When urologist Attilio Manca was found dead with two heroin needles still sticking out of his wrist and elbow in 2004, none of his friends believed for one minute he had overdosed. For one, Manca, who died alone in his home, was left-handed and the needles were stuck in his left wrist and elbow, which would not have been a natural way to inject the drug. A distinct lack of fingerprints on the syringes still protruding from the doctor’s body were also suspicious. Even had the doctor been careful, he likely would have left at least one print on the plunger. And his friend, a nurse named Monica Mileti, who was ultimately convicted of selling him the fatal heroin and sentenced to five years in prison, just didn’t fit the bill of a drug pusher.

This week, after Mileti pushed to have her case re-examined, Italy’s high court agreed that she had not sold the doctor the heroin and cleared her name. The court also ruled that Manca had not in fact died of a self-inflicted heroin overdose, but a mob-ordered one after Italy’s anti-mafia parliamentary commission investigated the case. Manca, who was born in Sicily but died in Viterbo, near Rome, it is now believed, was secretly flown to France to operate on Bernardo Provenzano, the top boss of the Sicilian Cosa Nostra, while he was in hiding.

Provenzano, who was famously arrested in a farmhouse in 2006 after 43 years on the run after police traced his freshly ironed shirts from his wife’s house to his hideout, died in prison in 2016. Several turncoats testified that Manca had been summoned to France to treat Provenzano's prostate cancer and that Provenzano was so afraid the doctor would rat him out and tell authorities where he was hiding, the capo dei capi or boss of bosses ordered his death. Manca had performed the first laparoscopic prostate surgery in Italy and had a reputation as a skilled surgeon.

Manca’s family then petitioned the court to clear their son’s name from being tied to the drug overdose. The court does not believe that Manca was affiliated with the mafia but instead was given little choice but to go operate on Provenzano. Killing the surgeon and staging it as an overdose, which included planting false evidence in the nurse’s home, was the only way to ensure his “testimonial silence,” according to the court summary.

Manca’s death is now being investigated as a homicide, though mafia hits are hard to pin down and rarely brought to justice. Still, investigators now say that the original autopsy showed evidence that Manca had been beaten and had a fracture in his nasal septum, but that evidence had somehow been overlooked during the original trial against the nurse. His body was placed in a way that was meant to imply he had fallen after the overdose, but upon re-examining the autopsy, the court ruled that he had more likely been subdued.

Authorities also believe that Mileti, the nurse, was likely threatened by the mafia to not fight the original conviction, but after Provenzano’s death, she decided to try to clear her, and the doctor’s, names. It is unclear if she has given any evidence of threats.

The final parliamentary commission deemed that “Attilio Manca was murdered after being involved in the care of the fugitive Provenzano in France” in their final report that informed the high court.

The commission head Giulia Sarti said after the ruling that the history of Manca’s death needs to be rewritten. “Attilio Manca has never taken drugs and never committed suicide,” she said. “He is a victim of the mafia.”