Origin and development of forensic medicine in the Kingdom of Saudi Arabia

The medicolegal death investigation system in the Kingdom of Saudi Arabia (KSA) is unique in the world. It is exclusively derived from Islamic judiciary based on Shari'ah law, which is the definitive Islamic law or doctrine. This law is applied on Saudi citizens as well as foreigners. This is different from other Islamic countries, which have a combination of Islamic and other judiciary systems.The forensic medicine centers in KSA are related administratively to the Ministry of Health (MOH) and its subdivisions in the different governorates. They are concerned with forensic medical examination and autopsy, as well as the clinical forensic medical examination of sexual assault cases, and those injured in civil and criminal cases. The assisting laboratories (forensic histopathology, microbiology, serology, forensic chemistry) are working independently under the funding of MOH, whereas the DNA laboratory and other departments of forensic sciences, for example, counterfeiting and forgery unit are related administratively to the Ministry of Interior represented by the Administration of Criminal Evidences. Efforts concerning crime scene investigations are shared with Administration of Criminal Evidences' crime scene investigators.Forensic medicine education in KSA developed in the past few years after the foundation of Saudi specialty certificate in forensic medicine. The certificate is a postgraduation qualification equivalent to a doctorate degree in forensic medicine and requires completion of a 4-year training program in both MOH- and Ministry of Interior-related departments, as well as passing annual evaluation and examination.This review is aimed at providing in the next decade the medicolegal centers with national forensic specialists throughout the kingdom and granting skillful headships for the next generations. Moreover, this review suggests more scientific associations with the academic universities in the various fields of forensic sciences through academic cooperation.     

Uncertainty of determining cause of death in a medicolegal material without autopsy. An autopsy study

In constrast to other studies, this investigation was made on cases of medicolegal deaths that would not normally be autopsied. 223 females and 322 males, whose deaths were found to be natural before as well as after autopsy, were studied. The cause of death was estimated by external medicolegal examination, and after autopsy.In 79 females and 109 males, i.e. 35% and 34% respectively, estimated cause of death was found to be different after the autopsy. This was mostly because ischaemic heart disease as a cause of death was overestimated at the external medicolegal examination. No constant relationship between differing causes of death and age group could be demonstrated. Underdiagnoses and overdiagnoses tended to outweigh each other. Pneumonia, pulmonary embolism, cor pulmonale and aortic stenosis were clearly underestimated before autopsy. In addition, a variety of diseases that were not even mentioned at the medicolegal examination was found (subarachnoid haemorrhage, uraemia, perforated and bleeding gastric ulcers, tuberculosis).The same unreliability in the estimated cause of death therefore exists among cases not normally autopsied as found in retrospective studies of cases where autopsy is performed under all circumstances at the request of the police.False information will thus be given to the mortality statistics among the approximately 5000 cases of medicolegal deaths not autopsied in Denmark per year, most of these being natural deaths. Besides, contagious and inherited diseases could be overlooked, relatives given false information and the value of scientific studies in causes of death diminished.The conclusion is that autopsy is still essential to ensure continuous control and correction of causes of death.     

The significance of medicolegal autopsy in determining mode and cause of death

A comparative examination has been made to evaluate decisions as to causes and modes of death among 436 consecutive medicolegal deaths before and after coming to autopsy. All available information was used, including police reports, in evaluating mode and cause of death prior to the autopsy. Among the women, the mode of death evaluation differed in 23.4% of the cases and the cause of death evaluation differed in 77.5% of the cases. Among the men, the mode of death evaluation differed in 23.4% of the cases and the cause of death evaluation differed in 46.9% of the cases. These figures were achieved, however, on the basis of the fact that in most cases the mode of death and cause of death were reported as unknown. After autopsy, the cause of death remained unknown in 3.3% of the females over the age of 2 years and in 4.2% of the males over the age of 2 years. No characteristics relationship was established between the differences found and the age groups. The investigation shows the importance of the medicolegal autopsy for correctly recording cases where the death is obscure.     

Is routine histopathologic examination beneficial in all medicolegal autopsies?

