DECLARATION All rights reserved. I declare that is my own work and it has never been produced by anybody before for any purpose at any demand either academic or public or official. With my knowledge, I understand that no part of this work may be reproduced, stored in a retrieval system in any means, without the prior permission in writing of Waswa Scott Wefwafwa.

NAME

REGISTRATION NUMBER

SIGN

DATE

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DEDICATIONThis is a special dedication to my dear parents, Patrick and Salome, for their encouragement through each and every situation that I have experienced through during my activities.

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ACKNOWLEDGEMENTFirst, I would like to thank my parents for their support they did to make sure that I carry out my attachment without difficulties by availing the needed materials on time.

Secondly, my gratitude goes to my closest siblings, brothers, sisters and friends who encouraged and assisted me during the attachment period

Thirdly I wish to thank and appreciate Masinde Muliro University of Science and Technology(MMUST),especially department of criminology and social work for all resources and knowledge they empowered in to make sure that I produce quality services while in the field. Not forgetting to point out Mr. Peter NdichuWa Muriuki my forensic teacher and mentor.

Finally cannot fail to mention my industrial internship supervisor Dr.Dixon Mchana Mwaludindi, Western provincial pathologist (Kakamega),who really molded me beyond my expectations.

Also to thank all the forensic scholars who we collaborated during our industrial period i.e. research colleagues.

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LIST OF ABBREVIATIONS.1. RTA-Road Traffic accident

2. PMI-Post mortem internal

3. PM-post mortem

4. CAP-chapter(as in a chapter of law)

5. AIDS-Acquired Immunodeficiency syndrome

6. DNA- deoxyribonucleic

7.IO-investigating officer

8. MVC-Motor vehicle crush

9. HIV-human Immuno deficiency Virus

10. UNK-unknown

11.MMUST-Masinde Muliro University Of Science And Technology.

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ABSTRACT.This report is divided into four chapters. Chapter one talks about the historical background of the hospital and in particular the department of the pathology and its organizational structure. its objectives, roles and goals . chapter two talks about the problem identification, cliental, etc. chapter three talks about all the activities I took part in during my internship period under the department of the pathology and case studies and finally chapter four talks about all the challenges faced during internship, what needs to be improved , my recommendations and conclusion and finally the appendix and the bibliography(references).

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ContentsDECLARATION.....................................................................................................................................1

DEDICATION........................................................................................................................................2

ACKNOWLEDGEMENT.......................................................................................................................3

LIST OF ABBREVIATIONS..................................................................................................................4

ABSTRACT............................................................................................................................................5

CAP1 INTRODUCTION............................................................................................................................7

HOSPITAL PROFILE.............................................................................................................................7

INFRASTRUCTURE..............................................................................................................................7

Departments and Services offered...........................................................................................................7

Mandate...................................................................................................................................................9

Vision......................................................................................................................................................9

Mission....................................................................................................................................................9

Values......................................................................................................................................................9

Organizational structure of the morgue..............................................................................................10

OBJECTIVES....................................................................................................................................11

CAP2.PROBLEM IDENTIFICATION.................................................................................................11

CLIENTELLE.......................................................................................................................................11

THEORY AND PRACTICE.................................................................................................................12

INFORMATION GATHERING...........................................................................................................14

Problem identification...........................................................................................................................14

EVALUATION OF THE OUTCOME..................................................................................................15

TASKS SUBMITTED TO DEPARTMENT SUPERVISOR....................................................................17

Duties carried out by a forensic pathologist:..........................................................................................17

Morgue case analysis:............................................................................................................................29

CHALLENGES FACED AND THEIR REMEDIES............................................................................30

Problems faced at the morgue............................................................................................................30

What needs to be improved.................................................................................................................31

RECOMMENDATION.......................................................................................................................31

Conclusion............................................................................................................................................31

APPENDICES.......................................................................................................................................32

BIBLIOGRAPHY................................................................................................................................32

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CAP1 INTRODUCTION

HOSPITAL PROFILEProvincial Kakamega General Hospital is situated at Kakamega town, Western province Kenya. Onthe plot title deed No. KAK/MUN/BLOCKIV/168(Survey No) in Kakamega Central district. The facility serves a population of 79,070 with an area of 377.4km2. The area predominantly agricultural with most of the farmers practicing small-scale peasant farming. It has a bed capacity of 450 authorised beds and 397 physical beds of which 60 are lots.

INFRASTRUCTURE

Departments and Services offereda. Administration.

Offers services to the offices for medical superintendent, Health Administrative officers, Nursing officer, personnel registry, DMSO, Accounts, Library, Records officer, Provincial clinical officer, E-Learning and telephone exchange.

b. Out – patient Department (OPD)- Pharmacy block - X-ray block- MCH & F/P Block- OPD clinic block- Laboratory block- Dental block- Physiotherapy- Orthopaedic block- Maintenance block- Casualty block- Mortuary block- Eye clinic

INPATIENT BLOCK

Ward I – Male medical Ward II – Male orthopedicWard III – Female medicalWard IV – Isolation wardWard VA–Pediatric wardWard VB – Pediatric surgical

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Ward VI – Male surgical Ward VII – Female surgicalWard VIII-Gynecologist.

Ward IX-Mental ward.Ward X-Ophthalmologist ward. -Eye theatre.

MATERNITY BLOCK.

-Ante Natal ward.

-Post Natal ward.

-Labor ward

-maternity theatre

MAIN THEATRE.

-For voluntary surgical contraceptive (VSC) theatre.

