Äußere Leichenschau: Untersuchung mit begrenzten Erkenntnismöglichkeiten

Bodies bounce - deflection of bodies following first ground impact after falls from height

Forensic examination of a scene where two bodies were found after a fall from a high-rise apartment building revealed a distinct tissue imprint resembling facial contours on the asphalt between the two bodies as well as a laceration on the back of the head and an abrasion on the forehead of one body. Tissue imprints located away from the positions of the bodies can indicate manipulation of the finding scene and injuries in opposing body regions at least two distinct blunt traumas. Initial assessment ruled out intermediate contacts with the building, pointing instead to a significant horizontal deflection of the bodies after the initial impact on the ground followed by a second impact. A review of the existing literature on falls from height was conducted, which provided limited information on the possibility of a body's deflection after fall from height. Detailed investigations into the biomechanical relevance of sequences following that impact are rare. In contrast, surveillance video footage from the presented case shows the deflection of the corpses by as much as 1.5 m after initial impact, followed by a second impact. In combination with the autopsy results this provided a good explanation for the unusual forensic findings and unique biomechanical insights. It demonstrates that, depending on various factors like the impacted body region, ground structure and height of fall, a body can be significantly deflected from the initial impact region, resulting in a second impact and sometimes forensically misleading injury patterns.

[What are the effects of different places of death of old people?]

Background

Inadequate quality of medical postmortem examinations has been discussed in the forensic medical literature for many years. It is known that older deceased persons are less likely to have a non-natural cause of death certified and autopsies are performed less frequently compared to younger deceased persons.

Methods

Death certificates of all deaths that occurred in Munich with an age of ≥ 75 years during the death period 01/01/2013-31/12/2014 were analyzed. Standardized, anonymized data entry was performed. The collected data were analyzed descriptively.

Results

A total of 26,303 persons died during the study period. Of these deaths, 16,146 (60.7%) were ≥ 75 years. Most common places of death for the aged were hospital (56.1%), private address (21.8%), and nursing home (20.0%). A natural mode of death was reported in 88.5%, unexplained in 8.8%, and non-natural in 2.7%. Most common immediate causes of death were diseases of the circulatory system (23.5%), inaccurately designated or unknown causes of death (20.0%), and diseases of the respiratory system (16.3%). Autopsies were performed on 4.9%, largely judicial. The parameters studied showed large differences in the analyses depending on the place of death.

Discussion

This study again shows considerable quality deficiencies in the issuance of death certificates. Despite the dual approach of the Munich health authority (control, training), the quality of death certificates could not be sustainably improved in recent years. Types and causes of death showed partly considerable differences depending on the place of death and the doctor who issued the certificate. The deficits identified in the information provided under the heading "Causes of death" are also likely to have a negative impact on the cause of death statistics.

Sterbefälle mit unbekannter oder ungenau bezeichneter Todesursache – attestierte Todesarten und durchgeführte Obduktionen

Hintergrund

Eine unzureichende Qualität von Leichenschau und ausgefertigten Todesbescheinigungen (TB) ist in der Literatur seit langem Gegenstand kontroverser Diskussionen. Häufig zu bemängeln sind fehlerhafte oder unplausible Kausalketten und eine fälschlicherweise attestierte natürliche Todesart.

Ziel der Arbeit

Es soll untersucht werden, welche Todesart bei einer unbekannten oder ungenau bezeichneten Todesursache durch den Leichenschauer attestiert wurde, und wie häufig bei diesen Fällen eine Obduktion am Institut für Rechtsmedizin (IRM) durchgeführt wurde.

Methode

Es wurden vertraulicher und nicht vertraulicher Teil aller TB des 2. Quartals 2013 der Stadt München standardisiert erfasst und statistisch ausgewertet.

Ergebnisse

Im Studienzeitraum wurden insgesamt 3228 TB erfasst. Es wurde bei 900 Fällen (27,9 %) unter Ia bzw. bei 462 Fällen (14,3 %) unter Ic eine unbekannte oder ungenau bezeichnete Todesursache attestiert. Trotz unbekannter Todesursache wurde gleichzeitig bei 4,0 % der Fälle eine natürliche Todesart bescheinigt. Eine Obduktion wurde bei Sterbefällen mit unbekannter Todesursache um ein Vielfaches häufiger (Ia: 52,0 % und Ic: 52,1 %) als bei Fällen mit ungenau bezeichneter Todesursache durchgeführt (Ia: 5,2 % und Ic: 7,5 %).

