Issues surrounding a reduction in the use of internal autopsy in the coronial system

In 2003 it was estimated that 2,700 full internal coronial autopsies were performed in Queensland at a cost of approximately A$5.3 million. This large number of internal coronial autopsies (almost 95% of all matters referred to the coroner) is of concern not only due to the economic cost but also because of the public heath risks, availability of specialist staff and significant religious and cultural sensitivities surrounding internal autopsies. In 2005 the authors began research funded by the Australian Research Council (ARC) to determine if unnecessary internal autopsies are being performed in Queensland and to establish guidelines for when an internal autopsy is required. This article highlights areas of potential concern when the issue of autopsy is reviewed within the coronial system through an examination of international literature on the issue of autopsy diagnosis and error rates more generally, and through preliminary discussion of the data obtained. The article considers the role and purpose of the autopsy generally as well as within the coronial system specifically; compares diagnostic error rates in hospital autopsies with those in the coronial system; the current situation internationally with regard to internal autopsies; and finally the specific circumstances existing in Queensland.     

Repeat autopsies on corpses from abroad. A futile effort?

A large number of corpses transferred to Athens and the Piraeus Morgue from abroad have been examined in second autopsies. Lack of information, mistakes in data, useless effort, and disappointment on the part of the forensic pathologists because of the lack of new information revealed are characteristic of these cases. With some exceptions, the second autopsy provided no news for the anxious relatives, who, for the most part, had been prompted by their attorneys or other "well-meaning friends" to demand a second autopsy on the corpses of their loved one (who generally died on board ship abroad). Nevertheless, in 10 of 59 cases, the cause of death was completely different from the determined in the autopsy performed abroad or assumed from the information available. This fact ensures that any corpse from abroad undergoes a careful and thorough examination on its arrival in Greece.     

Neuropathology of human immunodeficiency virus infection: a forensic autopsy study in Dar Es Salaam, Tanzania

The objective of this study was to examine the neuropathological changes in the brain of patients infected with human immunodeficiency virus (HIV) in the Tanzanian capital Dar Es Salaam, and investigate whether the prevalence of different forms of HIV-related neuropathology varies from other countries. The subjects were patients with risk factors for HIV infection in whom forensic autopsies were performed between 1997 and 1999. In Dar Es Salaam, forensic autopsy constitutes more than 90% of all autopsies, because hospital autopsy is limited due to socio-cultural and religious reasons. HIV infection was identified in 52 of 143 patients selected from forensic autopsies. Neuropathological findings were observed in 31 of 52 HIV-infected patients; these include lymphocytic meningitis 19, bacterial meningitis 3, tuberculous brain abscess 3, cryptococcal meningitis 3, basal ganglia calcification 3, and toxoplasma encephalitis 1. HIV encephalitis, lymphoma, and cytomegalovirus encephalitis could not be found in this study. Whereas the findings should be interpreted cautiously because of possible autopsy bias and a low percentage of cases examined compared to the total number of HIV-infected patients in Tanzania, our observations provide information on the likely diagnostic possibilities to be considered in the evaluation and management of HIV-infected patients with neurological symptoms in Tanzania. In the face of decreased hospital autopsy, most studies have focused mainly on the end-stage HIV disease; forensic autopsy is a potential source of materials for studies on HIV disease spectrum at different stages.     

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.     

Reliance on internal autopsies in coronial investigations: a review of the issues

Internal autopsies are invasive and result in the mutilation of the deceased person's body. They are expensive and pose occupational health and safety risks. Accordingly, they should only be done for good cause. However, until recently, "full" internal autopsies have usually been undertaken in most coroners' cases. There is a growing trend against this practice but it is meeting resistance from some pathologists who argue that any decision as to the extent of the autopsy should rest with them. This article examines the origins of the coronial system to place in context the current approach to a death investigation and to review the debate about the role of an internal autopsy in the coronial system.     

Surveillance of human immunodeficiency virus (HIV) antibodies in medicolegal autopsies in Finland--monitoring early changes in HIV-seropositivity among risk groups and average population.

In order to cooperate with voluntary screening programs aimed at the surveillance of the HIV epidemic in Finland, we have studied medicolegal autopsies for HIV antibodies since 1986 using an enzyme immunoassay on postmortem sera. The investigation covered 47.4% and 39.2%, respectively, of all deaths under the age of 65 years in the metropolitan areas of Helsinki and Turku--two cities on the densely populated southern coast of Finland from which most HIV infections have thus far been detected. Nine HIV-positive cases (0.12%) were detected among the 7305 medicolegal autopsies tested in 1986 to 1990. This figure is higher than the prevalence of 0.01 to 0.03% in voluntary screening programs for the general population would suggest. Seven of our cases had previously tested positive, and two were previously unknown cases, indicating that people at high risk are clustered in the medicolegal autopsy series. Of the six cases in an early stage of infection, three committed suicide suggesting the importance of HIV-screening in suicide cases in tracing symptomless HIV carriers. Five of the cases were detected in 1990, a year when the number of new HIV infections had more than doubled compared to the previous two years. This suggests that testing of medicolegal autopsies as surrogate tests for the population gives useful information even in low-prevalence areas like Finland. Such testing has none of the ethical problems of many other back-up surveys, and may be particularly sensitive to early changes in epidemiology.     

