Perceptions of near virtual autopsies

Attitudes of UK pathologists and judicial officers towards medicolegal view and grant examinations: a cross-sectional mixed-methods study

AIMS

Despite the 1988 'Dundee Initiative', which maximised the use of view and grant examinations to reduce the invasive forensic autopsy rate in Tayside, the view and grant itself remains controversial. This is the first study to measure attitudes towards view and grants, applying the Theory of Planned Behaviour to investigate what attitudes are held, the reasons behind them and their association with deciding the scope of postmortem examinations.

METHODS

A mixed-methods cross-sectional study examined 62 UK pathologists, coroners and procurators fiscal using an online questionnaire. Participants were asked their demographics and attitudes towards view and grants before allocating five fictitious reportable deaths to either view and grant or invasive forensic autopsy (both in ideal and real world conditions), explaining their decisions using free-text.

RESULTS

Participants held both positive and negative attitudes towards view and grants, and most were relatively strong and ambivalent. Attitudes predicted respondents' decisions to favour view and grant or invasive forensic autopsy in all ideal world scenarios, but no real world scenarios. There were significant differences in attitudes and decisions when comparing pathologists and judicial officers, and respondents working in Coroner and Fiscal systems. Thematic analysis was conducted on free-text responses.

CONCLUSIONS

Discrepancies between attitudes, and ideal and real world choices suggest that what respondents wanted to do did not necessarily translate to what they would actually do in the scenarios tested. Applying concepts of attitudes, norms and perceived control can help to understand decision-making by death investigators, and why some jurisdictions favour more invasive procedures.

Effect of minimally invasive autopsy and ethnic background on acceptance of clinical postmortem investigation in adults

OBJECTIVES

Autopsy rates worldwide have dropped significantly over the last five decades. Imaging based autopsies are increasingly used as alternatives to conventional autopsy (CA). The aim of this study was to investigate the effect of the introduction of minimally invasive autopsy, consisting of CT, MRI and tissue biopsies on the overall autopsy rate (of CA and minimally invasive autopsy) and the autopsy rate among different ethnicities.

METHODS

We performed a prospective single center before-after study. The intervention was the introduction of minimally invasive autopsy as an alternative to CA. Minimally invasive autopsy consisted of MRI, CT, and CT-guided tissue biopsies. Autopsy rates over time and the effect of introducing minimally invasive autopsy were analyzed with a linear regression model. We performed a subgroup analysis comparing the autopsy rates of two groups: a group of western-European ethnicity versus a group of other ethnicities.

RESULTS

Autopsy rates declined from 14.0% in 2010 to 8.3% in 2019. The linear regression model showed a significant effect of both time and availability of minimally invasive autopsy on the overall autopsy rate. The predicted autopsy rate in the model started at 15.1% in 2010 and dropped approximately 0.1% per month (β = -0.001, p < 0.001). Availability of minimally invasive autopsy increased the overall autopsy rate by 2.4% (β = 0.024, p < 0.001). The overall autopsy rate of people with an ethnic background other than western-European was significantly higher in years when minimally invasive autopsy was available compared to when it was not (22/176 = 12.5% vs. 81/1014 (8.0%), p = 0.049).

CONCLUSIONS

The introduction of the minimally invasive autopsy had a small, but significant effect on the overall autopsy rate. Furthermore, the minimally invasive autopsy appears to be more acceptable than CA among people with an ethnicity other than western-European.

Postmortem Computed Tomography: An Overview for Forensic Nurses Involved in Death Investigation

The traditional invasive autopsy has been considered the "gold standard" for death investigation worldwide. However, this has now been challenged by a new minimally invasive approach that utilizes cross-sectional radiological imaging to investigate the death. Globally, postmortem computed tomography is the most commonly used modality and is becoming increasingly available throughout the world. Forensic nurses working in association with coroners and medical examiners' offices, as well as mass fatality incidents, now need to update their knowledge base to understand these innovative techniques, the advantages and disadvantages to their use, and how they impact on medicolegal death investigation and the care of the deceased and bereaved. Using the example of the coroner system of England and Wales, this article provides a comparison between the traditional invasive autopsy and postmortem radiological alternatives and presents the impact postmortem radiology is now having on death investigation.

Use of the Randox Evidence Investigator immunoassay system for near-body drug screening during post-mortem examination in 261 forensic cases

BACKGROUND

This paper describes the performance of four Randox drug arrays, designed for whole blood, for the near-body analysis of drugs in a range of post-mortem body specimens.

METHODS

Liver, psoas muscle, femoral blood, vitreous humor and urine from 261 post-mortem cases were screened in the mortuary and results were obtained within the time taken to complete a post-mortem. Specimens were screened for the presence of amfetamine, barbiturates, benzodiazepines, benzoylecgonine, buprenorphine, cannabinoids, dextropropoxyphene, fentanyl, ketamine, lysergide, methadone, metamfetamine, methaqualone, 3,4-methylenedioxymetamfetamine, opioids, paracetamol, phencyclidine, salicylate, salicylic acid, zaleplon, zopiclone and zolpidem using the DOA I, DOA I+, DOA II and Custom arrays.

