‘Oh-oh,’ said the super. The coroner’s officer laughed. Then we reverted to silence.
I carried out a routine dissection of the victim’s internal systems and organs and checked that there were no rib or other fractures. It is essential to make sure there is no contributing natural cause of death. But the young man proved to be in perfect health. Apart, of course, from the fact that he was dead.
I was glad when the post-mortem ended and asked myself why the atmosphere had been so unlike other forensic post-mortems I had attended. I won’t say they are usually jolly affairs but there is a camaraderie, or anyway a level of noise or discussion, which was completely absent today. What could the problem be?
Back at the office I started to write my report.
Stab wound 1 lay 6cm to the left of the midline on the back … the upper margin of the wound was sharply pointed: the lower margin was blunted … the wound measured 26mm in length … The track of the wound passed between the fifth and sixth ribs of the left hemithorax … the track then entered the left upper lobe on its posterior aspect and passed forwards, slightly downwards and towards the midline. The track transversed the upper lobe of the left lung and incised the left pulmonary artery … This incision was 40mm in length and irregular … Over 1 litre of partly clotted blood was present in the left hemithorax … There was no bruising of the skin adjacent to the wound.
So, on the inside of the body, the wound was almost twice as long as it was externally. I included some analysis.
The route of the track through the muscles of the back was such that the left arm must have been raised at the time of the injury. The discrepancy between the size of the internal and external injuries suggests movement while the weapon was within the chest cavity.
This movement of the knife could have been significant. It certainly indicated that here was a dynamic situation, as many stabbings are. Either the victim or his assailant might have been moving, or they could have been still and the knife itself moved in the wound. Sometimes the significance of such movement only emerges later, so it must be noted.
I detailed the two other stab wounds and their tracks: they had penetrated only the muscle of the back. Then I numbered the ‘blunt’ injuries to the left side of the face.
There were lacerations, abrasions and contusions on this body. There were stab wounds. But, notably, no defence wounds. Classic defence wounds are easy to spot – in a knife attack the palms and the fingers of the hand can be slashed as a victim attempts to grasp the blade of the knife in a desperate attempt at self-protection. This young man had no defence wounds, but then, the main attack had been from behind.
Now for my conclusions. That’s the part of the report most people turn to first, the part laymen – police, and relatives, and so on – should be able to understand.
I knew the form by now. First exclude any chance that the victim died from a naturally occurring disease. Next, say what did actually cause death and how quickly the victim might have been expected to die. Then make any useful comment about possible weapons or events or actions that led to the injuries. Finally, give a medical opinion on the cause of death. This is the formal, legal, part of the report that will – if it is accepted – appear on the death certificate.
I wrote:
Death was not due to natural causes. Stab wound 1 … has caused haemorrhage. Death would have occurred in a matter of minutes. The appearance of the wounds is consistent with a weapon with a single cutting edge approximately 18 to 20mm in width at a distance of 15 to 17cm from the tip. The weapon must have been at least 15cm in length and most probably had a pointed tip.
Both the injuries to the right side and injuries (i) to (iv) on the left side of the face are consistent with a blow by or against a flat surface. The possibility that they were caused by collapse onto the roadway is unlikely but cannot be completely excluded. These injuries appear to have been caused some time prior to injury (v) on the left side of the face. This injury is consistent with contact with a rough surface.
Cause of death:
1a Haemorrhage
1b Stab wound to chest.
This crime, although no doubt decimating for the victim’s family, was actually routine for a forensic pathologist. My report was not the longest or most detailed I have ever written. But I think it took me half the night.
Once the lad had been formally identified I was able to use his name, but apart from that certainty I experienced self-doubt over every fact as well as over my deductions. Was I surmising too much? How sure was I that those facial injuries weren’t caused when he fell in the road? Should I give possible explanations for why the knife moved in the chest cavity? And did I sound confident enough? I didn’t want, once the police had put a man in the dock, counsel for the defence saying, ‘Tell me, Dr Shepherd: how many stabbing post-mortems had you carried out entirely alone before this one? What! None?’
Even though I had only just started my career, I had already understood that court appearances could be a minefield. It was one thing to write your post-mortem report in the office and quite another to deliver it as an expert witness under fire in court. I’d heard many courtroom stories from older colleagues and was both looking forward to and dreading my first appearance in the witness box at a Crown court.
The police were soon questioning a suspect in the Croydon stabbing, a man in his thirties who apparently was not previously known to the victim. The young man had gone to see him at some nearby lock-up garages to buy a cheap, probably stolen, car radio.
The police asked me to examine the suspect’s version of events and we agreed that it would be best to do this back at the scene. And so, a couple of days later, accompanied by the same detective superintendent himself, as well as a detective inspector and a detective sergeant, I returned to Croydon.
We stood by a dingy row of garages. Paint peeled off their doors.
‘The accused is saying somebody else stabbed the lad after he’d left this garage. That he must have been stabbed near to the place we found him,’ said the super.
