Detailed Summary
Como Sentence
The process
Albertani Stefania, summoned at the request of the judge for the crimes specified
in the epigraph, made a request to proceed with an expedited trial.
At the request of experts and psychiatrist consultants, the hearing was postponed
to 20.05.201l.
The investigation
Stefania Albertani was arrested on 07.10.2009 for attempting to kill her mother:
the interference of the police, which prevented the worst from happening, was possible
because the defendant was already under investigation for the disappearance of her sister
and her house was bugged. By listening live to what was happening inside the house
where the defendant lived with her parents (see N. 2040 conversation 7.10.2009 at
12.44), police officers station arrived to the Alberti house just in time to find Mrs. Alma
on the ground, cyanotic, partially conscious “wearing a flaming apron that was burning
her body.” (See record of the arrest of 10/07/2009).
The investigations against the accused were initiated in July of 2009, when she
had presented herself at the Appiano Gentile police station to report a fraud attributed to
her sister. The fraud supposedly took place in 2007 and was detriment of the family
company, 2AS Construzioni Ltd. Together with the denunciation, the accused had
attached a letter by Mariarosa Albertani with which the latter seemed to have actually
taken all responsibility for the bankruptcy of the company.
The story seemed full of anomalies and incongruences, and, among other things,
by pure accident the accused also informed the police of the death of her sister which
occurred, according to her, already two months ago.
The complaint had immediately attracted the attention. The denunciation of the
fraud, presented in a confusing form with months of delay, on the one hand, and the
inexplicable absence of a formal denunciation of the disappearance of the sister despite
her absence for the past two months, on the other hand, deepened the suspicions. The
police checked the operations with the credit card of Mariarosa after she had disappeared
and discovered that on 19.6.2010, the card was used to charge the mobile telephone (10
euro) which belonged to Stefania. These and other facts prompted the police to start an
investigation on Stefania under the suspicion of having abducted her sister.
The investigation started less than a week after the submission of the complaint,
13.7.2009. The following day the police searched the house where Stefania lived with her
parents and seized many materials that later proved useful for the.
The same day, the searches were extended to house in Cirimido (owned by the
family Albertani but abandoned for some time at the insistence of the accused) because
the police had reasons to believe that the death occurred in the house. On their arrival, the
policemen, accompanied by the suspect and her father, had faced an unexpected “strong
smell of rotting flesh” and had found a burnt skeleton positioned in the immediate
vicinity of the iron door to the rear of the house (for technical assessments see the
minutes of 14.07.2009).
Subsequent tests by Dr. Caligari and Dr. Cattaneo and entomologist Dr. Stefano
Vanin allowed the identification of the corpse and the date of death: it was undoubtedly
Mariarosa Albertani, the sister of the suspect, indicatively killed in May 2009.
The high degree of decomposition of the body did not allow establishment of the
exact cause of death. The presence of traces of benzodiazepines and promazine were
detected (see the acts 2011 - 2009 by Dr. Caligari Navy, accompanied by chemical
toxicological tests, and tests by Dr. Stefano Vanin: "The dental surveys have confirmed
that the remains found in Cirimido on 14.07.2009 belong to Mariarosa. Entomological
surveys trace the death to the second week of May 2009. The body was burned with
gasoline in the place of discovery, has burned a short time (on average 10-20 minutes),
the decomposition took place later. Due to the high degree of decomposition and
carbonization, the cause of death cannot be determined. The anthropological, histological
and microscopic lesions revealed no trauma correlated to death. The presence of traces of
benzodiazepines in all soft tissues signal their presence at the time of death. By no means
have these substances caused death, but it is likely that their presence may have had an
impact on psychomotor performance of Albertani making her less able to resist any
further detrimental actions by the third parties. "
After the discovery of the corpse, the investigations against Stefania Albertani
gained pace. The accused and her family were monitored for two months (from October
until the date of the arrest). The witnesses were questioned. In a short period of time, it
was possible to ascertain the criminal responsibility of the accused of all crimes now
attributed to her, and not just the attempted murder of her mother.
