Histologic evidence of repetitive blunt force abdominal trauma in four pediatric fatalities

In cases of acute fatal child abuse, certain injuries, including cutaneous blunt force trauma, skull fractures, subdural hematomas, intra-abdominal hemorrhage, and retinal hemorrhages are common and well described in the pediatric and forensic literature. These gross findings at autopsy, when taken into consideration with scene investigation and interviews with caregivers, may indicate both a clear manner and cause of death. In such cases, the discovery of additional pathologic changes attributable to older abusive injuries helps support a conclusion of death due to inflicted trauma. We discuss four cases of fatal child abuse in which acute blunt force abdominal trauma was the cause of death. In each of these cases, careful examination with proper sectioning and microscopy of select abdominal tissues revealed that the acute tissue trauma was superimposed on a background of older, healing injury. This older trauma was characterized by classic histologic elements of tissue repair, including fibroblast proliferation, early scar formation, increased vascularity, and hemosiderin-laden macrophages. Iron and trichrome stains were used to confirm the presence of hemosiderin and fibrosis in all four cases, but the recognition of fibroblast proliferation and a reactive vascular pattern was best seen on routine hematoxylin and eosin stains. The gross and microscopic autopsy findings, along with available investigative information, established the diagnosis of chronic physical abuse.     

False allegation of child abduction

Cases in which a child has been falsely reported as missing or abducted can be extremely challenging to the law enforcement agencies responsible for their investigation. In the absence of a witnessed abduction or an obvious crime scene, it is difficult to determine whether a child has actually been abducted or has become a victim of a homicide and a false allegation. The purpose of this study was to examine falsely alleged kidnapping cases and identify successful investigative strategies. Sixty-one adjudicated false allegation cases involving 66 victims were analyzed. The mean age of the victim was 5 years. Victims came from generally unstable, high-risk family situations and were killed primarily by biological parents. Victims were killed because they were unwanted or viewed as an obstacle to a desired goal, or they were victims of abuse or maltreatment that ended in fatality.     

The predictive value of history and scene investigation for toxicology results in a medical examiner population

Medical examiner offices vary in the extent to which they pursue postmortem toxicology. Our office routinely tests decedents for ethanol and drugs of abuse, and we decided to evaluate the usefulness of our practice. We reviewed 1180 medical examiner cases examined in 2002-2003. History and scene investigation indicated that alcohol or drugs of abuse were likely to be detected in 369 cases, yet toxicology testing revealed an intoxicating substance in 589 cases, a prevalence of 50%. Screening for toxicology testing based on investigative findings had a sensitivity of 0.47, a specificity of 0.84, and a positive predictive value of 0.74. Moreover, even in the 811 cases where initial investigation did not suggest substance abuse, toxicology testing revealed at least 1 substance that was pertinent to the subsequent investigation in one third of the cases (260), and the intoxicating substance was sufficiently important to merit inclusion as a cause of death or contributing factor in nearly half of those cases (113). We conclude that investigation alone is ineffective at predicting the presence of intoxicating substances within decedents.     

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario,Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.     

Who made the disclosure? Recorded discussions between children and caretakers suspecting child abuse

Within investigations of suspected child abuse, the child's account is often at the core of the judicial process. When analysing the child's account, it is therefore important to consider how parents may have discussed the suspected abuse prior to the official investigation. However, no studies up to the present time have investigated discussions in real cases where parents suspect that their children have been abused. We analysed a sample (N = 19) of recorded conversations between parents and their children, delivered to the police as evidence for alleged physical or sexual abuse. Analyses of the questions used and the information provided in the discussions showed that the parent's strategies when questioning their children were extremely leading and that in the majority of the cases, all new information was provided by the parents. In spite of this, the parents deemed the recorded conversations as records of the children's accounts. While the sample was small and likely to be unrepresentative of child abuse suspicions in general, the findings have important practical implications. The results indicate that when planning an interview in a case where the alleged abuse relies on what a child allegedly has told a parent, particular caution should be taken when referring to these conversations.     

Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome

A morphometrical analysis of retinal hemorrhages was performed in cases of physical child abuse including the shaken baby syndrome and in controls (severe head injury, intravital brain death, non-traumatic intracranial hemorrhage, SIDS including cardiopulmonary resuscitation). The extent of the retinal hemorrhages was significantly different between both groups. In all cases of physical child abuse, massive retinal hemorrhages in at least one eye could be found ranging between a maximum value of 19.2 and 73.2% of the entire retinal area. In contrast, only two cases of the control group (severe head injury with skull fractures and intracranial bleeding following traffic accident or fall) showed slight hemorrhages of 3.33 or 1.18% of the retinal area but only in one eye. Therefore, the results provide evidence that massive intraretinal hemorrhages indicate violent shaking — in particular in association with other signs of physical child abuse.     

574例高坠死亡案件分析

目的通过对大量高坠死亡案件的现场分析、尸体的损伤形态学观察并结合案情调查资料,构建高坠案件法医病理学案例库,为研究疑难坠落死亡案件奠定基础。方法收集并回顾分析5省市574例高坠死亡案件资料,包括死者个人信息、现场勘查资料、尸检结果、精神疾病史和毒物检验结果。结果男性的意外死亡率明显高于女性;在0～10岁年龄组未见自杀案例;在60岁以上年龄组,自杀率明显高于意外死亡;大多数的意外案例都发生在工作地点;坠落高度在10m以下的案例中,落地最先接触部位以头部居多,而在10～25m高度,足或下肢多见。结论大多数高坠案例都有明确的结论,但部分案例成伤机制及死亡方式判断呈现明显分歧,应为今后坠落伤研究的重点方向。     

Commotio cordis: A case report of a fatal blow

Commotio cordis secondary to a blunt blow to the chest wall can result in ventricular fibrillation and sudden death in children. While it is commonly reported in adolescents during sporting activities, it may result from non-accidental trauma especially in infants and younger children. We report a case of a 6-month-old baby boy who presented to the emergency department in cardiac arrest. The patient's hospital records, postmortem imaging, and the autopsy results were reviewed. External examination of the infant did not reveal any evidence of trauma. Postmortem imaging revealed multiple healing posterior rib fractures and a metaphyseal corner fracture, both considered fractures highly specific for physical abuse. The autopsy revealed a structurally normal heart with no microscopic abnormalities. The infant's father confessed to hitting the child on the chest after which the child became unresponsive. Given the constellation of postmortem imaging and autopsy findings in addition to the father's confession, the child's death was ruled as a homicide secondary to commotio cordis. Since there are no structural and microscopic abnormalities in the heart autopsy in cases of commotio cordis, timely on-scene investigation and a thorough investigation regarding the mechanism of injury are required to make this diagnosis. Early identification of non-accidental trauma is crucial and can prevent further abuse in other siblings.     

The Infant Injury Database: A Tool for the Study of Injury Patterns in Medicolegal Investigations of Child Abuse

In 2012, the Harris County Institute of Forensic Sciences began prospectively collecting injury data from pediatric autopsies. These data and associated case information from 635 pediatric cases are archived in the Infant Injury Database (IID). This paper introduces the IID to the forensic community and demonstrates its potential utility for child abuse and infant fatality investigations. The database is intended to be a source of evidence‐based research for coroners/medical examiners and clinicians in the recognition and diagnosis of child abuse. RR estimates were employed to quantify the relationship between individual autopsy findings to trauma‐related and nontrauma‐related causes of death. For example, unsurprisingly, the RR of trauma cases with multiple injury types is significantly greater than other causes of death, but the RR results provide a quantitative representation of the relationship. ROC curve modeling of the presence/absence of various injury types performed well at discriminating trauma from other causes of death (AUC = 0.96).     

