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Medical forensics specialist group minutes: 9 January 2019

Updated 5 July 2022

Minutes of the seventh meeting held on 9 January 2019, at 5 St Philip’s Place, Colmore Row, Birmingham

1. Welcome and introductions

1.1. The Chair welcomed all to the meeting. See Annex A for a list of representatives present.

2. Minutes from previous meeting and update on actions

2.1. The minutes of the previous meeting held on 05 September 2018 had been approved by members prior to the meeting and were published on the GOV.UK website.

2.2. All actions from the last meeting were complete.

3. FSR conference (5/3/19)- parallel session on Medical Forensics in SARC’S

3.1. The Regulator’s FSR conference would be held on 05 March 2019 which would include a session on medical forensics. Members were asked what topics should be included, who should be invited, and the best way to run the session.

3.2. A member suggested it would be helpful to have a session on the NHS Sexual Assault and Abuse Strategy and how the strategy supports the work of the Regulator in terms of quality, standards, and safeguarding (which formed core parts of the strategy). The five-year strategy had some limited funding available. Across the next few years, funding for sexual assault referral centres (SARCs) would increase from £30 million to £38 million. The member confirmed they would be happy to present on this topic at the Regulator’s FSR conference.

Action 1: NHS representative offered to present at the FSR conference 2019 on the government Sexual assault and abuse strategy.

3.3. A member suggested holding a practical session that would help individuals understand how to comply with the Regulator’s standards. This session would include clarifying what is meant by cleaning, deep cleaning, and environmental monitoring in the context of a SARC. The session would aim to help individuals to put guidelines in place and would also include information on anti-contamination practices. The Regulator suggested inviting a representative from the Central Elimination Database (CED) to present this topic. Another member mentioned it would also be useful to include feedback received from end-users (complainants), the group were advised that The Havens had conducted a survey which was sent to complainants for their feedback. It was suggested a representative from The Havens could discuss their results at the session.

Action 2: FSRU to liaise with The Havens representative to possibly present at the FSR conference 2019.

3.4. The UKAS member offered to present a high-level presentation on accreditation, as there may be organisations who would be new to the accreditation process. It was agreed this could be very useful.

Action 3: UKAS representative to be invited to present on accreditation at the FSR conference 2019.

3.5. A member queried whether invites had been sent out for the medical forensics session of the FSR conference 2019. It was confirmed no invites had been sent yet as topics and timings for the session was still being decided. It was suggested that a save the date invite could be sent to make people aware of the date. It was confirmed the FSR conference 2019 would be held in Birmingham and would a free invite only event.

Action 4: FSRU/ PR to send out save the date to potential medical forensics attendees of the conference. United Kingdom Association of Forensic Nurse and Paramedics (UKAFN) representative and Faculty of Forensic Legal Medicine (FFLM) representative to help facilitate as they have lists of stakeholders. Hong Tang to forward to stakeholders across government.

4. SARC self-assessment questionnaire (FSR-C-116 ANNEX A) review

4.1. Members were asked to discuss the feedback received and provide comments on the SARC self-assessment questionnaire.

4.2. It was noted that there were several comments about the types of training that should be provided to paediatricians who conduct forensic medical examinations on children. It was suggested that the document should direct readers to the Royal College of Physicians (RCP) and The Faculty of Forensic & Legal Medicine (FFLM) guidance and standards. The annex could provide essential revision for paediatricians who were experienced and those who were new. Another issue identified was the background checks conducted on providers. It was agreed this was outside of the remit for the standard.

4.3. Other feedback on the questionnaire included determination of the age appropriateness of the facility. A member suggested this information could be in the NHS/SARC key performance indicator guidance. The Care Quality Commission (CQC) representative confirmed when inspecting a SARC they would look at the facility and determine if it were age-appropriate against the CQC standards. It was felt that the wording could be amended to make this clearer.

