Browsing by Author "Martin, Lorna J"

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    Child death reviews in the context of child abuse fatalities - learning from international practice
    (Children's Institute, 2005-03) Mathews, Shanaaz; Abrahams, Naeemah; Martin, Lorna J
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    Ethical considerations in forensic genetics research on tissue samples collected post-mortem in Cape Town, South Africa
    (BioMed Central, 2017-11-29) Heathfield, Laura J; Maistry, Sairita; Martin, Lorna J; Ramesar, Raj; de Vries, Jantina
    Background: The use of tissue collected at a forensic post-mortem for forensic genetics research purposes remains of ethical concern as the process involves obtaining informed consent from grieving family members. Two forensic genetics research studies using tissue collected from a forensic post-mortem were recently initiated at our institution and were the first of their kind to be conducted in Cape Town, South Africa. Main body: This article discusses some of the ethical challenges that were encountered in these research projects. Among these challenges was the adaptation of research workflows to fit in with an exceptionally busy service delivery that is operating with limited resources. Whilst seeking guidance from the literature regarding research on deceased populations, it was noted that next of kin of decedents are not formally recognised as a vulnerable group in the existing ethical and legal frameworks in South Africa. The authors recommend that research in the forensic mortuary setting is approached using guidance for vulnerable groups, and the benefit to risk standard needs to be strongly justified. Lastly, when planning forensic genetics research, consideration must be given to the potential of uncovering incidental findings, funding to validate these findings and the feedback of results to family members; the latter of which is recommended to occur through a genetic counsellor. Conclusion: It is hoped that these experiences will contribute towards a formal framework for conducting forensic genetic research in medico-legal mortuaries in South Africa.
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    Forensic medicine in South Africa: associations between medical practice and legal case progression and outcomes in female murders
    (Public Library of Science, 2011) Abrahams, Naeemah; Jewkes, Rachel; Martin, Lorna J; Mathews, Shanaaz
    BACKGROUND: Forensic medicine has been largely by-passed by the tide of health systems research and evidence based medicine. Murder victims form a central part of forensic medical examiners' case load, and women murdered by intimate partners are an important subgroup, representing the most severe form and consequence of intimate partner violence. Our aim was to describe the epidemiology of female murder in South Africa (by intimate and non-intimate partners); and to describe and compare autopsy findings, forensic medical management of cases and the contribution of these to legal outcomes. METHODS: We did a retrospective national study in a proportionate random sample of 25 medico-legal laboratories to identify all homicides in 1999 of women aged 14 years and over. Data were abstracted from the mortuary file and autopsy report, and collected from a police interview. FINDINGS: In 21.5% of cases the perpetrator was convicted. Factors associated with a conviction for the female murders included having a history of intimate partner violence 1.18 (95%CI: 0.16-2.20), weapon recovered 1.36 (95% CI:0.58-2.15) and a detective visiting the crime scene 1.57 (95% CI:0.14-3.00). None of the forensic medical activities increased the likelihood of a conviction. CONCLUSION: The findings raise important questions about the role of forensic medicine in these cases.
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    Gender differences in homicide of neonates, infants, and children under 5 y in South Africa: results from the cross-sectional 2009 National Child Homicide Study
    (Public Library of Science, 2016) Abrahams, Naeemah; Mathews, Shanaaz; Martin, Lorna J; Lombard, Carl; Nannan, Nadine; Jewkes, Rachel
    Jewkes and colleagues present a cross-sectional study that reveals levels of child homicide in South Africa. Identifying causes and vulnerable mothers will lead to prevention methods and strategies.
