THE MEDICO-LEGAL AUTOPSY.pptx

Medical legal autopsy

1. AUTOPSY An autopsy, necropsy, or postmortem examination is a complete surgical examination of a body after death. Forensic/ Medico-legal autopsies Hospital or medical autopsies. Medico-legal autopsies under the jurisdiction of a coroner or a medical examiner. A coroner or medical examiner may legally order an autopsy and does not require consent from the legal next of kin background information is often limited

2. INQUEST ACT 12. Medical practitioner to make examination and report (1)Every  medical practitioner  upon the receipt of such direction shall, unless he or she procures the services of some other  medical practitioner  to perform the duty, immediately make an examination of the body, with a view to determine from the examination the cause of death, and to ascertain the circumstances connected with the death, and shall make a report in writing to the  coroner  describing the appearance of the body and the conclusions which he or she draws from the appearance touching the death of the person. (2)The examination shall extend, when the  medical practitioner  considers it necessary but not otherwise, to such dissection of the body as he or she may think requisite.

3. Academic autopsy: Dissection carried by student of anatomy. Pathological, hospital or clinical autopsy: Done by pathologists to diagnose the cause of death or to confirm a diagnosis. Physicians cannot order these autopsies without the consent signed by the next of kin. Medico-legal or forensic autopsy: Type of scientific examination of a dead body carried out under the laws of the State for the protection of rights of citizens in cases of sudden, suspicious, obscure, unnatural, litigious or criminal deaths. The basic purpose of this autopsy is to establish the cause and manner of death

4. Medical autopsies The cause of death is often already known Purpose of the autopsy is more an attempt to answer specific questions that family members or physicians may have regarding the case. Extent of disease, the effectiveness of therapy, or the presence or absence of other findings. The complete medical record is usually available to the pathologist prior to the autopsy. External examination may be relatively unimportant in medical cases Other procedures and tests that are commonly performed in medicolegal cases also tend to be quite rare in hospital cases. Special dissection techniques may not be performed

5. 5 5 Categories of Medico-legal Cases Violent death, i.e. non natural death Suspicious deaths – foul play or violence may be suspected. Sudden and unexpected deaths Death in custody Anaesthetic administration associated death or procedure related death Unattended deaths. (Individual jurisdiction may expand or contract these categories).

6. Cases that require an autopsy All homicides and suspected homicides Cases known or suspected to have been caused by other criminal violence In custody deaths and any other death associated with police action Hit and run pedestrian deaths Accidental deaths where criminal charges are expected Suicidal deaths where investigation suggests that autopsy is necessary Acute workplace related deaths Certain deaths alleged to involve medical therapy Certain ‘‘diagnoses of exclusion,’’ including drug related deaths Deaths caused by apparent electrocution Suspected drowning deaths Infant deaths that are unexpected and unexplained Toddler/small child deaths that are unexpected and unexplained Charred bodies Skeletonized bodies Any suspicious death Unidentified bodies in order to assist/aid in identification Deaths that require autopsy for cause of death determination Cases that require autopsy for evidence collection

7. AIMS OF AUTOPSY Who, when, where, why, how and what are the questions that the autopsy assists in answering. The objectives of medico-legal autopsy are to determine: Identity of the deceased in case of decomposed, burnt, mutilated or an unidentified body. Cause of death, whether natural or unnatural, and to interpret the significance and effect of the disease present in case of natural death. Approximate time of death, mode of death, age of injuries, and place of death. Manner of death, whether accidental, suicidal or homicidal. Poison or weapon responsible for death in case of homicide. Extent of external and internal injuries present. Whether the injury present is expected to cause death

8. Whether deceased received any treatment before death. In case of homicide, whether: One or more person(s) was/were involved. Any trace evidence was left behind on the body that may help in identification of the assailant. Any other offence was related with the death, e.g. strangulation along with rape. More than one method or weapon was involved in the crime, e.g. firearm along with knife.

