Healthcare professionals - supporting adults who present having experienced rape or sexual assault: clinical pathway

9. Forensic Medical Examination (FME)

This section sets out the processes for undertaking a FME. It is important to note that should the person wish to have a FME; this should be done as soon as reasonably possible in order to preserve as much forensic evidence as possible.

Key points

• The primary purpose of the FME for rape or sexual assault is to support the health and wellbeing of individuals and identify the healthcare needs of the person
• FME and evidence collection supports the judicial process
• Early evidence kits assist with the preservation of forensic evidence while a FME is awaited.
• It is important to minimise the number of times a person is asked about the incident. Obtain details from other professionals e.g. police, if already given, to avoid the risk of re-traumatisation

The Self-Referral National Protocol provides detailed guidance on providing self-referral FMEs. The primary purpose of the FME for rape and sexual assault is to support the health and wellbeing of individuals and identify the healthcare needs of the person. The secondary purpose is to collect evidence that would support any criminal investigation and future prosecution.

Should the person wish to have a FME, the options available for FME and evidence collection should be communicated to them. In exceptional cases, it may be appropriate to prioritise emergency medical care despite the possibility of some compromise of forensic evidence.

The introduction of the FMS Act means that people can request a FME without first contacting the police. Section 3 of the pathway provides an outline of the self-referral service and the Self-Referral National Protocol provides further guidance.

The principles of trauma-informed care should be at the forefront before, during and after the examination, offering the person flexibility and choice and ensuring that they have control of all parts of the process they have consented to.

9.1 Preserving Forensic Evidence

For both self-referral and police referral cases, the FME should be carried out in appropriate NHS healthcare facility, which is managed in line with the National DNA Decontamination Protocol^[85] to ensure the forensic integrity of evidence is maintained. Further guidance is available in the Self-Referral National Protocol and the Health Board service specification document^[86].

The forensic examination findings should be recorded by the SOE within the national clinical IT system, Cellma.

9.1.1 Early Evidence Kits

Early evidence kits assist with the preservation of potential forensic evidence while FME is awaited. They are used by police officers soon after the time of the initial police report. This may include the taking of mouth samples to allow the person to drink without risk of loss of evidence and urine bottles and forensically secure toilet tissue if needing to urinate before being examined.

When a FME is carried out, the SOE should be informed whether an early evidence kit has been used and which samples/items were taken.

Information on the role of the Sexual Offence Liaison Officer (SOLO) is available at Appendix B.

9.1.2 For All Types of Rape/Sexual Assault

• The type of seat the person sits on should be ‘wipeable‘. For further information, see the Health Board service specification document^[87]
• The person should be asked to avoid baths/showers/douching/changing clothes until after an examination
• If a condom was used, it should be retained
• Where possible the person should be asked to avoid eating, drinking, including alcohol or smoking if the assault included oral penetration

For further information, refer to current FFLM Recommendations.

9.1.3 Vaginal and Anal Rape/Sexual Assault

If possible:

• Any sanitary protection worn at the time of the assault or afterwards should be saved
• It is preferable to remove a tampon as part of forensic examination after external genital swabs have been taken. However, the person may prefer to remove the tampon themselves
• Document the order of swabs taken in relation to any tampons removed during the course of the examination

If possible, the person should avoid passing urine and/or opening their bowels before forensic examination. However, if they need to, offer to retain samples and tissue used to wipe as potential evidence.

Refer to the most current FFLM guidelines^[88] on sampling recommendations and guidance on personal protective clothing to maximise the opportunity for forensic capture and minimise the risk of DNA transfer.

9.1.4 Oral Rape/Sexual Assault

If possible, the person should avoid:

• Brushing their teeth or using mouthwash
• Taking fluid or food
• Smoking

If appropriate, offer to take toothbrushes/cigarette ends as potential evidence as appropriate.

