Forensic Science International 285 (2018) 21–28

Contents lists available at ScienceDirect

Forensic Science International

journal homepage: www.elsevier.com/locate/forsciint

Dismantling the justice silos: Flowcharting the role and expertise of

forensic science, forensic medicine and allied health in adult sexual
assault investigations
Sally F. Keltya,* , Roberta Julianb , Eva Bruenisholzc , Linzi Wilson-Wildec
a
Centre for Applied Psychology, University Drive, Bruce, Australian Capital Territory, 2617, Australia
b
Tasmanian Institute of Law Enforcement Studies (TILES), University of Tasmania, Private Bag 22, Hobart, Tasmania 7001, Australia
c
National Institute of Forensic Science Australia New Zealand Policing Advisory Agency, World Trade Centre, Flinders Street, Docklands, Victoria 3008,
Australia

A R T I C L E I N F O A B S T R A C T

Article history:
Received 18 May 2017 Forensic science is increasingly used to help exonerate the innocent and establishing links between
Received in revised form 22 November 2017 individuals and criminal activities. With increased reliance on scientific services provided by multi-
Accepted 18 January 2018 disciplinary (police, medicine, law, forensic science), and multi-organisational in the private and
Available online 31 January 2018 government sectors (health, justice, legal, police) practitioners, the potential for miscommunication
resulting unjust outcomes increases. The importance of identifying effective multi-organisational
Keywords: information sharing is to prevent the ‘justice silo effect’; where practitioners from different organisations
Information-sharing operate in isolation with minimal or no interaction. This paper presents the findings from the second part
Justice silos
of the Interfaces Project, an Australia-wide study designed to assess the extent of the justice silos. We
Forensic practitioners
interviewed 121 police, forensic scientists, lawyers, judges, coroners, pathologists and forensic
Case meetings
Tunnel-vision physicians. The first paper published in 2013 presented two key findings: first investigative meetings
were rare in adult sexual assault cases; second many medical practitioners were semi-invisible in case
decision-making with this low level of visibility being due to lawyers, forensic scientists or police not
being aware of the role/expertise medical practitioners offer. These findings led to the development of a
flowchart model for adult sexual assault that highlights the range of agencies and practitioners typically
involved in sexual assault. The rationale for the flowchart is to produce a visual representation of a typical
sexual assault investigative process highlighting where and who plays a role in order to minimise the risk
of justice silos. This is the second paper in a series of two.
© 2018 Elsevier B.V. All rights reserved.

1. Introduction With increased reliance on multi-disciplinary, multi-agency

forensic service delivery, the potential for miscommunication
Forensic, medical and allied health expertise is relied on resulting in unjust outcomes also increases, especially in serious
increasingly by police and the courts. In sexual assault cases the criminal matters, such as child or adult sexual assault inves-
forensic evidence has the potential to provide more information tigations. The more serious the matter, the more likely that multi-
than just the identification of the suspect. The physical evidence disciplinary and multi-agency personnel (Health, Justice, Police,
can establish the elements of the crime, assist in reconstructing the Child Protection, Education, private legal/medical/allied-health)
sequence of events, establish the identities of the victim and are involved. Inter-disciplinary difference adds to the investigative
assailant and corroborate or challenge witness statements and complexity and increases the risk of vital evidence being missed or
alibis [1]. miscommunicated, particularly if inter-agency information shar-
ing is problematic or not common. Further, many of these
personnel working within different fields will have divergent
work practices and differing views on what their role is in a sexual
assault investigation, or how and if they should meet during
* Corresponding author at: University of Canberra, Australia. criminal investigations or court trials.
E-mail addresses: [email protected] (S.F. Kelty),
[email protected] (R. Julian), [email protected]
To reduce the risk of unjust outcomes, more emphasis must be
(E. Bruenisholz), [email protected] (L. Wilson-Wilde). placed on how forensic experts communicate with each other and

https://doi.org/10.1016/j.forsciint.2018.01.015
0379-0738/© 2018 Elsevier B.V. All rights reserved.
22 S.F. Kelty et al. / Forensic Science International 285 (2018) 21–28

