Unnatural death in the elderly

The objective of the study was to determine the unnatural manner and causes of death in older people, defined as individuals at least 60 years of age at the time of death. A series of medico-legally examined deaths in older people, who were examined between January 1, 1999 and December 31, 2003, and whose deaths were considered unnatural after forensic examination were studied. All deaths took place in western Norway, in two whole counties and the north part of a third county, including one large Norwegian city and one medium-sized city on the west coast of Norway. Of the 2425 forensic examinations performed in the time period, 1169 were 60 years or older at the time of death. Of these, 228 deaths were categorized as accidental, suicidal, or homicidal. Drowning was the most common lethal accident in elderly males, whereas fatal traffic accidents were more frequent in women. Alcohol intoxication was very common among male drowning victims, and none of the drowning victims had used a life-saving floating device. None of the elderly traffic victims were intoxicated. Death after a falling accident in the home is probably underreported. Suicide is more common among elderly men than women. Among men, hanging was the most common cause of death, whereas intoxication resultiong from drug overdose and drowning were the most frequent causes of death in women. Cancer was present in 19% of the suicide victims, all men. Serious disease may be a predisposing factor for suicidal behavior. Homicide is uncommon as a manner of unnatural death among the elderly.     

Medical death certification by forensic physicians in the Netherlands: Validity and interdoctorvariation

The aim of the study was to assess interdoctorvariation and validity in death certification by forensic physicians using 19 written scenarios. The scenarios described typical cases from forensic-medical practice. Physicians were asked to determine the manner of death (natural/unnatural) and to provide an ICD-10 code for the cause of death. In contrast to most studies on this topic, the measure of agreement among physicians was chance-corrected and a standard was used to assess the correctness of the assigned cause and manner of death. Forty-seven physicians participated in the survey. The study demonstrated that forensic physicians varied widely in their conclusions. With respect to manner of death, adequate agreement (defined as kappa>0.70) was achieved in six scenarios (32% of all scenarios). Concerning the underlying cause of death, adequate agreement was reached in three cases (16% of all scenarios). Furthermore, predictors for the correctness of manner and cause of death were studied using logistic regression. Years of experience as a forensic physician significantly predicted the correctness of cause of death (p < 0.05). Other predictors remained insignificant. With regard to manner of death, none of the studied predictors proved to be significant. To conclude, there appears to be a lack of consistency among forensic physicians regarding death certification. The ICD-10 coding of causes of death applied by forensic physicians is questionable. Less experienced physicians need supervision by more experienced colleagues when making judgments concerning the cause of death. Altogether, there is an urgent need to work out consensus-based guidelines for forensic physicians on how to certify deaths.     

Trends in forensic autopsy in Chiba prefecture over the past decade

The death investigation system in Japan is in the midst of a great transformation. As part of efforts to revise this system, in this study we analyzed the reasons the police refer unnatural death cases for forensic autopsy and, from an understanding of the trends of such referrals, we discuss the future direction of handling unnatural deaths in our country. For 1618 forensic autopsy cases handled by the First Investigation Division of Chiba Prefectural Police that were referred to our institution for forensic autopsy between 2003 and 2012, we tallied the number of autopsies by sex, age group, and reason for forensic autopsy for each year and investigated trends in the referrals over time. The results revealed that the number of autopsies increased annually from 2003 to 2012, with a marked increase from 2010. The number of autopsies increased particularly for cases of suspected criminal deaths, where it was unclear to the police before the forensic autopsy whether or not the death resulted from a criminal act. Our findings suggest that the number of forensic autopsies will continue to increase into the future in Chiba prefecture, and is a trend that is inevitable if we are to prevent criminal death cases from being overlooked. Although referrals for forensic autopsy in Japan are made only when criminal activity is suspected, the original purpose of death investigations is not only to avoid overlooking crimes, but also to flag public health issues. Therefore, together with the police, we need to review the original purpose and conduct more in-depth discussions about when referrals are necessary.     

