Death abroad: Medico-legal autopsy results of repatriated corpses: A retrospective analysis of cases at the Department of Legal Medicine in Frankfurt am Main

INTRODUCTION

Repatriated corpses may have been autopsied abroad. The aim of the study was to compare the findings from second medico-legal autopsies with those from primary autopsies abroad to spotlight possible implications for the management of repatriated corpses.

MATERIAL AND METHODS

All autopsies from a 20-year period at the Institute of Legal Medicine in Frankfurt am Main on repatriated corpses of German citizens were reviewed. The results were compared with the information from the body passports, the protocols of the autopsies in the country of death, and the police files.

RESULTS

In total, 151 corpses repatriated from 56 different countries were autopsied. The interval between death and autopsy in Germany was 2-603 days (median: 11 days). 91 of the repatriated corpses (59.5%) had previously been autopsied abroad. Three body cavities had been opened in 78.0% (71/91) of the original autopsies; among them, there were 11 cases (15.5%) with dissection of all organs, as opposed to 7 cases (9.9%) with all organs intact and in situ. Of the previously autopsied corpses, 62.6% were accompanied by a body passport that noted the cause of death. In nearly 75% of these cases, the stated cause of death was compatible with that established at second autopsy. In 5 cases (10.2%), the cause of death established in the second autopsy disagreed with that on the body passport. The most prominent disparity was a cranial gunshot wound rather than the stated fatal fall.

DISCUSSION

This analysis of individual cases spotlights the problematics of an uncritical approval of the body passport. In light of the different procedural autopsy standards around the world, the validity of an autopsy abroad is discussed in the context of the second autopsy results.

CONCLUSION

A second external postmortem examination by qualified medical practitioners should be obligatory in all cases of repatriated corpses, with notification of the criminal police in all cases of non-natural or undetermined death. A timely second autopsy is recommended even in cases with previous autopsy abroad.

Stability of ten psychotropic drugs in formalin-fixed porcine liver homogenates

In forensic toxicology studies, drug concentrations must be estimated by the analytical data of formalin-fixed tissues if fresh or frozen tissue specimens are not available. We wished to investigate the stability and time-course of metabolism/degradation of drugs in formalin-fixed tissues using porcine liver homogenates (PLHs) instead of human tissue. Ten psychotropic drugs (amitriptyline, brotizolam, diazepam, diphenhydramine, estazolam, etizolam, levomepromazine, paroxetine, quetiapine and triazolam) were added to PLHs. After the PLHs had been fixed with neutral buffered formalin at room temperature, the concentrations of the drugs in the PLHs were determined by liquid chromatography-tandem mass spectrometry after 3 days, 1 week, 2 weeks, 4 weeks, 2 months, 4 months and 6 months. After 6 months, the residual ratio of amitriptyline, diphenhydramine and quetiapine was 80 %-95 %; that of diazepam, paroxetine and triazolam was 10 %-45 %; and that of brotizolam, etizolam and levomepromazine was 1 %-5 %. Estazolam was not detected from the first day of formalin fixation. These data suggest that the concentrations of drugs in PLHs measured after formalin fixation decreased to varying degrees compared with their initial concentrations. These time-dependent changes in drug concentration were due to degradation during preservation in formalin solution and metabolism by hepatic microsomal enzymes.

Forensic toxicological analyses of drugs in tissues in formalin solutions and in fixatives

Forensic toxicological drug analyses of human specimens are usually performed immediately after autopsy or on frozen preserved tissues. Occasionally, cases require analysis of drugs from tissues fixed in formalin solution. To improve the estimation of the level of drug in tissues following formalin fixation, we studied drug concentrations in human tissues, liver and kidney, that were collected from a drug-positive autopsy case. Parts of tissues were preserved in formalin solution for 1, 3, 6 and 13 months. Tissues obtained before and after preservation, along with tissue-exposed fixatives, were assayed using gas chromatography-mass spectrometry; all of the samples were assayed for the presence of drugs and changes in the drug concentrations both before and after preservation in formalin. Concentrations of assayed drugs decreased upon fixation in formalin; levels of these drugs did not necessarily show further decreases during subsequent storage in fixative, up to 13 months. Distinct trends in drug levels were found in liver and kidney. In liver, the levels of chlorpromazine, levomepromazine, and promethazine decreased to 23-39% at 1 month after preservation; all 3 of these drugs were detected at all tested time points of preservation. Bromazepam was not detected at 13 months after preservation. Milnacipran was the most unstable after preservation in formalin solution among all of the assayed drugs. In kidney, all assayed drugs exhibited reduced stability during preservation compared to levels in liver. Methamphetamine and methylenedioxymethamphetamine were not detected in any time points of tissues. The proportions of the drugs that remained within the tissues differed between liver and kidney. Also, S-oxide compounds of chlorpromazine and levomepromazine, which were not observed before preservation, were detected in fixed liver tissues and their fixatives at 3, 6 and 13 months of preservation. These results suggest that analyses in formalin-fixed tissues need to include analysis of various organ-tissues and their fixatives at multiple time points for the duration of preservation. These analyses should include detection of chemical degradation/denaturation products, such as S-oxides of chlorpromazine and levomepromazine.