Postmortem examinations are performed for a number of reasons. Medical autopsies are performed at the request of and with the consent of the next of kin of a decedent and are often requested to determine the extent of a disease process or to evaluate therapy. In contrast, medicolegal autopsies are performed by a forensic pathologist primarily to determine cause and manner of death but also to document trauma, diagnose potentially infectious diseases and report them to the appropriate agencies, provide information to families about potentially inheritable diseases, provide information to family members and investigative agencies, and testify in court. As medicolegal and hospital autopsies differ in their purpose, so do they differ in procedure. Medicolegal autopsies often include histologic analysis, but not always, as with medical autopsies. We designed a prospective study to address the question of whether or not routine histologic examination is useful in medicolegal cases, defining a routine case as one where histology would not normally be performed and where the cause and manner of death were readily apparent during the gross autopsy. We reviewed brain, heart, liver, kidney, and lung sections on 189 routine forensic cases and compared the results to the gross anatomic findings. Of the 189 cases, in only 1 case did microscopic examination affect the cause of death and in no case did microscopic examination affect the manner of death. Thus, we feel that routine microscopic examination (performing histologic examination in all cases regardless of cause and manner of death) in forensic autopsy is unnecessary. Microscopic examination should be used, as needed, in certain circumstances but is not necessary as a matter of routine.     

医疗纠纷法医学鉴定质量评价模型的建立

目的建立医疗纠纷法医学鉴定质量评价模型。方法收集同济医学院法医学系近10年410例涉及医疗纠纷的法医学鉴定的案例,对影响医疗纠纷法医学鉴定质量的10个关键指标,运用SAS软件进行了主成分分析。结果通过统计学分析,筛选出6个能反映所有原指标变量主要信息的主成分,并依此结果推算出评价法医学系医疗纠纷的鉴定质量评价模型。结论在建立“医疗纠纷鉴定质量管理体系”时,应按影响鉴定质量的主成分设计相应的对策。     

The effects of the (fentanyl-fueled) drug overdose epidemic on medicolegal death investigation in the United States

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology.     

Uncertainty of determining mode of death in medicolegal material without autopsy — A systematic autopsy study

Systematic autopsy was performed in 807 medicolegal deaths where the police had not requested autopsy. In all cases both the cause of death and the mode of death had been reported at the medicolegal external examination. The autopsy revealed differences in the mode of death in about 4% of all cases. This was due in particular to the problems associated with distinguishing presumed natural deaths from accidents and suicide. The cases of “concealed” suicide were found in particular among the higher age groups. However, no characteristic relationship was found between the proportion of differing modes of death and the age groups. All cases of homicide were recognized at the medicolegal external examination.Malignant disease that had not been diagnosed previously was found in about 4% of the cases, the reason being the large proportion of elderly subjects in the material. Syphilitic aortitis that had not been previously diagnosed was demonstrated in about 1% of all cases, and pulmonary tuberculosis that had not been previously diagnosed was demonstrated in 0.7% of the cases.The conclusion is that the results provide no support for replacing the medicolegal autopsy by medicolegal external examination alone, but rather suggest that the proportion of medicolegal autopsies should be increased.     

两地区医疗纠纷法医学尸检鉴定质量的比较研究

目的研究影响涉及医疗纠纷法医学尸检鉴定质量差异的原因。方法两个具有代表性的法医学尸检鉴定机构所涉及医疗纠纷的相关案例,进行字2检验、t检验等统计学研究。结果通过字2检验发现,在设定的10个指标中,有7个指标存在显著性差异,提示两鉴定单位在“涉及医疗纠纷的法医学尸检鉴定”中检验手段和标准、规范性等均存在极大的差异。结论通过研究,提示法医学鉴定人素质、尸检的标准化和规范化、尸检检材的提取标准化、死因或疾病的诊断标准、会诊制度及法医学鉴定书的书写规范化等是法医学尸检鉴定质量控制和管理的重要环节。     

Post-mortem examination prior to cremation--an instrument to verify the quality of medical post-mortems and uncover non-natural deaths?

The external post-mortem examination, its deficient quality and possible causes have been the subject of numerous political and professional discussions. The external post-mortem examination is the basis for the decision whether further criminal investigations are required to clarify the cause of death. It is thus an essential instrument to ensure legal certainty. Before cremation, a second external post-mortem examination is performed by a public medical officer to make sure that errors of the first post-mortem are corrected. In the present study, cases were retrospectively analyzed in which a forensic autopsy had been ordered on the basis of the results of the post-mortem examination performed before cremation. The entries on the death certificate regarding the manner and cause of death were compared with the autopsy results. Between 1998 and 2007, 387 autopsies were ordered after external examination before cremation. In 55 cases (14.2%), the autopsy revealed a non-natural death, although a natural death had been attested on the death certificate. In descending order, a wrong manner of death was attested by clinicians, general practitioners and emergency physicians. With regard to the place where the first external post-mortem had been performed the lowest error rate was seen in nursing homes. Concerning the cause of death, discrepancies between the first post-mortem and autopsy were found in 59.4% of the cases. In this respect, general practitioners and clinicians were ranking first, whereas in nursing homes the cause of death was wrongly assessed in over 70% of cases. At present, the medical post-mortem does not meet the required quality standards, especially with regard to legal certainty. Determination of the cause of death on the basis of the external post-mortem examination is a challenging task even for the experienced medical examiner. As to the categorization of the manner of death it has to be stated that non-natural deaths are often not recognized or that the possibility to certify a death as unclear is not sufficiently used. As a result, it seems important to demand intensive, qualified, additional training in external post-mortem examinations for physicians.     

