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Homicide, suicide, or accident?

15 Dec 2021

  • Local case report highlights need for psychological autopsies of suspicious deaths
BY Ruwan Laknath Jayakody In ascertaining the manner of death in suspicious circumstances, it is important for a psychological autopsy to be conducted and for there to be teamwork between the forensic pathologist and the forensic psychiatrist. This point was noted in a case report on the “Importance of a psychological autopsy to identify the manner of death: A case of a fall from a height”, which was authored by S. Raveendran and M. Vidanapathirana (both attached to University of Sri Jayewardenepura Medical Sciences Faculty’s Forensic Medicine Department) and published in the Medico-Legal Journal of Sri Lanka 7 (1) in June 2019. Raveendran and Vidanapathirana explained that sometimes, it may not be possible for the inquirer into sudden deaths or the magistrate to determine the exact manner of death, in circumstances such as a death following a fall from a height, and that therefore, in such situations, the manner of death may be ascertained as undetermined, as per J.E. Leestma and E.W. Sharp’s “Pathology and neuropathology in the forensic setting”. A fall from a height is defined by K. Turgut, M.E. Sarihan, C. Colak, T. Guven, A. Gur, and S. Gurbuz in “Falls from height: A retrospective analysis” as an injury to a person that occurs after landing on the ground following a fall from a higher place (a person may fall from a ladder, scaffolding, building, roof, or other elevated place or work area). In such circumstances, Raveendran and Vidanapathirana reiterated, the ascertainment of the manner of death may be difficult without performing a psychological autopsy, preferably by a forensic psychiatrist. Psychological autopsy is a tool of research with regard to completed suicide, and the method, according to E.T. Isometsa’s “Psychological autopsy studies: A review”, involves collecting all available information on the deceased via structured interviews with family members, relatives, or friends as well as attending healthcare personnel, and additionally, information collected from available healthcare and psychiatric records, other documents, and the forensic examination. Case report The body of a 49-year-old woman was found on the ground floor of a six-storey apartment in Colombo. She was a foreign national who had come to Sri Lanka as a tourist after travelling 14 hours in a flight. A red-coloured rash and swelling had developed in both her legs since arrival in Sri Lanka. Four days later, she had consulted a vascular (the circulatory system made up of the vessels that carry blood and lymph through the body) surgeon and a duplex scan (duplex ultrasound is a non-invasive evaluation of the blood flow through the arteries and veins) revealed that the venous system (the network of veins that work to deliver deoxygenated blood back to the heart) of both the lower limbs were normal. She was confused and severely disturbed due to her illness and had not slept adequately due to frequent urination. She had cried frequently on the day before her death. On the day of the incident, she had suddenly developed aggressive behaviour and had become confused. A domestic servant said the deceased was talking to herself about her body parts and acting like a film star in front of a mirror. Thereafter, she had started removing her clothes, one by one, and had thrown the clothes outside the balcony. When the domestic servant had tried to prevent her behaviour, the deceased had behaved aggressively and jumped off from the balcony of the sixth floor. Her past medical records revealed that she had bronchial asthma (causes the airway path of the lungs to swell and narrow, and due to this swelling, the air path produces excess mucus, making it hard to breathe, which results in coughing, short breath, and wheezing), arterial hypertension (high blood pressure in the arteries that go from the heart to the lungs), chronic venous insufficiency (occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for the blood to return to the heart from the legs), Forestier disease (characterised by the thickening, calcification, and ossification of soft tissues, mainly ligaments, joint capsules, and insertions of muscles and tendons), hyperlordosis of lumbar spine (excessive curvature of the lower spine), and a lack of vitamin D. The deceased has had arthritis (swelling and tenderness of one or more joints). The body was found naked in a prone position on the cemented floor in front of the building. A brassiere, blouse, panty, underskirt, frock, and some other clothes were also found on the ground floor in front of the building. A blue-coloured intervening metal ceiling sheet showed few indentations. She did not have a family history of suicides or psychiatric illness and had not had suicidal thoughts or previous suicidal attempts. No suicidal letter was recovered from the scene. The clothes were not torn. The autopsy revealed a well-preserved body and she was averagely built and nourished. The deceased had arthritis, a rash, and ankle swelling in both the legs. There were no red or pale patches or frostbites. There were no healed scars or deformities. There were abrasions and minor contusions on the scalp, extensive brush burns and contusions on the front aspect of the body, stretch lacerations of the left inguinal region (groin), multiple extensive bilateral rib fractures at several places, and the transection of the thoracic vertebral column at the T-12 level. No skull fractures, extradural, subdural, and subarachnoid haemorrhages were detected at the autopsy. The brain was macroscopically and microscopically unremarkable. The pericardium (a thin sac that surrounds the heart) was completely ruptured and clotted blood was found around it. The right atrium (the upper chamber through which blood enters the ventricles [one of the two large chambers toward the bottom of the heart that collect and expel blood received from an atrium towards the peripheral beds within the body and the lungs] of the heart) and the left ventricle of the heart were lacerated. The coronary arteries were patent. The aorta was transected and separated just below the arch. Both lungs were lacerated at the hilum (a depression or fissure where structures such as blood vessels and nerves enter an organ) and had collapsed. Peritoneal (the serous membrane forming the lining of the abdominal cavity) bleeding was not significant. No injuries were detected in the diaphragm. The liver was pulped with multiple lacerations. The right kidney was lacerated with surrounding haemorrhagic contusion. Raveendran and Vidanapathirana explained that without conducting a psychological autopsy, a case should not be concluded as a suicide, as it can create a social stigma to the deceased and the latter’s family. Also, as Leestma and Sharp have noted, the