06/07/2018

1

Forensic pathology in the Netherlands

Prof. Bela Kubat

Organization

• Forensic medicine – regional for. physicians• Forensic radiology – MUMC, Gouda• Other forensic medical disciplines and forensic

toxicology – NFI (Netherlands Forensic Institute)

Regional forensic medicine

• Crime scene• External examination – procedure advice to

the prosecutor• Death certificate issue• Medical examination of living victims• Medical care of persons in police custody

Netherlands Forensic Institute

• 36 forensic disciplines • Forensic medical department

- F. pathology- F. anthropology- F. medicine (complex cases)- F. pediatrics- F. medical photography

06/07/2018

2

Forensic pathology

• 5 pathologists • Clinical pathologists (5-years’ training)• Sub-specialization in forensic pathology (2-

years’ training)• Additional expertise in forensic

pediatric pathology, cardio-pathology, neuropathology & road and aviation accidents

What do we do• POST MORTEMS • Additional questions, cold cases, reconstructions• Expert witness testimony in court• External activities (Tsunami, MH17)

Question: “Doctor were you sure the victim was dead after the post mortem?”Question: “Now doctor, isn’t it true that when a person dies in his sleep, he doesn’t know about it until the next morning?”

Steps in forensic post mortem

• PM radiology• Case information• External examination – sex, body characteristics,

skin lesions

• Internal examination • Preliminary report• Additional tests• Final repport

PM radiology – total body CT-scan

• Documentation prior to post mortem• Visualization of e.g. fractures • Reconstruction – shot trajectory, 3-D crime scene

06/07/2018

3

What else can we do with X-ray

• A missing person suspected in a trash barrel• The top sealed with

polyurethane foam

Forensic versus clinical PM

• Extensive external examination• More photo’s

Forensic versus clinical PM

• Extensive external examination• More photo’s • Less well assessable or incomplete bodies and

body parts

Additional examinations

• Histology – disease, dating skin lesions• Neuropathology – trauma, dating of trauma,

disease• Anthropology

06/07/2018

4

Anthropology

• Skeleton examination• Identification – age, sex,

body length• Injuries and

reconstruction of injury mechanism

Radius

Micro trace analysis (MIT)

Causes of death in NFI population

Shooting, stabbing 32%

No COD (16%) & natural

COD(13%) 29%

Intoxications 16%

Beating 12%

Suffocation 8%Other 3% Almost no suicides

and road accidents come to post mortem in the Netherlands

Problematic COD’s

• Metabolic deregulation – hypo-/hyperglycemia, keto-acidosis

• Genetic arrhythmia’s – legal and ethical limitations

• Acute myocardial infarction• Sudden death in epilepsy• Drowning• Smothering

06/07/2018

5

Problematic COD’s

• Metabolic deregulation• Genetic arrhythmia’s • Acute myocardial infarction• Sudden death in epilepsy

• Drowning• Smothering

Male aged 45

• Mild (subclinical) form of von Willebranddisease (coagulopathy) and chronic alcohol intake

• Vascular risk factors in the family• Falls on the back of his head after a punch in

the face• 2 days after the incident mild neurological

complaints à GP prescribes aspirin and consultation with a neurologist the next day

Further course

• Brain CT: small subdural hematoma à stop aspirin, report if symptoms increase or change

• Next day: deep coma, large SDH à operation à death

• Forensic post mortem examination into the role of the person who punched the victim

Is there a connection between the punch and the death

Reflections

• SDH due to the fall? • The influence of aspirin? • Was the advice in the hospital correct?

06/07/2018

6

Reflections

• SDH due to the fall? Yes • The influence of aspirin? • Was the advice in the hospital correct?

Reflections

• SDH due to the fall? Yes • The influence of aspirin? None • Was the advice in the hospital correct? ???

Ruling of the court

• There is a causal relationship between the punch and the death

• A possible treatment error is not relevant to the assessment of the quilt

Thank you