Simulation of homicide to hide child's suicide

A case of pretending a homicide to conceal a child suicide is reported in which characteristic findings of the postmortem examination and conclusions from the analysis of forensic autopsy series provided substantial support for the police investigation. In the late night hours of a spring day the police authorities were informed that a 10-year-old girl had been found dead on a playground near its parents' house. As injuries of the neck were recognized by the police officers a homicide investigation was initiated. The post mortem examination showed a furrow symmetrically slanting from the front to the nape of the neck, discrete punctate haemorrhages of the skin of the face and numerous 'tram-line' bruises of the back, buttocks and extremities. These findings indicated as cause and manner of death suicidal hanging following corporal punishment. Confronted with these conclusions the mother immediately made a corresponding confession.     

Child abuse: practical application of autopsy, radiological, and microscopic studies

A 17-month-old male infant died at home. The infant's right arm was immobilized because of a humeral fracture 1 month earlier. The circumstances of death appeared unclear to the police investigators and a medicolegal autopsy was carried out. External examination revealed diffuse ecchymoses of varying color. Postmortem imaging was performed prior to autopsy (X-rays, multislice computed tomography [MSCT], and focused brain magnetic resonance imaging [MRI]). These investigations revealed four rib fractures of varying ages, one of which was posterior. Cerebral and pericerebral traumatic lesions were also diagnosed: bilateral subdural hematomas, intraventricular, meningeal, and interpedoncular hemorrhages. In the abdomen, fresh blood was visible within the anterior abdominal wall and the mesenteric root. Autopsy and microscopic study confirmed these lesions. This case report illustrates the valuable assistance rendered by MSCT and MRI to diagnose abuse when a child has died in unclear circumstances.     

"Natural" death of a person under the care of a custodian

An ambulance service doctor was called to the death of a 76-year-old woman and attested cardiac arrest and psycho-organic brain syndrome as the cause of death on the death certificate. At the second external examination mandatory before cremation, extensive hematomas were detected on the right thorax and multiple haematomas in the face and on the forehead. The autopsy initially ordered by the public health officer revealed serial rib fractures and a fractured skull. After notifying the prosecutor, a forensic autopsy was ordered and death was found to have been caused by fat embolism following massive blunt force to the thorax with serial rib fractures and haematopneumothorax. After that, the adopted son, who had been appointed care custodian for the woman, and his wife were suspected, because they had given contradictory explanations for the injuries. At first, they were only suspected of failure to render assistance, but in the end they were both charged with murder. Only because of the second external examination prescribed by the law still in force could the errors of the improper first external examination be corrected.     

Secondary combined suicide viewed by the wife]

A 47-year-old man was found dead at the bottom of a wall outward the door of the cellar of his house. Preliminary physical examination at the scene of the death revealed a laceration of the scalp, an incised wound in front of the neck and several stab wounds in the left chest penetrating through the clothing. Questioned by the police his wife told that her husband who suffered from severe depression had inflicted the incised and the stab wounds himself, had made an unsuccessful attempt at self-strangulation and had finally jumped down from the wall beside the stairs declining to the cellar of their house. As the circumstances of the scenario were suspicious and as the pattern of injuries arose doubts concerning self-infliction homicide was taken into consideration as well. Autopsy showed additional hesitation marks adjacent to the left end of the incised wound in front of the neck. The stab wounds of the chest were restricted to the region of the heart and displayed only minimal penetration of the chest-wall, findings characteristic of self-infliction. As a consequence the manner of death could be determined as prolonged suicide, and exact reconstruction was possible with the help of the wife's testimony.     

Decapitation due to early post-mortem canine gnawing

A 53-year-old male was found dead in his home. The deceased's head, almost totally skeletonized, was lying at a distance of about 150 cm from the thorax inlet. The other occupant of the flat was a mongrel sheepdog. The autopsy conducted for the inquest established extensive damage to soft tissue in the head, neck and chest. The second to sixth cervical vertebrae were missing. The seventh cervical vertebra and the right first rib displayed bone lesions. The tissue injuries were attributed in the diagnosis to post-mortem canine gnawing. Cause of death was given as intermittent haemorrhaging of the gastro-intestinal tract from oesophageal varices in a status of hepatic cirrhosis. There was no indication that death had been caused by another party. About two days were estimated to have elapsed since death. Attention is drawn to this doubtless rare instance of total decapitation of the deceased with displacement of the head caused by a dog during the early post-mortem period.     