Risk factors, diagnosis and prevention of sudden unexpected infant death

The diagnosis of the cause of sudden unexpected infant death (SUID) is often difficult work for forensic pathologists. Its misdiagnosis or misclassification is the cause of crucial epidemiological and medicolegal problems. During the sudden infant death syndrome (SIDS) epidemic, many reports described the risk factors of SIDS as well as mechanical suffocation during sleep. Meadow's report has invited worldwide debate over whether the cause of SUID is attributable to SIDS or suffocation. On the basis of this background, the problems concerning causal diagnosis and risk factors, particularly the accidental suffocation of infants during sleep, and the specific pattern of suffocation, was reviewed from the forensic pathological viewpoint. The following tasks remain to be done for the future: (1) to avoid preventable SUIDs, the most effective measure worldwide is to identify high-risk factors for all SUIDs, including SIDS, accidental suffocation and undetermined causes, and then transmit this information to the public. (2) SIDS should be uniformly defined and diagnosed as strictly as possible to gain its reliability in the public health community and in a legal framework.     

Undetected patricide: Inaccuracy of cause of death determination without an autopsy

Patricide (killing the father) is uncommon form of homicide. Usually the assaults occur at home in the absence of witnesses and adult sons are frequently involved. Homicides in a domestic context usually do not tend to recurrence, because the motivation for the crime ends with the death of the parent. However, this is not what was observed in the present case study dealing with the death of a 70 years old white man originally misclassified as accident and discovered three years later only after an additional homicide in a family context of a 60 years old white lady. Multiple stab wounds to the neck and thorax were misinterpreted at the external male body examination as blunt trauma falling down stairs. No forensic autopsy was requested and no comparison of medical findings with the results from the death scene, such as a bloodstain analysis was performed by the police officers nor required by the judicial authority. This was quite surprising because an additional but preliminary post-mortem external examination performed by a general practitioner on the male body already raised the suspicion that the external lesions were stab wounds thus requiring a forensic autopsy. Only the exhumation of the elderly body, performed years later, confirmed the diagnostic hypothesis raised by the first physician. The present case is quite representative of a death investigation not run professionally and performed by individuals with no specific training where most of the medico-legal investigations (especially for traumatic and violent deaths) are restricted to an external body examination without subsequent autopsy. Although misinterpretation of external lesions is inevitable and significant discrepancies between external body examination and forensic autopsy are not rare, in the case of contradictory results of post-mortem external examination or unclear/suspicious cause and manner of death, investigation should proceed necessarily with a forensic autopsy.     

Two cases of death due to plastic bag suffocation

Deaths due to plastic bag suffocation or plastic bag asphyxia are not reported in Malaysia. In the West many suicides by plastic bag asphyxia, particularly in the elderly and those who are chronically and terminally ill, have been reported. Accidental deaths too are not uncommon in the West, both among small children who play with shopping bags and adolescents who are solvent abusers. Another well-known but not so common form of accidental death from plastic bag asphyxia is sexual asphyxia, which is mostly seen among adult males. Homicide by plastic bag asphyxia too is reported in the West and the victims are invariably infants or adults who are frail or terminally ill and who cannot struggle. Two deaths due to plastic bag asphyxia are presented. Both the autopsies were performed at the University Hospital Mortuary, Kuala Lumpur. Both victims were 50-year old married Chinese males. One death was diagnosed as suicide and the other as sexual asphyxia. Sexual asphyxia is generally believed to be a problem associated exclusively with the West. Specific autopsy findings are often absent in deaths due to plastic bag asphyxia and therefore such deaths could be missed when some interested parties have altered the scene and most importantly have removed the plastic bag. A visit to the scene of death is invariably useful.     

