Case Report: Fatal Neglect of the Elderly by a Spouse 173

Case Reports
Fatal Neglect of the Elderly by a Spouse: A case report
A SAUVAGEAU, MD MSc
S RACETTE, BSc
Laboratoire de sciences judiciaires et de médecine légale, Édifice Wilfrid-Derome 1701, Parthenais
Street, 12th floor, Montreal (Quebec) Canada H2K 3S7
Correspondence: Anny Sauvageau. Tel: (514) 873-3300 Fax: (514) 873-4847
Email: a.sauvageau@msp.gouv.qc.ca
ABSTRACT
Neglect is one of the most common forms of elder
abuse, along with physical and psychological abuse.
It is defined as an elderly person alone who is not
able to provide for him or herself the services
necessary to maintain physical and mental health,
or who is not receiving those services from a
responsible carer. We present an unusual case of
neglect where a 69-year-old diabetic man was left
lying on the ground by his spouse after a sudden fall
from a cerebral stroke. The man was not able to move
or to get up and his spouse, unable to lift him up, did
not seek help. Although the victim’s spouse reported
having taking care of him, the man died four days
later from a fatal hyperglycaemia.

INTRODUCTION
The problem of elder abuse was introduced in
1975 with the notion of ‘granny-battering’
(Baker, 1975; Burston, 1975). In 1987, the
American Medical Association’s (AMA) Council on Scientific Affairs defined elder abuse and
neglect as actions or the omissions of actions
that result in harm or threatened harm to the
health or welfare of the elderly (AMA, 1987).
Today, elder abuse can be divided into six
categories: (1) physical abuse, (2) sexual abuse,
(3) neglect, (4) psychological abuse, (5) financial and material exploitation and (6) violation
of rights (Program Resources Dept. AARP and
AOA, 1993). It has been estimated that 3 to
10% of adults older than 65 years of age
experience a form of abuse (AMA, 1987;
Pillemer and Finkelhor, 1988; Kurrle et al.,
1992; Tsokos et al., 2000; Vida et al., 2002).

Although the medical profession has come
to recognise the problem of elder mistreatment, it is still thought that the reported cases
are only the tip of a much larger unidentified
and unreported problem (Kleinschmidt, 1997) .
This situation is referred to as the iceberg
theory of elder abuse (Tatara et al., 1998).
We report an unusual case of neglect of an
elderly man, left lying on the ground by his
spouse after a sudden fall.

CASE REPORT
A 69-year-old man with a history of diabetes
mellitus was found dead, lying in the corridor,
in his apartment.
During the night, the man got up from bed
to go to the bathroom. When he came back, he
was walking with difficulty and suddenly fell
on the floor lying flat on his stomach, slightly
on his left side. He was not able to move nor to
get up. Yet he was able to talk and say to his
spouse that he was not feeling any pain. His
spouse, unable to lift him up, decided to leave
him in place, on the floor, not knowing what
else to do. She did not call the emergency
services nor any other kind of help. She took
care of him in this position, feeding him and
covering him with a blanket. The man died
about four days later. However, it was only on
the next morning that the lady got out of the
house to ask for help at the local presbytery.

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174 Med. Sci. Law (2006) Vol. 46, No. 2

Figures 1A and 1B. Victim’s body showing bearing points, all compatible by localisation with the history
of a fall.
The spouse was known to suffer from
psychological problems. No further details
could be obtained, since accessing the spouse’s
medical records was not possible.
The autopsy showed a white man of
72.73 kg and 1.73 m, well-nourished, presenting numerous bearing points. Localisation of
those points was compatible with the history of
the previously described fall: left cheek, left
elbow, left thorax and both knees (Figures 1A
and 1B).
At internal examination, subacute cerebral
infarct was seen, extending through the right
fronto-temporal and left frontal regions, as
well as the cerebellum. According to microscopical observations, infarct could have
occurred one to four days prior to death, thus
being compatible with the reported history. An
aspiration pneumonia from feeding in a lying
position was also found. Other autopsy findings included a moderate to severe cardiac
atherosclerotic disease, severe atherosclerosis
of the aorta and the presence of an endovenous
filter in the inferior vena cava, suggesting
previous emboli.
No alcohol or drugs were detected by
toxicological exam. However, significant glucose and lactic acid concentration of the ocular
fluid led to the conclusion of fatal hyperglycaemia as the cause of death.
It was later found that, although the spouse
took care of the victim, feeding and nursing
him in the corridor, she had failed to administer his insulin.