In a nutshell: the evaluation of all evidence against the accused was duly made at
the request of the prosecutor in a very comprehensive and detailed manner. It
undoubtedly confirmed the criminal responsibility of the accused of all crimes attributed
to her. None of the defendants, it is worth stating, had contested any accusation. (p.11)
Reasons for the Decision
A few months of detailed investigations have allowed to reconstruct the full
picture of the crimes, revealing the responsibility of the accused for the kidnapping and
the murder of her sister, which occurred between 11 May 2009, the date of disappearance
of Mariarosa, and mid-May of 2009, the date of her death, preceded by the administration
of benzodiazepines that have put the victim in a state of mental confusion and inability to
react, the burning of the corpse, misuse of credit cards that belonged to Mariarosa
(appendix A) B) C) D), the offense against the will of the father, by administering him
medicinal substances, which took place from 11.09.2009 until the day of his arrest
07.10.2009, the attempted murder of both parents when the accused attempted to blow up
the car with both parents inside, and an attempted murder of her mother by means of
strangling with a leather belt (appendix E), F), and G).
It was easily discovered that the accusations against Mariarosa, put forward by
her sister in July 2009, were false. Further investigation made it possible to ascertain that
those charges were just an attempt to place the responsibility for the financial collapse of
the family business on the deceased while in fact it was the accused who caused this
damage.
The financial history of the family and the family company (2AS Albertani Ltd.
Albertani Silvano and Stefania), as well as the actions of the accused had been
reconstructed in detail by a report from the Financial Police. The findings confirmed the
sole responsibility of Stefania Albertani for the missing funds and financial disorder in
the company, as well as the complete estrangement of Mariarosa from the company
affairs or the opening of a joint bank account with Stefania, which was in fact opened
unilaterally (see the record from 20.09.2009).
The investigations have established, among other things, that after having stolen a
substantial share of the family company, the accused had further insisted on the sale of
the Cirimido estate, which represented, in economic terms, the most substantial part of
the family assets, and had since done everything possible to prevent her father from
financing the purchase of a house of Francesco De Marchi for Mariarosa.
Much was easily reconstructed by consulting the accounts of the company,
statements of the brother and the parents, through the unveiling of the dense web of lies
that the accused invented to prevent the purchase of the property (the accused had set up
an email account on behalf of the Avv. Pierpaolo Livio, who once represented the
interests of the family in a civil tribunal in Milan but was completely unrelated to the
letters the accused was sending from ‘his’ e-mail account, and had invented Att. Frigerio,
who had never actually existed, and managed through phone calls, letters, and various
other devices, to prevent the purchase of the house that her parents wanted to give to her
sister as a present).
Hence, economic motives clearly constituted the main motive for all crimes.
Firstly, the letters supposedly written and signed by Mariarosa had actually been
written and signed by the accused.
Second, 11 May 2009 was the last day the victim was seen by the parents, in the
company of her sister Stefania:
- According to the father, both sisters left home to go to an appointment with the lawyer
Friqerio, a non-existent character;
- Print-outs of phone calls from mobile phones of both sisters. 11.05.2009, at least until
21:01, the two phones and, therefore, the two sisters were together; at 21:01 the phone of
Mariarosa was switched off forever;
- Upon return home, the accused lied to her parents that she had received a text message
from Mariarosa that the latter would pass by to report on the meeting with the lawyer
Frigerio (no trace of such a text message);
- The accused certainly saw her sister after the last attempt to access Hospital Sant' Anna
di Como in the evening of 13.05.2009, in a state of extreme weakness;
- The accused did not mention any of such events to the family, although the parents were
distressed by the absence of their daughter.
- The accused had access to substantial quantities of benzodiazepines at home, and all
tables were removed at once (see record 14.07.2009);
- The accused had personally used the Postamat card to her own profit for withdrawing
money and payments for a total of 3.000,00 euro from the moment of disappearance of
Mariarosa up to the moment of discovery of her body;
- The accused had her sister’s documents, particularly, an Avis card damaged by the
flames, which was obviously taken from the victim's body after death and after the
burning of the corpse.
Further investigations have also made it possible to reconstruct in detail the
dynamics of the murder. In the evening, of 11 May 2009 Stefania brought her sister to
the house in Cirimido and began to administer her with excessive quantities of
benzodiazepines thus leading her into a state of confusion, against her will. Until the
evening of 13 May 2009 Mariarosa was still alive. This is confirmed by the neighbors,
who have seen the victim near their home, and called the police and the 118.
