The main use of tattoos and piercings in forensic medicine is in the identification of the bodies of unknown persons. Once again, the simple pres- ence of a tattoo does not constitute identification and there has to be a comparison with the tattoos of a known individual. Ante-mortem images can be very helpful when compared with images of the deceased, which can be used if a visual identifica- tion is not possible or so that they can be circulated when the identity is not known.
There is a huge diversity of skin tattoos in Western society, some of which may have specific meaning or significance within certain subgroups of society.
However, there is also much folklore about the sig- nificance of tattoos, a large amount of which may have been relevant in the past. Now that designs originating from throughout the world are used as body decoration internationally, little assistance is provided by assessing the tattoo design. Names and dates of birth within tattoos may be useful.
Decomposing bodies should be examined carefully for tattoos, which may be rendered more visible when the superficial desquamated stratum corneum is removed.
Body piercing is widespread, and the site and type of piercing should be noted and piercings can be used as part of visual identification or can be recovered for identification by relatives if visual identification is not possible.
Figure 4.2 Retained dentition after fi re.
4 Identification of the living and the dead
■ Identity of decomposed or skeletalized remains
When presumed skeletal remains are discovered, the investigators will want to know the answers to a number of questions. The answers to these questions may require the expertise of pathologists, anthro- pologists, odontologists, radiologists and scientists.
Questions include:
■ Are the remains actually bones? Sometimes stones or even pieces of wood are mistaken by the public or police for bones: the anatomical shape, character and texture should be obvious to a doctor.
■ Are the remains human? Most doctor should be able to identify most intact long bones. A foren- sic pathologist will be able to identify almost all of the human skeleton, although phalanges, carpal and tarsal bones can be extremely dif- ficult to positively identify as human because some animals, such as the bear, have paw bones almost identical to the human hand. It may be extremely difficult to identify fragmented bones, and the greater skills and experience of an experienced anthropologist or anatomist are invaluable. Cremated bones pose particular dif- ficulties and these should only be examined by specialists.
■ Am I dealing with one or more bodies (is there co-mingling of body parts)? This ques- tion can be answered very simply if there are two skulls or two left femurs. However, if there are no obvious duplications, it is impor- tant to examine each bone carefully to assess whether the sizes and appearances match.
It can be extremely difficult to exclude the possibility of co-mingling of skeletal remains, and expert anthropological advice should be sought if there is any doubt.
■ What sex are the bones? The skull and the pelvis offer the best information on sexing; although the femur and sternum can provide assistance, they are of less direct value. It is important to attempt to determine the sex of each of these bones and not to rely on the assessment of just one. Exami- nation by an anthropologist or anatomist is vital.
■ What is the age of the person? This will require a multi-professional approach utilizing the skills of the pathologist, anthropologist, odontologist and radiologist, each contributing to the overall picture.
■ What is the height (stature) of the person? The head to heel measurement of even a completely fresh dead body is seldom the same as the per- son’s standing height in life, owing to a com- bination of factors, including muscle relaxation and shrinkage of intervertebral discs. If a whole skeleton is present, an approximate height can be obtained by direct measurement but, because of variable joint spaces, articular cartilage, etc., this can only be, at best, an approximation. If only some bones are available, calculations can be made from established tables
■ What is the race or ethnic origin? This is very much the field of trained anthropologists and should not be attempted without their assistance.
■ Can a personal identity be discovered? The pre- vious criteria can allot bones to various groups of age and sex but putting a name to the indi- vidual depends, as does all identification, upon having reliable ante-mortem data. Occasion- ally, foreign bodies such as bullets or other metallic fragments may be found embedded in the skeleton; these may either relate to the cause of death or may simply be an incidental finding. Most body implants (e.g. pacemak- ers, joint replacement) bear a unique reference number which identify the maker – these and other unique medical data are often useful in establishing identity.
Where pre-mortem clinical radiographs are avail- able, the comparison of these with the post-mortem films may give a definite identity. If a skull X-ray is available, comparison of the frontal sinus pat- terns is incontrovertible as no two people have the same frontal sinus outline. Expert comparisons of the lateral skull X-ray and radiographs of the upper ribs, humeri and femurs can provide useful informa- tion based partly, in the limbs, on the pattern of the cancellous bone.
