2. Questionnaire
A Case Study
Definitions
Legislation
History & Examination
Early Evidence Kits
SARC services
3. I 3 point ID completed verbally with pt.
S 38yo ♀ referred to SW by Medical for
psychosocial and safety assessment post
sexual assault.
O Pt was observed to be scared, frightened,
withdrawn and very teary.
B Numerous grief/loss issues (parents
deceased, estranged from sibs, not caring for
children), hx of IVDU and physical assaults
4. A Attempt to contact NOK at pt request (distinction
between being alone and lonely).
On-going liaison with WAPOL re forensic specimens:
ROG, Response Team, SA Squad
On-going liaison with SARC.
Access to refuge accommodation (8 calls)
Consultation with CPFS re care status of child.
R Comprehensive Discharge Plan including
Safety Plan, accommodation, clothing, transport,
counselling and crisis payment info.
5.
6. Fortunately we do not see a lot
SARC see >300 emergency cases per year
7. Broad definition
Any sexual activity carried out against the will of a
person through the use of violence, coercion or
intimidation, even if it did not end in penetration.
8. Any unwanted sexual touch
Being forced to masturbate or watch someone
else masturbate
Being forced to give/receive oral sex
Being forced to perform sexual acts on oneself
or others
Sexual penetration by penis/object/other parts
of the body into vagina/anus/mouth
9. WA Criminal Code
-Sexual penetration without consent
-Aggravated sexual penetration without consent
Aggravated can include: causing injury; using a weapon; detaining the
complainant; the complainant’s age; if the complainant has a disability
-Indecent assault
-Aggravated indecent assault
Consent = freely given & voluntarily given
without force/threat
10. 16 years in WA
18 for anal sex in Queensland
Some nations only 15 years
PNG – 16 yrs for girls and 14 yrs for boys
People of authority
11. Is a free agreement – which cannot be given if
intoxicated, frightened, asleep, unconscious,
forced or coerced, no capacity to understand
what is happening, too young
Consent can be withdrawn at any time
12. If belief that a child/young person (<18yrs) has
been subject of sexual abuse
Freephone: 1800 708 704
www.mandatoryreporting.dcp.wa.gov.au
15. Sexual Assault & Abuse
Mental Health
Issues
Alcohol & Drug
Issues
16. Has an impact on-
The likelihood of the person seeking further
assistance
The likelihood of the person/complainant
reporting the crime and proceeding through
the criminal justice system
17. Listen & Believe
Private space
Reassure & be empathic
Uncomfortable for both pt & staff
18. Open
Direct disclosure of sexual assault
Brought to ED by police
Indirect presentation
Injury/Domestic violence
Requiring emergency contraception/STI screen
Intoxication +/- memory loss
Mental health w self-harm/suicidal ideation
20. Is patient safe?
From perpetrator
From themselves
Other mental health problems
Are children safe?
Does pt have somewhere safe to go?
Psych/Social worker referral
Pt can call/be seen by SARC for counselling
21. Injuries
-Acute medical takes priority over forensic
-5% have moderate & 1% severe physical injury
(head injuries, strangulation, fractures,
widespread soft tissue injuries)
-likelihood of significant genital injury is
uncommon (except in pre-pubertal girls & post-
menopausal women)
22. Contraception
-Risk of pregnancy?
-Emergency contraception
-Give ASAP up to 72 hours (or ?longer, may be
have some effect up to 5 days)
23. STI screening
-First void urine
-Serology – Hep B, C, HIV, syphilis
-Genital/oral/anal swabs if appropriate, but
consider need for forensic examination/specimen
collection
24. Azithromycin 1g orally for chlamydia alone
?Gonorrhoea - depends on region, risk &
likelihood of compliance
Ceftriaxone 500mg in 2mls 1% lignocaine IM
AND
Azithromycin 1g orally
Hep B vaccine/Ig if at risk
HIV PEP is rarely required
25. HIV
1/1250 risk from penile/vaginal & 1/60 from
penile-anal with a known HIV positive male
Risk increases w genital injury, concurrent STI,
receptive anal assault, assailant factors (high
prevalence countries, IVDU & MSM)
26. 2 anti-retrovirals for 1 month
Side effects rare
GI upset, headaches, rash, renal/liver dysfunction
D/W Immunology Reg on-call
27. Sexual health clinic
1 month: repeat swabs & urine, pregnancy test
3 months: repeat serology
Hep B vaccinations at both if required
28. A forensic medical examination can only be
conducted with a patient’s fully informed
consent
It is not done for therapeutic reasons, but to
assist a criminal investigation
Informed consent
-is specific
-freely given, no coercion
-competently given
-pt needs capacity
29. May consent to one part, but not another
Right to withdraw consent
<18 yrs – need child’s assent AND responsible
person’s consent
<18 yrs – can consent to medical, but not
forensic component depending on if police are
involved
Intoxicated – must wait until sober, but
consider EEKs
30. Not required in our ED
Unlikely to ever need to do it
Very detailed
Takes a long time
31. Brief history of assault and any injuries
Date, time and duration of the forensic
examination
Document source of information – police,
patient/victim
Direct quotes are helpful - patient’s own words
Volunteered v direct questioning
When, where and who of the alleged incident
Number assailants
Relationship to assailant
32. Force or weapon, threats
Penetration or attempted penetration
Patient actions in defence eg. scratching
Possible ejaculation and where on body/clothing
Condom use, lubrication, saliva
Any discomfort, dysuria, genital or anal bleeding
What has happened since the alleged assault eg
showering, changing clothes
Anything else?
