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Dr. Benedetta Guidi

Translation in English of the expert report:

Dr. Benedetta Guidi
Specialist in Forensic Medicine
Cellular +39 (338) 428-3994; Fax +39 (050) 221-8513

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

FORENSIC-MEDICAL OPINION

IN REGARDS TO THE MEDICAL DOCUMENTATION RELATED TO THE LESIONS SUFFERED BY REBECCA WHITE INFLICTED BY

CARLO PARLANTI

BORN IN MONTECATINI TERME (PT) ON NOVEMBER 1ST , 1964

Mrs. Nada Pacini and Mr. Michele Parlanti, respectively the mother and brother of Mr. Carlo Parlanti, introduced in the epigraph, requested a forensic-medical opinion regarding the formal and substantial requirements of the medical reports in the trial documentation and the consistency with the lesions reported by Rebecca White, the victim of a crime of sexual violence attributed to Carlo Parlanti, for which he has been sentenced to imprisonment in Ventura, California.

Documentation Reviewed


Factual Chronology


The forensic-medical analysis of the case requires the detailed chronology of the events.

On 7/18/2002:

Rebecca White, age 44 at the time of the events, accused her former live-in partner, Carlo Parlanti, of the crimes of sexual violence, domestic violence and kidnapping, having taken place in Ventura county (California) between the 6th and the 16th of July 2002. During the preparation of the police report, some photographic evidence was taken.

According to the accuser, on the date of 7/6/2002, Parlanti, in a state of drunkenness (having drunk 4 liters of wine [more than 1 gallon – TN]), and after having ordered her to leave the dwelling, had grabbed her head and beat it repeatedly against the furniture and then slapped her across the face, causing her, among other things, disclocation of the jaw, and had followed that with repeated attempts of strangulation and kicks to the thorax. He had dragged her by the hair, tied her hands and feet and raped her 3 times.

Three days after this violent episode, on 7/10/2002, she declared to have had a consensual sexual encounter with Parlanti. On 7/16/2002, at 4 in the morning, the man was leaving the city on a business trip.

On 7/20/2002:

Rebecca White contacted Detective Reilly by phone, modifying the date of the events; the violence was backdated to the week within 6/29/2002 and 7/8/2002.

On 7/20/2002, the same day, Detective Reilly completed his own report.

On 7/22/2002:

White modified her report again declaring to have suffered 5 instances of rape by Parlanti and that he had penetrated her vagina and rectum with a fist.

On the same day the woman went to the “Doctors on Duty” medical office in Monterey where she was examined by Dr. Troy Manchester (general practioner).

Following that date, White underwent additional medical examinations, listed below:

On 8/9/2002 examined by Dr. E.B., to whom she introduced herself under a different name (Xxxxxxxx Xxxxxxxx) reporting pelvic-perineal trauma with difficulties and pain micturating caused by the boyfriend when he had kept her tied up for 3 weeks.

On 8/16/2002 examined by Dr. Jeff Bivens, at the Ardmore Wellness Center in Oklahoma, to whom she reported having been beaten up by the boyfriend, tied up for 5 days and raped, resulting in the dislocation of the jaw and the fracture of two rib segments.

On 9/23/2002 Examined by Dr. B. Fore, where she complained of widespread algia and migraine.

On 10/21/2002 Examined by Dr. R. Patzokowsky, whom, upon the request of the “Victim of Crime Division” of California, drafted a form certifying the medical expenses incurred for the care of post-concussion cerebral migraine resulting from the aggression suffered on 7/12/2002.

On 11/5/2002 Examined by Dr. B. Fore, to whom she reported costal algia with bilateral periorbital hematoma.

On 4/20/2005 Examined by Dr. Neil Pugach, neurologist, for migraine and mnemonic deficit, vertigo and tinnitus. The patient underwent an MRI and hematic tests, with negative results.

On 5/23/2005 Examined by Dr. Neil Pugach, who, during the exam, suggested an endocrinological check-up (also taking into consideration her weight gain) and ophthalmological check-up, prescribing her Topamax (topiramate).

