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PubMed2006

An unusual case of suicidal asphyxia by smothering.

A case is presented of a 30-year-old man suffering from borderline personality disorder who committed suicide by means of smothering. He was hospitalized at the psychiatric department of a public hospital for several months and was found dead in the seclusion room. The death resulted from an obstruction of the upper aerodigestive tract after ingurgitation of pellets of toilet paper. A literature review revealed several cases of suicidal asphyxia by smothering of patients with a history of psychiatric illness. Our patient's operating process had not been reported before to our knowledge.

Adult↗
PubMed2006

Mechanisms of unexpected death and autopsy findings in Leigh syndrome (subacute necrotising encephalomyelopathy).

A 21-year-old previously-well woman who was undergoing medical investigations for problems with balance and suspected multiple sclerosis, developed a headache and breathing difficulties, and died suddenly and unexpected at home. The autopsy was unremarkable except for pulmonary and cerebral oedema. However, subsequent microscopy of the brain revealed characteristic features of Leigh syndrome with multifocal areas of astrogliosis, capillary proliferation, and parenchymal vacuolation. While Leigh syndrome is more commonly diagnosed in infancy, manifestations may occur throughout early life into adulthood. Sudden and unexpected death is a rare presentation that may be associated with cerebral necrosis and oedema. An awareness of the variable manifestations of Leigh syndrome is necessary in forensic practice as not all cases will present in a typical manner and sudden death may occur before a diagnosis has been established. The heritable nature of this condition makes accuracy of diagnosis essential.

Adult↗
PubMed2006

Drowning, haemodilution, haemolysis and staining of the intima of the aortic root-- preliminary observations.

In order to demonstrate that hyponatraemia due to haemodilution occurs within the left ventricle following freshwater drowning, and to determine whether lysed blood resulting from left ventricular haemodilution may cause staining of the aortic intima, the following studies were undertaken. Measurements of left ventricular sodium levels were performed in 74 consecutive coronial cases where death was attributed to drowning, consisting of 44 and 30 deceased who were believed to be victims of freshwater and saltwater drowning, respectively. Left ventricular sodium levels differed significantly between the two groups (p<0.001), with a range of 93-147 mmol/L in freshwater drowning (mean=117+/-14.2 mmol/L) and 123-183 in saltwater drowning (mean=153+/-14.4 mmol/L). In addition, the mean sodium level of 117 mmol/L in freshwater drowning was significantly lower than the standard range of 137-145 mmol/L. In a second study, portions of aorta and pulmonary trunk from a euthanised pig were soaked in lysed blood resulting in marked haemolytic staining of the intima of both vessels after 20 min. Water and a mixture of blood and water were then injected into the left ventricles in two further pig carcasses, respectively, resulting in haemolytic staining of the intima of the aortic roots, with no staining of the pulmonary trunks. These studies have confirmed that significant hyponatraemia secondary to haemodilution may occur within the left ventricle in freshwater drowning, and that haemolysed blood is capable of causing staining of the aortic root in an animal model. These results provide further data to support haemolytic staining of the aortic root intima as a possible manifestation of freshwater drowning.

Adolescent↗
PubMed2006

Somnambulistic sexual behaviour (sexsomnia).

Somnambulism or sleepwalking is a viable defence on the basis of automatism. The behaviours that occur during sleepwalking can be highly complex and include sexual behaviour of all types. Somnambulistic sexual behaviour (also called sexsomnia, sleep sex) is considered a variant of sleepwalking disorder as the overwhelming majority of people with Sexsomnia have a history of parasomnia and a family history of sleepwalking. Sexual behaviour during a sleep automatism can vary from explicit sexual vocalisations, to violent masturbation, to complex sexual acts including anal, oral and vaginal penetration. A recent case in England is reported where the defendant was acquitted on 3 charges of rape on the basis of automatism due to somnambulistic sexual behaviour.

Adult↗
PubMed2006

The medical and ethical aspects of photography in the sexual assault examination: why does it offend?

This paper reviews the literature in respect to the photo-colposcopic examination of anogenital injury in the sexually assaulted child, considered to be the 'gold standard' of examination, and how this compares with gross visualisation, still the standard procedure in adult examinations. It then examines the claim that, because the presence of injury does not provide a distinction between consensual and non-consensual intercourse in adults, photo-documentation is unnecessary medically and constitutes an invasive procedure which is ethically unacceptable. The paper questions whether the unwillingness of forensic physicians to extend photo-colposcopy to the examination of adult victims is related more to political and gender issues than to claims made on ethical and medical grounds, and concludes that any move to ban anogenital photography in adult forensic examinations (currently under consideration in the author's own jurisdiction) would possibly constitute an interference with independent clinical judgment and an incursion into the patient's right to evidence-based medicine.

Adult↗
PubMed2006

The epidemiology of drug facilitated sexual assault.

