The “mystery” of the train station: The importance of a forensic approach to a rare case of survival after a train-pedestrian collision

In the early morning a 28-year-old man was found lying on the tracks of a railway station with head injuries and fractures of the cervical spine resulting in permanent quadriplegia. He was in a club about 1 km away until about 2 h earlier and did not have any recollection of what could have happened. Was he the victim of an assault, did he fall down or was he hit by a passing train? The solution to this “mystery” came from a forensic evaluation that included the forensic branches of pathology, chemistry, merceology and genetics as well as the scene evaluation. Through these different steps, the role of a railway collision in determining the injuries was ascertained and a possible dynamic was postulated. The presented case is an expression of the importance of the different forensic disciplines and the difficulties the forensic pathologist encounters when analysing such peculiar and rare cases.     

Forensic odontology: Wrong convictions, “bad apples” and “the innocence files”

Forensic odontology (FO) provides expert testimony; however, new criticism has identified FO as one of the fields that must strengthen its scientific foundations. The recent Netflix documentary titled “The Innocence Files”, featuring wrongful convictions, dedicates three of its nine episodes almost exclusively to bite mark identification (BMI), one of the most questioned tests performed by FO. Although most of the FO fields have an undoubted utility in forensic and juridical context, only BMI has been questioned in recent years; the derogatory expression “Junk science” is used continuously in the documentary almost as a synonym for FO. We present a scoping review of cases reported in the US National Registry of Exonerations in which FO was false or misleading forensic evidence (F/MFE) leading to wrongful convictions. Although in the 26 cases identified the only declared F/MFE was the BMI (excluding any other type of dental expertise), only in 2 cases (7.69%) was F/MFE the sole contributing factor, and in 4 cases (15.38%) there was F/MFE plus three additional factors. Official misconduct was detected in 19 cases (73.08%) and perjury or false accusation in 16 cases (61.54%). It has already been mentioned how dangerous it is to consider FO as synonymous with “bite mark identification”, or even to publicly provide incorrect or decontextualized information. This review shows that erroneous convictions have been exclusively in the field of BMI, and that FO encompasses much more than just BMI. The relationship between the media and forensic sciences has been strained. The perspective of the new culture of risk management in forensics is also discussed.     

Historical forensic pathology – a “new” discipline

Forensic Science, Medicine and Pathology -     

The “Safari” Technique to Perform Difficult Subintimal Infragenicular Vessels

The purpose of this study was to describe the efficacy of planned combined subintimal arterial flossing with antegrade–retrograde intervention (SAFARI) to obtain the precise recanalization of the patent portion of a distal runoff vessel in critical limb ischemia (CLI) patients presenting long occlusions involving the popliteal trifurcation. Four patients at risk of limb loss due to long occlusions involving the leg vessel tree and not suitable for a surgical bypass were treated by the subintimal antegrade and retrograde (posterior tibial or anterior tibial artery) approach. The patent portion of the runoff vessel was previously assessed by magnetic resonance angiography (MRA) and directly punctured under Doppler ultrasound (US) guidance. A subintimal channel rendezvous was performed to allow snaring of the guidewires. Subsequently, a balloon dilatation was performed without stent deployment. All patients were successfully recanalized and had complete healing of the limb lesions. At the 12-month follow-up all patients showed clinical improvement with no major complications related to the procedure. This combined antegrade and retrograde subintimal approach is currently an excellent endovascular option in patients with long occlusions extending onto the leg vessels trifurcation and at risk of limb loss.     

The role of histology in forensic autopsies: Is histological examination always necessary to determine a cause of death?

In England and Wales there is a conflict between the law and advice from regulatory bodies in relation to the sampling of human tissue for histological examination following medico-legal post-mortem examinations. Considering the results of previous publications, we performed a specific study to investigate the role of histology in determining the cause of death in cases at a forensic unit. A retrospective study of 500 adult forensic cases was performed. Cases were categorized by the role the histological examination played in determining a cause of death and its contributory factors. Furthermore, cause of death, manner of death, organ systems involved, and discrepancies were assessed. Of the 500 cases, histology was undertaken in 287 cases (58 %). Microscopic examination provided the cause of death in 2 % of cases where histology had been undertaken, and it added to the cause of death in 8 %. In 61 % of cases microscopy confirmed the macroscopic findings, and in 30 % it did not influence the medical cause of death. Histological examination of all organs in all forensic cases for the purpose of providing a medical cause of death is not supported. Practice guidance should be adjusted to reflect that, while histological examination is essential in certain circumstances, the decision to retain material for histology should be made on a case by case basis at the pathologist’s discretion.     