with legal and law enforcement agencies. An absence of of the Interfaces Project was to explore how, or indeed if,
meaningful and regular communication between forensic science, information could or should be shared between agencies while
medicine, law and police was termed by Kelty et al. [2] as the maintaining professional boundaries as legal experts.
‘justice silo effect’. This is where practitioners, even within their In 2012 and 2013, the initial results were published [2]. Two key
own organisations, operate in isolation, unaware of the roles and initial findings were that although interagency meetings were
responsibilities of other justice personnel working on the same or routine in homicide cases, they were extremely rare in sexual assault
similar criminal investigations and trials. Although it is common- cases. Further, and of concern, was that forensic physicians and
place to think about the criminal justice system as a unified entity nurses were either ‘invisible’ or ‘semi-invisible’ in sexual assault case
with agencies working effectively toward a single purpose and goal decision-making, at either the investigative or trial stage. It was
[3] research in 2013 found a different scenario, with Australian law found that it was very rare that forensic medical experts shared their
enforcement, justice and health agencies/practitioners having a expertise in sexual assault cases, even if they had opinion evidence
fragmented and often siloed approach to collaboration in both that could assist. The interviews showed that the low level of
child and adult sexual assault investigations [2]. visibility of forensic medical experts meant that the role they played
An example of a “justice silo” occurred in Australia. In 2008, and the expertise they could offer was neither utilised nor
Farah Jama (FJ) was convicted of a rape he did not commit and understood by most lawyers, forensic scientists or police.
sentenced to six years imprisonment. No other circumstantial This paper presents the second part of the Interfaces Project,
evidence was presented at trial and the jury’s verdict rested on the which explored the forensic and evidentiary process in adult
basis of DNA evidence alone. In December 2009, it became sexual assault cases from initial reporting by an adult victim to the
apparent that there was a problem with the original DNA swabs trial preparation stage and developed a flowchart of this process.
(contamination of the swabs) and a prosecutor from the Victorian The research adopted a holistic, systemic approach to examine the
Public Prosecutions Office advised the Victorian Court of Appeal in role of forensic evidence in sexual assault cases. The flowchart
Melbourne that a ‘substantial miscarriage of justice’ had occurred; developed begins with first responders and although not exhaus-
FJ was acquitted immediately. In 2010, the Vincent inquiry report tive, examined the range of agencies and processes typically
into the wrongful conviction of FJ was released detailing an involved in the preparation of a prosecution brief. In the flowchart
extraordinary case of forensic evidence contamination [4]. we particularly addressed a strategy aimed at strengthening law
Although the miscarriage of justice in the FJ case may at first enforcement and judicial responses to sexual assault by identifying
instance appear to be an issue of contamination, the Vincent report critical points at which practices could be improved to enhance the
also detailed limited information flow between the medical, forensic investigation so that forensic evidence adds value to the
scientific and law enforcement practitioners involved and that this prosecution brief (where this may be important). In this way, this
lack of communication created undue risk of wrongful imprison- research focuses on the perpetrator whilst not losing sight of the
ment. It became apparent that during the investigation the police protection and safety of the victim as the primary concern.
involved became concerned with the lack of any other evidence
combined with a family alibi for the whereabouts of FJ at the time 2. Method and materials
of the incident. The limited interagency interaction to allay the
police officers’ suspicions comprised of phone calls between the 2.1. Participants
police and the forensic laboratory. At no point were any other
agencies contacted, even considered, including the forensic The participants were 121 practitioners from four professional
practitioners who carried out the medical examinations and groups who on a regular basis play a role in the investigation/
collected the DNA samples. criminal proceedings of sexual assault and other serious criminal
matters. The four professional groups were: forensic medicine,
1.1. Background and aim of the research forensic science, law enforcement and law. All 121 participants
were interviewed by one or more of the authors. The number of
Cases such as that of FJ discussed above show the importance of participants in the sample by type of discipline for each
ensuring that practitioners and personnel within the criminal professional group can be seen in Table 1. The age range was
justice system do not operate in isolation. One major recommen- 21–80 years. The participants were drawn from seven Australian
dation from the Vincent [4] inquiry into FJ’s wrongful imprison- States and Territories: Victoria, Australian Capital Territory,
ment was the need for better interagency communication. This
recommendation led to the Interfaces project proposal between Table 1
the National Institute of Forensic Science Australia New Zealand Discipline and number of participants interviewed.
(NIFS, 2013) and the lead authors of this paper to identify current
Type of participant Number
and preferred forms of communication between police agencies,
Forensic medicine
lawyers, forensic and medical scientists during investigations of
Pathologist 5
adult sexual assault matters and homicide matters. Of note, as this Forensic physician/forensic nurse 13
is the second paper in a series of two, it is recommended by the Forensic science
authors that readers read both papers together, please refer Kelty Laboratory sciences (biology and chemistry) 29
et al. [2]. Field sciences (crime scene, ballistics, fingerprints) 19
Law enforcement
The rationale was that despite the recommendations from the
Senior police forensic managers 5
Vincent inquiry (2010) it was unclear as to how justice agencies Senior police investigators 14
should interact so that their information-sharing had a positive Law
impact on the investigation, and that professional boundaries and Senior judiciary and state coroners 8
DPP and prosecution counsel 9
objectivity as expert witnesses were not undermined. After an
Legal aid and private bar defence counsel 14
extensive search of the literature, no empirical research could be Other services
located that had explored how forensic science, medicine, law and Department of health and family law policy advisor 1
law enforcement can communicate effectively. The literature that Victim services/rape crisis centre personnel 4
could be located was commentary articles [3,5] arguing for why Total 121

