Are coroners' necropsies necessary? A prospective study examining whether a "view and grant" system of death certification could be introduced into England and Wales

Unexpected findings and misdiagnoses in coroner's autopsies performed for trauma at the University of the West Indies, Kingston, Jamaica

There has been significant improvement in medical diagnostic technology, but discrepancy rates between clinical and postmortem diagnoses remain relatively high. This study aimed to identify misdiagnoses and missed (unexpected) findings documented during complete coroner's autopsies performed for trauma at the University of the West Indies (UWI) and evaluate their influence on patient outcome. We retrospectively reviewed the reports of all coroner's autopsies performed for trauma, between 2003 and 2012, at the UWI. For each case, we extracted age, gender, trauma type, mechanism and topography, clinical and postmortem diagnoses and hospitalization duration. The data were used to calculate frequencies, proportions and discrepancy rates. 955 coroner's autopsies were performed during the 10-year period; reports were available for 933. 396 of these were performed for trauma; 365 met the inclusion criteria. 260 (71.2%) of the 365 autopsies had at least one discrepancy. There were 746 clinical and 1118 autopsy diagnoses; 382 were discrepant (372 missed [unexpected] diagnoses, 6 mis-diagnoses and 4 over-diagnoses). The discrepancy rate (misdiagnoses and missed diagnoses) was 33.8%, and the majority (55%) occurred in patients hospitalized for <1 day. Cardiopulmonary diseases were the most commonly missed diagnoses. The discrepancy rate was intermediate to those previously reported in the literature. The short hospitalization duration in most patients suggests that limited time for clinical investigation may be a contributor to discrepancy. However, increased awareness among clinicians of the common major missed diagnoses should enhance their early diagnosis, even when clinical signs are subtle, hopefully producing improved patient outcome.

A bite into the history of the autopsy : From ancient roots to modern decay

The autopsy has had a checkered history, much of which has been surrounded by controversy. The roots of human dissection are found in the ancient world where rumors flourished that the prosectors of the day were engaged in vivisection as well as dissection. Bound up with the prevailing religious and political systems of the day, the autopsy has alternately been prohibited and encouraged, used to explore the nature of disease, and conceal questionable political policy. This review explores the history of the autopsy from its ancient roots in Egypt, Mesopotamia, Alexandria, and the Far East through the dark ages to medieval times and beyond into the renaissance. The development of the autopsy in Europe during the 17th to 19th centuries is discussed before briefly considering the decline of this diagnostic tool in the 20th century.

Sharp Force Injuries at the University Hospital of the West Indies, Kingston, Jamaica: A Seventeen-year Autopsy Review

OBJECTIVES

This study aimed to ascertain the prevalence and patterns of fatal sharp force injuries, victims' demographics, cause of death and average survival time at the University Hospital of the West Indies (UHWI), Kingston, Jamaica.

METHODS

The autopsy records for 1990-2010 were searched for fatal cases of sharp force injuries. The records for 1998-2001 were not located. A 17-year retrospective analysis was therefore performed and findings for the two periods, 1990-1997 and 2002-2010 were compared. All data were obtained from the provisional anatomical diagnoses (PAD) autopsy reports.

RESULTS

During the 17-year period, 57/4264 autopsies were performed for sharp force injuries, yielding an overall autopsy prevalence rate of 1.34% (1.25%, 26/2086 (95% CI 0.77, 1.73) in Period 1 and 1.42%, 31/2178 (95% CI 0.92, 1.92) in Period 2). The majority were males (91.1%), in the age group 15-39 years (77%), mean age of 30.9 years (range = 17─65 years). Stab wounds predominated (91.3%) and the chest was the area most frequently stabbed (42.1%). In the 24 fatalities due to chest injuries only, eight (33.3%) had injuries to the heart alone. Forty-five patients (79.0%) died within 24 hours from exsanguination. Injury documentation at autopsy was deficient.

