Case 4 Period of Neglect

One day at the end of June, in Milan (Northern Italy), at almost 06:30 a.m., a 50-year-old white female used an Emergency Call Service Number to request assistance for her 89-year-old mother (Gherardi and Lambiase, 2006). Arriving at the home, the physicians ascertained that the elderly woman was already dead. On the body, they observed some large defects of the skin colonized by Diptera larvae actively crawling and they interpreted them as postmortem changes. The defects were mainly located at the right iliac crest and in the perineal region where some faecal material was present and attached inside the diaper. Skin defects and faeces were heavily colonized by maggots. Based on this evidence, the physicians stated that the death could have occurred few days before body recovery. This estimated time since death was not consistent with the circumstantial data collected from the daughter.

The daughter of the decedent told to the investigators that the previous evening she had prepared the supper and helped feed her mother. A few minutes later, she realized that her mother was breathing in a strange way. This did not alarm her, since this had already happened many times in the past and it was previously naturally resolved. Therefore, she administered to her mother the hypnotic drug that she used to take for sleeping and, in her turn, she went to sleep. The following morning she woke up around 06:00 and found her mother in bed in her usual position. She called her several times, but she never replied. She attempted to waken her by shaking, but was not successful. Finally she decided to ask for medical assistance. With respect to the health of her mother prior to death, she said that the elderly woman had been confined in bed since 2001 when she felt accidentally at home breaking a leg. The long immobility in the bed served to increase pre-existing circulatory problems in the inferior limbs (deep venous thrombosis) causing an ingravescence foot deformation (equine foot with claw toes). Therefore, the elderly woman required daily assistance and was cared for by her daughter. She normally took only anti-inflammatory drugs along with some hypnotic drugs for sleeping.

Some neighbours of the same condominium where the two ladies lived were aware of the incapacitated status of the elderly woman and they stated that they had not seen her since her fall in 2001. Some of them also knew that the two ladies lived alone in their apartment resembling some kind of social isolation.

The neighbours also told the investigators that, on several occasions in the past, they had noted bad odours coming from the apartment. They believed this was because the ladies failed to remove rubbish from their apartment. The physicians as well as the investigators confirmed that the apartment, located at the sixth floor of the condominium, was exposed to sunlight all day long, and was characterized by very poor hygienic conditions and extreme squalor. The mattress on which the body was found lying on was largely covered by brown-blackish stains (Fig. 14.3). This was probably a mixture of dried feces and urine, indicative of poor personal hygiene and suggesting a form of senile-neglect.

Based on the discrepancies between the circumstantial data collected and the physical evidence observed by the physicians, the State Attorney decided to ask for a more detailed cadaver inspection which occurred a few hours following body recovery, at approximately 12:00 the same day. The postmortem changes were consistent with a PMI of 6-12 h according with the report provided by the daughter. Body rectal temperature was 33.7°C, while the room temperature recorded before body removal, at 10:30, was 30°C. Lividity was not fixed and the rigor was in development, present only at small joints like the mandible and fingers. No other signs of putrefaction were observed, such as green or blackish discolouration areas of the skin and/or marbling of veins. At external examination, the body showed poor conditions of nutrition with dystrophic integument along the inferior limbs and muscular masses hardly hypotrophic. The body was dressed in nightclothing and a diaper dirtied with fecal material. The body showed numerous large bedsores at the dorsal region (decubitus lesions caused by supine position), partly covered by sticking plasters, soiled with a brownish mix of feces and urine (Fig. 14.4). Specifically, such decubitus lesions were located in the right

Fig. 14.4 Body of victim showing bedsores covered partially by sticking plasters
Fig. 14.5 Necrotic tissue at right iliac crest showing infestation by maggots

and left scapular regions, along the dorsal line and in sacral area and also at the right parieto-occipital region, into the sub-mammary folds and in left peri-areolar region. On the right side of the abdomen, close to the iliac crest, there was an additional bedsore defect, round in shape, approximately 1.5 cm in diameter, with irregular necrotic borders reddish in colour (Fig. 14.5). The surrounding integument showed multiple small holes, 0.3 cm in diameter, produced by feeding activity of Diptera larvae. Also the skin of the perineal region, after removal of the faecal material attached, showed large inflammatory reaction mixed with some necrotic areas colonized by Diptera larvae.

However, the stage of development of Diptera larvae collected from the skin defects was not in agreement with the above tanatological findings and the brief PMI. The oldest maggots collected were 3rd instar larvae 15 mm long. The maggots were identified as Lucilia sericata specimens no more than 4-5 days of age based on temperatures provided from the nearest meteorological station. During the 7 days prior the body recovery, the MAX Ts recorded in Milan ranged from 33.1°C to 36.6°C (mean MAX T: 35°C) while the MIN Ts ranged between 20.2°C and 25.3°C (mean MIN T: 23°C). These temperatures were used for calculations as these were the only temperature data available to investigators. Although it is well documented that there can be significant differences between temperatures at the scene and those from established weather stations, in this case, the judicial authority did not allow experts to record temperature data at the site in order to compensate for these differences.

In this case the maggots did not show the minimum PMI interval as assumed by the physicians. In fact, Diptera colonization did not occur after death but when the elderly lady was still alive, colonizing the necrotic tissues associated with the bedsores. The period of insect activity (4-5 days) in this case of myiasis showed how long the elderly woman was without any assistance. It was a case of neglect of the elderly by the caretaker, the victim's daughter, who was indicted only for abandonment of incapacitated people (art. 591 Italian Penal Code). The entomological specimens provided enough evidence of such a violation for at least a few days prior to the death. In fact, development of bedsores on the victim may have required less than the 4-5 days in the estimate based on development at ambient temperatures, but certainly not indicative of the 6-12 h estimated postmortem interval presented based on postmortem changes observed to the body. The daughter was found guilty because she did not take care of the multiple decubitus lesions found on the body and/or she never asked for help to any physicians. There was no indictment for homicide since the death was ruled as due to natural causes.

A similar situation was reported by Benecke et al. (2004) for a case from Germany. In this instance, an elderly woman was found dead in her apartment with her foot wrapped in a plastic bag. Based on postmortem changes, the PMI was estimated as being 2 days prior to discovery of the body. Inside the plastic bag were numerous larvae of Lucilia sericata, approximately 4 days of age. Judging from the deep tissue loss, it appeared that the maggots had been feeding on the woman for approximately 1 week while she was still alive. Some had already left the body to pupariate elsewhere.

0 0

Post a comment