Medicine,Science and the Law

Complex Suicide (CS) is defined as an unusual form of suicide in which several harmful methods are used, simultaneously or in succession, whose purpose is to avoid the possible ineffectiveness of one of the methods used to produce a certain fatal outcome. The study of CS is of great interest and plays a fundamental role in characterizing the knowledge of these rare events. We have retrospectively evaluated all CS cases examined at the Institute of Forensic Medicine of Milan from 1993 to 2022 (n = 75) with the aim of characterizing the deceased who have resorted to it. We also compared the sample of 75 CS cases with a sample of paired 115 “simple” suicides (with a single method). Our analysis revealed that the CS cases were carried out by a “typical” subject identified as an adult male, between 41 and 50 years old, suffering from psychiatric disorders and, in particular, major depressive disorder. The most frequent harmful mode was plastic bag suffocation associated with self-poisoning. CS cases used less violent methods than simple suicide controls. The pathological-forensic approach has brought to light elements that can be useful both for forensic professionals (pathologists and psychiatrists) in correctly classifying these unusual and challenging events and for clinicians working on the front line. Some profiles have been outlined that can be used to identify potentially vulnerable individuals who could benefit from increased health surveillance to treat and prevent suicide.

Cultural competence among healthcare professionals and providers is pivotal to providing effective, safe, and quality services. This paper considers the feasibility of using a tool to measure cultural competence within forensic mental health services, adapted from the Cultural Competence and Linguistic Competence Policy Assessment (CLCPA) developed in the United States (US). The adapted tool was piloted at a secure forensic unit in England; this consisted of a two-phase approach to data collection comparing the results from an initial assessment (time 1, n = 50), with those of a follow-up assessment conducted three years later (time 2, n = 100). The aim was to assess the practicability of using the tool to measure perceptions of cultural competence among 150 staff members, as part of a wider quality assurance and improvement process. The results indicate that the tool has utility in measuring perceptions of cultural competence and that the information gathered can be used to plan service improvements. Yet, it is recommended that the tool is modified at site-level as part of a collaborative exercise with staff and patients and according to service need prior to implementation.

People are assumed to have moral responsibility, but the presence of mental disorder may call this into question. Nevertheless, when and how mental disorder affects moral responsibility is unclear. The insanity defence exculpates a defendant and effectively extinguishes their moral responsibility, although the criteria for insanity varies between different jurisdictions. Most successful cases of insanity are due to delusions, although the nature of delusions itself varies considerably. The recent case of Keal in England and Wales demonstrates some of the problems with the insanity defence, and a coherent philosophical basis for the defence is lacking. I argue that a volitional element should be added to the insanity defence in England and Wales such that a person may be exculpated on the basis of a mental disorder which sufficiently causes any of (1) defects of reason; (2) deficits in knowledge; (3) a lack of control; and (4) their ability to form intentions in crimes of intent, although the threshold should remain high. Reasons-responsive accounts of moral responsibility underpin many of these abilities. The extent to which mental disorder, particularly delusions, are considered a type of manipulation, rather than part of the self, is likely to be contributing to intuitions about exculpation although not all delusions will cause impairments or manipulation to the same extent. Amending the insanity defence in this way would be more just, more philosophically coherent and allow a more consistent approach for those with mental disorders who are charged with criminal offences.

To determine the cause of death and sociodemographic predictors of dead-on-arrival cases brought for autopsy, a cross-sectional study was conducted. A total of 422 dead-on-arrival cases brought for an autopsy to a tertiary center in Ethiopia were reviewed. Descriptive and analytic analysis were used, and logistic regression analysis was performed to examine the association between sociodemographic variables and the cause of death. The study found that dead-on-arrival cases accounted for 32.5% of all autopsied cases. The mean age was 38.9 ± 15.6 years and ranged from 15 to 90. Approximately two-thirds of the cases were in the 15 to 44 age range. Male victims accounted for more than two-thirds of the cases, and 82.9% of the victims were urban residents. The cause of death could not be determined in 6.6% of cases. Unnatural deaths were the leading causes, followed by communicable diseases and non-communicable diseases. Pneumonia and coronary artery disease were the leading specific causes of death. Residence and age were found to be associated with unnatural deaths. Urban residents had higher odds of dying due to communicable diseases compared to rural residents. Additionally, younger individuals aged 15–29 years had lower odds of dying due to non-communicable diseases compared to those older than 75 years. In conclusion, the high number of brought-in dead cases in Ethiopia, particularly among the younger population, is a concerning issue that requires immediate attention. Unnatural deaths were predominant, highlighting the need for improved safety measures and emergency medical services.