Locational characteristics of the increasing number of forensic autopsy cases in Kyoto, Japan

In Japan, the definition of unnatural death is not prescribed in law. However, a legal judgment recently defined unnatural death as all deaths, excluding natural deaths and deaths from diseases. Legally, unnatural deaths must be reported to the police. In the case of a reported death being considered as suspicious by the police, a forensic autopsy is required. The number of autopsies and the autopsy rate in Japan and Kyoto has increased over the last 10 years. Using data collected from 221 autopsy cases between 2008 and 2010 in Kyoto, Japan, the characteristics of locations where autopsy cases were discovered were analysed to identify reasons for the increase in autopsy numbers. It was found that factors including amount of human interaction and socioeconomic factors may help to explain the statistically significant correlations found.     

Medicolegal death diagnosis in Tokyo Metropolis, Japan (2010): comparison of the results of death inquests by medical examiners and medical practitioners

Purpose

Japanese methods of death inquests are still in developmental stages and many problems have been uncovered since an inspection error was reported in 2007. In this study, we investigated the latest results of medicolegal deaths in the Tokyo Metropolis, which is composed of areas with and without the medical examiner system, and compared the results of inquests performed by official medical examiners with those by medical practitioners to re-evaluate the effectiveness of the medical examiner system for the Japanese death inquiry system.

Methods

By using death certificates as inquest records in the Tokyo Metropolis, 2010, we made a comparison of the autopsy rates, causes of death and the numbers of death certificates containing defects between the inquests performed by official medical examiners and those by medical practitioners.

Results

Age distributions and male to female ratios were not different between the two groups. The autopsy rate of the medical practitioners’ cases was only 5.5%, whereas that of official medical examiners’ cases was 21%. The proportion of deaths due to circulatory system disease was higher in medical practitioners’ cases than in official medical examiners’ cases (P < 0.01), and the proportion of deaths from cerebrovascular disease in medical practitioners cases was twice as high as that in official medical examiners’ cases. The number of ambiguous causes of death, such as unspecific heart failure and arrhythmia, certified without autopsies was much higher in medical practitioners’ cases than in official medical examiners’ cases. For accidental deaths, the proportion of deaths by poisoning and heatstroke was lower in medical practitioners’ cases than in medical examiners’ cases (P < 0.01). The proportion of death certificates containing defects was much higher in medical practitioners’ cases (24.1%), especially in the rural areas (45.4%), as compared to official medical examiners’ cases (1.3%).

Conclusions

The lower autopsy rate and the higher frequency of defects in death certificates in medical practitioner’s cases likely led to the differences in the mortality statistics between the two groups. On the other hand, the medical examiner system leaves room for further improvement, such as in the autopsy rate. This study supports the necessity for implementation and improvement of the medical examiner system, and for reinforcement of under/postgraduate medicolegal education in Japan.     

Sudden death victims <45 years: Agreement between cause of death established by the forensic physician and autopsy results

PurposeThe goal of this study was to ascertain accordance between cause of death established by the forensic physician and autopsy results in young sudden death victims in the Netherlands.MethodsSudden death victims aged 1–45 years examined by forensic physicians operating in the participating regions which also underwent an autopsy between January 2006 and December 2011 were included (n = 70). Cause of death established by the forensic physician based on the external medicolegal examination was compared with autopsy findings using the ICD10-classification.ResultsAutopsy findings revealed that the majority of sudden death victims have died from a cardiac disease (n = 51, 73%). Most of the presumed heart disease related cases were confirmed by autopsy (n = 13, 87%). On the contrary, a large number of deaths caused by circulatory diseases were not recognised by the forensic physician (n = 38, 75%). In most of these cases, the forensic physician was forced to report an undetermined cause due to the lack of a solid explanation for death. Cause of death reported by the forensic physician appeared to be in agreement with the autopsy results in 12 cases (17%).ConclusionsCause of death determination in young sudden death victims is a difficult task for forensic physicians due to the limited tools available during the medicolegal examination. An effort should be made to standardize extensive post-mortem investigation after sudden death in the young. Autopsy can provide valuable information regarding the cause of death, which is of great importance in view of the identification of inheritable diseases among decedents and their families.     