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    Gender-based violence: strengthening the role and scope of prehospital emergency care by promoting theory, policy and clinical praxis
    (2017) Naidoo, Navindhra; Artz, Lillian; Martin, Lorna J
    Gender-based Violence has a considerable prevalence globally, but it is South Africa that has recorded the highest femicide rate in the world. Prehospital Emergency Care providers appear to be well positioned (as first responders) to respond to abuse early. The aim was to understand and strengthen current/potential practice of domestic violence intervention by prehospital emergency medical systems in the context of global health-sector responses. The paradigm was critical theory and the methodology was exploratory sequential mixed methods. Interviews with managers/policy-makers, focus group discussions of clinician-educators and non-participant observation of simulated practice resulted in hypothesis generation. The quantitative phase involved a survey and cohort study with a screening intervention in a public emergency service. The qualitative phase found challenges and threats to responses require organisational/ideological change as paradoxical practice exists relative to the domestic violence behavioural pathology. Further, role-definition, identity and violence re-contextualisation is needed amidst ambivalent and contradictory positions. Emergent theoretical propositions include: typologies of victims, perpetrators and stakeholder responses; an eco-systemic relationship of state/societal expectations; and a 'conceptual compass' for preventing systemic research bias. The cohort study found bio-psycho-social responses and prehospital screening for domestic violence effective and that the evaluation of prehospital met/unmet need was prudent. The historical domestic violence detection rate was found to be 5,1/1000. A nine-fold increase in detection following the screening training and implementation translated to 47,9/1000 emergency care patients, with no adverse events. These rates are unprecedented for South African emergency care and support screening-policy implementation. The difference in domestic violence detection, quantifies the extent of the practice gap, with an alarming missed case detection of 42,8 per 1000 patients (females, 14 years plus). Conceptualisation of the emergency care burden of domestic violence and an awakening to the unacceptability of current practice is warranted. There is a risk of regulatory and organisational 'capture' mediated by masculine hegemony and resuscitation bias. Professionalization should enable a community of practice approach to violence prevention. Recommendations include the national implementation of screening policy; mitigation of regulatory capture risk and professionalising responses through curriculum-reform. The proposed Risk-Need-Responsivity practice-model promotes clinical coherence in Emergency Care. This elevation of the emergency care discourse is likely to benefit the victim and emergency medicine community. Research is warranted in the evolving epidemiology of domestic violence, the acute/clinical needs of victims/perpetrators and the role of emergency medical systems and surveillance, in promoting health and preventing the associated morbidity/mortality, both as a forensic emergency care burden and as a social determinant of health.
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    Investigating the effectiveness and efficiency of forensic pathology practice in Western Cape, South Africa
    (2017) De Jong, Jacqui Anne; Davies, Bronwen; Martin, Lorna J
    Introduction: In South Africa (SA), the forensic sector faces significant challenges including how to meet increasing public expectations for high quality, reliable and valid scientific and medico legal results, whilst dealing with increasing caseloads and restricted resources in a developing country. Internationally, lean six-sigma and/or business-based frameworks have been developed to define, measure and analyse the efficiency, effectiveness and output of forensic laboratories, so as to assess performance to meet such challenges. Aim: This pilot project aimed to investigate the effectiveness and efficiency of forensic pathology practice at Salt River Mortuary (SRM) by applying lean six sigma principles (define, measure, analyse and improve) and FORESIGHT metric analyses to retrospective case and staffing data, as well as prospective observational analyses. Methods: A retrospective analysis of cases admitted to Salt River Mortuary in 2015 was conducted to define and measure a snapshot of forensic pathology practice in Cape Town. In addition, observations of autopsy processes were conducted to identify bottlenecks in the system and provide suggestions for improvement. Results: An analysis of post-mortem report turn-around for 3567 cases admitted to SRM in 2015 showed that approximately 10% of cases were closed (cause of death was determined) on the day of the post-mortem, 65% within 14 days and 80% closed within a 30 day period. Certain requested ancillary investigations delayed the finalisation of cause of death; for example, only 8.33% of carbon monoxide testing and 30.31% of histological examinations were completed within the year. A process map outlining autopsy practices at SRM was generated through observational data, which also identified key bottlenecks in the process (e.g.: equipment issues). Preliminary financial data suggested that it cost on average R16 155.03 per case. Staff data demonstrated a lack of pathologists compared to other staff categories and high case load requirements. Discussion: This pilot study investigates the utilization of metrics and strategic frameworks to assess forensic pathology processes in Cape Town. This study offers a cross-sectional insight into financial performance, efficiency and effectiveness of post-mortem investigations at SRM, highlighting bottlenecks and inefficiencies, and providing suggestions for improvement. The findings will assist in forming a basis for future work into the development of a framework for monitoring performance and progress, and developing benchmark standards for the death investigation system in South Africa
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    "Other patients are really in need of medical attention" - the quality of health services for rape survivors in South Africa
    (2005) Christofides, Nicola J; Jewkes, Rachel K; Webster, Naomi; Penn-Kekana, Loveday; Abrahams, Naeema; Martin, Lorna J
    Objective: To investigate in the South African public health sector where the best services for rape survivors were provided, who provided them, what the providers’ attitudes were towards women who had been raped and whether there were problems in delivering care for rape survivors. Methods: A cross-sectional study of facilities was carried out. Two district hospitals, a regional hospital and a tertiary hospital (where available) were randomly sampled in each of the nine provinces in South Africa. At each hospital, senior staff identified two doctors and two nurses who regularly provided care for women who had been raped. These doctors and nurses were interviewed using a questionnaire with both open-ended and closed questions. We interviewed 124 providers in 31 hospitals. A checklist that indicated what facilities were available for rape survivors was also completed for each hospital. Findings A total of 32.6% of health workers in hospitals did not consider rape to be a serious medical condition. The mean number of rape survivors seen in the previous six months at each hospital was 27.9 (range = 9.3–46.5). A total of 30.3% of providers had received training in caring for rape survivors. More than three-quarters of regional hospitals (76.9%) had a private exam room designated for use in caring for rape survivors. Multiple regression analysis of practitioner factors associated with better quality of clinical care found these to be a practitioner being older than 40 years (parameter estimate = 2.4; 95% confidence interval (CI) = 0.7–5), having cared for a higher number of rape survivors before (parameter estimate = 0.02; 95% CI = 0.001–0.03), working in a facility that had a clinical management protocol for caring for rape survivors (parameter estimate = 2; 95% CI = 0.12–3.94), having worked for less time in the facility (parameter estimate = -0.2; 95% CI = -0.3 to -0.04) and perceiving rape to be a serious medical problem (parameter estimate = 2.8; 95% CI = 1.9–3.8). Conclusion: There are many weaknesses in services for rape survivors in South Africa. Our findings suggest that care can be improved by disseminating clinical management guidelines and ensuring that care is provided by motivated providers who are designated to care for survivors.
