In forensic terms, deaths involving drug abusers often raise doubts about the real manner of death. These doubts are often multiplied by the presence of a variety of injuries, which are often extensive and could be accounted for by multiple theories such as an attack by another, self-mutilation, or repeated falls [8, 9]. Such sets of injuries are usually encountered in chronic cocaine and amphetamine drug abusers who have a high risk of developing psychosis [10,11,12]. During drug-induced psychosis, such individuals may pose a risk to themselves as well as to others. Typical symptoms include anxiety, tension, panic paranoia, hallucinations, insomnia, or even aggressive behavior and suicidal attempts [11, 13]. Self-mutilation cases frequently involve the use of a variety of tools such as knives, screwdrivers, or pens [1, 14, 15].

Injuries inflicted by screwdrivers could produce different patterns of injuries such as minor cut or stab wounds or less frequently hybrid sharp-blunt force trauma wounds [16] depending on the shape and sharpness of the tips of the tools. Less sharp tools produce wounds with uneven edges and a rim of abrasions as was the case reported herein. Importantly, screwdrivers may cause deep stab wounds penetrating the bones and causing fatal damage to internal organs despite the seemingly minor surface injuries [17, 18]. Injuries of the cavernous sinus are frequently encountered in cases of penetrating orbital injuries or iatrogenic skull base injuries [19,20,21,22]. Cavernous sinus walls are formed by fibrous tissue, rather than smooth muscles, causing prolonged bleeding [23,24,25]. The co-presence of the injury of the sphenoid bone wall enabled the blood from the cavernous sinus to flow to the nasopharynx and the digestive tract, as evidenced by the presence of blood in the stomach and the intestines. The massive blood loss resulted in the development of fatal hemorrhagic shock and death.

Since the fingerprints of both the victim and her flat mate were present on the screwdriver, the autopsy evidence was relied on to determine the manner of death. The multiple injuries present were indicative of repeated falls rather than an assault by another or self-defense, which made the homicide a less likely manner of death. The long depth of the stab track penetrating the sphenoid bone did not support the theory of the victim holding the screwdriver in her hand and stabbing it into her head. A more plausible theory was that of one end of the screwdriver being fixed against the wall or floor and the victim’s head bouncing against the screwdriver, which could account for the depth of the injury. The penetration into the skull was facilitated by the thinness of the temporal bone at the site of the injury. This theory is also consistent with the subsequent testimony of the victim’s flat mate, who testified that the victim, with her knees bent, held the screwdriver on the floor and kept bouncing her head against its tip. Later, she pulled the screwdriver out and threw it away. The consistency of the autopsy evidence and the testimony prevented the man from being charged with homicide.

Given the time between the infliction of the injuries and the death, it was necessary to address the procedures performed at the hospital. Upon admission, the CT scan revealed a temporal bone fracture without evident intracranial injuries. Anisocoria may have, however, raised a suspicion of a central nervous system injury, for example, of the oculomotor nerve, and thus of the severity of the victim’s condition. Unfortunately, the attending physicians attributed the condition only to intoxication by fentanyl and amphetamines [26,27,28]. A review of the treatment by an independent medical review panel noted that the case qualified as medical mismanagement due to the failure to identify the intracranial injuries, including the injury to the cavernous sinus. Had the posterior epistaxis been recognized early, treatment would have been available, either a nose packing or a surgical procedure introducing a hemostatic sponge and applying pressure on the site [19, 29, 30]. It was also noted that the interpretation of the CT scan was challenging owing to the penetration of the sphenoid bone, which enabled the blood to flow to the digestive tract and made the presence of the blood on the CT scan less prominent.

In light of all available evidence, the police closed the investigation as a case of suicide committed in the state of a drug-induced psychosis. Even though the course of treatment may have been different, the review did not unambiguously conclude whether the victim’s life could have been saved given the multiple injuries and the drug-induced psychosis. The treatment options were also limited by the fact that the victim was admitted in a small hospital without an immediate option of neurosurgery. Therefore, the police did not proceed with the prosecution of the attending physicians.