Andrello, Luisa

Castelli, Francesca

Osculati, Antonio

Re, Laura

Sozzi, Marta

Vignali, Claudia

Visonà, Silvia Damiana

OSCULATI, ANTONIO  MARCO MARIA

VISONA', SILVIA DAMIANA

CASTELLI, FRANCESCA

ANDRELLO, LUISA

VIGNALI, CLAUDIA MARIA

Archivio Istituzionale della Ricerca - Università degli Studi di Pavia

CASE REPORTDeath of a seven-month-old child in a washing machine:a case reportAntonio Osculati1 & Silvia Damiana Visonà1 & Laura Re2 & Marta Sozzi2 &Francesca Castelli3 & Luisa Andrello3 & Claudia Vignali1Received: 2 April 2016 /Accepted: 15 December 2016# Springer-Verlag Berlin Heidelberg 2016Abstract The authors present a case which brings out aunique modality of child homicide by placing the baby in awashing machine and turning it on. The murder was perpe-trated by the baby’s mother, who suffered from a seriousdepressive disorder. A postmortem RX and then a forensicautopsy were performed, followed by histologic examinationsand toxicology. On the basis of the results of the autopsy, aswell as the histology and the negative toxicological data, thecause of death was identified as acute asphyxia. This diagno-sis was rendered in light of the absence of other causes ofdeath, as well as the presence of typical signs of asphyxia,such as epicardial and pleural petechiae and, above all, themicroscopic examinations, which pointed out a massive acutepulmonary emphysema. Regarding the cause of the asphyxia,at least two mechanisms can be identified: drowning andsmothering. In addition, the histology of the brain revealedsome findings that can be regarded as a consequence of thebarotrauma due to the centrifugal force applied by the rotatingdrum of the washing machine. Another remarkable aspect isthat we are dealing with a mentally-ill assailant. In fact, thebaby’s mother, after a psychiatric examination, was confirmedto be suffering from a mental illness—a severe depressivedisorder—and so she was adjudicated not-guilty-by-reason-of-insanity. This case warrants attention because of its unique-ness and complexity and, above all, its usefulness in theunderstanding of the pathophysiology of this particular man-ner of death.Keywords Forensic pathology . Child homicide . Filicide .WashingmachineIntroductionChild homicide is a rare event that occurs at rates of 2.0 per100,000 inhabitants globally, with intra-familial cases faroutnumbering extra-familial ones [1]. Child homicides are amajor concern for forensic pathologists, both for the difficul-ties due to the frequent lack of specific findings at the autopsyand for the great impact on the community. Most child homi-cides occur in the first 2 years of life, the majority in the firstyear. In children 12 months of age or less, commonly theoffender is a parent; the death is caused, overall, by headinjuries, chest, and abdominal injuries or a mix of these [2].The present case brings out a unique modality of child homi-cide by the perpetrator placing the baby in a washing machineand turning it on. The murder was perpetrated by the baby’smother, who suffered from a serious depressive disorder.Case historyA 7-month-old baby was found in a turned on washing ma-chine by her father, who had just come back home from astroll with his older daughter. The 7-month-old baby hadremained at home with her mother. The baby’s mother wasin tears on the bathroom floor in front of the washing machine.On seeing his baby daughter in the drum, the man tried to stopthe machine, which took several seconds because the door hadbeen automatically locked. Finally, he managed to pull the* Silvia Damiana Visonàvisona.silvia@gmail.com1 Department of Public Health, Experimental and Forensic Medicine,Unit of Legal Medicine and Forensic Sciences BAntonio Fornari^,University of Pavia, Pavia, Italy2 Unit of Legal Medicine, University of Insubria, Varese, Italy3 Service of Legal Medicine of Canton Ticino, Bellinzona, SwitzerlandInt J Legal MedDOI 10.1007/s00414-016-1521-2baby out and laid her on the floor; her clothes were soaked incold, soapy water and there was a folded handkerchief in hermouth. Emergency services were called immediately and ar-rived 15 min later but resuscitation attempts were ineffective,so the death was declared.The baby’s mother suffered from a depressive disorder; shehad been taking an anti-depressant drug, ParoxetineHydrochloride 20 mg, for 10 days. Alprazolam (0.5 mg 3times a day) and Zolpidem (5 mg once a day) had also beenprescribed.When questioned about what happened, the woman statedthat, after a nap in the afternoon, she had decided to do thelaundry, so she had taken a pile of clothes from the bed andloaded them into the washing machine. She said that afterturning the appliance on, she had sat on the bathroom floorand fallen asleep until she was awakened by the screams of herolder daughter.The Police sequestered the nasogastric tube used by thephysicians and the laundry contained in the washing machine,consisting of a handkerchief, a cotton vest, a pair of stockings,a pair of panties, two towels and an empty plastic ball forwashing machine detergent.Forensic investigationsPostmortem radiographyBefore the autopsy, total-body radiography was performed,showing neither fractures nor dislocation of the examinedbones. Widespread and moderate pulmonary hypotransparencywas revealed, without pulmonary thickening. This exam did notshow any radiopaque foreign bodies.External examination [Fig. 1]The clothes were