The Role of the Forensic Nurse Expert
Written by Jennifer Johnson & Val Sievers   

PROFESSIONALS IN THE CRIMINAL JUSTICE ARENA may be familiar with the role and practice of the legal nurse consultant (LNC). The American Association of Legal Nurse Consultants defines legal nurse consulting as the analysis and evaluation of facts and testimony and rendering an opinion related to nursing care and practice and its outcomes (AALNC, 2019). The LNC generally works behind the scenes in a variety of malpractice and negligent death cases and does not usually testify in court. The LNC can work to assist the attorney in understanding medical technology, medical terminology, procedures, treatments and other healthcare related topics.

Similar but distinct, the forensic nurse expert (FNE) is a Registered Nurse or Advanced Practice Nurse in a consulting role that performs a critical analysis of the specifics of a criminal or civil case, may render an opinion, and can provide expert testimony related to the case. The FNE employs specific knowledge, training and experience to educate attorneys, juries, and the court about the medical forensic evidentiary examination, standards of practice, appropriate techniques, evidence collection, injury evaluation, and current forensic documentation.

The practice of forensic nursing is multifaceted, not limited only to sexual assault examinations or forensic examinations of the deceased. Forensic Nursing is defined by Lynch (2006) as the application of the forensic aspects of healthcare combined with the bio/psycho/social/spiritual education of the registered nurse in the scientific investigation and treatment of the trauma or death of victims and perpetrators of violence, criminal activity, and traumatic accidents.

Forensic nurse experts often have varied clinical backgrounds and have experience or hold positions in hospital and healthcare organizations, correctional facilities and jails, academic and teaching institutions, medical examiner or coroner offices, nurse-managed clinics, non-profit agencies, or independent practice. A forensic nurse with specific knowledge and expertise can also assist community and regional partners by participating on task forces and advisory boards that are focused on injury prevention or community approaches to violence and disasters. An example in one metropolitan area is the Complex Coordinated Terrorist Attack (CCTA). In a terrorist attack or an event that has produced mass casualties and living survivors requiring medical treatment, the FNE can aid the response by providing education and training to healthcare professionals and first responders on managing the living survivors of a mass casualty who have both medical and forensic needs. These living survivors may have valuable eye-witness information, evidence on their bodies that may need to be collected and retained for law enforcement, and specific documentation of injuries that can assist their medical treatment and may potentially be useful in the investigation that follows a disaster, mass casualty, or critical incident.

The forensic nurse expert can provide valuable information and consultation in cases that involve elder abuse, child abuse and neglect, intimate partner violence, injury-related assaults, gunshot wounds, penetrating trauma, sexual assault, strangulation, homicide, and human trafficking—to name a few. The FNE can provide information regarding the mechanism of injury and the identification of specific injury presentations in consideration of the case information, the disclosures of the victim, and the alleged perpetrator—while remaining objective and unbiased when considering the patient-care experience and the case investigation.

The medical, forensic evidentiary examination typically consists of the following components:

• Verbal disclosure of the events or history provided by the patient;

• Physical examination of the patient and/or alleged perpetrator;

• Identification and photo documentation of injuries or corroborating information related to scars, tattoos, piercings, or other physical alterations;

• Collecting and packaging perishable biological evidence as it relates to the disclosed events, history provided, or physical examination, while maintaining the chain of custody; and

• Thorough documentation and secure retainment of the forensic record and photographs.

The forensic nurse expert uses the information from the medical forensic evidentiary examination to aid the prosecution or the defense about the examination that was completed, the subjective and objective findings identified from the examination, deviations from the forensic standard, whether the injuries are or are not consistent with the disclosure of events, and a critique of any documentation that is not current, consistent, or has been omitted. The expert reviews the medical forensic documentation, forensic photography, law enforcement reports, criminalistics laboratory results, and other documentation specific to the criminal or civil case. Once the expert has reviewed the information and relevant discovery provided by the attorney, a consultation with the attorney is arranged to discuss the expert’s opinions and a decision is rendered if an expert-written report is to be submitted to the court outlining the information of the case, the findings, and the opinions rendered.

The forensic nurse expert may assist legal counsel by evaluating the case specifics and aiding in the development of case strategies, assisting with jury selection and development of voir dire and cross-examination questions.

Case Example 1

A criminal case example involved a report of manual strangulation between intimate partners. One attorney requested an expert review of the police reports, photography completed by law enforcement, statements made by the victim, and the medical evaluation completed in the hospital. The attorney suggested that he had limited experience with cases involving strangulation. The forensic nurse expert provided evidence-based information to the attorney regarding non-fatal strangulation and how a report of strangulation corroborated the events and findings in this case.

