Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Assaults from corrosive substances and medico legal considerations in a large regional burn centre in the United Kingdom: calls for increased vigilanc ...

Assaults from corrosive substances and medico legal considerations in a large regional burn... Burn injuries from corrosive substances have been recognised as a common method of assault in low and middle income countries (LMICs) motivated by various factors. Such injuries often leave survivors with severely debilitating physical and psychological injuries and scars. The number of reported cases of acid assaults within the United Kingdom (UK) appears to be on the rise. As one of the largest regional burn centres in the UK, we have reviewed our experience of chemical burns from assault. This study aims to: (1) e s review the demographics, incidence and patient outcomes; (2) evaluate the long-term psychosocial support provided; and (3) review current criminal litigation proceedings and preventative legislations in the UK specific to assault by corrosive substances. A 15-year retrospective review of 21 burn injuries from assault with e e e corrosive substances presenting to a regional burn unit was conducted. Victims were mostly young men; male perpetrators were more common. The most common motive cited was assault. The most common anatomical region affected was the face and neck. The number of victims who pursue litigation is disproportionately e e e lower than the number of total cases at presentation. In an effort to better understand the legal considerations s s s surrounding such assaults, we also collaborated with lawyers experienced in this particular field. We hope that our work will help educate healthcare professionals regarding the legal assistance and existing laws available to protect these patients. Keywords Assault burns, corrosive substances, legal, legislation, prevention, acid attack, scar St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK St. Andrews Anglia Ruskin Plastic Surgery and Burns Research Unit, Postgraduate Medical Institute, Chelmsford, UK Blavo & Co. Solicitors Ltd., Uxbridge, UK Corresponding author: Alethea Tan, St. Andrew’s Plastics and Burns Unit, Broomfield Hospital, Room 1, 9 Hazel House, Woodlands Way, Swan Housing, Chelmsford, CM1 7TH, UK. Email: alethea.tan@doctors.org.uk Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Scars, Burns & Healing Lay summary Burn injuries from corrosive substances can have fatal complications and leave survivors with severely debilitating physical injuries and psychological scars. The incidence of acid assaults appears to have increased in the UK and gained much publicity through widespread news coverage. This prompted us to look at our experience in managing patients who were victims of assault using corrosive substances. Over a 15-year period, we treated 21 people who sustained burn injuries as a result of an assault involving corrosive substances. Five people required hospital admission for the extent of their injuries and required significant burn reconstructive procedures. Interestingly, only nine out of 21 cases initiated a criminal investigation. Only two of the nine cases that initiated criminal investigations proceeded to indictment. In an effort to better understand legal considerations surrounding such assaults, we collaborated with lawyers experienced in this particular field and lay out for the first time the UK landscape of litigation in this complex area. We hope that our work will help educate healthcare professionals of the legal assistance and existing laws present to protect these vulnerable patients. Introduction 5 4 Acid burns have been well recognised as a vicious dissatisfaction over the marriage dowry. In Iran, act of assault among low and middle income political motivation has driven assaults with hom- countries (LMIC) including India, Iran, Jamaica, icidal intent towards government officials. Male 1–4 Bangladesh and Uganda. The profile of vic- victims are more common in Jamaica, with mari- tims varies accordingly to their cultural back- tal dispute and jealousy cited to be a driving fac- ground. For instance, victims in South Asia are tor for these crimes of passion. The use of commonly young women who have rejected a corrosive substances to inflict injury can also be suitor or young wives who have been punished by entirely motivated by random criminal acts such their husbands or in-laws as a result of as robberies. Excerpt 1 – Acid attack in Europe: A walk through history In ancient times, vitriol (containing sulphuric acid) was used to purify gold and fabricate imitation precious metals. It was introduced to Europe in the 16th century and not long after that, one of the first recorded acid assaults occurred in France. Its incidence continued to rise, what was described as ‘a wave of vitriolage’ occurred particularly in France. The term ‘La Vitrioleuse’ was coined gaining popular press coverage as ‘crimes of passion’, perpetrated mostly by women against other women, and fuelled by ‘jealousy, vengeance… and provoked by betrayal or disappointment’. Les Vitrioleuses intended to disfigure their disloyal mate or female rival. During the late 19th century, the image of Vitrioleuses was popularised by Art Nouveau artists. ‘La Vitrioleuse’ by Fernand Pelez is still considered an Art Nouveau masterpiece today. The first reported case of acid attack in Europe In 1990, Beare et al. reported ophthalmic injuries was thought to occur as early as the 16th century in 64 patients admitted to The Western Ophthalmic 6,7 12 (see excerpt 1). On the whole, burn injuries sus- Hospital in London as a result of chemical tained from assault with corrosive substances are assaults inflicted by gangs of male youths from relatively uncommon in western societies. lower socioeconomic backgrounds. Literature describing the incidences of chemical Regardless of the variation in patient demo- burns from assaults in the western world is lim- graphics globally, the physical and psychological ited. Acid was not the only agent used. In the morbidity of such assaults can be devastating United States, household lye (sodium hydroxide) (Figure 1). Patients can be left visibly disfigured, was noted to be a common agent preferred by per- some requiring multiple reconstructive proce- 9–11 petrators. Patient demographics also differ dures to recreate key facial features. Although with male victims predominating, and assailants there is legislation against such assaults, the pro- were more often women. Domestic disputes are portion of victims who fully pursue criminal often the motivating factor behind these assaults. charges against their perpetrator is low. We noted Tan et al. 3 gender and relationship of assailant, location of Fatal outcomes the assault, involvement of psychological support, •• Homicide involvement of police, documentation of likely •• Suicide criminal proceedings and number of successful •• Maternal mortality prosecution. We collaborated with a London-based law firm who has had experience dealing with vic- Non-fatal outcomes tims of acid assaults for their perspective on legal •• Physical health • (functional impairment, permanent proceedings and the UK legislation. disability, poor subjective health) •• Mental health • (Post-traumatic stress, depression, Results anxiety, low self-esteem, sexual dysfunction, eating disorders, substance abuse) Our initial search revealed 26 patients coded as •• Negative health behaviours • (under-eating, physical assault-related burns. Five patients were excluded inactivity) from this search following detailed review of the •• Chronic conditions • ( chronic pain syndromes, presenting history showing that these were actu- somatic complaints) ally accidental injuries. We included the remain- •• Reproductive health • (pregnancy complications, ing 21 patients for analysis of the following areas: unwanted pregnancy) •• Patient demographics Figure 1. Health Outcomes of acid attack violence. •• Burn demographics •• Extent of injury, management strategies and length of inpatient stay this recurrent theme during our literature 14 •• Psychological support provided search which led us to review our numbers of •• Circumstances of assault assault victims suffering chemical burns treated in a regional burn centre, with the intention of understanding: (1) current epidemiology; (2) Patient demographics some indictors of patient outcomes; and (3) leg- The male:female ratio was 15:6. The age range was islation and processes within the UK law available 16–56 years (mean age, 28.5 years). The propor- to assist such victims. We collaborated with an tion of victims aged 25 years or younger was almost independent law firm that has had experience in twice that in the above 25-year age group. Victims dealing with acid assaults within the UK. No arti- came from various cultural backgrounds such as cles specific to the UK have previously focused on Caucasian (n = 16), African (n = 3), Oriental an understanding of legal proceedings for vic- (n = 1) and South Asian subcontinent (n = 1). tims wishing to pursue criminal prosecution of Ten patients (48%) were unemployed, nine (43%) the assailant in this patient group. were in employment at the time of the event and two (9%) were students. Four patients had prior Methodology history of trauma sustained from another assault. One patient had a history of previous domestic From our available database spanning 1 January dispute resulting in trauma during the altercation. 