On that occasion Mariarosa was accompanied to S. Anna Hospital by the accused,
who came over during the rescue operation, as confirmed by the crew of the 118, and
convinced the victim to leave the Hospital without asking doctors for help. Mariarosa was
brought back to Cirimido's home. The murder followed, the body was wrapped in a cloth
and burned the morning after, after the accused warned the neighbors not to call fire
brigade as she was supposedly burning some old paper.
The accused had also committed other crimes. 11 September 2009, she had
administered her father excessive amount of drugs. On 7 October 2009 she tried to set
fire on the vehicle with both parents inside. The same day, while listening to the
conversations, the police could record live sound of footsteps, the screams of Mrs. Alma
and her cries for help and immediately after, gagging noise and the sound of opened
drawers. The police intervened immediately and took the mother to the hospital with a
deep second degree burn and a neck injury.
The non compos mentis of Alberti Stefania
There are many indicators that at the moment of committing her crimes, Albertani
Stefania acted without full control of her mental faculties.
The scientific psychiatric examination of the accused is discussed in detail below.
The question of full or partial possession of her mental faculties was initially brought to
the attention of the judge by the defense which had requested a psychiatric examination
of the accused.
In January 2010, two clinical consultations took place, which concluded that at
least on the day of the last crime committed in October 2009, the accused had acted under
the influence of a psychotic pathological condition (no precise diagnosis was offered) that
made her not fully aware of her actions. No conclusions were offered in regard to the
period May-September 2009 when the accused committed other crimes.
These first psychiatric test had prompted the judge to order another test, which
concluded that although dissociative disorders were traceable in Albertani Stefania, they
could not have completely affected the accused and she was fully capable of
understanding what she was doing at the moment of committing the crime.
A few months later, in September of 2010, the defenders have been granted a
permission to complement the already existing psychiatric tests with in-depth clinical
consultations with the help of neuropsychological tests, cognitive neuroscience and
behavioral genetics. These tests concluded that Albertani Stefania was partially non
compos mentis at the time of committing the crimes.
The different results emphasize the obvious problematic nature of the case, as
well as the increasing number of challenges which psychiatry faces when making
distinctions between health and mental illness and giving a precise diagnosis of
psychiatric disorders and, more importantly, evaluating the ability of the individuals to
act in full possession of their mental faculties.
In the face of the gradual expansion of areas of uncertainty of psychiatric
knowledge, the court had to screen these psychiatric findings attentively, and verify the
conclusions of the psychiatric tests because the psychiatric findings constitute an opinion
that does not provide technical truth but only knowledge, understanding of the events
and, often, attempts to understand what has happened. For the current legislation, it plays
a supplementary role in the process of taking a judicial decision.
The fact remains that the psychiatric examination does not imply that an
individual responsibility for a criminal act may be greatly diminished due to presence of a
mental illness that cannot be diagnosed by specialists. Therefore, when, as in this case,
the conclusions on the specialists are diametrically different, the judge must explain the
criteria under which he or she makes the choice in favor of one scientific theory or the
other, by providing adequate argumentation.
Given the assumptions above and the incompatibility of the results of the three
psychiatric conclusions, we have to explain why it was decided to give priority to the
results of the second consultation which concluded that at the moment of committing the
crimes, the accused had partially but not completely lost the possession of her mental
faculties.
Not entirely reassuring, in fact, was the method pursued by the first clinical test
based on only 2 clinical interviews in January 2010, that is, 3 months after the last crime.
The conclusion was that Stefania Abertani displayed no traces of “psychopathological
behavior.” She was found in a state of “a mental integrity” and “awareness of reality.”
She was found prey to a generic “psychotic-like condition” only at the time of the
attempted murder of her mother in October 2009 (no report, however, was made on the
mental condition of the accused at the time of the previous crimes, committed between
May and September 2009).
Drawbacks:
- The lack of logical argument
- The lack of flow of argumentation of psychopathic action (pp. 31-32)
- No other examinations of behavior, emotional congruence, mimics, the relationship
established with the therapist, etc., or the evaluation of speech, cognitive functions, the
critical capacity, intelligence, emotions, affection, etc.
Furthermore, the medical history (or anamnesis) reconstructed the events
simplistically, only on the basis of the facts told by the patient (pp. 33-34). In the
meantime, the evaluation of additional evidence would have allowed the consultant to
realize that the accused had often offered a completely distorted view of reality.
