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Afternoon report of the Annual Educational Event 2024
Lucy Thorne MAAPT gives an afternoon session overview of her first ever AAPT AEE
Following a morning of fascinating and thought-provoking presentations from colleagues both local and international, the afternoon session was filled with even more engaging content, shedding light on areas either completely new to many attendees or further bolstering knowledge on areas of budding expertise.
CBRN, an APT Career Highs and Lows
Mrs Ishbel Gall FAAPT, NHS Grampian
CBRN, or CBRN(E) covers a multitude of potential hazard groups, with the addition of E for explosives in recent years. Ishbel opened with a brief explanation of what CBRN actually stands for: Chemical, Biological, Radiological and Nuclear. Whilst biological hazards are something ever-present in daily APT life, there are naturally further health and safety considerations brought into force when considering the other raft of hazard groups CBRN covers.
My knowledge of this area prior to Ishbel’s presentation was rather sketchy; snatches of news stories or anecdotes from other APTs and associated professionals, but nothing formalised or concrete. Ishbel went on to provide a timeline of her training and exposure, starting with Longmoor in May 2006.
At Longmoor 8 volunteer APTs underwent a feasibility exercise; testing new protective clothing for functionality (whether you were 5’2” or 6’6”!) and removing “mustard gas” from the outer surface of body bags in order for each patient to continue their processing. Ishbel provided some excellent behind the scenes photos, giving a real insight into the camaraderie between each APT troubleshooting unknown territory, especially doing battle with the new full coverage suits in a wet environment!
A two day excursion to Leicester in 2007 saw different kit being tested, Civic Responder or CR1 kit being utilised during real post mortem examinations to test its functionality in the field before something that felt far more “real” (Winterbourne Gunner in March 2008).
This was at the Defence Chemical Biological Radiological and Nuclear Centre, where the national police CBRN centre was based before recently moving to Coventry, and was far more physical than the other exercises, with more of a military feel with practice for gas alerts.
It was obvious that the role of the APT had not been considered much before this point; seasoned veterans of this process from the Fire Service had thought ahead and brought their own BBQs for the long waits between (note to self: if in doubt, take snacks).
Finally, Ishbel took us through the final exercise before a long period of quiet. Also in 2008 (Crystal Palace), this was the largest test of official command structures, communications, logistics and space (including mortuary flow).
This was organised by the Forensic Pathology Department at the University of Leicester with attendance by the Metropolitan Police Service, London Fire Brigade, and others. Following this, nothing occurred – the London Olympic Games in 2012 came and went without incident (thankfully), before Ishbel’s refresher training in 2017 where she was the only delegate after battling traffic from Aberdeen!
Following this, Ishbel advised that she could go no further in terms of specific case studies, as there is an embargo on some information sharing for specific inquiries ongoing.
However, she could share that the process apparently should always have two Pathologists, 6 members of the police, two representatives from the Organisation for the Prohibition of Chemical Weapons (whose very important job is to sit and watch!), and just one APT donning 20kg+ of full kit.
Thankfully, the need for Ishbel’s expertise and the fact she was the only one of her profession on duty wasn’t something that escaped the notice of others, who made sure she took regular breaks and was generally well looked after. The dream for any APT – a tea in hand whenever available.
The final case study Ishbel focused on was a local case, whereby a patient had committed suicide and it was mentioned, although not appropriately recorded or shared, that the substance used may have been cyanide.
By day 3 the substance was still not established, with it finally being named as sodium nitrate after 4 days in Ishbel’s mortuary. Her final question from this case was what if it had been cyanide? It sounds as though whilst it was not the most straightforward case, there was plenty of learning to be gleaned around effective communication and establishing processes for the next time, when the outcome may not be as simple.
Ishbel left us with some questions and considerations; the CBRN cut off age is now 55 and it is unclear how many APTs are still practicing who were previously trained. Ishbel asked us to consider joining local resilience groups and asking questions, or looking at regional groups of APTs and ensuring each region has a pocket of trained APTs. This is something I will be considering in earnest.
Drug Deaths in Glasgow and the Role of the APT
Dr Esther Youd, Forensic Medicine and Science, University of Glasgow
Drug deaths are something I have been exposed to more as a qualified APT rather than during my traineeship, due to the increased infection risk particularly around intravenous drug use and blood borne disease. However, I had not anticipated the magnitude of the issue in Glasgow and how this compares nationally.
Dr Youd initially broke down some data for us, and naturally I was drawn to the part of the graph covering the East, being based at Colchester Mortuary which is towards the other end of the spectrum from Glasgow’s statistics.
The statistics come from the Scottish equivalent of the ONS, the National Records of Scotland. Due to the high volume of drug-related deaths, the official statistics for Scotland are more up to date than England and Wales, meaning any comparisons drawn are with older data from the rest of the UK. In terms of demographics, male deaths are twice that of female deaths, with the most deprived economic groups at risk, with age 35-54 at the peak.
This age shows that people are living longer with a habit perhaps, or forming a habit at a later date than the ‘norm’ – the preconception being that drug deaths are isolated to young people.
