Falsch bescheinigter natürlicher Tod nach ärztlicher Leichenschau: Ein immer aktuelles Thema

External post-mortem examination in virtual reality-scalability of a monocentric application

Conducting external post-mortem examinations is an essential skill required of physicians in various countries, regardless of their specialization. However, the quality of these examinations has been a subject of continuous debates, and notable errors were reviled. In response to these shortcomings, a virtual reality (VR) application was developed at Halle's medical department in Germany, focusing on the scene of discovery and the completion of death certificates. The initial trial of this VR application in 2020 involved 39 students and 15 early-career professionals. Based on the feedback, the application underwent improvements and was subsequently introduced to the medical department in Dresden, Germany, in 2022. Its primary objective was to showcase the VR training's adaptability and scalability across various educational structures and levels of medical expertise. Out of 73 students who participated, 63 completed the evaluation process. 93.1% (n = 58) of the evaluators reported increased confidence in conducting external post-mortem examinations, and 96.8% (n = 61) felt more assured in filling out death certificates, crediting this progress to the VR training. Additionally, 98.4% (n = 62) believed that repeating forensic medical aspects in their coursework was crucial, and 96.8% (n = 61) viewed the VR examination as a valuable addition to their academic program. Despite these positive responses, 91.6% (n = 55) of participants maintained that training with real corpses remains irreplaceable due to the insufficiency of haptic feedback in VR. Nevertheless, the potential for enhancing the VR content and expanding the training to additional locations or related disciplines warrants further exploration.

[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.

Die ärztliche Leichenschau – Welcher Arzt führt die Untersuchung wann und wo durch?

Hintergrund

Bislang existieren nur wenige Untersuchungen zu strukturellen Rahmenbedingungen der ärztlichen Leichenschau.

Material und Methode

Es wurden alle archivierten Todesbescheinigungen der Stadt Münster des Jahres 2017 hinsichtlich des Leichenschauarztes sowie Tag, Uhrzeit und Ort der durchgeführten Leichenschau einer deskriptiven Analyse unterzogen.

Ergebnisse

Insgesamt wurden 3844 Todesbescheinigungen analysiert. Die Rangfolge der Leichenschauenden setzte sich wie folgt zusammen (ambulant/stationär/gesamt; %): Krankenhausärzte (K) 0,0/100/58,6; niedergelassene Ärzte (N) 42,8/0,0/17,7; Palliativmediziner der spezialisierten ambulanten Palliativversorgung (P) 40,7/0,0/16,8; Notärzte (NÄ) 11,3/0,0/4,7; Rechtsmediziner (R) 5,2/0,0/2,2. An Werktagen (W) bzw. Wochenenden/Feiertagen (WF) war die Leichenschau im ambulanten Bereich (1589) von folgenden Ärzten durchgeführt worden (W/WF, %): N (46,5/34,7), P (35,1/54,6), NÄ (11,1/10,5), R (7,4/0,2). Krankenhausärzte führten relativ unabhängig von der Tages- und Nachtzeit die Untersuchung durch, niedergelassene Ärzte präferierten an Werktagen die Zeit von 12:00 bis 15:59 Uhr. Unterteilt nach dem Sterbeort attestierten vorrangig folgende Ärzte die Todesbescheinigung: häusliches Umfeld (578) > N (31,5 %), P (32,4 %), stationäre Pflegeeinrichtungen (726) > N (65,0 %); Hospiz > P (90,4 %); öffentliche Orte > R (52,9 %), NÄ (44,1 %).

Schlussfolgerung

Die ärztliche Leichenschau wurde 2017 in der Stadt Münster am häufigsten von Krankenhausärzten durchgeführt. Im ambulanten Bereich wurde diese Aufgabe zu etwa gleichen Anteilen von niedergelassenen Ärzten und Palliativmedizinern übernommen. Niedergelassene Ärzte präferierten die Mittagszeit zwischen den klassischen Praxisöffnungszeiten zur Durchführung der Leichenschau.

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.

[COVID-19-associated deaths]

INTRODUCTION

In December 2019, the new infectious coronavirus disease 2019 (COVID-19) first appeared in China. So far, no systematic evaluation of death certificates of COVID-19-associated deaths has been presented.

METHODS

The death certificates of all deaths in Munich during the period from 1 March to 31 July 2020 were analyzed. The previously defined inclusion criteria were the indication of corona, COVID-19 and SARS-CoV‑2 in the death certificates. The variables were entered anonymously according to a developed key. The collected data were evaluated descriptively.

RESULTS

In the period under investigation, a total of 5840 people died in the Munich City area. Of these deaths 332 (5.7%) were COVID-19-associated. In 281 deaths (84.6%) there was a definite COVID-19 and in 51 deaths (15.4%) the suspicion of this disease. The most frequent causes of death were acute respiratory distress syndrome or respiratory insufficiency (59.1%), multiple organ failure (21.4%) and sepsis (10%). An average of 1.8 pre-existing illnesses were reported in the death certificates. Most frequently mentioned were diseases of the circulatory system (54.8%), the nervous system (22.8%) and metabolic diseases (18.9%). The average age at death was 79 years and the most frequent place of death was a hospital (85%). An autopsy was attempted by the doctors who issued the death certificates for 18.1% of the collective, most frequently in the case of unexplained or unnatural causes of death and young age of the deceased. Clinical pathological autopsies were performed on 11% of the collective and judicial autopsies on 1%.

DISCUSSION

This study is the first evaluation of death certificates with respect to the novel infectious COVID-19. Number and essential characteristics of COVID-19-associated deaths in Munich during the so-called first wave could be mapped. The interest of physicians in autopsies was rather low despite the appearance of a new infectious disease.

[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.

[Violent death in old age-an analysis of autopsy reports]

BACKGROUND

More and more people in Germany reach increasingly higher ages. The risk of victimization is unclear because the lack of reliable numbers impedes assessment of the current relevance of violent death in old age.

OBJECTIVE

To close that gap this article presents epidemiological data obtained from autopsy reports, for the most frequent circumstances of violent death in old age and discusses the characteristics and means of prevention.

MATERIAL

All autopsy files of the Institute of Legal Medicine and Forensic Sciences at the Charité-Universitätsmedizin Berlin from 2005 to 2016 were analyzed with respect to age, circumstances of death and motive. A total of 11,381 cases were included.

RESULTS

Of all autopsied persons, 51.8% were aged 60 years or older. The homicide and suicide percentages of all cases were lower within the 60+ years age group in comparison to the younger group. Financial gain was the main motive in the case of 25.6% of people killed aged 60 years and over. Frequent suicide motives were diseases, particularly depression for women and malignant tumors as well as partnership issues for men. Being overburdened with taking care of the partner was a problem for men in particular. Dyadic death, i.e. the entirety of joint suicides and homicide-suicides, gained in importance within the 60+ years age group.

CONCLUSION

Fatal violence against older persons is presumably underestimated. The classification of dyadic death turned out to be impractical. Therefore, a replacement by erotic-aggressive, symbiotic and parasitic death is suggested. Suicide with subsequent suicide is described for the first time and dubbed suicide-suicide. Prevention by social inclusion of old people is essential.

Autopsy rates in Iceland

A clinical as well as forensic autopsy is a uniform medical investigation of the deceased, which mainly serves to verify the plausibility of information on the cause, mode and mechanism of death provided by the police and/or medical personnel. Despite its importance in the context of a conclusive assessment of a person's medical history and in detecting any criminal correlation or malpractice, a significant decline in autopsies is evident in Iceland. This article gives an overview on autopsy rates in Iceland and compares the situation with European countries.

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.