Investigation of Suspicious Injury/Death: Putting the Puzzle Together
By John Roark
 Cases of suspicious injury or death are much like a jigsaw
puzzle. Part of the forensic nurse’s role is to assemble the pieces without
jumping to conclusions. Does what you see connect with what you hear?
The responsibility of the forensic nurse is to use all
senses when examining injuries,” says Mary Dudley, MD, MSN, RN, chief medical examiner/forensic pathologist
and district coroner for the Sedgwick County Regional Forensic Science Center in
Wichita, Kan. “What they have, what they see, documenting it very carefully,
listening to what the individual has to say, listening to what is said from all
different aspects, observing body language. There may be a smell of alcohol or
other toxins on the body. Some people have the ability to smell cyanide, which smells like burnt
almonds. There may be the smell of gasoline — if they were dragged under the
car and they have chemical burns, it may be from gasoline.”
Eighty to 90 percent of cases that present have some forensic implication,
says Dudley. “Anything that would have possible medicolegal implications, or when injury
medicine would interface with the law,” she says. “I think it’s very
important, and it’s probably going to be required that the emergency room
nurses have forensic training, so that they are able to identify and know what
to look for on these different types of injuries that they may see.”
What should the forensic nurse be observant of, that will alert her to the
fact that more may be going on than the patient is sharing?
Red Flags
“A lot of times when injuries occur, the history that the patient gives is
inconsistent with the type of injury that they have,” says Linda Ebbert, RN,
SANE, president of Rose Heart Inc., a group specializing in sexual assault
examinations on individuals age 12 and older at University Medical Center in Las
Vegas. “That can be a signal of domestic violence.”
Ebbert recalls the case of a woman in her mid-30s who
continually presented with chest pains. “We did thousands of dollars worth of
tests on this woman, and everything always came up negative,” she says. “Finally
we discovered that yes, there was domestic violence going on in the home; she
was being sexually and physically abused by her spouse. It was a cycle, and
every time that it was going to happen, if she had the chest pain and she got
away; that gave him time to cool down and start over again. Any time forensic
nurse that we see someone with repeated complaints, which after testing are found
to be not valid, there is probably something going on that we need to look into.”
Is the injury consistent with the history that the patient gives? “Who brings them in, and who does the talking? Look for repeated excuses
for injuries,” says Ebbert. “As a SANE, when I encounter someone who
presents as a sexual assault victim, and whomever brings them in does all their
talking for them, I always suspect that there is something going on in the home
that needs to be looked into.”
“One of the things I always look for is repeaters of problems,” continues Ebbert. “They come in with vague complaints. I look for that because there is so much domestic violence going on, and
because of the fact that in at least 30 percent of the cases of domestic
violence, there’s also sexual assault involved.”
Body language plays a major part in patient-nurse interaction. “I
definitely look at their eyes,” says Ebbert. “If they do not make any eye
contact, that gives me the idea that either they do not want to talk to me about
something that is going on, or if they do talk to me, they are embarrassed or
ashamed about something that’s happening to them. A lot of times with those
cases, I find that there is something going on that I need to address.”
What should raise a red flag when examining children? Is the injury
compatible with the age of the child? Are there injuries that they attribute to
another sibling? Are there injuries or bruises that are unexplained, especially
in infants or toddlers? Infants and toddlers may receive bruises, but they would
be over bony prominences, says Dudley. “They may stumble and fall and run into
things and have bruises on the knees or the forehead. But if you see any bruises
along the shaft of long bones, and especially bruises of different ages — that
should raise some questions.”
Dudley also watches for fractures of different ages, especially on children
that aren’t walking, as well as skull fractures or rib fractures without any
history of trauma. There is no reason for fractures or multiple fractures on
children under one year of age, she says. “The story of a child rolling off of
a changing table onto a carpeted floor — that shouldn’t be giving them any
type of serious or fatal injuries.”
