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Social Aspects of Chain of Evide

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					Social aspects of
chain of evidence
    Dr Jan Welch
King’s College Hospital
       The Haven, Camberwell
•   24/7 sexual assault referral centre
•   Opened May 2000, 24/7, for adults initially
•   12 boroughs of South London
•   Part of Department of Sexual Health
•   Provided in partnership with the Metropolitan
    Police

    2 further centres
    opening 2004
           STIs and rape
• STIs found in 4-56% of raped women
• Often reflect pre-existing infection
• Character denigration in court

• STI evidence seldom useful in
  the sexually active
        STIs as evidence

Likely to be relevant in:

• abused children
• sexually inexperienced adults or
  orifice
• the elderly
  STI evidence and laws on
         disclosure
• Historical protection of Venereal
  Diseases Acts limited
• Identified infections may become
  available to courts
• Prophylactic antibiotics increasingly
  used
    STIs as evidence:
medico-legal considerations

• Choice of tests
• Management of the sample
         Choice of tests
Ideally:
• Well validated
• Capable of confirmation eg culture

 But newer methods (NAATs)
 increasingly used for
 eg chlamydia
            Medico-legal chlamydia NAAT algorithm

                     M/L
                        Extremes of age
                        Learning difficulties
                        Sexually inexperienced
                          client or orifice


               Yes                                              No



   Chain of evidence                                      NAAT for CT / GC
   Mark M/L                                               Consider
   NAAT for CT / GC                                         prophylactic
   If previous +ve, treat                                   antibiotics




               Chlamydia test result
               +ve            -ve                    -ve              +ve
 Send further sample,           No further tests                     Treat client
   using chain of evidence                                             Repeat test
   and M/L                                                               on original
 Test in parallel with                                                 sample in
   original sample                                                       case
 Treat                                                                 confirmation
                                                                         issue later




NB if tests positive for gonorrhoea, confirm by culture
(+/- microscopy) as usual
 Management of the sample
• Chain of evidence
• Storage of sample (ideally in duplicate at –
  70o)
• Additional tests eg reference laboratory
  for typing
• Overseen by senior

• Ideally ‘M/L’ protocol agreed
  with clinicians
Case study: Lucy aged 8
 Lucy presented to her GP with a
discharge 5 days after a bicycle
accident

Genital swab sent to laboratory
(no chain of evidence)
Result: +ve for chlamydia
              Lucy 2
Social services alerted
Lucy taken into care

Lucy assessed by community
paediatrician and forensic medical
examiner
             Lucy 3
Lucy denies being abused
Repeat swab taken for chlamydia

Result: negative
Lucy returns home
               STIs in children

• Sexual abuse – always consider
    but also
•   vertical transmission
•   accidental transmission
•   close non-sexual physical contact
•   voluntary sexual activity
          STIs in children -
            management
•   Microbiology / GUM / paediatrics
•   Screen for other infections
•   M/L – chain of evidence and procedures
•   Tests – predictive value in population
•   Additional – biopsy / typing / cultures
•   Reference laboratory
•   Care with drugs
Case study – Saffron aged 4
15th March
   Childminder notices discharge on child’s
     underwear
   GP treats for thrush and takes swab
22nd March
   Gonorrhoea culture positive - PPNG
   Child given ciprofloxacin
   Social services notified
             Saffron 2

26th March
  Medical examination shows hymenal tear

7th April
   Child protection conference
   Mother threatens to abscond to Jamaica
   Saffron taken into police protection
              Saffron 3
April

Mother and estranged father attend
 different GUM clinics for tests
Mother has PPNG (recent partner from
 Jamaica but he had no contact with child)
Father has fully sensitive strain of GC
             Saffron 4
November

Proceedings heard in High Court
Father denied abuse
Mother shared bed, bath, towels and
 flannels with Saffron
Reference laboratory – typing showed
 father had unrelated strain
             Saffron 5
November

Decision by court
Evidence of abuse but father not
 implicated
Saffron returned to mother with support
 and supervision
      STIs and evidence -
           summary

• May not be straightforward
• Diagnosis of an STI can have major
  implications
• M/L procedures useful but laboratory
  procedures crucial
• Need to determine role of new
  technologies
• Multi-professional considerations

				
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