Reasons, circumstances and results of repeat forensic medicine autopsy

There are only scant literature data on reasons and circumstances of medico-legal second autopsies. The present study includes 12 second autopsies from the period 1992-1997; the first post-mortem examination took place either in the home country (institutes of pathology) or abroad. 7 of the 12 cases of death investigated happened in Germany (exclusively in hospitals) and 5 of them abroad (Netherlands, Romania, Portugal, Libya). Repeat autopsies were ordered by criminal courts (n = 9), private persons (n = 2) and social insurances (n = 1). The main indication was possible medical malpractice (n = 6); acts of violence (n = 3), insurance questions (n = 2) and accidents (n = 1) followed. The time lapse between death and second autopsy was 2-35 days. It was striking, that German institutes of pathology had partially performed autopsies despite the certification of a non-natural death. Clinical autopsies were stopped twice, when evidence of a possible non-natural death occurred. It could be fundamentally stated, that first autopsies in German institutes of pathology had been carefully performed and sufficiently documented. In these cases the second autopsy presented no or only little additional information, as far as the broader taking of (toxicological) samples is not considered. The final medico-legal expertise was then mainly based on the findings of the clinical first autopsy. However, the concurrence of the forensic expert (instead of the clinical pathologist) is undoubtedly essential for the evaluation of these issues involving frequently questions of malpractice. By contrast, the quality of postmortems performed abroad varies widely. 4 of the 5 first autopsies done abroad were regarded as completely or partly insufficient with superficial or almost absent preparation of organs or contradictions in the medical reports, respectively. A repeat autopsy is absolutely necessary in such cases. On the whole, the initial question could be answered in all second autopsies at least in part. This emphasizes the high value of second autopsies and expertises, especially in non-natural cases of death (10 of 12 deaths were finally judged as non-natural).     

Medical negligence in drug associated deaths

According to epidemiological studies adverse drug events are one of the most frequently encountered complications during medical treatment, a leading cause of hospitalisation and frequent cause of death. However, medical malpractice claims due to medication errors seem to be relatively rare. Based on a retrospective multicentre study on medical malpractice cases with lethal outcome (n = 4450), drug related cases (n = 575) were further evaluated. In 50% of cases a causal connection between drug therapy and death could be ruled out already after autopsy. In 232 cases a causal connection between drug therapy and death could be approved (drug allergies, relative overdose, wrong application, mix-up of drugs and sepsis after injection abscess). However, within the legal context only in 70 cases a medication error was approved which was in 42 cases causal for death, in 28 not. Administration of contraindicated drugs, incorrect application and relative overdose in renal insufficiency are the prevalent mistakes. Concerning the frequency of ADE in epidemiological studies medication errors are underreported in all data sources on medical malpractice; this seems to be due to the fact that even doctors and attending physicians rarely recognize an ADE; furthermore approving the connection between drug effect and death is extremely difficult for the expert witness.     

Determination of cause and mode of death before and after medicolegal autopsy: a comparative study

Two hundred and twenty-eight consecutive medicolegal autopsies were studied as to the cause of death established by a physician, the mode of death as suggested in the police report, and findings of medical interest often discovered following autopsy. Corrections had to be made even in some cases which seemed to be obvious. With a decrease of the number of autopsies, the records of various registration bureaus would be affected. Autopsies are still necessary for control and correction of clinical causes of death.     

Medical malpractice: a study of case histories by the Forensic Medicine Section of Bari