“If the child can’t speak, it is very important to document exactly what
the caregiver says happened to the child,” says Dudley. “Is that compatible
with the age and with the developmental process of the child? If they say that
the child turned on the hot water, is the child able to do that? Are there any
developmental delays that would make it impossible?”
Ebbert’s experience with children has provided insight into familial sexual
abuse. “If a young girl is being sexually abused by someone within the family,
I find frequently that maybe they have a younger sibling who is coming up on the
age when their abuse started. They want to get that abuse taken care before it happens to the sibling,”
she says.
Does it all add up?
“The interview process is really powerful because you can read people as to
what they might be trying to mislead you on,” says Bobbi Jo O’Neal, RN, BSN,
F-ABMDI, deputy coroner at the Charleston County, S.C. Coroner’s Office. “Most
people aren’t trying to do that — most cases that we do are natural cases,
they’re not the traumatic homicides that make the paper. But the ones that are
the traumatic homicides are the ones where they’re trying to mislead you. If
you’ve done lots of interviews where they’re natural and you see how people
act when they’re not trying to hide something, you can pick up when people are
misleading you.”
“As a death investigator, the first thing that I’m going to do is look at
the body and make my own assessment of what I’m seeing. Then we talk with the
family, or whoever those individuals may be. From our perspective, we’re not
going to tell them what we’ve found. We want them to say it to us. We want
them to tell us what happened and then compare the two.”
A simple example would be a child who goes to the ER with bilateral
conjunctival hemorrhages, says O’Neal. “You recognize those as what they are. You sit down with the mom or the
caregiver, but you don’t mention the injuries. You want them to mention them
to you. It doesn’t mean that a crime has been committed. When we’re talking
about injuries, we’re going to discuss history, and if they never mention it,
we may not mention it either,” she continues. “I’m trying to get them to
say it. Or maybe I’ll say, ‘I noticed it looks like he’s got some sort of
injury. What happened there?’ All I’ve said is that I’ve noticed
something. To see if they’re going to blow it off, that it was nothing, or if they
say, ‘Oh, I forgot to tell you that.’ If it’s something real obvious and
they ‘forgot’ to tell you…”
“In one particular case we interviewed the (deceased child’s) parents
separately, and they gave the same statements,” continues O’Neal. “The
baby was taken for autopsy, and the medical examiner immediately said it was a
homicide — bilateral conjunctival hemorrhages means strangulation. But when we
went back and reviewed the medical records, the baby had bilateral conjunctival
hemorrhages from birth due to vacuum delivery. So you’ve got to compare what
you are seeing with what people are saying. It’s all one big puzzle. The whole
thing goes together — you can’t take one piece by itself. If you do, you’re
very dangerous.”
Bob Golden, supervisor of medical forensic investigations for the Sidney B.
Weinberg Center for Forensic Sciences in Suffolk County, N.Y., keeps an eye out
for inconsistencies when interviewing. “You get the general sense that the person has their own agenda,” he
says. “Regardless of what you are asking them, they want to give you
information that is self-serving in nature. You’re getting more information
than you were looking for. They’re on their own agenda, they have their own
script.”
“On the other end of the spectrum is somebody that is completely vague in
their statements; they’re not very forthcoming,” says Golden. “Keep in mind that we are talking to people very soon after
the death. Human nature being what it is, you get different reactions. Some
people are very talkative and they want to tell you their whole life story.
Other people can’t wait to get off the phone or can’t wait to get you out of
their house.”
Body Language
Golden also underscores the importance of body language. “I observe where
their eyes are at — are they looking at you? Are they veering away? Even the
posture of a person — are they defensive? Are their arms crossed? Are their legs crossed? Anything to give you a sense
that they are putting up a defensive wall,” he says.
Another important factor, says Golden, is space. “Some people feel very
uncomfortable if you get too close to them when they’re in the process of
trying to falsify their statements,” he says. “By getting a little too
close, less than three feet away — invade their personal space — they get
really uncomfortable and you can actually see them pulling away. They make
frequent excuses to leave: ‘I need a glass of water,’ ‘I need a trip to
the bathroom.’ Anything that will get them away from the table so they can
sort of compose themselves and maybe think about their answers.”
