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.”

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