Sudden death due to adrenal neuroblastoma: child abuse mimic?

Neuroblastoma is one of the most common malignancies in children. It is a tumor that can clinically present with varied symptoms that can mimic other entities, including child abuse. It is important that forensic pathologists are aware of the diseases that can masquerade as child abuse. A case of sudden, unexpected death in a 2-year-old due to previously undiagnosed neuroblastoma is presented. At initial presentation of the child in the emergency department, child abuse was considered as a possible explanation for the sudden demise. Death occurred before a full clinical workup could be completed and an autopsy was performed which unveiled the cause of death.     

Unnatural causes of sudden unexpected deaths initially thought to be sudden infant death syndrome

The aim of this clinicopathological study was to determine the frequency of infant deaths due to unnatural causes among cases of sudden and unexpected infant death. Nine institutes of legal medicine in Germany that took part in the German study on Sudden Infant Death Syndrome (GeSID), representing 35% of the German territory, investigated in a 3-year period (from 1998 to 2001) 339 cases of infant death that were not expected to be due to unnatural causes from the first external examination. All cases were investigated by complete, standardised, post-mortem examination including death scene investigation, autopsy, histology, toxicology and neuropathology. The frequency of unnatural deaths was 5.0% (n=17). The causes of death were head injury (n=7), suffocation (n=5), poisoning (n=2), neglect (n=2) and septicaemia due to aspiration of a foreign body (n=1). Two deaths were unsuspected accidents and 12 were due to infanticide. In 3 cases, it was not possible to differentiate between accidental death and infanticide. A complete postmortem examination including an analysis of the clinical history, death scene investigation, autopsy, histology, toxicology, and neuropathology is mandatory to differentiate sudden and unexpected deaths due to natural causes (e.g. SIDS) and cases of unnatural death.Contributors at Institutes of Legal Medicine: U. Deml, Friedrich-Alexander-University, Erlangen; A. Freislederer, University Duisburg-Essen, Essen; S. Heide, Martin-Luther-University, Halle; H.-J. Kaatsch, S. Ritz-Timme, Christian-Albrechts-University, Kiel; K.-P. Larsch, A. Fiegut, Medizinische Hochschule Hannover, Hannover; H.W. Leukel, Johann-Wolfgang-Goethe-University, Frankfurt am Main; C. Ortmann, Friedrich-Schiller-University, Jena; R. Penning, Ludwig-Maximilians-University, Munich.     

Postmortem CT compared to autopsy in children; concordance in a forensic setting

Objectives

The aim of this study is to assess the accuracy of postmortem CT (PMCT) in determining the cause of death in children who underwent a forensic autopsy because of a suspected nonnatural death.

Methods

We selected forensic pediatric autopsies at the Netherlands Forensic Institute, whereby the subject underwent PMCT between 1-1-2008 and 31-12-2012. Cause of death was independently scored by a radiologist and a pathologist. Cause of death was classified (1) in categories being natural, unnatural, and unknown; (2) according to the ICD-10; and (3) according to institutional classification.

Results

In the study period, 189 pediatric forensic autopsies were performed. Fifteen were excluded because of putrefaction. Of the remaining 174 autopsies, 98 (56 %) underwent PMCT. PMCT and autopsy identified the same category in 69/98 cases (70 %, kappa 0.49). They identified the same cause of death in 66/98 cases (67 %, kappa 0.5) using ICD-10; in 71/98 (72 %, kappa 0.62) using a forensic classification. PMCT performed better in unnatural deaths (59–67 % agreement) than in natural deaths (0 % agreement). If no cause of death was detected with autopsy, PMCT failed to identify a cause of death in 98 % (39/40).

Conclusions

Pediatric PMCT does identify the majority of unnatural causes of death, but does not identify new diagnoses (true positives) if no cause of death is found during autopsy. Diagnostic accuracy in natural deaths is low.