9. The body has been displaced from the original place of disposal. The relative positions of victim and the assailant(s) can be deciphered. In case of newborns, to determine the question of live birth and viability of the baby. In case of mutilated or skeletal remains, to determine if they are human if human, whether they belong to one or more than one person probable cause of death approximate time since death.

10. 10 10 Objectives of the medico-legal examination of a body To determine cause of death To document all findings/injuries To determine and or to exclude contributory factors to death To determine manner of death To collect trace evidence from bodies in criminally related cases. To positively identify a body.

11. 11 11 In addition, Medical Practitioner may subsequently be called upon to: Testify in court on findings Interpret their significance, how they occurred, nature of weapon(s) used (if any) Determine time of death Determine cause and manner of death Whether or not contributory factors are present such as: Alcohol and or drug intoxication Natural diseases

12. 12 12 MEDICO-LEGAL OPINION RELATING TO CAUSE AND MANNER OF DEATH IS BASED UPON Post-mortem examination Laboratory analyses Scene Circumstances surrounding the death Records of recent hospitalisation and medical history and psychological autopsy in relevant cases

13. 13 13 Three steps of Medico-legal investigation of dea th 1. Investigation of circumstances/history : authorization from police, Visit to scene, information from family or witnesses, medical or police reports if any 2. Examination of body : Autopsy or external examination 3. Laboratory tests: Ballistics, histology, toxicology,DNA profiling etc.

14. AUTOPSY PROCEDURE Permission for Autopsy A written request must come from the Police Officer, who is the investigation officer Preparation for Autopsy The Investigating Officer should fill the ‘Request for Postmortem’ and should submit the body in the mortuary Autopsy should be done without delay The I.O. and relatives should identify the body. In cases of unknown bodies, the I.O.is directed to take the photographs and fingerprints of the body and the doctor should note identification marks on the report.

15. AUTOPSY PROCEDURE Autopsy is conducted in a in the mortuary (of a government hospital) At times the autopsy is carried out in the open space/ area in emergency such as at the accident site in cases of mass disasters; air crash or train accident etc. The mortuary should have good lightening, equipments , facility of cold storage and proper drainage system along with the manpower. T he autopsy is done during the daytime, because of difficulty in appreciating certain The examination of clothing for blood stains and trace evidence and correlating the tears/ cuts on the clothing with bodily injuries is an important part of the autopsy. When fingerprints are to be taken for identification purposes, it should be done only after the examination of the hands. In all gunshot deaths and severely burnt bodies, X-rays should be undertaken.

16. Second Autopsy To find out the cause of death, when it can not be opined by the doctor who had conducted the First autopsy. When the relatives are not satisfied with the cause of death, they request to higher authorities for a second autopsy done. Negative Autopsy When the gross and microscopic findings fail to reveal any apparent cause of death, along with the examination of chemical analysis report and other relevant laboratory investigations, it is termed as negative autopsy. Inadequate history Lack of proper external examination Improper internal examination Insufficient histological examinations Inadequate Pathologist’s training

17. Exhumation It is the lawful digging out of an already buried body from the grave. Civil Cases ( i ) Accidental death claim (ii) Insurance (iii) Liability for medical negligence (iv) Workmans compensation claim (v) Inheritance and disputed identity cases. Criminal Cases ( i ) Deaths due to criminal abortion (ii) Homicide or suspected homicide

18. Purposes of death certification To confirm death has occurred To establish identity of deceased To ensure that unnatural deaths which require further investigations, are properly investigated prior to disposal of body To provide statistical information Settlement of decedent’s estate and death benefits 19

19. Who fills the death certificate Death certificate is used legally as proof that a given person has died Not necessarily as legal proof of the cause and manner of death in the court. Completed by a registered medical doctor Who has been attendant of the deceased From examination of body Autopsy performed (by Pathologist/Forensic Pathologist/FMO/Resident/ Registrar) 20