■ Mass disasters
A mass disaster requires appropriate collection of forensic samples; continuity and integrity of the sample trail; and once analysed the application of appropriate evidential standards. At the time it may not be known whether an event has happened by accident, natural disaster or as a crime. Ante- mortem data from potential decedents, including
Age estimation in the liv ing
dental, fingerprint and DNA samples should be sought at the earliest opportunity for later comparison. Fin- gerprints can be obtained from personal items, in the home or workplace or crime databases. DNA samples can be obtained from similar items but also families. Dental practitioners should be approached to provide dental records, radiographs and casts where available. Matching of the ante-mortem data with the post-mortem samples may be done manu- ally or using specialized software systems so that identities can be confirmed.
If multiple deaths are caused by some form of disaster the process of Disaster Victim Identifica- tion (DVI) should be established. In England and Wales a formal process called an Identification Commission and chaired by the Coroner will con- sider each identification to ensure that an accurate identification is made. Body recovery teams will identify where the deceased are. They will then be photographed before they are moved to assist any criminal investigation and to assist the Coro- ner in establishing cause of death. At the mortuary any personal items will be retrieved. These will be used as indicators of the potential identity of the person. Investigators will then go with a family liaison officer to recover items that could assist the identification, such as personal items from the deceased’s home that may yield fingerprints or DNA, or their dental records from their dentist. Once identification evidence has been collected this will be presented to the Identification Commission who will decide if it meets the standards required to confirm identity. Further evidence may need to be collected. If identity reaches the standard of proof required then the evidence will then be used for an inquest in the death to be opened.
■ Age estimation in the living
Many doctors will be asked to estimate or evalu- ate the age of an individual but few will have the knowledge or skills of assessing age or be aware of the limitations, even when undertaken correctly.
A small number will have the necessary skill to undertake an age estimation and provide responses appropriate to the respective degrees of certainty required in criminal or civil proceedings.
For the deceased, investigation of identity and age is generally undertaken by order of, and with
the consent of, authorities – the Coroner in England &
Wales.
In the living, other constraints apply. The essen- tial element of any age estimation procedure is to ensure that it complies with, and fulfils, all local and/or national legal and ethical requirements.
All practitioners, clinical or forensic, must take full responsibility for their actions in relation to the human rights of the subject undergoing investigation. It is essential that the practitioner, clinical or forensic, undertaking the estimation is ex-perienced in the interpretation and presen- tation of data emanating from the investigation.
They must have a current and extensive under- standing of the limitations of their investigation both in relation to the physical technology avail- able to them and to the nature of the database to which they will refer, for comparison purposes.
This also requires that the practitioner have a realistic understanding of the variation expressed by the human form and the extrinsic and intrin- sic factors that may affect any age-estimation process.
Four main means of age estimation are available (see below), and the more of these that are used the more likely it is that the result of the examina- tion will correlate well with the chronological age of the individual. Underestimation of age is unlikely to raise any issue in relation to an infringement of human rights (as younger persons tend to be treated better in law) but an over-estimation of age can have adverse effects. It is essential that the final estimation is robust and conveys a real- istic range within which the chronological age is most likely to occur. Any element of doubt must result in an increased range of possibilities. It is not possible in any circumstance to ascertain with certainty whether an individual is 20 or 21 years of age. An assessment of 20 years ranges from a specific calendar date (birthday) to a date that is 364 days beyond that date and only one day short of the assessment of an age of 21 years. The means of assessment that should be used now to estimate age in the living are:
■ social and psychological evaluation – this requires evaluation by a highly trained clinician or social work practitioner;
■ external estimation of age – this evaluation must be undertaken by a qualified clinician (a foren- sic physician, or a paediatrician for the child
4 Identification of the living and the dead
and geriatrician for the elderly – examination by more than one practitioner may be appropriate);
■ skeletal estimation of age – this investigation cannot be undertaken visually and therefore relies on technology to assist the process (expo- sure to much of the relevant technology has risk from ionizing radiation and can only be under- taken with informed consent)
■ dental estimation of age.
Certain aspects of each of these means of assess- ment are well recognized. External estimation of age should use Tanner staging to assess child maturity (Figure 4.3). Skeletal estimation will assess hand/
wrist radiographs in the first instance, which are compared against standards previously published. A visual intraoral inspection will inform the practitioner as to the stage of emergence and loss of the dentition and is particularly useful for age evaluation in the pre-pubertal years. Pubertal and post-pubertal individuals will, however, require a radiographic investigation.