On 7/21/2005 follow-up examination by Dr. Neil Pugach, whom adjusted the dosage of Topamax.

Throughout the reconstruction of the case one needs to take heed of a letter that White had sent to Dr. T. Manchester on 7/22/2004.

In it the woman was referring to further lesions suffered as a consequence of the domestic violence, particularly three dental fractures in addition to intestinal anomalies caused by a fist in the rectum which were not mentioned at the time of the 7/22/2002 examination.

Medical reports


1) Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002 (which means 4 days after the police report and 16 days after the suffered aggression).

Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002


Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002


Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002


Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002


Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002


Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002


Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002


Medical report issued to Rebecca White by Dr. Troy Manchester on the date of 7/22/2002

From this report one can deduce the following medical information: Rebecca White went to the “Doctors on Duty” clinic for an examination due to the appearance of thoracic pain lasting for two weeks. The examining doctor, Troy Manchester, performed a radiographical exam detecting the presence of a costal double fracture of the 6th and 7th segments of the right side. The thorax appeared in normal conditions with symmetrical respiratory effort and auditory evidence within the norm.

What was noticeable during the objective examination was only the presence of “tenderness”, in other words pressure-related algia in the area of the rachis in the dorsal-lumbar-sacral right stretch, with “no redness, no edema, no bruising, no visible deformity”.

No changes were noticed regarding other parts of the body, in particular there was no description of any hematoma at the facial level, nothing was reported concerning the periorbital zone; the head was also unscathed from lesions and the neurological examination had a negative result [for injuries - TN].

Facing such objectivity the doctor issued a diagnosis of mid-thoracic costal fractures on the right side, soft tissue injury, post traumatic anxiety, prescribing a medical treatment to resolve the pain (Celebrex, celecoxib).

Within the assessment the following was also inserted: “contusion face/head; chest pain NOS;” even in the absence of any objective evidence obtained during the clinical investigation.

In the report, the results of the radiographical exam are not transcribed; it is therefore impossible to extract any information on the evolutionary phase of the skeletal lesions needed for the dating of the fractures.

One also needs to give significance to the fact that even though the woman had also reported the sexual abuse, Dr. Manchester did not prescribe a gynecologically specialized examination.

Furthermore, the dental lesions that were successively complained about by White (at a distance of two years) were not detected.

Based on the above premises, it results in the facts that the report issued does not seem to respect the necessary formal and substantial requisites.

A medical report is the certification written about an event of technical nature destined to prove the truth. In other words, when certifying an event of technical nature detected in the practice of the medical profession, the doctor certifies in writing that such event is true and he, therefore, guarantees what has been certified. Although there are no dispositions concerning the precise modality with which a certification should be written, one can recognize some substantial and formal requisites that any certificate should possess.

Among the formal attributes of the certificate it is necessary to underline that, as widely agreed by the medical forensic doctrine, “only the clinical objectivity detected constitutes the fact of which the certificate is meant to prove the veracity. The document should certify only what is objective, not what has been declared by the patient nor the conclusions reached by the doctor in regards to the objective evidence (opinion)”.

In addition to the inclusion of the certifying doctor’s signature located at the bottom, other substancial requisites are:
1. particulars and qualifications of the certifier,
2. particulars of the person that the report is about,
3. subject of the report,
4. description of the objective clinical evidence,
5. date and place of preparation, it's included the signature of the physician.

A missing signature would render the same certificate nonviable for legal purposes.

In this particular case, the certificate issued to Rebecca White was devoid of the doctor’s signature; the reserved space was left blank (see above).

2) Medical report issued by Dr. E.B. on the dates of 8/9/2002 and 9/5/2002

Medical report issued by Dr. E.B. on the dates of 8/9/2002 and 9/5/2002

 

In this report, prepared 17 days after the police report, the doctor prescribed Estradiol in addition to the execution of a mammography due to the presence of a regular nodule with smooth surface, the results of which are recorded with the date of 9/5/2002.