20. If a doctor knows the cause of death, and that cause of death is ‘natural’ (without any suspicious or unusual features), they may issue a certificate of the medical cause of death (commonly called a ‘death certificate’). Every death certificate has spaces to be filled out covering a variety of personal information decedent’s name, date of birth (age), and time and date of death. It is a requirement that the certifying individual also signs the certificate. If a medical practitioner is of the opinion that the death was due to other than natural causes , he shall not issue a certificate mentioned

21. VERSIONS OF MEDICAL CERTIFICATE OF CAUSE OF DEATH

22. The cause of death must be etiologically specific. Etiologically specific means that the underlying cause of death is a diagnostic entity that cannot be attributed to any other pathologic process. Hypertensive and atherosclerotic cardiovascular disease Metastatic gastric adenocarcinoma Chronic Alcoholism Acute drug intoxications Gunshot wound of chest Blunt trauma of head 24 24

23. Non-etiologically specific causes of death are not permitted to stand alone on a death certificate. Cardiopulmonary arrest Sepsis Myocardial infarction Multi-organ failure Pulmonary embolism Cardiac arrhythmia Pneumonia Respiratory failure Exsanguination Skull fracture 25

24. Correct: Acceptable: Incorrect: Complications of perforated large intestine due to colon adenocarcinoma Sepsis due to colon adenocarcinoma Sepsis Correct: Acceptable: Incorrect: Hypertensive and atherosclerotic cardiovascular disease Cardiopulmonary arrest due to cardiac arrhythmia due to hypertensive and atherosclerotic cardiovascular disease Cardiopulmonary arrest due to cardiac arrhythmia Correct: Acceptable: Incorrect: Stab wound of chest Exsanguination due to stab wound Exsanguination Correct: - Incorrect: Gastrointestinal hemorrhage of unknown etiology - Gastrointestinal hemorrhage Correct: Acceptable: Incorrect: Left basal ganglia intracerebral hemorrhage due to acute cocaine intoxication Intracerebral hemorrhage due to cocaine abuse Intracerebral hemorrhage 26

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27. STEPS IN NOTIFICATION

28. REGISTRATION OF PERSONS ACT. PART VI: REGISTRATION OF DEATHS.    41.   Compulsory registration of deaths.    42.   Registration of deaths.    43.   Duty to give notice of death.    44.   Mode of notification and registration of Death.    45.   Registration of deaths occurring outside Uganda.    46.   Certificate of cause of death.    47.   Presumption of death.    48.   Certificate of death.

29. 46. Certificate of cause of death (1)In the case of a death occurring in Uganda of any  person  who has been attended during the  person ’s last illness by a medical officer, the medical officer shall sign a certificate stating to the best of the medical officer’s knowledge and belief the cause of death. (2)A certificate of cause of death signed in accordance with subsection (1) shall be forwarded forthwith by the medical officer to the  registration officer  who shall cause the particulars of such death to be entered in the register in the prescribed manner

30. 46. Certificate of cause of death (3)A medical officer who refuses or fails without reasonable cause to comply with any of the provisions of this section commits an offence and is liable, on conviction, to imprisonment for a term not exceeding one year or a fine not exceeding twenty four currency points or both. (4)Subject to the Inquest Act, where an inquest is held on the body of a deceased  person , the Magistrate holding the inquest shall forward to the  registration officer  a certified copy of such finding and upon receipt of such report, shall cause the particulars of such death to be entered in the register in the prescribed manner.”

31. Classical mistakes in forensic pathology Not being aware of the objective of the  medicolegal autopsy Performing an incomplete autopsy Permitting the body to be embalmed before performing a  medicolegal  autopsy Mistakes resulting from non-recognition or misinterpretation of postmortem changes Regarding a mutilated or decomposed body as un suitable for autopsy Failure to make an adequate examination and description of external abnormalities Confusing the objective with the subjective sections of an autopsy protocol (report)-intuition vs scientific interpretation Not examining the body at the scene of the crime Not making adequate photographs of the evidence Not exercising good judgment in the taking or handling of specimens for  toxicologic  examination Permitting the value of the protocol (report) to be jeopardised by minor errors Talking too soon, too much and to the wrong person