‘Fatal injuries consistent with fall, not abuse’

KOTA KINABALU (Sept 9): The Queen Elizabeth Hospital (QEH) did not detect any bruises or signs of abuse on the body of Zara Qairina Mahathir when she was brought there on July 16.

The third witness in the inquest proceedings, medical officer at the Emergency and Trauma Department of QEH, Dr Janefer Voo, 32, said she received the patient at 4.38 am in an unconscious state after she was found on the ground floor of the school dormitory.

According to her, an initial examination found serious injuries, including swelling and bleeding at the back of the head, a closed fracture of the left wrist, an open fracture of the left ankle, and a closed fracture of the right ankle.

“After the initial examination, the ‘Trauma Alert’ procedure was activated at 4.42 am for immediate referral to the specialist teams of Neurosurgery, Orthopaedics, Surgery and Anaesthesiology, while resuscitation was carried out on the patient.

“Initial assessment showed the patient was suspected to have suffered a severe traumatic brain injury, injury to the back of the head, fractures in both ankles, fracture of the left wrist, and possible internal bleeding,” she said while reading her witness statement before Coroner Amir Shah Amir Hassan on the third day of the inquest into the death of Zara Qairina on Tuesday.

She added that the patient’s very low blood pressure indicated a possibility of internal injuries due to high-impact trauma that caused internal bleeding.

“From my examination, there were no signs of bruises or abuse on the patient’s body, only injuries to the back of the head and fractures of the left hand and both ankles,” she said.

Janefer said that after the resuscitation process and further imaging were conducted, the patient was found to have brain bleeding, an open fracture of the left ankle and left heel, a closed fracture of the left arm, and the right leg.

“In addition, the victim was also found to have fractures of the second, third and fourth lumbar spine, and blood clotting in the pelvic bone and left psoas muscle,” she said.

She emphasised that the injuries sustained by the victim were consistent with trauma from high impact and did not show any signs of physical abuse.

This testimony directly refutes any initial assumptions regarding the possibility of abuse towards Zara Qairina.

When questioned, Janefer repeated that the patient’s condition upon arrival at QEH was very critical and required immediate action from a multidisciplinary medical team.

She said resuscitation was carried out immediately as soon as the patient was brought into the Emergency Department to ensure prompt initial treatment.

The proceedings also recorded that coordinating officer Datuk Badiuszaman Ahmad requested Janefer to sign the statement as confirmation of the court testimony.

It is understood that she is currently serving as a trainee medical officer from Universiti Malaysia Sabah (UMS) Hospital, stationed at QEH.

The fourth witness, QEH Neurosurgery Department medical officer Dr Pavankumar Balachandran shared that Zara was brought to the QEH Emergency and Trauma Department by the Pre-Hospital Care (PHC) team from Klinik Kesihatan Kinarut on July 16 at 4.38 am.

“According to the PHC team, she was discovered unconscious on the ground near a drain within the compound of a hostel. Trauma Alert was activated at 4.42 am,” he said.

He added that upon assessment by the Neurosurgery team, it was found that the patient was intubated and ventilated.

“Initial neurological assessment, namely the Glasgow Coma Scale (GCS), was E1VTM1 with fixed and dilated pupils with absent brainstem reflexes. External examination also revealed a posterior scalp haematoma and a laceration wound with a haemostatic suture applied to it,” he said.

He also said that following the assessment by the Neurosurgery team, a family conference was conducted to explain the patient’s critical condition.

“The family was informed in detail regarding the absence of brainstem reflexes, signifying a very poor and guarded prognosis,” he said.

He added that the patient was then admitted to the Neurosurgery Ward, escorted by the Emergency and Trauma Department, QEH staff on July 16 at 6.40 pm.

“In the ward, the patient showed no clinical signs of improvement. The patient gradually deteriorated and eventually succumbed to death on July 17 at approximately 1.07 pm. The cause of death was severe traumatic brain injury with hypoxic ischaemic encephalopathy,” he said.

He also said that the investigating officer was informed of the death and the body was kept in the ward until the arrival of the investigating officer.

“I explained to the investigating officer and the deceased’s mother regarding the cause of death. After the investigating officer’s discussion with the deceased’s mother, he instructed that the body be sent to the Forensic Medicine Department,” he said.

Meanwhile, a simulation carried out by the police at the hostel block found that the condition without a push was the closest to the fall position of the deceased.

The fifth witness in Zara’s inquest, Inspector Maidon Bernandus of the Criminal Investigation Department (CID) D10 at the Sabah Contingent Police Headquarters (CPH), said the test was conducted on August 3 at about 3 am at the scene.

He said the simulation was conducted together with the case investigating officer and four other personnel from D10 Sabah, with the presence of representatives from Papar District Police Headquarters and the school, namely the hostel warden.

“The simulation was carried out from the corridor near the third-floor toilet door using a dummy weighing 10 kilogrammes, which was added with weights until it reached a total of 53 kilogrammes, corresponding with the estimated weight of the victim.

“The dummy was dropped under two conditions, first without any push and second with minimal push,” he said when testifying before Coroner Amir Shah.

According to him, in the first simulation the dummy landed more than 2.14 metres from the building, while the second simulation recorded a distance of 3.45 metres from the wall.

“The findings showed that the first simulation, without any push, almost matched the actual fall position.

“I also found that the feet and back of the head sustained severe damage,” he said, adding that the weather conditions during the simulation were good, the wind was not strong and there was no rain.

Maidon explained that the test was carried out using forensic lighting to obtain a clear picture of the actual conditions at the location.

Briefings and guidance were also given to all officers and personnel before the test began to ensure the data was obtained systematically.

The simulation began from the corridor and toilet door area on the third floor of the hostel block, before the dummy was released in a controlled manner.

“After both tests were conducted, a full report was printed and signed to serve as an official investigation document,” he said.

He said that throughout the simulation a video recording was also made and could be used for reference and re-identification should it be required by the court.

Maidon has served with the Royal Malaysia Police (RMP) since 1994, and is currently working as a crime scene investigation inspector at CID D10 Sabah.

He said that during his service, he has attended various courses including fingerprinting, deoxyribonucleic acid (DNA), underwater investigation, diver safety training and several other training courses.

The inquest continues on Wednesday.