Decomposition

DECOMPOSITION is the process of the body breaking down and decaying. This starts as soon as death occurs however it is not immediately visible. There are many factors in decomposition and the rate at which is occurs.  The location of the body is one main factor – is it inside or outside.  The temperature of the location is another big factor.  The hotter the location the faster the body will decompose.  The condition of the body is another factor. Whether the body muscular or obese will be a factor as fat will decompose at a different rate than muscle.   If the person/body is sick or damaged in some way in which air, moisture or insects (covered in the next post) will reach the organs faster than normal, can speed up the process.

This are screen shots from my teaching powerpoint,  It shows some of the variations of decomposition.

The majority of these photos were taken of decomposed bodies inside residences.  The one with the foot labeled “desiccation”  was of a body that had been inside a warm residence for at least 2 months before being found and was essentially closer to being mummified.  This is what you would normally see of remains left outside in the heat for a long period of time.

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The Mortis Brothers. Who??? (What!)

The Mortis Brothers  

Rigor Mortis, Algor Mortis and Livor Mortis – sometimes referred to as the “Mortis Brothers”

Rigor Mortis

Rigor Mortis is due to a biochemical change in the muscles that occurs several hours after death, though the time of its onset after death depends on the ambient temperature.

• Within ½ to 1 hour = becomes apparent

• Approx 12 hours = increases to max

• Approx 12 hours = set / stays

• Approx 12 hours = decreases / relaxes

• Once fully established, the breaking of rigor in joints is irreversible and it will not reappear.

• Rigor mortis appearance and disappearance is accelerated by prior exercise, convulsions, electrocution or hot environmental temperature. In a hot environment, for example, the rigor mortis may disappear in only nine to twelve hours.

Algor Mortis

Under average conditions, the body cools at a rate of 2.0 F to 2.5 F per hour during the first hours, and slower thereafter, with an average loss of 1.5 F to 2 F during the first twelve hours, and 1 F for the next twelve to eighteen hours.

Livor Mortis aka Lividity

• Postmortem Lividity or postmortem hypostasis is a purplish-blue discoloration due to the settling of blood by gravitational forces within dilated, toneless capillaries of the deceased’s skin.

• Blood loss and/or anemia can cause difficulty in discerning Lividity.

• In individuals with dark skin pigmentation, Lividity in the skin can go unnoticed.

• In early stages, livor can be blanched by compression.

• In certain cases, it may be difficult to distinguish between postmortem livor and ante mortem bruises. Incision of the skin may be required.

There are many factors that affect rigor mortis, so the times listed above are only averaged guidelines.  Whether a person is obese or thin and muscular play a big factor since rigor occurs in the muscles, and certain disease processes can alter the time as well.  We use stages of rigor to help determine if the story we are told, as well as the scene, fits with the way we find rigor to be. For example, if we are told someone was speaking just before death, but they are stiff with rigor, we know the story is not accurate.  Another example would be if the rigor was not consistent with the position the person is now observed. We cannot pin point a time of death from rigor mortis. We can only determine if it is consistent with the time frame and story we are told.

  

Algor Mortis

Under average conditions, the body cools at a rate of 2.0 F to 2.5 F per hour during the first hours, and slower thereafter, with an average loss of 1.5 F to 2 F during the first twelve hours, and 1 F for the next twelve to eighteen hours. As with rigor mortis, algor mortis times are a guideline and not exact.  A person’s condition (such as body fat or disease) can play a part in how quickly – or slowly – their temperature drops. If they are on a pillow top mattress they will stay warmer longer because the pillow top retains body heat.  If they are inside but near an open window and with cold air blowing in, they will cool down faster. If we know someone has been deceased for awhile – such as several hours – but they are outside and their temperature is still very high, and especially if it is higher than normal, then we must consider heat exposure as a factor in their death. This can occur inside too, when someone does not have adequate temperature regulation and it is very hot outside. If it is very cold, and the decedent is inadequately dressed or outside, then we use their temperature to help determine if exposure to the cold could be a factor in their death.

Livor Mortis or Lividity.

Postmortem Lividity or postmortem hypostasis is a purplish-blue discoloration due to the settling of blood by gravitational forces within dilated, toneless capillaries of the deceased’s skin.

