Abstract
It is not always possible to determine the exact origin of death in cases of suspicious female deaths. Deaths resulting from falls present many challenges in forensic medicine. In order to overcome these difficulties, we screened the approaches to suspicious female deaths from international documents aimed at preventing violence against women worldwide, and we conclude that the Latin American Model Protocol (LAMP) is the most qualified one in addressing this issue. We have converted the LAMP into a checklist, compared it with the circumstances in the cases we present, and evaluated the potential benefits that LAMP could provide. The study examines three cases of women from Turkey who have died by falling from a height. In all cases, the women's partners were present with them at the time of incident. In all these three cases, partners were in a legally suspicious position and claimed that the incident was a suicide. The investigation and trial processes were different in all three cases, and various difficulties were encountered during the establishment of the truth. This study has demonstrated that, despite the actual occurrence of femicide, the use of the investigation steps proposed by LAMP and a comprehensive approach utilizing the scientific methods of forensic medicine, law, and other disciplines that can assist in analyzing the incident during the investigation process can help reveal the cases where defendants claim cases are suicide despite cases being a femicide.
Introduction
In recent years in Turkey, the suspicious deaths of women and the recording of these deaths as “suicide” or “accident” in official records have been increasing. 1 In some cases, no legal investigation is initiated; in others, even if an investigation is launched, the lack of evidence is cited as a reason, hindering the revelation of the truth. In some instances, despite the existence of evidence, cases are closed with a false manner of death due to the defendant's misleading tactics. However, in a limited number of cases, detailed legal examinations are conducted, often brought to the attention of the public through local or national media or through the efforts of women rights organizations that families individually apply. In these instances, the true nature of the situation is proven to be a femicide.
It is highlighted that in death investigations conducted in Turkey, there is a lack of standardization as well as serious deficiencies and errors in the investigation processes. This issue has also been emphasized in studies evaluating decisions of the European Court of Human Rights regarding the violations of the right to life. 2
According to data compiled by the “We Will Stop Femicides Platform,” a non-governmental organization monitoring femicides in the country, based on cases reported to them by the relatives of the deceased for the purpose of tracking the process, the increasing incidence of suspicious deaths of women is considered as a data point indicating not only a quantitative increase in violence but also a qualitative change (Table 1). This additive increase in suspicious women's deaths to the already high rates of femicide is seen as evidence of a shift in the nature of violence. 3
Rates of femicide and suspicious female deaths by year.
According to the same database, between the year 2020 and the first ten months of 2023, 10 women have suspiciously fallen from heights and lost their lives while in the presence of their spouses or boyfriends. When examining the methods of homicide in all cases, it is observed that firearms take the lead, followed by the varying use of cutting-piercing tools, strangulation, and the use of blunt traumatic objects. Women are most frequently killed by their officially or religiously married spouses, divorced spouses, partners, or family members. The primary reasons for the homicides include women's desires to make decisions about divorce or their own lives.1,3,4 During the period between 2020 and 2021, the COVID-19 pandemic, which adversely affected the entire world, is thought to have increased domestic violence cases, resulting in a numerical rise in female homicides.5,6 In this period, the prolonged coexistence of usual suspects and women in the same environment as a medical necessity may have led to a higher numerical increase in suspicious female deaths, as seen in Table 1. Furthermore, the economic crises and inflationary conditions experienced in many countries worldwide during this period, including Turkey, are undeniable factors playing a role in the numerical increase of female homicides, as evidenced by studies in the literature.7,8
In contemporary contexts, categorizing the death of women under terms like femicide or feminicide is deemed necessary from a feminist viewpoint to prevent their recurrence.9–11 However, determining the cause of death in falls from height poses significant challenges in forensic medicine, often defying clear determination solely through autopsy findings. Efforts to ascertain whether such incidents constitute homicide, suicide, or accident remain insufficient, emphasizing the need for multidisciplinary expert opinions. Situations where individuals, lacking relevant medical history, experience sudden and unexpected deaths, are deemed suspicious.12–15 It's crucial to clarify whether these deaths are accidents, suicides, or homicides for both the criminal justice system and forensic medicine. An ethical approach mandates determining causes based on professional standards, understanding factors involved in suicides or homicides, and preventing their recurrence. International human rights documents are mainstream in guiding ethical considerations at this juncture.