The therapist reproduces the story of the patient, which indicated the family
bankruptcy as the main cause for the psychopathic condition in which the patient tried to
kill her mother. Having not consulted the rest of documents, and by placing great
importance on the connection between the bankruptcy and the murder, the consultant
failed to notice that the bankruptcy was desired by Stefania. She could not feel as the
victim as she had arranged it herself for her own personal profit. The bankruptcy could
not have been the main cause for psychopathic reaction.
As a logical consequence of these incongruences, and given that the findings
clearly contradicted the facts, the report was found incomplete. It was clear that the final
diagnosis must be drawn on the basis of the assessment on the entire compendium of
evidence (which should also be made available to the consultant).
What is interesting here is that the crimes were related to intra-family dynamics.
The accused killed her sister and attempted to kill both parents. Her fury, aggression and
violent agitations were all addressed to the family nucleus (35-36). The full assessment of
the pleadings would undoubtedly have offered additional relevant insights to the
consultant who, instead, omitted any evaluation of the complex material, and therefore
failed to give the judge a sufficiently reassuring answer.
For the reasons set out above, the first method was found deficient due to the:
- Absence of psycho-diagnostic tests;
- Absence of logical argument;
- Absence of the precise pathology diagnosis;
- Absence of diagnosis of a specific disease;
- Absence of analysis of the facts given by the patient.
The second examination was more complete and combined traditional clinical
colloquiua, anamnesis, neuropsychological tests, and technical examination of the
structure and functions of the brain of the accused and her genetic heritage. Here the
medical history was written on the basis of the story independent from Stefania’s
distorted interpretation of reality. The judge could rely on it as it offered a complex study
of facts, images of brain and genetic molecular analysis, which reduced the risk of
distortion of the results (39-40).
"Brain imaging" and "genetic molecular” tests provide more precise diagnoses
than those obtained using only the traditional clinical methods of investigation. In this
case, they were complemented with the procedural findings, traditional clinical
interviews and tests, including those taken at the St. Anna Hospital in August 2009 when
the accused was hospitalized as a victim of a suicide attempt, when she was found not
fully psychopathic but strongly prone to anxiety and impulsive and dangerous behavior,
which would require deeper research than that offered by the Roschash test.
As noted by the consultants themselves, the conventional psychiatric approach
based on manifestation of mental illness can make use of neurosciences, which offer a
possibility of finding correlations between certain areas of the brain and the risk of
developing violent behaviour.
It does not introduce a “Copernican” revolution in terms of assessment, evaluation
and diagnosis of mental illness. Nor does it introduce deterministic criteria or
automatically infer that a certain morphological abnormality of the brain lead to a certain
behavior. Instead, it searchers for possible correlations between the anomalies of certain
sensitive areas of the brain or the presence of certain combinations of genes and the risk
of increased vulnerability to the development of socially unacceptable behavior. In
essence, it is very similar to genetic analysis. The presence of certain genes increased the
risk of violent behaviour. It is not deterministic. It is an increased probability (p.42)
This scientific information allows for a more precise idea of the mental infirmity
of the suspect but it does not establish the causality of the crime deterministically. As
cognitive neuroscientist Michael Gazzaniga puts it, “the neuroscience can give a new
way to understand behaviour. But we have to understand that even if a criminal act can
be explained by the function of the brain, the suspect cannot be not acquitted. The brain is
something automatic and determined; the humans are agents of will, and they are
personally responsible for their decisions.”
Thus the behavioral and clinical evaluation of a mentally ill person cannot be
replaced with the evaluation of his or her brain, brain imaging techniques, neuro-or
molecular genetic studies. The brain scans are complementary, they help to understand
the problem, but they do not explain it exhaustively. They offer supporting methods to
complement the traditional methods.
This is why the judge allowed also to the use of these new techniques, and offered
further insights into what could – or should – constitute evidence in criminal proceedings.
Under Art. 187 of the Code of Criminal Procedure (codice di procedura penale)
on the diminished responsibility of the suspect, any fact which helps the judge to take a
decision is taken into consideration, and the provisions of Art. 189 were introduced
precisely to ensure the necessary flexibility of the trial system in terms of using the
scientific proofs. The judge can use the proofs which were not directly
approved/recognized by law (“the law does not give the full list of proofs”) to discover
the facts. It would be a narrow position to refuse the use of new methods of evaluation,
which surfaced as a result of the scientific progress, especially now that they have
obtained international recognition. These methods must be relevant, not superfluous and
appropriate. In such capacity, they would facilitate the work of the court.