Diskussion

Bei den meisten Fällen haben die Leichenschauer die korrekte Todesart bei einer unbekannten Todesursache attestiert (96,0 %), jedoch bei 4,0 % auch fälschlicherweise gleichzeitig eine natürliche Todesart. Dies hat weitreichende, insbesondere strafprozessuale Konsequenzen, da bei Angabe einer natürlichen Todesart keine Benachrichtigung der Ermittlungsbehörden mit dem Ziel der Klärung der Todesumstände erfolgt. An dieser Stelle besteht das Risiko einer „Erfassungslücke“ nicht natürlicher Todesfälle.

Das Projekt rechtsmedizinische Leichenschau in Frankfurt am Main – Erste Leichenschau vs. Sektionsergebnisse

Hintergrund

In Frankfurt am Main (~750.000 Einwohner) wird die erste Leichenschau im Auftrag der Polizei tagsüber durch einen dafür eingerichteten rechtsmedizinischen Dienst vorgenommen. Nachts und am Wochenende führen diese Tätigkeit Ärzte des ärztlichen Bereitschaftsdienstes (ÄBD) der kassenärztlichen Vereinigung durch.

Material und Methoden

Für das Jahr 2019 wurden die im Rahmen dieser ersten Leichenschauen ausgestellten Leichenschauscheine hinsichtlich der attestierten Todesart ausgewertet und die Ergebnisse mit denen einer ggf. im Nachgang durchgeführten Sektion, inklusive Zusatzuntersuchungen, verglichen. Von den Ärzten des ÄBD konnten 461 Leichenschauen in die Auswertung eingeschlossen werden, davon erfolgte in 76 Fällen eine Obduktion. Im Nachgang der 364 rechtsmedizinischen Leichenschauen wurden 78 Obduktionen durchgeführt.

Ergebnisse

Veränderungen in der Todesart nach Sektion ergaben sich für die Leichenschauen des ÄBD in 57, bei den rechtsmedizinischen Leichenschauen in 49 Fällen, wobei insbesondere eine bei Leichenschau attestierte ungeklärte Todesart in einen natürlichen Tod spezifiziert werden konnte. Nach der Obduktion fanden sich bei den rechtsmedizinischen Leichenschauen 8 Fälle, bei denen des ÄBD 19 Fälle eines nichtnatürlichen (statt weiterhin ungeklärten) Todes. Bei den rechtsmedizinisch beschauten Fällen änderte sich zudem nach der Sektion in einem Fall die Todesart von natürlich zu nichtnatürlich, bei denen des ÄBD kam es in einem Fall zu einer Änderung von nichtnatürlich zu natürlich.

Diskussion

Die Veränderung bzw. Spezifizierung der Todesart nach der Sektion beider Kollektive verdeutlicht, wie wichtig eine Steigerung der Sektionsrate wäre, und dass auch bei professioneller Durchführung der Leichenschau das Erkennen der Todesart Probleme bereitet.

Death scene investigation and autopsy proceedings in identifying the victims of the terror attack on the Breitscheidplatz in Berlin 19th December 2016

We describe and discuss the forensic mission after the terrorist attack on the Breitscheidplatz in Berlin on 19th December 2016, focusing on co-operation with police authorities, and the injury patterns of the deceased. Even after massive blunt trauma, severe injury patterns are often unrecognizable by visual inspection of the body (“Casper’s sign”), which could instill false security among rescuers or, as happened on the Breitscheidplatz, may lead to distress or even trauma in rescue personnel when obviously primarily uninjured patients die suddenly.

[Qualified post-mortem examination-experiences from Bremen]

On 1 August 2017, the qualified post-mortem examination was introduced in Bremen by changing the relevant law. A substantial change is the separation of the pure death determination, which can be done by any physician, and the subsequent execution of the post-mortem examination by a suitably qualified physician. For the city of Bremen, the Institute for Legal Medicine (IRM) was charged with this task (in Bremerhaven, the health department).In this article, practical implementation, problems, and advantages and disadvantages of the new law are presented. For the year 2018 we did a statistical evaluation of the qualified post-mortem examination.After notification of a case of death to the IRM, the post-mortem examination will be carried out on the same or the following working day by an IRM doctor. In 2018, 7585 post-mortem examinations took place. In nearly 300 cases (4%) the type of death had to be changed (natural/not natural).Problems arise if external undertakers are involved. Further challenges arise in the collection of the anamnesis and implementation after extended weekends as well as due to the lack of knowledge about the death scene and generally the difficulty to conclude on the cause of death within the scope of an external post-mortem examination. One advantage to mention is that every deceased person is relatively promptly subjected to a post-mortem examination by a qualified doctor and overall the quality of the examination has improved. A disadvantage is the increased cost.