Despite numerous guidelines to combat the gender-based violence, the absence of specific regulations for suspicious women's deaths complicates the recognition of this issue. While the Istanbul Convention 16 and the Inter-American Convention on the Prevention, Punishment, and Eradication of Violence against Women 17 (Belem do Para Convention) include investigation principles for all crimes of gender-based violence, they do not comprehensively address ‘suspicious’ deaths. As far as we can find, the most comprehensive and detailed regulation on this matter is the Latin American Model Protocol (LAMP), which directly defines the investigation principles for femicides and suspicious deaths of women.9,18
Latin American model protocol
The LAMP, developed by OHCHR and UN Women, provides guidelines for conducting effective criminal investigations into cases where women are killed due to gender-based motives. The protocol aims to improve the practices of public officials, forensic experts, and other specialized personnel within the criminal justice system during the investigations and prosecutions, with the aim of identifying the perpetrators and facilitating the rehabilitation of surviving victims. It encourages the integration of gender perspective into investigation processes while providing practical tools to secure the rights of victims, survivors, and families, both directly and indirectly affected. These tools serve as a guiding force and empowerment for individuals dedicated to combating the impunity in the cases of femicide. 19
According to the protocol, in each case, hypotheses should be formulated based on preliminary findings that define “gender-related motivations” and determining these motivations must be one of the strategic objectives of the investigation. These hypotheses require the exploration of different manifestations of gender-based violence observed before, during, or after the killing of a woman, ultimately leading to a validation or refutation of the hypotheses.18–20 The fundamental steps for effectively designing investigations into femicides and indicators of femicide in forensic autopsies are presented in Table 2, aiming to guide the investigation process in cases of women's homicides and suspicious deaths.
LAMP investigation steps.
LAMP: Latin American Model Protocol.
The steps outlined in the LAMP are believed to serve as a guiding framework for illuminating suspicious death cases observed in Turkey and around the world. Because while the concept of “feminicide” may be seen as a particular issue for Latin American countries by authorities, the issues of “femicide” and “suspicious female deaths” are common worldwide.9,22 Especially for forensic experts and legal professionals whom plays a crucial role in the investigation of deaths, there is a need for a comprehensive gender perspective and a multidisciplinary approach, particularly involving the physical and mechanical aspects, as outlined in the LAMP protocol, to accurately determine the truth behind falls from heights. To illustrate this, three different cases of women's deaths that occurred as a result of falling from a height, with the defendants claiming suicide, were examined from a legal and forensic medical perspective in Turkey in recent years. The findings were evaluated in compliance with the LAMP guidelines.
Methods
The study has been retrospectively designed to include a descriptive evaluation of cases from a forensic and ethical perspective. Among completed cases monitored by the “We Will Stop Femicides Platform” in various regions of Turkey, three separate case files involving women's deaths resulting from falls from heights were selected to reflect the entire sample. The investigation's fundamental steps and stages were transformed into a checklist, and they were compared for compliance with the LAMP investigation basic steps. Ethical standards were maintained throughout the research process. Before starting the analysis, approval was obtained from the Trakya University Faculty of Medicine Non-Interventional Scientific Research Ethics Committee (Approval No: TUTF-GOBAEK 2022/216 Date: 30.05.2022). All case data were anonymized and coded to ensure that they were unidentifiable. The research adhered to the principle of privacy, and no personal or sensitive information was included in the analysis.
Cases
Case-1
Case-1, a woman in her twenties, living in Southeastern Turkey, lost her life by falling approximately 100 meters from a hilly area. During the incident, the victim's husband and a friend of his were also present. Upon the suspected husband claiming that his wife “accidentally slipped and fell,” the prosecutor decided that there is no need for a criminal prosecution. However, the family of the victim sought help from women's organizations to reopen the closed case. Subsequently, a trial process had begun.
