Case Report: Medicolegal evaluation in a pediatric case of fatal scald injury from rural Nepal

Introduction

Thermal injuries from hot liquid are a common cause of serious injuries to young children. Children are naturally curious about exploring their surroundings from a young age and are usually attracted towards steam from hot water.^1,2 Due to this, they are highly prone to develop superficial to deep scald injuries over body parts. The manner of such injuries may be accidental or homicidal.

Thermal injuries in children are preventable; however, ignorance and neglect may lead to a mishap and, in extreme cases, a fatality. Accidental scalds are a common form of thermal injuries that usually occur in home-settings.^1–5 Children under five years of age sustain ten times more thermal injuries than children above five years.⁴ Scald injuries affect younger children on a large scale. Sometimes, it is very difficult to differentiate whether the injuries inflicted on the body are because of an accident or a homicidal act. Thus, it is very important to rule out all possibilities before arriving at a conclusion in these cases. The present case describes a scenario from rural Nepal where a two-year-old girl child allegedly fell into a cauldron where animal feed was being stewed and sustained fatal scald injuries. The event was unwitnessed, and history was provided by the family members on the basis of circumstances. The present article further discusses the pattern and the nature of such injuries sustained by the victim.

Case report

Autopsy

The deceased was a female of weight 13.5 kg and length 80 cm. External examination revealed superficial to deep scald injuries present over the body involving about 90% of the total body surface area (Figure 1). Peeling of skin was observed over the body in several places, most notably on both lower limbs (Figure 2A and B). Yellowish discoloration of skin was observed over the mid-back and shoulders with the presence of foul-smelling wounds and unhealthy granulation tissue as a result of infected wounds. Reddish, healthy granulation tissue was also observed over the body at places. Hairs present over the scalp and other body parts did not show any sign of singeing. No other injury was noted over the body. Upon internal examination, organs were grossly congested. Otherwise, no remarkable finding was observed. The cause of death was opined as complications of scald injuries sustained involving about 90% of the total body surface area.

Figure 1. The front of the body showing the scalded area.

Figure 2. A and B. The back of the body and lower limbs showing the area involved in scald.

Discussion

Most of the cases of thermal injuries are reported from the low and middle-income countries around the globe.⁷ Scald injuries are an important public health issue worldwide. Although most scald injuries are preventable, when sustained they cause significant morbidity and mortality.⁸ Younger children are more curious in exploring their surroundings making them prone to suffer a variety of injuries. Hence, ensuring that they are not left alone while they are doing their routine activity may help to prevent any such kind of catastrophic event. Sustaining scald injuries even on a smaller area of the body may also cause sufficient damage to the skin of young children.

Almost 70% of all thermal injuries in infants, toddlers, and pre-school children are due to scalds and mostly occur at home.⁹ Shah et al., reported that the risk for scald injury was greatest in children of 13 to 24 months of age.⁸ This is most likely because of their dependency on the mothers and increasing mobility, thus involving more risk of getting injured by spillage of hot liquid or other material present in the household.⁹ A study on pediatric scald injuries conducted by Prabakaran revealed a slightly higher proportion of females (53%) compared to males (47%) in the study population.¹⁰ A similar trend where the female to male ratio was more was also observed in the studies conducted by Shah et al., (1.22:1), Rimmer et al., (1.08:1), Yeoh et al., and Agbenorku et al.^8,11–13 The World Health Organization states that adult females have slightly higher death rates from thermal injuries than males because of open fire cooking, unsafe cookstoves, and loose clothing.⁷ This is opposite to the usual injury pattern sustained by the victims, where rates of injuries are higher in males than females.⁷ Children too are vulnerable to thermal injuries as adult women as children accompany their mothers most of the times. While improper adult supervision is considered a major risk factor for childhood thermal injury, child maltreatment too should not be overlooked.⁷

Medicolegal examination of victims of thermal injury is a challenge in forensic practice.¹⁴ In cases of scalds in children, there is suspicion if the injuries were nonaccidental in nature. Thermal injuries in children involving buttocks and lower limbs point more towards abuse.¹⁵ Russo et al., in 1986 suggested some criteria to differentiate between nonaccidental and accidental injuries.¹⁶ The following features are suggestive of child abuse: if the history is inconsistent with the physical findings when there is a delay in seeking medical attention following injury, when there are multiple blunt force injuries with different stages of healing, and when there is localized burn involving the buttocks, genitalia, or perineum.^15,16 If a child is brought to the hospital by people other than the caretakers, it can also raise suspicions of abuse.⁸ The circumstances of injury should also corroborate the autopsy findings.¹³ In the present case, the manner of scald injury could not be established as outlined in the case report section.

Thermal injuries are fatal especially in children, with most deaths occurring during the first week after injury.¹⁷ In the present case, the victim died in the hospital a week after sustaining scald injury. The cause of death in fatal cases is usually due to complications of thermal injuries sustained, with the most common complications being septicemia, hypovolemic shock, neurogenic shock, and multiple organ failure.¹⁸ In such cases, timely management is important, especially the response from the first responder in the form of providing first aid at the site of the incident itself. Upgrading the rural primary health care centers and appointment of medical doctors would save time and lives in serious injuries in remote rural locations of a mountainous country like Nepal. In the present case, first aid was not provided at the scene or initial health center, and there was a delay in treatment as the victim was transferred. The government should frame a policy in this regard. Furthermore, campaigns for awareness can be conducted through radio, television, and in the form of pamphlets, brochures, and street plays. Such campaigns would make the general public aware of preventing unintentional injuries in younger children.

There were some limitations noted in the examination of the present case. Circumstantial evidence, death scene visits, and death scene photographs are important while considering the investigation into the manner of death. In the present case, a detailed death scene investigation and photographic evidence were not available. The police inquest mentioned that the child allegedly fell into the cauldron while playing with no additional analyses. As seven days had already passed and the victim died while under treatment, the police did not visit the actual scene of the incident and the inquest was conducted in the hospital itself. The police inquest detailed the location of the mortuary cold chamber where they viewed the dead body. The bereaved family was also reluctant to provide the details of the incident due to fears of the medicolegal nature of the case and potential legal hassle.

Conclusion

Most thermal injuries are preventable; educating the caretakers might help reduce further thermal injury-related morbidity and mortality in rural Nepal. Deficiencies in the inquest being conducted in rural Nepal and its impact on opining the manner of injury are highlighted in the present case.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

Consent

Written informed consent for publication of the clinical details and/or clinical images was obtained from the deceased’s mother.