agencies should collaborate; the how was not alluded to. One aim
S.F. Kelty et al. / Forensic Science International 285 (2018) 21–28 23

Western Australia, Queensland, New South Wales, South Australia participants in this research freely gave their consent and no
and Tasmania. rewards were offered or provided. All procedures adhered to the
National Health and Medical Research Council (NHMRC) guidelines
2.2. Procedure for ethical research carried out in Australia. No participants
withdrew from the study.
The data for the total Interfaces Project sample were collected in
two phases as detailed below. 3. Results and discussion: flowcharting critical points and the
Phase one involved interviews (n = 52) and focus group (n = 19) forensic process in adult sexual assault
with police investigators and forensic medical/science practi-
tioners to describe and map a ‘typical investigation’ (crime scene to The flowchart presented in Fig. 1 was developed to highlight
trial preparation stage) of an adult sexual assault case. A set of critical points in the investigative phase of adult sexual assault
research questions was specifically developed for this project. The investigations. The flowchart contains specific critical points at
interviews were digitally recorded one-on-one in-depth ranging which decisions are made that impact upon a case. The critical
from 1.5 to 2.5 h. The format included an opening general points refer to a time point in the sequence of events where a
discussion, then moved to the focus of the research to describe decision is made that impacts upon whether the case proceeds or
the stages of the forensic response in a sexual assault case in an not. The critical points also highlight the points in the sequence
Australian jurisdiction. Phase one data were collected between where forensic science and medical expertise is used effectively or
2012 and 2013. ineffectively depending on a number of risk factors. The term
Phase two involved in-depth one-on-one interviews (n = 7) or ineffective refers to actions or omissions of people, levels of
focus groups (n = 5). A set of research questions was specifically forensic knowledge, or agency philosophy or policies that result in
developed for this phase of the project. The purpose of each evidence contamination or the prevention of expertise contribut-
interview or focus group, was to understand where in the pre- ing to an investigation. The terms ‘expert’ and ‘expertise’ refer to
reporting and investigation stage of adult sexual assault cases, the police, science or medical practitioners who have specialised
various organisations typically take part, what services they offer, knowledge, training and qualifications in an area (such as sexual
and what type of feedback they receive or would like to receive on assault crime scene processing and collection of forensic speci-
the quality of their work/expertise. Phase two data were collected mens) and who are recognised by legal practitioners and the courts
during 2015 and 2106. as being able to present expert opinion in criminal trials.
The flowchart presented begins at the point where an alleged
2.3. Qualitative data and document analyses sexual assault takes place and ends at the point where accurate and
high quality forensic science and medical opinion is used to charge
All group and interview recordings were transcribed into word or eliminate suspects and where forensic expertise is used in the
documents. Recordings were erased following verification of the decision to prepare a brief for prosecution. Each critical point and
transcription. The data were subjected to narrative content associated risk factor for the ineffective use of forensic science is
analysis using a sequential idiographic approach, where each discussed.