The learning objectives of this paper are to study the actual extent of medical malpractice, the medical acts at risk, and their impact on mortality. The number of suits filed against physicians for deaths resulting from alleged malpractice and autopsies ordered by the Judicial Authority in cases of possible therapeutic misadventures are rising. A major factor pushing this trend is public mistrust of healthcare providers and public and facilities. This mistrust is partly fueled by the mass media which, often to gain larger audience shares, sensationalizes single cases of real or alleged iatrogenic injury. Further, the potential for astronomic settlements, either from the single doctor or from the healthcare institution, has increased the number of legal proceedings that start on the basis of mere suspicion. In this context, the autopsy becomes an important instrument for shedding light on the situation, and it must be carried out by highly qualified and experienced professionals capable of ascertaining the cause of death, identifying any possible misconduct, and assessing its consequences. We reviewed the data regarding autopsies performed at the Forensic Medicine Section of the Department of Internal and Public Medicine of the University of Bari over 1991 to 2000. We culled the cases alleged malpractice and, from these, identified those in which the death had truly been caused by medical error. This study also allowed us to understand the incidence of lethal therapeutic misadventures and to identify the medical and surgical branches more frequently involved.     

Usefulness of Systematic Histological Examination in Routine Forensic Autopsy*

Abstract: The forensic community does not agree on the need to perform histological examination at forensic autopsy. The aim of our study was to determine the usefulness of systematic standard histology in forensic autopsies. A prospective study was carried out on 428 autopsy cases for which standard histological examination was systematic. Mechanism of death not shown by gross anatomic findings was discovered by histology in about 40% of the cases. Cause of death was established by only histology in 8.4% of the cases. Microscopic findings affected the manner of death in 13% of the cases. Histology provided complementary information about prior medical condition of the deceased in about 49% of the cases. Traumatic lesions were better documented by histology in about 22% of the cases. According to the results of our study, systematic standard histology for the main organs should be used in routine forensic autopsies.     

Fatal child neglect in East Germany 1 January 1985 to 2 October 1990. Results of a multicenter study

No reliable data are available on cases of lethal child neglect in the area of the former German Democratic Republic. In a multicenter study we therefore examined the police and court records for such cases occurring in the period 1 January 1985 to 2 October 1990 in the entire area of the former German Democratic Republic. RESULTS: A total of 9 cases were reported to the study center. This does not include undetected cases, whose number, though indeterminate, is probably small due to the general obligation to perform autopsies on all children dying before their 16 birthday. Just over half of all victims were less than one year old, the oldest was 3 1/2 years old. Starvation and severe dehydration were by far the most common causes of death; in half of cases these occurred in combination with hypothermia. Most often mother killed their children by neglect, either alone or together with the victim's father. In the majority of cases no close bond existed between the parents and the child. Seventy percent of the perpetrators were chronic alcoholics. All 10 of the perpetrators were sentenced to imprisonment for periods ranging from one year to life long. Mitigating circumstances were presented at the sentencing phase of the trial on behalf of 20% of those convicted. The experience of legal medical and pathological institutes in the former German Democratic Republic underscores the need to perform an autopsy on all deceased infants and young children. Only this can ensure that no cases of lethal child neglect are overlooked.     

Medical malpractice charges in Germany--role of the forensic pathologist in the preliminary criminal proceeding

Medical malpractice charges from 1989 to 2002 were evaluated. A rising number of cases during this period is evident. The charges of practice falling below the standard of care (n = 285) were surveyed to determine who informed the prosecution, which clinical subjects are involved, what kind of charges can be found and whether such allegations can be appropriately assessed by means of a forensic autopsy. Forensic pathologists were found to be useful for ascertainment and interpretation of autopsy findings. If special questions arise, an additional expert opinion should be suggested by the forensic pathologist. There was no relevant shift in the range of subjects involved compared to former studies. The investigated charges might represent only a small fraction of cases of medical practice falling below the standard of care.     

胎儿畸形医疗纠纷法医学鉴定12例分析

目的 探讨因胎儿畸形产生医疗纠纷的主要原因,分析法医学鉴定的切入点以及鉴定思路.方法 参照相关法律、法规与临床诊疗规范,分析本组因胎儿畸形所致12例医疗纠纷法医学鉴定案例中的医疗过错及其参与度划分.结果 本组案例中,存在医疗过错的为5例,其中未履行告知义务的2例,对异常结果未进行综合分析的2例,医疗技术水平有限并报告表...     

