THE ROLES AND COMPETENCES FOR DOCTORS ASSOCIATED WITH THE EUROPEAN NPMs INJURIES IN DETENTION

1. THE EUROPEAN NPM PROJECT THE ROLES AND COMPETENCES FOR DOCTORS ASSOCIATED WITH THE EUROPEAN NPMsINJURIES IN DETENTION 7th Thematic NPM Workshop Warsaw, Poland, 14-15 December 2011

2. INJURIES I Mechanical II Asphyxial III Physical (thermal, electrical) IV Chemical V Psychical

3. I MECHANICAL INJURIES 1. Blunt force injuries 2. Sharp force injuries 3. Others mechanism: movement of object movement of body mutual movement (collision)

4. MECHANICAL INJURIES1. BLUNT FORCE INJURIES conditions: amount of force, time, region, extent of body surface, nature of object

5. MECHANICAL INJURIES3. OTHERS gunshot /explosive wounds ruptures penetrations detractions, conquasations bite injuries:

6. 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

7. 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

8. Some Common Methods of Physical TortureBeating: hitting, clubbing, kicking - whole body or specific parts (head, genitalia) with fists, clubs, rifles (telefono, falanga),Stabbings or razor cutsElectric 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 legsGenital torture: blunt or penetrating trauma, electrical, vaginal or anal rape, animal rapeOther trauma: planton, fingernail and toenail removal, removal of teeth or dental fractures, prolonged exposure to heat or cold

9. Some Common form of Psychological TortureThreats: pain, torture, executionIsolation and uncertainty about release Mock executions Sleep deprivationInterrogation for hoursExcessive noiseSensorial deprivationDetention in very small and possibly overcrowded roomsDetention in unhygienic conditions – forbidding access to a toiletThreats of torturing relatives or forcing the detained person to witness others being torturedPseudo-executions (mock e.)

10. HOW TO FIND AND DOCUMENT INJURIES?TERMS AND CATEGORIESDocumented allegations- cannot be referred to as“allegations”What can “document” an allegation of ill-treatment?1.Medical criteria 2. Non-medical criteria

11. TERMS AND CATEGORIEScredible allegations = they are not contradicted by other indirect information but are not supported by documents or medicalobservationsunverified/unverifiable allegations= the events took place too long ago and the injuries (if real) have disappeared, they cannot be cross-referenced, there are no documents or medical observations to support them

12. ASSESSMENT OF ILL-TREATMENTTotal 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.

13. ASSESSMENT OF ILL-TREATMENTbe aware of “statistical illusion”!1. visit – 20 allegations2. visit – 40 allegations conclusion = ill-treatment dramatically1. visit – 100 interviews and 20 allegations (20%)2. visit – 400 interviews and 40 allegations (10%)conclusion = ill-treatment significantly

14. 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

15. EXAMINATION PROCEDUREEXAMINATION PROCEDUREPrinciples of examination1. 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

16. EXAMINATION PROCEDUREEXAMINATION PROCEDUREPrinciples of examination4) 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

17. EXAMINATION PROCEDURETopographic examination1. The head and neckScalp- inspect the surface of the scalp - palpate the scalp Face- asymmetries, swelling, redness or surface markingEyes - asymmetric eye movements, pupillary abnormalities - subconjunctival hemorrhages, bilateral petechial hemorrhages Ears- traces of blood/blood crusts inside the external acoustic meatus

18. 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

19. 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

20. 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/

21. 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

22. 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 ill-treatment- 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

23. MEDICAL REPORTS medical records medical reports medico-legal reports

24. 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

25. 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

26. 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

27. 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

28. GUIDELINES: • Have good notes (complete,concise, consistent) • Write in standardized format • Avoid complicated medical/technical jargon • Avoid comments, describe facts

29. DOCUMENTING/REPORTING ILL-TREATMENTWHO 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.

30. 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.

31. 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

32. 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