The judge is then asked to work backwards to assert the fact already happened in
terms of likelihood and plausibility and to assess the rational credibility of a hypothesis.
The quality of this assessment is proportionate to the quality and quantity of information
at his or her disposal.
In this process, in the face of extreme difficulties and problematic nature of the
case that concerns us here, the neuro-scientific surveys were prepared by the experts
called by the defense to complement the findings of the traditional psychiatric and
neuropsychological tests.
The DSM-IV Diagnostic and Statistical Manual of Mental Disorders, the most
influential textbook of psychiatry in the Western world, has introduced an idea of
epistemological pluralism that cannot fail to take account the advances in neuroscience.
We now have to turn to the summary of the detailed research work carried out by
the technical consultants, called upon to help to make an assessment of the non compos
mentis of the accused at the time of the commission of the crimes.
The results offer a sufficiently complete technical contribution which, without
diminishing the value of the investigation experts, explores some aspects that were not
visible before (such as a pathological tendency of Stefania to lie, compulsive shopping
and eating disorders), also through the brain imaging and molecular genetics.
9 meetings between 14 October, 2010 – 2 February, 2011. Afterwards, the results
were complemented with the medical records obtained from Stefania, members of her
family, and compared with the rest of evidence.
On 19.10.2010 the accused was subjected to a neuropsychological evaluation,
which is being clinically evaluated for diagnostic purposes for detection and assessment
of cognitive and behavioral defects associated with dysfunction of brain structure. It was
followed by the collection of subjective information provided by the family members,
and objective information, obtained from a systematic behavioral observation, and guided
by the administration of neuropsychological tests, validated and standardized in the
Italian language, to ascertain the mental state and general efficiency of her mental
functions (attention, memory, perception, language, praxis, executive functions).
The general intellectual functions of Stefania were found to be normal, as well as
the individual mental functions, except for the function of autobiographical memory, the
ability to control impulsive action, the ability to assess the appropriateness of behavior in
social situations and making choices based on the probability that they are beneficial.
The personality tests (MCMI III to establish pathologies and severe clinical
syndromes; MMPI-2 to evaluate the tendency towards mental disorders; and PPI-R to
assess the degree of psychopathy) have yielded a picture of a person with:
- schizoid tendencies,
- strong introversion,
- social alienation and relational difficulties,
- depressive tendencies,
- with a tendency to manipulate others for personal gains,
- high levels of impulsivity and a poor ability to control the anxiety,
- obsessive compulsive disorder,
- compulsive shopping (confirmed by the parents),
- eating disorders (confirmed by the family members and the past physical
condition of Stefania when she weighed over 100 kg),
- pathological tendency to lie,
- dissociative amnesia, which is an indicator of dissociative identity disorder.
- general tendency to replace reality with fantasies.
As opposed to the first test, the mnemonic difficulties of the accused were
attributed not to a conscious calculation but to the dissociative amnesia. This conclusion
was based on the
- the results of the IAT and TARA technics (reconstruction of autobiography);
- the results of DES (a self-assessment scale that measures the level and type of
dissociative experience),
- the fact that mnemonic disorder was traceable also in the recollection of facts
and events that had nothing to do with the crimes or stressful events.
A final diagnosis: “mythomania with a dissociative identity disorder,” a condition
characterized by pathological lying, also unnecessarily, and belief in the fantasies (her
medical history shows that she invented lies to arouse admiration or interest from others).
It is a dissociative syndrome that explains how the accused could move from aggression
to normal behavior. Since there was a risk of damaging her own image, her brain did not
preserve the memory of actions performed during the dissociative phases. However
important, none of its symptoms can rule out a conscious participation of the accused in
her criminal acts.
The results are important because they confirmed the presence of abnormalities
that significantly increased the risk of developing a certain type of behavior.
An examination of brain structure (morphometric technique) to analyze the
morphology of the cerebral cortex of the brain, which controls the behavior and the
inhibition of impulses, the criticism, the moral sense to distinguish between good and
bad, showed statistically meaningful differences in the structure of her brain as compared
with those of “healthy” individuals of the same age and sex group. The differences in
morphology and in the volume of the brain have included “differences in the density of
gray matter in key areas of the brain, particularly in the area of the brain that inhibits the
automatic behavior, is involved in processes of regulating lies and aggression.” (p.54).
