A STUDY ON ASSAULT CASES ADMITTED TO COLOMBO SOUTH TEACHING HOSPITAL-SRI LANKA

Assault cases are commonly encountered in the day to day life of a Judicial Medical Of icer or an Accident Service Surgeon. Most of the admissions to the Accident Service Unit of anymajor hospital in almost anywhere in theworld are due to accidents and assaults. Accidents are preventable disasters and there are major organizations whosemain role is to draw strategies and plans to prevent accidents. On the other hand, assaults are alwaysman-made and the underlying factors are very different from those of accidents. Assaults are a serious health and economic burden in a country. Additionally, there are socio-economic, religious, ethnic, cultural and legal issues intermingled with the broad picture of ‘assaults’. Very few studies have been done in depth about assaults in the recent past which cover the multiple aspect of the issue. Even the conclusions drawn from the most extensive study on this subject may become obsolete and dilapidated after few years, as the patterns of wounding and the methods and trends are changing constantly across the globe. This justi ies the necessity of continuous research by different authorities to this ever-changing subject. This study discusses certain demographic characters of victims, assailants, contributory factors and legal implications of assaults.


INTRODUCTION
Patients with assaults are quite commonly encountered by the doctors working in accident and emergency treatment units as well as judicial medical of icers. They are not-uncommonly encountered by doctors of other specialties such as neurologists, neurosurgeons, orthopaedic surgeons, oro-facio-maxillology surgeons, radiologists and so on. Assault could broadly be considered as an unlawful placing of an individual in apprehension of immediate bodily harm without his or her consent Medical dictationary (2021). According to the section 342 of chapter 9 of the Penal Code of Sri Lanka, the word 'assault' is de ined as, 'whoever makes any gesture or any preparation, intending or knowing it to be likely that such gesture or preparation will cause any person present to apprehend that he who makes that gesture or preparation is about to use criminal force to that person' "Penal Code Consolidated" (2016).
There are several types of assaults; the commonest types being verbal, simple, aggravated and sexual. Verbal assault occurs when somebody is threatened by word of mouth. This is by far the commonest type of assault. Simple assaults are also fairly common which does not involve a weapon. The mere absence of a weapon may not reduce its dangerousness though. Aggravated assaults are physically more dangerous than other forms since the victim is attacked with a weapon which could even result in a lethal outcome. Weapons in aggravated assaults could range from simple household implements such as bricks, bats, broom-sticks, horse pipes etc. to more dangerous weapons such as knives, ish-knives, swards, irearms and hand grenades. The attacker's intention of killing or causing serious bodily injuries which could result in death could be assumed by taking the weapon he has chosen in to consideration. Another form of assault is sexual assault which could result from any verbal, gestural or physical advancement on a male or a female by another male or female without the consent of the subject Kianpour et al. (2021).
In this study we focus only on victims of physical assaults. Assaults are a common scenario in day-to-day medical practice which results in a serious health and economic burden to the country Lugo et al. (2018), Violence (n.d.). Additionally, there are socio-economic, religious, ethnic, cultural, moral and legal issues intermingled with the broad picture of assaults. Even though assaults are a common scenario, very few studies have been done in depth about assaults in the recent past covering the multiple aspects of the issue.

DESIGN AND METHODOLOGY
This research had been conducted in the Accident Service Unit of Colombo South Teaching Hospital, Kalubowila, Sri Lanka for a period of four months, by obtaining information from all assault cases admitted there, through a structured interview based on a questionnaire. 231 patients had been included for the study while excluding a few who were transferred to National Hospital Colombo or who were sent to ICU or who died soon after admission. Additionally, medical (clinical) information was obtained from Bed Head Ticket (BHT) of the patient. The written informed consent was obtained on a separate consent form prepared in Sinhalese, after adequately explaining to the patient the purpose of the research and the measures taken to maintain the con identiality of the information they disclose. The information regarding assailants/perpetrators was obtained from the victims and the investigating police of icers. Data collection was done by the three authors themselves. The analysis of raw data was done manually.

Concise summary of salient indings is given below
• From the total sample of 231 who participated in the study, 70% of the victims were males. (Figure 01).
• 77% of the victims had not studied beyond the 11 th Grade. (GCE. Ordinary Level).

Figure 1
• In the vast majority of assaults, (92%) the number of assailants was single.
• A 6% of assaults were caused by people known to the victim.
• 53% of assailants had used alcohol and nearly 20% had used narcotic drugs as well.
• 32% of assailants had previous convictions and 22.5% of them had pending court cases.
• Commonest immediate cause for the assault was sudden provocation while commonest underlying causes were occupational, land, inancial and marital disputes.
• Only 7.8% of assailants were physically injured during assaults, while 85% of the victims had visible injuries, commonest of which were abrasions and contusions caused due to blunt force, most of which were found on the head, neck and the upper limbs.
• Around 20% of victims had defence injuries.
• 42% of assaults occurred at public places.
• Only a few (07%) were associated with other crimes like robbery, abductions or sexual assaults.
• As per legal classi ication, 71% of assaults were non-grievous while 28.5% were grievous. Only 0.5% were fatal in the ordinary cause of nature.

Figure 2
• Out of 231 cases, 11 (4.76%) were police-battery while another 11 (4.76%) were spouse-battery (intimate partner violence) one (01) out of which was a husband battered by his wife.