MORGUE.

It’s one the storage facilities found at the hospital,the storage facilities.A morgue was set up to serve both the hospital and the community at large for preservation of the bodies, Autopsies (investigations), counts for bodies with injections. Has capacity of 100 bodies.

The components of the morgue:

1. Office Fitted with telecommunication system to assist in work collaboration with the hospital departments i.e. wards, outpatients and cash offices.Also ensures the needs of families who will be visiting the morgue. The increasing numbers should be taken into account by providing rooms for viewing of the bodies and issuing of burial permits.

2. Postmortem room It’s a clean, spacious, properly ventilated and well lit. Has plenty of running water, slab table and a flush toilet to be used during autopsy.

3. Embalming facilities / section Embalming is not required by law but it is widely practiced at various levels. The procedure consists of artificial infusion of embalming fluid and trocar perforations of the viscera (body cavities) to aspirate any liquids. This is a simple procedure that is widely popular since most bodies are not disposed within 72 hours after death, hence the importance of a mortuary establishing this service.

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4. Cold rooms Are rooms well refrigerated necessary for preservation of the bodies under low temperatures i.e. a capacity of 24bodies placed on trolleys.

Some major sections at the morgue are:- Bodies from hospital wards- Bodies from court injunctions- Bodies from hospital unidentified- Bodies from police identified- Bodies from outside with police cases- Exhumed bodies.

5. Stores and changing roomAre rooms set aside for storage of all equipment’s to be used at the morgue as changing or gearing up for work i.e. embalming or autopsy.They also store some of the exhumed caskets for exhumed bodies.

MandateKakamega provincial general hospital derives its mandate from public health Act (CAP 242 - Kenya) which provides procedures for exhumation, procedures for disposal of bodies etc.

Vision To be a leading region centre for excellence in holistic, health care delivery and, medical research and education.

MissionTo provide accessible, acceptable, affordable and sustainable quality, curative, preventive, promotive, rehabilitative and educational health care services to our clients.

ValuesTo develop, retain and motivate a high quality staff, through teamwork, transparency, accountability, honesty, fairness, respect and humility to achieve our vision and mission.

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MEDICAL SUPERINTENT

HEALTH ADMINISTRATIVE OFFICER

PATHOLOGIST

MORGUE ATTENDANTS

Organizational structure of the morgue.

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What is Forensic Pathology?

Forensic Pathology is the branch of Forensic science and a branch of Pathology entitled to the identification of the cause of death and reconstruction of the circumstances by which death occurred. It is always done in a meticulous and painstaking manner. Pathologists are primarily employed to investigate death of persons who are unexpectedly or suddenly or as a result of injury. However few pathologists in Forensic science work as consultants. For one to be a forensic pathologist, he /she should have done both human anatomy and clinical pathology. He should also have amalgamation of both pathologists, detectives, politicians and public relations person.

OBJECTIVES1. To determine how causes of death are examined.2. To determine how forensic examinations of the bodies are done i.e.

external/internal/clothing.3. To determine how they examine the absence / presence of diseases from tissue samples.4. To determine how examination of postmortem wounds and injuries are done.5. To determine how collaborative evidence is done i.e. blood, hair, semen samples, passed

to criminologists, toxicologists etc. for specialist analysis.6. To determine how collaborative investigations are done, i.e. body identification work

with forensic odontologist (dentist) and physical anthropologists.7. To determine how the forensic experts influence court rulings i.e. expert witness o expert

testimony.8. To determine time since death i.e. Postmortem interval.9. Determine how insects are associated with dead bodies i.e. blowfly and beetle.

CAP2.PROBLEM IDENTIFICATION.

CLIENTELLE The department is under the umbrella of the Laboratory but it carries out its duties without disrupting the normal laboratory services.

The clients of the department includes: the general public e.g.

- Patients requiring services from the pathologists, i.e. he is a consultant.- Relatives of the deceased who want to find out the cause of death of their beloved.- The Kenya criminal justice system to assist them in the work.- Other medical departments during the research i.e. clinical autopsy.

Most of these services are required by the criminal justice system includes:

- Compensation as a result of an assault or harm or injury.- To ascertain that a crime truly occurred and not an accident, i.e. corpus delicti.

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- Linking the suspect and a victim using Locard principle of exchange.- Disapproving or supporting a suspect or witness testimony.- Presentation of expert testimony.- How physical evidence was recognized, documented at a crime scene, collected,

preserved, analyzed and later interpreted the results. - They also help in identification of a suspect i.e. narrowing down or elimination,

providing an investigative lead.- Eliminating a suspect or exoneration i.e. innocent projects in USA.

THEORY AND PRACTICEIn this section, an analysis of the theory learned in class and lecture rooms was applied in the real life scenarios. The sections handled include:

- Forensic pathology- Forensic anthropology- Forensic odontology / dentistry- Forensic Taphonomy.- Forensic Entomology- Forensic Nursing- The identification and characterization of blood and blood stains.- Forensic toxicology- Social psychology- Forensic criminology

Forensic pathology – aims at determining the cause of death under legal jurisdiction e.g. either sudden or unexpected death i.e. through autopsy.

Forensic anthropology – entails the excavation of graves i.e. exhumation of dead bodies under legal issues.

Forensic odontology – is the application of art and science of dentistry to the legal system.

Forensic taphonomy–deals with history of the body after death. It’s vital in death investigation because postmortem change can affect estimates of time, since death, identification of the individual and ability to determine the cause and manner of death.