[Death certificates-an underestimated source of information for statistics, judicature, public health, and science]

The thorough external examination of a corpse and the correct completion of the death certificate are medical duties with far-reaching consequences. Data obtained from the death certificates are the basis for mortality statistics and for scientific research. They can be helpful in uncovering criminal offences or for the surveillance of medical facilities. For many years the deficiencies of external post-mortem examinations and death certificates have been discussed in professional journals.The important task of analysing all death certificates is performed by the local health authorities. This is the only opportunity for quality control and, if necessary, the doctors who issued the death certificate must be asked for corrections. This also improves the quality of the mortality statistics and contributes to the administration of justice.Additionally, important information for routine duties of the public health authorities can be obtained from the death certificates concerning the monitoring of narcotics, the supervision of medical facilities and the adherence to notification requirements for infectious diseases. Furthermore, death certificates contain relevant data for selected medical research projects.The high information content of death certificates is widely unknown and should be used by the health authorities comprehensively and systematically. Enough qualified staff needs to be allocated to further secure the important task of quality control of death certificates.

[On the quality of the external post-mortem examination in cases of fatal head trauma : A comparison of death certificate and forensic autopsy]

BACKGROUND

In Germany it is required by law that basically every type of physician needs to be capable of executing a correct external post-mortem examination of a corpse. In recent years, numerous investigations on external post-mortem examinations repeatedly reported systematic mistakes and erroneous procedures in various clinical and medicolegal case groups. Accordingly, the completion of death certificates is frequently performed incorrectly. As one of the typical unnatural death cases, decedents dying from fatal head trauma (FHT) represent a special autopsy case group, which is expected to be correctly recognized during the primary external post-mortem examination because the external injuries are mostly obvious.

OBJECTIVE

The present study aimed at investigating the quality of the external post-mortem examination in medicolegal FHT cases by means of comparison of death certificates and autopsy reports from a 10-year period.

MATERIAL AND METHODS

In a retrospective study design all autopsy cases from the Institute of Legal Medicine of the University Hospital Münster in the years 2006-2015 (n = 3611) were analyzed as to the presence of FHT. A total of 328 cases with FHT and the concomitant presence of a death certificate filled out before the autopsy were identified. Subsequently, the cause of death according to the death certificate was compared with the cause of death according to the autopsy. The degree of agreement was classified into six different categories from I to VI. While category I represented a complete lack of agreement, category VI was assigned to cases with full agreement.

RESULTS

In 58.5% of the cases (category VI) FHT was identified correctly during the external post-mortem examination. In 1.5% of the cases, a completely different cause of death was determined during the external post-mortem examination (category I). In 19.2% of the cases, no cause of death or the statement "unclear" was given as the cause of death in the death certificate (categories II and III). Cross-analyses and intuitive heatmap visualization were generated to identify case constellations with an increased risk for discrepancies. These analyses revealed that among all discrepant cases (categories I-V), falls were found significantly more often than in the nondiscrepant cases (p < 0.01), especially falls of women older than 57 years (median age of women) or falls considered as accidents by the examiner. In addition, traffic-associated FHT of men older than 44.5 years (median age of men) was identified more frequently in the external post-mortem examination.

CONCLUSION

Despite the fact that FHT should be a cause of death that is comparably easy to identify during external post-mortem examination, more than one third of the cases were not sufficiently recognized. Therefore, special attention must still be paid to certain case constellations during the external post-mortem examination. Typical examples of such cases are burned bodies, cases of advanced putrefaction and falls.

[Postmortem examination at crematories: experiences and forensic medical evaluations]

Cremation is the most common type of burial in Germany. Evidence is lost when cremating the body. A second postmortem external examination (postmortem external examination at the crematory) is required by law in almost all German federal states prior to cremation. This duty is often performed by a legal medical specialist.This article provides an overview of different, mostly legal, medical assessments of the postmortem examination at the crematory and reports on personal experience in postmortem external examinations at crematories.The second postmortem medical examiner detects formal, content-related, and in some cases serious errors on medical death certificates on a regular basis. In cases with indications for a non-natural death or uncertain identity of the body, the cremation is stopped and some cases are reported to the investigative authority. Indications of death caused by physical trauma or malpractice are the most common reasons for delaying a cremation during the postmortem medical examination at the crematory. The percentage of delayed cremations is minimal (up to 5%). The second postmortem examiner reports approximately 0.5-2% of cases to the investigating authorities. The number of court-ordered autopsies of decedents that had been reported as being conspicuous has always been low (approximately 1%).Currently, the postmortem external examination by a specialist postmortem medical examiner at the crematory remains a vital prerequisite for identifying non-natural cases of death. Only a high number of autopsy orders can significantly improve the cause-of-death statistics of the postmortem external examinations at the crematory.

