Forensic medicine natural death

DR.AB.HALIM MANSAR

1Dr. Ab. Halim Mansar

OBJECTIVES:

- most fundamental objectives of an inquest is to ascertain facts pertaining to the death i.e who the dead person was, when did he die, where did he die and how did he die? -Answers to these Qs are obtained from inquiry, post mortem examination(p.m.e)-Deaths due to (dt) MVAs + homicide invariably end up in a p.m.e,in other sudden, unexpected + unnatural deaths the body may be released without an autopsy if there is sufficient evidence + materials to satisfy the Coroner/ Magistrate on the cause, manner + circumstances of death.


THE MEDICO-LEGAL AUTOPSIES

INQUESTall deaths dt unnatural causes + deaths

believed to be dt natural causes but where the medical COD is not certain / known are subjected to an inquest.

According to Section 330 of the Criminal Procedure Code (CPC) of Malaysia

is a preliminary inquiry conducted by a Coroner / a Magistrate


OBJECTIVES:*An inquest is not a trial

-There is no complainant/ defendant + at the conclusion of the inquest, a verdict is arrived as to whether death was dt a natural, accidental, suicidal/ homicidal cause

-The authority in M’sia, (the Magistrate plays the role of the Coroner) which conducts the inquest will order a doctor to perform a medico-legal autopsy. -In sudden, unnatural + violent deaths, the police institute the inquest + executes the power to order a p.m.e by issuing the form Pol.61


OBJECTIVES:

*Consent from relatives of the deceased is not required.-In a sudden unexpected death, only a doctor after a p.m.e may be able to determine the COD.


DEATHS OCCURRING UNDER THE FOLLOWING CIRCUMSTANCES ARE SUBJECTED TO AN INQUEST:

1. All unnatural, suspected unnatural, violent deaths, e.g homicides 2. Deaths apparently from nat. causes but where the exact medical COD is not known. 3. Any death caused by an accident arising out of the use of a vehicle/ which was caused by an aircraft / rail accident 4. Any death arising out of industrial employment, by accident, industrial disease /industrial poisoning 5. Any death due to poisoning (alcohol intoxication, coal gas, insecticides, barbiturates,etc) 6. Any death where the circumstances would seem to indicate suicide


7. Deaths following anaesthesia, surgery/ any medical investigative procedure 8. Any death resulting from an accident in the home, hospital/ institution/ any public place. 9. Any death apparently caused by neglect (e.g.malnutrition) 10. Deaths in custody such as in police custody, remand prison, prisons, rehabilitation centers, detention camps etc

11. Deaths in mental institutions, asylums, etc. 12. Deaths associated with pregnancy, abortion, childbirth etc. (maternal death)


13. Any death of a newborn child whose body is found 14. Death of a child from suffocation (including overlaying) 15. Deaths of foster children 16. Any death as a result of a fire/ explosion 17. Death by drowning 18. Any death (occurring not in a house) where deceased’s residence is unknown


MALAYSIAN CRIMINAL PROCEDURE CODE (CPC)

CHAPTER 20- INQUIRIES OF DEATH

Meaning of “cause of death.” 328. In this Chapter the words “cause of death” include not only the apparent COD as ascertainable by inspection or p.m.e of the body of the deceased, but also all matters necessary to enable an opinion to be formed as to the manner in which the deceased came by his death + as to whether his death resulted in any way from, / was accelerated by, any unlawful act / omission on the part of any other person.


Difficult AutopsiesBody found in water.Body found by the road-sideDecomposed bodySkeletonised bodyBody fragmentsSeverely charred bodyMass disasterAnesthetic and post-operative deathsChild deathsDeaths in young adultsMaternal deaths.


The Medico-Legal Autopsy. • Autopsy is only one part of death

investigation. Body, history and scene are equally important. Each of the three aspects of the death investigation process are equally important.

• Scene:-Attendance by police officers,forensic pathologist, forensic scientist.- The aim is to collect the maximum information with minimum disturbance. - Photography,videos,trace evidence


History: -Social- from relatives,friends,police. -Medical-from GP,hospital notes. Often indicates the likely cause of death. -Psychiatric-from GP,hospital notes. May indicate possibility of suicide.

- Autopsy authority: -Police or Coroner(Magistrate). - “Police 61” form(Permintaan Pemeriksaan Mayat).


Identification Visual(relatives).Circumstantial(address,car,papers,cards,k

eys,cloths). Medical( scars,teeth,x-rays,DNA). Fingerprint.


Personal effects and clothing

By contrast with the hospital autopsy, the examination of personal effects and clothing is an integral part of the medico-legal autopsy providing information on life style, events leading to death, and often the actual cause of death.

Clothing findings are correlated with historical and scene information, e.g. appropriateness of clothing, source of stains, trace materials. Clothing findings must also be correlated with other autopsy data, e.g. injuries, source of blood stains.