Forensic entomology – implies the study of insects associated with dead bodies. Insects colonize the dead bodies immediately after death.

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Insects are used to determine time since death, from matters of hours to years, during postmortem.

Forensic Nursing – is the global practice of nursing when health care and legal systems interacts i.e. relates to the identification and collection of evidence derived from the living e.g. defilement, legal investigation of victims of violence, traumatic accidents, rape case etc.

The identification and characterization of blood and blood stains i.e. in understanding the science of DNA (Deoxyribonucleic Acid) Analysis.

Forensic toxicology – implies all forms examination of all aspects of toxicity that may have legal application. Its applications include:

i. Postmortem drug testingii. Work place testing e.g. Alco blow for drivers of public service vehicles.iii. In evaluation of contraband material to identify i.e. not allowed e.g. cocaineiv. Sports – Athletics, football and boxing.

Specimens collected for toxicological testing includes:

1. Blood – is mostly taken during postmortem is from the heart and peripheral sites e.g. hind limbs (50 – 100mm).

2. Urine-taken during postmortem investigations because its noted that certain toxins appear in urine in large quantities than in blood.

3. Gastric content-for highly toxic substances,very low concentrations will be in blood e.g. in the case of suicide, large amount of blood is in the stomach always certain this conclusions.

4. Vitreous humor (fluid s from the eyes)-this specimen is collected during postmortem investigations because an eye is an isolated bodily area. The vitreous humor is resistant to the putrefaction i.e. bacteria that start feeding immediately after death.

5. Bile and liver-liver is an organ heavily involved in drug metabolism. It’s likely to contain significant quantities of most drugs and in many occasions it permits the identification of agent causes death.

Social psychology-this was noted during postmortem .e public relations. The study of interaction of individuals after the death of their loved ones. It influences people reactions and actions.

Forensic criminology-it implies the scientific study of crime and criminals for purpose of addressing investigative and legal questions. E.g. was it really a crime or an accident? that is corpus delicti. The introduction of Locard principle of linking suspect to a victim i.e. the exchange of atom when the two bodies come in contact. This was much vital at the crime scene during investigations.

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Criminal law-is the study of the actions and intents involved in offence due commission or omission which is punishable by the law i.e. actus reaus and mens rea respectively. Mental intent examination is done through psychological counseling by forensic psychiatrists.

Kenyan law and legal systems-this is noted that all matters entailing all forensic criminology is stipulated well in Kenyan law and legal systems i.e. Constitution and other legal books for ethical issues.

1. Kenya new constitution, Acts for forensic investigations.2. The chain of custody i.e. The evidence act CAP 80.3. Evidence submission in court of law.CAP80.

Its noted that other areas were not covered/addressed due to logistical reasons.

INFORMATION GATHERING.Useful information is what I will consider in this case for legal significance.

Sources of information include;

a. Family members of the deceased.b. Friends and workmates.c. The police or law enforcers.d. Doctors and other medical practitioners.e. Willing eyewitnesses.f. Printed sources and internets.

Problem identificationThe main problem at hand is to certain whether or not a particular case can be termed as legal or not.

On arriving to this decision, the previous persons are of importance i.e.one reliable in bringing out the scene of crime either to the police or the pathologist.

It also comes to be an expected or sudden or when it is felt that someone’s negligence might have led to the loss of lives. i.e. through causing an injury, harm, through an assault or an omission by a professional in practice. This may lead to sudden death and unexpected death.

Odontology

He has a problem to determine the legal matter before him i.e. issues of age assessment to certain:

a) Juvenile delinquency behavior of an individual

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b) To determine the appropriate sentence to the offenderc) To determine an appropriate correctional institution to be admitted to as an

offender.d) To ensure an appropriate compensation in case of injury and harm during an

assault

Forensic Psychiatrics

He/she has also some issues at hand for legal approval i.e. for one termed as a suspect of delinquent behavior and criminal behavior e.g. To determine:

a) Sexual sadismb) Addiction to dyingc) Adolescence impact to criminalityd) Old age and its effectse) Legal Insanityf) Tests if a person can stand trials

Forensic pathologist

He has a duty to advice the court and the society at large what the cause manner of death ie this enables to solve a social conflict among the family members.

Also helps to approve if the case is legal or not i.e. forensic autopsy clinical autopsy.

EVALUATION OF THE OUTCOME1. Forensic Pathology

In this case the success is the satisfaction both the enforcement officers, court and the family members or the siblings on what may have claimed the life of their beloved. The condition that led to death is what the pathologist examines and explains adequately during autopsy exercise. At this point, all the involved parties are allowed to witness the autopsy.

Normally, before and during the process, the pathologist asks them questions on his or her lifestyle to build the medical history which may also invite them to be satisfied i.e. for what really happened. The pathologist ensures to convince both parties only through scientific and not legal truth. Without satisfaction, many issues may arise ie parties with unsolved issues hence may lead to exhumation of the bodies.

2. Forensic Psychiatry success

The successful administration and maintenance of one’s client was the first goal to be achieved. Some of them normally physical and so pose harm threat both to others and to the experts. It was done by restricting them physically, i.e. tying them with ropes , locking them up in rooms or even injecting them to make them zombies. In addition, the successful examination of a client

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also here was to come up with a definite decision as to whether they can stand trials i.e was positive. It is noted that the adoption of the psychiatric report by the court is a milestone in achieving the objectives of this sector.

3. Forensic odontology

Was successful on legal matters and cases of legal matters. i.e. in cases of insults cases for dental compensation on court request on medical history and dental examinations as well as age assessment.