It is often believed that when a person has been strangled, there will be observable evidence that it has occurred, such as physical signs of ligature marks, red marks, scratches, bruises, and petechiae. This is not always the case. It is estimated that jugular vein compression for approximately 10 to 30 seconds with 4 to 4.5 pounds of pressure will result in petechial hemorrhage (Lambe et al., 2008; Stapczynski, 2010). If the jugular veins are not compressed, the presentation of petechiae and scleral hemorrhage may not be evident. Compression of the carotid arteries for a duration of 10 seconds with 11 pounds of pressure will result in a loss of consciousness without petechial hemorrhage formation (Lambe et al., 2008). Loss of consciousness may produce a generalized seizure with subsequent loss of bowel or bladder function, which was experienced by the victim in this case. As a form of asphyxia, the individual experiences lethal pressure on the structures of the neck, including the airway, circulatory system, and nervous structures of the neck, which can lead to anoxia, irreversible brain damage, and death (Di Paolo et al., 2009; Green, 2013; Lambe et al., 2008). The lack of circulation of blood to the brain will result in unconsciousness in approximately 10 seconds and sustaining brain death in 4 minutes (Faugno et al., 2013).

Strangulation victims may exhibit a variety of symptoms and physical presentations, including a lack of visible injuries, neck pain, and the presence or absence of petechial hemorrhage. However, it is important to note that in 50% of reported cases of strangulation, there can be significant injury without noticeable bruises on the neck. In some cases, there may be the presence of defensive injuries, such as lacerations and scratch marks on the neck and chest, that may have been caused by the victim’s attempts to remove the pressure from the neck to improve breathing. The lack of knowledge by healthcare professionals of the absence of physical injuries may result in limited or inaccurate diagnostic evaluation for the victim with a history of non-fatal strangulation.

After a review of the information provided by the attorney, the forensic nurse expert identified key components of the case. The officers noted the presence of her physical appearance, an audible voice change on the scene, and encouraged medical evaluation. The female victim was seen in the emergency department and provided a history of strangulation with loss of consciousness. She was evaluated for strangulation through the completion of a CT angiogram of the neck and a CT of the head/brain without contrast. Both radiological studies had negative findings for significant structural or vascular injury. While in the emergency department, this patient also completed a medical forensic evidentiary examination. The following subjective and objective findings consistent with strangulation were documented:

1. Neck pain
2. Bruising/discoloration
3. Difficulty swallowing
4. Pain with swallowing
5. Lightheadedness
6. Memory loss
7. Loss of consciousness
8. Visual disturbances, left eye cloudy vision difficult to focus
9. Sore throat
10. Voice changes: raspy
11. Headache
12. Red spots right eye
13. Bowel incontinence

The emergency department nurse collected the underwear and jeans that were worn by the patient at the time of the event. These items were collected, sealed, and maintained until retrieval by the detective assigned to the case.

After a complete review, the forensic nurse expert opined that the injuries noted were consistent with the manual application of pressure on and around the throat and neck region. The forensic nurse expert provided a written report to the attorney for submission to opposing counsel. The defendant in this case opted for a plea agreement and the case was resolved.

Case Example 2

In another example, a plaintiff's attorney contacted a forensic nurse expert about a fall that occurred at a rehabilitation facility. The attorney provided the medical records from the rehabilitation facility, the medical facility where treatment was sought after the event, and the radiological studies that were completed. The attorney requested assistance in identifying deviations from the standards of care. The FNE reviewed the records and reported to the attorney the following:

Mrs. J. was discharged from a hospital facility following a lumbar fusion. At the time of discharge, Mrs. J. was noted to be a fall risk, requiring the use of a walker to ambulate. Upon admission to the rehabilitation facility, Mrs. J. was also noted to be a fall risk; however, there was varying nursing documentation regarding the numeric value assigned to the level of the fall risk. Mrs. J. further reported to staff “I can’t make it all the way to the bathroom before I have to go.” This statement further suggested a need for assistance when ambulating, use of a walker, or placement of a commode to facilitate activities of daily living while reducing the risk for falls.

Mrs. J. sustained a fall while under care, supervision, and rehabilitation at this facility. The fall that Mrs. J. sustained was omitted in the nursing documentation on the date of the occurrence. The only written documentation of the fall was in a nursing note dated March 15, 2017, in which the nurse documented “this is the first time I have heard of a fall.” This nursing documentation was not dated; however, it accompanied the nursing shift report dated March 15, 2017. It was further noted that another provider on March 15, 2017 documented “resident seen yesterday smiling and laughing, needs psych.” Mrs. J. continued to request pain medication for the complaint of pain but was informed that she would have to wait until it was due to be administered because of the time schedule for the prescribed pain medication. There were no documented phone calls to the patient’s healthcare provider to report the increased pain that Mrs. J. was experiencing, or that she had sustained a fall in the bathroom.

