BMI OF SOMEONE WITH ADVANCED CANCER
Dr Paul conducted the autopsy of Ms Piang Ngaih Don on Jul 27, 2016, the day after she was found dead in her employer’s flat by the family’s doctor.
“The deceased was very emaciated, with hardly any flesh on her cheek, on her face, and a scrawny neck, with her collarbones all sticking out,” said Dr Paul.
If she had been starved further, she could have suffered changes in consciousness, multi-organ failure and eventually death. he said.
“In a very crude sense, the body would start digesting itself to sustain (itself),” said Dr Paul.
The victim was 145cm tall and weighed 39kg in April 2015, just before she started working for the family.
After she died, her weight including the body bag was 24kg.
Her body mass index had dropped from about 18.3 to 11.26 over 10 months.
“If you notice such a drop has taken place, you’d suspect the person to be either suffering from advanced cancer, or extensive widespread tuberculosis involving not just lungs but other organs,” said Dr Paul. “And you’d expect this person’s life to be threatened.”
He had ruled out disease processes after examining the body, leaving the only other possibility to be severe malnourishment.
ABNORMAL STOMACH FINDINGS
He said the examination of the maid’s abdominal space where organs lie also showed some abnormal findings.
“In normal people, there will be, on the wall of the abdomen some fat,” said Dr Paul. “Even the thinnest of people will have some fat. There will be fat surrounding all the organs, for example around the kidney, around the intestines, because this is the body’s way of storing for dire times.”
When a person is unable to have food, the body consumes its own fat. When the fat runs out, the body begins consuming muscle, followed by other structures like brain tissues, said Dr Paul.
In the victim’s case, what was “outstanding” to him was that there was no abdominal wall fat.
He said in response to questions from the defence that it was “very evident that all the fat has been consumed”. There was also some amount of protein loss, as the muscles had wasted.
Ms Piang Ngaih Don’s abdominal area was also filled with water, with edema fluid taking the place where fat cells should be.
Dr Paul said edema usually occurs if an organ is diseased such that the body is unable to maintain its pressure, and fluid leaks out.
Organs which should have been functioning to handle the maid’s food were not doing so, he added. Her intestines were very shrunken and small, her liver appeared pale and with a lot of bile staining, and her gall bladder was distended with thick, concentrated bile and some mucus.
“The basic reason is that either the diet is absent of fat, or there is no diet,” declared the forensic pathologist.
“Normally, I would suspect a very debilitating life-threatening illness. The only other conclusion is – she is severely malnourished,” said Dr Paul.
Questioned on how long the victim might have been malnourished, Dr Paul said it would be at least two or three months if not longer.
The amount of deprivation also had to be very severe and sustained, and it was not the situation of someone who “starved today and fed tomorrow”, he added.
HOW POOR NUTRITION COMPOUNDED A NECK INJURY
Dr Paul said the victim’s poor nutritional state compounded her inability to tolerate the repeated trauma to her neck.
A normal person would have the ability to tense up, to guard and resist any “trauma” or blows when anything happens to their neck, said Dr Paul.
Ms Piang Ngaih Don’s neck would have been “absolutely flaccid”, he added, emphasising that her death was not due to a lack of nutrition but due to her neck injuries.
Dr Paul said that if the victim had been in a normal state of nutrition, he would have “expected much (fewer) effects of the neck injury and the secondary … injury to the brain, which swelled up and caused death”.
The victim had been taken to a clinic for leg swelling in May 2016, a few months before her death. However her abuser declined further tests suggested by the doctor to find out the underlying root cause.
Asked if there was any relation between the leg swelling and weight loss, Dr Paul said there was “very much so”.
A malnourished person’s liver would not be optimally functioning, and this would lead to blood thinning that results in water leaking into the body. The legs will begin to swell as the liquid tends to leak there.
The prosecution showed Dr Paul that the victim ate about 60 meals in the last 35 days of her life. Of these, 19 consisted of bread soaked in water.
Deputy Public Prosecutor Sean Teh asked if this was sufficient nutrition for a person.
Dr Paul said a person working in a house would need at least 1,800 to 2,200 calories per day.
“A slice of bread is not going to give little more than 100 calories,” he said.
The trial continues.