The files of the Victorian Institute of Forensic Medicine were reviewed for all cases of alleged drug facilitated sexual assault for the 12 month period concluding in April 2003. Seventy-six cases were identified from a total of 434 (17.5%) cases of adult sexual assault. The median delay from alleged incident to time of examination was 20 h. Alcohol consumption in the hours prior to the assault was reported by 77%. Alcohol was still present in 37% when subsequently examined, with an average blood alcohol concentration of 0.11% at the time of examination. Forty-nine percent reported using prescription medications and 26% reported the use of recreational drugs. Drugs not reportedly consumed by the subject were detected in 15 cases (20%) of the study group or 3% of all adult sexual assault cases. The drugs detected included cannabis (four cases), antidepressants (4), amphetamines (3), benzodiazepines (4) and opiates (3). The study indicates that covert administration of drugs in the setting of adult sexual assault appears uncommon. The true incidence however may be higher (due to non or delayed reporting) or lower (due to inaccurate self reporting of drug consumption) however the frequent findings of high concentrations of alcohol has implications for the health and safety of these individuals.

Adult↗
PubMed2006

Adolescent complainants of sexual assault; injury patterns in virgin and non-virgin groups.

INTRODUCTION: Misconceptions about the likelihood of sustaining injuries following rape or sexual assault can have a detrimental effect on the justice process. This is particularly noticeable with regard to first time intercourse. Forensic physicians have a duty to put any examination findings in context. This study sets out to compare the findings in virgin and non-virgin adolescents seen at the St Mary's Sexual Assault Referral Centre, after an allegation of non-consensual intercourse. METHODOLOGY: The records of all females aged 12-17 years old, examined in an 18 month period were reviewed. RESULTS: Two hundred and twenty-four clients fitted this group with a mean age of 14.8 years. Eighty-one were "virgins" and 97 had been sexually active prior to the assault. The virgin group took longer to present for examination then the non-virgin group (90 h compared to 44 h). Of all clients 51% had a non-genital injury. These tended to be minor. 32% of the non-virgin group had a genital injury. In the virgin group, 53% had a genital injury, however only 32% had the type of genital injury that would leave permanent evidence of penetration (i.e. if examined several weeks or more later). Alcohol use prior to assault was common. CONCLUSIONS: Genital and or body injuries are not routinely found in adolescents after an allegation of rape or sexual assault even when there has not been previous sexual experience. The absence of injury does not exclude the possibility of intercourse, whether with or without consent.

Adolescent↗
PubMed2006

Facilities for complainants of sexual assault throughout the United Kingdom.

BACKGROUND: A sexual assault referral centre (SARC) is a model of service established to address the forensic and therapeutic needs arising following sexual assault. As yet, only a minority of urban areas in England are served by one, the rest of the United Kingdom (UK) being served by police victim examination suites. OBJECTIVE: To examine variations in service offered to complainants of sexual assault within the United Kingdom in 2005. METHODS: A purpose designed questionnaire sent to all areas of the United Kingdom. Data were received and analysed from 12 of 13 SARCs and 54 of 58 non SARC services. RESULTS: Very wide disparities in service, most marked between SARC and non SARC services. SARCs see a proportion of complainants from non-police sources. The non SARC services do not usually offer a forensic examination without police involvement, and a significant minority have so few doctors that they cannot provide a 24h rota for examinations. Inadequate numbers of forensic physicians are available for child examinations, and a robust service for 'acute child sexual assault' is virtually absent. Photodocumentation with appropriate safe storage is available in all SARCs, while 45% of non SARCs have no facility for photodocumentation. DNA contamination issues were perceived to be significant in many of non SARC services. Most non SARC services for adults do not provide baseline screening for sexually transmitted infection (STI) or offer prophylaxis against STIs. Follow up is by referral to local clinics which complainants may have to arrange themselves. Funded counselling is rare in the non SARCs with the exception of Yorkshire. CONCLUSION: In the non SARC services, lack of co-operative working with local health services, lack of equipment, and lack of 'in house' medical follow up arrangements is the norm. Many areas rely on the good will of a small number of doctors to provide a service without a rota.

Ambulatory Care Facilities↗
PubMed2006

The use of an alternative light source to detect semen in clinical forensic medical practice.

One of the primary aims of forensic examination in sexual offences is to detect and recover biological material that will link the offender with the complainant. One potentially valuable method by which trace biological evidence may be identified in other forensic settings is via the use of an Alternate Light Source (ALS). The aim of this study was to determine whether or not there was any potential benefit in using an ALS as an adjunct in sexual assault examinations to aid the detection of forensically relevant areas on the body which are not identifiable on visual inspection for sampling. We present two case reports, which illustrate the potential value of using an ALS in clinical forensic medical practice as an adjunct in sexual assault examinations to detect potentially forensically useful areas of skin to sample for semen. Prior to introducing the ALS into our clinical forensic medical practice, we undertook a number of simple laboratory studies to determine a protocol for its use. Semen is known to fluoresce using an ALS at a wavelength of 450 nm. Although we did not conduct a rigorous scientific evaluation of the technique, we evaluated the use of an ALS to detect semen on a range of inanimate surfaces as well as human skin. On all surfaces, visibility of fluorescence was increased by reduced distance of light source from the surface and increased concentration of semen on the surface, but was not noticeably affected by the angle at which the light source was held in relation to the surface.