Natural,Unexpected Deaths: Reliability of a Presumptive Diagnosis*

Abstract: We retrospectively analyzed 100 deaths because of suspicions and concerns expressed by the family. We compared the preautopsy cause of death, as determined by a thorough review of the clinical data and circumstances, to the autopsy‐derived cause of death. In the majority (91/100), the preautopsy and postautopsy proximate causes of death were in agreement. In 9%, the autopsy provided information that resulted in a proximate cause of death different than anticipated. In four instances, the manner of death also was incorrect and was determined to be an accident rather than the originally presumed natural. No homicide or suicide would have been misclassified. In another nine instances, where the premortem and postmortem proximate causes of death were in agreement, the autopsy provided a specific mechanism of death. With a quality initial medicolegal death investigation, a subset of sudden deaths in adults may be reliably certified without an autopsy.     

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.     

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。     

Acute poisoning involving the pyrrolidinophenone-type designer drug 4'-methyl-alpha-pyrrolidinohexanophenone (MPHP)

A 36-year-old woman consulted the medical emergency unit of a private health center for abdominal pain and gastroenteritis of 5 days duration. Acute right pyelonephritis was diagnosed. Five hours after admission she became unconscious in a state of clinical shock. She was transferred to an intensive care unit but resuscitation attempts were unsuccessful and she died 3 h later. Three days after death, she was buried in the family vault. Five days after the burial, her husband lodged a complaint with the public prosecutor because he had not received a clear explanation from the physicians concerning the cause of his wife's death. After analysis of the medical records of the deceased by two forensic pathologists, a medicolegal autopsy was ordered by the public prosecutor. The corpse was exhumed and autopsy performed 9 days after death. Massive hemoperitoneum was diagnosed with a macroscopically ruptured subcapsular hematoma. Pathological study confirmed acute right pyelonephritis and demonstrated the precise cause of the hemorrhage: rupture of the hepatic artery at the hilar part, following infectious arteritis which was probably secondary to the acute pyelonephritis. To the best of our knowledge, this is the first published report of such a case.     

宝鸡市358例法医送检器官的组织病理学分析

目的 分析法医尸体检验后送检器官的病理学特征,总结此类案件的特点.方法 对宝鸡市法医送检358例尸体解剖器官标本进行常规检查并进行组织病理学诊断. 结果 358例中以青壮年男性为主,死亡原因主要为创伤、猝死、中毒.组织学能明确死亡原因250例,无典型组织学病变101例,组织自溶腐败7例.病理诊断以心血管疾病为主,其次为呼吸、神经、消化系统疾病. 结论 法医解剖具有专业特点,与病理解剖不尽相同.组织病理学检验进行死亡原因诊断时,应积极与法医沟通,以充分掌握案情、死亡经过及特定的法医病理学特征.     

Medicolegal death investigator workplace safety hazards: A scoping review of the literature

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.     

The epidemiological study on registered cases of sudden infant death syndrome (SIDS) in Tokyo: examination of the effect of autopsy on diagnosis of SIDS and the mortality statistics in Japan

In the United States and most of European countries, a diagnosis of sudden infant death syndrome (SIDS) may be given only after an autopsy has been performed. Under the new definition of SIDS in Japan, an autopsy is now mandatory for the diagnosis of SIDS. However, according to the official records on autopsies, the proportion of autopsy for sudden infant death in Japan is still low (less than 30%). If a physician suspects SIDS from a review of the patient's medical history and medical findings, he can write 'suspected SIDS' as the cause of death on the death certificate without performing an autopsy. Such a clinical diagnosis is entered in the Vital Statistics section by the Japanese Ministry of Health and Welfare. In this report, a comparative epidemiological survey of registered cases of SIDS--after autopsy and with no autopsy--was carried out by examining the data from the death certificates registered by the Japanese Ministry of Health and Welfare (vital statistics in Tokyo from January 1979 to December 1996). There were 369 cases of SIDS registered in Tokyo. We found 247 diagnosed after autopsy (66.9%) and 122 with no autopsy (33.1%). The following epidemiological variables were used: address of the deceased (a specific area in Tokyo), sex, year of death, time of death, month of death, age at death, occupation of householders, and place of death. There were epidemiological differences at the 0.05 significance level between registered cases diagnosed after autopsy and those diagnosed without autopsies, as follows: year (P=0.016) and place of death (P=0.037). In addition, there were slight epidemiological differences at the 0.10 significance level between registered cases diagnosed after autopsy and with no autopsy, as follows: month of death (P=0.076) and age at death (P=0.082). This suggests that the quality of diagnosis of SIDS is not completely guaranteed. With respect to the area of residence, the incidence of SIDS is high in those areas where autopsy is performed frequently. In Tokyo, the medical examiner system is enforced only in the urban area and there is a possibility that SIDS is being underdiagnosed in the rural area of the Metropolitan Tokyo. It is likely that the diagnosis of SIDS without autopsy will influence the quality of SIDS diagnoses. The administrative inadequacy in the autopsy system in Japan should be corrected to improve the accuracy of SIDS diagnosis.     

