National Forensic

Nursing Conference

Friday 22nd February 2013

Sydney

Working Together

The Use of Multidisciplinary Teams to

Provide Clinical Forensic Medical Services

A UK Perspective

Margaret M Stark

Director, CFMU, NSW Police Force

Adjunct Professor, University of Sydney

Presentation Aims

• Outline the changes in legislation that have enabled

multi-disciplinary team (MDT) service delivery

• Provide an example of one model of MDT healthcare

in police custody

• Illustrate the need for the development of quality

standards for healthcare professionals

• Explain the requirement for robust clinical governance

procedures

Are there any lessons for Australia?

Guardian 22/06/2010

“Rapists going free through errors by inexperienced

doctors says BMA: vital clues being missed due to

shortage of fully trained forensic experts, according to

British Medical Association.”

= Need for a Clinical Forensic Medical Service

(CFMS)

Clinical forensic medicine (CFM)

• …includes all medical [healthcare] fields which

may relate to legal, judicial and police systems (Payne-James JJ. 1994)

Divided into the disciplines of:

– General forensic medicine – custody, traffic, crime

scene

– Sexual offence medicine – adults/children

CFM – shared aspects

• Consent and confidentiality

• Injury interpretation

• Mental health

• Forensic science and toxicology

• Medical witness

History in the UK

• 1830 First “Superintending Surgeon” appointed to the

Metropolitan Police established 1829

• 1888 The Metropolitan Police Surgeons‟ Association was formed

• 1951 Developed into a National Association, with many

international members, Association of Police Surgeons (APS)

• 2002 Association of Forensic Physicians (AFP)

• 2006 Faculty of Forensic and Legal Medicine of the Royal

College of Physicians of London (FFLM)

– Professional body for forensic physicians, setting standards.

Legislation in England and Wales

• Police and Criminal Evidence Act 1984 and Codes of

Practice issued under the Act – in force 1986

• Code C - The Detention, Treatment and Questioning

of Persons by the Police

• Registered medical practitioner provide care

• Audit Commission 1998 Recommendation to review

CFMS provided in the light of the increasing demand

Impetus for change?

• Paucity of skilled forensic physicians (FPs)

• Increasing cost of the current service provision

• Compulsory risk assessment of those detained in

police custody resulting in increased call-outs

Introduction of health care professionals

• Kent Custody Nurse Scheme commenced in 2000 with

the Gannon report, an independent evaluation, published in 2002

• Onsite nurse improves the clinical care of detainees

• Stressed the importance of training and adhering to the relevant professional standards

• Home Office Working Party report 2001 recommended amending the Codes

• 2003 Home Office Circular introduced the concept of Healthcare Professionals in custody centres

Healthcare professional

• Defined as a “Clinically qualified person who is

working within the scope of practice as determined by

their relevant professional body and who is registered

with that body as competent to practice.” (Home Office Circular

020/2003

• National Occupational Standards were then

developed to deliver healthcare services in police

custody regardless of the model of service provision (www.skillsforhealth.org.uk Functional map for HCPs working in police custody settings. Skills for health, 2007.)

Regulatory and Professional bodies

• General Medical Council (gmc-uk.org)

• Nursing and Midwifery Council (nmc-uk.org)

• Health & Care Professions Council (hcpc-uk.org)

• Faculty of Forensic and Legal Medicine (fflm.ac.uk)

• College of Paramedics (college of paramedics.co.uk)

• British Medical Association BMA (bma.org.uk)

• Royal College of Nursing RCN (rcn.org.uk)

Partnership working needed

• Police with local healthcare teams

• Little research looking at the health needs of detainees in police custody (cf. prison)

• Evidence that detainees are more likely to have chronic health conditions when compared to the general population

• Increased incidence of alcohol/drug use and mental health problems

Ceelen M. et al. Health care issues and health-care use among detainees in police custody. JFLM 2012:19;324-331

Payne-James JJ. Et al. Healthcare of detainees in police custody in London, UK. JFLM 2010:17;11-17

Provision of healthcare in custody

• Doctors, nurses, paramedics, emergency care practitioners

• Outsourced to private/commercial companies, employed staff, self-employed contractors/ service providers

• No formal data, variable standards, no formal regulation

Payne-James JJ. et al. Provision of forensic medical services to police custody suites in England and

Wales: Current practice. JFLM 2009; 16:189-195

Example of HC provision Webb, Stark, Cutts et al. JFLM 2010:17;368-373

• MDT using forensic physicians, nurses and paramedics supported by admin staff

• Call centre/management with appropriate triage

• Protocols developed to assist decision making; used by police and call centre staff (training)

• Nurses/paramedics cover the majority of calls

• FPs examine all complainants of sexual assault, assessments under the Mental Health Act/RTA, detainees/police officers post TASER and critical incidents

• Support non-medical staff/provide police with advice

HCP Training

• Two day training course/Shadowing

• Level 1 HCP all assessments (50) discussed with duty

doctor

• Assessment of practice by Level 4 HCP: review of

notes ensuring full range of cases, competency logbook

• Learning needs analysis throughout

• Level 2 – trained for PGDs, practice autonomously

using protocols/advice from duty doctors as required

HCP Training 2

• Level 3 Minimum of 150 cases to required standard

• Further training to take forensic samples, report writing and courtroom skills

• Continue to be supported by duty doctor at all times with telephone advice and clinical supervision provided by Level 4 HCP

• Level 4 HCP clinical supervisors/managerial role in the area

Forensic physicians

• Similar training except the third days covers the

knowledge base for the physician-only cases

• Further training required for sexual assault

examination for both children and adults

Record keeping

• Clinical pro forma

• Scanned with police documentation

• Computer system can produce statistics for audit purposes, e.g.