transcript is analysed in full before moving onto the next and Of importance, the flowcharts presented apply mainly to sexual
where themes running through the narrative are highlighted and assault cases where the collection of forensic and medical evidence
coded. Document analysis was also carried out on organisational is still feasible and/or where the forensic evidence has potential
policy and procedural manuals, in place as of 2015 and 2016 for the evidentiary/probative value. There are three different incidences
reporting and investigation of adult sexual assault cases. where flowcharts may not apply.
The combined interview and document analysis was then used Many cases of adult sexual assault occur where victims do not
to inform the development of the investigative procedure report the assault until weeks or years later. Victims in historical
flowcharts (Flowcharts 1 and 2) and then the subsequent more cases rarely keep forms of physical evidence that can assist the
expansive flowcharts. The expansive flowcharts detailed potential forensic investigation (for example clothing or bed sheets).
opportunities for interagency information flow/advice/collabora- Some cases of adult sexual assault occur between people
tion and potential feedback loops to inform practitioners of the already known to each other (whether acquaintances or partners).
quality of forensic evidence/advice. In cases where victim and alleged perpetrator are known to each
other, some forms of forensic evidence do not assist the
2.4. Triangulation of method investigation; as you may expect to see DNA, fingerprints, or in
some cases evidence of sexual contact. Often in these cases,
To ensure methodological rigour, two triangulation methods investigation and trial outcomes rest on victim and eyewitness
were employed. Triangulation is a technique that ensures testimony and issues of consent.
reliability of qualitative data through cross verification [6]. First, Even with high quality forensic evidence being collected and
data triangulation was achieved by gathering the same information used effectively throughout an investigation, there are many
using different methods and populations (focus groups and reasons as to why adult sexual assaults cases do not proceed; for
interviews in four different professional groups, and organisational example, where a victim, at the final stage, decides they do not
policy documents). This ensured that much of the interview want to testify in court and the police decide not to pursue the
narrative was verified through organisational documents. Second- matter further.
ly, investigator triangulation was achieved by ensuring experi- Finally, it is important to note, the flowchart was developed to
enced interviewers carried out the interviews and focus groups; present an ideal model for guidance purposes. As the investigation
thus collecting high quality data. of sexual assault can involve many different agencies with different
powers and differing roles depending on the country/state/county/
2.5. Ethics approval and confidentiality considerations for interfaces 2 jurisdiction it would be impossible to present a flowchart that
participants would work in all forensic, medical, allied health, legal and law
enforcement agencies in every circumstance. The flowchart in
The study had ethical approval from the Social Sciences Human essence should be seen as a guide, whereby criminal justice agency
Research Ethics Committee at the University of Tasmania. All personnel who wish to map out the process in their state or
24 S.F. Kelty et al. / Forensic Science International 285 (2018) 21–28

Fig. 1. Critical points, risk factors and feedback loops in the use of forensic medicine and science in adult sexual assault investigations.
S.F. Kelty et al. / Forensic Science International 285 (2018) 21–28 25