9.1.5 Clothing

For both self-referral and police referral cases, in a forensically secure environment:

• The person should change out of the clothes worn at the time of the rape/sexual assault as soon as possible. If the person is wearing the same clothing and/or has not washed since the incident they should be asked to stand when undressing on a paper ground sheet to allow recovery of body fluids or foreign particles that may fall from clothing or body during examination.
• The person should be given a DNA free modesty gown to wear.
• Each item of clothing should be placed in a separate paper evidence bag (not plastic)
• All items should be labelled immediately with identifying details, date and name of the person labelling
• Underwear worn at the time of or after the incident, should also be collected and placed in a separate paper evidence bag

Ideally professionals should avoid handling clothing; if this must happen, it should be done with double gloves.

If clothing has to be cut:

• It should be cut along the seams of the item
• Do not cut through any damaged areas or breaks in a garment; which may be the result of the assault or use of weapons
• Do not cut through blood, semen or fluid marks

9.1.6 Wounds and Blood/Saliva/Semen Stains

Blood, saliva or semen stains and injuries should have forensic swabs taken prior to cleansing wherever possible.

9.1.7 Collection of Firearms Residue and Trace Samples

For collection of items e.g. weapons, restraints, tape, bullets, paint, glass, soil:

• Contact the on call forensic scientist for advice
• Wear PPE to collect items of potential evidence as per FFLM guidelines^[89]

9.2 Examination

9.2.1 Introduction to the forensic medical examination

Using trauma-informed principles:

• Ensure safety and build trust
• Consider any person specific needs depending on age, sex, religion, sexual orientation, language requirements etc.
• Offer choice and control where possible
• Maintain the person’s privacy and dignity at all times
• Minimise re-traumatisation by avoiding identified triggers. For further information on triggers, refer to the Health Board service specification document^[90]
• Keep the person informed of processes and changes

This examination may include:

• A detailed head to toe examination
• Documenting the presence or absence of injuries and their interpretation
• Dealing with any injuries requiring immediate medical treatment
• Identifying any medical conditions that may affect interpretation e.g. skin conditions, bleeding disorders
• Developing an opinion on timing, mechanism and causation of injury
• Documenting and interpreting any forensically relevant features or injuries
• Collecting appropriate forensic specimens in accordance with FFLM (2018) guidelines

For police reports, incident details should be provided by investigating officers and recorded in Cellma prior to commencing the examination.

9.2.2 Key Elements in a Forensic Medical History

The purpose of taking a history as part of a FME is to obtain any information that may assist with both assessing the healthcare needs of the person and to aid interpretation of forensic findings. This should be documented as recommended in the digitised National Form in Cellma.

9.2.3 Forensic Examination Procedure

The SOE and the corroborating witness, normally the FTN, should put on the recommended PPE in the correct order. It is important to ensure the examination room has been decontaminated in accordance with the National DNA Decontamination Protocol^[91].

PPE should be donned in the following order:

• Face mask and beard snood (if applicable)
• Mob cap
• Disposable gloves (pair 1)
• Gown/coveralls or disposable sleeves
• Disposable gloves (pair 2)
• Safety glasses or goggles (optional)

A video containing more information on the PPE that should be worn is available^[92].

In addition to the examiner wearing the recommended PPE including facemask, powder free double gloves (nitrile) should be worn throughout the sampling process and when handling samples (including tamper-evident bags) with the top pair of gloves changed between sampling each different body area.

The clothing and ground sheet should be submitted as evidence. Similar consideration may be given to submitting any couch cover or seat cover if deemed likely to be relevant.

Any condoms, sanitary wear (tampons or pads) or incontinence pads should be submitted as appropriate.

The person should be given a DNA free modesty gown to wear.

The SOE should undertake a detailed top to toe external examination to ascertain the presence of any injuries and their sequence. These should be measured and documented on body maps in the digitised forensic examination form in Cellma, using recognised terminology for the type of injury and their position detailed relevant to anatomical landmarks.

Detailed genital and ano-genital examination should be undertaken with additional lighting. This may include colposcopy digital video documentation - see section 9.3

The Recommendations for the Collection of Forensic Specimens from Complainants and Suspects^[93] should be followed.

The history and nature of the assault and timing of exposure or contact will determine which forensic samples are relevant.