Computed tomography as routine in connection with medico-legal autopsies

CT-scanning as routine examination before medico-legal autopsy was introduced at the Institute of Forensic Medicine in Copenhagen, Denmark, in December 2002. The present series comprises of 525 medico-legal examinations performed in the year 2003. The purpose is to determine the value of CT-scanning prior to the post-mortem examination. All findings, CT- as well as patho-anatomic findings - more than 4000 - were registered in a database. To increase the clearness, the findings are divided in accordance to regions such as head, thorax, abdomen, pelvis, extremities and vessels and the CT-findings are compared to the patho-anatomic findings, with the purpose to estimate the advantages and disadvantages with the two types of examination. The preliminary results show, that the CT-scanner is superior when it comes to detection of extremity fractures. The scanner has ability in detecting hemorrhages and hematomas, especially, intracranial.     

Postmortem dog bites after sexually motivated homicide with multiple stab wounds--differential diagnostic aspects

The body of a 20-year-old woman that had undergone significant putrefaction was found lying on the bed of her apartment in a supine position. The legs were straddled and apart from a T-shirt, she was naked. The inner side of the right thigh showed a circumscribed 20 cm x 40 cm defect exposing the underlying muscles. The wound margin was ragged and superficial scratch-type abrasions were found in the vicinity of the injury margin. The investigating police officers classified the injuries to be caused postmortem by a crossbreed dog that was inside the apartment. No other signs of external force were found on the body at the death scene and due to the previous history of the deceased, a drug death was assumed. Autopsy revealed 13 vital stab wounds in the neck and aspiration of blood in the lungs as well as signs of manual strangulation. The observed coincidence of injuries due to postmortem animal depredation and stab wounds, although in different localization, can be regarded as a rare entity in the light of the literature. The morphological appearance of traumatic injuries due to other causes can be modified by the simultaneous presence of postmortem injuries caused by animals and difficulties can arise concerning the differential diagnosis especially under poor conditions (e.g. advanced putrefaction) at the death scene.     

Abnormally high alcohol concentration in the heart blood

A 46-year-old male alcoholic whose whereabouts had been unknown for about a month was found dead at the foot of a cliff 31 m deep. Fractures of the mandible, thorax and left patella were found at autopsy, but fatal injury to the brain or other organs was not observed. The alcohol distribution was 7.44 mg/g in the heart blood, 13.91 mg/g in the left thoracic cavity fluid and 1.88 mg/g in the urine. The high ethanol concentration in the heart blood was assumed to be mainly due to the diffusion of ethanol from the contents of the stomach and postmortem production of ethanol. It was decided that the cause of death was not acute alcohol intoxication but respiratory failure caused by fractures of the thorax.     

Unusual carbon monoxide poisoning

Despite of indicative death scenes or characteristic findings of the external examination, about 40% of the accidental fatal intoxications due to carbon monoxide are not recognized before the performance of the autopsy. Six cases are reported which illustrate possible reasons for the delayed establishment of the diagnosis: unusual circumstances of the intoxication or sources of carbon monoxide, only subtle degree or lack of external signs of the intoxication or a competing cause of death at autopsy.--Cases 1 and 2: 53, respectively 54-year-old couple, found dead in a caravan, extreme putrefaction of the bodies, spectrophotometric detection of the fatal carboxyhaemoglobin level in oedema fluid of the scalp.--Case 3: 23-year-old lorry driver, found dead in the tightly closed cab of his lorry, operation of a source of electricity with "environmentally friendly" fuel, carboxyhaemoglobin level 83%.--Case 4: 19-year-old man, found dead in the flat of friends, removal of the CO-source before alerting the police forces, lack of the bright pink coloration of livor mortis, haemopericardium due to atrial rupture at postmortem examination, carboxyhaemoglobin level 65%.--Case 5: 27-year-old man, found dead in his flat, advanced decomposition of the body, residues of a charcoal fire in a metal bucket in the sink, carboxyhaemoglobin level 80%.--Case 6: 42-year-old woman, lying dead in the garage beside her car, engine switched-off, ignition key next to the body on the floor under the car, carboxyhaemoglobin level 46%.     

Unexpected natural death secondary to intra-abdominal bleeding: report of one idiopathic spontaneous intraperitoneal hemorrhage case

A 39-year-old woman was found dead at home. She was single, foreign national, chronic alcoholic, and had given shelter to a compatriot for three days. This man found the deceased in her bed, after a night of heavy drinking. The emergency medical team observed numerous recent blue ecchymoses of the upper limbs. Because of the unclear circumstances, a medicolegal autopsy was ordered by the public prosecutor. Massive hemoperitoneum was diagnosed with no visible internal traumatic injury. Autopsy revealed hepatic and pancreatic abnormalities secondary to chronic alcoholism, which were confirmed by pathological study. The source of the hemoperitoneum was not identified despite careful visceral and vascular examination. The authors concluded that death was secondary to idiopathic spontaneous hemoperitoneum or abdominal apoplexy. The forensic literature on unexpected death due to massive nontraumatic intra-abdominal hemorrhage in association with liver cirrhosis is sparse, with only five cases reported, including the present case.     