Witnesses reported in their statements that the marriage took place without the consent of the woman's family and the husband frequently subjected the victim to physical violence, and a few months before the incident, victim informed her husband that she wanted a divorce of which he responded by saying “There is no divorce in our culture, there is only death.” The defendants denied the accusations, claiming that the deceased lost her balance and fell, adding that she had a previous diagnosis of vertigo.
During the trial process, this situation was examined, and it was found that about three years before the incident, the victim had been hospitalized twice with a diagnosis of vertigo, but no medical treatment had been applied.
In the post-mortem examination conducted after the incident, widespread abrasions, ecchymoses, and lacerations were detected throughout the body. Fractures were found in the ribs, pelvis, and the right ankle. Toxic substances were not detected in blood samples taken from the body, and no DNA belonging to a male individual was found in the nail bed swab samples. However, due to the absence of the forensic medicine expert responsible for the city where the death occurred, an autopsy could not be performed on the body.
According to the incident reconstruction based on the statements of the defendants, the victim and her husband were assumed to be sitting on cascading rocky blocks during the incident. It was determined that the woman, starting from the initial sitting position, moved horizontally 115 cm forward, then jumped twice on cascading rocky surfaces, and fell off the cliff. The first of these steps is approximately 410 cm high and 268 cm long, and the second one is approximately 60 cm high and 120 cm long. The rocky surface ends at the end of this leveling and extends to the edge of a cliff about 100 meters high. During the legal process, the Council of Forensic Medicine was asked to evaluate whether the falling incident was related to external factors, but the response was that it was not possible to medically determine the cause of the fall. Then, at the request of the victim's side, an evaluation of the situation considering the laws of physics was requested from the Physics Department of a university. In the expert report received, it was stated that it was not possible for the fall action to occur unaided, proving that the suspicious death was a case of femicide, and this situation served as the basis for the perpetrator to be sentenced to life imprisonment.
Case-2
Case-2, a 30-year-old woman, who lived in a metropolis in the Western Turkey, lost her life by falling from the balcony of her apartment where she lived with her family, the balcony was about 15 meters high. During the incident, the woman's husband and child were also present at the scene. The victim's husband reported that he woke up to his daughter's crying at night, searched the house, he couldn’t see his wife, saw blood and a knife in the bathroom and a bloody blanket in the kitchen, informed other family members living in the building, and they found his wife's deceased body in the garden area under the victim's balcony.
In their statements, the relatives of the victim reported that there was incompatibility between the victim and her husband and leading up to the incident the husband occasionally subjected her to physical abuse. Prosecutors found that 5 years before the incident, due to the husband's violence, the woman went to her family home and stayed there for a while. On another occasion 5 months before the incident, they saw bruises on the woman's face, and when they asked the cause, she said her husband did it. They also mentioned that the husband recently broke the woman's cell phone, hindering her outside communication.
In the autopsy performed by forensic experts after the incident; in the external examination, 11 cutting-piercing tool wounds distributed in an area of 9 × 5 cm in the upper middle abdomen, 17 cutting-piercing tool wounds and/or cuts in an area of 11 × 4 cm on the front of the neck, a 5.5 cm long horizontal incision on the front of the right wrist that revealed soft tissues, a flap-like epidermal separation in the back of the right thigh and the sole of the left foot, a “Y” shaped laceration near the vertex on the head, numerous ecchymoses, and abrasions of various sizes on the extremities were observed. Fractures were detected in the skull, cervical vertebrae, sternum, clavicle, and ribs. Toxicological analysis did not detect any sedative or narcotic substances, and it was reported that the person's death was due to internal and external bleeding caused by cutting-piercing tool injuries and general body trauma leading to intracranial bleeding and subsequent brain damage.
In the examination of the house after the incident by the prosecutor and the police, a suicide note allegedly left by the victim was found in one of the rooms, a knife and blood pooling were seen on the bathroom floor, a bloody blanket and non-intensive blood traces were seen on the kitchen floor, and a sliding blood trace was seen on the balcony railing in the kitchen. However, no blood trace was found in the corridor extending between the bathroom and the kitchen, and no blood trace was found under the victim's feet. An expert examination was requested to determine whether the alleged suicide note left by the victim was produced by the victim's hand, but no graphological relationship could be established between the comparison writing samples claimed by the defendant in the case to belong to the victim and the suicide note. Also, the relatives of the victim stated during the trial process that the victim could not read or write.
