A post mortem of two autopsies

This appeared in the Herald of March 27,2007
http://www.oheraldo.in/pagedetails.asp?nid=1562&cid=2

The alleged lapses or failure to disclose injuries during the first autopsy of British teenager Scarlet Keeling carried out by Goa Medical College (GMC) professor and Head of Forensic Medicine and Toxicology Dr Silvano Sapeco has come to the fore during the recent controversy. Yesterday, the government suspended Dr Sapeco. The question, however, is: Is the autopsy that Dr Sapeco carried out really faulty? The autopsy report did not state the possibility of homicide. But is this in any way suspicious?
The fact is that autopsy surgeons are not required to comment on the manner of death. They only have to state the cause of death. There’s a good reason for this: forensic surgeons do not visit the site of the crime, and consequently, are not familiar with its circumstances.
In 2007, as many as 1,534 autopsies were performed by the department at GMC, and the manner of death was never commented on or explained even in a single case. Determining the manner of death, say experts, is legally and technically the task of the police, who can demand from the autopsy surgeon any information that will help them in their investigations.
The Sapeco autopsy said: “Cause of death is due to drowning in the beach sand waters.” It went on to say “viscera and materials have been preserved.” In the confusion that followed, nobody took cognisance of these words. These six crucial words imply that the report on the cause of death (finally) will depend on the analysis of the sealed viscera and materials and the post mortem examination report.This is what is defined in the manual Medico-Legal Autopsy: “Homicidal drowning —Murder by drowning is very rare, except in the case of infants and children. A person may be pushed into a river or into the sea. Marks of strangulation or throttling or severe violence applied to the head are presumptive of homicide. Bruises are strongly suspicious. Homicidal drowning in shallow water is possible, if the assailants hold the victim’s head in such a position as to cover the nostrils and mouth. Signs of struggle or marks of violence on the body are likely to be found in such cases. If a person is taken unawares or rendered senseless and defenceless by alcohol or hypnotic drugs, and the head is submerged in water for five to 10 minutes, no marks of violence will be found on the body.”
Though PSI Nerlon Albuquerque has insinuated that Dr Sapeco did not actually state homicidal drowning (he was not bound to), he should have done better than that having been taught the basics by the same manual. The critical question is, why did PSI Albuquerque wait from the date of the autopsy (February 18, 1700 hrs) till March 6 to inform Dr Sapeco that the Central Forensic Science Laboratory (CFSL), Hyderabad, could not perform viscera tests till 2010? The Goa Police already knew (as did entire the police force in India) that CFSL had stopped testing from February 1,2007.
Dr Sapeco in fact wrote on the reverse of the PSI’s request letter: “.the preserved viscera and materials were supposed to be sent for chemical analysis for detection of . (this part ineligible) and drugs like narcotic drugs or drugs of abuse which might get destroyed in view of such undue delay in transportation and analysis. The vaginal swabs and smear slides have significant value in the case for evidence of recent sexual intercourse. These facts too were explained immediately as this could be a case of homicidal drowning in view of the pattern of injuries. The Anjuna police should act immediately , These corroborative evidences have significance to the suspected homicidal drowning.. I also request you to take serious note of the aforesaid facts which shall have relevance and significance as to the final opinion in the case ..”
PSI Nerlon Albuquerque has reason to dislike Dr Sapeco. In the Quepem murder case, while the PSI’s suspension was lifted after nearly two years, Sapeco’s suspension was lifted in less than a month after he successfully defended himself. In fact, the Anjuna posting was the PSI’s first after his suspension was lifted. PSI Albuquerque has blamed the failure of the first autopsy to specifically declare Scarlet’s death as homicidal, for the confusion in the minds of the investigating police.
Dr Sapeco hand wrote his opinion and warning on the reverse of letter no: PI/ANJ/1549/2008 of March 6, in which PSI Albuquerque requested a covering letter for the evidence to be sent to the Forensic Science Laboratory, Mumbai, where it could be analysed much faster. Perhaps this was the only time in the case that PSI Albuquerque made use of his medico-legal training. These notes were reported in a section of the media as a “supplementary autopsy” but in actual fact they are not.
To come to the actual post mortem reports, while the Sapeco autopsy reveals five distinct external injuries to the body, the largest an abrasional area (multiple abrasions) of 7x2 cm, and one internal injury (more about this later), the team led by Dr Edmund Rodrigues shows 50.
Now though it sounds impressive to the layman, this has little or no medical significance. For example, Dr Rodrigues shows injuries as tiny as 8x3 mm and 2x2 mm that, intrinsically, are covered in a single notation in the Sapeco autopsy. An expert explained to this writer: “If I were to claw or scratch you face with my hand, the right thing would be to indicate a single scratch or injury. But if I wanted to, I could indicate five injuries, each representing one finger, and it would sound so much more impressive.”
As many as 27 of the injuries in the second autopsy are marked post mortem (caused after death) and one was marked “pending histopathological examination.” This leaves 23 ante mortem (before death) injuries that are mostly covered by the first post mortem. Here too, opinion counts. An abrasion on the forearm identified as “fresh and ante mortem” by Dr Sapeco has been listed as “post mortem” by Dr Rodrigues.
Ultimately, after listing all these 50 injuries, what conclusion does the second post mortem reach about the cause of death? None. Instead it says that drowning as a cause of death “cannot be ruled out” - almost exactly the same conclusion as the first post mortem. It then goes on to “recommend” that the death be investigated as homicidal.
But the interesting thing is that the Sapeco autopsy clearly shows “left lower labial sulcus at mucogingival aspect has 3/4 x1/2 cm red bruise. On section it was ¬ cms deep.” In layman’s terms this injury, on the inside of the lower lip, could easily have been caused if Scarlet’s face was pressed into the sand by the attacker(s) trying to kill her, assuming it was a case of murder. One expert said: “Hypothetically, this one injury was enough to warrant a conclusion of homicide, even if one assumes that the first autopsy was so poor that it did not reveal any other injuries.” Still, PI Albuquerque chose not to act fast, but instead wait.
Experts also point to this very kind of lip injury as an example of why autopsy surgeons are not supposed to comment on the manner of death. If a victim receives mouth-to-mouth resuscitation, the giver could leave similar telltale marks on the inner lip that could totally deceive investigators. Dr Sapeco also seems to have made sure that he got a dental cast, because this would determine Scarlet’s age. He probably became suspicious of the age (20 to 25 years) given by the Anjuna police when they brought in Scarlet’s body.
This may not be the last we hear about post mortems. A source close to Fiona MacKeown says she intends to ask for a third autopsy in England, soon after the body is taken there. But it is not expected to reveal anything new.