Laryngeal obstruction by heroin packets

A 28-year-old healthy man collapsed while being arrested by the police for alleged possession of heroin and was found dead on admission to the hospital. Autopsy revealed complete occlusion of the laryngeal opening by a cellophane bag containing 24 packets of heroin powder.     

Post-mortem examination prior to cremation--an instrument to verify the quality of medical post-mortems and uncover non-natural deaths?

The external post-mortem examination, its deficient quality and possible causes have been the subject of numerous political and professional discussions. The external post-mortem examination is the basis for the decision whether further criminal investigations are required to clarify the cause of death. It is thus an essential instrument to ensure legal certainty. Before cremation, a second external post-mortem examination is performed by a public medical officer to make sure that errors of the first post-mortem are corrected. In the present study, cases were retrospectively analyzed in which a forensic autopsy had been ordered on the basis of the results of the post-mortem examination performed before cremation. The entries on the death certificate regarding the manner and cause of death were compared with the autopsy results. Between 1998 and 2007, 387 autopsies were ordered after external examination before cremation. In 55 cases (14.2%), the autopsy revealed a non-natural death, although a natural death had been attested on the death certificate. In descending order, a wrong manner of death was attested by clinicians, general practitioners and emergency physicians. With regard to the place where the first external post-mortem had been performed the lowest error rate was seen in nursing homes. Concerning the cause of death, discrepancies between the first post-mortem and autopsy were found in 59.4% of the cases. In this respect, general practitioners and clinicians were ranking first, whereas in nursing homes the cause of death was wrongly assessed in over 70% of cases. At present, the medical post-mortem does not meet the required quality standards, especially with regard to legal certainty. Determination of the cause of death on the basis of the external post-mortem examination is a challenging task even for the experienced medical examiner. As to the categorization of the manner of death it has to be stated that non-natural deaths are often not recognized or that the possibility to certify a death as unclear is not sufficiently used. As a result, it seems important to demand intensive, qualified, additional training in external post-mortem examinations for physicians.     

Fatal subarachnoid hemorrhage during sexual anal self-stimulation in a female: a case report

Sudden death after sexual activity is a well-known entity, but it is rare in females. Herein we present a case of fatal, massive subarachnoid hemorrhage from a ruptured berry-shaped aneurysm, during sexual anal self-stimulation. A 39-year-old woman was found dead on a couch, with the wooden handle of a spring twirl whisk inserted inside her anus and rectum as a dildo-like object. External examination was unremarkable with no signs of injuries. Intracranial examination showed a massive subarachnoid hemorrhage, up to 6 mm in thickness, especially around the brainstem and the inferior side of the brain. After removing the blood clots, the saccular aneurysm was found at the site of the bifurcation of the left internal carotid. In this case study, we underline the utility of forensic autopsy, as well as death scene investigation, in reconstructing the mechanism of death, as well as the dynamics of the event.     

Death after anal "fisting"

A 45-year-old homeless woman was found dead at her usual sleeping place. Apart from traces of blood on the lower abdomen of the body, the police investigations did not produce any clues pointing to an unnatural death. At autopsy, it was found, however, that death had been caused by extensive disruptions of the intestine. After being confronted with the results, the sexual partner of the victim admitted manual anal penetration, but claimed that this had been done by mutual agreement. The court did not accept that statement and sentenced him to life imprisonment for murder. The frequency of such fatal outcomes of anal penetration, the relationship between the perpetrator and the victim and the special features at the scene are discussed.     

Thiodicarb and methomyl tissue distribution in a fatal multiple compounds poisoning

Abstract:  Thiodicarb is a nonsystemic carbamate insecticide whose acetylcholinesterase activity is related to its main methomyl degradation product. A 40-year-old woman was found dead in her car. Empty packages of medicines and an open bottle of Larvin^® containing thiodicarb were found near her body. No signs of violence nor traumatic injuries were noticed upon autopsy, and police investigations strongly suggested a suicide. Systematic toxicological analysis performed on postmortem specimens revealed the presence of various sedatives, hypnotics, and antipsychotic drugs in blood, urine, and gastric content. Some of the compounds identified were determined at blood concentrations well above the known therapeutic concentrations: zolpidem (2.87 mg/L), bromazepam (2.39 mg/L), nordazepam (4.21 mg/L), and levopremazine (0.64 mg/L). Specific analysis of thiodicarb and of its methomyl metabolite was then performed on all fluids and tissues collected during autopsy by liquid chromatography ion trap tandem mass spectrometry (LC-MS-MS). The anticholinesterase capacity of blood, urine, and gastric content collected at autopsy was 83%, 82%, and 32%, respectively (normal value: 0%). The presence of thiodicarb in the bottle found near the body corroborates the hypothesis of an intake of that compound. Although thiodicarb was only detected in gastric content (24.3 mg/L), its methomyl metabolite was quantified in most postmortem tissues and fluids: gastric content (19.9 mg/L), peripheral blood (0.7 mg/L), urine (8.5 mg/L), bile (2.7 mg/L), liver (0.7 mg/kg), kidney (1.7 mg/kg), lung (1.5 mg/kg), brain (9.3 mg/kg), and heart (3.6 mg/kg).     