Correlations of injury, toxicology, and cause of death to Galaxy Flight 203 crash site

This report details the medical investigation of the crash of Galaxy Flight 203, on 21 Jan. 1985, near Reno, Nevada. Sixty-eight persons died at the scene, two died during hospitalization, and one victim survived. After completion of autopsies on all victims, pathologists determined causes of death based upon injuries, evidence of smoke inhalation, and toxicologic results. Our research shows that the majority of victims survived the impact only to succumb to toxic gas and fire. We correlated the causes of death, various injuries, and toxicologic findings to body location at the crash site to aid in reconstructing the events surrounding the accident and to address medicolegal problems and safety considerations. Our experience clearly supports the need for thorough medical investigation, including autopsy of each victim and determination of the precise cause of death for all fatalities.     

Investigation of drug-related deaths. An overview

Drug-related deaths encompass fatal overdoses, the medical derangements from chronic consumption, and violent death from the alteration of normal behavioral patterns. Determining the extent to which a drug contributed to a death necessitates correlation of all aspects of the death investigation; autopsy and toxicologic findings must be interpreted in the light of antecedent events, medical and social history, and thorough scene investigation. The approach to the medicolegal investigation of drug-related deaths is discussed along with some legal ramifications and certain potential problems of death certification.     

Forensic medicine in Great Britain. II. The origins of the British medicolegal system and some historic cases

The British medicolegal system, which today is largely based on the Coroner's Act of 1887, developed slowly, beginning with the election of county coroners in the 12th century. The duties of the medieval coroner included the collection of revenues due to the Crown, recordkeeping, presiding over inquests, and overseeing juries in cases of sudden or unnatural death. However, by the 14th century, the influence of the coroner had diminished and the office fell into disrepute. The practice of forensic medicine in the United Kingdom can be dated from the 17th century, when the first autopsy was recorded. However, the first original textbook on this subject did not appear in Britain until the early 19th century. Around the same time, due to a wave of homicidal poisonings, toxicology emerged as an important discipline. A number of historical cases of homicidal poisoning, as well as several cases of homicide by external wounding, are discussed herein. In the present day, with the passage of various laws, the British coroner deals only with sudden and unnatural death and treasure trove.     

Postmortem Computed Tomography in Firearm Homicides: A Retrospective Case Series,

Postmortem computed tomography (PMCT) is integrated into the evaluation of decedents in several American medical examiner offices and medicolegal death investigative centers in many other countries. We retrospectively investigated the value of PMCT in a series of firearm homicide cases from a statewide centralized medical examiner’s office that occurred during 2016. Autopsies were performed or supervised by board-certified forensic pathologists who reviewed the PMCT scans prior to autopsy. PMCT scans were re-evaluated by a forensic radiologist blinded to the autopsy findings and scored by body region (head–neck, thoracoabdominal, and extremities). Injury discrepancies were scored using a modified Goldman classification and analyzed with McNemar’s test. We included 60 males and 20 females (median age 31 years, range 3–73). Based on PMCT, 56 (79.1%) cases had injuries relevant to the cause of death in a single body region (24 head–neck region, 32 thoracoabdominal region). Out of these 56 cases, 9 had a missed major diagnosis by PMCT outside that region, including 6 extremity injuries visible during standard external examination. Yet all had evident lethal firearm injury. We showed that PMCT identifies major firearm injuries in homicide victims and excludes injuries related to the cause of death in other regions when a single body region is injured. Although PMCT has a known limited sensitivity for soft tissue and vascular pathology, it can be combined with external examination to potentially reduce or focus dissections in some of these cases depending on the circumstances and medicolegal needs.