I said, ‘There was no blood in the garage, so that could be true.’
They looked disappointed. It was not the last time in my career I would disappoint detectives.
‘Well, we think the accused stabbed him right here. But then … there’s no bloodstains outside the garages. Or in the road. Or anywhere but underneath the body.’
I felt important. I felt like Simpson. Closely followed by the high-ranking officers, I paced the route (a hundred paces) and timed it at the slow speed expected of a dying man who had been stabbed through the lung (fifty-three seconds) – not forgetting to move more and more slowly at the end to allow for his increasing breathlessness and dizziness.
I turned to the detectives.
‘You may be right: he could have been stabbed at the garage and got to the road where he was found.’
They smiled.
I wrote:
In my opinion it is entirely possible for an individual with a wound such as Injury 1 to have travelled this distance on foot before collapsing.
The lack of bloodstains on the route may be explained by two factors. First, there would have been little external bleeding from an upright individual following Injury 1 until the level of blood within the chest reached the site of the wound in the skin. Second, the deceased was wearing clothing, in particular a thick jacket, which would have absorbed a significant quantity of blood.
I need not have worried about my court appearance. The first trial collapsed when the jury was discharged on a technicality before I could give evidence. By the time the case came to trial again I was a veteran of so many homicides that defence counsel had no idea this had been my very first case.
I gave my evidence and the cross-examination went smoothly enough.
It looked clear-cut to me. I had seen the evidence against the defendant and thought it was compelling. And three stab wounds including one deep penetration of the victim’s lung from behind gave the tabl
oids a chance to use one of their favourite phrases: ‘frenzied attack’. It was certainly used by the prosecution too, in an attempt to disgust the jury.
I was astonished, therefore, when the defendant was acquitted. Evidently the jury had not been convinced of his guilt beyond reasonable doubt. I worried for a while about what had gone wrong and whether, because this was my first case, I had somehow failed to present an effective report. Or had I struck the wrong note with the jury? I would never know.
It happened that a couple of years later I was reading the Evening Standard on the bus when I noticed a name which looked familiar in a court report. I read how a slim and attractive young man of about eighteen had been knifed by a stranger three times. One stab wound, into the left lung, had very nearly proved fatal. By some miracle the victim had survived to identify his assailant: in fact, he was able to reveal that the man had hung over him and suggested that, since he was dying, a suitable last act might be to have sex.
I remembered that very first case of mine. Same defendant. Same crime. Different – but very similar-looking and very lucky – victim.
I knew about the defendant’s earlier murder charge. The jury, of course, did not when they found him guilty of attempted murder.
9
My second case was another stabbing. At about nine o’clock one night I was called to an ordinary London red-brick, terraced house, distinguishable from all the other houses in the road only by the presence of the police outside.
Inside was an unexpectedly ornate interior. On the banisters, blood. I followed the trail upstairs and, just inside a bedroom door, feet nearest, naked in a huge puddle of blood, lay a grey-haired man, face down.
I pushed the door open. The dull, patterned wallpaper darkened the room and large, heavy, wooden furniture darkened it further. Although cluttered, everything was in its place. The alarm clock. The radio. The framed photos. The small TV on a mahogany chest of drawers facing the bed.
Here was the room of a man who led a well-ordered, working life. But that well-ordered life had been extinguished and the working man was lying awash with his own blood.
It was difficult to tread round him. His back was patterned with spatters and rivulets of blood. There was blood on the wall. The bed was half covered by a duvet but this did not hide the huge, deep bloodstains over the sheets. On the floor, by an electrical socket, almost floating in blood, was a long, wooden-handled kitchen knife.
I turned the body over with great care. I could see one gaping knife wound in his chest. I thought there were probably more wounds, hidden by blood.
Then I took his temperature. Since he was already naked, this was easy. Taking a rectal temperature, especially if it involves removing clothes, can create forensic chaos so I had already learned that quite often it is better to get the body straight to the mortuary and take the temperature there. Now I saw that the victim’s temperature was 26.6°C.
The detective who was watching me said, ‘So, Doc, what time did he die, exactly?’
My heart sank. Especially at the word ‘exactly’. That’s the question everyone asks first. That’s the question everyone thinks we can answer. That’s the question which reveals the huge gap between the public perception of pathologists and the truth. I blame those TV cop shows. The fact is, it is very hard indeed for us to determine with any accuracy when a death occurred.
The detective was waiting.
I said, ‘Well … I can’t be sure …’
Body temperature may be the best forensic indicator we have for estimating the time of death but it is not a very reliable one. Basic physics tells us that a hot body will cool as its heat passes into the cooler environment. But of course, it’s not that simple. A generalization would be that a body feels cold to touch within eight hours of death. It’s not that simple, either. In fact, a body may not feel cold for as much as thirty-six hours and residual metabolic activity may mean the temperature never drops to the ambient level. Then, when decomposition is underway, the temperature will even start to rise.