CONCLUSION

Stabbing was the most common sharp force injury, mainly involving the chest and young men were at greatest risk. Most patients died from exsanguination within 24 hours of admission. Introduction of synoptic-type reports for both clinical and autopsy examination may improve documentation.

Intracranial Hemorrhage: Traumatic Fall versus Terminal Collapse

When approaching a case in which a decedent's body is on the ground, death investigators collect circumstantial, historical, and clinical (radiographic) information to infer whether the person fell to the ground and sustained a head injury or simply experienced a terminal collapse due to a natural event. We have observed that cases presenting as presumed accidental head trauma, some of which have diagnosed subdural hematomas, are sometimes proven to be of natural causes following autopsy. Autopsies sometimes demonstrate that either 1) the intracranial hemorrhage is intracerebral rather than subdural, 2) the subdural hemorrhage is an extension from an intracerebral hemorrhage, or 3) there is no intracranial hemorrhage at all. In each of these examples, the autopsy established that the manner of death is natural rather than accidental, as originally presumed at the outset of the investigation.

We performed a 5 year retrospective study on cases indicating intracranial hemorrhage in the cause of death statement in order to assess how often the cause and manner of death would have been incorrectly certified without an autopsy. We found that 6% of cases presumed at the time of initial investigation to represent falls with accidental head trauma (specifically, subdural hemorrhage) were proven by autopsy to represent intracranial hemorrhage of natural manner. Conversely, 7% of cases with intracranial hemorrhage that were presumed to be due to natural disease were proven by autopsy to represent accidental trauma.

Proper certification of manner of death has important legal implications which may be of critical importance to family members.

How can we reduce the number of coroner autopsies? Lessons from Scotland and the Dundee initiative

Currently the medicolegal dissection rate for England and Wales is 22% (110,000 coronial autopsies for 500,000 deaths per annum), yet there is a general lack of evidence about the utility of and justification for such a high level of activity, which is between double and triple the rate in other jurisdictions. The government is currently consulting on how to reduce the numbers, and the Coroners and Justice Act 2009 is permissive of external examinations as an alternative to dissections. We describe the philosophy and practice of the Scottish system of postmortem external examinations, and the 20-year experience of a local initiative to maximize use of such external examinations. Currently our regional medicolegal dissection rate is 6%, which if applied to England and Wales would reduce the number of dissections from 110,000 to 30,000 per annum, with all of the social, resource and management implications. While the autopsy is an important tool in modern death investigation, an almost automatic recourse to it is inappropriate. In our view external examinations are not only cost-effective but also a necessary element in any death investigative system which wishes to strike an appropriate balance between intrusion by the state and the rights of the bereaved.

Postmortem computed tomography is an informative approach for prevention of sudden unexpected natural death in the elderly

INTRODUCTION

Less than 10% of unnatural death cases have been examined by autopsy in Japan. In particular, the causes of death in the elderly have not yet been actively investigated. Here, we evaluated the possible use of postmortem computed tomography (PMCT) to investigate the causes of sudden unexpected natural death (SUND) in the elderly.

METHODS AND SUBJECTS

Death cases confirmed within 24 hours since the onset of symptoms at the Emergency Department of Mie University Hospital were defined as sudden death cases. A total of 212 sudden death cases, including 175 SUND cases, that occurred in a 3-year period from September 2006 to August 2009 were investigated.

RESULTS AND DISCUSSION

The number of sudden death cases was highest in patients in their seventies (56 cases, 26%), followed by patients in their eighties and sixties. Sudden death occurred more in men than in women in their fifties to seventies, while it occurred more in women than in men over the age of 90. PMCT was performed in more than 80% of SUND cases regardless of age of the deceased. The causes in 26 cases (27.1%) were established by PMCT, many of which were hemorrhagic diseases. Signs of aortic aneurysm rupture were detected by PMCT in the thoracic and abdominal areas of 8 patients in their seventies and over, whereas signs were absent in the younger group. Also, more than 18% of sudden death cases in patients in their seventies and over were bathing-related sudden death (BRSD). BRSD was rarely caused by hemorrhagic diseases, suggesting that a drop in blood pressure caused by bathing is an important factor in BRSD.