2000 up to and including 31 December 2014 (15 Only one patient was known to social services years), approximately 680 total chemical burn prior to the assault. Current trends of assault injuries have been recorded during that period involve more female victims than male victims which included both accidental injuries and inten- compared to a decade ago (Figure 2). tional burns. A retrospective review of all patients coded as sustaining assault related to burn injuries from chemical or corrosive substances on our data- Circumstances of assault base was carried out from that 15 year database. A list of 26 patients was generated. The inclusion cri- A total of 76% (n = 16) cases occurred on the teria was all patients who were assaulted with chem- streets, although assaults were also noted to occur ical or corrosive substances during that period. at home (14%, n = 3), hostel (5%, n = 1) and The study was registered with our clinical govern- pub (5%, n = 1). Concurrent substance abuse ance department (CA14-135) as an audit and a ser- such as combination of alcohol and/or recrea- vice evaluation. We obtained medical case-notes, tional drugs by the victims at time of assault was from which information was collected on patient reported in six cases. Seven (33%) of the assail- epidemiology, burn details, substances used, ants who carried out the attacks were known to 4 Scars, Burns & Healing Male and Female proportions Anatomical Involvement M F Lower Limb 10% Face Trunk 37% 69 6 14% 2000-2004 2005-20092010-2014 Upper Limb Figure 2. Trends of total cases noted every 5 years, with the 23% number of male and female victims described. Neck their victims prior to the incident. Eight assail- 16% ants were documented to be men, one woman and four unknown as they had their faces cov- Figure 3. Chart demonstrating anatomical involvement. ered, and in eight cases there was no documenta- tion at all. In 16 cases, there was clear documentation of the patient account indicating Eye Involvement a motive for the assault and five cases were ran- dom or unprovoked. Police involvement at presentation was docu- mented in 15 cases (17%). Five cases (24%) self- presented and there was no initial or subsequent police involvement. In one case, it was unclear whether police were involved. Criminal investiga- tion was only initiated in nine cases (43%). Of these, only two cases have successful criminal 43% prosecution thus far. With regard to the Criminal Injuries Compensation Act, only two victims pro- ceeded to make claims. 57% Burn demographics The total burn surface area affected was in the range of 0.3–16% with a median of 1% TBSA. The burn depth was either full thickness or mixed depth type. Acid was the most commonly Figure 4. Chart showing ophthalmic involvement. documented substance used (n = 10), followed by alkali (n = 4), bleach (n = 3), unknown (n = 2) all of whom received ophthalmology review and other (n = 2). In all 21 cases, first aid was acutely (Figure 4). given although there was a delay in four patients. Sixteen patients presented immediately to their nearest accident and emergency department Extent of injury, management strategies while in the other five cases, there was a delay and length of inpatient stay (median, 1 day). Burn injuries sustained during the assault often affected more than a single Five patients were admitted to hospital as a result region of the body, with the face being the com- of their injuries at initial presentation. Their monest area to be affected (18/21), followed by length of stay in hospital was in the range of 0–41 the upper limbs (11/21), neck (8/21), trunk days with an average of 6.3 days (median, 1 day). (7/21) and lower limbs (5/21). Many patients One patient also sustained upper limb fractures had involvement of multiple anatomical sites during the assault. Sixteen patients (76%) were (Figure 3). Nine patients had eye involvement, solely managed non-operatively with dressings Tan et al. 5 and outpatient visits. Five patients (24%) also been used as forms of violence during rob- required surgical debridement at presentation beries, political protestations and, in rare cases, and wound coverage with autografts and skin of assassination plots. Our series showed a substitutes such as Matriderm®. higher proportion of young male victims and One patient developed burn wound infec- male perpetrators, contrary to that seen in tion and graft loss, necessitating further surgery. LMICs. In Taiwan, victims were mainly women, Two patients suffered cartilage loss of an ear as a with a higher proportion of male perpetrators. result of the burn injury. These patients required Marital and financial problems were cited as the late repeated burn reconstructive procedures as most common motive. In the United States, vic- a result. Of the nine patients who had eye involve- tims were generally men and perpetrators were 8,14 ment, only one subsequently developed partial women although motive(s) were unclear. loss of sight as a result. These findings suggest the demographics of burns from assault using corrosive substances vary geographically and points to complex under- Psychological treatment lying social and cultural factors relating to both perpetrators and victims. Eight of the 21 patients received clinical psychol- Any corrosive substance can be used as a ogist review and follow-up. All patients admitted weapon in an assault. Acid is commonly used, to our burns unit are offered psychosocial sup- with sulphuric acid quoted to be a common port. Patients whose burn injuries were managed agent. In LMICs, sulphuric acid is easily obtaina- at outpatient clinic visits are always referred on to ble from most car garages at an affordable price clinical psychology when required or upon to the public. Lye, caustic soda and caustic pot- patient request. All inpatients were seen by the ash have also been described in the literature as clinical psychologist. Four of the 16 outpatients potential substances used in assault. An accu- received clinical psychologist input. One possible rate description of the substance used is often explanation for the discrepancy between the difficult to ascertain unless there are characteris- total number of cases and the numbers actually tic features to the burn injury indicative of the receiving psychosocial support is patients refus- acid type such as nitric acid (which forms yellow ing to be referred on, but the reasons were not stains and produces a garlic odour). Our review clear. In cases where victims self-presented unac- showed that identification of the exact substance companied by the police, they declined review by used by perpetrators was difficult and the descrip- a clinical psychologist. tion ‘colourless liquid’ was used. It is therefore important that initial evaluation of the burn Discussion wound includes pH measurement, which itself can be challenging particularly in cases where Approximately 1500 acid assaults are reported presentation is delayed. In our study, we also worldwide annually. Burn injuries from acid found that bleach was frequently used, and attacks have been well described in LMICs. household bleach is both cheap and easily Bangladesh has the highest worldwide incidence accessible. of acid violence and acid burns, constituting 9% Despite the vast variation in motives and epi- of its total burn injuries. In Pakistan, around demiology of acid assaults, there are recurrent 400 acid attacks on women occur annually themes of concern outlined in the existing litera- although this figure may represent an overesti- ture. Acid attacks are malicious attacks with the mation from non-formal data collection tech- intent to cause devastating bodily mutilation and nique. Sri Lanka, India, Cambodia and Uganda functional impairment. The resulting disfigure- have also reported cases of acid assaults although ment can be a constant taunt to the survivors its true incidence is difficult to ascertain. This is mentally, physically and emotionally. Often, the largely due to problematic reporting mecha- long-term psychosocial effects are so severe that nisms and under-reporting by victims. they can impede the progress of social reintegra- The epidemiology of acid violence varies geo- tion following the burn injury. As a result, many graphically. Examples from the published litera- victims lead a life as a recluse. Although loca- ture show that in Bangladesh, victims are often tion is not a key factor in social reintegration, we young women who have rejected a potential found that these injuries most commonly suitor or new brides punished by their husbands 2 18 involved visible and public facing parts of the and in-laws over dowry disputes. In Cambodia, body such as the face, neck and hands. Our find- the majority of victims are young mistresses ings mirrored that reported by Faga et al. attacked by their lovers’ wives. Acid burns have 6 Scars, Burns & Healing Psychological morbidity of burns survivors assist as much as they can. The above-mentioned 22,23 have been extensively studied. Mannan et al. charities can provide advice and direction for showed that burn injury and the event itself (the individuals seeking legal support beyond the ini- assault), are both important contributors to psy- tial phase of hospital care. chosocial outcomes. The study also noted lower self-esteem in women who have suffered acid Classification of assaults and expected attacks. Anatomical location of the assault, rela- sequence of litigation events tionship to the assailant and consequent func- tional limitations have been shown to be There is no