Even in this certification the formal and substantial requisites of a medical certificate have not been observed: the particulars of the patient do not correspond to the ones of Rebecca White but to Xxxxxxxx Xxxxxxxx; in addition the signature or the particulars and the qualifications of the certifier are not recorded. Such omissions render this certification devoid of any legal value.

3) Medical report issued by Dr. Jeff Bivens on the date of 8/16/2002

Medical report issued by Dr. Jeff Bivens on the date of 8/16/2002


Medical report issued by Dr. Jeff Bivens on the date of 8/16/2002

In this report the substantial requisites have been satisfied such that it contains, beside the particulars of the patient, those of the doctor and his signature.

In regards to the medical information therein, some inconsistencies are obvious between what has been reported by White about the suffered aggression and the clinical evidence highlited by Dr. Jeff Bivens, whom, by the way, is not a doctor, but a “physician assistant" (PA-C).

In particular, this report states that White was seeing the doctor for a suspected viral syndrome characterized by fever, migraine and nausea.

In the anamnesis the woman reported the violence suffered and the injuries caused by it.

During the visual examination of the patient, the doctor highlights the presence of a fading bilateral hematoma of the upper and lower eyelids on the face, without focal neurological alterations or other anomalies affecting the remaining body parts (“she has no swelling of the head or scalp area. No battle signs.” Therefore no hematoma behind the ear that would be a typical external manifestation of a cranial encephalic trauma, particularly of a fracture of the cranial base).

The evidence of the periorbital hematoma cannot be related to the reported domestic violence dated, according to the same report, seven weeks prior.

It is, in fact, well known that the hematic intra-tissual spillage caused by trauma follows a typical evolution characterized by successive chromatic modifications (related to the transformations of hemoglobin) which take place gradually until the complete reabsorbtion and that become particularly important in determining the “age” of the ecchymosis. Such phases take place in a total timeframe equivalent to about one month.

Initially, when the spilled blood is still oxygenated, a red coloration is observed; in as little as a few hours, parallel to the reduction of hemoglobin, a reddish-violet coloration can be observed; after about one week the ecchymosis is normally of a color leaning toward green and thereafter yellow (after 8-12 days), as a consequence of the transformation of hemoglobin into hemosiderin and ematoidina. The chromatic changes start from the outskirts progressing toward the center of the hematic spillage. The disappearance comes about in variable periods, average 2-3 weeks, and it is also related to the size of the ecchymosis. An ecchymosis of a diameter corresponding to 8-10 cm [3-4 inches – TN] disappears after 15-20 days; the functional limitations caused (pain, etc.) are generally limited to 4-5 days.

On the basis of such considerations, therefore, it is possible to state the absolute chronological incompatibility between the periorbital ecchymosis (“black eye”) detected by Dr. Bivens and the alleged trauma inflicted by Carlo Parlanti.

Such injuries, ascertained during the examination, necessarily must have an origin subsequent to the reported blows of June 29th, 2002.

In addition, no injuries were reported at the time of the police report on July 18th, 2002, as proved by the photographs taken at such time by the police detectives, nor at the time of the first medical examination performed by Dr. Manchester on July 22nd, 2002, whose report is silent in regards to such injuries.

4) Medical report issued by Dr. Benjamin Fore on the dates of 9/23/2002 and 10/07/2002

Medical report issued by Dr. Benjamin Fore on the dates of 9/23/2002 and 10/07/2002

This report also carries a formal flaw, because it does not carry the particulars nor the qualifications of the underwriting doctor.

As far as the medical information is concerned, White reported a migraine the advent of which was attributed to the blows of 6/29/2002 (in reality, as we will see throughout the document, White was a subject with cephalic problems who had a positive history for such ailment). The doctor prescribed anti-inflammatory (Bextra belongs to the Coxib family, actually discontinued, and Darvocet, in other words acetaminophen associated to propoxiphone), Triptan (specifically prescribed for migraine and cluster headache, in this instance Axert was prescribed) and muscle relaxants. In the same medical report Ultracet, an opioid analgesic in which tramadol is associated with acetaminophen, is prescribed.