Key points

? The case mix is an important predictor for the concordance between PMCT and autopsy. ? In case of an unnatural death, 72–-81 % of PMCT results matches autopsy results. ? In case of a natural death, 0 % of PMCT results matches autopsy results. ? If no cause of death is identified with autopsy, 98 % of PMCT results concurs.     

Sudden natural deaths in Edirne, Turkey, from 1984 to 2005

The aim of this study is to evaluate the characteristics of sudden natural deaths (SND) in forensic autopsy cases which were performed in Trakya University Department of Forensic Medicine, Edirne, Turkey. For each case, a complete autopsy, toxicological screening and histological examination were performed. Deaths due to unnatural causes, alcohol, drug overdose and undetermined causes (negative autopsy) were excluded from the study. Autopsy reports of 959 consecutive forensic cases performed in a 22-year period were reviewed. Two hundred and seventy-eight (278) SNDs were identified, involving 232 males (83.4%) and 46 females (16.6%). The age group of 50-59 years accounted for 21.58% of the cases. In the majority (55%) the cause of death was related to the cardiovascular system--principally ischemic heart disease. The second most common cause of SND was related to the respiratory system (19.1%), especially pneumonia. Most of the SNDs occurred in the winter months. Ethyl alcohol was detected in 5.3% of cases. In conclusion, sudden natural deaths related to the cardiovascular system are shown to be a significant problem in the Trakya region of Turkey.     

Homicides against infants, children and adolescents in Budapest (1960-2005)

IntroductionThe objective of this study was to determine the characteristics and trends of fatal child abuse that would assist family doctors in detecting signs of maltreatment.SubjectsThere were 363 (193 males, 170 females) such cases autopsied at the Department of Forensic and Insurance Medicine at Budapest from 1960 to 2005. Information was collected from forensic autopsy records. Data were analyzed according to age, gender, type of abuse, injured body region, and seasonal distribution. The firs detection of fatal injuries and death certification were usually done by GPs or ambulance at the scene of the homicide or hospital paediatricians in cases with survival period between the injuries and death.ResultsOur results suggest a definitive decrease in fatal child abuse cases during the investigated period. In the first part of study period suffocation of infants represent a great number of cases. Infanticide rapidly dropped after the mid 1970s. In this material 89.3% of fatal cases was detected and reported by family doctors.ConclusionsRate of homicides against infants, children and adolescents reflect the effectiveness of the preventative strategies, the child protection policy and the unique primary health care system for youth. GPs have an important role in the investigation of infanticides and homicide cases against children and adolescents.     

Fatal intussusception in infancy: an experience in forensic autopsy

Intussusception, although a common cause of pediatric surgical emergencies, is a rarely fatal condition. A 7-month-old infant who was discovered in her cot was unresponsive and pronounced dead after 2 h of uneventful cardiopulmonary resuscitation in an emergency hospital. Forensic autopsy which was performed in order to clarify the circumstances surrounding the death revealed intussusceptions at two sites of the ileum. Although morbidity and mortality rates from the condition have progressively declined in recent decades but avoidable deaths still occur as was experienced in the present case. The forensic pathology significance in this case was the occurrence of 'painless intussusception' whereby the affected child clinically exhibited no discomfort or characteristic features of acute abdomen until death. In summary, the present case has exhibited an uncommon fatal occurrence and demonstrated the importance of forensic autopsy in such unexpected sudden infant deaths.     