CONCLUSION

PMCT is a method that is relatively acceptable by bereaved families. It is useful for establishing the causes of approximately 30% of the SUND cases examined. The PMCT findings suggested that early detection and treatment of thoracic and abdominal aortic aneurysms and preventive measurements of bathing-related drop in blood pressure are important for the prevention of SUND in the elderly.

Virtopsy versus digital autopsy: virtual autopsy

Multislice computed tomography (MSCT) and magnetic resonance imaging (MRI) are being increasingly implemented in forensic pathology. These methods may serve as an adjuvant to classic forensic autopsies. Imaging of the interior of corpses is performed using MSCT and/or MRI. MRI, in addition, is also well suited to the examination of surviving victims of assault, especially choking, and helps visualise internal injuries sometimes not seen on external examination of the victim. Various postprocessing techniques can provide strong forensic evidence for use in legal proceedings. The documentation and analysis of postmortem findings with MSCT and MRI and postprocessing techniques (virtopsy) is investigator independent, objective and noninvasive and will lead to qualitative improvements in forensic pathologic investigation. Apart from the accuracy and three dimensionality that conventional documentations lack, these techniques allow for the re-examination of the corpse and the crime scene even decades later, after burial of the corpse and liberation of the crime scene. We believe that this virtual, noninvasive or minimally invasive approach will improve forensic medicine in the near future.

Clinical, educational, and epidemiological value of autopsy

The autopsy is now often regarded as of marginal use in modern clinical practice. In this Review we contend that the autopsy remains an important procedure with substantial, if largely underused, potential to advance medical knowledge and improve clinical practice. Many doctors lack familiarity with autopsy practices, and are insufficiently aware of the benefits for not only bereaved families but also present and future patients. In this Review, which has an international perspective, we consider the ascent and decline of the autopsy, the legal frameworks that govern its use, the value and potential pitfalls of alternatives to the conventional method, and the autopsy's role in undergraduate medical education. We also draw attention to the continuing ability of autopsies to improve the completeness and reliability of death certification, which is important for public-health strategies and for some bereaved families.

Do we know what people die of in the emergency department?

OBJECTIVE

To establish the discrepancy rate between the predicted cause of death and the actual cause of death as determined by postmortem examination result, for all deaths in the emergency department reported to the Scottish Procurator Fiscal and subsequently undergoing postmortem examination.

METHODS

A prospective study of all patients who were dead on arrival or died in the emergency department of a busy Glasgow hospital over a 12 month period. The most senior emergency physician present at the time of death predicted the cause of death. This was then compared to the actual postmortem examination determined cause of death and was considered either to be correct or incorrect.

RESULTS

During the study period, 146 patients were pronounced dead in the department. Of these, 81 patients (age range 39-99 years, median 71; male:female 2.5:1) had death certificates issued, 63 patients (age range 26 days to 99 years, median 48; male:female 2.4:1) had a postmortem performed by the forensic pathologist, and two patients underwent a "view and grant". Of the 63 deaths reported to the Procurator Fiscal, the emergency physician attributed 51 (80.1%) to non-trauma, 9 (14.2%) to trauma, and in 3 (4.7%) cases were uncertain. Of the 63 (39.7%) deaths, 25 were inaccurately predicted (99% confidence interval 24.3% to 56.6%; p<0.0)1. Cardiovascular related and drugs poisoning deaths occurred most commonly. They were also the most accurately predicted cause of deaths. Intracranial events, pulmonary thromboembolism, and airway obstruction were also frequently predicted, but were often wrong.

CONCLUSIONS

This study highlights the difficulties in accurately identifying cause of death for patients who die suddenly. This could have implications for the accuracy of health service statistics.