next of kin will not be able to get full insurance claims. Further, Raveendran and Vidanapathirana pointed out that reliable clinico-pathological analysis on the basis of the pathology and crime scene is not always possible in predicting the kind and degree of the psychic symptoms that were observed. In this case, the presence of extensive brush burns and contusions on the front aspect of the body, stretch lacerations of the left inguinal region, multiple extensive bilateral rib fractures at different places and transection on the thoracic vertebral column at the T-12 level are suggestive, the duo observed, that the deceased had suffered blunt force injuries. The presence of the transection of the aorta just after the arch, bilateral collapsed and lacerated lungs, kidney lacerations, and multiple liver lacerations with minimal peritoneal bleeding are suggestive, as per R.F. Buckman and P.D. Buckman’s “Vertical deceleration trauma: Principles of management”, that these were due to sudden deceleration following a fall from a height. This was further confirmed by the presence of indentations in the metal intermediate object and independent eyewitness evidence. The deceased had abrasions and contusions on the soft tissues of the head; however, there were no skull fractures or meningeal/cerebral haemorrhages. “Her initial fall stopped as she hit the shed. In that, she probably did not hit her head. Then, from there, she had fallen to the ground, which is a small fall. The lack of skull fractures, meningeal/cerebral haemorrhages, and brain injuries were unusual when compared with earlier reported cases of a fall from a height (V. Armbrustmacher and C.S. Hirsch’s “Trauma of the nervous system” and A.C. Mckee and D.H. Daneshvar’s “The neuropathology of traumatic brain injury”). The brain was congested and had no macroscopic injuries, but the injuries of the brain cannot be excluded completely because of the nature of the quick death and there being no time for the appearance of ante-mortem evidence of diffuse brain injuries/severe diffuse axonal (a long, slender projection of a nerve cell) injuries (Armbrustmacher and Hirsch). Further, the deceased had chest injuries, abdominal injuries, lower limb, and upper limb injuries,” Raveendran and Vidanapathirana explained. Therefore, the cause of death was given as multiple injuries to the body due to blunt force injuries and the injury pattern was consistent with a fall from a height. The next important medico-legal issue in this case was the manner of death – whether it was a homicide, suicide, or accident? The deceased was living happily and returned to her homeland to see her relatives and native places. According to the history from the relatives and the witness, there had been no reasons to commit suicide. The deceased had jumped out through the balcony of the sixth floor and it had been witnessed by the domestic servant. It was compatible with an act of suicide when it is analysed superficially. It may be further supported by her illness and depressive symptoms such as the loss of sleep and crying before the incident. Her body was found naked and she had removed her clothes before jumping off from her sixth floor residence. “Paradoxical undressing with the hide and die syndrome in hypothermia was excluded due to the absence of other associated features such as red or pale patches or frostbites, where the victims, despite low environmental temperatures, paradoxically remove their clothes due to a sudden feeling of warmth, and the temperature of the environment in this case was warm (E. Descloux, K. Ducrot, M.P. Scarpelli, A. Lobrinus, and C. Palmiere’s “Paradoxical undressing associated with subarachnoid haemorrhage in a non-hypothermia case?”). However, she had behaved in a confused manner before the act of jumping, which is compatible with acute psychotic behaviour. Therefore, her sudden onset of abnormal and violent behaviour may be an act of automatism without volitional control due to an undiagnosed inorganic or organic disease of the brain (R.J. McCaldon’s “Automatism”). The deceased had arthritis and a rash on both legs and chronic venous insufficiency, which may be associated with various types of vasculitis (inflammation of the blood vessels) and autoimmune disorders, and may be the other cause for the transient hypoxia (oxygen is not available in sufficient amounts at the tissue level) to the brain or autoimmune inflammatory encephalopathy. These are, according to S.K. Matthew and J. Dalmau’s “The merging link between autoimmune disorders and neuropsychiatric disease”, called autoimmune brain diseases. “It might not have been diagnosed earlier and such illness therefore may also be a reason for her sudden provocation with psychotic symptoms and the self motivated act of jumping off from a height,” Raveendran and Vidanapathirana elaborated. According to the forensic psychiatrist’s opinion, different types of psychiatric disorders can cause depression, aggressive behaviour, bizarre type of activities, and suicidal tendencies. If the above disorders are excluded, then the psychogenic, organic and non-organic automatism induced behaviour can be considered as the reason for her jump. These, Raveendran and Vidanapathirana emphasised, are beyond the scope of the forensic pathologist; however, they can be diagnosed by performing a retrospective psychological autopsy by a forensic psychiatrist, though this is not a routine practice in Sri Lanka. If the act was due to an automatism caused by an organic disease, it should be detected by the forensic pathologist through a thorough autopsy investigation including multiple sections of the brain with special stains and immunohistochemistry, as per Leestma and Sharp. However, except for the combination of two histological stains (hematoxylin and eosin), these tests were not done in this case due to the lack of facilities. Therefore, such meticulous autopsy investigation is important for the forensic psychiatrist to interpret automatism. In “Extreme complication of a somnambulism death due to an accidental fall from a height”, S.R. Kolle and V.A. Chaudhari reported a case of a 21-year-old man who succumbed to injuries following a fall from a three-storey building with a homicidal or suicidal act suspected by the relatives and the Police, but which was later concluded as an accident due to somnambulistic automatism. Therefore, the importance of a retrospective psychological autopsy in such circumstances is reiterated for the forensic pathologist in order to reach the final conclusion regarding the manner of death. Finally, in this case, the magistrate reported the manner of death as being due to an accident. The witnessed suicidal behaviour was reverted to an accident as a manner of death since labelling such as suicide will end up in both negative social stigma and the loss of insurance claims.


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