Adult↗
PubMed2006

Suicide by tapestry needle.

A case of completed suicide committed by a 46-year-old male by inserting a tapestry needle in his heart is described. Scene investigation findings and autopsy examination revealed signs of self-harm efforts as well as punctures at both forearms and the right and left sides of the neck. The deceased caused a penetrating cardiac injury which resulted in cardiac tamponade.

Cardiac Tamponade↗
PubMed2006

A deceptive case of gunshot entry wounds -- beware of frangible bullets.

In December 2003, two young men decided to go shooting in the countryside near Montpellier, France. One accidentally shot the other. Upon crime scene examination and autopsy of the victim experts observed, at the right thorax, two round wounds, distanced 5mm from each other, presenting typical characteristics of entry wounds of bullets shot from a distance. Because of the presence of two clear cut round wounds, the Procurator suspected voluntary homicide. However, thanks to the balistics expertise, the authors concluded that all fragments belonged to a unique projectile, 22 Short caliber (Remington cartouche) of the frangible type. The barrel of the rifle infact presented an imperfection where the screw was fixed on the frontsite. The screw had obviously been changed, and the new screw was longer and therefore extended into the barrel, causing a small obstacle to the bullet when exiting the barrel. Shooting tests were performed, allowing the authors to conclude that a single bullet had fragmented before entering the body into two fragments. This lead the Procurator to consider the lesions consistent with an accident.

Accidents↗
PubMed2006

Sudden death due to sickle cell crisis during law enforcement restraint.

We report a case of vaso-occlusive sickle cell crisis in a young schizophrenic man with undiagnosed sickle cell trait who was restrained. Prior to being restrained he had locked himself in his apartment for two days without food or water. He was subsequently restrained, and transferred to hospital while handcuffed to the stretcher. He died suddenly during restraint. At autopsy, there was acute vaso-occlusive sickle cell crisis associated with hypernatremic dehydration. There were no injuries present. We conclude that the death was due to vaso-occlusive sickle cell crisis secondary to dehydration. It is important for the forensic pathologist to remember that death may occur suddenly during restraint from an unexpected mechanism other than excited delirium leading to cardiac arrhythmia or restraint asphyxia.

Adult↗
PubMed2006

Dramatic lightning injury with exit wound.

This is a case report of an environmental accident due to lightning where one school boy sustained current, blast, and flame effects of it. A bolt of lightning directly struck the pole of a football ground and the scatter struck the child. In addition to burn injuries, he showed an exit wound of lightning in left foot. The exit wound of lightning current is a very rare finding. The body of victim had flame and heat effect of atmospheric electricity on head and neck, face, and trunk. In this incidence of lightning other team mates of the victim were safe. The patient survived the attack.

Burns↗
PubMed2006

Sudden death due to tuberculosis.

Forensic pathologists deal not only with criminal, accidental and suicidal deaths, but also with a wide range of deaths from natural causes. Many of these deaths are sudden, unexpected, clinically unexplained or obscure, even though there need be no criminal element in their causation. Unnatural deaths have always to be investigated by the police, but very often natural deaths forms the basis of medico legal investigation, if they had occurred suddenly in apparently healthy persons. Often at autopsy these so called unnatural deaths may turn out to be natural and vice versa. Two cases of sudden death occurring in young individuals under suspicious circumstances are presented. On autopsy they were diagnosed to be secondary to tuberculosis.

Adult↗
PubMed2006

Bandaged penis.

This is a case of a male in his late 30s who died due to acute myocardial ischemia. His penis was bandaged. The penis was inflamed and had infected abrasions. The possible relevances of such an incidental finding and its contribution to sudden death is explored. The case report shows photographs of the bandage in situ and its components, inflammation of frenulum, injury to the shaft, and the generalized inflamed and mildly swollen penis. These changes were considered to be caused by bites. The micro-photographic findings in the case were of acute myocardial ischemia, pulmonary oedema, and fatty liver.

Adult↗
PubMed2006

A degloving foot injury in a traffic accident.

An unusual human remain found on a road became one key to reconstruct the traffic accident. A woman was found dead on a snow-covered road. Her left foot showed a large deficit of skin and underlying fat tissue. The detached skin and tissue were found into her left sock and shoe lying at a distance of 23 m from the body. There were multiple fractures on her back and occipital cranial bone. Severe injuries revealed in heart, liver, and brain. The neck remained intact. These findings suggested that her back has been strongly hit by the object with the flat surface, for example, the front side of a cab-over or truck, from behind at a high speed. Furthermore, the degloving injury in her left foot suggested that a vehicle ran over the foot which faced the vehicle. We reconstructed the accident as follows. Firstly the wheel of the vehicle ran over the victim's foot, and then, the victim turned away from the vehicle. Finally, the front side hit her twisted body from behind, resulting in a traumatic degloving injury.

Accidents, Traffic↗