single law firm dedicated solely to acid predictors of distress. Psychosocial support is assaults prosecutions. We collaborated with a legal important as part of burn rehabilitation. firm that has previously dealt with acid assaults. Worldwide, charitable foundations exist to offer These assaults fall into two categories: domestic vio- a vital source of support to these victims beyond lence or criminal assault. The ability to deal with their initial injury. In the UK, The Katie Piper domestic violence law or criminal law by any law Foundation (London), Acid Survivor Trust firm dictates its ability to manage acid assault cases. International (ASTI) and Domestic Violence The most common setting for chemical attacks UK are among charities available to provide to take place is within domestically violent relation- support beyond initial injury. Beyond the UK, ships. If the crime is committed within a domestic government organisations (GOs) and non-gov- relationship, the survivor could be introduced to ernment organisations (NGOs) exists worldwide domestic violence organisations and thereafter to support victims of acid violence (Table 1). potentially to family law solicitors. Threats of vio- In 2001, the National Burn Care Review lence originate from the perpetrators who, in order Committee (NBCRC) had acknowledged that to affirm their control, threaten to throw acid on psychosocial rehabilitation, which is an integral their partners. A Non-Molestation Order and part in burn care, had been seriously neglected in Occupation Orders from the family courts could the UK. Following their report, recommenda- potentially be sought in such circumstances. tions have been put forward including the need If the act is carried out and acid is thrown at for a named coordinator for psychosocial reha- a victim, then this attack is dealt with as a crimi- bilitation who is responsible for managing these nal offence, which is most likely to be considered aspects of care for the burn patient. Since then, under one of the following two offences: improvements have been built upon this princi- ple, including the set-up of psychological care ser- (1) Grievous Bodily Harm (GBH): This offence vices in various burn units across the nation. is committed when a person unlawfully In our review, nine cases out of a total of 21 and maliciously, with intent to do some resulted in the initiation of a criminal investiga- grievous bodily harm, or with intent to tion. The number of cases that actually proceed to resist or prevent the lawful apprehension court cases was difficult to ascertain accurately. We or detainer of any other person, either: have identified two successful prosecutions that wounds another person; or causes griev- have gained publicity through news coverage. ous bodily harm to another person. One possible explanation for this disparity is the (2) Attempted Murder: This offence is com- unwillingness of patients to pursue the case or mitted when a person does an act that is press charges. Several studies have previously more than merely preparatory to the 3,38,39 reported similar findings. Victims who are commission of an offence of murder, experiencing the emotional and mental trauma and at the time the person has the inten- following an assault may feel unsafe and vulnera- tion to kill. ble, fearing that pressing charges may provoke fur- ther attacks. Lack of knowledge on how to instigate If the offence committed is GBH, then this will legal proceedings may also account for the low be dealt with in a Crown Court and can result in proportion of victims pursuing court action. This a maximum sentence of life imprisonment. is especially important for victims where perpetra- Criminal sentences of more than 10 years for this tors are still ‘out there’. offence are rare. However, if acid is used in a fur- ther manner, for example, poured down the vic- tim’s throat, this is deemed to be an attempted Acid attacks and the law murder. The sentencing for this varies depend- ing on the nature of the offence and the extent Within the UK, the police or hospital are usually of damage caused. There is arguably no need for the first point of contact and would be able to Tan et al. 7 Table 1. International organisations supporting victims of acid violence. Organisation Role Cambodian League for the Promotion • PAT programme provides financial, counseling, medical, and legal and and Defense of Human Rights (LICADHO); advocacy assistance Cambodia • Reporting of incidences Children’s Surgical Centre (CSC); USA-based • Burn treatment assistance and rehabilitation NGO Cambodian Acid Survivors Charity (CSAC); • Surgical, medical and psychological treatment Cambodia • Vocational training and social reintegration • Legal assistance and advocacy for legal reform • Awareness through research, education and advocacy Campaign and Struggle Against Acid Attacks on • Assists survivors with access to legal, medical and social services Women (CSAAAW); India • Works to prevent further attacks Acid Survivors Foundation; Bangladesh • Assistance with treatment, rehabilitation, legal and advocacy for legal reform, increase awareness through research advocacy and prevention measures Naripokkho, Bangladesh • Works to advance situation of women, to struggle against violence and inequity, lobby for women’s rights • Brought media attention and initiated campaign against acid violence in mid 1990s Acid Survivors Foundation Pakistan ASFP; • Stop acid and burn violence and prevent the proliferation of attacks Pakistan • Ensure survivors receive the best available medical treatment in the long run • Ensure survivors get justice, exercise their fundamental rights in accordance with the Pakistani constitution and international conventions • Enable survivors to end up as proactive, democratic, empowered and autonomous citizens Human Rights Commission of Pakistan (HRCP); • Collects statistics from newspaper reports pertaining to acid attacks Pakistan Human Rights Watch (HRW); International • Investigate and report on human rights violations on global scale Ansar Burney Trust; Pakistan • Medical treatment aid and legal support [35] Acid Survivors Foundation; Uganda • Funds medical care • Trains and educates community • Police and other agencies • Provides counselling and advocacy any legislative change in the UK unlike other Applying for Legal Aid and instigating countries as the sentencing powers reflect the court proceedings severity of the crime. In 2004 Greenbaum et  al. suggested that Entitlement to Legal Aid has recently changed the incidence of acid violence has remained due to the Legal Aid, Sentencing and Punishment steady. However, from 2006 onwards, the number of Offenders Act (2012). Up-to-date information of reported admission from acid assaults is given on the following website: http://www.jus- tice.gov.uk/private-family-matters-legal-aid/vic- has gradually risen according to NHS data 44 46 The discrepancy could be attributed tims-domestic-violence. If victims wish to apply (Table 2). to better reporting systems for acid assault cases for Legal Aid to cover the costs of seeking protec- and increased reporting in the media. tion from domestic abuse (e.g. a Non-Molestation 8 Scars, Burns & Healing Table 2. Assaults by a corrosive substance as reported by the violence should always be included. This is a NHS Information Centre. short hearing without compulsory notice to the Respondent. In almost all cases it is necessary to Year Admissions get a return hearing date as soon as possible (usu- ally within 1–2 weeks). Sometimes this is neces- 2006–2007 44 sary because there is a fear that as soon as the 2007–2008 67 Respondent learns about the application, they may cause more harm. The judge then makes a 2008–2009 69 decision (after hearing from the Respondent at 2009–2010 98 this hearing) as to whether the order will con- tinue and the duration of the order. The court 2010–2011 110 rarely makes an Occupation Order at this stage, as this issue is more complex and a further sub- stantive hearing will be needed, with notice to Order, Occupation Order or Forced Marriage the Respondent. Protection Order) then victims will qualify for Even with an order in place, one should not Legal Aid subject to a means test. assume that the victim is completely protected. Individuals who are threatened with or Threats of acid violence are very serious. While a become victims of acid violence can try and court order can be a deterrent, it may not always obtain protection from their abuser by applying stop the respondent/perpetrator from carrying for a civil injunction or protection order. An out the acts. injunction is a court order that requires someone to do or not do something. In order to apply for an order, the applicant must be an ‘associated Collaborative efforts and working person’ otherwise the matter would not fall framework under family law. An integrated public health response with strong If the applicant does not fall within the defi- formalised partnership between survivors, GOs nition of an associated person under the Family and NGOs, health authorities and law enforce- Law Act but is being continually harassed, threat- ment can lead to better collaboration and coor- ened, pestered or stalked after a relationship has dination of efforts to end acid violence. ended, they may have grounds to apply for a civil Governments should also maintain a zero-toler- injunction under the Protection from Harassment ance policy in order to eliminate acid violence. Act 1997. In this way they will still be able to