医疗损害诉讼中专家辅助人制度的构建

由于医学的复杂性和法官知识的局限性,导致医疗损害案件的审理中存在法官过分依赖鉴定意见的现象。以新修改的《民事诉讼法》为视角,界定了专家辅助人的概念,明确了构建专家辅助人的意义,分析了构建专家辅助人制度的理论和实践基础,最后探讨了在医疗损害诉讼中构建专家辅助人制度应明确的几个问题。     

Variation in the growth and incidence of medical malpractice claims

This study analyzes the incidence of medical malpractice claims since 1976, using data drawn from the 1982 core survey of the American Medical Association's Socioeconomic Monitoring System. The data show that, on average, physicians incurred twice as many claims per year in the years 1976 to 1981 as they did during their careers prior to that period. Using Tobit analysis, we find the annual frequency of claims to be greater among surgeons, obstetricians and gynecologists (OBGs), physicians in group practice, and physicians in states which apply the legal doctrine of informed consent. In addition, we find that the number of years since medical residency is positively related to physicians' claims incidence during the first 27 years of practice, and that OBGs and medical specialists who spend more time with their patients per office visit incur fewer claims.     

Minimizing mistakes in clinical diagnosis.

It would be quite reasonable for us to expect the progress made in diagnostic technology to be accompanied by a parallel improvement in diagnostic accuracy. In reality, however, the frequency of misdiagnoses remains the same, despite the fast progress which has been made by medical technology in the last 30 years. Autopsy is the best source of information on diagnostic accuracy. According to one hypothesis, an increase in the number of autopsies performed and the follow-up on them could reduce the number of diagnostic mistakes. In recent times, however, the number of autopsies in comparison with the registered number of deaths has been declining steeply. We studied the autopsy reports for 1997, kept at the archive of the Institute for Forensic Medicine. We only took into account the deaths which occurred within 24 h of admittance to the emergency wards of the Ljubljana University Hospital, including those patients who died subsequently as a consequence of accident or injury. We also included cases of sudden deaths which occurred during operating or within 24 h after it. Following selection, we analyzed 444 out of the total of 921 autopsy reports, for each of which we carried out a comparison between the postmortem diagnosis and the clinical diagnosis, contained in the medical report on the death and the causes of death, which is modeled on WHO recommendations, i.e., the International Classification of Diseases (ICD), and in the medical documents, if any were submitted. Data are entered in these by using the ABC system where: A) direct cause of death, B) are circumstances that influenced the occurrence of death, and C) is original cause of death. The findings were then organized into five groups, depending on the degree to which the clinical diagnosis agreed with the postmortem diagnosis. The first group is comprised of the cases where the clinical and postmortem diagnoses agree completely; the second group is comprised of the cases of partial disagreement on the direct cause of death; the third group is comprised of the cases of disagreement on the original disease; the fourth group, of complete disagreement between the clinical and postmortem diagnoses. The fifth group is comprised of those cases where, under the ABC standards on the classification of diseases, injuries and causes of deaths as specified by the WHO, the documentation was incomplete. A complete agreement between the diagnoses was established in 48.87% of cases; partial disagreement in 22.74%; and total disagreement in 13.5%. 9.68% of cases were classified as falling into group 5. For the three diseases that are among the most common causes of death, we established the percentage of agreement, the percentage of overdiagnosis and the percentage of underdiagnosis. The most frequently underdiagnosed disease (in 61% of cases) was pulmonary thromboembolia; in 15% a thromboembolia was confirmed in autopsy. In 24%, a myocardial infarction was not diagnosed clinically and in 60% the clinical diagnosis of a myocardial infarction was confirmed in autopsy. In 33% a heart failure was not diagnosed during the clinical stages but only in autopsy, in 66% the clinical diagnosis of a heart failure was confirmed in autopsy.     