The brain-morphological tests were complemented with genetic tests,
internationally associated with an increased risk of impulsive, aggressive or violent
behavior. The outcome is that Stefania has traces of all three genes that significantly
increase the risk of developing aggressive impulsive violent behavior.
The overall picture of the psychiatric tests allow to conclude that Stefania has
committed the offenses which are discussed today without retaining full ability to control
her actions or to perceive/evaluate her asocial behavior.
Once the psychiatric science identified the possible bio-psychological abnormality
of the mind, the judge is now able to assess the legal relevance of the data for the
purposes of establishing criminal liability based on the complex procedural and logical
evaluation of all proceedings.
The dynamics of crimes reveal highly disorganized behavior. Stefania kills her
sister and leaves the burned body on the crime scene. She never really does anything to
get rid of the corpse or the traces of the murder. She leaves at home the bowl of
benzodiazepine which she gave to her sister. She keeps the empty packs of drugs. She
warns the neighbor not to call the fire department. She keeps the IDs of her sister, which
are found in her car later. She uses her sister’s card to recharge her phone. She tries to kill
her mother knowing that her father is in the immediate vicinity, etc.
She constantly repeats lies which almost always aim at presenting her in a
favorable light or triggering compassion (she invented a degree in architecture,
boyfriends, and abortions). Most of them are unexplainable and highly improbable (on
several occasions, she told her audience that her father was dead). She also revealed a
difficulty to adapt to reality, as well as a tendency to take refuge in a fictitious reality.
She also displayed a tendency to impersonate others (non-existent lawyers), that
blends well with other reports by psychiatrists and neuropsychologists. She wrote
accusing letters and personally distributed to family members and police attributing them
to her sister, in which she pretended to be her sister and which, in fact, tell much about
her own criminal acts.
Even in the immediacy of her arrest and during the early days of imprisonment
the accused has admitted to having tried to kill her mother but reiterated, in contexts
completely unexpected and without procedural purposes, not to have a detailed memory
the dynamics of the incident (see the section on the clinical diary of the first two
interviews in October 2010).
In conclusion, the design of criminal activity has not always been consistent and
logical. The explanations are often incongruous and inconsistent, sometimes even
counterproductive. All this leads to the conclusion, that the accused suffered from
psychiatric problems, and that these problems have, at least in part, had a direct causal
impact on the crimes, by diminishing her capacity to reason and inhibiting the control
over her behavior.
Both psychiatric tests, supplemented by the results of brain imaging and
molecular genetics, allow to detect signs of severe mental dysfunction: Stefania
Albertani, in short, while maintaining good self-control, has not shown herself to be
perfectly capable of making effective use of knowledge and principles of reality, nor to
be able to act in a socially appropriate manner, or to independently determine and to act
in accordance with the values of her own culture and the demands of rationality and
logic.
Stefania Albertani should be considered a socially dangerous individual and a
person at risk of recurrence of violent criminal behavior.
It follows, that the accused must go through a medical treatment in custody in a
closed and protected environment.
It is estimated that the duration of this fair measure of security must be three
years, subject to revocation or extension by the judge.
The penalty
It is not considered possible to mitigate the penalty because of the extreme gravity
of the offense, the intensity of the deceit, and the progression of the illegal conduct that
lasted for many months.
All criminal acts are considered parts of a single criminal scheme.
The penalty which is believed reasonable, therefore, takes into account all the
criteria mentioned above: 30 years of imprisonment (22 years for the murder of the sister,
one year for the alleged kidnapping, 6 months for the alleged destruction of the corpse, 6
months for the abuse of the credit card, 1 year for poisoning the father, 4 years for the
attempted murder of the mother, 1 year for the attempted murder of both parents).
The above penalty could be reduced to 20 years of imprisonment as prescribed by
Art. 442.
Stefania must also pay court costs and her own maintenance in prison. Under Art.
29, she is permanently banned from public office and, under Art. 32, her parental rights
are suspended.
Under Art. 219, the security measures must be in the place in the hospital for at
least 3 years. Her medical treatment must start immediately.