to notice and register any trace of violence
compatible with torture
- automatic transmitting of such information to the prison or
judiciary surveillance authorities
- detainees can obtain a copy of their medical report at any
time
- doctors must clearly distinguish between the allegations and
the complaints from the objective findings
- if the doctors’ training and/or experience allow it, they must
indicate whether the patients’ allegations are compatible with
their own clinical findings.
CPT recommendations:
- ……
- the results of examination and relevant statements and the
doctor’s conclusions, should be formally recorded and made
available to the detainee and his lawyer
- prison health care services: systematic recording of injuries
and, if appropriate, providing general information to the
relevant authorities. Information could also be forwarded on
specific cases, though as a rule such action should only be
undertaken with the consent of the prisoners concerned.
CPT recommendations (continuation):
- ……
- any signs of violence observed when a prisoner is medically
screened on his admission to the establishment should be fully
recorded, together with any relevant statements by the prisoner
and the doctor's conclusions. Further, this information should
be made available to the prisoner.
- the same approach should be followed whenever a prisoner is
medically examined following a violent episode within the
prison or on his readmission to prison after having been
temporarily returned to police custody for the purposes of an
investigation
SPT recommends:
- what medical examination of each detainee should include
and place on record
- medical records should be made available to the detainees
or their legal representatives upon the detainees’ request
- doctor should record these findings in the register established
- medical checks should be performed upon arrival by qualified
medical staff
- medical files should be maintained, in conformity with Prison
Procedure No. 10, on Prison health care, and international
standards
- such medical records should be made available to the
inmates or their legal representatives upon the inmates’
request