During the trial process, due to the defendants claim that the incident was a suicide, the Council of Forensic Medicine was asked whether it was possible for a person to injure themselves with a knife in this way and then pass through the corridor and kitchen and jump off the balcony by using a chair. The institution responded that it was possible for a person to perform stabbing and jumping actions on their own, the person was alive when falling from the balcony, the knife wounds on the victim were caused by the same knife's sharp or blunt side, and another tool could also have been used.
After evaluating all the evidence obtained during the trial process, the court found that the possibility of the person performing the falling action alone was not in line with the normal course of life, and the victim's husband was sentenced to aggravated life imprisonment based on the report of the Council of Forensic Medicine.
Case-3
Case-3, a person in their twenties living in a metropolis in the Central Anatolia region of Turkey, lost her life by falling from the window of an office building, approximately 60 meters high. At the time of the incident, the victim had two male friends with her. One of the defendants stated that he was in a different room at the time of the incident, and due to the influence of alcohol, he was drunk, so he did not see the incident. The other defendant stated that he noticed the moment the victim was hanging from the window, tried to hold her by the ankle but couldn’t hold and as a result, she fell. The prosecutor, finding the suspects’ statements consistent, ruled for their trial without detention.
The relatives of the victim stated in their testimonies that there was no reason that could lead the victim to commit suicide. A psychological autopsy was performed by evaluating the incident in the Department of Psychiatry at a university and reported that there wasn’t any underlying psychological factor for a suicide. Additionally, cell phone messages sent by the woman to a friend on the night of the incident, indicated an uneasiness with the environment and desire to leave. These were also included in the investigation file.
In the autopsy performed by forensic experts after the incident; numerous contusions, lesions, and lacerations were found on the body, an ecchymosis with a fractured hyoid bone was detected in the middle part of the right horn of the neck, and a chemical analysis revealed ethanol in the person's blood and vitreous humor, and mirtazapine, a drug substance, was detected in the urine, but not in lethal doses. Sperm cells were not observed in vaginal and anal swabs, but prostate-specific antigen and salivary amylase were detected in anal swabs. In two of the nine nail swab samples belonging to the victim, a suitable Y-STR profile for comparison was found. However, the underwear identified to be on the victim in the crime scene investigation images could not be analyzed due to its loss at an unknown stage in the chain of custody, which is crucial for establishing sexual assault. The forensic pathologists stated that a definitive medical opinion on the exact cause of death could not be formed.
The court requested an evaluation from the Council of Forensic Medicine regarding the cause and manner of the death. The committee responded that the detected hyoid bone fracture could be due to strangulation, and the person's death might have occurred as a result of mechanical asphyxia due to compression of the neck and shortly afterward (within approximately half an hour) falling from a height, or the person's death might have occurred as a result of severe general body trauma with widespread bone fractures, major vessel laceration, and extensive soft tissue damage. However, due to severe general body trauma throughout the body, it could not be determined whether there was an additional trauma before the fall, whether the fall occurred with the person's own will or accidentally, and whether mechanical asphyxia due to compression of the neck occurred before the falling event.
Upon this, the victim's side requested a scientific opinion from the forensic medicine department of a university hospital for the examination of the incident. The expert witness, who examined the crime scene and the case file, stated that the position of the window and the objects behind it, along with the inconsistent narrative of the incident drawn by the defendants, and considering the physical characteristics of the victim and the absence of fingerprints of the victim on the mentioned window, it would not be possible for the person to perform this action alone without the influence of someone else. Evaluating all the findings, the court, considering the biological evidence found in the victim as an indication of sexual assault, convicted the defendants of sexual assault, deprivation of liberty, and intentional killing.