Information on other relevant fields

1. odontology

I visited the dental clinic at PGH. Had a short session with the dentist, what I learned?

a) Age assessment by use of teeth was based on permanent teeth development.i. Incisors- it comes at the age of six years in boys and 4 years in girls

earliest .i.e. begins with the lower jaw then the upper.ii. Canine-comes at the age of nine years

iii. Premolars – comes at the age of twelve yearsiv. Molars –comes at the age of 18-20 years.v. All teeth development i.e. 32 teeth for the adult at 25 years of age.

b) Root formation

It takes one to two years to fully develop. If its developing it takes one to two years for a root to be fully developed.

It’s noted that to estimate the age, we age the duration of two years of root development to that of apparent age upon eruption.

c) Enamel erosion

We can estimate age by examining the degree of erosion of the teeth. i.e. it implies the usage of the teeth.

d) Dental fibers

It implies the wearing of dental fibers leads to loss of teeth i.e. they loosen.

It’s noted that other factors that lead to loss of teeth are:

Nutrition i.e. poor food, lack of calcium and potassium which aids in teeth formation

Genetical heredity Poor oral hygiene

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Legal matters

In insult cases for dental compensation on court request, we should note, the medical history of the victim and the examination. The gums heal faster than the bones of the jaws. For any claim of tooth exhortation, or removal as a result of an assault examination is necessary i.e. observation and further X-Ray can be done to certain this.

It’s noted that if the exhortation is recent, the gums may have healed but the bones of the jaws may not as shown by the X- Rays shots of photographs.

The dentists also give out an expert testimony in courts.

2. Forensic psychiatry

I had session with the psychiatry who told me his duties on medical legal. The act that led to the establishment of the mental Act CAP 248.

Their duties

a) help the court rule the sanity

b) locking up patients in the units to prevent them from harming society.

c) to certain those who should be locked in maximum security facilities at Mathare.

Its noted that in ancient days mentally challenged were treated to be possessed with evil spirits. Some were sent away into the forests.

CAP 3 :TASKS SUBMITTED TO DEPARTMENT SUPERVISOR

Duties carried out by a forensic pathologist:1. Reviewing a medical history

I noted that medical history is a vital part as a starting point of any investigation. As most deaths do not involve apparent injury , the issues in ,most jurisdiction is either the death meets a two-pronged test.

1. is the death sudden?The death that may occur within a few hours on onset of symptoms or death without any symptoms.

2. is the death unexpected?To determine this, it requires a medical perusal on medical history. If the person has been diagnosed with a disease then the death is unexpected. At the end of medical history analysis, the pathologist can be able to a certain and certify the cause of death. A comprehensive medical history helps the pathologist to draw attention to matters that require special attention at autopsy and other matters requiring special investigations.

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2. Reviewing witness statementsKnowing that witnesses recall of the activities of the deceased prior to death or injury is extremely vital. The information would help to determine the jurisdiction in cases where injury is not obvious there is a crime and not an injury i.e development of corpus delecti. Pathologist will deal with recreating circumstances of death. He or she will be able to refute witness statement.3. Crime scene examinationIn the best situations, the pathologist will examine the scene of death or the location where the body was found eg case X from Malava forest.Questions of post injury movement, time between injury and death, time of injury, time of death and questions about what exactly happened to cause death are raised and sometimes answered by the examination of the crime scene. This activity is vital since some changes occur on a dead body during transportation longer distances to the morgue. 4. Obtaining appropriate specimenIn many forensic autopsies, specimen is removed for toxological testing. Most specimens collected are urine from the bladder; blood is taken from the aorta and large veins or hind limbs, bile from gall bladder. EtcSome portions of internal body organs are also taken for examination eg. Kidney, heart, liver, stomach. Blood and urine are taken to determine the presence of drugs such as alcohol or cocaine. 5. Microscopic ExaminationSmall portions of internal organs are put in solutions of Formaldehyde to preserve them for further studies i.e to examine any form of abnormality in body cells and tissues.

6. DNA AnalysisMost pathologists while carrying out there work they usually preserve one specimen from an autopsy that can be used for future DNA analysis.There are two common methods used:

1. A spot of blood can be used by placing it on an absorbent paper and allowed to dry i.e paper chromatography. 2. pull headhairs and placed in an envelop i.e its vital when pulling hair to remove the bulb that contains nuclear DNA.

7. PhotographyIt was noted that each crime should be photoed as thoroughly as possible ie photos taken in situ –original form. Wide angle photos shows where crime occurred as surrounding area, entrance and exit.Intermediate distance photos show location of evidence and relationship to entire scene. The close up photos shows appearances of evidence at crime scene as found by the investigator. The crime that has occurred indoor; all the walls, ceiling and floors of room and of the adjacent rooms should be photographed. If the body is present, should be

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photoed from intermediate range to show relationship with crime scene. After body removal, area under it should be photoed and additional photos should be taken from different angles and perspectives. A series of close up photos are taken to detailed for piece of evidence and any victim, suspects and witness. Each photo taken is recorded into a photo log which has:

a. Date and timeb. Camera settingsc. Film roll numbers and exposure numberd. Film namee. Type of shot i.e overall, midrange, etc.

Taking of photographs and preserving of the crime scene as well as autopsy helps to reconstruct a crime scene as well as documentation of the evidence at crime scene or autopsy. Nowadays, high resolution digital photographs are a routine sometimes at a crime scene is done by crime scene managers from police.