9.2.4 Forensic Sampling and Sequence

Appropriate clothing and biological samples, for forensic examination, should be collected, packaged and stored as per FFLM guidelines.

National, standardised forensic kits should be available to assist with the samples, which should be taken in the sequence listed. In general, non-intimate samples are taken before intimate samples and at the time of top to toe examination followed by the genital examination.

On completion of the forensic evidence collection:

• Double gloves are worn until the tamper-evident bag is sealed
• Check each sample is correctly labelled
• Check the person’s name
• Check the person’s date of birth
• Date and time sample was taken
• Sample description e.g. if related to a swab - Endocervical (1)
• The SOE signs each sample
• Each sample should also be signed by the corroborating witness, normally a FTN and the SOLO if present
• All specimens are packed in the tamper evident bags provided in the kit (except toxicology specimens)
• The SOE should complete all relevant information relating to productions in the forensic examination form
• Tamper-evident bags to be labelled appropriately
• Keep the toxicology specimens separated from the Sexual Offences Examination Kit i.e. they are not packaged together
• In police referral cases, the SOE and corroborating witness should provide witness statements to the police
• Facility for the individual to wash/shower after examination should be offered. Food, drink and additional clothing should be offered. For further details, refer to the Health Board Service Specification^[94]
• The SOE should complete the forensics section of the digitised National Form within Cellma along with the Summary of Findings report.

The medical assessment should be undertaken during the time at the healthcare facility and the findings and outcomes should be recorded in the health section of the digitised National Form within Cellma. This will form part of the individual’s health record and will not be shared with the police. Details of this assessment can be found in section 8 of the pathway.

Useful Resources

Faculty of Forensic and Legal Medicine Recommendations for the Collection of Forensic Specimens from Complainants and Suspects^[95]

9.2.5 Submitting Specimens to the Police

For police reports, once taken and labelled, specimens should be passed to the SOLO who will sign samples and bags.

9.3 Role of Colposcopy in Forensic Medical Examination

Magnification and lighting provided by colposcopes may increase the rate of injury detection. Colposcopy allows recording and imaging for peer review purposes and has the potential to be used to facilitate further expert medical opinion.

9.3.1 Storage and Retention of Digital Images

In line with Guidance for best practice for the management of intimate images that may become evidence in court^[96] from the Royal College of Paediatrics and Child Health and the Faculty of Forensic and Legal Medicine, intimate images form part of the medical record and are retained by the Health Board (RCPCH and FFLM 2020). Health Boards are generally the data controller for the images. Images, including intimate images should be shared and stored in line with data protection legislation and in line with local Health Board protocols. Sharing of intimate images that form part of the medical record should only be done in certain circumstances for example where there is appropriate informed consent or there is a court order.

9.3.2 Forensic Photography

Photography of injuries is a useful addition to body map documentation and the description of findings. In all cases in which the person presents with non-genital injuries, they should be asked to consent to relevant photography for use as part of the clinical and/or forensic record. When seeking consent, it should be made clear that photography is an important part of the investigation and prosecution process and may be used in any subsequent court proceedings.

In police referral cases, SPA photographers should be requested to take photographs of non-genital injuries observed during a FME of an adult or a Joint Paediatric Forensic Examination of a child or young person. However, if in exceptional circumstances an SPA photographer is not available to take the photographs, it is acceptable for the examining clinician to perform that role using an approved NHS digital device. The use of personal devices/smart phones is prohibited.

In the case of self-referral for adults, it is also acceptable for the examining clinician to perform that role, or they can request a medical illustrator to take photographs of non-genital injuries if deemed appropriate.

The reason why the photographs were not taken by a trained photographer should be recorded in the national form.

The requirements for photographs taken as part of a self-referral FME, include:

• clear, high-resolution, colour photographs of all non-genital injuries observed
• a close up view so that the detail of the non-genital injury can be analysed and;
• a wide angle to provide a perspective about the location and size of each non-genital injury is needed.

All photographs must be stored securely in line with Health Board procedures in a way that ensures that they are available when requested by Police Scotland or COPFS.