Discussion and evaluation of cases in the light of LAMP
The compatibility of the legal processes of the cases presented in the study with the LAMP steps is presented in Table 3. In all cases, there is a woman who lost her life by falling from a height while being with her partner, and their partners claim that this situation is a suicide. This claim of the defendants has been accepted by the prosecutors in cases 1 and 3 where traumatic lesions, except for blunt traumatic lesions, were not observed in the victim, and no hypothesis suggesting that the incident could be a homicide has been formed. However, according to the LAMP principles and the literature, situations where the claim of the woman's suicide raises suspicion are as follows.18,23
Sudden and unexpected death in an apparently healthy individual, Death scene showing signs of suicidal tendencies, The woman being found dead by her current or ex-partner, Secondary evidence of one of the partners wanting to end the relationship, Previous domestic violence cases by the partner, The woman being found dead in her own home.
Assessment of cases according to the Latin American model protocol for investigation basic steps.
These factors are a feature of many femicide cases and in particular missing persons who are later found murdered. In all cases examined in the study, meet at least four of the six specified conditions. However, the failure to consider the possibility of murder at the beginning of the investigations has led to delayed justice. Therefore, in our opinion, the most crucial step in the LAMP process is the “initial hypothesis” step. The failure to form the initial hypothesis that the incident is a case of female homicide can lead to a lack of necessary care in subsequent steps, unnecessarily prolonging the legal process or even resulting in wrongful case being filed at all. 19
In Cases 1 and 3, where the hypothesis is not formed according to LAMP, the process of collecting physical evidence naturally did not take place in accordance with the protocol. Therefore, in these cases, a post-incident scene reexamination had to be conducted with the participation of experts from different disciplines. As is known, a properly conducted scene examination and the involvement of accurate analysts is critically important in determining the manner of death. The use of imaging techniques can assist the analysis of these data by individuals from different fields after the incident. However, it is an undeniable fact that the active participation of forensic experts in the early stages of the scene, personally going to the scene and actively assisting the examination process, enhances the quality of the investigation. 24
Many professionals are involved in the investigation of deaths; this can vary between countries. In Turkey, this task is assigned to all physicians regardless of their specialization. The process of post-mortem examination, which involves medically determining the occurrence of death, the time of death, and identifying the medical identity of the deceased, is conducted by physicians. 25 In cases where the answers to the aforementioned questions cannot be determined through post-mortem examination, bodies are sent to forensic medicine centers for autopsy. However, as observed in Case-1, in some situations, the physicians conducting the post-mortem examination or prosecutors who oversee the forensic post-mortem process may consider that they determined the cause of death through post-mortem examination and choose to send the bodies to cemeteries for burial rather than for forensic autopsy. In such cases, developments that may occur over time (such as the emergence of someone confessing to poisoning of the person) can pose challenges in revealing the truth. In these situations, the individual's grave is opened, and autopsy procedures, as well as toxicological and biological examinations, are carried out on the remains. Some toxic substances or traumatic changes that have occurred in relatively less-decomposable tissues of the body (such as bones) can be identified after the exhumation process, providing insights into the cause and mechanism of death. 26 However, as seen in Case-1, in situations where the defendants claim that the victim fell from a height due to a pathological reason without conducting an autopsy, it will not be possible to make a medical distinction between whether the person was thrown or accidentally fell.
While the responsibility for determining the cause of death in Turkey lies with the physicians, the responsibility for determining the manner of death belongs to the judicial authorities. Regarding a death incident considered to be of a forensic nature, during the investigation stage, public prosecutors, and during the prosecution stage, judges, examine the witness and defendant statements, crime scene investigation reports, and the analysis of evidence, as well as medical treatment records or medical documents related to post-mortem assessments. Based on this examination, they decide on the manner of death and, consequently, under which legal provisions the trial will proceed.24,27 However, even if the physician responsible for determining the cause of death and the judge responsible for determining the origin of death collaborate closely, it is evident, as illustrated in Case-2, that they cannot independently resolve every case. In Turkey, judges have access to the case file containing all details such as crime scene findings, analysis results, and statements from suspects and witnesses. However, judges, due to nature of their profession, are not familiar with the intricacies of the functioning and deterioration of the human body. Therefore, in cases where the object of litigation is a compromised individual, judges seek expert opinions from forensic medicine specialists. However, if forensic experts evaluate the victim solely in terms of injuries, isolating them from the context of events that happened before and after the incident and the crime scene, they can make fallacious decisions, as observed in Case-2. In the real world, a healthy individual can survive after inflicting nearly 30 cutting or stabbing wounds on their body and then throwing themselves from a height. However, if an individual, after inflicting nearly 30 cutting or stabbing wounds on themselves in a room of their home, crosses the corridor without leaving blood trails and throws themselves from the balcony of another room, it raises serious doubts and does not align with neither natural occurrence nor scientific facts.
