Assessment of An Animal(S) For A Potential Animal Abuse Or Neglect Case
General Considerations
The general assessment of live animals as evidence is discussed in Chapter 2. These general principles apply to assessment of animals for a neglect and/or abuse case: (1) the animalfs) should be uniquely identified and that identification should follow the animal for the entire case; (2) the animal should be examined by a licensed veterinarian in good standing; (3) the chain of custody for the live evidence must be maintained as well as for any sample or test result that comes from that live evidence; (4) the animal should be reevaluated periodically, preferably by the same veterinarian; (5) the documentation of the examination should be compliant with the standard set by the veterinary regulatory authority; (6) the documentation should be consistent between the evaluations; and (7) live and non-live evidence is to be kept secure for the duration of the case.
Special Considerations for Neglect/Abuse
Ancillary Testing
The physical examination results in neglect/abuse cases are often very revealing and graphic. However, quite often, important information beneficial to the case can be obtained with ancillary testing (Ettinger & Feldman, 2000).
The advantages of ancillary testing include: (1) completeness and defensibility of the evaluation, and (2) more thorough understanding of the extent of the harm done to the animal by the neglect/ abuse. The expense of ancillary testing can be prohibitive when the cost of a case is being borne by an agency with limited resources, especially in large-scale cases. However, even if just the basic tests can be performed, the results can be invaluable to the judicial system (author’s personal experience).
Depending on the type of presentation, typical ancillary tests for an animal abuse and/or neglect case may include complete blood cell count (CBC), serum chemistry, heartworm test, fecal analysis, skin scraping, and radiographs (overviews of entire animal and specific views of affected areas) (see Figure 16.3a-c). Specific findings may warrant additional testing. Abnormalities in these tests should be monitored and followed during the animal’s recovery.
As these animals are live evidence, all samples and test results are considered evidence. Therefore, the samples and results should be handled with an appropriate chain of custody and with the defense being allowed access to review. All test results and notes pertaining to such are discoverable for the court case.
Body Condition Scoring
Body condition scores (BCS) and scoring systems are detailed in Chapter 1. A BCS should be assessed and documented for every animal involved in a neglect or abuse case. This score should be reassessed at each subsequent evaluation. The initial BCS can indicate the effect the neglect or abuse had on the animal. Equally important to the judicial system is the change and/or return to normal BCS of the animal (see Figure 16.4a,b). Documentation of the time and intervention^) necessary for the animal to return to normal assists the prosecuting authority and judge/jury in understanding the severity of the neglect and/or abuse.

Figure 16.3 (a) Duck with chronic injury. (b,c) Radiographs of an injured duck.
Pain Scale Scoring
The veterinarian’s ability to assess the pain the animal is experiencing, document the assessment in the case report, and articulate this information to the judicial agencies is critical to the neglect and/ or abuse case. The veterinarian should be knowledgeable in the general indicators of pain in animals and for those specific to the species of animals involved in the case. The evaluation of the animal

Figure 16.4 (a) Emaciated Boxer-type dog, initial examination photograph, (b) Emaciated Boxer-type dog, follow-up examination photograph.
within its environment and then during the physical examination should note pain indicators such as attitude, facial expressions, body posture, willingness to move, reluctance to move, sit, or lie down, restlessness, withdrawal or reluctance to interact with others of the same species and/or humans, aggression, bite attempts when touched, vocalization, under- or over-grooming, and/or self-mutilation. Several references that discuss pain assessment and management are listed at the end of this chapter.
Another valuable assessment tool that can be incorporated into the initial and subsequent physical examination of animals from a neglect or abuse case is pain scale scoring.
The extent of pain and suffering that an animal has endured due to the act of abuse, or failure to act, in animal neglect, is a core concern for the judicial system. While suffering and pain are not the same, pain is one component of suffering. Often, whether the judicial system considers an act to be “torment” (often charged as a misdemeanor) or "torture" (often charged as a felony) [NC General Statute § 14-360(a), (al) and (b)] may rest on the veterinarian’s ability to articulate the amount of pain inflicted on the animal by the act or failure to act. Although specific acts may, by their very nature, define the seriousness of the criminal charge, often it is a judgment call. Being able to refer to an objective assessment of pain is beneficial to making that judgment call.
Several pain scales for dogs and cats have been published. Colorado State University Veterinary Medical Center has published the CSU Acute Pain Scale for canines and felines and a Canine Chronic Pain Scale. These scales have pictures of typical body postures associated with pain levels as well as descriptive text (Colorado State Veterinary College Pain Scales 2006, 2006)
Another set of veterinary pain scales is the Glasgow Composite Pain Scale for Dogs, and a similar one for cats (Glasgow Composite Pain Scale (https://www.ava.eu.com/wp-content/ uploads/2015/11/GlasgowPainScale.pdf).
Regardless of which pain scale is used for the initial assessment, as an animal is recovering from the neglect and/or abuse, the animal pain/comfort level should be evaluated at each subsequent examination using the same pain scale. Valuable information can be gleaned from the animal’s return to a normal comfort level. Information to be included in the documentation of the case includes the animal’s initial level of pain, what measures were required to relieve the animal’s pain and for what duration, and the animal’s new “normal” comfort level once it has recovered. In the event in which damage done by the neglect/abuse results in significant pain which cannot be relieved, this information should also be relayed to the judicial agencies in as objective a manner as possible, so the best decision can be made for the disposition of the animal.
Periodic Réévaluations
Although the initial physical examination and test results are vital to the assessment of the case, the case often does not end at this stage. How the animal and its medical conditions respond to reasonable veterinary care and normal husbandry practices can be critical information for the judicial system. For instance, if an emaciated dog returns to a normal body condition within a short time frame with just the provision of a medium-grade dog food that is easily available to most people, then this information may be clear and convincing evidence of the neglect of that animal by its owner. On the flip side, if the damage done to the animal is so severe that the animal cannot recover despite the provision of veterinary care, this too can speak volumes to the judicial system as to the criminality of the suspects act or failure to act.
Inherent to these cases is the periodic réévaluation of the animal victim. The frequency of such réévaluation in a neglect case will depend on the age and medical condition of the animal. In the author’s experience, neonates, very young animals, and animals in critical condition may need to be reevaluated daily if not several times a day. An emaciated adult animal should be reassessed on at least a weekly basis until such time as the body condition has return to a stable, noncritical level. The medical record of neglected and victims of abuse should contain the medical plan of action, which includes the schedule for réévaluations. This schedule can be modified as appropriate to the animal’s recovery.
Questions
Some common questions asked of veterinarians who assess animals for neglect and cruelty cases will be answered during the physical examination of the animals (author’s personal experience). The examiner should consider questions typically asked in these cases: (1) Are the medical conditions/lesions acute or chronic in nature? (2) If chronic, in the judgment of the veterinarian, how long was the neglect/abuse occurring in order for the animal to present in its condition? (3) Is there evidence of chronic malnutrition? (4) Are there veterinary medical conditions present that resulted from failure to treat minor conditions? (5) Was this condition^) preventable? (6) Could the suffering of this animal have been avoided or minimized if the owner or person responsible had acted earlier? (7) Did the environment in which the animal was housed contribute to the animal’s suffering? (8) Was there an underlying medical condition present that may have caused or contributed to the animal’s current condition? and (9) What would a reasonable person have done?