Close collaboration with forensic criminologist, receive protection from the courts. psychologist and perpetrators may help develop A Non-Molestation Order is aimed at pre- a better understanding of motivations and ana- venting the abuser from threatening violence lyse root causes of such assaults. Beyond local against, intimidating, harassing or pestering the organisations, such collaborations should ven- victim in order to ensure their safety and wellbe- ture out to include international and regional ing. An Occupation Order regulates who can live working groups that offer a platform for infor- in the family home and can restrict the abuser mation sharing and raising awareness in prevent- from entering the surrounding area (e.g. 100 ing acid attack violence. m). A breach of a Non-Molestation Order is a criminal offence and is punishable with up to 5 years’ imprisonment. Breach of an order can Education and prevention result in contempt of court and can be dealt with in the family courts. The perpetrator or respond- Prevention remains key to reducing the inci- ent who continually harasses the victim can be dence of burn injuries. Publicised education imprisoned for a period of 2 years following com- campaigns have increased awareness and appear mittal in the family courts. to have reduced the number of attacks in The application is made on Form FL401: LMICs. Some have feared that publicity can Application Form for Non Molestation Order lead to an increase in such attacks, but there is no and Occupation Order, supported by a sworn evidence to support this view at this time. statement. This statement will set out the facts Healthcare professionals would benefit from and the reasons for making the application and education and information on the available psy- why the victim protection of the court. The most chosocial and legal support for such assault vic- recent and most traumatic incidents of domestic tims. As the first point of contact in a protected Tan et al. 9 3. Asaria J, Kobusingye OC, Khingi BA, et  al. Acid burns from environment such as in hospital, this may be the personal assault in Uganda. Burns 2004; 30(1): 78–81. only opportunity to provide these patients with a 4. Maghsoudi H and Gabraely N. Epidemiology and outcome of setting in which they may feel ‘safe’ enough to 121 cases of chemical burn in East Azarbaijan province, Iran. accept help. There are dedicated charitable Injury 2008; 39(9): 1042–1046. foundations to acid assault survivors within the 5. Mannan A, Ghani S, Clarke A, et  al. Psychosocial outcomes derived from an acid burned population in Bangladesh, and UK such the KPF and ASTI. Together, these char- comparison with Western norms. Burns 2006; 32(2): 235–241. ities offer information on burn scar rehabilita- 6. Shapiro A-L. Breaking the Codes: Female Criminality in Fin- tion, support access to quality medical care, assist De-Siecle Paris. Stanford, CA: Stanford University Press, 1996. with survivors’ psychological and social rehabili- 7. Harris R. Murders and Madness: Medicine, Law and Society in the tation, and advocacy work to prevent further Fin-De-Siecle. Oxford: Oxford University Press, 1989. 15,24 8. Purdue GF and Hunt JL. Adult assault as a mechanism of burn attacks. injury. Arch Surg 1990; 125(2): 268–269. Regarding prevention laws, more stringent 9. Brodzka W, Thornhill HL and Howard S. Burns: causes and legislation on the purchase of corrosive sub- risk factors. Arch Phys Med Rehabil 1985; 66(11): 746–752. stances is needed. Currently in the UK, corrosive 10. Milton R, Mathieu L, Hall AH, et al. Chemical assault and skin/ substances such as heavy-duty drain cleaners are eye burns: two representative cases, report from the Acid Survivors Foundation, and literature review. Burns 2010; 36(6): 924–932. easily obtainable by the general public from large 11. Wolfort FG, DeMeester T, Knorr N, et al. Surgical management DIY superstores. While it is impossible to stop the of cutaneous lye burns. Surg Gynecol Obstet 1970; 131(5): 873–876. public purchasing such agents freely over the 12. Beare JD. Eye injuries from assault with chemicals. Br J counter, a legal requirement for sellers to record Ophthalmol 1990; 74(9): 514–518. details of every purchase should be implemented. 13. Heise L, Ellsberg M and Goetemoeller M. Ending violence against women. Population Reports. Baltimore, MD: Johns Such a step may assist criminal investigations. We Hopkins University School of Public Health, Population appreciate this may not completely restrict other Information Program, 1999. means of obtaining corrosive substances by other 14. Krob MJ, Johnson A and Jordan MH. Burned-and-battered means, such as that from car batteries. adults. J Burn Care Rehabil 1986; 7(6): 529–531. Nonetheless, this will reduce the number of avail- 15. Acid Survivor Trust International. http://www.acidviolence. org/index.php/how-we-help/specialist-teams. able sources for the potential assailant. 16. Acid Survivors Foundation. 6th Annual Report. Dhaka: ASF, 2004. 17. Human Rights Commission of Pakistan (HRCP). http://hrcp- web.org/hrcpweb/campaigns/. Conclusion 18. Ly H, Sarom N, Gollogly, et al. 88 Burns operated at the ROSE rehabilitation Centre, Phnom Penh. Paper read at the 7th Burn injury by assault with corrosive substances is annual Cambodian Surgical Congress, November 2001. a malicious criminal act intended to cause griev- 19. Yeong E, Chen MT, Mann R, et al. Facial mutilation after an ous bodily harm with potentially devastating assault with chemicals: 15 cases and literature review. J Burn long-term morbidity to the victim. As healthcare Care Rehabil 1997; 18(3): 234–237. professionals, we have a professional and ethical 20. Harchelroad F and Rottinghaus D. Chemical Burns in Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: obligation to provide the best standard of care to McGraw-Hill, 2004. our patients. For victims of assaults, this includes 21. Faga A, Scevola D, Mezzetti MG, et al. Sulphuric acid burned offering prompt access to existing legal, psycho- women in Bangladesh: a social and medical problem. Burns social and external agency support. To prevent 2000; 26(8): 701–709. these injuries, we recommend stricter legislation 22. Blalock SJ, Bunker BJ and DeVellis RF. Psychological distress among survivors of burn injury: the role of outcome expecta- on purchase of corrosive substances, which is tions and perceptions of importance. J Burn Care Rehabil 1994; likely to have a significant impact on reducing 15(5): 421–427. future rates of these attacks. 23. Williams EE and Griffiths TA. Psychological consequences of burn injury. Burns 1991; 17(6): 478–480. 24. Katie Piper Foundation. http://www.katiepiperfoundation.org.uk. Declaration of conflicting interests 25. Domestic Violence UK. http://domesticviolenceuk.org. The authors declare that there is no conflict of interest. 26. Lim J-A. Violence Against Women in Cambodia. Phnom Penh: LICADHO, 2006. 27. Children’s Surgical Centre (CSC). http://www.csc.org. Funding 28. Cambodian Acid Survivors Charity. Helping survivors heal and This research received no specific grant from any funding working to prevent future acid attacks. http://cambodianacid- agency in the public, commercial, or not-for-profit sectors. survivorscharity.org. 29. Campaign and Struggle Against Acid Attacks on Women (CSAAAW) Vs. Department of Women and Child Welfare. References 30. Acid Survivors Foundation. http://www.acidsurvivors.org. 1. Branday J, Arscott GD, Smoot EC, et  al. Chemical burns as 31. Naripokkho. http://www.copasah.net/naripokkho.html. assault injuries in Jamaica. Burns 1996; 22(2): 154–155. 32. Acid Survivors Foundation Pakistan. http://acidsurvivorspaki- 2. Das KK, Khondokar MS, Quamruzzaman M, et al. Assault by stan.org/about. burning in Dhaka, Bangladesh. Burns 2013; 39(1): 177–183. 33. Human Rights Watch (HRW). http://www.hrw.org. 10 Scars, Burns & Healing 34. Ansar Burney Trust. http://ansarburney.org. 41. Section 18 of the Offences Against Person Act 1861. 35. Acid Survivor Foundation Uganda. asfuganda.org. 42. Section 4(1) of the Criminal Attempts Act 1981 36. National Burn Care Review 2001: Standards and Strategy for 43. Legal Aid. http://legislation.gov.uk/ukpga/Vict/24–25/100. Burn Care. http://www.britishburnassociation.org/down- 44. Assaults by a corrosive substance as reported by the NHS loads/NBCR2001.pdf (2001, accessed 6 April 2015). Information Centre. http://www.dawsoncornwell.com/en/ 37. Mary Konye guilty of acid attack on friend Naomi Oni. http:// documents/Acid_Violence.pdf page 8 (2015) www.bbc.co.uk/news/uk-25867695 (2014). 45. Legal Aid, Sentencing and Punishment of Offenders Act 38. Mannan A, Ghani S, Clarke A, et al. Cases of chemical assault 2012. worldwide: a literature review. Burns 2007; 33(2): 149–154. 46. GOV.UK. Legal Aid. http://www.justice.gov.uk/private-family- 39. Greenbaum AR, Donne J, Wilson D, et  al. Intentional burn matters-legal-aid/victims-domestic-violence. injury: an evidence-based, clinical and forensic review. Burns 47. Acid Survivors Foundation. Research Advocacy and Prevention. 2004; 30(7): 628–642. http://www.acidsur vivors.org/Research-Advocacy-and- 40. Blava & Co. Solicitors. http://www.legalblavo.co.uk. Prevention (2015). http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Scars, burns & healing Pubmed Central

Assaults from corrosive substances and medico legal considerations in a large regional burn centre in the United Kingdom: calls for increased vigilanc ...

Scars, burns & healing , Volume 1 – Nov 18, 2015

Loading next page...