A moving human body causes fatal blunt trauma: an unusual traffic accident

In urban traffic accidents, mainly pedestrians and cyclists are at risk of being injured and killed. Lethal injuries are usually caused by the immediate impact of a car or a tram. This paper presents a fatal accident without any direct contact with a motor vehicle. A 63-year-old woman sitting on a chair in a pavement cafe was killed by the impact of a 60-year-old male cyclist, who was flung in her direction after colliding with a car. Autopsy yielded intracutaneous haemorrhages on the impact sites of the female victim (left cheek, left shoulder and left upper arm). The woman sustained a ring fracture of the skull base encircling the foramen magnum with subtotal severance of the brain stem and massive chest trauma. All the injuries were caused by the blunt impact of the moving human body. The head was forcibly bent towards the contralateral shoulder resulting in a depression fracture of the skull. Reconstruction of the accident at the scene was challenging, as the fatally injured victim remained sitting on the chair and did not show any striking external signs of traumatisation. According to the assessment of the technical expert, the collision velocity of the moving body amounted to 6-8 m/s.

Knowledge, competencies and attitudes regarding external post-mortem physical examination: A survey among German post-graduate trainees in general practice

Background: The external post-mortem examination (EPME) is an important medical, legal and socio-economic task with far-reaching relevance; however, due to discrepancies between findings from EPMEs and actual cause of death, improvements in accuracy and quality are needed.

Objectives: To investigate knowledge, competencies and attitudes regarding EPME in general practitioner (GP) post-graduate trainees.

Methods: Before four post-graduate training courses on the EPME for general practitioner trainees, organized in 2014 in the German federal state of Baden-Wuerttemberg, a questionnaire on the EPME was distributed by the lecturer, completed by the GP post-graduate trainees and returned to the lecturer. The questionnaire consisted of 19 items related to three main categories: knowledge, competencies and attitudes.

Results: Out of 380 GP post-graduate trainees, 128 completed and returned the questionnaire (response rate 33.7%). Less than 18% felt adequately confident in identifying a natural cause of death and less than 5% felt adequately confident in identifying an unnatural cause of death. Only 33% consistently fully uncover the corpse for the EPME.

Conclusion: We found an important uncertainty in GP post-graduate trainees regarding their EPME knowledge and competencies.

[Mortui vivos docent : The dead teach the living]

There are considerable similarities and intersections between forensic medicine and emergency medicine. This applies especially to frustraneously resuscitated patients or other lethal clinical courses of traumatized patients who are subject to latter forensic autopsy. Cooperation between departments of emergency and forensic medicine not only has emergency medical training potential, but also the possibility of retrospective evaluation of medical emergency measures - both in individual cases and with regard to epidemiological aspects. In particular, the widespread registration of autopsied pre-hospital trauma deaths that occurred despite on-scene resuscitation attempts is useful. The pre-hospital situation represents a hotspot, but also a blind spot in the overall trauma mortality. In recent clinical registers, preclinical deaths go mostly unrecorded, despite the undisputed benefits of clinical registers.

Secondary skull fractures in head wounds inflicted by captive bolt guns: autopsy findings and experimental simulation

Apart from one article published by Rabl and Sigrist in 1992 (Rechtsmedizin 2:156-158), there are no further reports on secondary skull fractures in shots from captive bolt guns. Up to now, the pertinent literature places particular emphasis on the absence of indirect lesions away from the impact point, when dealing with the wounding capacity of slaughterer's guns. The recent observation of two suicidal head injuries accompanied by skull fractures far away from the bolt's path gave occasion to experimental studies using simulants (glycerin soap, balls from gelatin) and skull–brain models. As far as ballistic soap was concerned, the dimensions of the bolt's channel were assessed by multi-slice computed tomography before cutting the blocks open. The test shots to gelatin balls and to skull-brain models were documented by means of a high-speed motion camera. As expected, the typical temporary cavity effect of bullets fired from conventional guns could not be observed when captive bolt stunners were discharged. Nevertheless, the visualized transfer of kinetic energy justifies the assumption that the secondary fractures seen in thin parts of the skull were caused by a hydraulic burst effect.