Strangulation Realities

10/7/2013
Strangulation Realities: What
You Don’t Know Can Hurt Her
KIMBERLY WYATT
DEPUTY PROSECUTING ATTORNEY, KCPAO
GABRIELLE CHARLTON
DEPUTY PROSECUTING ATTORNEY, KCPAO
TERRI STEWART RN
SANE HCSATS
DETECTIVE JENNIFER SAMPSON
SEATTLE POLICE DEPARTMENT, DV UNIT
WHITNEY HELLYER, MSW
ADVOCATE KCPAO
CSI vs. REALITY
VS.
Realities of Strangulation
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“ He choked me”
asthma.WAV
What does it mean to us
when the victim says he
choked her?
MEDICAL REALITIES
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“Choking” vs. “Strangulation”
Choking
Choking is an internal blockage of the
airway (e.g. choking on a piece of food).
Strangulation
Strangulation is an external blockage of the blood
vessels and/or airway. It occurs from pressure
placed on the neck resulting in a reduction of blood
flow to the brain also known as asphyxia.
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STRANGULATION
Occurs from pressure placed upon the neck
Resulting in reduction of blood flow through the
brain
If this persists, then oxygen delivery to the brain is
impaired, and the brain cells become hypoxic (low
oxygen), then anoxic (lack of oxygen), then dead
This type of serious bodily injury is called
ASPHYXIA, and it occurs first at the cellular level,
then throughout the body
Asphyxiation
The rate of development of asphyxiation depends
primarily on the circulation of blood through the
brain
To a much lesser extent it depends on the victim’s
ability to breath through the airway
Airway obstruction is rarely a factor in fatal
strangulation assault
Death may be accelerated if suffocation occurs simultaneously
with the strangulation assault.
Types of Strangulation
Most often the blood flow through the brain is
obstructed by compressing the jugular veins, while
leaving the carotid arteries open.
Obstruction of the carotid arteries requires a great
deal of force, but if it is done, then unconsciousness
and death can occur in just a few seconds
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Types of Strangulation
Manual
Hands around neck
Ligature
Use of a device (belt, cord, necklace, etc) around neck
Neck Holds
i.e. “choke” hold
Injury Realities
External signs of strangulation are absent in half of
all cases
Death can occur without any external marks
Lack of visible injury should not mean lack of
medical assessment
HYOID BONE
CAROTID ARTERY
THYROID CARTILAGE
(with fracture shown)
JUGULAR VEIN
TRACHEAL
RINGS
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Why the victim will lose
consciousness
blocking of the carotid arteries
depriving the brain of oxygen
blocking of the jugular veins
preventing deoxygenated blood from exiting the brain
closing off the airway
causing the victim to be unable to breathe
Loss of Consciousness
Unconsciousness can occur in a strangulation event
within 10 to 30 seconds.
Brain death will occur in 4 to 5 minutes, if
strangulation persists
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Most Common Symptoms
Hoarseness if the most frequent symptom
Caused
by crushing of the nerves/vocal cord against
neck structures
Temporary
May
Potentially
Can
nerve damage
be reversible
irreversible
require surgical intervention
Most Common Symptoms
Scratches to the Neck
Caused by the victim (she did do it to herself)
An
attempt to get assailants hands off neck
response with goal to stay alive
Primal
Most Common Symptoms
Memory Loss
Commonly found after major trauma and may be a cause of
memory loss after strangulation
May
not be able to record memory of the event due to the
traumatic experience
May mean victim had a period of unconsciousness with lack of
oxygen to the brain
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Most Common Symptoms
Loss of Consciousness (LOC)
Result of lack of oxygen to the brain and death of brain cells
Unconsciousness occurs rapidly after closure of the carotid
arteries
Patients
reporting LOC need IMMEDIATE medical evaluation for
potential stroke or clotting in the vessel
A singular petechiae to the face or eye after passing out means
there are petechiae in the brain which means there is
permanent damage to brain blood vessels and tissue
Damage
can never be repaired and can be seen on autopsy even 60
years later
Most Common Symptoms
Urination or Defecation
This is a response of the autonomic nervous system, an
involuntary body response
Indicates a profound loss of consciousness causing relaxation
of the sphincters
This
is a higher degree of loss of consciousness than is seen in the
operating room
Indicates a near fatal assault/strangulation
Physical Signs and Symptoms
Primary Initial Signs
Specific: Pattern injuries such as ligature abrasion or
fingernail abrasion
Non-Specific: Erythema, swelling, abrasions, contusions
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Secondary Physical Signs
Facial congestion, cyanosis
Petechiae
Facial skin especially periorbital
Conjunctivae of eyes, eyelids
Oral mucosa
Petechiae (tiny red spots)
Rupturing of capillaries (causes brain cells to die)
Where will you find petechiae?
