Richard Jones argues that investigations into serious accidents at work could be assisted if environmental health officers enlisted the services of forensic physicians.

Environmental health professionals involved in the investigation of accidents at work are often placed in the position of trying to investigate the cause of injuries to a victim, with limited information about the events that led to those injuries. Following an accident where injuries are sustained, with the victim having been admitted to hospital or treated in the local casualty department, the investigating officer has the opportunity to interview the injured person and speak with the clinicians that treated them. Patient medical records pertaining to their current injuries can be obtained with the consent of the injured person, but there is often little in the way of a medical view on the interpretation of those injuries.

Generally, the goal of the clinicians is to obtain the most relevant information about the likely cause of the accident, in as much as it will impact on the way in which they manage that patient. They are not concerned with the intricacies of the way in which the injuries were caused. A medical opinion and interpretation as to the cause of injury is not within the expertise of the casualty doctor. The investigating officer can therefore find themselves in the position of knowing what injuries the victim has suffered from, but still no closer to discovering how they occurred. This is a particular problem where the person has suffered a severe head injury and lost consciousness at the time of the accident, and where the accident was not witnessed. Forensic physicians (or police surgeons or forensic medical examiners (FMEs) as they are sometimes known) do have the expertise with which to examine wounds and patterns of injury and give an interpretation as to how they were caused.

FMEs are usually contracted by local police forces to examine victims of assault and to examine and treat those in custody. They take blood samples in cases of suspected drink-driving offences, and interpret blood alcohol or drugs levels. Where those in custody are due to be interviewed, the FME may be asked their opinion as to whether prisoners are fit to be interviewed or even detained at the police station, or whether they should be transferred to hospital. Where there is a suspicious death, they pronounce life extinct and assist in the investigation of the scene of death for signs of criminal activity etc. In order to assist an accident investigation where injuries have been sustained, and there is doubt as to how they were sustained, the investigating officer or team has a potentially useful ally. An early consultation with an FME would allow the team to obtain advice on the likely cause of a victim's injuries, and thus advise on where to concentrate their efforts during the investigation. The FME would also be able to add authoritative weight to the evidence collected, by virtue of the fact that they are among the only medically qualified personnel who are conversant with evidential matters and the preparation of statements and medico-legal reports. FMEs would also be able to visit the scene of the accident with the investigating team, to advise on evidence collection and preservation (if the scene is intact), or assist in the interpretation of the injuries in the context of the scene of the accident itself. Even where the accident has occurred some time before, as long as the conditions at the scene have been adequately documented (particularly with good quality photographs), the opinion of the FME could still be beneficial to the investigation and can assist in the verification of the statements of witnesses, if there are any.

The victim should be examined by the FME (after consent has been obtained) who will then request that the injuries be documented in the most appropriate manner. Generally this involves good quality photography, taken in well-lit surroundings, and with a scale included in the photograph for evidential purposes. The medical illustration department of most large hospitals would be well placed to carry out this task. Alternatively, the FME may advise that a police photographer is used for optimal results. The impact of this evidence should not be underestimated. When entered into evidence in court, it forms a powerful visual aid to the extent of injuries that will, in all probability, have long since healed by the time a prosecution reaches the courts.

Why should environmental health professionals approach FMEs for this kind of assistance? Investigating serious accidents is not something that most environmental health professionals have a great deal of experience with. In order to offset the considerable costs of an investigation, it is important that the resources expended are maximised. For an additional initial layout, the retention of an FME could actually focus the investigation on the probable cause of the accident, saving time and expense. Should the case be taken for prosecution, the costs incurred in seeking the FME's opinion, and obtaining effective forensic evidence of the injuries sustained by the victim, can be added to the rest of the costs of bringing the prosecution. If the case is solid, it is more likely to succeed in the courts and the prosecuting authority will be able to recover those costs incurred.

Where the accident has resulted in a fatality, the police are generally involved. They are able to direct their considerable resources towards investigating the scene of the accident and interviewing witnesses etc. The role of the forensic pathologist is to visit the scene, to examine the body and to pass opinion as to the cause of death. This involves examination of wounds and injury patterns and using their knowledge of the scene of the incident, to provide an interpretation as to how the injuries were caused. The environmental health professional can gain an enormous amount of information from the pathologist, but it is rare for any dialogue to be entered into between the two parties. The investigating team rely on the post-mortem report to guide their enquiries. However, a discussion between the two parties could provide further lines of enquiry that are not immediately obvious from the post-mortem report.

I have investigated a serious accident involving a petrol service station employee, who was found at the rear of a lorry, lying in a pool of blood next to a fully laden cage pallet whose contents had spilled over the forecourt. The incident was not witnessed by anybody and was not captured on the CCTV system in operation at the site. The injured person suffered a fractured skull and lost consciousness. He subsequently remembered nothing of the incident, and could not account for his being in the location in which he was found. The accident was not reported to the environmental health department until the scene had been cleared, and the police did not attend. Having been given permission to access the injured person's medical records, they did not shed any light on the likely mechanism of his injuries, and as a consequence, the investigation could not be focused on any particular aspect of the system of work, or the environment in which the accident occurred.

In retrospect, the investigation could have been assisted in those crucial early days of the investigation had an FME been consulted, and an opinion been obtained as to the likely cause of the injuries. The injuries could have been documented more fully, and presented at the subsequent trial to demonstrate the seriousness of the incident. The defendants in this case were found guilty, and fined a substantial amount, but one is left with the uneasy feeling that the outcome would have been different had the court been shown the horrific injuries suffered by the victim. The companies involved did not learn from their mistakes, and have since been prosecuted for similar offences by other local authorities. Accident victims deserve to have their cases investigated to the best of the investigating officer's ability, and in my opinion, the use of forensic physicians to examine injuries, and provide expert evidence as to the cause of those injuries should become routine practice in accident investigations carried out by environmental health professionals.

Richard Jones BSc (Hons) Lldip (evidence) MCIEH MRIPHH is a part-time environmental health officer with the London Borough of Islington, and a clinical medical student. The opinions expressed in this article are the author's own, and should not necessarily be taken to represent those of his employer. Any enquiries about the utilisation of forensic physicians in accident investigations should be forwarded to the author via E-mail: rmj@ehresources.co.uk
Further information about forensic medicine, and the role of forensic physicians and pathologists can be found at www.forensicmed.co.uk