Edda Guareschi

During the investigation of a shooting homicide, a series of pelvic fractures was found in a young female victim. The cause of these fractures instigated a detailed investigation to establish their relationship, or otherwise, with the homicide. Pelvic fractures can involve any pelvic bones and achieve anatomical instability of the pelvic ring. They can be complicated by internal or external hemorrhages, related to lacerations of major blood vessels or organs, caused by sharp edges of dislocated bone fragments. These lacerations can be life-threatening by evolving into a rapidly fatal hemorrhagic shock. Most pelvic fractures result from high-energy injuries, typically in motor vehicle accidents and falls from a height. In falls from a height, a positive correlation between the level of the height and the seriousness of the injuries has been analysed in the scientific literature and established. Postmortem pelvic fractures are difficult to detect at the autopsy by reason of their anatomical location in the human body, thus the routine use of a non-contrast postmortem computed tomography (PMCT) before performing the conventional autopsy has been recommended since the late 2000s.

The death of an infant, especially outside hospital or medical settings, immediately raises questions, if not patent suspicions, about child abuse. If child abuse is excluded, the differential diagnosis between sudden infant death syndrome (SIDS) and a huge number of congenital or acquired diseases might prove critically challenging for the pathologist. In this chapter, a case is presented where the overall circumstances could suggest child abuse, SIDS and/or medical malpractice. The post mortem clinical diagnosis, which led to assess the cause of death as natural by desquamative interstitial pneumonia (DIP), was achieved by histology. Medical malpractice was ruled out in conjunction with reference to an accurate analysis of hospital records. It is crucial and morally mandatory for both pathologists and law enforcement to remember that misdiagnoses/overdiagnoses in similar cases might hold dire and long lasting familiar, social and legal consequences.

The exhumation of a female toddler girl in 1992 triggered off a long judicial litigation about an alleged commingling of skeletal remains in a modern cemetery setting. The examination of the skeletal remains was conducted using the scientific principles, methodology and practice of forensic anthropology and forensic genetics. Some elements in the skeletal assemblage were easily recognizable as human, and were labelled by morphology, whereas others were fragmented. All bones and fragments were dry and odourless, and most, but not all, showed small size and developmental juvenile morphology. Representative bones of both the juvenile individual and other older individuals were selected for genetic analysis, and compared to the DNA of both the toddler’s parents. The outcome of the combined examination confirmed the commingling of skeletal remains. The case exemplifies how anthropology is a useful forensic tool when dealing with juvenile osteology, posthumous genetic identification and bioarchaeology in modern cemetery settings, especially when unusual taphonomic alterations are observable.

In this case, a 43 years old mentally disabled man died of septic shock, caused by severe and untreated burns. He lived in an apartment in a flat complex, owned and also inhabited by his mother and various relatives who, beyond denying any knowledge of his living conditions, did not seek any medical assistance after a fire broke out into his apartment a few days before death. The carcasses of a dog, a cat and a turtle in different stages of decomposition were also found in the apartment. The following investigation, beyond cause, mode and manner of death, was directed to assess the timeline of the deceased’s mental disability, thus the duration of potential neglect from the family part. The investigation was multidisciplinary, and it revealed about 20 years of neglect of a person whose mental disability was completely unknown by health, social and welfare services. The veterinary forensics assessment determined that also the pets were neglected, and most likely starved to death.

A case of suicide by insulin overdose is apparently simple to handle and file, but it triggers more than a few questions and reflections, both because it is rare and because the postmortem assessment can be quite complex. In this example the deceased person was not immediately identified, and the body was found in the open and close to a water source (creek). Critical information, such as clinical and psychiatric history, and/or a farewell letter, were missing, the body had been hastily moved from the death scene by rescue staff. An entomology expert was also needed for the estimation of the postmortem interval (PMI). The external examination and the autopsy ruled out external violence, but the decomposition stage prevented any reliable identification of injection marks. Postmortem biochemistry on blood was consistent with the hypothesis of hypoglycemic encephalopathy by insulin overdose with suicidal intent as cause, mode and manner of death. A short review of up to date literature on insulin overdoses is also outlined, with the aim of providing solid scientific references for similar cases.

A cold case was reopened three years later, following a suspect’s confession. The victim, a mature lady suffering from Alzheimer’s disease, was murdered for financial reasons, and her body was dumped in the backyard of an abandoned country house. She was positively identified by genetic analysis on her skeletal remains. The inexperience of the expert witness appointed by the procurator led to the necessity of a re-assessment of the skeletal remains, in order to perform a thorough bone trauma analysis, which unearthed a history of domestic violence and abuse dating back at least several years before the homicide. Bone trauma analysis is crucial in the examination of skeletal remains, and it must be distinguished from both pathology and taphonomy. Once established, it should be investigated with regards to antemortem, perimortem or postmortem changes. The case showed a lack of understanding by the Italian judicial system and highlighted the significance of the cooperation between forensic pathologists and forensic anthropologists in the study of skeletal remains.

Postmortem imaging is the application to forensics of imaging techniques used in the routine assessment of clinical diagnoses. The techniques involve, but are not limited to, ultrasound, X-rays, computed tomography and magnetic resonance. The aim of postmortem imaging is to complement, and in some cases substitute, traditional autopsies. Postmortem imaging has developed dramatically since the turn of the millennium. In 2011, the International Society of Forensic Radiology and Imaging (ISFRI) was founded, and in 2013 the related journal was launched. An updated list of imaging techniques and a summary of five cases are outlined in this chapter. The findings in the case study vary from incidental to elements of personal identification, through imaging misdiagnosis and bone trauma analysis. Finally, postmortem imaging is almost always carried out before a traditional autopsy, but a post autopsy imaging is justified in limited cases.

Two natural and unusual causes of death are depicted in this chapter, both regarding adult women living in peculiar social settings. In the forensic pathologist’s routine natural deaths can, sometimes, be more difficult to determine, and explain, than violent deaths, such as homicides, suicides and accidents. The first deceased was a 39 years old woman living alone in an old and isolated country house, whose death was determined at autopsy as a fulminant septic shock by a pelvic inflammatory disease (PID) connected to the intrauterine presence of a contraceptive device (IUD). In the second case, the cause of death of the 44 years old homeless and mentally disabled woman was revealed by histopathological findings, which not only contradicted the diagnosis on admission to the infective diseases ward of the city hospital, but were also inconsistent with both the diagnosis of the cause of death delivered by the treating clinicians and the report of the clinical pathologist appointed to perform the autopsy. The second case was further complicated by the request of the prosecutor to evaluate the possibility of medical malpractice on the part of the hospital’s treating staff.