From point of strangulation and up – never below
outside and inside
Hairline
Inner ear (usually only visible with magnified scope)
Presence or lack of presence does not prove or disprove
strangulation
Eyelids, both
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Internal Brain Injuries
If there is one spot of petechiae on the face or eyes,
there are petechiae in the brain
If there are petechiae in the brain there is cell death
and brain damage
Seriousness of
Strangulation and Suffocation
There is a continuum of responses to strangulation and
suffocation
Even the moment of loss of consciousness is
unpredictable
Many
victims are rendered unconscious in seconds
Death can occur within minutes or even days later
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Non-Fatal Prolonged or Delayed Medical
Complications of Strangulation Assault
Persistent failure of swallowing with malnutrition
Persistent hoarseness of voice or aphonia
Recurrent headache and persistent neck pain are
common complaints, but too vague in origin to state
within reasonable medical certainty that it was caused
by the strangulation.
Miscarriage is alleged to occur, and the physiology for
the fetus would be impacted by the event, but proof of
causation would be difficult.
Potentially Fatal Medical Complications
of Strangulation Assault
Aspiration of gastric contents with pneumonitis
Fracture of trachea or larynx with air leak
Swelling of the glottis or larynx with airway obstruction
(complicated by intoxication)
Carotid artery dissection or thrombosis with stroke
In one case, persistent pain on swallowing apparently
caused the victim to become dehydrated in a hot residence,
and death was by dehydration.
Medical Treatment
Document patient statement, visible injuries and
physical symptoms
Photograph injuries
Patients with visible injuries or physical symptoms
should ideally be monitored in an ED for 6 hours
Patients reporting loss of consciousness should
ideally be medically monitored for 24 hours
Anyone reporting strangulation should advised to
have someone with them in the immediate 24-48
hours post strangulation
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BUILDING YOUR CASE
The Importance of First Responders
Things that can change as time passes:
Guilt
Regret
“It’s my fault”
Pressure from suspect
Pressure from family members
Money, housing, jail, etc …..
“Did I exaggerate – was it really that bad?”
“I don’t see any bruises”
Ask, Ask, Ask &
Document, Document, Document
1.
How did he strangle you (What method was used)?
2. How long did he strangle you?
3. What did you see when he was strangling you?
4. Did you have difficulty breathing?
5. Did you lose consciousness?
6. What did he say while he was strangling you?
7. What did you think was going to happen?
8. Did you notice anything else about your body?
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Describe the Method of Strangulation
One Hand
Two Hands
Describe the Method of Strangulation
Strike
Arm
Methods continued…..
Carotid Restraint Hold
Ligature used?
“Choke Hold”
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Signs & Symptoms
And follow up questions…
Visible Signs of Strangulation
BLOOD RED
EYES
NECK
SWELLING
RED SPOTS
(PETECHAIE)
SCRATCHES
BRUISING
ROPE BURNS
Scratches
Vertical vs Horizontal
Vertical – victim’s
fingernails
Instinctive effort by
victim to regain ability to
breath. The marks show
she tried to pry whatever
blocked her ability to
breath away from her
neck.