Four days later, Mrs. J. presented to the emergency department with a history that she had sustained a fall and that no radiological studies were completed after the fall, which was supported by the medical record from the rehabilitation facility. Mrs. J. underwent a CT scan which indicated a traumatic sacral fracture. The traumatic sacral fracture required surgical repair. Following surgery, Mrs. J. was discharged to a different rehabilitation facility for post-operative care and therapy.

The forensic nurse expert opined that the rehabilitation facility deviated from the standard of care regarding Mrs. J. being a documented fall risk, that inappropriate documentation and management of the fall occurred within the facility, and there was inappropriate initiation of treatment for Mrs. J. due to the fall that occurred. This case settled out of court.

Experienced forensic nurses in clinical, administrative, education, and positions of independent practice are uniquely qualified and well positioned to assist attorneys with a variety of criminal and civil cases. The forensic nurse expert can leverage their specialized knowledge, skills, education, and practice expertise to positively affect healthcare services provided to both the victim and the accused, while serving the interests of justice.

*All initials and dates have been altered to protect the identity of individuals in the case examples.


About the Authors

Dr. Jennifer Johnson (DNP, APRN, WHNP-BC, AFN-BC, SANE-A, SANE-P, DF-AFN) is a board-certified women’s health nurse practitioner, board-certified advanced forensic nurse, and sexual assault nurse examiner with more than 20 years’ experience in practice. She developed and manages a comprehensive forensics program for AdventHealth in the Midwest and is the president and owner of Johnson Legal Nurse Consulting, LLC, a criminal and medical malpractice consulting business. Johnson is an appointed member of several professional and governmental organizations related to forensic medicine, including the National Institute of Standards and Technology/National Institute for Justice Evidence Management Project, and End Violence Against Women International’s Medical Forensic Expert Panel.

Valerie Sievers (MSN, RN, CNS, SANE-A, SANE-P, DF-AFN) is a Forensic Clinical Nurse Specialist with more than 35 years of health care experience as a registered nurse, advanced practice nurse, educator and consultant with extensive practice experience in the arenas of emergency and critical care nursing, academic education and forensic clinical practice. As a Clinical Nurse Specialist, Sievers provides advanced education regarding the care and treatment of patients affected by violence and abuse. She is currently dual board certified as an adult-adolescent and pediatric sexual assault nurse examiner, owner of MedLaw Consultants, LLC, a forensic healthcare consulting business, and is a board member of the Academy of Forensic Nursing.


References

American Association of Legal Nurse Consultants. 2019. What is an LNC. Retrieved 5/20/2019 from http://www.aalnc.org/page/what-is-an-lnc

Di Paolo, M., B. Guidi, L. Brushini, G. Vessio, R. Domenici, and N. Ambrosino. 2009. Unexpected delayed death after manual strangulation: Need for careful examination in the emergency room. Monaldi Archives for Chest Disease. 71(3): 132–134. http://dx.doi.org/10.4081/monaldi.2009.359

Faugno, D., D. Waszak, G. Strack, M. A. Brooks, and C. Gwinn. 2013. Strangulation forensic examination best practice for health care providers. Advanced Emergency Nursing Journal. 35(4): 314–327. http://dx.doi.org/10.1097/TME.0b013e3182aa05d3

Green, W. 2013. Evaluation and management of sexually assaulted or sexually abused patient (2nd ed.). Dallas: American College of Emergency Physicians. Retrieved from https://www.mncasa.org/wp-content/uploads/2018/07/Sexual-Assault-e-book.pdf

Lambe, A., K. Pushel, and S. Anders. 2008. Extensive petechiae in attempted self-strangulation. American Academy of Forensic Sciences. 54(1): 212–221.

Lynch, V.A. 2006. Forensic nursing. St. Louis, MO: Elsevier Mosby.

Rahman, M. and M. Moran. 2018. Forensic science: Complex admissibility standard for scientific evidence and expert witness’s testimony. New York City College of Technology Academic Works. Retrieved 20 May 2019 from https://academicworks.cuny.edu/cgi/viewcontent.cgi?article=1401&context=ny_pubs

Stapczynski, J. S. 2010. Strangulation injuries. Emergency Medicine Reports. 31(17): 193–204. Retrieved from https://www.reliasmedia.com/articles/19950-strangulation-injuries

This article appeared in the Fall 2019 issue of Evidence Technology Magazine.
Click here to read the full issue.

 
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