jurisdiction, can use the flowchart as a guide and insert the 4.2. Critical point two: correct expertise
agencies, tasks, roles and personnel specific to their location. The
lead author is happy to discuss with readers the initial ideas of The second critical point is the decision made by police
modifications of the flowchart for their use. investigators about whether to call experts and determining which
forensic experts can best assist in the investigation.
4. Critical points and risk factors in forensic evidence/opinion
used in adult sexual assault cases 4.2.1. Risk factors in critical point 2
In some cases it will be obvious to call in a forensic expert, such
The following discussion describes each of the critical points in as when a victim presents at a police station and a decision is made
a typical adult sexual assault case and highlights the risk factors to call a medical practitioner. However, it does not always follow
and suggestions for managing risk. that the right expertise is called at the right time or whether the
appropriate experts can attend. For example, police investigators
4.1. Critical point one: response of first responders may call an on-duty medical practitioner to see a victim; the
question is whether the police have the skills, or are expected to
The first critical point is when the victim makes a decision to have the skills, to be able to differentiate between a licenced
either report the incident to police, and/or to seek out health medical practitioner with limited forensic expertise and a licenced
services, and/or victim support services. In Australia, there are four medical practitioner with extensive training in forensic medicine.
main points where adult victims of sexual assault can seek This can impact on injury interpretation, or lack of injuries on an
assistance: alleged victim in the absence of sperm/DNA. The issue would be
whether a doctor with limited forensic knowledge would report
1. Police (via 000 or to a police unit/station: police first there is no evidence to support the victim was assaulted.
responder); Having experts attend scenes (whether they be primary or
2. Hospital and hospital clinics (to seek assistance for injuries, secondary) can be vital for effective investigations. It is also
family planning services, sexually transmitted infections) imperative that experts remain within their boundaries of knowl-
(collection of evidence with sexual assault kits may or may edge and that the collection of evidence is not contaminated through
not be carried out in hospitals depending on injuries or whether flawed, outdated practices, or through limited knowledge as in the
there is a dedicated forensic rape crisis centre available); example above. What counts for expert opinion has been under
3. Specialised rape crisis clinics with dedicated forensic examina- scrutiny in recent years, in relation to what the criminal courts regard
tion facilities; as having ‘expertise’ [10,7,11] (Julian and Kelty, 2011). According to
4. Victim support services (these can be in the form of telephone McClellan [11], with the increased reliance on specialised knowledge
counselling or physical victim support centres where victims in society, the role of experts in the criminal justice system has
can get advice, support and advocacy). expanded so that they now play a crucial role in many civil and
criminal trials. One danger of relying on expertise is when experts act
outside their area of knowledge and legitimate expertise.
4.1.1. Risk factors in critical point 1 Regardless of the motive for why people act beyond their area of
Within critical point 1, the largest risk factor is the loss of the expertise (whether it be self-interest or wishing to assist the police