4.4. There were also concerns raised around cleaning, for example would a DNA cleaned bathroom be required when examining a child. The members agreed the standard should be high regardless of whether a child or adult is being examined.

4.5. It was felt that further guidance around the requirements for airflow systems in SARCs would be helpful. It was raised by the Regulator that all new build facilities should include airflow systems along with other equipment to meet the standard with existing facilities needing to be upgraded. A member mentioned further guidance would be helpful especially for architects who would be designing the facilities and whether the medical requirements for infection control met the same requirements for DNA labs. The Regulator suggested if a representative from a forensic science provider whose facilities do meet the standards partner with a representative from the NHS facility to share experience.

Action 5: FSRU to arrange meeting between a representative of an FSP, the NHS and The Havens to discuss airflow standards required.

4.6. There were several points raised around ensuring that safeguarding for children was a priority, however the Regulator stated this was outside their remit and therefore of the standard.

4.7. The members felt it would be important to include a ‘chain of evidence’ for sexually transmitted infections (STIs) if the contraction of an STI were to be used in evidence. Guidance on evidence chains had been published by the Royal College of Pathologists and so it may be useful to consult this.

4.8. The issue of wearing face masks (and hair nets) when examining children had emerged in the consultation and was discussed by the members. The wording in the document did not state that the use of face masks was compulsory as some practitioners felt that wearing a face mask could make them appear intimidating to the patient, however it was preferable to minimise the risk of contamination. A member suggested that the examiner’s DNA could be added to the elimination database. The Regulator felt preventing the sample from being contaminated in the first instance was preferable to avoid the examiner’s DNA from masking the perpetrator’s DNA profile in a sample. The Regulator informed the group that an evidence base was being produced on the anti-contamination benefits of wearing face masks when conducting an examination. The Havens had conducted a study on how patients felt about masks been worn, however most of the responses were from adults rather than children. An evidence base would be built and in future could determine if this should be included in the standard. It was decided to leave it as discretionary at this point, but that the use of face masks should be encouraged to reduce contamination.

Action 6: The updates to the standard and guidance to reflect the position on wearing face masks as agreed by the group.

Action 7: FSR to liaise with The Havens regarding the research that they have been carrying out on face masks and contamination and see if this could be extended to children.

4.9. A member queried which individuals present at the examination had their DNA samples taken for elimination purposes. It was agreed that obtaining consent to obtain DNA samples from relatives may be a challenge, and that as a minimum DNA elimination samples should first be obtained from the medical examiners. In addition, the names of those present in the examination room should be recorded.

4.10. The members discussed the terminology used to describe the individual who conducts the examination. Members agreed ‘forensic health examiner’ would be most suitable, and would include paramedics, nurses, doctors and other healthcare professionals. A definition would be added to explain whom would be included in this term.

Action 8: FSRU to add the terminology ‘forensic health examiner’ and include a definition of what this means in the document.

4.11. A member suggested providing a definition on what the differences were between a facility and a service provider. It was confirmed facility was fixed service only, for example standalone SARCs, and a service provider had multiple roles, for example a SARC within a hospital. It was clarified that accreditation would be issued to the organisation responsible for running the service within the facility, and this should be made clear in the document.

Action 9: FSRU to add a definition for ‘facility’ and ‘service provider’ to the guidance for clarity.

Action 10: FSRU to add clarification on accreditation and service providers to the guidance.

4.12. A member queried whether the term ‘complainant’ or ‘victim’ should be used in the Regulator’s guidance. NHS England used the term ‘patient’ in their guidance since examinations were carried out in a medical setting. Members agreed ‘patient’ would be the most suitable term to be used in the Regulator’s guidance. The introduction to the guidance would set out use of the term and why it had been selected. Members also queried use of the terms ‘offence’. Members agreed that ‘alleged offence’ should instead be used throughout the guidance.

Action 11: FSRU to use the term ‘patient’ in guidance and include a definition and justification.