Blood loss and/or anemia can cause difficulty in discerning Lividity.  In individuals with dark skin pigmentation, Lividity in the skin can go unnoticed.  In early stages, livor can be blanched by compression.  In certain cases, it may be difficult to distinguish between postmortem livor and ante mortem bruises.  Incision of the skin may be required.

Lividity is often mistaken for bruising by the untrained. One of the ways we check lividity, is by applying moderate pressure with a finger.  If the pressure is able to change the color to white, we consider that “blanching” and lividity is NOT set.  If the coloring does not change, then we consider the lividity “set” or “fixed.” (see pic)

Occasionally we will see some lividity on both the anterior (front) and posterior (back) of the body.  This indicates the body had been in a position for awhile, then moved to another position. If we are told the decedent was NOT moved, then our findings contradict the story. This is important, however it is not unusual for someone to find their loved one face down and roll them over when they don’t respond. If they admit this up front, then mixed lividity would not be as surprising.  Lividity can often tell us where the person had been laying. See the photo inserted.  You can see where the decedent had been lying on a flat service causing part of their back to not have lividity.

In an investigation, we use each finding as part of the puzzle of what happened.  By checking many different factors, we can discover if there is something that does not fit with the story and/or the other findings. This helps us determine if there is something suspicious in what might otherwise appear to be a nature or non-criminal death.

 

Time of death

TIME OF DEATH (TOD)

Establishing time of death is often more complicated than they make it seem on television.  The following information is based on California laws regarding death certificate criteria.

Determining TOD in an unwitnessed death is almost impossible to do.  There are times when someone dies alone or “unwitnessed” and there is something that can help us narrow down the approximate time the person died, such as a gunshot being heard, or the dying person being on the phone with someone when they stop breathing, or an event that caused an immediately fatal injury such as a traffic accident, explosion, a lightning strike and other similar events.  For example, there was a case handled by my office in which someone was attempting to steal copper wiring from a metal control box. When they attempted to cut the wire, they were electrocuted and actually caught fire. Although the event was not witnessed, there was a loss of power to a small area and the time of the power loss was recorded by the company as well as the people who lost power.  In that instance we can have a pretty good idea what time death occurred because it would have been instantaneous due to the amount of electricity.  There have also been many time a traffic accident is heard, and when first responders arrive one or more of the victims are already deceased and their injury is one that would be immediately fatal such as extreme crushing injuries to the head and chest. One issue with time of death is the person has to be officially pronounced dead by someone qualified to do so. This is usually a first responder such as a paramedic, or law enforcement official. In hospital deaths, it is usually a physician, or a nurse at the direction of a physician.  In many cases, the time of death (TOD) is the pronouncement time as recorded by the physician or first responder.

However, in unwitnessed cases, we often use the term FOUND TIME instead of TIME OF DEATH.  The reason for this is we do not know the actual time of death.  We take the time the first responder arrived and confirmed the person was deceased. We then determine when the decedent was last known to be alive.  If it was not on the same day they were found, we will list a FOUND DATE, then list the pronouncement time listed in the TOD space. This basically certifies we cannot establish the exact time of death but only when the person was found.  In our investigative report we will elaborate more about the last time known alive, and how long the physical findings indicate the person was probably deceased.  This is where temperatures, exposure, stages of rigor mortis and decomposition come into play.  I will discuss those topics in a later post….

A second area on the death certificate which is important in NON-NATURAL deaths, is the INJURY section. In some cases, the injury date and time is the same or very near the time of death, and in others it can be years apart. In an unwitnessed death this entry is often marked UNKNOWN. If a gunshot, traffic accident or other factor can provide the injury time we will use it.

Grief…. Is “Closure” possible??

CLOSURE….. I have come to dislike that word.  So many people use it.  You hear cops, doctors, family and television use that word. The family needs closure. I want closure.  If I just know who did it, or what happened, or if we just find the body, or if the suspect gets convicted…. THEN I/we/they will have closure. NO I say they won’t. Let me explain WHY I say this. To say someone will have closure at some point after the loss of a loved one indicates that the living will be able to say I got my answer and now I am done grieving and will move on. As someone who has lost many friends and family, including both of my parents, I don’t believe there is any answer a loved one can receive that will bring THAT much relief. I also, at least for myself, do not believe someone ever stops grieving.  We may reach a point in which we stop allowing our grief to control our life. We may reach a point where we are now able to get up, go out into the world and move forward but that does not mean we are done grieving.  My mother has been gone for over 10 years now, but I still miss her, and some days I truly grieve for her – and yet I am finally at a place I can go through boxes I packed up after she died, see memories, see things written in her handwriting, and once in rare instance come across an article of clothing that has been packed away in such form that I can still smell my mom’s perfume or more often her cigarettes, and it makes me smile sadly at the memory it invokes, but I no longer curl up in a fetal position and cry.