ability to collect potentially valuable forensic evidence. This risk can investigation), the outcomes for justice can be less than optimal.
occur through a lack of forensic knowledge or awareness by
personnel working within each of the four main places that victims 4.3. Critical point three: timely submission and effective triage
may present themselves. Forensic awareness refers to knowledge of
effective forensic science and medical evidence capture, timely The third critical point is the timely submission of sexual assault
collection and evidence management. For example, do all first kits, clothing and other forensic evidence to the laboratory for
responder police officers know to secure effectively both the primary analysis, followed by effective case conferencing and/or inter-
scene (where the alleged incident took place) and secondary scenes agency information sharing as appropriate and warranted.
(the victim, clothing and the alleged perpetrator/s, if known)? The
philosophy or policies of organisations combined with the level of 4.3.1. Risk factor 1 in critical point three
forensic awareness can impact positively or negatively on the The first risk is the timely submission of evidence following
effective collection of evidence from primary and secondary scenes. collection. This can be crucial for certain analyses where time can
For example, non-forensically trained medical practitioners in erode forensic traces. Evidence from Julian et al. [8] has found that
emergency departments may have as their priority to attend to a police officers do not necessarily have an in-depth knowledge of
victim’s injuries at the expense of physical evidence contamination forensic traces and erosion time frames for different types of
or collection. Notifying police to secure the primary scene may only traces. The work by Strom and Hickman [12] showed that police in
occur much later in time. Further, victim support staff or counsellors/ the US are also not always timely in their submission of evidence to
psychologists from non-medical clinics/agencies may have as their the laboratory in serious criminal matters, especially for sexual
priorities to make the victim feel safe and to address traumatic assault kits. One issue that became apparent in our interviews with
reactions; they may not be aware, for example, of the importance of police and forensic practitioners was that the longer the items
carrying out the collection of evidence using a sexual assault kit as remain un-submitted the greater the chance they may become
soon as possible before changing or showering. damaged, misplaced or lost; such as where items of clothing or
Over the past few years maintaining the integrity of the crime other physical evidence were lost/destroyed and therefore unable
scene (including primary and secondary scenes, especially victims to be examined for the presence of hair, DNA, glass, other trace
and alleged perpetrators) and the management of personnel in evidence (for example, destroyed at autopsy, incinerated at the
attendance has gained attention as a critical point in the forensic hospital, or misplaced at the police station [13].
process. If the front end of a criminal investigation is not handled
effectively, there can be significant flow-on effects in the forensic 4.3.2. Risk factor 2 in critical point three
process and, potentially, in justice outcomes [7–9]. Noting that all Refers to a narrow range of forensic analyses being carried out
points in the forensic process are important. (where analyses are limited to the ‘usual’ DNA, glass, fingerprints).
26 S.F. Kelty et al. / Forensic Science International 285 (2018) 21–28