5. SARC standard (FSR-C-116) document review

5.1. Several responses had been received to the public consultation on the Regulator’s forensic medical examination standard for sexual assault complainants, FSR-C-116. Members discussed feedback received from members of the academic community, as well as professionals in health settings who interact with complainants. Some of this feedback concerned issues around having clear professional standards when taking statements from complainants. Members agreed that information on taking statements, or consultations that are documented from complainants should be referenced in the document, and members were asked to provide the FSRU with examples that could be referred to in the standard.

Action 12: MFSG members to provide the FSRU references to guidance on taking statements from complainants for inclusion in the Regulator’s standard.

5.2. Other feedback mentioned the importance collecting the complainant’s clothes for evidence. This was already carried out as a matter of course; however, it would be useful to reiterate this. The feedback also mentioned a concern regarding disclosure of colposcopic imagery for evidence. There was guidance from the Crown Prosecution Service (CPS) on colposcopic images that could be referred to. Members were not aware of any instances where these images were shared.

5.3. The 72-hour grace period in which to conduct forensic sampling was mentioned in the feedback and was discussed by members. It was felt this would depend on the clinician’s skill in assessing the urgency for sampling and the mental state of the complainant. The Regulator expressed it was important that the holistic care of the patient comes first, however the standard covers forensic sampling only. It was suggested that the introductory section of the standard could explain the focus on forensic sampling but make it clear that the clinician would be responsible for the holistic care of the patient and that this was of upmost importance.

Action 13: FSRU to strengthen language used in the standard regarding the holistic welfare of the patient.

6. SARC guidance (FSR-G-212) document review

6.1. Members discussed the feedback received to date from the public consultation on the forensic medical examination: assessment, collection and recording of forensic evidence guidance (FSR-G-212), which would close on 31 January 2019. It was agreed that registered midwives should also be included in the definition of a forensic examiner.

6.2. An issue had been raised in the consultation feedback regarding the appropriate type of overshoe to be worn during a forensic medical examination. Members agreed that provided overshoes were clean, it would be at the discretion of the individual to choose the type. It was suggested that the guidance specifies examiners must wear overshoes ‘or equivalent footwear that can be cleaned to a forensic standard for example crocs.

6.3. Feedback had been received that the recommendation in the FSR-G-212 document regarding urine sampling did not meet the FFLM guidance. This would be amended and brought in line with FFLM guidance on urine sampling and a reference to the guidance would be included.

Action 14: FSRU to include registered midwives in definition of forensic health examiner, update guidance on overshoes and urine sampling.

7. Stakeholder updates

CQC

7.1. The representative from CQC provided members with an update. The CQC had commenced an inspection programme of SARCs for which four inspections had been completed. An evaluation of the four inspections had taken place and no major issues had been reported. One issue identified were providers with multiple locations had issued generalised policies and procedures but had not tailored these to each location. Another potential issue raised was that SARCs not imbedded in NHS trusts may experience problems with governance and quality assurance (QA).

7.2. A workshop arranged by the CQC would be held on 01 March 2019. The workshop would aim to provide individuals and organisations with more information about the CQC and what they do, including tips on how to prepare for inspections. A short presentation would be given during the session which would provide attendees with the latest information and documents available on inspections. There would also be a Q&A session. It was suggested by the Regulator it would be useful to invite UKAS to present and answer any questions.

7.3. It was suggested CQC and UKAS could conduct inspections together. The Regulator highlighted that it was important that CQC and UKAS should not be duplicating effort, and there should also be no gaps. The Regulator mentioned if there were a requirement set for UKAS accreditation to ISO 15189 for medical forensics in the standard, this could result in a joint inspection programme with CQC and UKAS. A member mentioned it would be useful to produce a map that would identify what areas the Regulator, CQC, and UKAS were responsible for and this could be used identify any gaps.

Action 15: CQC representative to summarise which areas that CQC do not inspect and to it send to the Regulator.