■ Further information sources
A v. London Borough of Croydon and Secretary of State for the Home Department; WK v. Secretary of State for the Home Department and Kent County Council, [2009] EWHC 939 (Admin), UK: High Court (England and Wales), 8 May 2009. http://www.unhcr.org/refworld/
docid/4a251daf2.html (accessed 22 November 2010).
A by his litigation friend Mejzninin vs. Croydon London, Borough Council [2008] EWHC 2921 (Admin).
http://www.childrenslegalcentre.com/OneStopCMS/Core/
CrawlerResourceServer.aspx?resource=76D78C51-B4F2- 4F9F-9904-51A50ADC8634&mode=link&guid=fc8af87a1ce 544dea1dd05eb961e2882 (accessed 22 November 2003).
Benson J, Williams J. Age determination in refugee children.
Australian Family Physician 2008; 37: 821–824.
Black S, Aggrawal A, Payne-James JJ. Age Estimation in the Living. Wiley, London 2010.
Bowers CM. Forensic Dental Evidence: An Investigator’s Handbook, 2nd edn. Academic Press, Amsterdam 2011.
Crawley H. When Is a Child Not a Child? Asylum, Age Disputes and the Process of Age Assessment. London Immigration Law Practitioners’ Association (ILPA), 2007.
Stage G = genitals (boys) B = breasts (girls) P = pubic hair (girls)
1 Pre-adolescent Pre-adoloscent No hair
2 Scrotum pink and
texture change, slight enlargement of the penis
Breast bud Few fine
hairs
3 Longer penis
larger testes
Larger, but no nipple contour separation
Darkens, coarsens, starts to curl
4 Penis increases
in breadth, dark scrotum
Areola and pailla from secondary mound.
Menarche usually commeneces at this stage
Adult type, smaller area
5 Adult size Mature (pailla
projects, areola follows breast contour)
Adult type
Figure 4.3 Tanner staging.
F urther information sourc es
Crossner CG, Mansfeld L. Determination of dental age in adopted non-European children. Swedish Dental Journal 1983;7: 1–10.
Dalitz GD. Age determination of adult human remains by teeth examination.Journal of the Forensic Science Society 1962;3: 11–21.
Dvorak J, George J, Junge A, Hodler J. Age determination by magnetic resonance imaging of the wrist in adolescent male football players. British Journal of Sports Medicine 2007;41, 45–52.
Euling SY, Herman-Giddens ME, Lee PA et al. Examination of US puberty timing data from 1940 to 1994 for secular trends: panel fi ndings. Pediatrics 2009; 121(Suppl 3):
S172–S191.
Flecker H. Roentgenographic observations of the times of appearance of epiphyses and their fusion with the diaphyses.Journal of Anatomy 1933;67: 118–64.
Gilsanz V, Ratib, O. Hand Bone Age. A Digital Atlas of Skeletal Maturity. Berlin: Springer, 2005.
Gleiser I, Hunt EE Jr. The permanent mandibular fi rst molar;
its calcifi cation, eruption and decay. American Journal of Physical Anthropology 1955; 13: 253–84.
Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist. Stanford, CA:
Stanford University Press 1959.
Jeffrys AJ, Wilson V, Thein SL. Hypervariable minisatellite regions in human DNA. Nature 1985; 314: 67–73.
Kaplowitz PB, Oberfi eld SE. Reexamination of the age limit for defi ning when puberty is precocious in girls in the United States: implications for evaluation and treatment.
Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society. Pediatrics 1999;104: 936–41.
Kvaal SI, Kolltveit KM, Thompsen IO, Solheim T. Age determination of adults from radiographs. Forensic Science International 1995; 74, 175–85.
Lindstrom N. Regional sex traffi cking in the Balkans:
transnational networks in an enlarged Europe. Problems of Post-Communism 2004; 51: 45–52.
Liversidge HM, Molleson TI. Developing permanent tooth length as an estimate of age. Journal of Forensic Sciences 199944: 917–20.
Liverpool City Council (R, on the application of) vs. London Borough of Hillingdon [2008] EWHC 1702 (Admin).
Marshall WA. Growth and sexual maturation in normal puberty.
Clinics in Endocrinology and Metabolism1975;4: 3–25.
Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Archives of Diseases in Childhood 1969;
44, 291–303.
Marshall WA, Tanner JM. Variations in the pattern of pubertal changes in boys. Archives of Diseases in Childhood 1970;
45: 13–23.