Horizontal - Suspect
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Impression
marks
Crescent moon shapes =
fingernails
Signs of Strangulation
Petechiae
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Symptoms of Strangulation
VOICE CHANGES: hoarseness, change in pitch, raspy voice,
partial or total loss of voice
SWALLOWING CHANGES: difficult but not painful, pain when
swallowing, pain to throat, and coughing or clearing of throat
BREATHING CHANGES: hyperventilation, having trouble
catching breath
BEHAVIORAL CHANGES: memory, amnesia, agitation, anger,
concentration – often dismissed as “drama”
LOSS OF BODILY FUNCTION: Vomit, urinate, defecate
Symptoms found to worsen with increasing # of strangulation
incidents
Documentation/Scene Checklist
PHOTOS: don’t ask permission, just take them
The victim’s body is the crime scene / evidence
Don’t forget the defendant – are there defensive
wounds? (E.g. bites marks, scratches on
hands/arms)
Take the rope, necklace, weapon, torn clothes/wet
clothes (check bed, sofa, floor, etc and document)
The scene tells the story
Photograph Must Haves
The body is a crime scene
Victim and Suspect
Full
Mid
body (establishing shot)
Must show the face
range
Area of injury
Close
up of injury
With and without a ruler
Common Mistake: Single photo of injury without an
establishing shot – Whose body does that injury belong to?
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Injuries/Medical Attention
Injuries from strangulation are often not
visible:
Injuries from strangulation can be internal – no signs or
symptoms
Onset of symptoms can be delayed (e.g. internal swelling,
respiratory or neurological damage)
Pregnant victims – injury to fetus is always possible
Symptoms can worsen if subjected to repeated strangulation
incidents
Call the Medics – err on the side of caution
Investigation Recap
Patrol Officer – most important piece of investigation
(window of opportunity)
50% + have no visible injuries
with or without loss of consciousness
Ask the questions & document the answers
Remember, a follow up visit may be necessary to document delayed signs
and symptoms
Collect the evidence and get a written or recorded statement
Call for medical attention / Get medical release signed
Hurtado – step outside the room/ambulance
Statements
Statements should include “Smith Affidavit”
“Do you declare under penalty of perjury under the
laws of the State of Washington that the statement
you have made is true and correct and may be used
in court?”
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Get Certified Online in 30 minutes!
www.strangulationtraininginstitute.com/training.html
Lethality and Law Enforcement
ADVOCACY & LETHALITY
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Continuum of Violence
Strangulation?
Study by Glass, et all, 2008
Study examined non-fatal strangulation by an
intimate partner as a risk factor for homicide
Researchers compared women who had experienced
physical intimate partner violence that did not
include strangulation to women who had
Victims of prior non fatal strangulation were found
to be 7 times more likely to become a homicide
victim than those who had not
Victims of prior non-fatal strangulation were found
to be 6 times more likely to be the victim of an
attempted homicide
The Chicago Women’s Health Study
• Found that 24.6% of the 57 women killed by a male
intimate partner in 1995 and 1996 were killed by
strangulation or smothering
• Of the women sampled in Chicago hospitals and
clinics who reported having been a victim of intimate
partner violence, 47.3% had experienced at least one
incident of strangulation in the past year
• Of 289 incidents of strangulation, 4.8% resulted in
death
• Of 4,722 incidents of violence other than
strangulation, only 1% resulted in death
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The Power of Advocacy
Listen for What You Can’t See
• Horse voice
• Headaches
• Loss of voice
• Memory loss
• Difficulty or pain
• Dizziness
•
•
•
•
•
swallowing
Neck Pain
Headache
Nausea/Vomiting
Difficulty breathing
Loss of consciousness
• Problems concentrating
• Coughing
• Trauma symptoms (ie.
insomnia, nightmares,
flashbacks, hyper
vigilance)
Encourage Medical Care
Clients often refuse medical aid because:
They don’t think their injuries are serious enough.
They don’t have medical insurance.
Their symptoms don’t appear until hours or days later.
