While the majority of patients who attend Irish SATUs are referred by the gardaí, other sources of referral include hospitals (such as emergency departments or sexually transmitted infection clinics), GPs, and Rape Crisis Centres (RCCs). Patients may also directly self-refer to a SATU.
SATUs are located in Dublin, Galway, Cork, Letterkenny, Waterford and Mullingar. Most have a clinician available on-call, at all times.
Choice of assessment type
Upon referral to a SATU, patients are provided with a choice of three options:
- Forensic clinical examination at the SATU along with reporting to the gardaí, (this includes the collection of forensic samples and their immediate provision to An Garda Síochána, in keeping with chain of custody requirements; this is the most popular option),
- Health check at the SATU (the focus is upon ensuring that essential medical treatment is provided; no forensic samples are obtained and the gardaí are usually not involved),
- Forensic clinical examination at the SATU without immediate reporting to the gardaí, but including collection and safe storage of forensic samples for potential use at a later date (this option is only available to patients of 18 years of age or older, as mandatory reporting procedures apply to younger patients).
Special care is taken to ensure that patients are fully informed of the available options and that they are empowered to select that which is most appropriate.
Patients who present (for example, to a garda station) within seven days of an alleged incident, and who choose to have forensic samples taken, will normally be provided with an appointment to attend a SATU within three hours of reporting, so as to minimise time-related degradation of biological trace evidence.
Typical assessment
Upon arrival, a patient will be greeted by the examining clinician (doctor or nurse/midwife specialist), an assisting nurse, and a psychological support worker from a local RCC. The patient is first offered the opportunity to talk privately with the psychological support worker.
When the patient is ready, informed consent is obtained by the clinician. Care must be taken to ensure that the patient has the capacity to consent, with due consideration given to emotional distress, alcohol/drug use, and fatigue.
Each part of the forensic clinical examination is explained to the patient in a step-by-step fashion, so as to help the patient to understand what is involved and to afford them the opportunity to decline any aspect of the examination that they do not wish to undergo.
A patient-centred approach, where the patient is the central decision-maker, is recommended – and patients are especially advised that they can stop the assessment at any time.
The forensic clinical examination begins with the clinician taking a complete past medical history. This will include details of current and past health problems, medication use, allergies, previous surgeries, mental health problems, and physical/intellectual disabilities. For female patients, a gynaecological history is relevant. A sexual history (for example, last sexual activity, use of contraception, etc) is important for all patients. The patient’s lifestyle is explored (such as alcohol and drug use, smoking status, safety in the home environment, etc).
Comprehensive history taking is essential to the provision of quality medical care. In the context of an alleged crime, the background history can also be highly relevant to the accurate interpretation of clinical examination findings.
Brief account
The clinician then obtains a brief account of the reported incident from the patient. It is sometimes noted in subsequent court proceedings that the patient’s account of events, as documented by the SATU clinician, is at variance with the statement provided by the patient to An Garda Síochána. To a clinician, this is not at all surprising. The nature of the history taking performed by the SATU clinician is very different to the recording of a garda statement. The clinician seeks to establish what injuries might be present, what conditions might arise in the coming hours or days (for example, did the patient sustain a head injury during the assault that might merit an urgent brain scan?), what medications might be appropriate, and what blood tests might be required.
After the SATU assessment is complete, a garda may take a much more detailed statement, with emphasis upon recording every relevant detail that might contribute to establishing what happened, and who might have been involved. The variations in roles and objectives of the clinician and the garda may explain why inconsistencies arise.
Physical examination
Next, the patient, examining clinician, and assisting nurse move to a forensically clean examination room (a room that has been rigorously cleaned to minimise the presence of background DNA contamination). A head-to-toe physical examination is carried out so as to identify and record injuries to the body surface.
While very many patients will have no injury whatsoever, others could have, for example, injuries consistent with forced restraint (such as finger-tip bruising on the upper arms), attempted strangulation (for example, tiny pinpoint red bruises around the eyes and bright red bleeding within the white of the eye), bite marks, ligature marks, and/or bruising and abrasions consistent with being pressed against a hard surface.
A systems examination (checking blood pressure and pulse rate, feeling the abdomen, assessing level of consciousness, etc) is essential to the detection of less readily discernible injury present beneath the body surface (such as damage to the spleen after a blow to the abdomen).
The overriding emphasis is always on the health of the patient and the identification of injuries that require treatment. Where a serious health need arises, the provision of appropriate medical care supersedes the collection of evidence.