 
/lp/pubmed-central/assaults-from-corrosive-substances-and-medico-legal-considerations-in-0ajz0YH1s6

References (41)

Publisher
Pubmed Central
Copyright
© The Author 2015
ISSN
2059-5131
eISSN
2059-5131
DOI
10.1177/2059513115612945
Publisher site
See Article on Publisher Site

Abstract

Burn injuries from corrosive substances have been recognised as a common method of assault in low and middle income countries (LMICs) motivated by various factors. Such injuries often leave survivors with severely debilitating physical and psychological injuries and scars. The number of reported cases of acid assaults within the United Kingdom (UK) appears to be on the rise. As one of the largest regional burn centres in the UK, we have reviewed our experience of chemical burns from assault. This study aims to: (1) e s review the demographics, incidence and patient outcomes; (2) evaluate the long-term psychosocial support provided; and (3) review current criminal litigation proceedings and preventative legislations in the UK specific to assault by corrosive substances. A 15-year retrospective review of 21 burn injuries from assault with e e e corrosive substances presenting to a regional burn unit was conducted. Victims were mostly young men; male perpetrators were more common. The most common motive cited was assault. The most common anatomical region affected was the face and neck. The number of victims who pursue litigation is disproportionately e e e lower than the number of total cases at presentation. In an effort to better understand the legal considerations s s s surrounding such assaults, we also collaborated with lawyers experienced in this particular field. We hope that our work will help educate healthcare professionals regarding the legal assistance and existing laws available to protect these patients. Keywords Assault burns, corrosive substances, legal, legislation, prevention, acid attack, scar St. Andrew’s Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK St. Andrews Anglia Ruskin Plastic Surgery and Burns Research Unit, Postgraduate Medical Institute, Chelmsford, UK Blavo & Co. Solicitors Ltd., Uxbridge, UK Corresponding author: Alethea Tan, St. Andrew’s Plastics and Burns Unit, Broomfield Hospital, Room 1, 9 Hazel House, Woodlands Way, Swan Housing, Chelmsford, CM1 7TH, UK. Email: alethea.tan@doctors.org.uk Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Scars, Burns & Healing Lay summary Burn injuries from corrosive substances can have fatal complications and leave survivors with severely debilitating physical injuries and psychological scars. The incidence of acid assaults appears to have increased in the UK and gained much publicity through widespread news coverage. This prompted us to look at our experience in managing patients who were victims of assault using corrosive substances. Over a 15-year period, we treated 21 people who sustained burn injuries as a result of an assault involving corrosive substances. Five people required hospital admission for the extent of their injuries and required significant burn reconstructive procedures. Interestingly, only nine out of 21 cases initiated a criminal investigation. Only two of the nine cases that initiated criminal investigations proceeded to indictment. In an effort to better understand legal considerations surrounding such assaults, we collaborated with lawyers experienced in this particular field and lay out for the first time the UK landscape of litigation in this complex area. We hope that our work will help educate healthcare professionals of the legal assistance and existing laws present to protect these vulnerable patients. Introduction 5 4 Acid burns have been well recognised as a vicious dissatisfaction over the marriage dowry. In Iran, act of assault among low and middle income political motivation has driven assaults with hom- countries (LMIC) including India, Iran, Jamaica, icidal intent towards government officials. Male 1–4 Bangladesh and Uganda. The profile of vic- victims are more common in Jamaica, with mari- tims varies accordingly to their cultural back- tal dispute and jealousy cited to be a driving fac- ground. For instance, victims in South Asia are tor for these crimes of passion. The use of commonly young women who have rejected a corrosive substances to inflict injury can also be suitor or young wives who have been punished by entirely motivated by random criminal acts such their husbands or in-laws as a result of as robberies. Excerpt 1 – Acid attack in Europe: A walk through history In ancient times, vitriol (containing sulphuric acid) was used to purify gold and fabricate imitation precious metals. It was introduced to Europe in the 16th century and not long after that, one of the first recorded acid assaults occurred in France. Its incidence continued to rise, what was described as ‘a wave of vitriolage’ occurred particularly in France. The term ‘La Vitrioleuse’ was coined gaining popular press coverage as ‘crimes of passion’, perpetrated mostly by women against other women, and fuelled by ‘jealousy, vengeance… and provoked by betrayal or disappointment’. Les Vitrioleuses intended to disfigure their disloyal mate or female rival. During the late 19th century, the image of Vitrioleuses was popularised by Art Nouveau artists. ‘La Vitrioleuse’ by Fernand Pelez is still considered an Art Nouveau masterpiece today. The first reported case of acid attack in Europe In 1990, Beare et al. reported ophthalmic injuries was thought to occur as early as the 16th century in 64 patients admitted to The Western Ophthalmic 6,7 12 (see excerpt 1). On the whole, burn injuries sus- Hospital in London as a result of chemical tained from assault with corrosive substances are assaults inflicted by gangs of male youths from relatively uncommon in western societies. lower socioeconomic backgrounds. Literature describing the incidences of chemical Regardless of the variation in patient demo- burns from assaults in the western world is lim- graphics globally, the physical and psychological ited. Acid was not the only agent used. In the morbidity of such assaults can be devastating United States, household lye (sodium hydroxide) (Figure 1). Patients can be left visibly disfigured, was noted to be a common agent preferred by per- some requiring multiple reconstructive proce- 9–11 petrators. Patient demographics also differ dures to recreate key facial features. Although with male victims predominating, and assailants there is legislation against such assaults, the pro- were more often women. Domestic disputes are portion of victims who fully pursue criminal often the motivating factor behind these assaults. charges against their perpetrator is low. We noted Tan et al. 3 gender and relationship of assailant, location of Fatal outcomes the assault, involvement of psychological support, •• Homicide involvement of police, documentation of likely •• Suicide criminal proceedings and number of successful •• Maternal mortality prosecution. We collaborated with a London-based law firm who has had experience dealing with vic- Non-fatal outcomes tims of acid assaults for their perspective on legal •• Physical health • (functional impairment, permanent proceedings and the UK legislation. disability, poor subjective health) •• Mental health • (Post-traumatic stress, depression, Results anxiety, low self-esteem, sexual dysfunction, eating disorders, substance abuse) Our initial search revealed 26 patients coded as •• Negative health behaviours • (under-eating, physical assault-related burns. Five patients were excluded inactivity) from this search following detailed review of the •• Chronic conditions • ( chronic pain syndromes, presenting history showing that these were actu- somatic complaints) ally accidental injuries. We included the remain- •• Reproductive health • (pregnancy complications, ing 21 patients for analysis of the following areas: unwanted pregnancy) •• Patient demographics Figure 1. Health Outcomes of acid attack violence. •• Burn demographics •• Extent of injury, management strategies and length of inpatient stay this recurrent theme during our literature 14 •• Psychological support provided search which led us to review our numbers of •• Circumstances of assault assault victims suffering chemical burns treated in a regional burn centre, with the intention of understanding: (1) current epidemiology; (2) Patient demographics some indictors of patient outcomes; and (3) leg- The male:female ratio was 15:6. The age range was islation and processes within the UK law available 16–56 years (mean age, 28.5 years). The propor- to assist such victims. We collaborated with an tion of victims aged 25 years or younger was almost independent law firm that has had experience in twice that in the above 25-year age group. Victims dealing with acid assaults within the UK. No arti- came from various cultural backgrounds such as cles specific to the UK have previously focused on Caucasian (n = 16), African (n = 3), Oriental an understanding of legal proceedings for vic- (n = 1) and South Asian subcontinent (n = 1). tims wishing to pursue criminal prosecution of Ten patients (48%) were unemployed, nine (43%) the assailant in this patient group. were in employment at the time of the event and two (9%) were students. Four patients had prior Methodology history of trauma sustained from another assault. One patient had a history of previous domestic From our available database spanning 1 January dispute resulting in trauma during the altercation. 