Assessment, education, and resource referrals can
reduce barriers and make sure victims of non-fatal
strangulation get the medical care that may save
their lives.
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Educate, Educate, Educate
(Did I mention educate?)
Knowledge can improve the physical and emotional
safety of our clients.
Strangulation Brochure
Document It App
Everyone needs to know this
information. Everyone. Tell
them.
PROSECUTION
&
NON-FATAL
STRANGULATION
After the police report…
• Felony
• Misdemeanor filing – city or county
• No PC – not referred to prosecutor
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King County Statistics
• King County PAO Stats: file 200+ A2 Strangulations per year
• 2nd most common felony DV crime
• Since 2007 (change in law), over 1000
• These statistics do not take into account misdemeanors charged
at county and city levels or cases referred for prosecution and not
filed
• Safe to say, county-wide numbers are much higher as to rate of
occurrence
Felony Filing
King County Prosecutor’s Office Filing Standard
Domestic violence strangulation and suffocation cases shall
normally be filed as Assault in the Second Degree when
there is sufficient admissible evidence that the victim suffered a
temporary, but substantial, loss or impairment of the
ability to breathe. Examples of strangulation include: loss
of ability to breathe, which is more than momentary; injury to
the neck including bruising or injury to the voice box; petechial
hemorrhage; temporary loss of a bodily function (e.g.
consciousness, bowels, etc).
*RCW 9A.36.021(1)(g).
Misdemeanor Filing
When prosecuted as misdemeanor, must treat it as one of the
most serious misdemeanor cases.
If you think this case should be a felony, don’t be afraid to ask
us to review.
Consider whether follow-up is warranted based on new info
from victim, advocate, etc – does this change misdemeanor
vs. felony analysis?
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Prosecution Challenges
• Limited physical evidence
• “He choked me and left no marks”
•
•
•
•
He said/she said – no other witnesses
Loss of consciousness/memory
Victim minimization/recantation
Lack of education/awareness surrounding
strangulation
• Dispelling juror misconceptions/expectations (CSI
effect)
How to Face the Challenges:
Where to look for additional evidence
911 recordings -what did the victim say- is she coughing/
trying to clear her throat. Is she trying to catch her breathe
(like the opening 911 call we heard)?
Jail recordings- Did the defendant make admissions about
the strangulation
Children- what did the children seeFire/Medic run sheets
Work with your Advocate, Detective and Medical
Professionals
Look for missed witnesses
Why coordination matters
Ashley’s story
Jail calls – use as leverage
Defendant sent to prison for 57 months on the A2-
strangulation (based on criminal history)
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Another story
V was 5 months pregnant
Visible petechiae and marks on neck
Limited photos
Child present (D’s nephew)
Medics not called – no meds
Felony filed
V recant
Outcome: D PG to A4
Promising Practices
System Coordination
Co-located prosecutors
Other ways to increase coordination?
SANE/Forensic Nurses in strangulation cases
Technology
Use of Experts
Using your Experts
Think outside the box
Combatting CSI effect
Training Institute on Strangulation Prevention
Suggested use of experts
Types of experts
Forensic Nurses/SANE’s
Factual and Expert witnesses
Detectives
DRE, DUI cases
Sample scripts are available
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The Realities of a Community Response:
Looking Ahead
Educate
Reframe
Collaborate
ALL INCIDENTS OF STRANGULATION ARE
EITHER FATAL OR NON-FATAL
STRANGULATIONS TREAT THEM THAT WAY!
A Cheat Sheet
Special Thanks
Training Institute on Strangulation Prevention
Tracy Orcutt
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Contact Information
Kimberly Wyatt, King County Deputy Prosecuting Attorney
[email protected]
Gabrielle Charlton, King County Deputy Prosecuting Attorney
[email protected]
Terri Stewart, RN, Harborview
[email protected]
Detective Jennifer Samson, Seattle Police Department
[email protected]
Whitney Hellyer, MSW, Advocate, King County Prosecutor’s Office
[email protected]
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