wellingtongoose (wellingtongoose) wrote,

Semantics of Healthcare 4.1 - How Sherlock and Molly Faked His Death

In my last post: Meet Miss Molly Hooper, I have suggested the Molly need not do an autopsy on Sherlock. In this short meta I will:

  • Explore how John could have realised it was a set up

  • Explore how Sherlock and Molly handled the delicate matter of his body.

  • Suggest why Mycroft needs to be involved because his meddling would collapse the whole scheme

You might have heard all of this before - but I just thought I'd throw my two pennies in.

Feedback is always very appreciated so take the time to leave a short message, thanks!

Strawberry Jam on the Pavement – How John could have realised it was a set up

As a medical student, I would first like to point out that a fall from a very high building will most likely hideous disfigure Sherlock’s face. Although I am not an expert on physics, I have been an unfortunate witness to several bicycle accidents, one of which was fatal. Nearly all the riders had not been wearing helmets and the impact from falling off a bike was enough to fracture their skull.

The human skull and facial bones are surprisingly fragile and a fall off a tall building is enough to produce extensive factures, loss of facial structure, and usually a loss of cerebral contents i.e. Sherlock’s brains should be splattered across the pavement.

Sherlock’s features are surprisingly intact but this might be possible if he landed face up, but it doesn’t look as if he did. I certainly would expect more disfigurement to one side of his face than is shown.

The brain is a highly vascular structure; an impact like the one Sherlock suffered should technically rupture several arteries outside the dura (lining of the brain) and in his scalp. Arterial blood is bright red – the colour of really bad fake blood. Arterial wounds (and scalp wounds in particular) bleed profusely because the blood is under a high pressure and create a huge loss of blood. From TRF scenes, we see that Sherlock’s bleeding is extensive but not as much as one might expect and the blood looks more venous than arterial. Granted in the time that it takes John to get to Sherlock, some of his blood might have started to clot but it appears that John only took less than a minute to get to Sherlock. I'd actually still expect Sherlock to be bleeding but that does depend on the damage to his brain stem/other organs.

Cerebral matter is white with the consistency of very soft tofu. If you dropped “fresh brain” it would splatter all over the floor. With a massive head injury like the one Sherlock should have sustained – I would expect leakage of cerebral matter. Cerebral matter when mixed with blood produces a pink colour (the brain is made up of grey and white matter, which are actually different shades of off-white).

Obviously these are very small points that John, who is in shock, is not going to stop and question but if he had…I think as a doctor he might have realised something was up even before he started trying to diagnose death from a peripheral pulse!

He ain’t heavy, he’s just pulseless

Any doctor will tell you that one cannot diagnose death from a peripheral pulse. Just because you have no pulse in your right wrist does not mean that you are dead. We need to give John some credit though – he is in shock.

It is incredibly easy to occlude the brachial artery in your arm and give the illusion of not having a radial pulse. If you ever have your blood pressure measured – you will not be able to feel the pulse in your wrist when the pressure is high enough. It is quite likely that Sherlock either tied a tourniquet really tightly around the top of his arm, or squeezed the rubber ball he was bouncing around under his arm pit. It works, and it fooled John.

Doctors diagnose death in different ways. Unfortunately there is no legal or medical guideline to tell us how dead is actually dead. Doctors in hospital have to demonstrate:

  • Absence of a central pulse on palpation

  • Absence of heart sounds on auscultation

And some of the following

  • Asystole on a continuous ECG display

  • Absence of pulsatile flow using direct intra-arterial pressure monitoring

  • Absence of contractile activity using echocardiography

…in order to certify death. We also occasionally test papillary reflex (the shrinking of pupils to light) to look for brain death.

As an army doctor – John had to complete both Basic Life Support and Advanced Trauma Life support. These courses teach doctors how to deal with massive trauma and I assume that the army has its own trauma life support course because their doctors would have to deal with soldiers who have been blown up by bombs on a frequent basis.

Sherlock must have known the first thing John would check if he was even vaguely coherent is ABC: airway, breathing, circulation. John couldn’t be allowed to check any of these things or it would completely blow Sherlock’s game plan.