Martrille L, Baccino E. Age estimation in the living. In:
Payne-James JJ, Corey T, Henderson C, Byard R. (eds) Encyclopedia of Forensic and Legal Medicine. Oxford:
Elsevier, 2005.
Pyle SI, Waterhouse AM, Greulich WW. A Radiographic Standard of Reference for the Growing Hand and Wrist.
Cleveland, OH: The Press of Case Western Reserve University. 1971.
Ritz S, Schütz HW, Peper C. (1993) Postmortem estimation of age at death based on aspartic acid racemization in dentin: its applicability for root dentin.International Journal of Legal Medicine 1993; 105: 289–293.
Royal College of Paediatrics and Child Health. The Health Of Refugee Children: Guidelines For Paediatricians. London:
Royal College of Paediatrics and Child Health, 1999.
Saunders E. The Teeth, a Test of Age, Considered with Reference to the Factory Children, Addressed to the Members of Both Houses of Parliament. London:
Renshaw,1837; 1–2.
Schaefer M, Black SM, Scheuer L. Juvenile Osteology:
A Laboratory and Field Manual. London: Elsevier, 2009.
Scheuer JL, Black SM. The Juvenile Skeleton. London:
Academic Press, 2004.
Schmeling A, Olze A, Reisinger W, Geserick G. Age estimation of living people undergoing criminal proceedings. Lancet 2001;358: 89–90.
Schmeling A, Grundmann C, Fuhrmann A. et al. Criteria for age estimation in living individuals. International Journal of Legal Medicine 2008; 122, 457–60.
Schmidt S, Mühler M, Schmeling A, Reisinger W, Schulz R.
Magnetic resonance imaging of the clavicular ossifi cation.
International Journal of Legal Medicine 2007; 121: 321–4.
Solheim T. A new method for dental age estimation in adults.
Forensic Science International 1993; 59: 137–47.
Tanner JM. Foetus into Man: Physical Growth from Conception to Maturity. London: Open Books, 1978.
Tanner JM, Whitehouse RH. Clinical longitudinal standards for height, weight, height velocity, weight velocity and stages of puberty. Archives of Diseases in Childhood 1976; 51, 170–9.
Tanner JM, Whitehouse RH, Healy MJR. A New System for Estimating Skeletal Maturity from the Hand and Wrist, with Standards Derived from a Study of 2,600 Healthy British Children. Paris: Centre International de l’Enfance, 1962.
Tanner JM, Whitehouse RH, Marshall WA, Healy, MJR, Goldstein H. Assessment of Skeletal Maturity and Prediction of Adult Height (TW2 Method), 2nd edn.
London: Academic Press, 1975.
Tanner JM, Healy MJR, Goldstein H, Cameron N. Assessment of Skeletal Maturity and Prediction of Adult Height (TW3 Method). London: W.B. Saunders, 2001.
Todd TW. Atlas of Skeletal Maturation. St Louis, MO: C.V.
Mosby, 1937.
Ubelaker DH. Human Skeletal Remains: Excavation, Analysis and Interpretation. Washington, DC: Smithsonian Institute Press, 1978.
van der Linden FPGM, Duterloo HS. The Development of the Human Dentition: An Atlas. Hagerstown, MD: Harper and Row, 1976.
Wheeler MD. Physical changes of puberty. Endocrinology and Metabolism Clinics of North America 1991;20: 1–14.
Wittwer-Backofen U, Gampe J, Vaupel JW. Tooth cementum annulation for age estimation: results from a large known- age validation study. American Journal of Physical Anthropology 2004; 123, 119–29.
Chapter The appearance of the body
after death
■ Introduction
It is accepted that, if irreversible cardiac arrest has occurred, the individual has died and eventually all of the cells of the body will cease their normal met- abolic functions and the changes of decomposition will begin.
Initially, these changes can only be detected biochemically as the metabolism in the cells alters to autolytic pathways. Eventually the changes become visible and these visible changes are important for two reasons: first, because a doctor needs to know the normal progress of decomposi- tion so that he does not misinterpret these nor- mal changes for signs of an unnatural death and, second, because they may be used in estimating how long the individual has been dead (i.e. the post-mortem interval, or PMI).
The appearance of the body after death reflects PMI-dependent changes, but the reliability and accuracy of traditional ‘markers’ of the PMI has become increasingly doubtful, given their depend- ence on incompletely understood biological and environmental factors.