Unnatural deaths among children in the Transkei region of South Africa

Nearly 99% of the 10.9 million children worldwide under the age of five years who died in 2000 were from developing countries. This amounts to at least 29,000 deaths per day (UNICEF, 2005). This study aims to trace the pattern of unnatural deaths in the Transkei region of South Africa. It is a records review of the medico-legal autopsies carried out between 1996 and 2004 at Umtata General Hospital (UGH). All subjects aged 18 years or below were considered as children. Between 1996-2004, 7,303 unnatural deaths were recorded. Of these, 1,449 (19.8%) were children. Trauma accounted for 1,028 (70.9%) child deaths and 421 (29.1%) were deaths related to other causes such as hanging, burns, lightning strike, drowning, gas suffocation, falls from a height and poisoning. Motor vehicle accidents accounted for 469 (45.6%) deaths and homicides for 553 (54.4%) deaths. The homicides were firearms injuries, 196 (19%), stab wounds, 185 (18%), and blunt trauma, 178 (17.3%). Non-traumatic deaths were hanging, 81 (19.2%), drowning, 166 (39.4%), lightning strike, 38 (9%), burns, 51 (12.1%), gas suffocation, 24 (5.7%), poisoning, 33 (8.4%) and falls from a height 28 (6.7%). There is a high risk of unnatural death among children in the area of Mthatha. It threatens the survival of young children in this region of South Africa. Poverty is an underlying cause for these preventable deaths.     

Death certification practices of forensic physicians within the Strathclyde region of Scotland, UK

Data relating to the perceived and actual cause of death, in those dying in the community is sparse. This in part is related to how each country deals with death investigations and certification of death. Under common law in Scotland, sudden unexpected deaths are referred to the Procurator Fiscal. Autopsy is not always the final arbiter of truth. While actual figures are not available at present, anecdotally the police indicate that general practitioners (GPs) are often declining to attend or certify in the vast majority of cases. The purpose of this prospective observational study was to examine the certification practice of the forensic physicians working for Strathclyde Police. In conclusion, the results from this short study indicate that in cases where the cause of death for an individual, who died suddenly in the community and where an autopsy is deemed necessary, forensic physicians are no better or worse than a pathologist in predicting the underlying reason.     

Sudden death of a child because of an intestinal obstruction caused by a large congenital mesenteric defect

Transmesenteric hernias are internal hernias caused by a congenital defect in the mesentery. They are rare causes of intestinal obstruction, but most commonly affect the small bowel. We report an unexpected death of an infant with a bowel obstruction caused by a congenital mesenteric defect, which was undiagnosed despite visits to three different hospitals. Mesenteric defects are usually 2-3 cm in diameter. At autopsy, we found an oval, 14 × 7 cm congenital defect in the ileal mesentery through which the small bowel had herniated. Diagnosis of such defects remains difficult, even with currently available imaging techniques. Diagnosis is particularly difficult in infants who usually have nonspecific symptoms. Therefore, it is important that sudden unexpected deaths in children undergo full forensic evaluation to establish the precise cause of death. It is also important for forensic physicians to inform clinicians of the risk of such diseases, particularly in emergency situations.     

Todesfälle im Altenheim

Background

Due to an increased life expectancy in the population of Germany there is a concomitant increase of multimorbid residents of nursing homes. Post-mortem external examination and definition of the manner and cause of death can be a challenge, particularly concerning deceased multimorbid patients.

Aim

In this article the quality of the medical post-mortem external examination of multimorbid residents of nursing homes is analyzed by comparing the manner and cause of death given on the death certificate to the final result of the autopsy.

Material and methods

Final autopsy reports as well as any additional medical expert reports of residents of nursing homes over the age of 60 years were analyzed and compared to the information on the death certificates in retrospect.

Results

The analysis of the 356 included cases showed a high degree of multimorbidity. In approximately 10?% of the cases certified as natural death, the result of the autopsy showed an unnatural death. On the other hand, more than 40?% of the cases declared as an unnatural death were identified as a natural death by the autopsy. In 53.7?% of the studied cases the cause of death stated in the death certificate matched the result of the autopsy.

Conclusion

Defining the manner and cause of death during the post-mortem external examination of the body often requires differential diagnostic considerations, especially where multimorbid residents of nursing homes are concerned. Patterns of medical reports indicating an unnatural death can be only slightly developed or be completely missing. An inconclusive manner and cause of death or subtle but suspicious injuries should lead to a forensic autopsy for further clarification.