External Examination

-This is a detailed head to toe examination of a naked body, documenting stains and soiling, general and specific individualising characteristics,postmortem changes(temperature,lividity,rigor mortis,putrefaction).

-The location, extent and type of staining or soiling of the body are described.


Injuries

All injuries are described systematically either

by grouping them according to anatomical

location or in numerical order.

Injuries are described as to their type, (bruise, abrasion laceration,incised

wound,puncture of stab wound,gunshot wound,burn,fracture), location,size,shape and colour.

Internal injuries are described in continuity with the related externally apparent injuries.

Old injuries are segregated from recent injuries.


- Signs of medical intervention.-Medical intervention is described under a

separate heading. This includes all medical equipment attached to,or accompanying the body.

-External surgical incisions are described in continuity with internal evidence of surgery.


Internal examinationThe internal examination is systematic description

of natural disease and recent injuries. Negative observations are included,e.g. no pulmonary thrombo-emboli,no significant coronary atherosclerosis,etc.


Other examinations-Any special dissections,(neck dissection),or further

examination of organs(brain after formalin fixation), together with microscopic, biochemical and toxicological studies shoulder also be described.

Definition-Mechanism of death: the physiological or biochemical

derangement produced by the above cause, which is incompatible with life: i.e. how the disease or injury leads to death.

-Manner of death: explains how the cause of death came about : I.e. whether natural, accident, suicide, homicide or undetermined/unascertained. The manner of death as determined by the forensic pathologist is an opinion based on the facts concerning the circumstances leading up to and surrounding the death in conjunction with the findings at autopsy and the laboratory tests.


SUDDEN AND UNEXPECTED NATURAL DEATH

Although from the description above given a natural death cause no obvious criminal or accidental, it nevertheless becomes of some concern to the forensic pathologist simply because of the difficulty or even impossibility to furnish a certifiable cause of death

The numerous causes of sudden natural death may conveniently be classified according to the different anatomical systems of the body.


Definition - Death within 24 hrs from onset of symptoms- Some accepts : death within 1 hrs of onset of

symptoms- An unexpected witnessed death (nat. causes

wit/out preexisty disease than occurs within 6 hrs of onset of symptoms

- Cor. Heart Disease > 75 % of sudden Cardiac Deathsother Cardiac conditions : = 20 % of casesCOD remains unknown : 1 – 2 % of cases


Cardiovascular SystemDeaths resulting from diseases and disorders

of the circulatory system account for the vast majority of sudden natural deaths.

They are considered under diseases of the vessels, the heart muscles and the heart valves.

In some cases there is an overlap from one system to another.


Ischemic heart diseaseInterruption or interference with the blood flow to

the heart along the coronary arteries will have profound effects on the heart itself

In the extreme-the heart will suddenly cease functioning

In less extreme, areas of the heart will fail which in turn causes a chain reaction and finally the complete heart failure.

At autopsy, one or more of the main branches of the two coronary arteries may show of severe disease process. There will be a deposition of soft white or yellow necrotic fatty material on the lining of the arteries


Hypertensive Heart DiseaseAn enlargement of the left ventricle of the heart with

accompanying increase in the thickness of the muscle wall will result in a raise blood pressure, frequently to a level twice as high as normal.

So that, rupture of vessels is frequently seen in the presence of hypertension – raised blood pressure. Example: rupture of a cerebral artery.

The cardiac enlargement almost limited to the left ventricle, the three remaining usually within normal size.

In many cases the cause for cardiac enlargement is unknown, when the term primary or essential hypertension is used.


Death occurs quite suddenly and unexpectedly.

There may be an incident of exertion, anger, emotion and stress but equally the death may follow a period of rest.

One reason for a sudden collapse and death is that the mass of heart muscle has outstripped its own blood supply.


Aortic Valve diseaseSudden death result because of the

hyperthrophied left ventricle to force the blood through the diseased and narrowed valve.

An alternative reason is that the disease process may spread out from the valve and impede the entry of blood into the ostia of the nearby coronary arteries.


RESPIRATORY SYSTEMThe main causes are massive haemorrhage in

the air passages, pneumothorax, infections and asthma.


Haemorrhage in the Air PassagesWhen a massive haemorrhage occurs into the

major air passages death results from an obstruction to normal respiratory gaseous exchange.

Erosion of a large pulmonary vessel by a malignant tumor or by an expanding pulmonary infection.Example: Tuberculosis, produces a massive bleed and death follows very shortly

In former years the frequency of syphilitic aortic aneurysms in the thorax means that many would erode into a bronchus leading to a rapid death


PneumothoraxThe spontaneous rupture of an emphysematous

bulla on the periphery of a lung. e.g.: following a bout of coughing or straining during some physical exertion, can be lead to a massive escape of air into one of the pleural cavities.