33. As you would for any other patient
Injury
Do you have any injuries that are not obvious to me? Head
injury, loss of consciousness, strangulation, genito-anal injury.
Gynaecological history
Last menstrual period, pregnancy, contraception, sexual
partners within last 10 days, pre-existing discharge or concern,
previous sexual abuse/assault
Mental health
Have you suffered from stress or depression in the past? Have
you ever thought of hurting yourself? Do you feel safe from
yourself? Are you safe from others? Who would you go to for
support in difficult times?
34. Site
Position (distance from anatomical landmarks)
Injury type
Colour (shape, surface, margins, healing)
Size /Dimensions
Associated swelling/debris/infection
36. Redness – could be from infection,
inflammation or trauma
Tenderness - subjective
37. Leakage of blood from blood vessels in the skin
and subcutaneous tissues, which have been
disrupted by blunt force
You cannot age a bruise
38. Petechial – often arises from disruption of
small venules, eg. above site of strangulation,
suction type injury
Tramline – struck with a rod-like object
Fingerpad
Patterned
39. The presence of yellow discolouration in a
bruise indicates it is older than 18 hours
Very subjective
40. Result from simultaneous application of force
and movement to the skin causing disruption
of its outer layers
-linear
-brush
Can be a directional component with skin tags
at the end of the abrasion
Describe any bleeding, scabbing or dehiscence
of scabs, but it is not possible to give an a clear
indication of its age
41. Result from the application of a blunt force
which causes splitting or tearing of the skin
and/or subcutaneous tissues
Different to an incised wound which is caused
by a sharp force
43. Not practical in the ED
NO personal mobile phones
Police photographers
Chain of evidence
44. Associating injury w possible
causes/mechanism
Rare in medicine for a finding to have only one
possible mechanism of causation
Risk of over-interpreting
Need to be objective
Respect boundaries of expertise
Exact mechanism often not able to be
determined by physician
45. May still be worthwhile even if
-the patient has showered/bathed/been for a
swim
-the person has had consensual sex w another
person before/after the assault
-the complainant doesn’t think the assailant
ejaculated
Samples can be collected & stored for up to 3/12
46. Oral DNA- 6 hours usually
up to 24 hours possibly
Affected by oral intake
Vaginal DNA- up to 24 hours usually
up to 3 days is likely
5-10 days is possible
Anal DNA- up to 24 hours
up to 48 hours possibly
Affected by bowel actions
Skin DNA- only 46 cells to identity DNA
up to first shower
48. Allows patient comfort with preservation of
evidence, prior to a formal forensic examination
It patient unsure if they want to report to
police/undergo formal exam
Urine (biology & toxicology)
Labial/Penile wipe +/- peri-anal wipe
Oral rinse
Blood (Toxicology)
Clothing
49. Blood
Urine
Assists if victim was unable to consent to sexual
contact due to intoxication
Document patient weight and collection time
May have to collect before pt able to consent,
but await capacity before handing over to
police
50. Available in the ED
Standard hospital supplies can be used
Plain labels (NOT hospital pt labels)
Consent
No need for these to be observed
51. 10mls sterile water
1 yellow top container-labelled as “oral rinse”
1 pair of gloves
52. Pt to wear gloves & hold pot
Place sterile water in mouth & thoroughly rinse
around
Spit fluid into pot and replace top
Label with pt name & date of birth
53. 2 yellow pots
Labelled “urine” & “vulval wipe” or “penile
wipe”
Sterile gauze
10mls sterile water for men
Pair of gloves
Bright yellow sticker (Please fwd to C.C.WA)
54. Pt given items & go to bathroom
Pt puts on gloves
First part urine into pot & replace top
Use gauze to gently wipe vulva
Men – moisten gauze w sterile water & wipe
shaft & tip of penis
Place in pot, allow to dry before replacing lid
Attach yellow label to urine sample
55. If required
Same procedure
Gloves, moisten gauze with 10mls sterile water
& wipe around anus
Place in pot, allow to dry
56. Following suspected drug facilitated assault
2 x fluoro-oxalate (grey) or 2 x EDTA (purple)
blood tubes
Sterile water to clean skin
Plain labels, Exact time of collection
Toxicology consent form
57. If pt wishes to change
Separate PAPER bag for each item of clothing,
change gloves between items
Seal & Label each bag
58. Place all specimens, copy of consent & list of
specimens in envelope/plastic bag
Seal w Evidence Label/completed label & sign
across it with your name, date & time
Hand either to police OR to patient to take to
SARC (keep in fridge if going home first)
Document in notes
60. Document times and events
Note who, what is done, when & where
Seal all specimens in forensic envelopes with
red evidence tape to ensure that it is tamper
proof
61. Swabs, slides, tape, envelopes etc in the Full
SARC sexual assault examination kits
Probably only required in regional EDs/rural
clinics
Here – go to SARC
62. Awareness of risks
Clean environment
Use of bleach/trigone to clean surfaces pre &
post examination
The Vincent Enquiry
63. 24-Hour Emergency Line
(08) 9340 1828
Freecall 1800 199 888
Business line (08) 9340 1820
64. SARC
N.E.I.Langlois and G.A.Gresham, “The Ageing of Bruises”: A
review and study of the colour changes with time,” Forensic
Science International, 50 (1991) pp227-238
Maguire S, Mann MK, Sibert J, Kemp A (2005), 'Can you age
bruises accurately in children? A systematic review', Arch Dis
Child 90:187-189
http://what-when-how.com/forensic-sciences/sexual-assault-
and-semen-persistence/
http://aifs.gov.au
http://www.mandatoryreporting.dcp.wa.gov.au