2000 up to and including 31 December 2014 (15 Only one patient was known to social services years), approximately 680 total chemical burn prior to the assault. Current trends of assault injuries have been recorded during that period involve more female victims than male victims which included both accidental injuries and inten- compared to a decade ago (Figure 2). tional burns. A retrospective review of all patients coded as sustaining assault related to burn injuries from chemical or corrosive substances on our data- Circumstances of assault base was carried out from that 15 year database. A list of 26 patients was generated. The inclusion cri- A total of 76% (n = 16) cases occurred on the teria was all patients who were assaulted with chem- streets, although assaults were also noted to occur ical or corrosive substances during that period. at home (14%, n = 3), hostel (5%, n = 1) and The study was registered with our clinical govern- pub (5%, n = 1). Concurrent substance abuse ance department (CA14-135) as an audit and a ser- such as combination of alcohol and/or recrea- vice evaluation. We obtained medical case-notes, tional drugs by the victims at time of assault was from which information was collected on patient reported in six cases. Seven (33%) of the assail- epidemiology, burn details, substances used, ants who carried out the attacks were known to 4 Scars, Burns & Healing Male and Female proportions Anatomical Involvement M F Lower Limb 10% Face Trunk 37% 69 6 14% 2000-2004 2005-20092010-2014 Upper Limb Figure 2. Trends of total cases noted every 5 years, with the 23% number of male and female victims described. Neck their victims prior to the incident. Eight assail- 16% ants were documented to be men, one woman and four unknown as they had their faces cov- Figure 3. Chart demonstrating anatomical involvement. ered, and in eight cases there was no documenta- tion at all. In 16 cases, there was clear documentation of the patient account indicating Eye Involvement a motive for the assault and five cases were ran- dom or unprovoked. Police involvement at presentation was docu- mented in 15 cases (17%). Five cases (24%) self- presented and there was no initial or subsequent police involvement. In one case, it was unclear whether police were involved. Criminal investiga- tion was only initiated in nine cases (43%). Of these, only two cases have successful criminal 43% prosecution thus far. With regard to the Criminal Injuries Compensation Act, only two victims pro- ceeded to make claims. 57% Burn demographics The total burn surface area affected was in the range of 0.3–16% with a median of 1% TBSA. The burn depth was either full thickness or mixed depth type. Acid was the most commonly Figure 4. Chart showing ophthalmic involvement. documented substance used (n = 10), followed by alkali (n = 4), bleach (n = 3), unknown (n = 2) all of whom received ophthalmology review and other (n = 2). In all 21 cases, first aid was acutely (Figure 4). given although there was a delay in four patients. Sixteen patients presented immediately to their nearest accident and emergency department Extent of injury, management strategies while in the other five cases, there was a delay and length of inpatient stay (median, 1 day). Burn injuries sustained during the assault often affected more than a single Five patients were admitted to hospital as a result region of the body, with the face being the com- of their injuries at initial presentation. Their monest area to be affected (18/21), followed by length of stay in hospital was in the range of 0–41 the upper limbs (11/21), neck (8/21), trunk days with an average of 6.3 days (median, 1 day). (7/21) and lower limbs (5/21). Many patients One patient also sustained upper limb fractures had involvement of multiple anatomical sites during the assault. Sixteen patients (76%) were (Figure 3). Nine patients had eye involvement, solely managed non-operatively with dressings Tan et al. 5 and outpatient visits. Five patients (24%) also been used as forms of violence during rob- required surgical debridement at presentation beries, political protestations and, in rare cases, and wound coverage with autografts and skin of assassination plots. Our series showed a substitutes such as Matriderm®. higher proportion of young male victims and One patient developed burn wound infec- male perpetrators, contrary to that seen in tion and graft loss, necessitating further surgery. LMICs. In Taiwan, victims were mainly women, Two patients suffered cartilage loss of an ear as a with a higher proportion of male perpetrators. result of the burn injury. These patients required Marital and financial problems were cited as the late repeated burn reconstructive procedures as most common motive. In the United States, vic- a result. Of the nine patients who had eye involve- tims were generally men and perpetrators were 8,14 ment, only one subsequently developed partial women although motive(s) were unclear. loss of sight as a result. These findings suggest the demographics of burns from assault using corrosive substances vary geographically and points to complex under- Psychological treatment lying social and cultural factors relating to both perpetrators and victims. Eight of the 21 patients received clinical psychol- Any corrosive substance can be used as a ogist review and follow-up. All patients admitted weapon in an assault. Acid is commonly used, to our burns unit are offered psychosocial sup- with sulphuric acid quoted to be a common port. Patients whose burn injuries were managed agent. In LMICs, sulphuric acid is easily obtaina- at outpatient clinic visits are always referred on to ble from most car garages at an affordable price clinical psychology when required or upon to the public. Lye, caustic soda and caustic pot- patient request. All inpatients were seen by the ash have also been described in the literature as clinical psychologist. Four of the 16 outpatients potential substances used in assault. An accu- received clinical psychologist input. One possible rate description of the substance used is often explanation for the discrepancy between the difficult to ascertain unless there are characteris- total number of cases and the numbers actually tic features to the burn injury indicative of the receiving psychosocial support is patients refus- acid type such as nitric acid (which forms yellow ing to be referred on, but the reasons were not stains and produces a garlic odour). Our review clear. In cases where victims self-presented unac- showed that identification of the exact substance companied by the police, they declined review by used by perpetrators was difficult and the descrip- a clinical psychologist. tion ‘colourless liquid’ was used. It is therefore important that initial evaluation of the burn Discussion wound includes pH measurement, which itself can be challenging particularly in cases where Approximately 1500 acid assaults are reported presentation is delayed. In our study, we also worldwide annually. Burn injuries from acid found that bleach was frequently used, and attacks have been well described in LMICs. household bleach is both cheap and easily Bangladesh has the highest worldwide incidence accessible. of acid violence and acid burns, constituting 9% Despite the vast variation in motives and epi- of its total burn injuries. In Pakistan, around demiology of acid assaults, there are recurrent 400 acid attacks on women occur annually themes of concern outlined in the existing litera- although this figure may represent an overesti- ture. Acid attacks are malicious attacks with the mation from non-formal data collection tech- intent to cause devastating bodily mutilation and nique. Sri Lanka, India, Cambodia and Uganda functional impairment. The resulting disfigure- have also reported cases of acid assaults although ment can be a constant taunt to the survivors its true incidence is difficult to ascertain. This is mentally, physically and emotionally. Often, the largely due to problematic reporting mecha- long-term psychosocial effects are so severe that nisms and under-reporting by victims. they can impede the progress of social reintegra- The epidemiology of acid violence varies geo- tion following the burn injury. As a result, many graphically. Examples from the published litera- victims lead a life as a recluse. Although loca- ture show that in Bangladesh, victims are often tion is not a key factor in social reintegration, we young women who have rejected a potential found that these injuries most commonly suitor or new brides punished by their husbands 2 18 involved visible and public facing parts of the and in-laws over dowry disputes. In Cambodia, body such as the face, neck and hands. Our find- the majority of victims are young mistresses ings mirrored that reported by Faga et al. attacked by their lovers’ wives. Acid burns have 6 Scars, Burns & Healing Psychological morbidity of burns survivors assist as much as they can. The above-mentioned 22,23 have been extensively studied. Mannan et al. charities can provide advice and direction for showed that burn injury and the event itself (the individuals seeking legal support beyond the ini- assault), are both important contributors to psy- tial phase of hospital care. chosocial outcomes. The study also noted lower self-esteem in women who have suffered acid Classification of assaults and expected attacks. Anatomical location of the assault, rela- sequence of litigation events