There has also been a change from the type of drugs people are taking, with more of a shift seen to ‘cocktails’ of drugs, mixtures of drugs which have different effects on the body, or people taking heroin alongside their methadone prescription. Many combinations of drugs are taken in order to increase the high of heroin for example, or to prolong the effects of a particular drug group.
Dr Youd then took us through the requirements for PM as laid out by the Procurator Fiscal. Until 2020, 2 Pathologists were required for all drug deaths, with two toxicologists for corroboration.
Dr Youd emphasised the importance of keeping an open mind when risk assessing any case; it cannot be assumed from someone’s history or circumstances of death that they are an active user or have a confirmed disease or infection on the back of that.
The usual practices I utilise for any higher risk post mortems come into play; enhanced PPE combined with usual safe sharps practice. Interestingly, Dr Youd advised that with many cases the cause of death can relate to pathology relating to illicit drug use, rather than an overdose itself. However, such cases do not count in the statistics shared at the top of her presentation, meaning that – sadly – the numbers are far more than we initially saw.
As my exposure to drug deaths has been minor compared to Glasgow, I found Dr Youd’s next section extremely helpful, with external features on a patient which may be indicative of drug use being discussed. These included burns from crack pipe usage, sinuses being formed from repeated injection of drugs at the same site, and injuries; many individuals who partake in illicit drug use are vulnerable and may be victims of physical harm in life.
I found Dr Youd’s presentation very insightful, and it shows the on-going issues Glasgow has with illicit drug use and how this is tackled at post mortem. It also highlights the different exposure, nationally, that APTs face depending on their area and the demographics forming their local population.
Not Anthropology – Victim Identification and Other Things
Michael Conway MBE CSci FAAPT, Chesterfield Royal Hospital & University Hospitals of Derby & Burton NHS Foundation Trusts
The final presentation of the day was by an APT with the best beard in the business; Mike Conway. Covering a huge patch based at Chesterfield and seeing 2,200-2,500 deaths per annum, as an APT Mike oversees an extensive portfolio of work as well as disaster identification.
His presentation covered three main areas:
- The Skull
- Dilemmas in DVI
- “Not” Anthropology
The Skull
Mike’s story began with a skull being found in Buxton; having received a call from local police, they wished to know whether it was a) real and b) if it was a teaching specimen. This had been found in a locker at the local police station, having been brought in some years prior by a local woman taking residence in a home purchased from a former doctor. It had remained in the locker until the retirement of the Chief Inspector.
It was radiocarbon dated and – much to the delight of my inner archaeologist – was found to be from the 17th – 19th century. From the image Mike displayed on screen, it was most definitely not a teaching specimen; very brown in colour, incomplete and looking every inch the grave find that it was.
Dilemmas in DVI
Many of us in the room have had some experience with identification of individuals where they are disrupted, deteriorated or otherwise untraceable. To date, I have only had experience of forensic odontology, prints and DNA being used to identify someone who is not suitable for visual identification; these are our primary identifiers. Something I hadn’t previously needed to consider were secondary identifiers and assistance identifiers, but as Mike went on to explain, these are not without their pitfalls.
Secondary identifiers can range from tattoos, scarring, blood type, overlaying of plain film imaging, disease, serial numbers in implantable devices (including hip replacements) and any bespoke/specially made clothing or jewellery items.
Some pitfalls may include ‘flash’ tattooing, whereby the individual has entered a tattoo shop and chosen, for example, a bulldog, a heart and scroll, or a Harry Potter deathly hallows tattoo. As these are not designed specifically for that individual, and many others may have the same or a similar design, descriptions need to be very specific.
Another issue Mike mentioned was that overseas on military exercise there may be large groups of individuals who have the same design tattooed on their bodies as a bonding exercise, and even the placement of the tattoo may be the same.
Of course, many of the identification methods above are void if there is no deceased patient present. In this scenario, antemortem records and reference pieces (for example photographs of tattoos or of bespoke jewellery) are vital.
“Not” Anthropology
In this segment, the real takeaway was that context matters. Mike had received another call from a police officer from Buxton, advising that some teeth had been recovered – the main issue was identification of them as human or otherwise.
The police officer, it transpired, was not keen on the drive from Buxton to Chesterfield so photographs were taken and emailed over.
What was concerning from Mike’s perspective was that the bones appeared wet (i.e. fresh!) – on a second look, it appeared as though the police had been a little too thorough in their preparation of the bones prior to taking a photograph of them.
They had been washed and were resting on a sheet of kitchen paper. Once the rest of the material was at Chesterfield, Mike then ascertained that these were an assortment of individuals – usually cavers who have found themselves in a tight spot – one of many bones found across the Peaks.
Mike’s presentation and his way of storytelling was captivating. From his slides and anecdotes about Buxton (not only famous for its bottled water!), I can only imagine how many stories there are still to come out of his catchment area.
Across the board, there was a broad and appealing range of speakers and presentation content this year. This was my first AEE of (I feel) many.