Decisions about what to analyse, and the timeframe, are primarily feedback loop would occur during post investigation non-specific
carried out at the point of triage. Triage can be narrow, being practice improvement groups meetings.
carried out by one person using written reports from police Of note, the feedback loops are not intended to be onerous, and
investigators to prioritise a case (high to low) and to decide what to under no circumstances is it suggested that feedback loops could
analyse. Triage meetings can also be in person, such as case replace the value of attending practice improvement seminars/
conferences, where several different agencies will attend. Holding groups or the opportunities for practitioners to meet face to face.
case conferences in homicide matters is routine across Australia Without feedback loops between police and lawyers and forensic
[2]; however in cases of adult sexual assault this rarely happens, experts, any problems that impact negatively on the reliability and
even in the most serious of cases. quality of forensic evidence will not be addressed. This adversely
When there is an absence of meaningful and regular impacts on court outcomes and economic efficacies within police
communication between experts in forensic science, forensic and forensic agencies.
medicine, law and police this is the ‘justice silo effect’. Justice silos
mean that practitioners, even within their own organisations, 5.1. Feedback loop 1: quality of forensic evidence collected
operate in isolation, unaware of the expertise that other justice or
health personnel can offer. The silos created from the semi- This feedback loop is specifically concerned with the quality of
invisibility of forensic experts is an ineffective use of forensic the forensic samples collected, including the contents of sexual
medicine and science because vital expertise is not called upon or assault kits, swabs, clothing, other physical evidence, CCTV
acted upon when police make decisions about how to proceed with imagery, computer data, fingerprints, shoe marks or other forensic
their investigations. Invisibility (i.e. not asked to investigative or samples, evidence labelling, packaging and wording of the analysis
pre-trial cases meetings) of forensic experts is not necessarily requests.
deliberate [2], rather it can be more of an omission by the police,
forensic scientists and lawyers who did not invite them to 5.1.1. Suggested method to operationalise this loop
meetings. Some practitioners seem to not be on the radar as At the bottom of a forensic analysis request submission form (or
being a useful resource. similar documents/emails) for sexual assault kits or other forensic/
physical evidence collected, the forensic scientist, clinical or
4.4. Critical point four: forensic analysis reports forensic medical practitioner who collected the samples should
leave their email address, or ID number if the feedback can occur
4.4.1. The risk factor in critical point four is the readability of forensic via a forensic register/case management system. The scientist who
reports carries out the analysis (or their team leader) will complete the
Recent research by Howes et al. [14] has suggested that many feedback, which would take the form of a few questions with tick
police officers find the written reports from forensic scientists yes/no or unsure responses. If appropriate a short sentence from
(specifically DNA and glass reports) to be overly complex, dense the analyst for future practice improvements for the collection/
and not user-friendly. This research shows that when police ‘know’ packaging of samples could be included. The questions would
the scientists involved they feel more able to ring the scientist and provide an initial indicator of the quality of the samples collected
ask what the forensic results mean. Police are often left with the and submission procedures.
problem of not knowing whether forensic results will support an This was the most requested feedback loop from the majority of
arrest and charge or not [7]. Although forensic science and medical forensic and medical practitioners in our research. Of importance,
reports can be seen user-friendly by peers in the same profession, this loop is not suggested to be an indicator of whether a case
they are often seen as not user-friendly or helpful to personnel proceeded to court and the court outcome.
working outside the field. This means that forensic science reports
are understandable to forensic scientists, but not necessarily to 5.2. Feedback loop 2: usability of forensic reports by police and lawyers
most police or lawyers or persons outside of forensic science
[14,13]. This feedback loop would provide police and legal practitioners
This risk factor is problematic for two reasons. First, each field (including counsel, solicitors, magistrates, judges, coroners) with
develops guidelines for the structure and content of their reports. the opportunity to provide feedback to field and laboratory
Therefore, even if a field views its reports as professionally drafted forensic scientists and clinical and forensic medical practitioners
and with content reported according to discipline knowledge, it about the usability, clarity and comprehension of their reports.
does not mean that the report is end-user friendly. Second, our
findings have shown that unless people know each other, or have 5.2.1. Suggested method to operationalise this loop
met, they are less likely to converse with each other by email or on To facilitate the provision of feedback the delivery method for
the telephone. It follows that unless a police officer or lawyer feedback should match the delivery method of the report. For
knows a forensic practitioner they are unlikely to ask them to state example, if reports are delivered as a PDF by email, the feedback
in plain terms what they are trying to say in a report. This lack of should be by return email. Similar to feedback loop 1, for loop 2 the
clarity may contribute to the exclusion of practitioners who are feedback could take the form of a few questions with tick yes/no or
already siloed in the justice system, such as clinical (hospital) and unsure responses. If appropriate a short sentence to the report
forensic medical practitioners. writer for future practice improvements. Again this loop is not
suggested to be an indicator of whether a case proceeded to court
5. Embedding forensic practice improvement feedback loops in or the court outcome.
adult sexual assault cases
5.3. Feedback loop 3: practice improvement groups (the value of
During the data collection for this project, three feedback loops championing them)
were identified by the practitioners we interviewed as being
suitable opportunities to provide a mechanism to receive feedback One of the unanticipated findings from our research was the
on the quality of their work. Feedback loop 1 and 2 would be growth of non-case-specific practice improvement groups (PI
standardised feedback loops occurring during the investigative groups). Interdisciplinary PI groups meet to share information and
and adjudicative phases of an adult sexual assault case. The third knowledge, with informal and semi-formal groups across most of
S.F. Kelty et al. / Forensic Science International 285 (2018) 21–28 27