tionship to the assailant and consequent func- tional limitations have been shown to be There is no single law firm dedicated solely to acid predictors of distress. Psychosocial support is assaults prosecutions. We collaborated with a legal important as part of burn rehabilitation. firm that has previously dealt with acid assaults. Worldwide, charitable foundations exist to offer These assaults fall into two categories: domestic vio- a vital source of support to these victims beyond lence or criminal assault. The ability to deal with their initial injury. In the UK, The Katie Piper domestic violence law or criminal law by any law Foundation (London), Acid Survivor Trust firm dictates its ability to manage acid assault cases. International (ASTI) and Domestic Violence The most common setting for chemical attacks UK are among charities available to provide to take place is within domestically violent relation- support beyond initial injury. Beyond the UK, ships. If the crime is committed within a domestic government organisations (GOs) and non-gov- relationship, the survivor could be introduced to ernment organisations (NGOs) exists worldwide domestic violence organisations and thereafter to support victims of acid violence (Table 1). potentially to family law solicitors. Threats of vio- In 2001, the National Burn Care Review lence originate from the perpetrators who, in order Committee (NBCRC) had acknowledged that to affirm their control, threaten to throw acid on psychosocial rehabilitation, which is an integral their partners. A Non-Molestation Order and part in burn care, had been seriously neglected in Occupation Orders from the family courts could the UK. Following their report, recommenda- potentially be sought in such circumstances. tions have been put forward including the need If the act is carried out and acid is thrown at for a named coordinator for psychosocial reha- a victim, then this attack is dealt with as a crimi- bilitation who is responsible for managing these nal offence, which is most likely to be considered aspects of care for the burn patient. Since then, under one of the following two offences: improvements have been built upon this princi- ple, including the set-up of psychological care ser- (1) Grievous Bodily Harm (GBH): This offence vices in various burn units across the nation. is committed when a person unlawfully In our review, nine cases out of a total of 21 and maliciously, with intent to do some resulted in the initiation of a criminal investiga- grievous bodily harm, or with intent to tion. The number of cases that actually proceed to resist or prevent the lawful apprehension court cases was difficult to ascertain accurately. We or detainer of any other person, either: have identified two successful prosecutions that wounds another person; or causes griev- have gained publicity through news coverage. ous bodily harm to another person. One possible explanation for this disparity is the (2) Attempted Murder: This offence is com- unwillingness of patients to pursue the case or mitted when a person does an act that is press charges. Several studies have previously more than merely preparatory to the 3,38,39 reported similar findings. Victims who are commission of an offence of murder, experiencing the emotional and mental trauma and at the time the person has the inten- following an assault may feel unsafe and vulnera- tion to kill. ble, fearing that pressing charges may provoke fur- ther attacks. Lack of knowledge on how to instigate If the offence committed is GBH, then this will legal proceedings may also account for the low be dealt with in a Crown Court and can result in proportion of victims pursuing court action. This a maximum sentence of life imprisonment. is especially important for victims where perpetra- Criminal sentences of more than 10 years for this tors are still ‘out there’. offence are rare. However, if acid is used in a fur- ther manner, for example, poured down the vic- tim’s throat, this is deemed to be an attempted Acid attacks and the law murder. The sentencing for this varies depend- ing on the nature of the offence and the extent Within the UK, the police or hospital are usually of damage caused. There is arguably no need for the first point of contact and would be able to Tan et al. 7 Table 1. International organisations supporting victims of acid violence. Organisation Role Cambodian League for the Promotion • PAT programme provides financial, counseling, medical, and legal and and Defense of Human Rights (LICADHO); advocacy assistance Cambodia • Reporting of incidences Children’s Surgical Centre (CSC); USA-based • Burn treatment assistance and rehabilitation NGO Cambodian Acid Survivors Charity (CSAC); • Surgical, medical and psychological treatment Cambodia • Vocational training and social reintegration • Legal assistance and advocacy for legal reform • Awareness through research, education and advocacy Campaign and Struggle Against Acid Attacks on • Assists survivors with access to legal, medical and social services Women (CSAAAW); India • Works to prevent further attacks Acid Survivors Foundation; Bangladesh • Assistance with treatment, rehabilitation, legal and advocacy for legal reform, increase awareness through research advocacy and prevention measures Naripokkho, Bangladesh • Works to advance situation of women, to struggle against violence and inequity, lobby for women’s rights • Brought media attention and initiated campaign against acid violence in mid 1990s Acid Survivors Foundation Pakistan ASFP; • Stop acid and burn violence and prevent the proliferation of attacks Pakistan • Ensure survivors receive the best available medical treatment in the long run • Ensure survivors get justice, exercise their fundamental rights in accordance with the Pakistani constitution and international conventions • Enable survivors to end up as proactive, democratic, empowered and autonomous citizens Human Rights Commission of Pakistan (HRCP); • Collects statistics from newspaper reports pertaining to acid attacks Pakistan Human Rights Watch (HRW); International • Investigate and report on human rights violations on global scale Ansar Burney Trust; Pakistan • Medical treatment aid and legal support [35] Acid Survivors Foundation; Uganda • Funds medical care • Trains and educates community • Police and other agencies • Provides counselling and advocacy any legislative change in the UK unlike other Applying for Legal Aid and instigating countries as the sentencing powers reflect the court proceedings severity of the crime. In 2004 Greenbaum et  al. suggested that Entitlement to Legal Aid has recently changed the incidence of acid violence has remained due to the Legal Aid, Sentencing and Punishment steady. However, from 2006 onwards, the number of Offenders Act (2012). Up-to-date information of reported admission from acid assaults is given on the following website: http://www.jus- tice.gov.uk/private-family-matters-legal-aid/vic- has gradually risen according to NHS data 44 46 The discrepancy could be attributed tims-domestic-violence. If victims wish to apply (Table 2). to better reporting systems for acid assault cases for Legal Aid to cover the costs of seeking protec- and increased reporting in the media. tion from domestic abuse (e.g. a Non-Molestation 8 Scars, Burns & Healing Table 2. Assaults by a corrosive substance as reported by the violence should always be included. This is a NHS Information Centre. short hearing without compulsory notice to the Respondent. In almost all cases it is necessary to Year Admissions get a return hearing date as soon as possible (usu- ally within 1–2 weeks). Sometimes this is neces- 2006–2007 44 sary because there is a fear that as soon as the 2007–2008 67 Respondent learns about the application, they may cause more harm. The judge then makes a 2008–2009 69 decision (after hearing from the Respondent at 2009–2010 98 this hearing) as to whether the order will con- tinue and the duration of the order. The court 2010–2011 110 rarely makes an Occupation Order at this stage, as this issue is more complex and a further sub- stantive hearing will be needed, with notice to Order, Occupation Order or Forced Marriage the Respondent. Protection Order) then victims will qualify for Even with an order in place, one should not Legal Aid subject to a means test. assume that the victim is completely protected. Individuals who are threatened with or Threats of acid violence are very serious. While a become victims of acid violence can try and court order can be a deterrent, it may not always obtain protection from their abuser by applying stop the respondent/perpetrator from carrying for a civil injunction or protection order. An out the acts. injunction is a court order that requires someone to do or not do something. In order to apply for an order, the applicant must be an ‘associated Collaborative efforts and working person’ otherwise the matter would not fall framework under family law. An integrated public health response with strong If the applicant does not fall within the defi- formalised partnership between survivors, GOs nition of an associated person under the Family and NGOs, health authorities and law enforce- Law Act but is being continually harassed, threat- ment can lead to better collaboration and coor- ened, pestered or stalked after a relationship has dination of efforts to end acid violence. ended, they may have grounds to apply for a civil Governments should also maintain a