Deaths of British nationals abroad--a 10-year survey

On the handling of German citizens who died abroad

Background

Decedents who are repatriated to Germany from abroad are not systematically registered nationwide. In Hamburg, in addition to an epidemic hygienic examination, registration and examination of the content of the documents accompanying the corpses of German citizens has been carried out since 2007. In this way, unclear and non-natural deaths in particular are to be followed up as necessary.

Material and methods

Protocols of external and internal autopsies of German nationals who died abroad and were repatriated to Hamburg via the port or airport between 2007 and 2018 were retrospectively evaluated with respect to numbers, completeness of the autopsy abroad and correctness of manner and cause of death.

Results

Between 2007 and 2018 a total of 703 corpses were repatriated via the port or airport of Hamburg and examined by the Port Medical Service for epidemic hygiene and for anything conspicuous in the documents accompanying the corpse. Of them, 307 corpses were examined at the Institute of Legal Medicine at the University Medical Center Hamburg-Eppendorf. In total, 82.4% of the examined cases had an incorrect, unspecific or incomplete foreign death certificate. Of the deceased, 238 were subjected to a second external autopsy by a forensic pathologist and 69 deceased were autopsied again or for the first time in Hamburg. It was found that 84% of the autopsies performed abroad were not performed according to German and European standards. The most common discrepancy was incomplete preparation of the organs. In almost one quarter of the autopsies performed in Hamburg a different cause of death than abroad was determined at autopsy.

Conclusion

Since the quality of autopsies performed abroad sometimes does not meet the standards in Germany and Europe and many papers accompanying corpses are incomplete or incorrectly filled out, a systematic review procedure in the home country is recommended. Through the system established in Hamburg in 2007, at least a re-evaluation of the cases takes place.

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.

Post-autopsy computed tomography. Pros and cons in a firearm death

Many studies have focused on the importance of post-mortem computed tomography (PMCT) prior to or in substitution of standard forensic autopsies in case of firearm death. However, due to the fact that PMCT is not routinely performed in all countries, in cases of death abroad it can happen that a CT scan is performed only after a first autopsy. A case of post-mortem re-examination, including the external examination and a post-autopsy computed tomography (PACT), of a gunshot victim of homicide in a foreign country is presented, and the pros and cons of imaging in post-autopsy setting are discussed. PACT could be a tool for carrying out more complete investigations and for obtaining information on bone injuries and foreign bodies trapped within peripheral soft tissues that can be re-analyzed after the arrival of the first autopsy report. Given that the value of information derived may be strongly influenced by the previously performed autopsy, in order to process the definitive considerations it is necessary to compare and interpret the data obtained through PACT with the results of the first autopsy, and to continue the international cooperation effort and the application of international guidelines in order to share information at the repatriation of the corpse.

Autopsy findings in bodies repatriated to the UK

Following the death of a British National on foreign soil, a primary investigation is conducted by the authorities of that country; HM Coroner and the United Kingdom police have no jurisdiction to conduct investigations abroad. Upon repatriation of a body, the legal investigation in the UK remains largely unchanged since the publication of the "harmonisation of medico-legal autopsy rules" (1999) and the passing of the Coroners and Justice Act (2009). We identified 44 cases within a 10-year period. An invasive autopsy had been performed abroad in 25 cases; an autopsy report was received prior to UK autopsy in one case. Seven cases showed incomplete evisceration; the absence of part or whole organs was recorded in 11 cases. Toxicology was performed abroad in five cases. Recurring technical difficulties related chiefly to embalming, including difficulty with dissection and noxious fumes. When an autopsy had been performed abroad, the time to UK inquest was prolonged by an average of seven months. A verdict of unlawful killing was returned in nine cases. The discussion expands on these issues, and attempts to offer reasoned explanation where possible. Two cases are used as exemplars to highlight difficulties to both the pathologist and Coroner. This casework remains rare but the potential problems include: absence of tissue; lack of information; technical difficulties; and a disproportionately high number of unlawful killings, making clear the need for experience and caution when making the post mortem examination.