5) Medical treatment verification signed by Evelin J Bean, insurance clerk, dated 10/28/2002

Medical treatment verification signed by Evelin J Bean, insurance clerk, dated 10/28/2002 


Medical treatment verification signed by Evelin J Bean, insurance clerk, dated 10/28/2002 


Medical treatment verification signed by Evelin J Bean, insurance clerk, dated 10/28/2002Through such documentation (Victim Compensation and Government Claims Board) the Victims of Crime Division recognized the medical expense imposed on Rebecca White ($ 35) for the treatment of “migraine, post-cerebral concussion” caused by the blows suffered during the domestic violence not attributed to the date of June 29th, but of July 12th, 2002. The doctor that provided the treatment was Robert G. Patzkowsky D.O. which means Doctor of Osteopathic Medicine.

6) Medical report issued by Dr. Benjamin Fore on 11/5/2002

 Medical report issued by Dr. Benjamin Fore on 11/5/2002

This certification is incomplete from the standpoint of the formal requisites, because like some previous ones, it is missing the qualifications and the particulars of the certifying physician. The objective evidence reported is inconsistent with the reconstruction of the events as narrated by Rebecca White. During this examination the woman was complaining about costal algia, migraine and positional vertigo.

The doctor noted the presence of marked bilateral periorbital hematomas: “2 very black eye”, caused by occipital trauma dating back to more than 5 months previous.

For this evidence we can apply the same consideration as expressed above regarding the lack of subsistence of a chronological link.

7) Medical report issued on 4/20/2002 by Dr. Neil Pugach

Medical report issued on 4/20/2002 by Dr. Neil Pugach


Medical report issued on 4/20/2002 by Dr. Neil Pugach


Medical report issued on 4/20/2002 by Dr. Neil Pugach

The above certificate, like all others prepared successively by Dr. N. Pugach, does not refer to Rebecca White but to a different name, “Xxxxxxxx” (the same of the medical report of 8/9/2002).

In regards to the medical information contained therein, they seem to contradict the anamnestic information offered by the patient. In the clinical history there is mention of a serious cranial trauma with transitory loss of consciousness and CSF rhinorrhea (leakage of spinal fluid through the nose, CSF) which lasted about two months and spontaneously resolved itself.

In this regard, one needs to remember above all, that according to the timeline the CSF rhinorrhea should have been present at the time of the first medical examination performed by Dr. T. Manchester, in which there is instead no mention of a leak of CSF from the patient’s nose nor was there obviously any such sign during the clinical examination, as in the case of no other neurological anomalies.

The term CSF rhinorrhea indicates the more or less abundant leakage of liquid from the nasal cavities; it may happen prematurely and cease spontaneously within 2-3 weeks of the trauma or persists beyond this period.

The premature CSF rhinorrhea appears immediately after the trauma with leakage of fluid mixed with blood and may not be recognized until the end of the hemorrhage. It is usually tied to a frontal impact which has caused a fracture of the walls of the frontal sinus, of the ethmoidal cells, of the cribiform plate or the sphenoid sinus with dural and arachnoidal breakage. The premature CSF rhinorrhea has a tendency to cease spontaneously for dural scarring but may cause fluidal infection and consequent meningitis. The therapy of choice for the first 2-3 weeks is conservative and consists of lying supine and pharmacological treatment.

The persistent post traumatic CSF rhinorrhea requires, instead, surgical intervention due to the pinching of nerve tissue inside the fracture line or to bone splinters that impede the spontaneous regeneration of the dural tissue elevating the risk of meningeal infections. The procedure consists of performing an accurate dural plastic surgery of the base of the anterior cranial cavity after a uni or bilateral frontal craniotomy. Although a rare occurrence, a CSF rhinorrhea may be caused by a fracture of the rocca petrosa; in these cases the dural breach is usually on the base of the median cranial cavity.