It is my personal and professional opinion that there is no set time for grieving. Is it possible to be locked in your grief to the point of it being unhealthy – of course, but I hate when someone tells a grieving person that it has been long enough and the need to “get over it”. Please do not criticize, or judge a person who is grieving. Do not ask them what will give them closure, because I believe there is no true “thing” for anyone that completely provides closure.

Grieving to little is just as bad. I say this because if you just shove those feelings deep into the back of your mind and force yourself to move on and not think about then someday, one day, I assure you – you will crack and shatter, and it will not be pretty.

When I would speak with families during the process of my investigations, I would tell them to take their time and do not be hard on themselves or on each other. Everyone grieves differently.  If you have lost more than one loved one, you will likely grieve differently with each. It also matters how you find out about the loss of your loved one.  For those of us (yes including me) have been the one to find your loved one dead from a traumatic event, such as suicide, homicide, decomposed, etc., it is even more traumatizing than being at the bedside in a hospital or being told after the fact. Once you see your loved one like that, you cannot flush the vision out of your mind. Eventually you can go days, weeks, maybe even months without thinking about it, but it will come and go and it will never go away completely.  I would always discourage and sometimes prevent family members who would come to the scene from seeing their loved one in a bad way. Working a job like mine made my grief harder to push past.

In closing I beg of you to please be supportive to those who grieve and if/when you (the reader) are grieving, please seek a support group or someone you trust if you need to talk about it.  Don’t keep it all inside and wait until you explode.  Do something that helps you. One thing I did was make a memorial garden for my parents. My husband made a beautiful wooden bench and I can sit and “visit” my parents anytime as they both have engraved granite urns that have been placed in the garden. My cousin had a star named after my mom.  There are little things you can do to honor and memorialize your loved ones.

The Autopsy

   

AN EXTENSIVE ACCOUNT OF AUTOPSIES

Any case in which additional information is needed from examining the organs or closer inspection of injuries will necessitate an autopsy.  This process is also often referred to as a “post-mortem examination.”  In most cases, autopsies are performed by pathologists assisted by technicians. Each county varies slightly, depending on whether they are a Medical Examiner’s office or part of the Coroner system. The main difference is political in which the position of Coroner is an elected position and often co-joined with the county Sheriff’s department. That is the type of system I worked in and my experience is based in. Autopsies are done in what is commonly referred to as an autopsy suite. The room is outfitted with special workstations where the table/gurney can be rolled up to the sink area and locked into place with the end of the table resting over the sink.  On either side of the sink are areas for the doctor to perform dissection and study of the organs. There is a scale that hangs over the sink for weighing of organs. Collection containers for body fluids and organ specimens are prepared and labeled prior to the start of the autopsy After the external examination has been completed and blood samples collected, the body is laid supine (flat on back) on the table. The head of the table is able to be raised if needed. The foot end of the table has a hole so the body fluids can drain down special channels in the outer edge of the table and out the hole into a large sink. A special block is placed under the decedent’s neck to raise the head for easier access to the skull and throat. Often, an additional block is placed under the shoulders to allow for easier Y incision.

The hair is parted across the top of the head, from ear to ear. The scalp is opened to the skull with a scalpel (within the ear to ear hairline part). The scalp is then manipulated and separated from the skull and folded down onto the face, and the back down over the back of the skull.  When the skull is exposed, a Stryker saw is used to make a separation in the skull across the front, about the top of the forehead, and another cut is made towards the bottom, across the back of the head.  The 2 cuts are made to intersect, usually about behind the ear area so the “skull cap” can be lifted off and a large opening allows access to the brain. When fully developed, the membranes coving the brain create a tight suction of the cap to the brain.  This suction is usually broken with the use of a “skull key” which has a flat edged protrusion that looks much like a large standard screw driver.  This is gently worked into the top cut and twisted just enough to break the suction. The membranes are removed from the inside of the skull cap to allow the pathologist to examine the inside for evidence of recent or past injury, including staining from brain injuries. The brain is gently separated from the skull sides by running a finger between the brain and the sides. Next, the top of the brain is manipulated to allow visualization of the brain stem. The brain stem is severed as deeply as possible with a scalpel, and the brain and stem are removed and weighed. The cleaned skull cap and remaining skull are examined thoroughly to look for indications of head injuries.  Any fractures or staining (from bleeding in the head) are photographed and noted in detail by the pathologist.