Fatal penetrating abdominal injury by a metallic projectile

Penetrating abdominal injury is often a life-threatening condition, which is mainly associated with inflicted injuries. Fatal self-inflicted sharp force abdominal injuries too have been reported in the literature. Inadvertent penetrating abdominal injuries are a rarity and are caused by sharp objects of low-velocity and often nonmissile-type. A 27-year-old male factory worker was brought dead to the emergency department with an alleged history of sustaining abdominal injury by a sharp metal projectile while working on a metal cutting grinder. Autopsy observations were consistent with the history of inadvertent penetrating injury. Our case reports a fatal missile-type inadvertent sharp force trauma over the abdomen with intestinal perforation, a relatively uncommon scenario in occupational/workplace settings. The present case report describes the significance of the death scene visit and corroborating the medical findings with investigating agencies. This case further emphasizes on the need for adopting proper safety measures at the workplace.     

Multidrug poisoning involving nicotine and tramadol

A fatal case of multidrug poisoning by tramadol and nicotine is reported. Tramadol is a centrally acting analgesic used in the treatment of moderate to severe acute or chronic pain. Nicotine, a lipid-soluble alkaloid, is one of the most readily available drugs in modern society. A 46-year-old man was found dead in his bed, and a suicide note was discovered near the body. He had 25 transdermal nicotine patches attached to his thorax and abdomen. Two half emptied bottles were found on the bedside table; the toxicological examination revealed that they contained tobacco and nicotine as well as other drugs such as diphenhydramine. At autopsy, areas of fresh and old myocardial infarction as well as diffuse pulmonary congestion and edema were present. The tramadol concentration was 6.6 μg/mL in femoral venous blood, while levels of nicotine and its primary metabolite cotinine were determined to be 0.6 and 2.0 μg/mL in femoral venous blood. Based on these results, we determined the cause of death to be cardiorespiratory failure induced by the additive effects of tramadol and nicotine shortly after consumption.     

MRI detects hemorrhages in the muscles of the back in hypothermia

Morphological findings in death due to hypothermia are variable and predominantly unspecific. Goal of this study was to check the usefulness of post-mortem cross-sectional imaging methods in the diagnosis of externally invisible findings in death due to hypothermia. Three consecutive forensic cases that died due to hypothermia were examined using post-mortem multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) prior to autopsy. MSCT excluded traumatic skeletal and fatty tissue injury. Using MRI, it was possible to detect hemorrhages within the muscles of the back in all three cases, a so far unknown finding in death due to hypothermia. MRI also allowed the detection of hemorrhages in the iliopsoas muscles. Wishnewsky spots remained radiologically undetected using the present examination techniques. In conclusion, hemorrhages of the muscles of the back might serve as a new sign of death due to hypothermia; however, additional studies on their specificity are necessary. Post-mortem MRI is considered as a good diagnosing tool for muscular hemorrhages, with a great potential for examination and documentation.     

Suicidal yew ingestion

A 41-year-old man was found dead, lying in prone position on the ground near a parking area, where the car of the person was parked. Remarkable were the spasm-like hands of the decedent, cause of death was unknown. Primary an epileptical attack was assumed. A medicolegal autopsy was performed followed by histological and forensic toxicological analysis. Furthermore a plant anatomical investigation was applied. Autopsy revealed fragments of greenish needle-like leaves in the stomach and the intestines, but not in the colon. Plant anatomical investigation indicated the presence of yew. Histological findings were in concordance with the literature, in addition the investigation of bone marrow was performed for the first time. Forensic toxicological analysis revealed the presence of 3,5-dimethoxyphenol, the marker for intoxication with taxus baccata.This case reports the importance of medicolegal examinations in order to avoid misdiagnosis. Here the suspection of an epileptical attack as a possible cause of death was excluded by an autopsy, in addition an intoxication by yew leaves was proved.     

Accidental electrocution during autoeroticism: a shocking case

A case of atypical autoerotic death is described. An 18-year-old white man clad in two brassieres was found dead in his bedroom by his brother. Two wet green terry cloths were under the brassiere cups, connected to the house current via two metal washers and a bifid electrical cord. Literature depicting nude women was found near the victim. Autopsy revealed second-degree and third-degree burns of the mammary regions. Death was attributed to accidental self-electrocution. The authors will discuss typical and atypical forms of autoerotic death.