Martina Focardi

Age estimation for forensic purposes in Italy: ethical issues

Age assessment in children and young adults is a relevant medicolegal issue due to the gradual increase of persons devoid of proper identification documents in European countries. Because of the illegal immigration and growing crime rates among children and adolescents, age estimation for forensic purposes is often required. The scientific research and the extensive experience of forensic experts in the last decades focused on the use of radiographic methods addressed to evaluate the degree of skeletal or dental development as the most accurate parameters to estimate the chronological age of children and adolescents. This paper analyzes the ethical issues related to age estimation procedures based on radiographic methods, showing how the ethical principles of beneficence, nonmalevolence, justice, and autonomy may be guaranteed during the execution of the age assessment in forensic practice. The procedure might be conducted in accordance with international guidelines and protocols, though they need a higher homogenization and standardization. A strong collaboration between various scientific societies of professionals (forensic odontologists, forensic pathologists, forensic anthropologist, radiologists, pediatricians, and psychologists), who have been involved in age estimation for years, is needed to reach this goal.

Accidental death in autoerotic maneuvers

The authors from the Florence Forensic Department present a case that demonstrates the paradigms attached to accidental deaths while performing autoerotic maneuvers. The incidents of such practices are underestimated and are only the tip of the iceberg since they do not represent the cases that are never reported due to successful practice. After analyzing the statistic data, the authors describe the case and discuss about the element that prove the accidental nature of the death and the importance of the correct application of forensic methodology at the scene and in the mortuary.

An unusual case of incaprettamento.

Incaprettamento is a ritual strangulation that represents a method of homicide typical of the Italian Mafia. While the victim is in the prone position, he/she is bound by one end of a rope, creating a slipknot around the throat, while the other end is used to tie the limbs behind the back. Forensic investigations reveal that in most cases, the binding of the extremities and the positioning of the victim are carried out after death due to others means and are intended to hold somebody in contempt and to punish betrayers. When the victim is tied while alive, the death is caused by self-strangulation because it is impossible to maintain the legs in this forced position. Here, we describe in detail a case with a lot of similarities to incaprettamento, although we define it as atypical because of the unusual methods of the actual binding and the circumstances in which death occurred. In fact, the investigation of the crime scene, the external and internal findings, and the histologic examination result show that this is a crime of passion.

Pulmonary Cement Embolism After Kyphoplasty

Pulmonary polymethylmethacrylate (PMMA) cement embolism after kyphoplasty (KP) surgery is a quite frequent event as well as the pulmonary embolization of central venous catheter fragment. This report shows the case of a subject who, after KP, developed pulmonary embolism and who underwent thoracic surgery. After hospital discharge, the subject advanced a claim for damages toward the hospital where he was operated, complaining sensation of tenderness at the chest surgical scar and esthetic damage. To understand the nature of the embolism (either central venous catheter fragment or cement), chemical investigations were then ordered. Spectrometry identified the PMMA cement used for KP. When doubts rise about the origin of the embolized material, chemical investigations may reveal important data not only for clinical but also for forensic purposes.

The Claims Management Committees trial: Experience of an Italian Hospital of the National Health System

INTRODUCTION In Italy, health care is mainly financed by earmarked central and regional taxes, with regions receiving their allocated share of resources from the National Health Fund. The Council of the Tuscany Region in 2009 began an experimentation aimed to enforce the extrajudicial conciliation. The Council established the Claims Management Committees (CMC) for civil liability in the Tuscan Health Service. The CMC trial provides that the damages are compensated directly by the hospital, removing the cost of liability insurance. The aim of this study is to collect and compare the liability-insurance-period and the CMC trial-period. MATERIALS AND METHODS Data were derived from the management claims database of the Health Directorate of the Careggi Hospital in Florence between 2006 and 2012. Two main periods are considered for the comparison of data: 2006-2007-2008 during the insurance management and 2010-2011-2012 during the CMC trial. RESULTS During the insurance management period, the total expenditure was equal to the €14,846,334.44 paid in the 3-year period. The total expenditure during the CMC trial 3-years period was equal to €7.076.370,75. Under the CMC management, we observed a marked decrease in the recourse to legal action in the face of a substantial maintenance of the number of claims opened for each year. The CMC trial showed a greater speed in setting claims for damages. DISCUSSION AND CONCLUSIONS Under CMC management, a greater and more diligent efficiency is matched by a lower economic outlay. The use of the direct management of damage compensation may be an important tool for risk management, thus guaranteeing the recourse to targeted and appropriate interventions.