Charles Wetli, MD, chief medical examiner in the division of medical-legal
investigations and forensic sciences in the Sidney B. Weinberg Center for Forensic Sciences, stresses two major points when looking
at what may be a forensic scene.
“Make sure you keep an open mind, and don’t become prejudiced about
things,” he says. “Keep in mind that sometimes the cause of a car crash is a
bullet in the chest. Or the fire is started to cover up a homicide. Those kinds
of things have to be kept in mind. You have to think dirty in these situations.”
“Everything has to correlate together,” he continues. “If you have
knowledge of the scene — that has to correlate with what you find at the
autopsy. If things don’t correlate, then you have to go back and start putting
the pieces together and continue your investigation. For example, it looks like a suicide, but the site of the gunshot wound is
not correct, it’s going at a weird angle — could this in fact be a homicide
made to look like a suicide?”
“You must approach the autopsy with much more intelligence, to answer
questions that are going to be asked anywhere from the next day to five years
later,” says Wetli. “I think the art of forensic pathology or forensic
nursing is going to be to document things now in anticipation of questions that
won’t be asked for maybe three or four years down the road. It’s your one
chance to document everything. If questions do come up, you can go back to the file and look at the
photographs and the diagrams and answer those particular questions that you
have.”
| Cases Involving Children
By John Roark
Cases relating to children are among the most
emotionally taxing to investigate. But the importance of proper investigation is paramount.
“When it comes to children, a hysterical reaction to things seems to kick
in,” says Charles Wetli, chief medical examiner in the division of medical-legal
investigations and forensic sciences in the Sidney B. Weinberg Center for
Forensic Sciences in Suffolk County, N.Y. “The child can be in complete, full
rigor mortis, obviously dead, and the parents will attempt CPR. The child is
then taken to a hospital where it is pronounced dead. With children, you have to really look objectively and put emotions aside.”
“Because of the sympathy generated by a childhood death, there is a
tendency for nurses in particular, in emergency rooms, to allow the family or
family members to come in and hold the baby, view it, and so forth,” says
Wetli. “What’s going to happen if say, the grandmother comes in to hold the
child, she’s grieving and so forth — she’s destroying evidence. Don’t forget that we are living in an age of DNA technology, where you lick
a postage stamp and there’s enough on that stamp for you to be identified.
Now all of a sudden you’re altering all of this evidence. You could be
altering the appearance of various injuries and all kinds of things. So as much
as you want to have sympathy for the next of kin, you have to assume that every
childhood death is a homicide until proven otherwise. You have to treat it from
that perspective on the whole issue. We get this a lot of times from nursery
staff in the ER, saying, ‘How can you be so cruel?’ But you don’t know
that that child wasn’t murdered by one of these caretakers.”
If the child is not deceased, there is a tendency to look at the major injury
component, observes Wetli. “Let’s say a broken arm, for example. You’re
getting your suspicions as to whether it’s an accidental injury versus a
twisting child abuse-type injury. If all the focus is on the major injury, you
have to stand back and look critically at the child for other subtle signs which
will build your case about child abuse.”
“If you have a broken arm, fine. We know the arm is going to be taken care
of,” continues Wetli. “But look at the frenulum of the upper lip — is it
ruptured? This would indicate that the kid was smacked in the mouth. Look for fingertip
bruises on the arms and the chest. Do a retinal examination and see if you can
find any retinal hemorrhages or evidence of prior retinal hemorrhages. These
need to be very carefully documented and photographed both by diagram and by
actual camera because in a couple of days, these things are going to be gone.
That can be very crucial because when you go into the judge three weeks
later, social services goes in and says, ‘We think this child should be
removed from the home, and here are the photographs as to why.’ That’s going
to help you an awful lot.”
Accidents certainly do occur, says Wetli. “There is always the tendency to
assume that the parents are the grieving parents of the child, when in fact,
they may have been the murderer of the child.”
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