NB: the sample photos may not be included in this report because of unethical legal issues i.e. have no permission from the relatives of the deceased.8. Preparation of forensic report

I had to learn and practice how a written forensic report is done, since every autopsy examination has to have a forensic report. An examination can be termed as gross if it deals with what can be seen by the naked eyes and microscopic if it involves examination under a microscope. The forensic autopsy report should be flexible, and understandable to clinicians, pathologists and especially to relevant law enforcement agencies e.g. police and insurance agencies or families. The forensic autopsy report should address the following:a). who the victim wasb).when the death and injuries occurredc).what injuries are present (type, distribution pattern, path and direction).d).which injuries are significante).why and how the injuries and death occurred (cause, mechanism, and manner

of death.)

An appropriate post mortem report should include the following:a). patient biographical details e.g. Name, gender and ageb).history of the circumstances of death and patients medical historyc) external examinationd )internal examinatione). list of specimen taken (NB chain of custody/evidence).f). Provisional diagnosis i.e. before the results of the laboratory tests available.g).Reporting of histology and other lab tests.

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h).Summary and findings.i).Comments and conclusions (opinion of the pathologist).j).Final cause of death.

All diagrams and photographs should be attached as labeled annexure, with numbering of injuries and other findings corresponding to the text of the report.

The findings should be summarized in a logical manner. The cause of death should be determined. If this is not possible, the pathologist should

give an opinion as to whether the death was natural or unnatural. Any inferences drawn should be stated clearly as opinions, not fact. This will help to

minimize biasness. Opinions should be included under comment section.

Uses of forensic autopsy reports

The groups listed below may use the autopsy report in the administration of justice.

Group Use of reportPolice In order to find evidence to help solve crimes.Prosecutors In order to prepare charges in cases of

suspected homicide.Defense lawyers In order to defend a person accused of

homicide.Judicial officers In order to determine whether or not persons

accused of homicide are guilty.Plaintiffs In order to bring legal claims dependent on

establishing the relevant cause of death.Members of disciplinary committee In order to determine whether or not the

healthcare professionals are guilt of committing disciplinary offences resulting to a death of a patient.

Insurance companies In order to verify claims dependent on establishing the relevant cause of death and identify of the deceased.

9.Forensic testimony presentation.

Forensic pathologist spends much of his time testifying about their findings and opinions. In criminal courts, forensic pathologist is required to prosecute a defendant for

manslaughter or murder or even one of RTA. They often testify as expert witnesses in cases in which they did not examine the body of

the deceased.

Sample case

I visited the kakamega law courts in the company of the medical pathologist to testify on the reference case PGH/11/AUT/2011-Nancy Anami as a result of blunt trauma.ie. car crash. His

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duty specifically was to explain to the court what the forensic report findings before the court was implying. It is noted that the expert report and testimony is treated as facts. And it is only the court that declares one to be an expert.

Autopsy examination

It implies the dissection of the human body to determine the cause of death ie. Autopsy means top look at one’s self. Nectropy examination, entails the e removal through incision (cutting) of the internal organs of the chest, abdominal and the head.

There are two types of autopsies:

a). Medico-legal autopsy-which is performed as a legal requirement to investigate the cause of death. It forms part of investigations into death, the others being the history of death and scene examination. In addition, medico-legal autopsy is mainly concerned with the pathology of injury, whether immediate, recent or past. The purpose is to determine whether a person is legally responsible for the causation of death.

b). The hospital autopsy or clinical autopsy is mainly geared towards discovering the disease processes that led to death in order to give an explanation to the next-of-kin so as to aid the bereavement process. It also helps the improvement of medical practice i.e. adding knowledge through audit, teaching and research.

Aims of forensic autopsies

1. to determine the cause, manner, mechanism and time of death.2. to recover, identify, and preserve evidentiary material3.to provide interpretation and correlation of facts and circumstances related to death.4. to provide an objective and factual medical report for law enforcement, prosecution and defense agencies.5. to separate death due to disease from death due to other causes for the protection of the innocent or prosecution of the perpetrator.

Importance and value of the autopsya). Value to patientsEnsures the quality of medical diagnosis and care is highIdentify and remove unnecessary sources of infection in hospitals.b). Value to familyAssist in bereavement (grief) counselingProvide information for genetic counselingProvide a method for organ donation

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Discovers risks to families from infectious diseases e.g. tuberculosis, heart diseases, cancer, etcProvide information for insurance and death benefit claims eg RTAs, Electrocuted, etc

c). Value to societyImprove accuracy and usefulness of statistics related to causes of deathMonitor known and identify new category of diseases.Ensure better medical care (audit function)Helps in administration of justiced). Value to cliniciansHelps to evaluate new diagnostic and therapeutic procedures .Helps to discover new diseases and unusual expressions of known diseasesHelps in research and education

Laws governing autopsies in Kenya includes chapter 5 of Section A(Inquests)a). investigation of death (inquest act) criminal procedure code of Kenya CAP 75b). births and deaths registration acts of Kenya CAP 149c). Public Health Act of Kenya CAP 242d). human tissue act of Kenya CAP 252 and Anatomy Act of Kenya CAP 249

Steps in performance of an AutopsyCrime scene InvestigationAn examination of the body at the scene in situ where it was found before it has been moved or interfered with is very helpful to the pathologist who is to conduct the autopsy. If the pathologist is unable to visit the scene of crime, investigating officer has the onus of providing the pathologist with as much as details as possible including photographs and sketches, so that the pathologist is able to have a clear idea of the scene. This information enables the pathologist to correlate findings at the autopsy with those at the scene e.g. Patterns of blood splatter for example a case scenario termed as Shinyalu homicide.