zero-toler- injunction under the Protection from Harassment ance policy in order to eliminate acid violence. Act 1997. In this way they will still be able to Close collaboration with forensic criminologist, receive protection from the courts. psychologist and perpetrators may help develop A Non-Molestation Order is aimed at pre- a better understanding of motivations and ana- venting the abuser from threatening violence lyse root causes of such assaults. Beyond local against, intimidating, harassing or pestering the organisations, such collaborations should ven- victim in order to ensure their safety and wellbe- ture out to include international and regional ing. An Occupation Order regulates who can live working groups that offer a platform for infor- in the family home and can restrict the abuser mation sharing and raising awareness in prevent- from entering the surrounding area (e.g. 100 ing acid attack violence. m). A breach of a Non-Molestation Order is a criminal offence and is punishable with up to 5 years’ imprisonment. Breach of an order can Education and prevention result in contempt of court and can be dealt with in the family courts. The perpetrator or respond- Prevention remains key to reducing the inci- ent who continually harasses the victim can be dence of burn injuries. Publicised education imprisoned for a period of 2 years following com- campaigns have increased awareness and appear mittal in the family courts. to have reduced the number of attacks in The application is made on Form FL401: LMICs. Some have feared that publicity can Application Form for Non Molestation Order lead to an increase in such attacks, but there is no and Occupation Order, supported by a sworn evidence to support this view at this time. statement. This statement will set out the facts Healthcare professionals would benefit from and the reasons for making the application and education and information on the available psy- why the victim protection of the court. The most chosocial and legal support for such assault vic- recent and most traumatic incidents of domestic tims. As the first point of contact in a protected Tan et al. 9 3. Asaria J, Kobusingye OC, Khingi BA, et  al. Acid burns from environment such as in hospital, this may be the personal assault in Uganda. Burns 2004; 30(1): 78–81. only opportunity to provide these patients with a 4. Maghsoudi H and Gabraely N. Epidemiology and outcome of setting in which they may feel ‘safe’ enough to 121 cases of chemical burn in East Azarbaijan province, Iran. accept help. There are dedicated charitable Injury 2008; 39(9): 1042–1046. foundations to acid assault survivors within the 5. Mannan A, Ghani S, Clarke A, et  al. Psychosocial outcomes derived from an acid burned population in Bangladesh, and UK such the KPF and ASTI. Together, these char- comparison with Western norms. Burns 2006; 32(2): 235–241. ities offer information on burn scar rehabilita- 6. Shapiro A-L. Breaking the Codes: Female Criminality in Fin- tion, support access to quality medical care, assist De-Siecle Paris. Stanford, CA: Stanford University Press, 1996. with survivors’ psychological and social rehabili- 7. Harris R. Murders and Madness: Medicine, Law and Society in the tation, and advocacy work to prevent further Fin-De-Siecle. Oxford: Oxford University Press, 1989. 15,24 8. Purdue GF and Hunt JL. Adult assault as a mechanism of burn attacks. injury. Arch Surg 1990; 125(2): 268–269. Regarding prevention laws, more stringent 9. Brodzka W, Thornhill HL and Howard S. Burns: causes and legislation on the purchase of corrosive sub- risk factors. Arch Phys Med Rehabil 1985; 66(11): 746–752. stances is needed. Currently in the UK, corrosive 10. Milton R, Mathieu L, Hall AH, et al. Chemical assault and skin/ substances such as heavy-duty drain cleaners are eye burns: two representative cases, report from the Acid Survivors Foundation, and literature review. Burns 2010; 36(6): 924–932. easily obtainable by the general public from large 11. Wolfort FG, DeMeester T, Knorr N, et al. Surgical management DIY superstores. While it is impossible to stop the of cutaneous lye burns. Surg Gynecol Obstet 1970; 131(5): 873–876. public purchasing such agents freely over the 12. Beare JD. Eye injuries from assault with chemicals. Br J counter, a legal requirement for sellers to record Ophthalmol 1990; 74(9): 514–518. details of every purchase should be implemented. 13. Heise L, Ellsberg M and Goetemoeller M. Ending violence against women. Population Reports. Baltimore, MD: Johns Such a step may assist criminal investigations. We Hopkins University School of Public Health, Population appreciate this may not completely restrict other Information Program, 1999. means of obtaining corrosive substances by other 14. Krob MJ, Johnson A and Jordan MH. Burned-and-battered means, such as that from car batteries. adults. J Burn Care Rehabil 1986; 7(6): 529–531. Nonetheless, this will reduce the number of avail- 15. Acid Survivor Trust International. http://www.acidviolence. org/index.php/how-we-help/specialist-teams. able sources for the potential assailant. 16. Acid Survivors Foundation. 6th Annual Report. Dhaka: ASF, 2004. 17. Human Rights Commission of Pakistan (HRCP). http://hrcp- web.org/hrcpweb/campaigns/. Conclusion 18. Ly H, Sarom N, Gollogly, et al. 88 Burns operated at the ROSE rehabilitation Centre, Phnom Penh. Paper read at the 7th Burn injury by assault with corrosive substances is annual Cambodian Surgical Congress, November 2001. a malicious criminal act intended to cause griev- 19. Yeong E, Chen MT, Mann R, et al. Facial mutilation after an ous bodily harm with potentially devastating assault with chemicals: 15 cases and literature review. J Burn long-term morbidity to the victim. As healthcare Care Rehabil 1997; 18(3): 234–237. professionals, we have a professional and ethical 20. Harchelroad F and Rottinghaus D. Chemical Burns in Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: obligation to provide the best standard of care to McGraw-Hill, 2004. our patients. For victims of assaults, this includes 21. Faga A, Scevola D, Mezzetti MG, et al. Sulphuric acid burned offering prompt access to existing legal, psycho- women in Bangladesh: a social and medical problem. Burns social and external agency support. To prevent 2000; 26(8): 701–709. these injuries, we recommend stricter legislation 22. Blalock SJ, Bunker BJ and DeVellis RF. Psychological distress among survivors of burn injury: the role of outcome expecta- on purchase of corrosive substances, which is tions and perceptions of importance. J Burn Care Rehabil 1994; likely to have a significant impact on reducing 15(5): 421–427. future rates of these attacks. 23. Williams EE and Griffiths TA. Psychological consequences of burn injury. Burns 1991; 17(6): 478–480. 24. Katie Piper Foundation. http://www.katiepiperfoundation.org.uk. Declaration of conflicting interests 25. Domestic Violence UK. http://domesticviolenceuk.org. The authors declare that there is no conflict of interest. 26. Lim J-A. Violence Against Women in Cambodia. Phnom Penh: LICADHO, 2006. 27. Children’s Surgical Centre (CSC). http://www.csc.org. Funding 28. Cambodian Acid Survivors Charity. Helping survivors heal and This research received no specific grant from any funding working to prevent future acid attacks. http://cambodianacid- agency in the public, commercial, or not-for-profit sectors. survivorscharity.org. 29. Campaign and Struggle Against Acid Attacks on Women (CSAAAW) Vs. Department of Women and Child Welfare. References 30. Acid Survivors Foundation. http://www.acidsurvivors.org. 1. Branday J, Arscott GD, Smoot EC, et  al. Chemical burns as 31. Naripokkho. http://www.copasah.net/naripokkho.html. assault injuries in Jamaica. Burns 1996; 22(2): 154–155. 32. Acid Survivors Foundation Pakistan. http://acidsurvivorspaki- 2. Das KK, Khondokar MS, Quamruzzaman M, et al. Assault by stan.org/about. burning in Dhaka, Bangladesh. Burns 2013; 39(1): 177–183. 33. Human Rights Watch (HRW). http://www.hrw.org. 10 Scars, Burns & Healing 34. Ansar Burney Trust. http://ansarburney.org. 41. Section 18 of the Offences Against Person Act 1861. 35. Acid Survivor Foundation Uganda. asfuganda.org. 42. Section 4(1) of the Criminal Attempts Act 1981 36. National Burn Care Review 2001: Standards and Strategy for 43. Legal Aid. http://legislation.gov.uk/ukpga/Vict/24–25/100. Burn Care. http://www.britishburnassociation.org/down- 44. Assaults by a corrosive substance as reported by the NHS loads/NBCR2001.pdf (2001, accessed 6 April 2015). Information Centre. http://www.dawsoncornwell.com/en/ 37. Mary Konye guilty of acid attack on friend Naomi Oni. http:// documents/Acid_Violence.pdf page 8 (2015) www.bbc.co.uk/news/uk-25867695 (2014). 45. Legal Aid, Sentencing and Punishment of Offenders Act 38. Mannan A, Ghani S, Clarke A, et al. Cases of chemical assault 2012. worldwide: a literature review. Burns 2007; 33(2): 149–154. 46. GOV.UK. Legal Aid. http://www.justice.gov.uk/private-family- 39. Greenbaum AR, Donne J, Wilson D, et  al. Intentional burn matters-legal-aid/victims-domestic-violence. injury: an evidence-based, clinical and forensic review. Burns 47. Acid Survivors Foundation. Research Advocacy and Prevention. 2004; 30(7): 628–642. http://www.acidsur vivors.org/Research-Advocacy-and- 40. Blava & Co. Solicitors. http://www.legalblavo.co.uk. Prevention (2015).

Journal

Scars, burns & healingPubmed Central

Published: Nov 18, 2015

There are no references for this article.