Determination of postmortem interval (PMI) is a fundamental aspect of forensic medicine, aiding in the reconstruction of the time of death in medico-legal investigations. The present study aims to compare gender-based postmortem changes and investigates the role of collagen fibers as a potential indicator of PMI in albino rats. Eighteen male and nine female adult albino rats were examined. Three prostates, three uterine horns, and the quadriceps muscle of the hind limb of each animal were collected at six time points (0, 6, 24, 36, 48, and 144 h postmortem) after scarifying rats by neck dislocation. Morphological analysis revealed progressive softening of the organs with darker discoloration with increasing PMI. Histological examination using hematoxylin and eosin staining showed cellular degradation up to 48 h PM. Masson's trichrome staining highlighted the persistence of collagen fibers up to 144 h. Notably, male prostates exhibited greater resistance to postmortem degradation compared to female uteri, suggesting that potential sex identification by gonads is possible up to 48 h PM.

Child abuse, including physical, sexual, or emotional violence or neglect, is a global problem with serious and long-term consequences for children. Even though child abuse is prohibited in Denmark, the estimated number of physically and sexually abused children is relatively high, whereas the annual number of forensically examined children is low. We present the Danish practice and legal foundation for the clinical forensic medical examination (hereinafter referred to as “forensic examination”) in suspected child abuse cases. Forensically documented findings may contribute to the police investigation and legal assessment of child abuse cases, safeguarding the rule of law for both children and suspected perpetrators. The forensic examinations are accredited according to international and European standards, and the Department of Forensic Medicine is regularly assessed for the fulfillment of accreditation. Accreditation, delimitations from medical treatment and police employment, and the fact that the department refers to the University of Copenhagen ensure impartiality from the police and the judicial system. A cross-sectoral intervention project has significantly increased the annual number of forensically examined children at the Danish Children's Advocacy Center (CAC) in Copenhagen, which supports children's legal rights and holds research potential due to systematic and continuous data collection.

Black oesophagus, or acute necrotising oesophagitis, is characterised by diffuse circumferential black discolouration of the distal oesophagus associated with mucosal necrosis. A consistent feature is a very sharp line of demarcation at the gastro-oesophageal junction. Two cases are reported to demonstrate differences in the lower margin. Case 1: a 63-year-old man who died of gastrointestinal haemorrhage complicating black oesophagus was noted to have an irregular lower border located approximately 5 cm from the gastro-oesophageal junction. This was associated with columnar mucosa typical of Barrett oesophagus. Case 2: a 79-year-old man who aspirated gastric contents following gastrointestinal haemorrhage due to black oesophagus had diffuse black discolouration of the oesophageal mucosa with the more usual sharply demarcated inferior margin at the gastro-oesophageal junction. Sparing of the distal oesophagus in case 1 was most likely due to the protective effect of metaplastic columnar epithelium, a finding that may, therefore, be a potential macroscopic marker for Barrett oesophagus in individuals with black oesophagus.

Thrombosis of the deep veins of the legs is a relatively common occurrence initiated by venous stasis, endothelial damage or hypercoagulable states. Prolonged sitting has also been associated with thrombotic events. A case is reported where immobility caused by drug overdose resulted in lethal pulmonary thromboembolism. Case report: A 50-year-old male was found sitting in the driver's seat of his car slumped forward. A suicide note was present. At autopsy finely granular tablet residue was found in the stomach. Deep venous thrombosis was present in both calves with bilateral pulmonary thromboembolism. Toxicological examination of blood revealed elevated levels of amitriptyline (0.92 mg/L), nortriptyline (0.41 mg/L) and oxycodone (0.17 mg/L). Death was due to pulmonary thromboembolism arising from bilateral deep venous thromboses complicating mixed drug toxicity. Prolonged immobility should be considered a possible mechanism for venous thrombosis in drug takers.