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    Out-of-hospital assessment and management of rape survivors by pre-hospital emergency care providers in the Western Cape
    (2016) Gihwala, Raina Tara; Martin, Lorna J; Naido, Navindhra
    South African incidence of rape ranks amongst the highest worldwide. No direct policy exists for the emergency care provider management of rape victims in the pre-hospital setting. The pre-hospital exposure to rape cases is unknown as its health information system is not gender-based violence sensitive. In the absence of a clearly defined protocol, indiscretion in the emergency care treatment of rape victims remains undocumented. As a particularly vulnerable group globally, victims of rape are deserving of focused intervention. A qualitative, descriptive approach guided the research in which nine semi-structured voluntary interviews were held with emergency care providers, forensic medical practitioners and emergency consultants. Through a critical theory lens thematic content analysis was employed. University of Cape Town ethics approval was attained. The study found that pre-hospital providers lack knowledge and skills of rape victim identification and management but are desirous of evidence-informed guidelines for treatment and referral in a multidisciplinary approach. Educational and policy deficiencies are documented. The recommendations support a community of practice that is mutually inclusive of specialist rape-care centres, emergency department and pre-hospital providers in the interest of forensic emergency medicine. Due regard must be had for needs of practitioners at risk of vicarious traumatization from sexual assault management. Transformative curricula and responsive clinical guidelines are likely to redress any complicity of the health sector non-response to rape/sexual assault. This study is likely to benefit emergency care regulators, educators and researchers whose professional interest is to promote responsivity of the health system to rape.
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    The prevalence of infection related death at Salt River Mortuary for the years 2013 and 2014
    (2017) Kruger, Maria Magdalena; Heathfield, Laura; Martin, Lorna J; Maistry, Sairita
    Infection related death is of major concern world-wide. This is especially true in developing countries where there is a high burden of disease. In some cases infections may present atypically and death occurs without a diagnosis in life. Many countries, including South Africa, classify these deaths as sudden unexpected or unexplained, which, under the Inquests Acts, necessitates a medico-legal autopsy. In order to understand the mechanisms underlying such deaths, a systematic review of the literature was undertaken on sudden death due to infection. Data from published research and reports identified many pathogens associated with sudden or unexplained death in infants and older individuals. However it remains important to understand locally relevant pathogens. In addition, many risk factors have been identified in different age groups but it is not known what risk factors are prevalent in a local setting and if these correspond to international trends. In order to contribute to local data a case file review was undertaken of infection related deaths at Salt River Mortuary between 1 January 2013 and 31 December 2014 (n=809). Deaths due to respiratory infections were the leading cause of death across all ages and in both sexes. It is not known to what degree this is a true reflection of the cause of death as the extent of autopsy, ancillary investigations and availability of ante-mortem clinical information varied widely. There has been a call for standardised protocols for the post-mortem investigation of these deaths and the data analysed reiterated this need. Many of the modifiable risk factors for infant death identified in the literature review were also identified in the Western Cape Metropole area, with the exception of sleeping position: side sleeping, as opposed to prone sleeping, was identified as the distinctive risk factor. In older individuals tuberculosis was identified as either the cause of death or a major contributor to comorbid conditions, which highlights the importance of further surveillance of vulnerable individuals. These data have provided insight into the extent of infection related death and associated risk factors in a local context. A standardised protocol for the investigation of these deaths across mortuaries would enable more accurate data to be collected which in turn could be fed back into the healthcare system.