Forensic samples
If the patient has chosen to have forensic samples collected, the clinician takes skin swabs, mouth swabs, hair samples, nail clippings, etc, as deemed appropriate. The types of samples obtained vary from case to case, depending largely on the history of events provided by the patient. Samples are signed by the clinician and, if the gardaí are involved, they are immediately countersigned by a garda who must be present in the examination room at all times in order to observe appropriate chain-of-evidence procedures.
After the assessment, the garda transports the forensic samples to the national forensic science laboratory for analysis, and results are returned directly to the gardaí. Where patients have chosen to have forensic samples collected, but not to report to An Garda Síochána (option 3 above), the samples are stored securely by the SATU staff in a tamper-proof bag to ensure chain of evidence, and kept available for release to the gardaí should the patient decide to report at a later date.
If a patient has decided against forensic sampling and only wishes to have a ‘health check’ (option 2 above), then no forensic samples are obtained, and the entire focus of care is on identifying and addressing health needs.
Intimate examination
An intimate examination of the genital and anal areas is also carried out. That is performed in an especially sensitive manner, employing a patient-centred approach. Any anogenital injury is carefully documented.
Examination
In Ireland, the anogenital examination takes place without use of specialised magnification and video-recording equipment, which are used routinely in some other countries.
Forensic swabs and specimens of hair are taken from the anogenital area if the patient has chosen to have forensic samples collected. Very much has been written about the significance, and indeed the insignificance, of anogenital injuries.
They must be interpreted with caution and their relevance explained carefully to the patient, An Garda Síochána, the DPP, legal professionals, a jury, the judge, etc – always taking into consideration evidence-based knowledge and the unique circumstances of the individual case. Anogenital injury can arise from consensual sexual intercourse. Absence of anogenital injury does not necessarily mean that a particular sexual encounter did not occur, or that it was consensual.
Other health needs
Ensuring all health needs are appropriately managed represents the final stage of the assessment at SATU. This varies considerably from one patient to another, depending on individual requirements.
Care
Examples of the care that is typically provided include emergency contraception (usually in the form of a tablet), treatment to prevent sexually transmitted infection (usually in the form of antibiotic tablets, but on some occasions also requiring antiviral tablets to prevent HIV infection and/or an intravenous drip to prevent Hepatitis B infection), and vaccination against sexually transmitted infection (for example, an injected vaccine against Hepatitis B).
Some patients with soiled wounds may need a tetanus vaccination.
Other important aftercare issues include an assessment of suicide risk, onward referral for any unmet health needs identified during the assessment, follow-up psychological support, and mental health service referral where necessary.
Most patients will also require follow-up sexually transmitted infection screening tests (such as swabs from the mouth and anogenital areas, blood tests, and urine samples) over the course of the weeks and months after the initial incident and assessment. Patients are provided with the option of returning to the SATU for follow-up testing, but some choose not to attend or to attend elsewhere, such as at their own GP or at a hospital clinic.
Medico-legal report
The clinician prepares a medico-legal report, either immediately after the assessment or at a later date based upon contemporaneous records. Clinicians vary in their approach to report writing, but many follow a suggested template provided in the national guideline document (see ‘Look it up’). If the patient has chosen to involve An Garda Síochána, the report is routinely issued directly to the investigating garda. The Department of Justice pays an agreed fee for the report.
The report details the entire assessment, provides a list of forensic samples obtained and to whom they have been provided, and includes physical-examination findings and an interpretation of their significance in the context of the reported allegation.
Where the patient has decided not to involve the gardaí, no medico-legal report is issued; however, it can be issued at any time should the patient so choose.
Occasionally, SATUs receive requests for medico-legal reports in relation to civil proceedings. These are provided only after the patient provides informed consent. When obtaining consent, it is important to ensure that the patient understands the sensitive nature of the contents, and extent to which they may be shared with other parties (such as the defendant’s legal team, the defendant’s medical expert, the defendant, the judge, the open court, etc).
SATU clinicians attend court to present evidence and to be challenged upon that evidence. In addition to cross-examination, clinicians may encounter opposing opinion evidence from expert medical witnesses occasionally instructed by defence teams.
Clinical examination of suspects
The Irish healthcare and forensic response to adult patients who report sexual violence compares well with international practice. However, there is a very significant deficit, compared with international practice, in the forensic clinical examination of sexual crime suspects.
Ireland does not have a national guideline for the examination of suspects in cases of sexual crime.
There is also no standardised training requirement for healthcare professionals who undertake such work with suspects. The failure to competently examine a suspect, in line with international best practice, has been known to collapse criminal cases.