soaked in water.The following lesions were pointed out: a few roundedecchymosis extended all over the head [Fig. 2]; some super-ficial reddish abrasions at the nasal and perioral region [Fig. 3](particularly, one on the inferior lip was suggestive of havingbeen produced by a fingernail).At the inspection of the oral cavity, no injury was found.AutopsyThe autopsy revealed a massive blood infiltration in the softtissues around the skull, located in the area corresponding tothe ecchymosis revealed during the external examination; alsosome petechiae were seen on the galea capitis.The examination of the upper airways allowed the detec-tion of some whitish foam in the trachea and in the bronchiallumen. The laryngeal cartilages were carefully investigated,without finding any fractures or bleeding.The epicardium and the pleural surface of the lungs showedmany petechiae. The lungs presented amassive hyperexpansion.The stomach contents consisted of about 50 ml of whitish andfruity alimentary fluid.Histological findingsThe brain and the spinal medulla showed marked edema, as-sociated with haematic congestion and several perivascularmicrohemorrhages [Fig. 4]. The other remarkable findingsFig. 1 The corpse before the autopsyFig. 2 The ecchymosis on the baby’s headFig. 3 The abrasions on the baby’s face, especially observable, theabrasions on the nasal regionInt J Legal Medwere a massive acute emphysema involving the entire lungs,accompanied by some fields of edema [Fig. 5]; a few intra-alveolar red blood cells were also detected.Toxicological analysesToxicological analyses were carried out on autopsy samplesand on fluid collected from the probe used during resuscitationattempts so as to establish whether the baby had been givenpsychotropic drugs such as alprazolam, paroxetine, andzolpidem that her mother had been prescribed. We analyzedthe child’s blood and gastric contents (a whitish odorlessmush, pH 7) as well as the washing powder found in thehouse.Systematic toxicological analyses were carried out on 1 mlof blood, 1 ml of gastric contents, 1 mL of probe fluid, and100 mg of washing powder, using gas chromatography-massspectrometry (GC-MS), after solid phase extraction followingthe method detailed in a previously published study [3]. GC-MS data files were also processed using a procedure we havedeveloped for the automated purification of mass spectra fromthe total ion chromatogram [4]. This method can identify acid-ic, neutral, and basic drugs of forensic interest at therapeuticand toxic levels. Body fluids (blood and gastric contents) andprobe fluid were also submitted to LC-MS/MS analysis asdescribed in a previously published study [5]. This method,in combination with GC-MS analysis, offers the possibility toperform a real generic screening, with a much wider range ofsubstances detectable, including thermolabile and polar me-tabolites. The analyses ruled out any presence of pharmaceu-tical or illicit drugs in all samples.We therefore went on to check the chemical components ofthe washing powder in the baby’s blood and gastric contentsas well as in the fluid collected from the probe. The compo-nents of the washing powder are detailed in Table 1.A targeted search of all the compounds listed on the labelwas not performed. However, we did try to identify somecomponents of the washing powder. Detergent samples(100 mg) were dissolved in 100 ml water and n-hexane andanalyzed by high-performance liquid chromatography andGC-MS, respectively. Analyses revealed two unidentifiedcompounds in the washing powder which were not found inthe baby’s blood, gastric contents or in the probe fluid, whichall underwent the same analyses. Our findings appear to sug-gest that the baby did not swallow the detergent, although thiscannot be fully ruled out, as the detergent may have beencompletely removed from the stomach bymedical staff duringresuscitation attempts (however, the absence of washing pow-der components in the blood sample allows us to exclude theiruptake).Finally, any toxicological cause which might have contrib-uted to the baby’s death was excluded.DiscussionOn the basis of the results of the autopsy, as well as the his-tology and toxicological data, the cause of death was identi-fied in an acute asphyxia. This diagnosis was rendered in lightof the absence of other causes of death, as well as the presenceof typical signs of asphyxia, such as epicardial and pleuralFig. 5 The left lung, showing massive acute emphysema (EE, 120×)Fig. 4 The brain, showing haematic congestion and several perivascularmicrohemorrhages (EE, 120×)Table 1 The components of the washing powderCOMPOSITION PercentNon-ionic surfactants; soap; natriumsilicate;phosphonates; polycarboxylates; sodiumbicarbonate; carboxymethylcellulose;zeolite A; citric acid<5Anionicsurfactants; brighteners 5–15Sodiumcarbonate; sodiumsulphate 15–30Dyes; enzymes; perfume; polyethyleneglycol anti-foaming agentsNot specifiedInt J Legal Medpetechiae and, above all, the microscopic examinations, whichpointed out a massive acute pulmonary emphysema.Regarding the cause of the asphyxia, it was certainly, atleast partially, due to a drowning: first of all, the entering ofwater into the upper airways was undeniable, since the doctorswho tried to resuscitate the baby had sucked soapy water fromher airways; in addition, the autopsy pointed out the presenceof foam in the larynx and trachea. This hypothesis is