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.     

A survey of drug use and attitudes toward drugs among male law students and police trainees in Queensland,Australia: A research note

During first semester 1980, 96 first and last year male police students and 166 law students were surveyed about their drug use patterns and attitudes towards alcohol. Of these students, 69.3 percent drank at least once a month, 80.7 percent used coffee or tea, 23.6 percent analgesics, 3 percent antihistamines and marijuana and less than 1 percent sedatives, tranquilizers, stimulants, hallucinogens, cocaine or opiates once a month or more. Law students used caffeine and marijuana significantly more frequently than police students. On the whole, there were more similarities than differences between the two groups in terms of drug consumption. In terms of attitudes, police students felt significantly more than law students that alcoholism was caused by moral weakness and medical illness as shown in the Attitude Towards Alcoholism questionnaire. But significantly more police students (82 percent) than law students (37 percent) felt that it was important to have drug and alcohol education as part of their course of study. Also significantly more police students (58 percent) than law students (24 percent) felt that they were prepared to manage drug or alcohol problems professionally.     

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).     

Unexpected findings in the investigation of an airplane crash

We report on the discovery at autopsy of an unexpected cause of a crash during landing of a small sports plane with four people on board. Surprisingly, an intact bullet and fragments of the casing were found in the body of the pilot. As expected, autopsy of the other passengers predominantly revealed signs of polytraumatization. In addition, one passenger had a tunnel wound to the left hand and another, a soft tissue tear between the thumb and forefinger of the right hand. These wounds were considered to be associated with a shooting incident in the cabin. The autopsy findings and additional gunpowder trace investigations suggested that the pilot had been incapacitated by a shot from behind, resulting in the plane crash. The present findings underscore the importance of conducting autopsies on all air crash victims.     

KEEPING THE PEACE

This article presents the results of an evaluation of 11 parent-adolescent mediation and family therapy programs in Australia established to prevent youth homelessness. The article examines the impact of these services on the resolution of family conflict and the living circumstances of young people who are at risk of youth homelessness. Ninety-two families participated in the pre-and postintervention stages of the evaluation. The majority of parents and adolescents felt they had made some progress in resolving their problems and improving family relationships. Indicators of risk of homelessness were lower at the time of follow-up for most young people.     

Pathology of sudden death during recreational sports activity: an autopsy study of 31 cases

A growing number of people are involved in recreational physical activity. It is therefore not uncommon for a medical examiner to encounter sports-related sudden deaths and to be faced with the legal implications. The authors examined the clinical and cardiac pathologic patterns in 31 persons who died suddenly during sports activities and underwent autopsy at the Institute of Forensic Medicine of Paris between 1991 and 2001. Twenty-nine male subjects, ranging in age from 7 to 57 years (mean 30 years) and two female subjects, 8 and 60 years old, died suddenly during sports activities. The sports involved were various, with running the most frequent: 13 cases. Cardiomyopathies (10 cases) and coronary artery disease (9 cases) were the most frequent causes of deaths. Despite the severity of lesions, only 4 subjects had a known cardiovascular disease. In conclusion, with regard to prevention, efforts should be continued to improve the sensitivity and specificity of diagnostic tools and screening strategies. In this regard, medicolegal autopsies should be systematically performed in cases of sudden death during sports activities, because they provide accurate and useful information for a better knowledge of sports-related mortality.     

Coroners' autopsies: quality concerns in the United Kingdom

Safety in health care has increasingly become a key focus of health care providers. Data on "patient outcomes" and evidence-based clinical decision-making have led to real changes in health care policy and care provision. Specialist groups such as the National Patient Safety Agency which operates the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in the United Kingdom are reliant on good information in order to identify factors that lead to poor patient care. In a recent study the NCEPOD reviewed the quality of coroners' autopsy reports on which they rely for much of their core data. The study found that just over half of the reports (52%) were considered satisfactory by the reviewers, 19% were good and 4% were excellent. However, over a quarter of autopsies were marked as poor or of an unacceptable standard. While analysing the factors associated with poor-quality autopsies, comments and recommendations were made with regard to the processes of death investigation and the degree to which the coroner's death investigation meets the needs of health care services.     