Preliminary Procedures 1. First we check for the relevant police form i.e. section CPC 386(post mortem form) and further obtain more history if indicated. Using available clinical and laboratory information, the pathologist must plan a strategy for a particular autopsy ie standard autopsy, protocol. Examples of planning beforehand would be to conduct special dissection techniques e.g. case of hanging, ensuring appropriate preservatives for toxological analysis are available (for alleged poison).

2. Verify the identity of the deceased ie post mortem or mortuary number and/or name to be counter checked with the morgue admission number.

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3. Examination of the body before removal of clothing aimed at:a). to retrieve any foreign objects and trace evidence before it is lost.b). to determine the condition of the clothing and to use the clothing as a means of

identifying the deceased.c). to correlate tears and defects on the clothing with injuries found on the body.

4. We make sure the clothing, body and hands of the deceased are protected from contamination e.g. for gunshot residue tests. e.g. forensic palistics.5. The clothing are removed carefully eg cut along the seam of trousers so that an examination can be done later or keep clothing as an exhibition for a subsequent court case i.e. Cham of evidence.

Autopsy procedures 1. Note date, time, and place of autopsy.2. Note the names of all people present at autopsy (observers and participants).3. Note general state of the body i.e. describe all physical characteristics such as state of nutrition, muscular development, mass, height or length probable age (to be estimated by the pathologist and not the police) and gender.4. Note post mortem changes and state of decomposition e.g. temperature, presence and absence of rigor mortis and state of lividity. 5. Note any special identification features such as hair and eye color , scars, tattoos, teeth(number present, general condition, presence of and type of dentures and or dental work such as bridges, crowns and fillings) and for signs of abnormalities or deformities .6. Note the presence of any signs of diagnostic and or therapeutic procedures such as intravenous catheters, in dwelling urinary catheters, chest drain.7. We look carefully for a sign of disease and injuries (look carefully at all the hidden areas). Document all findings with a help of a sketch or photographs with reference scales.8. X-ray the body to locate bullets or other radio opaque objects as well as to identify the victim and to document fractures and medical implants.9. Dissect the body in organ systems bearing in mind that certain special dissection procedures may have to be undertaken if required. E.g. the neck dissection in a case of strangulation should be done after cranial and thoracic organ removal in order to create a bloodless field.10. Describe the head, neck, cervical spine, thorax, abdomen, genitalia, and extremities in logical sequence.11. Take an appropriate specimen as required.12. Finally we have the pathological opinion.NB:All above procedures in Kenya are provided on section CPC 38C of police Act post mortem form (illustrations on the appendix.)

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Dissection procedures during autopsyThe dissection techniques used at autopsy are more or less like those used in surgical operations, done meticulously and with dignity and not mere butchery. To enable an internal examination, the body is cut open, usually through V shaped incision extending from the front of each shoulder to the bottom end of the breastbone, through to the pubic bone deviating to avoid the navel. This incision is made deep enough to expose the inside of the abdomen and the chest wall. The ribs are then sewn off to expose the organs underneath in the chest cavity. The organs are then examined and studied systematically. A common way of removing the organs is known as the Ghons Method.(en block) where by organs are removed as related group. E.g. heart and lung. The lettules method is whereby all the organs are removed as one (ne masse method), then separating outside the body. Another method is Vischows which involves careful dissection of each organ from its attachment inside the body , one at a time and thoroughly studying it. The Rokitansky method involves studying each organ while inside the body (in situ). Whatever method used, ultimately each organ is separated, weighed and studied individually. Most organs are cut up in sections using a surgical knife or scalpel. Intestines are drained in a sink to remove undigested food or faeces that remain. Its noted that sometimes we use our hand s for internal dissections i.e. blind dissection to avoid tempering with internal bodily tissues which are delicate. To study the brain, the skull cap is sawn open after cutting the scalp skin using a line that runs from behind each ear connecting to the top. NB: its noted that some religion cultures, nectropy is prohibited due to their tradition. Negative autopsyImplies one in which no cause of death is determined. It is a death whereby the cause remains unascertained even after thorough full external and internal examinations including toxicology, virology, and bacteriology and until recently molecular genetic studies. For these cases, specimens for special test are taken for further testing i.e. blood, urine, stomach and its contents, liver and kidney should be taken for toxicology. A peer review of the findings by experienced pathologist is highly recommended a pathologist should concede defeat and not be embarrassed when an answer is not provided. The pathologist should not attribute significance to insignificant findings i.e. the most vital is that the findings should be as negative in the records, in order to leave the case open for future review of further facts that may come to light.

Limited autopsy/incomplete autopsyIs one whereby the examination is restricted to a region of a body, a single body cavity or even a single organ. It is commonly done in hospital autopsies at the request of the relatives who would not wish for full autopsy i.e due to religious and and cultural sensitivities eg nectropy is not allowed among Islamic religion and hindu. The doctor

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perfoming an autopsy has an idea of the cause of death and will limit examinations to the area affected.