alsosupported by the bruises on the baby’s head, which means thatshe was still alive when she was put into the washing machine.Therefore, the mechanism of asphyxia was, at least in the finalphase, a drowning. Yet, the toxicological analyses made onthe infant’s blood, gastric contents and fluid contained in thedevice used during the cardiopulmonary resuscitation to suckthe fluid from the upper airways and digestive tract, did notshow the presence of the detergent used in the washing ma-chine. This fact leads to consider that the drowning was notthe only cause of death, probably occurring only during thefinal phase of the asphyxia.It is also worth mentioning that the histological examinationof the brain [Fig. 4] revealed marked edema associated withhaematic congestion and several perivascularmicrohemorrhages:these findings can be regarded as derived from the barotraumadue to the centrifugal force applied by the rotating drum of thewashing machine. Interestingly, the effects of a barotrauma aredescribed only occasionally in literature, and, to our knowledge,never postmortem [6]. Therefore, the findings described here areof interest because they are not only the result of the asphyxia,but also of a previously almost unknown mechanism from aforensic point of view.Another mechanism of the asphyxia was smothering.Indeed, the handkerchief, several times folded, which wasfound into the baby’s mouth, certainly contributed to the deathby obstructing her upper airways. Furthermore, at the nasaland perioral region, some superficial red abrasions were seenas follows: one of them, located at the inferior lip, was typi-cally produced by a fingernail. These lesions, even thoughirrelevant in causing death, are strongly indicative for an ex-ternal force applied on the baby’s face when she was alive.Smothering is probably the most common method of ho-micide in infants and young children [7].It is worthy to underline that, unlike most other forms ofphysical abuse, fatal smothering can occur without externalsigns on the face or body, and without incriminating evidenceat postmortem examination [8]. In this very unusual case, itwas possible to consider the smothering because the handker-chief was still in the baby’s mouth, and there were some typ-ical signs on the child’s face. But it must be regarded as anexception, as smothering a little child is very easily accom-plished and requires a small amount of force.Another remarkable aspect of the present case is that we arereferring to a mentally-ill assailant. In fact, the baby’s mother,after a psychiatric examination, was considered suffering froma mental illness, a severe depressive disorder, and so she wasadjudicated not-guilty-by-reason-of-insanity. The woman wasdetained in a psychiatric hospital for almost 2 years, and thenthe court decided for her conditional release; the main reasonfor the court’s decision was that the woman no longer repre-sented a concrete risk to anyone. The history of major psychi-atric disorders, defined as psychotic, affective or personalitydisorders, were found to be a strong independent factor offilicide [9], so this aspect should be taken into account alsoby the forensic pathologist, among the anamnestic data.In conclusion, the highlighting of this case is relevant be-cause of its uniqueness and complexity and, above all, itsusefulness in the understanding of the pathophysiology of thisparticular manner of death.References1. Hedlund J, Masterman T, Sturup J (2016) Intra- and extra-familialchild homicide in Sweden 1992-2012: a population-based study. JForensic Legal Med 39:91–99. doi:10.1016/j.jflm.2016.01.0112. DiMaio V, Dimaio D (2001) Forensic pathology. CRC Press, BocaRaton, pp. 337–3553. Polettini A, Groppi A, Vignali C, Montagna M (1998) Fully-automated systematic toxicological analysis of drugs, poisons, andmetabolites in whole blood, urine, and plasma by gaschromatography-full scan mass spectrometry. J Chromatogr BBiomed Sci Appl 713:265–279. doi:10.1016/S0378-4347(98)00062-04. Polettini A (1996) A simple automated procedure for the detectionand identification of peaks in gas chromatography-continuous scanmass spectrometry. Application to systematic toxicological analysisof drugs in whole human blood. J Anal Toxicol 20:579–586.doi:10.1093/jat/20.7.5795. Sempio C, Morini L, Vignali C, Groppi A (2014) Simple and sensi-tive screening and quantitative determination of 88 psychoactivedrugs and their metabolites in blood through LC–MS/MS:Application on postmortem samples. J Chromatogr B 970:1–7.doi:10.1016/j.jchromb.2014.08.0396. Moulton C, Yates DW (1992) Barotrauma in a washing machine.Injury 23:339–357. doi:10.1016/0020-1383(92)90185-U7. Banaschak S, Schmidt P, Madea B (2003) Smothering of childrenolder than 1 year of age—diagnostic significance of morphologi-cal findings. Forensic Sci Int 134:163–168. doi:10.1016/S0379-0738(03)00135-X8. Meadow R (1999) Unnatural sudden infant death. Arch Dis Child80:7–14. doi:10.1136/adc.80.1.79. Lysell H, Runeson B, Lichtenstein P, Långström N (2014) Risk fac-tors for filicide and homicide: 36-year national matched cohort study.J Clin Psychiatry 75:127–132. doi:10.4088/JCP.13m08372Int J Legal Med

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Death of a seven-month-old child in a washing machine: a case report

Death of a seven-month-old child in a washing machine: a case report

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