Next a Y incision is made with a scalpel.  The top of the Y starts at each shoulder and meets mid chest over the sternum.  A single incision is then continued from the intersection over the sternum and down the torso, making a small departure around the navel and down to the pelvis. The tissue is then peeled back away from the ribs, and the incision is opened over the abdomen and through the Parietal Peritoneum, exposing the internal organs. Throughout each step the newly exposed area is inspected for trauma or other abnormalities. Pruning shears (or a similar tool) are then used to cut the sternum away from the ribs by cutting the connective tissue (costal cartilage) that holds the sternum to the ribs. The sternum plate is then removed and set aside.  The organs in the chest and abdomen can now be removed.  Some pathologists and technicians prefer to remove them in “blocks” which are several organs removed together and others prefer to remove the organs one at a time.  As each organ is removed, it is weighed, then inspected by the pathologist who looks for injuries, as well as other anomalies such as tumors, scar tissue or congenital defects. As each organ is dissected, a small piece is placed into a “stock” jar to be stored for a determined amount of time, depending on the final cause of death.  For example, natural death stock jars are usually kept for a year, traumatic deaths (suicide, traffic, accident, etc) are kept for 2-3 years and homicides are usually kept for an extended amount of time.

The empty chest and abdominal cavities are closely inspected for injury or anomalies. The bladder, reproductive organs, aorta, esophagus, trachea and bronchial tubes, epiglottis and tongue are removed. Again, these sections of tissue as well as the area they are removed from are examined for injury and anomalies.

When the intestines are removed, the connecting tissue is cut in order to be able to extend the intestines to their length.  The intestines are then cut at the upper end, and the cut continues all the way to the end (rectum). This process is usually referred to as running the bowels. They are then rinsed clean and inspected by the pathologist.

In addition to the blood and vitreous samples taken at the beginning of autopsy, the contents of the stomach, urine, a liver sample and brain sample are collected during the autopsy.

When the internal and external examinations have been completed, the remaining organ and tissue is placed back into the body cavity inside a plastic bag before the remains are sewn closed and wrapped in plastic for transport to a mortuary.

The topics of TOXICOLOGY, INJURIES and CAUSE OF DEATH / MANNER OF DEATH will be covered in separate posts.

External Examinations

An external examination is similar to a (live) physical but obviously a bit more thorough. The remains are looked at from head to foot – literally! We look at the scalp through the hair, we feel the head for lumps and bumps, we check the eyes for petechia, and the mouth for trauma such as a damaged frenulum can be very telling – especially in children and infants when someone has held a hand over the child’s mouth and it struggles against the hand causing the frenulum (that little piece of skin between your front teeth and your gums) to tear.  The neck is checked for enlarged glands, thyroid abnormalities, and visible contusions. The torso is checked for palpable rib fractures, lumps, extreme and unusual firmness or large amounts of free fluid. Free fluid in the abdomen can mean an internal injury with internal bleeding or it can be a sign of infection such as ascites or sepsis which can mean a liver or kidney problem or a perforated intestine. We look for signs of sexual assault as well.  We look for scars – which can reveal laparoscopic surgery, bypass, hernia, cesarean sections, etc. We look at the lower legs and feet which can reveal peripheral vascular disease and diabetes. We are also looking for scars or fresh needle marks that can reveal a history of drug abuse or in an assault case the use of forced injections. We look for signs of restraint.

The external examination can tell us many things, which we then compare when we do an autopsy to see if the underlying tissues are consistent which what the external showed.

… next time what we doing during an autopsy!

Suspicious death!!! … or IS IT???

Is it natural? Does the scene look right, or staged? Many scene investigations start basically the same as far as qualifiers go… Is there blood, weapons, what is the story, etc. From there we separate what the facts are and what they reveal.  I have had several cases start out as suspicious because the person “reportedly” died alone and there is a lot of blood – either around them, on them or through the house.

