Forensic Pathology: serving the cultural needs of the indigenous community in the NT
Although working in the Northern Territory (NT) has its challenges, it can provide forensic pathologists with a unique opportunity to learn about rare natural and unnatural pathological entities. Dr Marianne Tiemensma is a forensic pathologist at Royal Darwin Hospital. She says working in the NT has given her the chance to experience and learn about different cultural practices related to death and grieving, and to think outside the box, because of the complex provision of adequate health services for a small population spread out over a massive area of land.
“The NT has a unique geography and demography, creating challenges for medico-legal death investigation. These challenges can include the often-remote locations of death scenes (including deaths that occur on nearby islands, such as the Tiwi islands), with many difficult and extended search, rescue and retrieval operations, the timely transport of bodies to mortuaries, and meeting the specific cultural needs of the ethnically diverse community.
“In addition, some of the health conditions encountered in our routine forensic pathology practice will rarely be seen in other parts of Australia or the world, such as melioidosis, various stages of rheumatic heart disease, complex auto-immune disease(s), and the occasional snake- or crocodile-related fatality. Unfortunately, the NT has the highest rate of suicide in Australia, in both adults and children, with overrepresentation of the indigenous population. A high prevalence of complex renal disease and end-stage kidney disease is also found, confined to indigenous persons, living in remote, under-resourced areas.”
The NT is a large, but sparsely populated region. It accounts for 18% of the landmass of Australia yet only has around 1% of the population. In addition, it has an ethnically diverse population with 30% of the population coming from indigenous communities and around a third born overseas; two distinct climate patterns (a subtropical climate in the Top End, and a desert climate in Central Australia); and unique fauna and flora. The NT also has a young population, with a median age of 31 years.
“As the NT has such an ethnically diverse population, there are certain factors which need to be taken into consideration. Every effort is made to contact next of kin following the death of any person. The need for autopsy is carefully explained, and on most occasions, an agreement to the extent of post-mortem examination is reached following careful discussion. There are however many barriers, including language, complex family structures, resistance against invasive post-mortem investigation, and difficulty to reach next of kin because of remote or unknown locations.
“All available background, medical, and circumstantial information is reviewed by the coroner and forensic pathologist, and full autopsies are only performed when essential. In some cases, sudden and unexpected deaths may be viewed as “suspicious” in the community, and it is very important to explain the cause of death, to avoid potential “pay-back” or revenge,” said Dr Tiemensma.
Due to the humid climate in the NT, decomposition sets in at an accelerated rate, therefore timely transport of deceased bodies is essential. Where possible, post-mortem interval (time between death and the post-mortem examination) should be limited for optimal post-mortem examination.
“Often, there are delays in post-mortem examinations. This can be due to waiting for a case to arrive from a remote location where there may be no refrigeration available, identification of the deceased, and delay in communication with the next of kin. In such cases, judicious discussion and planning between the various role players is needed to ensure that the investigation can proceed in a timely manner.
“Following post-mortem examination, specific cultural practices such as collection of clothing or hair by next of kin for traditional smoking ceremonies, are honoured. The development of a purpose-built forensic mortuary in Darwin, with provision for the conduct of on-site traditional smoking ceremonies is also currently being planned,” said Dr Tiemensma.