Sherlock needed that group of homeless people to prevent John from feeling his carotid pulse or feeling for a heart beat (he is very skinny so it would be easy to palpate his apex beat). If John had been thinking more clearly he would have made sure to do both things right there and then.

Molly in the Morgue

Even if you have a coherent doctor, diagnosing death on the street is not good medical practice. No matter how very dead you think the person is, you should call an ambulance and not a funeral director. Additionally there is always a chance against all the odds that the person could be resuscitated.

Now, I have no idea how Sherlock and his homeless network got his body into the morgue, or if they got his body there at all.

I can imagine that Sherlock could have paid off some people to dress like paramedics, come running around the corner and carry him into Bart’s morgue.

Paramedics are allowed to pronounce (but not certify) death and in certain circumstances they will pronounce patients dead at the scene. However once a person is pronounced dead most paramedic crews do not then transport their body to the hospital morgue. In the vast majority of cases people who die outside of hospital are left at home with their family who will then arrange for transportation to the funeral directors.

Hospital morgues are almost always reserved for patients who have died after arriving in hospital or patients who require an autopsy. Suicide does not always automatically lead to an autopsy. However in the absence of anyone to claim Sherlock’s “body”, even real paramedics would need to transport his body to the nearest morgue.

The problem with taking Sherlock to the morgue is that he died during the day. Although there is always a pathologist on call 24 hours a day, the on call pathologist would be doing their normal job during office hours. For Molly as a histopathologist, she probably should be in the lab.

If she is the on call pathologist, she will be responsible for processing Sherlock’s body as he comes in. Unfortunately, there will also be other pathologists working in the morgue if there is a post-mortem scheduled. They would find it rather suspicious if several paramedics came in with Sherlock’s body straight off the street. They should really have taken him to accident and emergency for the doctors there to attempted resuscitation/diagnosed death and then have the porters take him down to the morgue wrapped in a sheet.

However if Sherlock committed suicide on a weekend, then that pretty much solves our problem of witnesses. Pathologists do not work out of hours if they can help it because they don’t have to. Molly though would have 24 hour swipe card access to the morgue and she would have made sure she was the on-call pathologist on the day of Sherlock’s death.

All Molly has to do now is sign Sherlock’s death certificate (no other doctors required provided he isn’t about to be cremated). Pathologists don’t usually sign the death certificate because another doctor would have written out the certificate before the body arrived in the morgue. Should anyone (like Mycroft) start asking for answers about why there was no attempt to resuscitate Sherlock and why the pathologist was the first to diagnose death – Molly would be in a rather sticky position.

However if Mycroft was in on the whole game, there would actually not be any need for Sherlock to even appear in the morgue at all. Molly can just write and file a death certificate. She would then record a log of when Sherlock came in and when Mycroft took his body away. Not all morgues have cameras so there might not be any corroborating evidence. As long as Molly does the paper work right, no one would be in the least suspicious. Pathologists do not like to hold onto corpses for longer than necessary (there are only a limited number of freezers). Usually after death, the relatives arrange for their love ones to be taken away within the same day. Therefore a quick in and out is something the pathologists would be very relieved about.

Identity Parades

The bodies of the deceased are only relinquished to the next of kin. In Sherlock’s case, his next of kin would be listed as Mycroft Holmes.

Mycroft does not need to identify Sherlock’s body; this legal procedure is only done by the police in ongoing investigations. Most of the bodies coming into the morgue are from hospital patients who have all their details registered on the hospital database. As long as Sherlock’s “paramedics” have filled in their paramedic assessment form correctly, doctors wouldn’t question the details. They will merely call up the listed next of kin and get them into the hospital where a specialist counsellor will break the bad news. Things only become a problem if they can’t contact the next of kin or if the police walk in and start an investigation.

Sherlock is also quite disfigured by the fall (thanks to good make up). In these cases, doctors would advise the family not to see the corpse. Of course, the relatives are allowed to make this judgement call. If Mycroft is not aware of Sherlock’s plan, he would definitely want to look at his brother (after all he’s not a squeamish man). This makes life difficult for both Molly and Sherlock. Molly would have to either produce another bashed up body (that would arouse Mycroft’s suspicions) or just make Sherlock up to look like a corpse.