For example: In a locked residence, I had a case where the downstairs was very clean with a few empty alcohol containers here and there. The upstairs was same except for the master bedroom which had a large area of blood on the bed, some on the pillows, as well as on the floor and some pillows on the floor laid out as if someone was sleeping on the floor. There was some blood in the bathroom and some bloody clothes on the floor. There were alcohol containers upstairs as well as a bowl of ice-cream by the bed and the empty ice-cream container in the bathroom… both had spoons in them. As for the decedent, she had been located on a landing in the middle of the staircase, in a sitting position, leaning against the wall. She had some blood in her short hair, but barely any elsewhere, including on her tied/laced shoes – AND NO OBVIOUS INJURIES!!! So what happened?

Well, there were no splatters and few smears. An interesting finding was a strange pattern on the pillows on the bed which was sort of a feathered pattern, which I determine to be consistent with the decedent moving her head back and forth in a way that her hair, which had blood on it, had made the pattern.  I also noticed mucous in the coagulated blood.  I examined each area of blood separately, noted all of the alcohol containers and what I had been told about the decedent as well as the lack of injuries and her un-bloodied clothes and laced and tied shoes.  My initial findings were that it appeared she had suffered several episodes of vomiting blood due to presumed ruptured esophageal varices, cleaned herself up, moved from the bed to the floor and vomited more blood.  And again cleaned herself up. Then attempting to go downstairs, apparently collapsed on the staircase landing and expired.   The autopsy supported my findings. She had lost too much blood for her heart to function and it stopped. All of that blood and it was a natural death because CHRONIC alcoholism and the damage it does to the body is considered natural.

In another case a man was found in a chair, slumped over with a head laceration that was dripping onto the floor, bloody pants, bloody hands, a large area of blood on the floor, bloody handprints on the nearby glass kitchen table, and again a locked residence with no one else having been with him.  My first noted odd finding was that it was obvious he had laid on the floor, in the blood, long enough time for it to start to dry. I say this because on the back of his head, where the laceration was, there was a flattened area of dried blood, as if he had laid there long enough for it to dry and flatten his hair on the back of his head, at yet he was in the chair! My first step was to follow the blood.  It wasn’t anywhere else in the house and there weren’t any signs of physical altercation or forced entry.  I noted he had a walker nearby. I also noted his dark pants were down low enough that his feet were covered by them.  I noted the bottoms were bloody. He also had an alcohol problem (which thins the blood and makes you bleed more).

I looked and his hands and the bloody hand prints on the glass table and their location. Through determining each step in what appeared to have happened, I determined he had fallen, probably because of his droopy pants and because he had left his walker on the other side of the room. He hit his head on the floor causing the big laceration on his head and probably knocking him out for a little bit. He came to, pulled himself up by gripping the table with his bloody hands and plopped into the nearest chair. He then fell into unconsciousness again and died – from a combination of the blood he lost, the bleeding inside his head under where the laceration occurred and the alcohol in his system. This case was mannered as an accident – mechanical fall. Again it looked a bit suspicious at first glance, but after careful investigation I was able to get an idea of what had really occurred. It’s very important to go into a scene with an open mind and not be too quick to draw conclusions!!

Another issue is medication, alcohol and /or illicit drug overdoses. I had a case of an elderly female, who lived with a relative, had a meticulously clean room (the residence itself was clean as well), was active and worked outside the home cleaning house for other folks. She was found in her bed, in pajamas, and it appeared to be a natural death. She was reported to not have a regular doctor or prescribed medications, but she was known to smoke. I must admit I was shocked when toxicology came back with methamphetamine overdose. I had not seen anything to indicate she was a user. I discussed it with the pathologist who was just as surprised, so much so that we requested another sample be tested – and sure enough it came back positive again!!  I called family, not sure how they would take the news – only to have them confess they knew she “used” from time to time… OHHHHH NOW YOU TELL ME!! I would have never guessed that would be the cause of death in this case!!! And it is not unusual for family to not reveal such information because they think they are protecting the decedent – but in reality they are interfering with my investigation!! Unfortunately, in a case without suspicious circumstances, we do not go through every drawer, the closet and under the bed, etc.  We look in the obvious places – the bathroom, the area near where they were found, and of course we didn’t go through the other family member’s room because we had no reason to… it’s a hard call sometimes!

Gunshot wounds: Suspicious, Suicide or Accidental??