Injury deaths among Finnish residents travelling abroad

The increasing international mobility raises the possibility of foreign nationals dying abroad. Here, a descriptive, retrospective and population-based study of deaths abroad among Finnish residents from 1969 to 2007 is presented. The data were collected from the Statistics Finland data based on certificates of cause of death issued after repatriation of the corpse and after review of medical documents or a medico-legal autopsy. The frequency of injury deaths, proportional mortality rates (PMRs) and mortality risk estimates (MREs) were measured. During the study period, 6894 Finnish residents died abroad. Spain, Sweden and Thailand were the top three destination countries for number of deaths, accounting together for 40.3% of all the deaths. Cardiovascular diseases were the most common cause of deaths. The overall injury deaths represented 26.7% of all deaths abroad and occurred at a higher proportion than in Finland (PMR: 3.3). The most common injury deaths were traffic accident and drowning, which together represented more than 50% of all unintentional injury deaths. High PMRs were found for traffic accidents in Russia, Germany and the US and for drowning in Spain, Portugal, Greece and Turkey. The MRE for injury deaths was 73.5 per 100,000 person-years of exposure. Finnish travellers abroad are a population subgroup with a high risk of injury death. Common travel health interventions must be backed by actions to prevent injuries abroad, particularly traffic accident and drowning.

Did he drown or was he murdered?

An unemployed, 60-year-old Singaporean gentleman died during a brief overseas trip to another South-East Asian country. He had, presumably, drowned in the bathtub of his hotel room, which he shared with his then 44-year-old companion, who was supposedly his nephew. The relevant public health and medico-legal authorities of the host country conducted an external examination of the body at the scene, whereupon they agreed with the police that his death was probably due to accidental drowning following an episode of syncope. It would appear that this verdict was based almost entirely on circumstantial and hearsay evidence. No autopsy was performed. In its place, considerable reliance was placed on the observation that abdominal compression resulted in the outflow of a small amount of water from the mouth, as being proof of drowning. A few days later, the body was cremated in the host country and the remains (ashes) were subsequently repatriated to Singapore. It later transpired that, shortly before they embarked on the ill-fated trip, the deceased's 'nephew' had purchased, on the former's behalf, travel insurance policies (covering accidental injury and death) amounting to a total of S$800,000 from five different insurance companies, as well as a separate life policy for a further S$100,000, most of which had been issued within the fortnight prior to their departure. Interestingly, the beneficiary (later the plaintiff in the ensuing civil trial some three years later) of all of these policies, was the ex-wife of the deceased's 'nephew', with whom he had, in fact, continued to live although they were officially divorced several years ago. Whilst the claim against the life policy had been settled, the first five insurers declined to issue payment on grounds of suspicion that the deceased had been the victim of a homicide, planned or executed by the 'nephew', wherein the beneficiary was a conspirator of sorts. The author was approached by defence counsel (representing the various insurers), for assistance in this matter. It was felt that a proper forensic review was seriously hampered by the lack of a full autopsy which would have been indispensable in ascertaining the actual cause of death and in eliminating other possibilities, apart from drowning, such as death from natural causes, other forms of injury, poisoning, or homicide. It was also emphasized that the mere presence of ingested water is not diagnostic of drowning. Eventually, after a protracted but unsuccessful attempt at mediation (in the course of which, the plaintiff rejected the offer of a reduced, although apparently sizable quantum), the matter came before the High Court, which found in favour of the defendants. It appeared that the judge was more than convinced that the deceased was indeed the victim of a homicide of which the plaintiff was a conspirator and her ex-husband, the perpetrator, as even a cursory perusal of the written judgement would indicate. Accordingly, the court ruled that the plaintiff (in her capacity as both the beneficiary of the insurance policies and executor of the estate) and her ex-husband had, effectively, deprived the insurers of their contractual right (as stipulated in the insurance policies) to have an autopsy conducted on the body of the deceased and they were, therefore, entitled to deny liability. This case illustrates the difficulties inherent in conducting an independent review of a putative instance of drowning, where convincing and reliable forensic evidence and documentation are largely wanting; this being compounded by its occurrence in a foreign jurisdiction whose medico-legal practices differ substantially from that to which one is accustomed. It may even be said that the corpus delecti was destroyed, in this instance, by cremation. It is also unusual in that a de-facto finding of murder was made in a civil court (whose standard of proof is that of a balance of probabilities) and that this had, subsequently, spurred the police to undertake a criminal investigation for conspiracy to murder. In the event, the civil appeal was dismissed by the Court of Appeal, but no charge was laid against any of the suspects for want of sufficient forensic or investigative evidence of a criminal offence having been committed.