The manner of death was ruled homicide by
neglect. However, legal pursuits were withdrawn since it was judged that the spouse did
not intend to harm nor was she fully aware,
considering her psychological problems, of the
life-threatening situation.
DISCUSSION
Victims of abuse are usually older than 60
years of age and often present with cognitive
impairment, minimal social interaction and
low self-esteem. Proximity and demanding
attitudes towards the caregiver are also very
typical characteristics of the victims (Lachs
and Pillemer, 1995; Lett, 1995; Kleinschmidt,
1997; Tatara et al., 1998). As for the abuser,
typical risk factors include mental illness,
alcoholism and substance abuse, legal difficulties and violence or antisocial behaviour (Lett,
1995; Kleinschmidt, 1997). Abuse is even more
strongly correlated with the emotional and
financial dependence of the caregivers on the
elderly (Kleinschmidt, 1997).
It has been evaluated that in 90% of cases,
the perpetrator was known to the victim,
typically being a family member such as an
adult child or spouse with whom they lived
(Kleinschmidt, 1997; Tatara et al., 1998). A
retrospective study of 125 fatal abuse cases
revealed that the most common perpetrator
was the victim’s son, followed by a grandchild,
daughter-in-law or son-in-law (Akaza et al.,
2003).
Elder abuse usually occurs in the context of

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Case Report: Fatal Neglect of the Elderly by a Spouse 175

long-term care (Kosberg, 1988; MeierBaumgarther and Püschel, 1996); neglect,
physical and psychological abuse being the
most common forms of mistreatment (Jones et
al., 1997). Neglect is defined as an elderly
person living alone who is not able to provide
him or herself with the services necessary to
maintain physical and mental health, or who is
not receiving those services from a responsible
carer (Lachs et al., 1998).
In the forensic setting, some cases of elder
abuse by neglect have been reported. Collins et
al. (2000) reported the case of an elderly white
woman found dead in her soiled bed in the care
of a male friend. The cause of death was
related to pseudomonas sepsis with dehydration secondary to deep purulent decubitus
ulcers over the sacral and inferior buttocks
regions (Collins et al., 2000). Ortmann et al.
(2001) presented two cases of neglect. In the
first case, a 82-year-old bedridden woman was
neglected by her son and finally died from
septic-toxic heart failure from surinfected
pressure sores and purulent bronchitis with
bronchopneumonia. The second case was one
of a 72-year-old-man also dying from septictoxic heart failure, from infected pressure
sores of the right arm, with maggots infestation, leading to osteomyelitis (Ortmann et al.,
2001). Again in the same year, an unusual case
of neglect in an 80-year-old woman looked
after by her son was reported by Rickert et al.
(2001). Autopsy revealed the presence of
Marchiafava-Bignami disease in a nonalcoholic woman. It was actually presumed
that malnutrition associated with neglect was
related to the disease (Rickert et al., 2001).
More recently, Akaza et al. (2003) reported 15
cases of fatal elder mistreatment, including
four cases of neglect, all but one in combination
with other forms of abuse. In the one pure
neglect case, the victim’s son forced the man to
eat food, but the latter died from choking on
aspirated food. The son left the corpse in place
for 19 days (Akaza et al., 2003). Finally,
Shields et al. (2004) realised a ten-year retrospective review of morbidity and mortality
among elders. They found 22 fatal cases of
suspected neglect, with victims dying from
bronchopneumonia, sepsis, dehydration, is-

chemic/hypertensive heart disease and trauma
from a fall (Shields et al., 2004).
Here reported is the case of a 69-year-old
man who suffered from a sudden fall in his
residence and was left on the floor by his spouse
for about four days before his death. This case is
a very unusual and atypical case of neglect.
Indeed, most cases of neglect of the elderly occur
in the context of long-term care, which is not the
situation here. In fact, there was no evidence
that the victim had been abused or neglected
prior to his fatal sudden incident.
Our case is an example of acute medical
neglect. Medical neglect, a particular form of
neglect, has been defined as failure to seek
medical care appropriate for the patient’s
condition (Collins et al., 2000). As a matter of
fact, the victim’s spouse did present the
intention to care for her male companion by
covering him with a blanket and trying to feed
him. However, she failed to provide the needed
insulin pharmacotherapy and to call for help.
During the spouse’s interrogation, she
claimed that the victim told her he was well,
though not able to move, and didn’t want her to
call emergency help. Thus, she stated having
only followed his instructions. This element
brings the perspective of self-neglect, where
help is declined by the elder in need (Lachs et
al., 1998). Nevertheless, even though a person
can decline medical help for himself, lack of
seeking such help by the caregiver in a lifethreatening situation constitutes severe
medical neglect. However, to what extent can
someone force a person to receive treatment or
help, especially since abusive negligent caregivers are known to be often emotionally and
financially dependant on the abused elder
(Kleinschmidt, 1997)? Therefore, dissociating
respective weights of neglect and self-neglect
can be rather complex.
ACKNOWLEDGEMENTS
The authors would like to thank M. Thierry Marcoux
for technical support.
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