What about gunshot deaths? What type of gun was used? Is it still there? If it’s not, then it probably wasn’t a suicide! Or did a family member think hiding it would save the family the embarrassment of a suicide? – which it doesn’t – it only creates suspicion – usually toward the person covering it up… So many little factors to consider.  What does the blood say? Does it make sense with the story provided, is it where you would expect it to be? Is it smeared when it shouldn’t be? Are there any footprints or fingerprints in the blood? What type of wound is it? Is it one that the victim could have lived a few minutes? If they used a long gun, it is possible or impossible they could reach the trigger? What do the measurements say? We measure the from the end of the barrel to the trigger, and the end of the arm to the wound. Did they use something to reach the trigger? I had one fella that used a large bar-b-que brush to push the trigger because his arm wasn’t long enough – but the blood was where it belonged.  And of course the brush was right there next to him and under part of the shot gun. Is there a note or a video of their intent to kill themselves? Have they made any recent threats or comments about suicide? Were they familiar with guns?  Were they AFRAID of guns? If someone suggests it was an accident during “cleaning” the gun, then I want to know have they ever cleaned a gun before? Where was the gun usually kept? Did that person know the gun was there if it was not theirs? Many questions to consider when a gun has been used.

Something that really confuses family is they often say the person had been depressed but recently had been in a better mood, so they are shocked that they might have killed themselves after being so “happy” lately! The reason this happens is that the person has made up their mind to kill themselves and they begin to feel less stressed and relieved that their pain (emotional and/or physical) will soon be over. They tend to give things away, get their affairs in order, spend time with people they care about, etc… Sometimes we will find literature at the scene indicating suicide planning. There are people who have basically written the “how to’s” of suicide – which I won’t list the sources or titles here for obvious reasons.

I will cover the guilt and grief of those left behind after a suicide in a later post – and unfortunately I will partly be speaking from personal experience.

Hanging deaths: Suspicious, Suicide or Accidental?

What makes a death suspicious? Besides the obvious, like a knife in the back – some deaths can be quite questionable and not what they seem! Suicides for instance… Is there more than one mark on the neck in a hanging – what is the angle of the mark, does it match the ligature – how was the ligature tied or fastened? Does lividity and rigor mortis match the found position of the remains? When was the person last seen alive? Was there a recent altercation – physical or verbal? Are there scratch marks on the neck showing hesitation or resistance? Any defensive wounds? Any notes or recent verbal threats of suicide?

Did you know it takes much less pressure than suspected to “hang” or “suspend” in the terms of a ligature death. It can be as simple as tying a scarf or belt from a bathrobe to a door knob something similar, then put your head in the loop and lean forward so that your neck is on the loop.  The weight of your head and torso leaning forward can create enough pressure to suppress your ability to breath, causing asphyxiation. Often accidental hanging deaths happen during experimentation with autoerotic asphyxia.

How does a death investigation begin??

Each case starts with a phone call to my office of someone reporting a death. The call starts with basic questions, where is the body, were they on hospice care, any recent surgeries, falls, injuries, suspicious circumstances, unusual amounts of body fluid – vomit, diarrhea, blood and is it near the body or through-out the scene? Is family present? Any drugs, alcohol, open or empty prescription pill bottles? Was anybody home? Was their death witnessed? Did paramedics respond to the scene? Did they do any treatment? If no one was home, was the residence locked? Why did police/fire respond if no one else was home – who called and why?

These are just SOME of the questions we ask when we receive the initial phone call in order to determine what else needs to be done and where to take the investigation next. If the person has a significant medical history, no recent injuries, is at least 65 years old, has been seen by a doctor on a regular basis, no signs of medication abuse, no blood, no contacts for APS (adult protective services), no recent falls, etc… that it appears to be a natural death and the primary care physician is willing to sign the death certificate, then in those cases the person can go to the mortuary and we do NOT need to go out there. Usually in these cases I will send an email or fax to the primary care physician and advise them of the circumstances of the death and why we did not respond. Sometimes they need a little direction in how to word the death certificate so I assist with that too.

If someone is on hospice care it pretty much goes the same. However even a hospice case can warrant further investigation if there are signs of abuse or neglect such as bedsores that are not being cleaned and bandaged, unusual bruises or cuts, dirty bedding, lack of food, apparent dehydration, clogged feeding tube, missing medications, and odd incriminating spontaneous statements by family or caregivers. Then it goes from a medical-natural to something else.

As for the “something else” types of cases, I will get into those on a more individual format.  Stay tuned!!!!