The importance of medico-legal autopsies. An analysis of the complex problems regarding damages

One hundred forty-four medico-legal autopsies were performed at the University Institute of Forensic Medicine in Copenhagen during the period 1973-77, all requested by the National Office of Social Security in order to estimate whether the cause of death could be related to the work of the deceased. The total number of medico-legal autopsies in the same period was 4050. The material included only four women. One hundred seventeen men died during work, 26 cases were accepted. Clear cases of accidents were always accepted and damages were paid. In cases where the deceased died on his way to or from work damages were rejected. Nineteen men (13%) had died after returning to their homes. Two cases among these were accepted (fall from scaffolding during working hours, arsenic poisoning where death occurred later in hospital). The mean age of the group was about 50 years, which is less than in an average medico-legal population. In all cases but two the autopsy revealed the cause of death, i.e. that unknown causes of death totalled 1.4%. The manner of death was elucidated in all cases. The most frequent cause of death in men turned out to be coronary sclerosis and coronary thrombosis. All such cases were rejected as being due to working conditions, because in no case was extraordinary working stress found to be evident. The two cases of death which occurred at home showed the importance of being aware of injuries due to working conditions, even if death could not be directly related to an industrial accident.     

Dental participants in mass disasters--a retrospective study with future implications

Mass casualty incidents continue to require the services of forensic dentists to determine the identity of victims. Across North America and Europe. teams of forensic dentists train, using mock disaster exercises, to prepare for such duties. It is vital that these mock exercises simulate the features of real disaster situations as far as possible. In order to inform those responsible for the design and implementation of mock exercises, a study was undertaken to determine the features of actual disasters that dental personnel had attended. Using a questionnaire, data were solicited from 38 odontologists. The average number of disasters attended by the respondents was eight, with an average casualty number of 94. Aircraft crashes were the most frequent cause of disasters that were attended by the odontologists. The authors conclude that future mock disaster exercises should replicate features of aircraft crashes as closely as possible by using commingled, fragmented, and burned remains. In addition, mock disasters should require the identification of a realistic number of individuals to ensure authenticity and the maximum logistical preparedness of participants.     

Examination results and autopsy findings in assaults on elderly people

As the percentage of elderly people in the population grows, violence against persons of advanced age constitutes an increasing social problem. The findings of the clinical forensic examinations (CE group) and autopsies performed on elderly violence victims (> or = 60 years) between 1999 and 2008 at the Institute of Legal Medicine of the Hanover Medical School were retrospectively analysed. In all, the study material comprised 55 victims of the CE group (35 females and 20 males, median age 73.5 years) and 55 autopsies (33 females and 22 males, median age 72.7 years). In most of the autopsy cases, the suspect was a family member or partner. In contrast, the alleged perpetrator was a stranger in most cases of the CE group. Blunt force injuries were most often found in the CE group victims (63.6%). Altogether, 38.2% (CE group) and 20.0% (autopsy cases) of the violent assaults were associated with robbery. In the majority of the CE cases, the victims suffered potentially or acute life-threatening injuries. In summary, the analysis shows that elderly people frequently become victims of robbery and blunt force injury. In most homicides of old people, the perpetrator is familiar to the victim. In surviving elderly violence victims, the assault is more likely to be reported to the police if the suspect is a stranger.     

Medical malpractice as reflected by the forensic evaluation of 4450 autopsies

A multicentre retrospective analysis of 4450 autopsies carried out due to suspicion of medical malpractice in 17 German institutes of forensic medicine from 1990 to 2000 was performed for the German Federal Ministry of Health. During the time period analysed an increase of cases could be mentioned. The main results of the study are: in the cooperating institutes the total number of autopsies due to suspected medical malpractice ranged from 1.4 to 20%. In more than 40% of the cases preliminary proceedings were started because the manner of death was certified as non-natural or not clarified. Hospital doctors were more affected by medical malpractice claims than doctors in private practice. However, the number of confirmed cases of medical malpractice was higher for doctors in private practice than for hospital doctors. Although surgery is still at the top of the disciplines involved in medical malpractice claims the number of confirmed surgical cases was below the average. Mistakes in care were confirmed to be above the average. Medico-legal autopsies are still a very sufficient method to evaluate cases of medical malpractice: 2863 cases could already be clarified by autopsy. Up to now there is no systematic registration of medical malpractice charges in Germany. A systematic registration should be initiated to build up and/or improve error reporting systems and, thus, to improve patient safety. Compared to other sources of medical malpractice claims (arbitration committees of the medical chambers, reference material of health and insurance companies, files of civil courts) the data of the present multicentre study are in so far unique as only lethal cases were evaluated and a complete autopsy report was available as basis of an expert opinion in alleged medical malpractice cases.     

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.     

Subdural Hemorrhage,a Retrospective Review with Emphasis on a Cohort of Alcoholics

Subdural hemorrhage (SDH) is a common cause of death. As external evidence of injury may be absent, an autopsy is frequently needed to detect it. We conducted a 3‐year review of SDH from the New York City Office of Chief Medical Examiner, with emphasis on a cohort of alcoholics. Our study population of 1942 included 1588 alcoholics. Of the alcoholics, c. 8% had SDH (26% of the total number of SDH). Of the alcoholics with SDH, 57% had associated brain injuries. As alcohol intoxication is frequently associated with aggressive and violent behavior, we are concerned that 6% of alcoholics in our review had no autopsy or imaging studies. It is possible that a portion of these may have had a SDH due to an unrecognized inflicted injury. We recommend that autopsies be performed on all alcoholics without a clear cause or mechanism of death.     

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.