Professional bodies

7.4. The representative from the UK Association of Forensic Nurses & Paramedics (UKAFN) provided members with a brief update.

A higher apprenticeship in advanced healthcare forensic practitioner was being developed by UKAFN and was progressing well. It was confirmed there would be a project pilot being held in Scotland for forensic examiners.

7.5. The representative from the Faculty of Forensic Legal Medicine (FFLM) presented members with an update. The Regulator mentioned they had been working with the FFLM to arrange a meeting with the NPCC lead for adult sexual offences. The meeting would discuss the FSR standards and ensuring all police forces were meeting the standards.

7.6. The representative from Royal College of Paediatrics and Child Health (RCPCH) provided members with a brief update. It was confirmed that the RCPCH were encouraging paediatricians to attend a two-day training course which would focus on the forensic examination of children who had been sexually abused. The training course would not provide a qualification but would aim to provide paediatricians with more confidence on this sensitive area work and provide revision for those already undertaking assessments. The course could also increase the workforce of paediatricians carrying out sexual assault casework.

NHS/Policing

7.7. The NHS England representative informed members about the NPCC National Rape Working Group. The group consisted of representatives from policing, NHS, Ministry of Justice (MOJ), Home Office and CPS. It was suggested that this group should be kept informed of the Regulator’s work on FSR-C-116 and FSR-G-212. The member agreed to facilitate contact between the Regulator and the chair of this group. Action 16: NHS representative to facilitate contact with the Regulator and the national rape working group.

7.8. In April 2018, NHS England had published a strategy document outlining how services for victims and survivors of sexual assault and abuse, in all settings of the health and care system, needed to evolve between 2018 and 2023. It set out six core priorities that NHS England would focus on to reduce inequalities experienced. This would be shared with the MFSG for information.

Action 17: NHS representative to share NHS England strategy with secretariat for distribution to the MFSG.

7.9. A stakeholder event was held on 22 November 2018 which focused on implementation of the strategy. Over 130 senior strategic leaders had been in attendance. Ten regional implementation plans were developed to deliver the six strategic objectives of the strategy. NHS England funding for SARCs would be increased to £38 million by 2021.

7.10. Child House, which would enable children and teenagers to receive medical, social care, therapeutic, and advocacy services from a single location in Camden had opened in London. In its first month of operation, the centre had received 70 referrals, which confirmed the demand for this service. There would be a further five Child Houses opening in London.

8. AOB

8.1. An article had been published on the BBC News website concerning forensic samples taken at SARCs. The article highlighted concerns about young victims of sexual assault not being forensically examined within a critical period. The report also highlighted incorrect recordings of injuries, and evidence contamination. To a large degree, the issues raised in the article had already been addressed and indicators had been introduced to SARCs to monitor their performance. Some issues raised in the article were still occurring however. It was suggested ensuring separate staffed rotas in SARCs for examination of victims and suspects was essential. It would be helpful to include anti-contamination guidance within SARC service specifications.

9. Date of next meeting

9.1. The next meeting would be held on Wednesday 5 June 2019 in Birmingham.

Annex A

Organisation representatives present

• Independent National Forensic Advisor (chair)
• UK Accreditation Service (UKAS)
• Faculty of Forensic Legal Medicine
• UK Accreditation Service
• The Havens London
• Criminal Case Review Commission
• UK Association Forensic Nurses
• Care Quality Commission
• NHS England - Health & Justice Specialised Commissioning
• Royal College of Paediatrics and Child Health
• Forensic Science Regulator
• Forensic Science Regulation Unit
• Forensic Science Regulation Unit
• Home Office Science Secretariat

Apologies

• Hampshire Constabulary
• NHS
• Health Justice Trailblazer
• General Medical Council
• The Chartered Society of Forensic Sciences
• NPCC lead -Rape Working Group
• Department of Health
• General Medical Council
• Police Service Northern Ireland
• Police Scotland