死后尸体CT在法医学鉴定中的应用价值初探

目的 对不同类型案件中的死者进行死后尸体CT扫描和常规尸体解剖,探索PMCT在法医学鉴定中的应用价值.方法 对7例因不同原因死亡的个体进行全身PMCT扫描,随后进行系统的尸体解剖,通过比较两种方法检测的结果,分析PMCT与传统尸体解剖在不同类型案件中应用的优点和不足.结果 在7个案例中,尸体上总共检出67处阳性发现.其...     

Diagnostic angiography in postoperative autopsies

Postmortem angiography was used as a diagnostic tool to rule out surgical malpractice in 227 medicolegal autopsies following postoperative deaths in Finland. Of the cases, 111 involved neurosurgical patients or patients undergoing operations on the carotid arteries, 62 involved coronary bypass patients, and 54 patients died following abdominal surgery. A portable perfusion device for postmortem angiography at the autopsy table involves attaching quick couplings to a compressed airline. Permanent cast and three-dimensional topographic assessment of vascular anatomy are achieved using solidifying silicone rubber with lead oxide as a contrast medium and stereopair radiographs. This technique can be performed by experienced autopsy technicians and can be linked to normal autopsy services. In our experience, postmortem angiography is useful in investigating all complicated deaths following surgical operations.     

Forensic Pathological Examination on 73 Medical Malpractice Cases of PediatricsCSCD

Objective: To analyse 73 medical malpractice cases of pediatrics for discussing the importance of forensic pathology in solving the issues such as medical malpractice of pediatrics. Methods: From January 2002 to August 2016, 73 medical malpractice cases of pediatrics with age of death between 28 days old and 10 years old were collected from Institute of Judical Expertise of Nanjing Medical University. The relationship between causes of death and related medical institutions was retrospectively analysed. Results: In 73 cases, the male to female ratio was 1.70:1, and ages of 28 days old to 1 year old were common (26 cases, 35.62%), followed by ages between 1 year old and 3 years old (21 cases, 28.77%). In 71 cases which had been determined the cause of death by postmortem examination, the main cause of death was disease, especially respiratory diseases (33 cases, 46.48%), followed by cardiovascular diseases (12 cases, 16.90%). In 75 medical institutes which involved with these medical malpractices, most were tertiary medical institutes (32, 42.67%), followed by the sub-secondary (excluding the secondary)medical institutions (23, 30.67%). The clinical diagnosis of 38 cases (52.05%) completely or mostly corresponded with the pathological findings. There were 35 cases (47.95%) undefined or misdiagnosed cases. Conclusion: Autopsy and forensic pathological examination contribute to determine causes of death, which not only provide scientific evidence for medical malpractice of pediatrics, but also enrich and develop clinical medical knowledge, and thus improve diagnosis and treatment level in a certain extent. © 2018 by the Editorial Department of Journal of Forensic Medicine.     

The attitudes of medical students to autopsy

To assess the attitudes of medical students to autopsy, 6th year students in the Medical Schools located in Istanbul, Edirne and Bursa in Turkey were asked to participate in a questionnaire. In the questionnaire, the main questions were on the number of autopsies they had attended, the number of autopsies they had participated in, their reaction to the first autopsy, whether they felt the conditions were adequate or not and what would their objectives be upon deciding to perform an autopsy. In the evaluation, it was detected that most of the participants had attended an autopsy, only a minority had participated in autopsy and most of them felt uncomfortable and inadequate on performing autopsy. The results were discussed with respect to the literature.     

Recent status of the medical examiner system in Japan: demographic variation of medicolegal deaths in Hyogo Prefecture and uncertainty in medicolegal investigations conducted by medical practitioners.