Limitations and pitfalls of autopsies.When there is no positive findings, of a disease or injury,on the body,or after special tests,the pathologist must record the cause of death as uncertain. For example,the report should reflect no specific anatomical cause of death found at autopsy o unascertained. A doctor performing autopsy, can be sued due to:

Making a wrong diagnosisHarvesting inappropiriate tissueDisclosing information to the wrong parties

Autopsy sample casesCase1 : forensic autopsy Findings- an African male, height of 5’8”feet age 28 years, with a good nutrition and well physique. Circumstances surrounding death

2 jackets and shirt socked with bloodHead injury deep cut with a blunt objectBody well preserved (refrigerated)Fractured skull caused by a blunt object , zigzag10-12cm.Punctured skull due to blunt object 3* 2 cm to the brains3 days to the post mortem day i.e 48 hrsNo medical history or intervention.

Post mortem changes1. dessication –dryness of the lips2. presence of ligormotis but not complete i.e. stiffness of the muscles3. presence of livermortis i.e purplish color beneath the body(lividity) – the position of the body after deathb is is predicted or if it has moved.

Opinion of the pathologistCerebral hemorrhage i.e internal bleeding on the brain cavityAsphyxia secondary to an assault i.e. severe head injury

Case 2: clinical AutopsyParticipated in an autopsy which was presumed to be a clinical.

Findings: wasted muscles Tumor development in the brain i.e meningitis Paralyzed i.e stroke

It was noted that the dead had just developed stroke upon delivery. Legal question raised were is there one to be held responsible for such a case due to negligence i.e. medical

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practitioner? This case turned from medical to forensic autopsy . hence further investigations basing on pathologist oipinion.

Case3: negative autopsyI witnessed on negative autopsy where a prisoner claimed to have run away was short on one of his hind limbs a single bullet which is claimed to be the cause of his death which was reputed openly by the pathologist. Pathological questions raised were:

- Was he smothered?- Was he tortured?- Was he poisoned?

Delayed autopsy may not certain smothering.There was no any evidence to prove they caused death. Since the prison warden shot him as a way to arrest, but had to save life. The pathologist concede the defeat and ordered for further investigations i.e. specimen taken for further analysis.

Case4: limited autopsyParticipated an external examination of homicide bodies from Shinyalu. The main purpose is to examine if one has been diagnosed of any diseases or infection since we knew the manner of death for three bodies. It was also done on the request by the human rights activists in collaboration by the media fraternity.

Circumstances surrounding death Intact clothing (torn) soaked in blood. Neck injuries –sharp injuries Defence injuries on the wrists. Both shoulder stapes-sharp injuries.

Pathological opinion- Severe spinal injuries secondary to sharp object trauma.

Changes that occur in a body after death.Post mortem changes (PM changes)With brain death, breathing and circulation eventually stop because the lower part of the brain controls a person’s ability to breath and the mechanism that allows them blood to circulate.

Immediate signs of death

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Cessation of circulation i.e. blood Cessation of respiration Changes in the eyes Clouding of the cornea and loss of fluid from the eye Eyeball becomes soft (flaccid) Pupils become dilated Absence of all neurological reflexes Primary flaccidity. The body becomes limp (flaccid) because the muscles lose

their tone.

Early changes after death Cooling of the body (it loose heat and its temperature drops to that of the

environment). Ie. Algarmotis Rigarmotis (post mortem stiffening of muscles, which follows the initial

flaccidity of the body) Livormotis (post mortem lividity/hypostatis) I.e refers to pooling of blood in the

gravity dependent part of the body.

Secondary mascular flaccidity (the body becomes limp as rigormotis wears off with the onset of decay i.e putrefaction).

Dessication i.e. drieness of the lips i.e one who is alive leaks his/her lips.

Late changes after death: Post mortem decomposition (putrefaction) is process of decay of the flesh and organs

of the body which becomes full of gas and eventually liquefy. Saponification (adipocere formation) Mummification Maceration Post mortem wounds produced by animals,birds and fish These changes are influenced by a wide range of factors. The time over which they

occur is variable.

Some of the trauma witnessed at the morgue.

Lacerations is a tearing injury due to friction or impact with a blunt object.Typically lacerations has edges which are ragged3,bruised,and/or abraded.They are usually used to show the impact direction of the blunt force i.e motor vehicle crush.

Incised wound is a cutting injury due to slicing action of a bladelike object.The wound edges are smooth.

Puncture is apenetrating injury due to pointed object without a blade,such as an ice pick.

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Abrasion is a friction injury removing superficial layers of skin,allowing serumto exclude and form a crust.It was noted that abrasion may not be visible on wet skin,may be visible after 36hours or after thawing.

Contusion is a bruise due to rapture or penetration of a small-caliber blood vessels walls.Likely to be seen on the surfaces of the internal organs(eg brain and heart)as well as skin and mucous membranes.

Gunshot wounds.

Major determination involved in with legal implications.

Homicide-someone else caused the victim’s death,whether by intention or by criminal negligence.

Suicide-the victim caused his/her own death on purpose.This can either be through strunggulation,poisoning,stabbing,self immolation etc.During investigation we should first search for a suicide note at the crime scene,clothings followed by autopsy.

Accidental-in this manner of death the individual fall victim of the hostile environment.some degree of human negligence may be involved, but the magnitude of the negligence falls short of that reasonably expected in negligent homicide i.e motor vehicle crush(MVC)/road traffic accident(RTA).

Natural causes-here,the victim dies in absence of an environment reasonably considered hostile in human life.legal questions raised include;was he assaulted?was he poisoned?was he smothered?sometimes clinical autopsy done for research.

