Victorian Institute of Forensic Medicine

Post-mortem detection of a medicine following suicide can be due to two main reasons: the decedent was taking that medicine therapeutically before death, and/or the medicine was involved in the suicidal act (poisoning-related suicide). We aimed to investigate how antidepressant concentrations differed between poisoning and non-poisoning suicides. We hypothesized that the predictive value of these concentrations and the separation between poisoning and non-poisoning concentrations would improve by adjusting for dose dispensed to the decedent. We analysed post-mortem toxicology results from suicides in Australia, July 2013 to October 2019, linked to the individual's dispensing history. Suicides were classified as poisoning- or non-poisoning-related by coroners. We analysed the distribution of concentrations through descriptive statistics, precision-recall curves and quantile regression to compare poisoning and non-poisoning concentrations. We adjusted concentrations by estimated daily dose and total drug quantity dispensed in 90 days and re-assessed model performance. We had sufficient sample size to analyse nine antidepressants: amitriptyline (n = 149), mirtazapine (n = 399), citalopram (n = 116), escitalopram (n = 297), fluoxetine (n = 183), sertraline (n = 253), duloxetine (n = 122), venlafaxine (n = 261), desvenlafaxine (n = 194). Selective Serotonin Reuptake Inhibitor non-poisoning and poisoning concentrations were similar, with no high certainty threshold for poisoning for citalopram and sertraline. Amitriptyline had the best separation between poisoning and non-poisoning concentrations. Adjustment by estimated daily dose improved the separation of lower quantiles through quantile regression but did not help identify thresholds that separated poisonings and non-poisonings. Dose adjustment generally did not improve the separation of poisoning vs non-poisoning suicides, indicating that post-mortem concentrations may not have clear dose-concentration relationships.

Purpose Research supporting the utility and effectiveness of reflective practice in forensic settings is steadily growing, with recognition that the benefits of structured reflection for staff who work in these environments are significant. However, much of the research examining how to maximise the effectiveness of the reflective process does so from the perspective of session participants. When the perspective of the facilitator is considered, it is generally done so with respect to how to improve the process for group members, as opposed to recognising and addressing the challenges that are faced by facilitators. Design/methodology/approach This paper aims to describe some of the intrapsychic and ethical challenges experienced by facilitators of a Reflective Practice Framework in a forensic mental health setting. Findings Four main challenges are discussed: the pull to problem solve, the importance of bringing “ourselves” into the room, responding to psychological hazards commonly experienced in forensic mental health settings and balancing duty of care and confidentiality. Practical implications The relevant research literature is reflected upon, followed by a description of how facilitators navigated these challenges. Originality/value This paper provides practical support to facilitators of reflective practice in navigating the complexities of delivering this service to staff in a forensic mental health setting and highlights key implications for practice.

As post-mortem (PM) imaging in children becomes more common, there is a need to review the available evidence for its diagnostic yield in suspected child physical abuse. The aim of this review is to synthesise current evidence, assess study quality, and identify ongoing challenges. Following PRISMA guidelines, databases were searched until 31 December 2024. Original research articles reporting data on at least ten children with PM imaging in the context of physical abuse were included. Titles and abstracts were screened by two expert reviewers; full texts were assessed by a third, independent reviewer and one of the previous reviewers. Data was extracted by one of 12 experts and independently verified. The study risk of bias was evaluated with the ROBINS-I tool. Study heterogeneity precluded meta-analysis, resulting in descriptive synthesis. Eighteen out of 1687 potential papers were included. Seven described PM radiography, five post-mortem computed tomography (PMCT), four both PM radiography plus PMCT, and two post-mortem magnetic resonance imaging (PMMR). All but one were retrospective, and most (11/18, 61%) had a moderate-to-high risk of bias. Post-mortem skeletal survey (PMSS) detected subtle fractures, particularly corner metaphyseal fractures. PMCT provided a high-resolution assessment of injuries, particularly rib fractures. PMMR contributed soft-tissue and intracranial detail. All studies emphasised the importance of correlating autopsy findings. Technical variation and potential biases limited direct comparisons between studies. PM imaging can reveal important injury patterns that may be overlooked by autopsy. Nevertheless, standardised imaging methods and larger prospective trials are needed to reduce bias and establish best-practice guidelines. Question What is the evidence for PM radiologic imaging in suspected physical abuse of children? Findings PM imaging complements autopsy, but diagnostic accuracy varies by modality. Study heterogeneity and bias limit current evidence. Clinical relevance PM imaging can detect injuries missed at autopsy in child abuse cases. Standardised protocols and higher-quality studies are urgently needed.

