8 Strategies for Consulting on SANE Cases

In consulting on sexual abuse cases as a Certified Legal Nurse Consultant I’m often reviewing many hundreds of pages of records. I’ve learned that the greater the volume of records to review, the easier it is to waste time figuring out where to start and how to begin. My strategy for efficient and accurate analysis is as follows:

1. Identify the available documents. You may receive documents (either hard copies or on a disk) already categorized into files. It’s helpful to list on a Word^® document the following: “I have reviewed the following documents from your office pertinent to xxx case” and then list the available documents according to the name on disk or paper file. Next to the name, list the date or time period covered by that document. Once you have the documents listed, you can review them in whatever order is helpful to you. Other times when you’re consulting on a SANE case you may receive a disk with one file numbering several thousand pages. In that case, skim through to begin a cursory identification of the file contents and list headings on your Word document such as psychiatric hospitalization at [facility] from [date] to [date]. When you later go through each page you will need to refine those headings. The materials you receive may contain the complaint, various depositions (plaintiffs, defendants, witnesses), medical and psychiatric records (inpatient and outpatient), nursing home records, school records, responses to interrogatories and requests for production, police reports, documents submitted by facilities (job descriptions, training content, policies and regulations) and reports of criminal disposition.
2. Identify the purpose in looking at these documents. What are the allegations? What are the defenses? The attorney will usually inform you of the specific allegations of sexual assault (verbally or in a letter outlining the case as well as the formal complaint document). Whether you are on the plaintiff or defense team, you’ll review whatever documents you receive for evidence supporting the plaintiff’s allegations of sexual assault as well as evidence strengthening the defense team’s response to the allegations. For example, a female resident in an assisted living facility alleges that she was sexually assaulted by the male attendant who brought her evening medications. Both plaintiff and defense will review documents for evidence to support their respective positions and refute or diminish the position of the other.
3. Identify information necessary to advance the allegations or defenses. The team for the plaintiff needs to understand the victim’s background, functioning prior to sexual assault, evidence surrounding the sexual assault, and the immediate and long term impact of the assault. If the assault occurred within an institution, the plaintiff’s team looks for failures to have or maintain standards, failure to put in place or enforce policies and procedures regarding sexual assault, failure to provide adequate training and supervision of staff members concerning sexual assault and failure to provide a safe environment for the patient or residents.In addition to the SANE report and other specific data, you are also looking at less tangible but equally important data concerning the victim: what the victim reports as well as her use of coded speech, changes in eating, sleep and behavior patterns, changes in cognitive functioning and physical health, and changes in emotional status. You also will want to assess the physical space and circumstances in which the alleged assault occurred. For example, if a preschool child says the janitor touched her in the bathroom stall, you need to consider whether the four-year-old was alone in the bathroom, where was her teacher, what is the policy of children being alone in the bathroom, where was the janitor, who were the witnesses to the janitor’s location, etc. You should also review the documents of what the child told parents, forensic examiners, and therapists both short and long-term.

   A good defense team looks at this same data and attempts to show that the alleged event did not occur, or occurred but was consensual, or could not have been anticipated or prevented, or all standards, policies, procedures, training and supervision were in place and appropriately followed. For example: a fifteen-year-old girl was sexually assaulted by a twenty-year-old employee at a community center after hours. The employee used his key to enter the building. Both say that the sexual activity was consensual; both say she told him she was eighteen. The defense team will focus on the statements that the activity was consensual and that the victim lied about her age to the offender while the plaintiff team will focus on the age of consent and the ongoing emotional and psychological effects including suicide attempts since the event. Both will look at among other issues, the use of the community building. Was an employee allowed to enter the building after hours, was this an authorized reason to enter, what training did the employee receive about entering the building after hours, etc? Each side needs to be familiar with the same information.

   Identifying necessary information as a Certified Legal Nurse Consultant also involves determining what is missing or needs to be explored further. It’s helpful to add the heading of “observations” at the end of this same Word Document; here you can list as you go along what you think is missing or unexplained or just “doesn’t sit right”. This will change, but writing your observations as you go along keeps everything in one place. For example, a male coach was accused of sexually assaulting a female student who described a specific tattoo on his body; physical exam of the coach revealed no tattoo. What was missing was that no one had questioned the coach under oath if he had used a temporary tattoo.