There are so many variables that can affect the rate at which we cool after death: body temperature when death occurs, the environmental temperature, fluctuations in the weather, central heating, open windows, the amount of clothing on the body, the tog value of a duvet over it, the posture of the body (as we all instinctively know, a curled position retains more heat), bodyweight (fat is a good insulator), muscle bulk (less muscle means faster cooling) and the age of the deceased (children have a larger surface area to body weight and so lose heat more quickly) … a multitude of small factors make it a mug’s game to estimate the time of death from the temperature of a body.
Even a computer program, after taking countless variables into account, would still not be able to give an accurate answer about the time of death. It may suggest that death occurred between a range of times but those times would probably be many hours apart. And still no one would expect accuracy of more than 90 per cent.
The detective nodded wisely. He said, ‘I expect you’ll be able to tell from the rigor mortis.’
Well, no. That’s another misconception. Rigor mortis is one of death’s most obvious processes but it is so highly variable that it is an even less reliable basis than body temperature for estimating the time of death. Its speed and onset are determined by temperature. A body outside in a cold winter may have no rigor after a week, although there can be a rapid onset of rigor as the body warms up when it is brought into the higher temperature of the mortuary. And there are other confounding factors. Was the deceased exercising just prior to death? Rigor mortis will be faster due to the lactic acid produced by physical exertion. Was death associated with a high fever? Again, rigor will be faster. Was electrocution the cause of death? This speeds up rigor, perhaps because of the stimulation of the muscle cells. Did death take place in front of a warm fire? Faster rigor. In a hot bath? Faster rigor.
Rigor mortis is actually caused by complex changes that occur once the heart has stopped beating and the muscle cells are deprived of the oxygen they need in order to metabolize. For years rigor was assumed to start in the face, as anyone making a delayed attempt at mouth-to-mouth resuscitation may recognize. We now understand that it develops uniformly throughout the body but that it is simply most detectable in the smaller muscles first – and these small muscles are found mainly in the jaw and around the eyes and fingers. As a generalization, rigor can be felt in these areas about three hours after death. It then appears to spread down the body from the head to the legs, although in fact this is just the differential stiffening of larger and larger muscle groups. The stiffening of the muscles generally occurs faster than the body cools, so there is usually a period when the body is both warm and stiff. And it doesn’t last for ever: rigor mortis wears off after a day or so and the muscles become flaccid again.
In a temperate climate like the UK, rigor mortis may have affected all of the muscles – ‘fully established’ rigor – within twelve hours. In hot equatorial regions, rigor can be fully established and then disappear in just one hour. And it may sometimes seem that certain people – the very young, the very old or the emaciated – don’t have it at all, because they have so little muscle bulk.
Its strength can be surprising: there are famous pictures of full rigor with the head on one chair and feet on another and the unsupported body in between as straight as a board. So, performing a post-mortem on a body in a state of rigor mortis poses its own problems – unless the deceased has obligingly died on his back with his arms by his sides.
The easiest choice is to wait for rigor to pass. Unfortunately, waiting is not an option for the forensic pathologist helping in a homicide investigation, where speed is of the essence.
That night I soon left the blood-filled bedroom for the mortuary. The deceased arrived very shortly after me. His neck, arms, jaw and knees had rigor mortis and he had actually died with one arm behind him and one folded in front. His right leg was raised.
I needed him to lie
flat for the post-mortem and so I had to break rigor. This can require some strength. If an arm is bent I must push firmly on the joint until I break the chemical bonds between the molecules of actin and myosin in the cells. Once that bond is broken, the arm can be laid down flat on the table. But sometimes if the rigor is particularly strong – for instance, if the deceased is a muscled young man whose job involved heavy lifting – I’ll need a mortuary assistant to help me. Breaking rigor involves putting considerable pressure on a specific joint to loosen the muscle and it then gives way gradually, not suddenly like a bone snapping.
In this case the patient was sixty-two years old and rigor was quite easily broken by vigorously moving the arms backwards and forwards until they felt loose.
At the repeated request of the police officers, I used the two unreliable guides – body temperature and stiffness – to arrive at a range of times between which death might have occurred. Bearing in mind that there are any number of variables, of course. In this case, I gave an estimated time since death of four to six hours.
‘Well done, Doc,’ said the senior detective, who was just coming into the post-mortem room after taking a phone call. ‘The bloke who killed him says it was about four thirty, five o’clock this afternoon.’
‘You’ve got him already?’
‘He’s just turned himself in. They were in a homosexual relationship. Says he lost his temper.’
It was quite a serious loss of temper. There were eight stab wounds, one of them a really gaping wound on the outside which inside had directly penetrated the heart. So clearly do knives leave their tracks and hilts their bruises that I was able to sketch with detailed dimensions the weapon which had been used by the murderer. It was my first knife sketch ever based on wound tracks and I was amazed when it exactly matched the dimensions of the kitchen knife the police found at the scene. From now on, Shepherd was a knife man.
Unnatural Causes Page 7