The Scene Where 41 Dead at the Scene

Not examining a body at the scene has been considered a potential pitfall for the pathologist in a medicolegal death investigation (15,23). Scene visitation is not always

Table 1

Autopsy Authorization and the Five "Ws"

Hospital autopsy

Forensic autopsy

Authorization (13,16-21)

"Why"?—The cause of death "Under what circumstances?"—The manner of death (2,6,8,13,22)

Usually by appropriate family member or legally authorized representative

A major focus

Natural death, i.e., caused by disease and/or age

Hospital

Other health care facilities Home (rarely; chronically ill person under palliative care and no suspicions regarding the circumstances of death)

Usually known Confirmed at autopsy by • Hospital bracelets (wrist, ankle)

Mandated by statute.

Depending on jurisdiction— coroner, medical examiner, or other legal authority

A major focus

The cause of death can assist in assigning a manner of death

Natural

• A sudden and unexpected death from disease

• Any disease that could account for death and was unattended by a physician

Accident

• A death from an unintentional and unpredictable event/act

Suicide

• A death from a self-intentional act

Homicide

• A death from the harmful intentions of another

Undetermined

• A death in which there is insufficient or incomplete information to determine the manner (e.g., conflicting versions of events leading to death, skeletal remains)

Anywhere

The medicolegal investigation may have to consider more than one scene—where the body was discovered, where the individual was actually injured/died and subsequently moved, where he/she was last seen alive

Investigation of death in health care institution, identification as for "hospital" autopsy

(Continued)

Table 1 (Continued

Hospital autopsy

Forensic autopsy

Tags (body bag, toe) Review of medical records

"When?" — Time of death (see Chapter 2)

Pronouncement of death in medical setting Exact time if witnessed, e.g. during resuscitation

Presumptive

• Visual identification.

• Clothing and personal effects.

• Circumstances (e.g., sole occupant of a locked apartment).

• General physical features (age, race, sex, height)

Confirmatory—i.e., comparison of unique antemortem/ postmortem information

• Fingerprints

• Dental examination

• Specific physical features (e.g., cutaneous findings such as tattoos, scars, previous surgery, deformity)

Exact time if reliable witness Unwitnessed death ^ assessment of certain postmortem changes (rigor mortis, livor mortis, temperature, decomposition) can assist in estimating time of death necessary or possible for a pathologist conflicted by other duties. Death scene and witness information from different investigators (coroner, medical examiner or investigator, police, fire marshal, etc.) can be communicated to the pathologist by various means (diagrams, photographs, video and digital images) prior to the autopsy (13,23).

If called to the scene, the pathologist needs to document where the death occurred, who was present, and when the scene was attended. At the scene, the pathologist's focus must be on the deceased and the surroundings relevant to cause of injury and death (e.g., blood stain on a surface, medications, medical paraphernalia, etc.). Investigators can question family and witnesses about medical, psychiatric, family, and occupational history. If an individual had been hospitalized previously, hospital charts must be obtained through a formal medicolegal request. Note is made of any resuscitation efforts that could have created artifactual injuries (see Chapter 3, Subheading 2.6. and Chapter 8, Subheading 6.2.). Information about the deceased's position and observable postmortem changes needs to be documented (13). The body must not be moved prematurely. Premature or inappropriate removal of a body at the scene compromises the assessment of the relation of certain findings to the surroundings, including postmortem changes used to assess time of death; affects the collection of evidence; raises issues about the presence and integrity of certain personal effects and clothing; and potentially causes

Fig. 1. The autopsy. The necessary investigative steps to successfully resolve a medicolegal death investigation.

postmortem artifacts. Any initial manipulation of the body is confined to the recovery of trace evidence (e.g., hair, fibers) that could be lost during transport, a search for means of identification, and an overview of injuries (13,23). Evidence must be preserved by using a sealed body bag if the death is suspicious. Detailed examination is deferred until the actual examination of the body in the autopsy facility.

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