DISCUSSION
Majority of the participants (70%) were male in the present study and most of them (60%) belonged to 20-40-year age group. These indings recon irm the indings of a similar study conducted in the same unit at CSTH in 2016 Saleeth and Almeida (2020). A similar study conducted in African region shows a similar inding of higher incidence of being subjected to victims of assault among male gender though the percentage there is 75.7 which is even higher than the igure in our study Samuel et al. (2009). Male dominance in assaults may be due to socio-cultural settings. According to the World Health Organization (WHO), an adult is a person older than 19 years of age unless national law delimits an earlier age Canêo and Neirotti (2017). A study done in the USA shows, the reason for the assault being unknown increased with the advancing age of the victim Loder et al. (2020). This fact is reconirmed by the indings of this study as the majority of our study population was adults and only 6% was caused by people who are known to the victim.
In the literature it is stated that in most instances the perpetrators are under the in luence of alcohol or other drugs and such assailants are capable of causing relatively more serious types of assaults Brookoff (1997), Martin et al. (1988). This fact is recon irmed by our study. The indings of our study shows that 32% of assailants had previous convictions and 22.5% of them had pending court cases. Similar study conducted in the USA including 62 participants, shows that 89% of assailants had previous convictions Brookoff (1997). Small sample size, deference in cultural and social factors as well as the difference in the criminal justice process may have contributed to this contrast in the indings as compared to our study.
42% of assaults occurred at public places and only a few were associated with other crimes like robbery, abductions or sexual assaults. A previous local study done in CSTH stated similar indings Saleeth and Almeida (2020). In the present study, majority of the assailants were not arrested at the time of interviewing the victim for the research or at the time of medico-legal examination of the victims. Though similar indings were obtained in the local literature, the indings in the international literature are different from this as the majority of assailants were arrested Brookoff (1997). Changes in the mechanism of arresting assailants and the difference in the practical functioning of the criminal justice systems would have led to this difference. 85% of the victims had visible injuries, commonest of which were abrasions and contusions caused due to blunt force, most of which were found on the head, neck and the upper limbs. Findings in the literature are compatible with these results. For example a Sri Lankan study conducted by Department of Forensic Medicine, University of Peredeniya shows that commonest form of injuries in assaults were blunt force trauma with super icial injuries like abrasion, and contusions while such injuries were seen on head, neck and upper extremities commonly. (12) Another study conducted in the city of New York using 31 selected elders who were victimized in physical abuse showed that the injuries due to physical assaults were commonly seen in upper extremities of the body such as head, neck and upper limbs Rosen et al. (2016).
As per the legal classi ication in the Sri Lankan Penal Code, there are several categories of hurt as simple/non-grievous, grievous, endangering life (also under grievous hurt), fatal in the ordinary course of nature and necessarily fatal "Penal Code Consolidated" (2016). Findings of a previous study done in the same unit stated that 55% out of a total of 170 cases were categorized as grievous Saleeth and Almeida (2020). In our study, the percentage of grievous hurt has come down to 28.5 while the majority were simple or non-grievous hurt accounting for 71%. Only 0.5% in our study had injuries or consequences of injuries which could be categorized as fatal in the ordinary course of nature. A signi icant difference between the percentages of grievous hurt is evident in these two studies. As the former study had been conducted almost ive years prior to our study, this gives a clue as to the need of repeated conducting multi-centred meta studies regarding dynamic issues such as assaults, sexual assaults and road traf ic accidents etc. whose pro ile and patterns may vary with the rapidly changing socio-cultural, lifestyle and legal background of the country.
According to the WHO indings the prevalence data of life-time intimate partner violence (IPV) range from 20% in the Western Paci ic, 22% in high-income countries and Europe and 25% in the WHO Regions of the Americas to 33% in the WHO African region, 31% in the WHO Eastern Mediterranean region, and 33% in the WHO South-East Asia region WHO (2021). In the present study percentage of intimate partner violence was 4.7%. This clearly does not tally with the above data. Our study was not aimed to estimate the prevalence of IPV or 'Gender-Based Violence' (GBV) but we have only mentioned the percentage of IPV out of our study population of assaults. It is common knowledge that most of IPV or GBV do not end up in injuries requiring hospital admissions. Our study con irms that out of all assaults requiring hospital admissions, 4.7% have been resulted due to IPV. This data, when considered in the light of WHO data on GBV/IPV, it could be inferred that only a minority of GBV/IPV cases result in injuries requiring hospitalization.

LIMITATIONS
• The information pertaining to assailants (perpetrators) were obtained mainly from the victims. Therefore, the reliability of such information is questionable.
• The 'arrest rates' and 'conviction rates' in the study are based on information as at the time of examining the victims. This does not depict the actual 'arrest rates' and 'conviction rates' in the criminal justice system in Sri Lanka as the process could take place at a later date.
• As the duration of the study is relatively short, it will not depict seasonal variations of crime and assault and their changing patterns across the year.

RECOMMENDATIONS AND CONCLUSIONS
• Trauma following assaults should be considered as a unique health issue in the country. A policy decision should be made to introduce a national trauma management campaign in the health care system of the country. Though this, the infra-structure should be improved and developed to effectively manage trauma. The management should essentially include primary prevention which reduces the economic burden of trauma on the country.
• More extensive research on trauma should be encouraged and the contributions of experts on the subject including the sociologists and criminologists should be obtained in conducting multi centred large scale studies covering all facets of the problem. WHO. (2021). Violence against women. Retrieved from https://www.who.int/news-room/ fact-sheets/detail/violence-against-women