In cases where the theoretical knowledge of judges and physicians prove to be insufficient during the investigation process of a death incident, forensic sciences, which have adapted almost the entire field of natural sciences to human nature, come into play. 28 Especially with the today's rapid developments in the field of forensic genetics, the use of genetic examinations has become essential, particularly in determining secondary individuals physically contacted the victim. Investigations into sexual assault allegations are a typical example of this. 29 Indeed, in cases of female deaths, the exclusion of the possibility of murder requires the use of all available current technological methods, such as digital crime scene reconstruction as seen in Case-3. The fundamental precondition for each sub-discipline of forensic sciences to effectively contribute to the investigation process is to obtain all evidence detectable at the crime scene and on the body, and to maintain it under strict supervision, as emphasized in LAMP. For example, in Case-3, forensic biological examinations from anal swabs detected prostate-specific antigen and salivary amylase, but sperm or STR profiles could not be obtained. In cases where at least two men are involved in the suspected position with these two biological samples obtained, it is not possible to determine the identity of the individual or individuals who committed the assault. However, if in Case-3, the woman's underwear had not been lost due to oversights in the supervision chain and had the genetic analysis been performed, the true perpetrator or perpetrators of the sexual assault could have been identified.
In deaths resulting from falls from a height, which we emphasize in this study, determining the origin of death is a challenging task worldwide in the field of forensic medicine. We believe that this difficulty fundamentally arises from the relatively limited coverage of the kinetic branch of physics in forensic medicine theory. When looking at a fall from a physicist's perspective, the object falling, even if it is a living individual, is essentially a heterogeneous object that can itself be in motion. The manner, duration, and position of the fall are influenced by different forces acting on this object. In the case of free fall or throwing, the fundamental variable determining the orientation of the object will be a vector composed of the vectors of these different forces, including the force of gravity. 30 However, physicists, like judges, are not sufficiently or necessarily familiar with human nature and physiology. The existence of the “emergency assessment meetings and coordination” step in LAMP is precisely added to overcome this problem. LAMP suggests that experts from different disciplines come together, analyze different aspects of the incident within their limits, and share them with their counterparts to uncover the most likely truth.
Conclusion
In cases where women are killed in connection with their gender, the expectation from medical sciences is primarily to contribute to the fight against violence and the prevention of harm against women. When the harm occurs, the scientific approach of medicine is expected to provide reliable evidence, and in cases where death occurs, it is expected to contribute to the accurate determination of the cause and manner of death. The investigation processes of suspicious female deaths in Turkey do not comply with the LAMP principles. In suspicious and challenging cases, especially in deaths resulting from falls from a height, it is believed that conducting autopsies in accordance with the Minnesota Protocol and applying a holistic LAMP approach will assist the legal process and clearly facilitate the discovery of the truth. In the context of Turkey, the determination of the source of death is not the responsibility of forensic experts but falls within the jurisdiction of judicial authorities. This situation requires considering the gender perspective in all investigative processes and legal frameworks in the judiciary. As a result, the application of LAMP standards for suspicious female deaths in Turkey and worldwide, and aligning the legal infrastructure with the universal women's rights, is considered of great importance.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval
Ethical approval was obtained from the Trakya University Faculty of Medicine Non-Interventional Scientific Research Ethics Committee (No: TÜTF-GOBAEK 2022/216, Date: 30.05.2022).
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