RESULTS

Liver and muscle specimens were obtained from each of the 261 post-mortem cases; femoral blood, vitreous humor and urine were available in 98%, 92% and 72% of the cases, respectively. As such, the equivalent of 12,978 individual drug-specific, or drug-group, immunoassay tests were undertaken. Overall >98% of the 12,978 screening tests undertaken agreed with laboratory confirmatory tests performed on femoral blood.

CONCLUSIONS

There is growing interest in the development of non-invasive procedures for determining the cause of death using MRI and CT scanning however these procedures are, in most cases, unable to determine whether death may have been associated with drug use. The Randox arrays can provide qualitative and semi-quantitative results in a mortuary environment enabling pathologists to decide whether to remove specimens from the body and submit them for laboratory analysis. Analysis can be undertaken on a range of autopsy specimens which is particularly useful when conventional specimens such as blood are unavailable.

Post-mortem magnetic resonance foetal imaging: a study of morphological correlation with conventional autopsy and histopathological findings

The aim of the present study is to offer our experience concerning post-mortem magnetic resonance (PMMR) in foetal death cases and an evaluation of the differences between the findings acquired by PMMR and by forensic autopsy. Fifteen foetuses were recruited from July 2014 to December 2015. These had suffered intrauterine death in women in the 21st to 38th week of gestation who were treated in the emergency department for non-perception of foetal movements. We performed a PMMR on foetuses, 3 ± 1 days on average from the time of death, and then a complete forensic autopsy was performed. All 15 foetuses were examined with a whole-body study protocol, starting from the skull, down to and including the lower limbs. The total time of examination ranged from 20 to 30 min in each case. The external evaluation and description of post-mortem phenomena (maceration), record of the weight and detection and the various measurements of foetal diameters were evaluated before performing autopsy. A complete histopathological study was performed in each case. Out of 15 cases examined, eight were negative for structural anatomical abnormalities and/or diseases, both in the preliminary radiological examination and the traditional autopsy. In the remaining seven cases, pathological findings were detected by PMMR with corresponding results at autopsy. PMMR can provide useful information on foetal medical conditions and result in improved diagnostic classification. It may enable the planning of a more suitable technique before proceeding to autopsy, including focusing on certain aspects of organ pathology otherwise not detectable. The association between PMMR, post-mortem examination and related histological study of the foetus-placenta unit could help reduce the percentage of cases in which the cause of foetal death remains unexplained. Lastly, it may allow a selective sampling of the organ in order to target histological investigations.

Tissue microscopic changes and artifacts in multi-phase post-mortem computed tomography angiography in a hospital setting: a fatal case of systemic vasculitis

A 27-year-old man suddenly died in hospital of acute respiratory distress syndrome secondary to severe systemic vasculitis. Multi-phase post-mortem computed tomography angiography followed by scientific autopsy of the thoracic and abdominal cavity and histology was performed, illustrating the advantages and drawbacks of such techniques. Imaging enabled us to examine the cranium, as the family refused cerebral dissection. MPMCTA revealed absence of opacification of the left middle cerebral artery. But parenchymal findings of thoracic and abdominal organs were still difficult to interpret after both imaging and macroscopic examination during the autopsy. Microscopic examination provided the definitive diagnosis of cause of death. Analysis revealed systemic vasculitis of the lung complicated by diffuse alveolar, mediastinal, splenic and retroperitoneal lesions. We were unable to determine the type of vasculitis, whether polyarteritis nodosa or microscopic polyangiitis, because of artifactual glomerular collapse. We observed some structural changes in tissue secondary to contrast agent injection, affecting the vascular system and renal parenchyma in particular. Such artifacts must be known in order to avoid misinterpreting them as pathological findings. MPMCTA and conventional autopsy are two complementary techniques showing both their specific advantages and limits which have to be known in order to choose the appropriate technique. One limit of both techniques is the detection of microscopic findings which can only be obtained by additional histological examination. This case report underlines this fact and demonstrates that caution is required in some cases if microscopic analyses are carried out after contrast agent injection.

Interobserver agreement of the injury diagnoses obtained by postmortem computed tomography of traffic fatality victims and a comparison with autopsy results

The present study investigated the interobserver variation between a radiologist and a forensic pathologist in 994 injury diagnoses obtained by postmortem computed tomography (CT) of 67 traffic fatality victims, and the results were compared with diagnoses obtained by autopsy. The injuries were coded according to the abbreviated injury scale (AIS). We found a low interobserver variability for postmortem CT injury diagnoses, and the variability was the lowest for injuries with a high AIS severity score. The radiologist diagnosed more injuries than the pathologist, especially in the skeletal system, but the pathologist diagnosed more organ injuries. We recommend the use of a radiologist as a consultant for the evaluation of postmortem CT images. Training in radiology should be included in forensic medicine postgraduate training. CT was superior to autopsy in detecting abnormal air accumulations, but autopsy was superior to CT in the detection of organ injuries and aortic ruptures. We recommend a combination of CT and autopsy for the postmortem investigation of traffic fatality victims.