Other activities involved in

1. embalmentThis entails the process of dead body preservation.They use an embalmment system i.e. formalin mixed in the ration of 1:4 with water and flows by gravity.The small incision at the neck for search of carotic artery and the femur artery at the femur.At the neck, the formalin flows anticlockwise while the femur clockwise.Other substances used include:

1. actelic liquid mixed in a ratio with water at 1:4.2. sulphur 60mls in 20 litres of water.3.Baby powder to dry skin spillage4. salt for dehydration

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2. backstitching This was after autopsies and embalming legal question arises i.e. ethical legal issues surrounding the dead bodies.30 days maximum for deposition of dead bodies through a court order due to decomposition.

3.Interpretations of forensic settings during autopsy.

Premorterm injury-it implies injuries which tends to heal through blood clotting.Before death cell division still taking place .i.e dark-red hematoma showing a sign of an assault.Postmorterm injury-it implies injury after death(dead cells i.e no cell division).A pale yellow injury.Some of detergents (for cleaning ) used includes:

- Keraphus mixed in the ration of 80mls to 20litres of water for the floor.- Jik for white linens used in the morgue i.e. preparation of a body for

autopsy dissection .- Sanitizers for sterilizing the hands and other dissecting apparatus.

Morgue case analysis:

Cause of death Gender Age unknown knownMob justice M 23 UNKMob justice M 19 UNKMob justice M 24 UNKMurder M 37 UNKMurder M 25 UNKRTA M 32 UNKMob injustice M 40 UNKMob injustice M - yesMurder M 20 UNKsudden death M 33 UNKsudden death M 45 UNKRTA M 41 UNKFatal Accident M - YesSudden death M 35 UNKSudden death M 38 UNKRTA M 37 UNKMob injustice M 37 UNKMurder M 27 UNKSuicide M 60 UNKMob injustice M - UNKMob injustice M - UNKMob injustice M - UNKMob injustice M - UNKRTA by MVC M 70 UNK

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Suicide M 52 yesSuicide M 31 UNKSuicide M 67 UNKSuicide M 18 UNKMurder M 53 UNKDrowning M 11 UNKDrowning M 50 yesDrowning M 2 UNK

The above table analysis show several findings on the causes of death and its prevalence in the kakamega locality.

1. men are more target victims i.e of crime eg, .mob injustice. This is because of the patriachial society.

2. state vof anarchy is prevalent among male gender compared to women hence anomie causes suicidal death.

3. Most prevalent targets male of middle age i.e. most productive in the society.4. Most of the death cases reported at the morgue are unknown from the data.

CHAPTER 4

CHALLENGES FACED AND THEIR REMEDIES.

Problems faced at the morgue1. language barrier during work times i.e. working the locals as main stake holders.2. poor and inadequate storage facilities at the morgue.3. lack of basic personal protective equipment and clothing for mortuary staff. i.e. gloves, masks, gowns and boots.4. long delays in authorizing medicolegal autopsies as well as delays in disposal of bodies create unhygienic conditions i.e. health hazard5. exposure to biological risks i.e. spread of viral and bacterial diseases such as HIV, hepatitis B, tuberculosis, etc.6. exposure to chemical risks i.e. formalin , disinfectants and other chemical substances.7. psycho-social problem i.e. trauma. Constant exposure to the dead and putrefying bodies in morgue causes psychological problems.8. physical risk i.e. electricity, assaults, collapse of building, temperature variations,fire, falls due due tio slipping on body fluids,needle stick injuries.9. ergonomic i.e, damage to the body arising from poor techniques in lifting and transferring bodies.10. cultural restriction i.e. muslim do not mix with others.

What needs to be improved.

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1. security and safety measures i.e. fire extinguishers, and emergency exits to be established. First aid kit.2. hire skillful and trained staff,i.e offer trainign to morgue staff.3. acquisition of new modified, hightechnological equipments and instruments for efficiency and effectiveness.4. expansion of their infrastructure i.e. due to population increase 5. decentralization of management i.e. should be separated from the main hospital administration.6. introduction of morgue laboratories.

RECOMMENDATION1. a morgue should be well structured and properly equipped for prerequisite for good autopsy practice as well as safety for personnel, visitors and community.2. setting up a morgue facility is a demanding exercise as a platform to enhance forensic medicolegal and scientific capacity of emerging issues.3.All autopsies should be done within a duration of 24 hours for objective finding of results.4. All autopsies should be done by highly skilled and trained staff for objective results.5. Those people performing autopsies should be allowed or called upon to visit the scenes of crime i.e. to enable them collect vital evidence to be added to the one of autopsy as well as offer first aid since they are medical practitioners i.e. they have to save life.6. Introduction of mass pool tank for decomposing bodies7. Improve technological equipment i.e. automated and computerized to make work easier.

ConclusionThis report has widely brought out what we expect of a forensic criminologist, as he or she crime scientifically and criminals for purpose of addressing investigative and legal questions i.e. basing on medicolegal contexteg forensic medicine. It is noted that scientific truth is different from legal truth hence “science never lies.”

APPENDICES.

1. Autopsy form.

2. Autopsy procedural diagram.

3. Burial permit form.

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BIBLIOGRAPHY.

1. mohhamed a.et al(2005) forensic medicine, m edical law and ethics in east Africa, published by imlu(international medical legal unit), www.imlu.org,nairobi.

2. an article by IMLU(2012) august, a just world free from torture.

3. Istanbul protocol VII international sysmposium on torture. Torture as a challenge to thye health, legal and other proffesions(2002) independent medico-legal unit,Nairobi.

4. enhancing accountability for torture,(2012),independent medico-legal unit, Nairobi.

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