4. Develop a plan for organizing data. Start with broad categories so that you can write comments under each heading as you review documents. In sexual abuse cases there are several broad categories that are almost always included: background of the victim (personal and family history, health [medical and psychological including medications] history, social and emotional history), status prior to incident of alleged sexual assault (for example, resident of Happy Hollow Nursing Home, ninth grade student in honors class, etc.), incident of sexual abuse (reports from victim, police, other witnesses, medical records, information from depositions), response of those to whom victim reported abuse (school, family, medical, facility, police), victim’s status post sexual abuse to the present (medical/psychiatric information in chronological order including diagnoses, treatment, and medications; school/work functioning; emotional state; behavior/life functioning), information on perpetrator, and summary of depositions and other reports (e.g. report from investigation of a nursing home by Department of Health and Human Services, report from a Board of Registration in Nursing following report of a sexual assault).Sometimes when many persons are named who are prominent in the story, it’s helpful to list a “cast of characters” after the list of documents reviewed. (e. g. one case has forty-six files [more on the way] with parents, step-parents, grandparents, siblings, medical personnel, and others all actively involved).
5. Go through the documents in order of perceived helpfulness. For example, if a nursing home has been investigated following an alleged sexual assault, the report of that investigation provides a useful summary of events. However, one cannot assume that this information is entirely accurate. For example, one nursing home took legal action following such an investigation to show that conclusions drawn that a sexual assault had occurred were false and based on incomplete interviews and misinterpretation of data in nursing notes. Inaccuracies in the report led to deficiencies being applied to the nursing home and massive fines levied.Start with the complaint and the police report (if available) is also helpful. Looking at the dates of the documents helps you read them in chronological order although some information can be gleaned from a variety of documents (e.g. while you may know that the teenage victim accompanied her mother on her prostitution activities when the victim was a small child, it’s not until the twenty-fifth file that you read that the victim was molested by one of her mother’s paramours and in another file that she was sexually abused by a cousin before pre-school age.
6. Use liabilities as assets and assets as liabilities. For example, the sexual assault victim who appears to be a weak witness because she appears insecure, anxious, passive, vulnerable, frightened and easily intimidated (liability) can be shown by the plaintiff attorney as someone who could readily be targeted by a perpetrator who could assume she was an easy target (asset). In one case, nursing notes written by a licensed practical nurse for one male patient stated that a certified nursing attendant saw him being sexually abused by his roommate. Both patients were severely cognitively impaired. Details were clearly listed including the actions taken. This would seem an asset for the plaintiff. However, because the policy in the nursing home did not allow nursing attendants to write notes; she dictated her version of the events to the licensed practical nurse and had never read what the licensed practical nurse had written. Several months later in a deposition when the certified nursing attendant was shown what was written in the note, she stated that part of the note was inaccurate although the sexual abuse part was correct. The defense could now use this note as a liability stating that if one part were inaccurate, how you could assume that the remainder was accurate.
7. Abstract information (with document page number for reference). Just write what you learn; grammar, sentence structure and style can be refined later. As the Certified Legal Nurse you won’t always know what the documents contain or how the final document will be organized. What’s important are the facts and in which document and on which page those facts are located. Because you have listed the documents at the beginning of your Word document, you can easily copy and paste the name where you need a reference and add the page number. For example, in your review you may come to medications someone’s taking for anxiety and depression following sexual assault. Instead of listing them at this point just write “medications in 2012” and the document name and reference number. When you later determine how you will present this information (e.g. in a table or paragraph summary) you can come back for the information. For example, three siblings were sexually assaulted on the playground and a fourth witnessed some of the activity. Their records are intermingled. Until you decide how the material can best be presented, you can list the mother’s version of events and then create headings for each child and list information as you read it. If you later create a separate document for each child, you can cut and paste from your original document.
8. Determine what would be the most expedient way to organize the information for final presentation. Much of the data you’ve obtained about the victim can be summarized in the categories listed above. In addition, some data is best presented in table form; for example, for someone who is cognitively impaired, a table may demonstrate pre- and post-assault changes in physical and emotional status, sleep and eating patterns, behavior, medication usage, participation in activities and use of coded speech. A time-line will graphically illustrate the delay (or lack of response) from the time a sexual assault occurred until notification of medical staff, administration, police, and family. You may prepare charts of school grades, attendance, and behavior and other observations made by school staff pre- and post-assault. Also, attorneys may make specific requests. For example, a woman in a psychiatric hospital alleges in the evening that she was sexually assaulted by a male psychiatric attendant earlier that day. The attorney asked for a detailed chronology documenting the patient’s and the attendant’s activities from early morning until the time of her report. The attorney may also request life-planning documents with recommendations for needed services.Researching the following is also relevant 1) Laws in a particular state about the placement of sexual offenders in nursing homes, 2) Information from a particular facility’s website describing its mission statement, services provided, philosophy of care, 3) Information about a particular medical condition, 4) Explanation of medications or treatments, 5) Board of nursing requirements in a particular state for nurses conducting physical exams (during which inappropriate behavior occurred).

   No report is complete without your comments and questions about the data obtained and your suggestions about what further information is needed. Examples include 1) Incident reports of sexual assault are missing, 2) There is no record of deposition of social worker assigned to Mrs. X who apparently talked with her following the sexual assault, 3) Records reviewed do not contain daily records of eating sleeping, activities, medications of Mrs. Y, 4) The detailed school psychologist’s report does not mention rape even though the perpetrator had been incarcerated, 5) Following the sexual assault, the perpetrator continued to fondle other patients in the nursing home, 6) Following the observed sexual assault, there was no record of a revised care plan, 7) Additional medical and psychiatric records are relevant, 8 ) Almost illegible comment found that pre-school director told parent of allegedly abused child that she had spoken previously to custodian about not being in the bathroom area with the pre-school children; she was never asked about this comment, 9) Bus driver who molested special needs students was hired by current company even though the past bus company’s reference stated they terminated him “with cause” and would not rehire him. 10) After a young teen in a psychiatric hospital reported a sexual assault by his roommate, the attendant did not notify the nurse until the following day, never notified the physician or police or parents. 11) Need records of sexual assault training in nursing home, 12) Two-year-old observed mother being sexually assaulted; there is no mention in the records of any evaluation of him.

These 8 strategies work for me on SANE cases and I am confident they will work for you too.

Carolyn J. Bilodeau, RN, BSN, MS, CLNC

Guest Blogger

P.S. Comment to share your tips for consulting on SANE cases.