The vacuum normally present is lost and there is an immediate collapse of the affected lung.

In the absence of special medical equipment death may rapidly ensue, especially if there is concomitant disease in the other lung in the heart.


InfectionsWhilst most chest and lung infections can produce

a severe illness which may lead on slowly to death, there are few bacterial and viral infections, which can produce sudden and unexpected deaths in very short time

Example1: a sports master at large school used to spend his lunchtime break playing indoor football with some of the other teacher before returning to their classes for the afternoon. After a quarter of an hour the game finished and the member of staff went to the changing room to find the sports master dead on bench.


Example 2: A young man, shortly to be married, was decorating his future home one evening after a day’s work along with his father. The young man said that he had some tightness across his chest and that he would not continue painting. His father completed what he was doing and joined his son in another room 20 minutes later, where he found him dead.

In both these cases, there was an acute hemorrhagic bronchopneumonia.- Culture and virological studies showed a florid viral infection.

Chronic bronchitis can also on occasions cause a sudden death.


AsthmaAsthma is the sudden and prolonged spasm of

the smooth muscles in the walls of bronchioles.The bronchospasm causes sever constriction

of the air passages.In the case, the death is due to respiratory

failure in the exchange of oxygen and carbon dioxide within the lungs. This may due to obstruction in the airways, restriction in the ability to expand the lungs, allergic neuromuscular problems and ventilation abnormalities.


CENTRAL NERVOUS SYSTEMNearly always caused by hemorrhage which

may occur either within the brain, or outside within the meninges


Cerebral HaemorrhageThis is often referred to as cerebrovascular accident,

although the word accident is a msnomerThe massive bleed usually occurs either within the

basal ganglia or more distally in the internal capsule.The hemorrhage is associated with raised blood

pressure, so that the victim is usually an elderly person with hypertensive heart disease and widespread arteriosclerosis, especially of the cerebral arteries.

May also occur in other sites such as pons or the cerebellum but they are much less frequently seen.


Circulatory, non-hemorrhagic causes

The formation of a cerebral thrombus in one of the cerebral arteries at the base of the brain, or in a smaller within the brain may cause loss of consciousness leading to death within a short time. The thrombus is usually formed in association with a localized plaque of arteriosclerosis.

A most unusual cause is that of a cerebral embolus, which may arise from an area of thrombus formation within the cavity of the heart, passing upwards to the brain via one of the carotid arteries.


EpilepsyEpileptic sufferers may die during a prolonged

single seizure or more usually during a series of repeated seizures termed status epilepticus

Death is due to asphyxia if the epileptis ceases to breathe or aspirates regurgitated vomit, or has an airway obstructed by the tongue.


GASTROINTESTINAL SYSTEMA Massive bleed may occur when a gastric or duodenal

ulcer erodes through the sub mucosal tissues and into an artery lying close by.

The profuse bleeding may pass down the intestinal tract emerging from the anus, or it may enter the stomach and be vomited up, or more frequently it will pass in both directions.

Another form of dramatic fatal bleeding occurs when varicose and distended veins at the lower end of the esophagus become eroded and burst. This usually occurs in a patient who had developed severe fatty change or even cirrhosis of the liver brought about by chronic alcohol use.


Fatty change to the liver can also produce a sudden death but the exact mechanism remains unknown.

In some cases there is microscopic evidence of fat embolization to the lungs or even the heart or brain.

Equally there may be a sudden disturbance to the nearby pancreas and insulin activity.


OTHER SYSTEMSIn pregnancy, sudden deaths are usually

associated with haemorrhage. The rupture of an extra-uterine pregnancy may

produce a massive intra-abdominal haemorrhage which on occasions has caused death.

Premature separation of a placenta previa may both cause severe exsanguinations unless there is medical aid.

Attempts at abortion by inexpert persons may cause death either by perforation by the instrument of a major vessel, or by causing pulmonary embolus by means of air, chemical fluids or the release of amniotic fluid into the blood stream.


The adrenal gland may be a related to a sudden death as a result of bilateral adrenal haemorrhage produced during a meningococcal septicemia

Usually, there is evidence of the bacterial infection elsewhere followed by adrenal collapse and death.


SUDDEN DEATH FROM UNKNOWN CAUSES

There is nothing more frustrating and no case remains so memorable, than a death for which there is no demonstrable cause

All pathologists of cases where, after autopsy, toxicology, bacteriology, virology, histology and a review of the history of the case with all the professional concerned, there is no reasonable cause to be found.

One very special group of deaths which still remains a mystery is the sudden death in infancy syndrome.


These deaths invite further research into their causation:1. reflex cardiac deaths during or following minor

surgical or medical procedures2. the strange deaths of apparently fit and

healthy young persons during some sport or game

3. on a worldwide scale the deaths of healthy persons who have been cursed to die.


Thank you


Forensic medicine natural death

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