The criminal justice system's considerations of so-called near-virtual autopsies: the East Midlands experience

Patterning of fractures in a case of intimate partner homicide (IPH)

South Africa is a country overwhelmed by crime and violence, with very high incidences of abuse against women and children. It is not often that a case of intimate partner homicide is seen in a forensic anthropological context. Here, we report on such a case where the remains of the victim had been buried for some time. The victim was a middle-aged female, while the suspect was a younger adult male. The deceased had suffered massive, repeated trauma during her lifetime with healed fractures and evidence of soft tissue trauma to virtually all parts of her body. A partly healed rib fracture indicates that the abuse continued until shortly before her death. She ultimately succumbed after suffering trauma to her head and face after reportedly being hit by a brick, evidence of which can be seen as perimortem fractures of the face. It is important for forensic anthropologists to identify specific patterns and report on the presence of healed fractures, as they can raise suspicion as to the possibility of chronic abuse. In this case, the evidence suggests a very long period of extreme and repeated trauma, which were apparently not reported or noticed by family members or the medical fraternity.

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.

Postmortem imaging findings and cause of death determination compared with autopsy: a systematic review of diagnostic test accuracy and meta-analysis

BACKGROUND

The aim of this study was to evaluate the sensitivity of postmortem computed tomography (PMCT), postmortem magnetic resonance imaging (PMMR) and PMCT angiography (PMCTA) compared with autopsy in cases of adult death investigations.

METHODS

For this systematic review and meta-analysis, Embase, PubMed, Scopus, Web of Science and Medline were searched for eligible studies in October 2016; a follow-up literature search was conducted in March 2018. Studies referring to PMCT, PMCTA and/or PMMR of more than 3 cases with subsequent autopsy were included. Data were extracted from published texts in duplicate. The extracted outcomes were categorized as follows: soft tissue and organ findings, skeletal injuries, haemorrhages, abnormal gas accumulations and causes of death. The summary measure was sensitivity, if 3 or more studies were available. To combine studies, a random effects model was used. Variability and heterogeneity within the meta-analysis was assessed.

RESULTS

Of 1053 studies, 66 were eligible, encompassing a total of 4213 individuals. For soft tissue and organ findings, there was a high pooled sensitivity with PMCTA (0.91, 95% CI 0.81-0.96), without evidence for between-study variability (Cochrane's Q test p = 0.331, I² = 24.5%). The pooled sensitivity of PMCT+PMMR was very high in skeletal injuries (0.97, CI 0.87-0.99), without evidence for variability (p = 0.857, I² = 0.0%). In detecting haemorrhages, the pooled sensitivity for PMCT+PMMR was the highest (0.88, 95% CI 0.35-0.99), with strong evidence of heterogeneity (p < 0.05, I² > 50%). Pooled sensitivity for the correct cause of death was the highest for PMCTA with 0.79 (95% CI 0.52-0.93), again with evidence of heterogeneity (p = 0.062, I² > 50%).

CONCLUSION

Distinct postmortem imaging modalities can achieve high sensitivities for detecting various findings and causes of death. This knowledge should lead to a reasoned use of each modality. Both forensic evidence and in-hospital medical quality would be enhanced.

Diagnostic accuracy of post-mortem CT with targeted coronary angiography versus autopsy for coroner-requested post-mortem investigations: a prospective, masked, comparison study

BACKGROUND

England and Wales have one of the highest frequencies of autopsy in the world. Implementation of post-mortem CT (PMCT), enhanced with targeted coronary angiography (PMCTA), in adults to avoid invasive autopsy would have cultural, religious, and potential economic benefits. We aimed to assess the diagnostic accuracy of PMCTA as a first-line technique in post-mortem investigations.

METHODS

In this single-centre (Leicester, UK), prospective, controlled study, we selected cases of natural and non-suspicious unnatural death referred to Her Majesty's (HM) Coroners. We excluded cases younger than 18 years, known to have had a transmittable disease, or who weighed more than 125 kg. Each case was assessed by PMCTA, followed by autopsy. Pathologists were masked to the PMCTA findings, unless a potential risk was shown. The primary endpoint was the accuracy of the cause of death diagnosis from PMCTA against a gold standard of autopsy findings, modified by PMCTA findings only if additional substantially incontrovertible findings were identified.