Bayesian networks of age estimation and classification based on dental evidence: A study on the third molar mineralization

Not only does the Bayesian approach offer a rational and logical environment for evidence evaluation in a forensic framework, but it also allows scientists to coherently deal with uncertainty related to a collection of multiple items of evidence, due to its flexible nature. Such flexibility might come at the expense of elevated computational complexity, which can be handled by using specific probabilistic graphical tools, namely Bayesian networks. In the current work, such probabilistic tools are used for evaluating dental evidence related to the development of third molars. A set of relevant properties characterizing the graphical models are discussed and Bayesian networks are implemented to deal with the inferential process laying beyond the estimation procedure, as well as to provide age estimates. Such properties include operationality, flexibility, coherence, transparence and sensitivity. A data sample composed of Italian subjects was employed for the analysis; results were in agreement with previous studies in terms of point estimate and age classification. The influence of the prior probability elicitation in terms of Bayesian estimate and classifies was also analyzed. Findings also supported the opportunity to take into consideration multiple teeth in the evaluative procedure, since it can be shown this results in an increased robustness towards the prior probability elicitation process, as well as in more favorable outcomes from a forensic perspective.

An Unusual Homicide Involving Strangulation after Transdermal Fentanyl and BuprenorphineIntoxication

Fentanyl and buprenorphine are powerful opioids used for the induction of anesthesia as well as for severe pain management. Transdermal fentanyl and buprenorphine patches are widely used for outpatient management of chronic pain. However several cases of deaths connected with their administration have been described in literature. We present an unusual and exceptional homicidal death attributed to a combination system of acute transdermal opioids poisoning and strangulation. The concentration of the drugs and their metabolites in femoral blood and urine were capable of causing fatal intoxication. This manner of complex homicide raises the question of the importance of mechanisms involved.

Decomposition pattern and insect colonization in two cases of suicide by hanging

ABSTRACT Hanging is one of the most common methods of suicide worldwide. Despite the high incidence, only a little knowledge about the pattern of cadaver colonization by insects on hanging corpse is available. Different types of hanging can alter the body decomposition process as well as the pattern and rate of insect colonization. Two case studies where the hanging occurred with a similar postmortem interval of 34 days are described. The two bodies showed different patterns of insect colonization and decomposition scored using the Total Body Score (TBS) and the TBS for hanging (TBShang). The first case was about the body of a 24-years-old male, with mummification of the unclothed upper anatomical parts. A TBS of 14 and a TBShang of 18 were assigned. The second body, belonging to a 15-years-old male, was found pre-skeletonized lying on the ground with the skull disarticulated. A TBS of 31 and a TBShang of 32 were assigned. Average temperatures of (21.5 ± 2.5) °C for the first body and (25.1 ± 2.7) °C for the second body were recorded in the 34 days preceding the bodies’ discovery for a total of 731 and 853 Accumulated Degree Days (ADD) respectively. According to previous studies, the different decomposition patterns were related to temperatures of exposition and to the diversity of arthropod community found on the bodies because of the different types of hanging: totally suspended vs. in contact with the soil. The limited insect activity caused by hanging explains the delay in decomposition of hanging bodies in which mummification can take place, especially on the upper body parts. In vertical body position, the body fluids accumulated in the lower body parts accelerating the desiccation of soft tissues on the upper parts. The effect of gravity can also explain the decrease of internal maggot mass as larvae easily fall from the hanging body to the drip zones below where they are unable to recolonize the body if totally suspended. Furthermore, in a hanging body a greater surface is exposed to wind and sun with a quicker skin drying preventing the additional Diptera colonization. This paper shows the weaknesses of scoring scales and regression models developed to predict ADD when irregular decomposition and mummification have not taken into account.

Hemidiaphragm Paralysis after Robotic Prostatectomy: Medical Malpractice or Unforeseeable Event?

The authors present a case of suspected malpractice linked to the onset of hemidiaphragm paralysis after robot-assisted radical prostatectomy (RARP). The approach to the case is shown from a medico-legal point of view. It is demonstrated how, after a thorough review of the literature, this was not a case of medical malpractice but an unforeseeable event. This paper aims at contributing to the very few reports dealing with the onset of hemidiaphragm paralysis after RARP, thus fostering clinical knowledge of these rare events and meanwhile providing useful data for the medico-legal handling in case of alleged negligence of surgeons.

A Case of Insect Colonization Before the Death

Forensic entomology is a branch of forensic science in which insects are used as evidence in legal investigations relating to humans, domestic animals and wildlife. One of the theoretical pillars on which the discipline is based concerns the fact that flies colonize a body after death. However in cases of myiasis, maggots are present before death, with consequences in the correct estimation of the minimum postmortem interval (mPMI). We report here the case of a woman, largely colonized by fly larvae, who has lain alive in her garden for four days prior to being rescued. Larvae were found on the conjunctivae, the bronchi, the rectum and vagina. The womans death, two months later, was caused by tetanus. The consequences of myiasis on mPMI estimation are here discussed. In fact, despite she was still alive larvae, indicated and estimated age of 1.5–2.5 days, based on environmental and body temperature.