Australia. What was apparent was that for many practitioners, [17]). More specifically, in the area of sexual assault, police benefit
regardless of their profession, attending non-case-specific working from inter-agency and multi-disciplinary collaboration in a
groups was an important mechanism to promote what their number of ways: increased knowledge about sexual assault and
disciplines could offer and to network (therefore reducing the risk sexual assault victims leading to a shift in attitudes away from
of agency and knowledge silos). The formation of these groups adherence to traditional ‘rape myths’ and improved reporting
often occurred in two ways. practices [18,19]; increased knowledge about the role of forensic
The self-initiated PI groups usually formed when a practitioner evidence in the investigation and prosecution of sexual assault
from an agency became aware of certain practices by other cases [20]; and ‘a greater capacity to see themselves as partners
agencies that impacted negatively on forensic/police practice, and alongside other agencies in supporting victim/survivors to engage
where this was in part a manifestation of the silo effect. For in the justice system and to prevent further offending’ [21: 264].
example, where deceased persons were collected from scenes by As PI groups are an effective and efficient way for collaboration
newly appointed private undertakers who had not been briefed on and information-sharing to occur between agencies, with a flow-
procedure for the collection of bodies for forensic post-mortem on effect in improved practices and reporting, it is important that
and this lack of knowledge created problems in the morgue. This they are championed by police organisations. Two key elements of
individual, rather than ignoring the problem, set up an informal successful interagency collaboration are organisational support
working group where all personnel who attend suspicious death and recognition – especially by senior managers – of the value of
scenes within a given geographical area met to discuss roles and these groups to the organisation [2].
what practices each agency did that was beneficial or problematic
for the others. As X2, one of the participants who had initiated a 6. Research recommendations
group like this commented, “you don’t get things fixed by sitting
down in your office thinking someone else will do it”. Based on the research findings and the flowchart as presented
The second manner was as a direct consequence of recom- above, a number of recommendations are proposed to improve the
mendations from parliamentary inquiries or judicial reviews. As in effectiveness of practice in adult sexual assault investigations.
the self-initiated groups, and even though this second type was
formed to address recommendations (usually that agencies 6.1. Recommendation 1: need for a victim advocate
communicate), the actual setting up of these groups required
the initiative and leadership of individuals. To assess the feasibility of a victim advocate and to determine in
The benefits for practitioners of taking part in PI groups, which agency or organisation the advocate would be best
regardless of profession, were more holistic in nature than purely situated. The findings from the adult sexual assault process
to resolve practice issues. The holistic qualities of PI groups include. showed that once an adult victim enters the criminal justice
system there are few supports during the investigative stage that
Ability to put a face to an email. guide them through the forensic and investigative process. The
Understanding what other people do and their role. support of the victims often falls to police investigators within
Knowing someone allows you to ask those questions you do not sexual assault squads who provide a form of pastoral care. The
like to ask strangers. role of a victim advocate was proposed by all practitioners in this
Having an actual point of contact when something looks wrong. project. The advocate would support the victim from the initial
report up to the court preparation stage.
Of note, during the phase 2 data collection carried out in 2015
and 2016 it was apparent that the number of opportunities
provided for PI groups to meet appeared to have diminished and 6.2. Recommendation 2: wider collection of forensic evidence
did not have the same momentum as was observed during phase 1
in 2012. The factors responsible for this were: To deliver training to police and forensic medical experts (nurses
and physicians) on the value of forensic evidence other than
Changes in staffing. Where the original ‘champion’ of a PI group DNA, the value of DNA in no suspect cases, and the value of DNA
had either left or taken a new role and the person filling the role in non-stranger (i.e. acquaintance) sexual assault.
of the old champion did not see the value in continuing with, or
meeting often as, a group.
Narrow understanding of the value of PI groups. Where the PI 6.3. Recommendation 3: operationalise feedback loops for
group was formed to address one issue. Once the issue was practitioners
resolved the group ‘leader’ felt the relevance of the group had
ended and did not consider the more holistic benefits for group To integrate the proposed feedback loops. Regardless of delivery
members. method, the feedback loops proposed need to be integrated into
Resources and tightening budgets. Less opportunity to attend both the investigative or adjudication process of adult sexual
meetings due to reduced staffing numbers resulting in staff assault matters. Without feedback loops between police, lawyers
doing their primary work tasks with no time to attend meetings. and forensic experts any problems that impact negatively on the
reliability and quality of forensic evidence will not be addressed.
The third feedback loop occurs during PI group meetings where This will adversely impact on court outcomes and economic
practitioners discuss practice improvement in the collection, efficacies within police and forensic agencies.
analysis and forensic report writing issues. A fundamental feature
of PI groups is collaboration. The benefits of collaboration have been
recognised by policing organisations in recent years with the 6.4. Recommendation 4: multidisciplinary teams and practice
development of new policing models such as partnership policing, improvement meetings
multi-agency policing [15] and third party policing [16].
Approaches such as these enable practitioners to become aware To ensure that Practice Improvement groups meet, on an
of the expertise of other agencies while encouraging the cross- informal or semi-formal basis, to share information and
pollination of ideas to better address complex problems (see Ref. knowledge. Attending non-case-specific working groups was
28 S.F. Kelty et al. / Forensic Science International 285 (2018) 21–28

identified in the Interfaces project as an important mechanism to References

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