Cranial-encephalic traumas are one of the most common causes of death in industrialized countries. Based on the time relationship between the traumatic event and the appearance of the alterations, the cerebral lesions may be traced back to two categories: primitive lesions, direct or from impact, and secondary lesions. The direct lesions that result from physical forces released at the time of impact, are divided in immediate and delayed in relation to the elapsed time before the onset of symptoms. The immediate direct lesions include: cranial fractures, cerebral contusions and lacero-contusive centers. The cranial fractures are the result of a considerable traumatic force which causes a cranial deformation that, once surpassed the tolerance level of the bone, induces the fracture [itself - TN]. The direction and the expansion of the fracture lines depend on the type and the violence of impact and on the consistency of the cranium. Among the immediate direct lesions one may include concussions, characterized by a transitory loss of conscience that develops as a direct consequence of the amnesia regarding the event [itself - TN] (retrograded amnesia). The delayed immediate direct cerebral lesions include assonale diffused damage, cerebral edema and endocranic hematomas. The direct secondary lesions include ischemia, anosmia, endo-cranic hypertension and infections.

The evolution and result of a cranial-encephalic trauma depend on numerous factors among which, in addition to the entity of the encephalic damage, are the degree and the length of time of the loss of conscience, the combination with non-neurological lesions, the age and, in particular, the timeliness of the medical-surgical care.

The cranial encephalic trauma, therefore, constitutes in other words a serious traumatic entity and, wherein it caused a bone fracture with loss of cerebral-spinal fluid, requires hospitalization and prompt medical/or surgical treatment.

The overall objective examination was negative; there were no alterations noted, even at the local level. The neurological exam’s result was also negative: the woman was “alert and fully oriented”, without any memory problems (“recent and remote recall”) or any language alterations. The cranial nerves were unscathed.

The medical report also lists the tests performed with instruments:

  • an MRI without contrast (performed on 2/25/2004) had a negative result (the exam did not show any pathological results, current or previous);
  • an EEG (performed on 2/25/2005) devoid of any recorded anomalies.

In his diagnostic opinion, Dr. Pugach classified the patient as a subject affected by chronic cephalitis, hypothesizing (considering the symptoms that the woman complained about) an overlaying of a hormonal pathology for which he suggested to her a specialized exam.

Also, in regards to the reported visual symptoms (amaurous fugax), the doctor deemed useful a specialized check-up.

In addition, he prescribed an MRI with contrast dye and blood exams.

8) Medical report issued on 5/23/2005 by Dr. Neil Pugach 

Medical report issued on 5/23/2005 by Dr. Neil Pugach

This report refers to Xxxxxxxx Xxxxxxxx and not to Rebecca White, challenging the validity of the certification.

In regard to the medical information, it is known that the patient underwent instrumental and laboratory tests suggested to her during the previous exam; such tests had negative results. Even the eye exam did not highlight any pathologies.

9) Medical report issued on 7/21/2005 by Dr. Neil Pugach

Medical report issued on 7/21/2005 by Dr. Neil Pugach

Such report indicates that the woman underwent the endocrinological exam, however the specialist made no indication for the hormonal treatment.

10) Open letter written by Dr. Neil Pugach on 11/23/2005

Open letter written by Dr. Neil Pugach on 11/23/2005

In this open letter Dr. N. Pugach refers to a permanent and progressive cognitive deterioration, without possibility of improvement, of such seriousness as to impede any work–related activity. Such deficit is connected, by the doctor, to the domestic violence suffered by the patient, even though during previous visits the same [doctor - TN] had certified the absence of neurological alterations, not only on the basis of the clinical examination (“she is alert and fully oriented with intact attention and concentration, language, and recent and remote recall”), but above all because of the neuro-imaging exams (cranial-encephalic MRI with and without contrast dye) performed, which resulted devoid of any notable pathologies. The same [doctor - TN] had simply diagnosed a chronic migraine with contemporary dysthyroidism (pathologies not connectable to the alleged violence). Moreover, we highlight that the doctor never prescribed any specific medication for the cognitive defects, but only for the migraine.

Dr. Benedetta Guidi


 

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Dr. Benedetta Guidi

 

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