Case report: Forensic anthropological assessment in a suspected case of child abuse from South Africa

Not many case reports of suspected child abuse as assessed solely on skeletal remains are available. Forensic anthropologists have intimate knowledge of normal skeletal anatomy, bone trauma and processes of healing of bone and may therefore be of help in suspected cases of child abuse. Patterns of trauma in juvenile skeletal remains which are suggestive of abuse include fractures in different phases of healing, multiple fractures, typical fractures on ribs and long bones and severe, complicated cranial fractures. The aim of this paper is to report on the findings of the analysis of the skeletal remains of a 3.5 years old boy. Forensic pathological examination indicated that the boy had died from a massive cranial fracture, with multiple injuries present to the rest of the body. After the body had been buried for some time, it was exhumed and we were requested to look for signs of chronic, long-term abuse. Findings included a massive cranial fracture, another fracture in the roof of the orbit, two areas of non-specific subperiosteal bone growth and several untreated carious teeth. No clear healed fracture could be found, except for a possible healed cranial base fracture which stretched transversely across the petrosal bone. This area showed signs of recent bone activity. The court decided that this was not enough evidence of chronic abuse and found the accused guilty of murder but not of chronic child abuse. This case illustrates the difficulty to obtain clear signs of chronic injury on juvenile remains.     

Suicide by intravenous injection of cocaine. A report of three cases

Death as a consequence of cocaine abuse is continuing to increase in all parts of the United States. Cocaine use may cause the development of psychosis, with subsequent expression of suicidal ideations, and potentially even successful suicide. Cocaine dependence may also cause depression in the individual who is unable to control his or her craving for the drug, and suicide may be perceived as the only solution to a desperate problem. Despite the dramatic escalation of cocaine abuse and the potential toxicity of this drug, there have been no reports within the United States of cocaine being used as the agent to accomplish a suicide. Herewith are reported three cases in which depression and desperation over cocaine dependence were the motivations for successful suicide, which was accomplished through the intravenous injection of cocaine to the point of death. True cocaine suicide is probably only identified through the presence of objective scene information that unequivocally proves suicidal intent, such as notes or letters which contain information to this effect. A careful search of the scene of death in cocaine fatalities is mandatory, and diligent application of routine scene investigation principles may reveal that suicide through the use of cocaine is more widespread than first appearances would suggest.     

Inflicted head injury in infants

There is scant neuropathological information in the child abuse literature; even the best reviews include assumptions based on the findings of a few inadequate early studies. Our recent series of 53 fatal cases (Brain 124 (2001) 1290, 1299 [1,2]) demonstrated age-related patterns of brain injury and showed the substrate of severe encephalopathy in the infants to be hypoxic brain damage, not diffuse traumatic axonal injury ('DAI'), as had previously been thought. About one-third had craniocervical injuries, particularly in the brain stem, suggestive of stretch injury to the neuraxis. Our interpretation was that this finding implied a mechanism of injury--brain stem damage from stretch injury to the neck with resultant apnoea--that could account for the clinical scenario in many cases, and for which violence would not necessarily be required. Since publishing this study we have turned our attention to the subgroup of infants who die without objective signs of injury, such as skull fracture or impact, whose carers are accused of abuse, usually, "violent shaking", on the pathologic findings alone. Given the striking discrepancy that there often is in such cases between the relatively trivial findings in the brain and the accusations of violence, we have been looking at the pathogenesis of the typical intracranial bleeding. A histologic study of dura from 50 paediatric autopsies, none of whom had suffered a head injury, has led us to propose that the subdural and retinal bleeding in such cases may well have a physiological aetiology, rather than being caused directly by trauma.     

The case of two trials: Father-son incest

Although efforts for investigating and prosecuting child abuse cases have increased little attention has been paid to juror response to child testimony. This paper, developed as part of a pilot study to test a questionnaire for polling jurors' opinions in child sexual abuse cases, analyzes a case in which there was a reversal of outcome at retrial. Poll results of the jurors' opinions suggest the need for testimony from law enforcement and child sexual abuse experts to explain children's perception, memory, and recall of a reported experience.     