J.M. receives funding from the Department of Home Affairs for research into the Australian illicit nicotine market. J.M. also has an unpaid role as Tobacco Harm Reduction Advisor to the board of the non-profit organisation Harm Reduction Australia. This arrangement creates no obligations and in no way compromises the independence of J.M. J.L.S. has no conflicts to declare. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Interventions to prevent aggression and reduce use of restrictive practices are essential for recovery-oriented mental health nursing care. This study explored how nurses can best enhance employment of a structured risk assessment instrument paired with an aggression prevention protocol. Fourteen nurses with responsibilities for reducing restrictive practices attended focus groups, and three consumer consultants working with mental health nursing staff participated in one-to-one interviews. The focus groups and interviews were designed to elicit recommendations to assist nurses use of the violence risk assessment instrument and apply the protocol interventions. Thematic analysis was used to analyse the data. Four themes were interpreted from the data. Theme one: The nurses are experiencing incredible difficulty talking about how they can be supported. Theme two: 'calming the farm': The need to self-regulate, with the subthemes: (1) some nurses may need support to 'calm the farm' and (2) if you can't 'calm the farm' another nurse may need to step in. Theme three was the need for robust training and education and the final theme was: The need for 'decompressing' before leaving the shift. Participants suggested while some nurses were very skilled at regulating their emotions while intervening to prevent violence, some had difficulty, or were not aware of their emotional state, and may need support from colleagues when intervening. Suggestions for enhancing the application of aggression prevention interventions include use of mental wellness check-in forms, engaging in clinical supervision and safety huddles at the end of the shift to assist nurses to decompress before leaving.

This paper describes the quantitative findings of a systematic literature review of research on patients on conditional discharge from forensic mental health services in England and Wales (part one of two). Conditional discharge is a frequently used discharge option which allows forensic patients to receive care within the community, while subject to certain restrictions. In total, 23 quantitative and five mixed-methods studies were included. A synthesis of the quantitative findings identified factors associated with recall and recidivism, as well as positive outcomes for patients. Patients on conditional discharge showed lower violence and recidivism rates compared to those on absolute discharge. We develop hypothesized causal links between predictors and patient outcomes using a novel method of directed acyclic graphs (DAGs). The methods of this review, implications of findings, and directions for further research are discussed.

Paediatricians serve as expert witnesses in child maltreatment cases, informing decision-makers about injury mechanisms, likely injury-dates, and consequences. Despite paediatricians' multifaceted role in responding to child maltreatment, the impacts on paediatricians of their involvement in legal processes are not well understood. This systematic scoping review identified and synthesized scientific research findings on the benefits and harms to doctors, particularly paediatricians, who testify in child maltreatment cases. Included studies focused on doctors (paediatricians and paediatricians-in -training) who were subpoenaed and/or testified in court on child maltreatment cases. Following PRISMA-ScR guidelines, six databases were searched: Medline, EMBASE, PsycINFO, CINAHL, Criminal Justice Abstracts, and the Cochrane Library. Data were extracted and categorized across four levels of impact: individual, relational, professional, and societal. Testifying posed significant psychological, professional, and systemic challenges for paediatricians. Individually, they reported stress and dissatisfaction stemming from fears of discreditation, negative courtroom experiences, and perceptions of legal systems failing to protect children. Professionally, inadequate training and low confidence in testifying, coupled with financial losses and disruptions to clinical schedules, further compounded these difficulties. Systemically, strained relationships with legal professionals and insufficient familiarity with court procedures, alongside broader concerns about the legal process, contributed to a reduced willingness among paediatricians to report and engage in child maltreatment cases. This review highlighted the range of the impacts on paediatricians who were subpoenaed and/or testified in child maltreatment cases and absence of interventions that reduce negative personal and professional impacts. Across the profession there is a need for greater education and training, policy/practice reform to better support paediatricians in their roles as expert witnesses, and intervention research to evaluate strategies that might reduce negative impacts.