Working as a forensic practitioner


GP and medico-legal adviser Dr San Sumathipala tells Good Practice about the unique challenges and rewards of working as a forensic practitioner (FP). Interview by Dr Richenda Tisdale.

At the end of a morning surgery session, GP Dr San Sumathipala, received a call from the local constabulary. He was asked to come and assess a detainee for fitness for interview.

Issues around confidentiality are complex and the position in the FP-detainee relationship is very different from that in the usual therapeutic doctor-patient relationship.

FPs may have a dual responsibility when assessing a detainee – to the police in collecting forensic evidence and preparing a report for criminal proceedings, and to the detainee as a patient if he or she requires medical treatment. FPs should explain clearly to the detainee at the outset that this is the case, and that no assurance of confidentiality can be given. 

However, not all information disclosed to the doctor should necessarily be passed on to the police. Following a parliamentary debate on the Criminal Procedures and Investigations Act 1996, the situation on confidentiality for FPs was clarified for England, Wales and Northern Ireland. It was determined that reports prepared for criminal proceedings may be given to the police, but information obtained for therapeutic purposes would be subject to the usual law and ethical guidance on confidentiality. 

Dr Sumathipala explains that if a detainee disclosed in confidence that, for example, they were HIV positive and required medication for this, a separate medical record detailing the patient's medical history should be kept. This should not be disclosed to the police unless required by law or in the public interest. 

Some medical information-sharing with the police may be appropriate, including when the patient consents to the disclosure, or when it is necessary for the protection of the health of the detainee or those around them. Conditions which are not transmissible through ordinary contact (for example HIV) should, however, not be disclosed. If a patient requires transfer to another institution, then the relevant medical information should be sent with the patient in an envelope marked 'confidential'.

FPs should also provide custody officers with clear details regarding the level and frequency of medical supervision necessary, and specify any medication the detainee requires. 

A typical evening as an on-call FP might include requests to prescribe medication for a person in custody. Dr Sumathipala describes the Sword of Damocles which can hang over a consultation with a detainee who may be ill but have no medical records.

"You worry about missing a serious illness or injury in a patient about whom you have little or no medical information. Take, for example, when you are assessing a patient who is agitated and aggressive and has been arrested following an alleged assault. It is important to consider whether there may be an underlying mental or physical health condition, a possible head injury, or drug or alcohol misuse that requires treatment. 

"The incidence of mental illness and drug misuse is higher in detainees than in the general population, and their health needs can be complex. At times it can feel that you are treating blind, without the benefit of the records that we would usually depend on."

For some clinical presentations there is clear guidance for FPs, for example, on the management of head injuries. The Faculty of Forensic and Legal Medicine (FFLM) guidance for this outlines the criteria warranting urgent admission to hospital, and provides advice sheets which can be given to the patient, custody officer or responsible adult.

FPs may also be asked to take samples from detainees or victims of crime or to perform an intimate body search.

While consent is not legally required for an intimate body search for weapons if authorised by a police inspector, the BMA and FFLM both advise that doctors do not perform such examinations without consent.

Dr Sumathipala explains that working at the MDU has increased his awareness of the consequences of what can appear to be an innocuous consultation.

"I can think of times when, although I sought a patient's informed verbal consent and documented this, I would now seek written consent if practical. It has also brought home the necessity of making clear and careful notes of the advice given to the patient and custody officer as you may need to rely on this later during an investigation or coroner's inquest."

During a recent five year period, the MDU opened an average of one case a month to assist members working as forensic practitioners. These range from complaints, to coroner's inquests and GMC investigations, as well as advice on ethical matters such as consent and confidentiality.

The MDU offers the following advice for doctors working as FPs:

  • Ensure that you are working within your competence and area of expertise. The Faculty of Forensic and Legal Medicine has details of courses and qualifications relevant to FPs. There is also helpful joint guidance from the BMA and FFLM.
  • Ensure that a detainee has given informed consent to examination, and understands the role of the FP, including that not all information will necessarily be kept confidential.
  • Keep careful written records, including written consent where possible. Try to separate out forensic evidence from medical information which relates solely to therapeutic care as you go along and only disclose in accordance with the law and advice.

Despite the obvious challenges, Dr Sumathipala finds working with potentially vulnerable patients, and the complex and varied needs that this can bring, "very rewarding". He adds: "I also really enjoy the opportunity to experience something so different from my day-to-day work in general practice. It's good to work alongside the police and to use my skills in what can be a challenging, but ultimately satisfying role."

Forensic practitioner subscriptions are based on the average number of clinical hours worked per week. When calculating this, as well as including time spent with patients, you should also include time doing patient related administration (such as writing notes, making referrals, arranging transfers, requesting investigations and reviewing results).

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This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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