Disaster victim identification—experiences of the “Autobahn A19” disaster

The chain reaction pile-up on the multilane highway (“Autobahn”) A 19 in April 2011 was regarded as the most severe traffic accident within the last 20 years in Germany. The situation worsened when 34 of the 83 involved vehicles caught fire. As a result of this crash, 8 high-grade heat-damaged victims were found. The victim identification algorithm of the IDKO (Identification Commission of the German Federal Office of Criminal Investigation) was applied as the standard tool for forensic mass disaster evaluation. This approach included inspection of the body at the scene, post-mortem CT-scan with 3-D reconstruction, and full autopsy with toxicological examinations and DNA-analyses. As a result of the investigations we were able to identify all 8 victims. Independent of successful victim identification according to IDKO standards, the exact sequence of events and cause of death remained unclear in some of the victims.     

A lactation credit model to support breastfeeding in radiology: The new gold standard to support “liquid gold”

Breastfeeding has medical and economic benefits and providing an environment supportive of breastfeeding should be a priority in radiology to promote diversity, equity and inclusion. Most breastfeeding radiologists do not meet their breastfeeding goals and inadequate time for pumping is the most commonly cited barrier. The UCSF lactation credit model sets the standard for breastfeeding support in medicine by providing protected time without productivity penalties and it should be adapted and implemented across radiology practices to more fully support breastfeeding radiologists and radiation oncologists.     

Unraveling the mystery of confiscated “jackal horns” in India using wildlife forensic tools

International Journal of Legal Medicine - Internationally, illegal wildlife trade involves highly prized and charismatic species and their derivatives. At the same time, common or less known...     

“The Up and Down Approach” to Localize and Exclude Sites of Intraspinal CSF Leaks

Myelography is a commonly performed procedure to locate cerebrospinal fluid (CSF) leaks in patients with spontaneous intracranial hypotension. Often, the site of leak within the spinal canal cannot be located creating a diagnostic dilemma for clinicians. This technical report describes a novel method to locate and exclude intraspinal CSF leaks in patients with multiple potential sites of CSF leak using a lumbar and cervical approach to inject intrathecal contrast and subsequently performing CT myelography.     

The doctrine of “Reasonable Doctor” in medical negligence: Need to be more reasonable

The model of a ‘reasonable doctor’ has been quite successfully used to deliver justice in disputes involving medical negligence. However, many a times a doctor is held guilty of negligence when viewed through the narrow lens of an ideal ‘reasonable doctor’ and without looking into the circumstances under which he was working which could have actually led to the alleged act of negligence. This short write-up highlights the importance of applying this doctrine more reasonably in the best interest of all stake holders and the drawbacks of the doctrine of ‘reasonable doctor’ in adjudicating medical negligence cases with few international case laws.     

“Broken heart” syndrome in an elder abuse case: forensic considerations from the case

“Takotsubo” cardiomyopathy (also known as stress cardiomyopathy or “broken heart syndrome”) is a recently recognised transient condition that frequently mimics acute coronary syndrome. It is typically precipitated by acute emotional stress. Elder abuse is the infliction of physical, emotional or psychological harm on an older adult. As in other forms of abuse, elder abuse is a complex problem, easily prone to misconceptions and, therefore, to under-reporting. Herein, the authors present a case of a 76-year-old Caucasian woman, living in a dysfunctional family environment, who presented to her local Emergency Department with acute chest pain following an altercation with her daughter. Diagnostic criteria for “takotsubo” cardiomyopathy were met, namely, ST-segment elevation and T-wave changes, a mild increase of cardiac enzymes, an akinesia of the mid-portion and apex of the left ventricle and no significant epicardial coronary artery disease. The victim was admitted to the Cardiac Department on the second day and her condition improved over the following week. She was discharged and sent home after the situation was reported to competent authorities and subsequently to medico-legal services, who assessed the situation while still in-hospital. The case implications are discussed, as well as the impact that such cases may have when addressing elder abuse management and prevention, with a view to improving the forensic examination of these patients.     

Postmortem CT findings of “gastromalacia”: a trap for the radiologist with forensic interest

Autolytic rupture of the stomach, so called gastromalacia, is a well recognized artifact at autopsy. A 50 year old Asian woman with a past history of alcoholism, head injury and posttraumatic epilepsy was found deceased at home following a 12 h period of feeling unwell, seizures and vomiting. Postmortem CT images of the abdomen showed free gas in the peritoneal cavity adjacent to the stomach and no other abnormality. There were no external or radiological features of putrefaction. Appearances were stated by a radiologist to be strongly suggestive of gastro-intestinal tract perforation. Autopsy revealed typical findings of autolytic gastric rupture without features of peritonitis. Cause of death was determined by the pathologist to be “complication of status epilepticus (posttraumatic)”. This case demonstrates that gastromalacia may occur rapidly after death and can be detected on postmortem CT, even in the absence of external putrefactive features or CT findings of putrefaction such as gas within the anterior abdominal wall, cardiac chambers or hepatic vasculature. The radiologist with forensic interest must be aware of this postmortem CT artifact in order to avoid ascribing the presence of free intra-peritoneal gas to antemortem perforation of the bowel.