FINDINGS

Between Jan 20, 2010, and Sept 13, 2012, we selected 241 cases, for which PMCTA was successful in 204 (85%). Seven cases were excluded from the analysis because of procedural unmasking or no autopsy data, as were 24 cases with a clear diagnosis of traumatic death before investigation; 210 cases were included. In 40 (19%) cases, predictable toxicology or histology testing accessible by PMCT informed the result. PMCTA provided a cause of death in 193 (92%) cases. A major discrepancy with the gold standard was noted in 12 (6%) cases identified by PMCTA, and in nine (5%) cases identified by autopsy (because of specific findings on PMCTA). The frequency of autopsy and PMCTA discrepancies were not significantly different (p=0·65 for major discrepancies and p=0·21 for minor discrepancies). Cause of death given by PMCTA did not overlook clinically significant trauma, occupational lung disease, or reportable disease, and did not significantly affect the overall population data for cause of death (p≥0·31). PMCTA was better at identifying trauma and haemorrhage (p=0·008), whereas autopsy was better at identifying pulmonary thromboembolism (p=0·004).

INTERPRETATION

For most sudden natural adult deaths investigated by HM Coroners, PMCTA could be used to avoid invasive autopsy. The gold standard of post-mortem investigations should include both PMCT and invasive autopsy.

FUNDING

National Institute for Health Research.

Differences between postmortem computed tomography and conventional autopsy in a stabbing murder case

OBJECTIVE

The aim of the present work is to analyze the differences and similarities between the elements of a conventional autopsy and images obtained from postmortem computed tomography in a case of a homicide stab wound.

METHOD

Comparison between the findings of different methods: autopsy and postmortem computed tomography.

RESULTS

In some aspects, autopsy is still superior to imaging, especially in relation to external examination and the description of lesion vitality. However, the findings of gas embolism, pneumothorax and pulmonary emphysema and the relationship between the internal path of the instrument of aggression and the entry wound are better demonstrated by postmortem computed tomography.

CONCLUSIONS

Although multislice computed tomography has greater accuracy than autopsy, we believe that the conventional autopsy method is fundamental for providing evidence in criminal investigations.

Adult post-mortem imaging in traumatic and cardiorespiratory death and its relation to clinical radiological imaging

The use of post-mortem imaging is expanding throughout the world with increasing use of advanced imaging techniques, such as contrast-enhanced CT and MRI. The questions asked of post-mortem imaging are complex and can be very different, for example for natural sudden death investigation will focus on the cause, whereas for trauma the cause of death is often clear, but injury patterns may be very revealing in investigating the background to the incident. Post-mortem imaging is different to clinical imaging regarding both the appearance of pathology and the information required, but there is much to learn from many years of clinical research in the use of these techniques. Furthermore, it is possible that post-mortem imaging research could be used not only for investigating the cause of death but also as a model to conduct clinically relevant research. This article reviews challenges to the development of post-mortem imaging for trauma, identification and cardiorespiratory death, and how they may be influenced by current clinical thinking and practice.

Surgical interventions with fatal outcome: utility of multi-phase postmortem CT angiography