An unusual case of child abuse homicide/suicide

This case report examines a child abuse homicide in which the perpetrator committed suicide a few hours after the infant's death. At the time of the perpetrator's suicide he was not under investigation, nor was he a suspect in the death of the child. Although the literature does not contain reports of similar cases, we are sure they exist. This report raises the question of the degree of social stigma attached to the accusation of child abuse. It also serves as a warning to those who must deal with the potentially suicidal child abuser.     

Sudden infant death syndrome: a subject of medicolegal research

During the last decade, much attention has been paid to the risk factors of sudden infant death syndrome (SIDS). Many researchers have demonstrated that infant-care practices are linked to the risk of SIDS. Prone sleeping, bed sharing, maternal substance abuse, and cigarette smoking have been reported to be significant potentially modifiable risk factors for SIDS. Despite the reports that the incidence of SIDS has decreased by 38% in the United States, it remains the leading cause of death in the first year of life. Deaths resulting from child abuse or neglect inflicted or permitted by their caretakers being second only to SIDS in infant mortalities and some recommendations regarding the differentiation of SIDS and child abuse have generated speculation that some cases of infanticide were misdiagnosed as SIDS. To reach a proper conclusion as to the cause and manner of death of an infant who died suddenly and unexpectedly, investigation must be thorough and professional.     

The Role of Forensic Botany in Solving a Case: Scientific Evidence on the Falsification of a Crime Scene

Forensic botany can provide useful information for pathologists, particularly on crime scene investigation. We report the case of a man who arrived at the hospital and died shortly afterward. The body showed widespread electrical lesions. The statements of his brother and wife about the incident aroused a large amount of suspicion in the investigators. A crime scene investigation was carried out, along with a botanical morphological survey on small vegetations found on the corpse. An autopsy was also performed. Botanical analysis showed some samples of Xanthium spinosum, thus leading to the discovery of the falsification of the crime scene although the location of the true crime scene remained a mystery. The botanical analysis, along with circumstantial data and autopsy findings, led to the discovery of the real crime scene and became crucial as part of the legal evidence regarding the falsity of the statements made to investigators.     

Sex differences in the experience of child sexual victimization

This study analyzed 390 (303 girls and 87 boys) cases of child sexual abuse to understand sex differences in child sexual victimization. Analyses focused on three domains that have received considerable empirical attention: victims' relationships with the offender, type and extent of abuse, and disclosure. Findings largely replicated previous efforts that reported sex differences in terms of victims' relationships with offenders. Although results also replicated previous findings about sex differences in disclosure patterns, these sex differences were minor in comparison with similarities in the way most instances of abuse were eventually identified. In terms of type and extent of abuse, results were the opposite of previous findings: girls, not boys, were the victims of more physical injury, violent threats, and use of force; and girls, not boys, were more likely to have physically resisted abuse. Divergences in findings were interpreted in terms of memory biases and social forces operating differently on the sexes.     

道路交通事故二次损伤致死17例分析

目的探讨道路交通事故二次损伤致死的法医学鉴定思路和要点。方法收集17例道路交通事故二次损伤致死的案例,通过事故现场勘验和尸体检验收集交通事故发生的基本信息以及损伤分布、性质等资料。根据收集的信息,重建事故发生过程,明确死者的致伤过程,分析损伤的致伤方式和机制、损伤的严重程度,判断属生前伤抑或死后伤,明确死者的死亡原因。结果道路交通事故二次损伤致死案例存在损伤严重,多发伤与复合伤常见,生前伤、濒死伤与死后伤并存,致伤方式多样,致伤机制复杂,甚至多次损伤相互掩盖等特点。结论道路交通事故二次损伤致死的法医学鉴定需结合事故现场勘验、尸体检验等综合分析和判断。