– Type of call type

– HCP involved

– Response time

– Statement requests

– Court attendances

Clinical Audits performed

• Clinical pro forma content (mandatory content)

• Medicines management (medication

given/review of drug records)

• Forensic sampling (which samples taken and

within FFLM recommendations)

Clinical Incidents and Positive

Interventions

• Specific reporting form

• Review by the Risk Management Committee

• Feedback provided to reporter as appropriate,

e.g. remedial action required

• Lessons Learned publication sent to all agencies

Clinical Incidents and Positive

Interventions

• Survey period Jan-Dec 2009

• 86,184 patient/detainee episodes

• Over 11 constabularies

• 159 clinical incidents/positive interventions

(0.2%)

• Limitations – underestimation

• Need to encourage reporting of incidents

Clinical Incidents and Positive

Interventions

• Clinical incidents n=39

• Prescribing issues n=38

• Health and Safety n=13

• Organisational n=23

• Positive interventions n=21

• Professional n=25

Clinical governance

• Risk management

• Staff management and performance

• Continuous professional development

• Clinical audit

• Information management – patient records

• Communication

• Leadership

• Team working

Next steps

• e-learning modules

• Reflection monthly clinical conundrum online forum

• Further mental health and substance misuse training

• SOM nurse examinations: Level 1 adults only, 20 cases

with high quality colposcopic pictures

• Adolescents post pubertal 10 further cases

• Joint examination with paediatricians

Need for standards

• CFM not recognised as a speciality

• No nationally agreed mandatory standards for

training

• Current quality of training sub-standard and

inconsistent when compared with the relevant

standards as set out by the regulator GMC

Stark MM. & Norfolk GA. Training in clinical forensic medicine in the UK - Perceptions of current regulatory

standards. JFLM 2011: 18; 264-275

Quality standards FFLM

[See www.fflm.ac.uk]

• Developed for doctors (2011) and HCPs (2012)

• Recommendations for Regional Sexual Assault Referral Centres (2008)

• Recruitment

• Initial training

• Workplace-based supervision

• Continuing professional development

• Service level standard

Recruitment

• Crucial

• Experienced practitioners

e.g. high quality nurses with evidence of decision

making and autonomous practice

e.g. doctors with postgraduate experience – post

membership/fellowship

Initial training

• Induction to a different environment

• Face-to-face training using a variety of teaching methods

• Trainer should be subject matter expert

• Online/distance learning component

• Cover core competencies

• Regular assessment by trainer/supervisor

• Individuals learning needs assessed – use of spiral curriculum where new learning is related to previous learning

Training of new recruits

• Structured formal training

• Named clinical and educational supervisor

• Educational supervisors should be trained and undergo

performance review Stark MM. & Norfolk GA Training assistant forensic medical examiners in London, UK. JFLM

2010:17;194-197

• The professional body, the FFLM, should set up

training programme for educational supervisors,

including appraisal skills Stark MM. Principal forensic physicians as educational supervisors. JFLM 2009:16;392-396

Continuing professional

development CPD

• CPD - online/face-to-face

• Appraisal

• Ongoing supervision/mentoring

• Post graduate qualifications

Supervision

• Educative

• Supportive

• Managerial/administrative

Kilminster et al. AMEE Guide No.27: Effective educational and clinical supervision. Medical Teacher

2007;29:2-19

Supervision

• Clinical supervisor is a

trainer who is selected and

appropriately trained to be

responsible for overseeing a

specified trainee‟s clinical

work and providing

constructive feedback during

a training placement

• Educational supervisor is a

trainer sho is selected and

appropriately trained to be

responsible for the overall

supervision and management

of a specified trainee‟s

educational progress during a

training placement and

responsible for their appraisal

Postgraduate qualifications

• Diploma in Forensic Medical Sciences

• Diploma in the Forensic and Clinical Aspects of

Sexual Assault

– Worshipful Society of Apothecaries

• PgC/PgD/MSc in Advanced Forensic practice

(custody and/or sexual assault) badged by

UKAFN for nurses/paramedics Staffordshire

University

Postgraduate qualifications - 2

• Membership of the FFLM

• FFLM has plans to introduce a Licentiate

examination for nurses and paramedics

• Diploma/MSc course at Ulster and Central

Lancashire Universities

Inter-professional education (IPE)

• This is essential for MDT working

• Develop insights, shared knowledge and team

work skills that promote effective collaboration

to deliver high quality care efficiently (Freeth,

2007)

• Reciprocal shadowing

• Case-based discussions

Conclusion

• Variability in service delivery in the UK

• Training & support paramount

• Expertise requires relevant knowledge, required

skills and experience = „considerable caseload‟

• Significant risk

– Vulnerable population: complainants and suspects

– Actions scrutinised in court!

Thank you!

www.fflm.ac.uk