Cases of fatal outcome after surgical intervention are autopsied to determine the cause of death and to investigate whether medical error caused or contributed to the death. For medico-legal purposes, it is imperative that autopsy findings are documented clearly. Modern imaging techniques such as multi-detector computed tomography (MDCT) and postmortem CT angiography, which is used for vascular system imaging, are useful tools for determining cause of death. The aim of this study was to determine the utility of postmortem CT angiography for the medico-legal death investigation. This study investigated 10 medico-legal cases with a fatal outcome after surgical intervention using multi-phase postmortem whole body CT angiography. A native CT scan was performed as well as three angiographic phases (arterial, venous, and dynamic) using a Virtangio(®) perfusion device and the oily contrast agent, Angiofil(®). The results of conventional autopsy were compared to those from the radiological investigations. We also investigated whether the radiological findings affected the final interpretation of cause-of-death. Causes of death were hemorrhagic shock, intracerebral hemorrhage, septic shock, and a combination of hemorrhage and blood aspiration. The diagnoses were made by conventional autopsy as well as by postmortem CT angiography. Hemorrhage played an important role in eight of ten cases. The radiological exam revealed the exact source of bleeding in seven of the eight cases, whereas conventional autopsy localized the source of bleeding only generally in five of the seven cases. In one case, neither conventional autopsy nor CT angiography identified the source of hemorrhage. We conclude that postmortem CT angiography is extremely useful for investigating deaths following surgical interventions. This technique helps document autopsy findings and allows a second examination if it is needed; specifically, it detects and visualizes the sources of hemorrhages in detail, which is often of particular interest in such cases.

Detection of hemorrhage source: the diagnostic value of post-mortem CT-angiography

The aim of this study was to compare the diagnostic value of post-mortem computed tomography angiography (PMCTA) to conventional, ante-mortem computed tomography (CT)-scan, CT-angiography (CTA) and digital subtraction angiography (DSA) in the detection and localization of the source of bleeding in cases of acute hemorrhage with fatal outcomes. The medical records and imaging scans of nine individuals who underwent a conventional, ante-mortem CT-scan, CTA or DSA and later died in the hospital as a result of an acute hemorrhage were reviewed. Post-mortem computed tomography angiography, using multi-phase post-mortem CTA, as well as medico-legal autopsies were performed. Localization accuracy of the bleeding was assessed by comparing the diagnostic findings of the different techniques. The results revealed that data from ante-mortem and post-mortem radiological examinations were similar, though the PMCTA showed a higher sensitivity for detecting the hemorrhage source than did ante-mortem radiological investigations. By comparing the results of PMCTA and conventional autopsy, much higher sensitivity was noted in PMCTA in identifying the source of the bleeding. In fact, the vessels involved were identified in eight out of nine cases using PMCTA and only in three cases through conventional autopsy. Our study showed that PMCTA, similar to clinical radiological investigations, is able to precisely identify lesions of arterial and/or venous vessels and thus determine the source of bleeding in cases of acute hemorrhages with fatal outcomes.

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.

Format preferences of district attorneys for post-mortem medical imaging reports: understandability, cost effectiveness, and suitability for the courtroom: a questionnaire based study

AIMS

The objective of this study was to explore the perception of the legal authorities regarding different report types and visualization techniques for post-mortem radiological findings.

METHODS

A standardized digital questionnaire was developed and the district attorneys in the catchment area of the affiliated Forensic Institute were requested to evaluate four different types of forensic imaging reports based on four cases examples. Each case was described in four different report types (short written report only, gray-scale CT image with figure caption, color-coded CT image with figure caption, 3D-reconstruction with figure caption). The survey participants were asked to evaluate those types of reports regarding understandability, cost effectiveness and overall appropriateness for the courtroom.

RESULTS AND CONCLUSION

3D reconstructions and color-coded CT images accompanied by written report were preferred regarding understandability and cost/effectiveness. 3D reconstructions of the forensic findings reviewed as most adequate for court.

Targeted cardiac post-mortem computed tomography angiography: a pictorial review

With the introduction of targeted coronary artery angiography to post-mortem computed tomography (PMCT) it is now possible to assess the coronary arteries and left ventricle after death without, case dependent, the necessity to undertake an invasive autopsy. The purpose of this pictorial review is to act as a walk through aid memoire and educational learning document for radiologists and pathologists alike who may be new to the use and interpretation of targeted PMCT angiography. By using an example scanning protocol, which uses both positive and negative (air) contrast mediums, this pictorial review provides a systematic approach to vessel and ventricular assessment that is based upon clinical cardiac angiography but adapted to PMCT.