The medical examiner system has been steadily abolished in Japan. Instead, medicolegal investigations are entrusted by the police to medical practitioners, who are not permitted to perform autopsies. The necessity for the medical examiner system was assessed through inquest records in Hyogo, one of the three prefectures which still have medical examiner systems. Standardized mortality ratios (SMRs) for accidents and suicides were negatively associated with population density, being high in rural areas with a large proportion of elderly citizens, while the SMR for natural deaths was high in urbanized areas and associated with the proportion of inquests to total resident deaths. The high proportion of inquests, however, did not always mean that inquest records were of good quality. Significant differences in the quality of medicolegal investigations seemed to exist between medical examiners and medical practitioners. That is, in order to certify the cause-of-death, medical examiners performed autopsies in about half of their cases, while only 2% of medical practitioner cases were subjected to autopsies. Medical practitioners, who certified the cause-of-death as "heart failure" without advising an autopsy, were regularly entrusted with inquests. It is likely that the causes-of-death for medicolegal cases may be questionable since more than 85% of all medicolegal deaths were investigated by medical practitioners, which may cause inaccuracy in at least 3-7% of mortality statistics. It is necessary to educate medical practitioners concerning the importance of mortality statistics and ICD and on the validity of autopsies, in order to obtain accurate mortality statistics from medicolegal cases.     

The current status of medical malpractice countersuits

The dramatic growth of medical malpractice litigation in recent decades has contributed significantly to an overall increase in health care costs in this country. Although lawmakers, physicians, and other responsible citizens have proposed numerous solutions in an effort to curb the crisis, these proposals have generally been ineffective. In this Article the Author endorses countersuits as the most appropriate response to frivolous medical malpractice actions. The Author also suggests that contingent fee systems, coupled with the economic motivation of private insurers to settle claims quickly, provide incentive for plaintiffs to initiate frivolous claims. This Article analyzes the general legal approaches available for countersuits, emphasizing recent successful actions based on malicious prosecution and abuse of process, and proposes more widespread use of these approaches.     

涉及死亡医疗纠纷的发生:27年医疗纠纷法医尸检回顾性研究之一

为了探讨医疗纠纷法医尸检的特点,回顾性研究了1972～1998年27年间318例医疗纠纷尸检资料.在这第一篇报告中,介绍与死亡有关医疗纠纷发生上的一些特点:医疗纠纷尸检的案例数从1972～1983年的23例上升到1984～1998年的295例;死者中男女性别无显著差别;年龄分布有两个高峰,10岁以下有104例(32.71%),20～40岁组161例(50.63%);发生在市(县)级中等大小医院的纠纷最多见,有195例,占61.32%,近年私人诊所的医疗纠纷明显增多;医疗纠纷尸检最常涉及外科(71例,22.33%)和产科(58例,18.24%);也简略讨论了206例非医疗过失纠纷和99例医疗过失纠纷发生的原因.     

新生儿医疗纠纷相关因素的初探

目的　从法医学和管理学的角度初步探讨新生儿科医疗纠纷的防范与处理。　方法　收集华中科技大学同济医学院法医学系 1994— 2 0 0 2年 8年间 2 7例新生儿尸体解剖案例 ,进行回顾性分析研究。　结果　 2 7例新生儿尸体解剖案例中 ,男性患儿 12名 ,女性患儿 15名 ,平均年龄 18.2 2天。其中围产期 10例。其家属要求均为查明死因。经过鉴定 ,其中医疗事故为 0例 (3 7.0 3 % ) ,不是医疗事故 17例 (62 .97% )。　结论　新生儿医疗纠纷的防范应从医方、患方以及国家与社会 3方面努力进行防范 ;在处理方面 ,及时的尸体解剖和病理检查是解决医疗纠纷一种行之有效的方法。     

The unrealized potential of malpractice arbitration

Although the use of arbitration in the commercial arena has increased tremendously in recent years, there has been a reluctance to adopt arbitration of medical malpractice claims in place of litigation. After discussing the benefits of arbitration in medical malpractice cases, Professor Metzloff examines why the use of arbitration has not become predominant, discussing such factors as judicial hostility, failure of state statutes designed to encourage arbitration, and lack of hard evidence that arbitration works. Professor Metzloff then explores the future of arbitration in medical malpractice cases, citing examples from his own work experience with Duke Law School's Private Adjudication Center, and discusses attributes which would make malpractice arbitration successful in the future.