I don’t know how hard it would be to fool Mycroft, he’s not John but he’s still devastated by his brother’s death (if he doesn’t know it’s fake). People tend to see what they expect to see, particularly when grief and shock cloud their judgement. It is not impossible that with Molly’s skills she could make a convincing corpse out of Sherlock.

The problem arises when Molly has to relinquish the corpse to Mycroft, who would most likely want his brother’s body delivered to the appropriate funeral directors. I can imagine that Sherlock would know exactly which one Mycroft would use and then bribe them to switch bodies/fill one coffin with sand. Given Sherlock has just jumped off a very tall building; an open casket funeral is not going to be very…tasteful. It would be easier to perform a switch at the funeral directors rather than the morgue.

Mycroft is Not Impressed...

However I am of the firm opinion that Mycroft was in on the whole thing because Mycroft is not the type of man who will sit by quietly when his only brother has committed suicide.

He would demand a full police investigation and this means someone has to perform a forensic autopsy. In medicine there are two distinct kinds of autopsy:

Medico-legal/forensic autopsy - carried out at the express request of a Coroner in order to ascertain facts that will have bearing on a police investigation or legal case. For suicides, these are really only carried out if there is suspicion of foul play by the police. Non-suspicious cases fall under the second category of autopsy

Clinical autopsy - perform only with written consent from the patient’s family to determine the pathological sequence leading to death. This is usually only done for unexpected deaths. Open and closed suicides are a very sensitive topic and pathologists usually do not offer an autopsy to the family.

It would be unlikely that Mycroft or the Met would allow Molly to do a forensic autopsy on Sherlock. Although pathologists are trained in the process, the Met has its own forensic pathologists who have much more experience than Molly.

Molly and Sherlock have to find a really convincing corpse. The forensic autopsy is much more meticulous than a clinical autopsy and has additional extras including a full toxicology screen. Therefore a homeless man off the street is not going to cut it, neither will Jim Moriarty’s corpse.

Also they need to fool Mycroft. The corpse they would need has to look exactly like Sherlock. Irene might have fooled Mycroft but Sherlock is his brother. He probably knows most of Sherlock’s scars, birthmarks, moles etc.

However if Mycroft does not kick up a fuss because he was in on the whole scheme, Sherlock and Molly have plain sailing ahead.

The police have plenty of witnesses to say Sherlock’s death was a suicide. They are probably relieved to just file it as an open and closed case. If Mycroft does not ask for an autopsy, then Molly would not even need to perform a post-mortem at all.

If there was an investigation, by the time they’ve come investigating Molly might have already relinquished Sherlock’s body to Mycroft. This in itself is not suspicious because relatives usually want to get their loved ones out of the morgue as soon as possible. If Mycroft arranges a swift burial, the police are at a dead end; ordering an exhumation is a long and difficult process. At this point, the Met usually give up as they have hundreds of other cases that need attention.

Over Jim’s Dead Body

Some fans have suggested that Sherlock used Jim’s body and switched it for his own. This would probably cause more problems than it would solve.

Firstly, the police are going to investigate the scene of Sherlock’s “accident” even if the case is an open/close suicide. They are then going to find abundant traces of Jim’s blood but no corpse. If Sherlock wanted to draw as little police attention to his death as possible, removing Jim’s corpse would not be the best solution.

Secondly, Jim’s corpse is not going to fool Mycroft. He may not need to identify his brother’s body, but he would want to look at him one last time before he was buried. If Mycroft is in on the scheme, then Sherlock’s coffin can simply be filled with sand.

I am convinced the Jim’s body would be left on the roof top and the police would also reach a verdict of suicide.

Other Parts in the Series:

Part 1 - Exploring Dr Watson's Army Career
Part 2 - How can an Army GP be fighting on the front lines? John's Dual Career

Part II.I - Dr Watson: scientist and psychiatrist

Part 3 - Guide to making John a Realistic Army Surgeon
Part 4 - Meet Miss Molly Hooper
Tags: meta: john watson, meta: molly hooper, meta: mycroft holmes, meta: sherlock holmes

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