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    Retrospective analysis of abandoned live births, stillbirths and non-viable foetuses admitted to Salt River Mortuary, Cape Town
    (2018) du Toit, Chante; Heathfield, Laura J; Martin, Lorna J
    The abandonment of neonates in locations where discovery and survival is not intended is a global concern. These cases comprise non-viable foetuses and stillbirths (natural deaths), as well as abandoned live births (unnatural deaths); the latter having possible legal consequences. To describe the profile of abandoned neonates and obtain a global perspective of the post-mortem investigation in such cases, a systematic review of the literature on abandoned foetuses, concealed births and neonaticide was conducted. This revealed a paucity of research on the subject; only one published South African study and less than 30 studies from other parts of the world were obtained. While guidelines were available, a standard protocol for conducting the medico-legal investigation on abandoned neonates did not exist and the necessary extent of the investigation was debated. Furthermore, seemingly higher rates of abandoned neonates were observed in South Africa compared to elsewhere in the world, warranting investigation of these cases in a local setting. In an attempt to add to the data concerning abandoned neonates in South Africa, a case file review was carried out on abandoned live births, stillbirths and non-viable foetuses at Salt River Mortuary between 1 January 2012 and 31 December 2016 (n=249). Despite the majority of the cases being natural deaths, the cause of death frequently remained 'undetermined’ in these cases, often due to the presence of decomposition. Histological analyses were only performed in a small fraction of undetermined cases. Furthermore, the hypothesis that the prosecution rate of abandoned live births is extremely low was supported by this study, with only one case prosecuted in the 5- year period. For the remainder of the cases, the court status was given as either 'under investigation’ (47.8%) or 'case closed’ (47.8%). In the majority of the instances, the case was closed due to the unknown identity of the biological mother; however, DNA analyses were not performed in all of these cases. Overall, the data highlighted the need for the development and implementation of standard protocols, to ensure that cause of death and identification of the neonate can be established as far as possible.
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    Violence against women : epidemiology and pathology of femicides and suspected sexual homicides in Cape Town : a 10-year follow-up study
    (2016) Molefe, Itumeleng; Martin, Lorna J; Artz, Lillian
    Background: Violence against women (VAW) is the most pervasive human rights abuse and a global health threat. The most extreme forms of physical and sexual violence are the intentional killing of a woman (femicide) and rape, or the combination of both in the form of r ape homicide, preferably termed 'sexual homicide' in this study. Motivation: Martin's research in 1999 reported a rape homicide incidence rate of 12.3/1000 female rapes reported to the police in Cape Town while the National study performed by Abrahams et al in 1999 reported an incidence rate of 10.9/1000 female rapes reported to the police in South Africa (SA). These high incidence rates, definitional problems, methodological limitations, changes in the law, and inconsistent management of suspected sexual homicides motivated the author to undertake this follow - up study. Objectives: To describe the epidemiology and pathology of femicides in Cape Town and thereby identify risk factors, magnitude and criteria for suspected sexual homicides. Design and Methodology : This is a retrospective descriptive study. Data was collected from autopsy reports of female bodies admitted at Salt River Forensic Pathology Laboratory in Cape Town from the years 2000 to 2009. A 10 - year period improves the sample size and the validity of the results. Limitations : Time constraints led to inadequate information on perpetrators of femicides and therefore a report on intimate femicide is limited in this study. Main findings and Discussion: Results showed an average femicide incidence rate of 12.4/100,000 female population in Cape Town Western Metropole which is half the South African national incidence for 1999, equates to the 2009 national rate and is almost five times the global average. Sexual homicide was suspected in 19.9% of all femicides, slightly higher than the 16.3% previously reported by Martin for Cape Town. The median age of victims was 32 years. Most femicide victims died from gunshot injuries (35.2%) followed by those who were stabbed (29.6%), while the majority (35.7 %) of victims of suspected sexual homicide died from asphyxial deaths, including strangulation. Taking specimens for the Sexual Assault Evidence Collection Kit correlated significantly with genital (77.7%) and anal injuries (64.5%), and 41% of femicide victims had alcohol levels above 0.05g%. Conclusion: The incidence of femicide and sexual homicide in Cape Town is higher than previously reported. Gun violence and alcohol abuse are persistent problems. Recommendations : Findings should be used to motivate for intersectoral collaboration in the form of female homicidal death review (FHDR) teams. These teams should aim to develop standardised guidelines for the forensic management, prosecution, prevention and monitoring strategies for femicides and sexual homicides in South Africa.