FORENSIC VERSUS HOSPITAL AUTOPSIES

An autopsy represents a postmortem surgical examination of a human body, but not all autopsies are equivalent. There are two basic types of autopsies: forensic or medico legal autopsies and hospital or medical autopsies. There are several very important differences between the two. The first is that forensic autopsies fall under the jurisdiction of the local governmental death investigation office (coroner or medical examiner), whereas hospital autopsies do not. As such, forensic autopsies do not require consent from the legal next-of-kin and the coroner or medical examiner may, by law, order an autopsy. Hospital autopsies require a properly executed and witnessed consent signed by the decedent’s (dead person’s) legal next-of-kin before the autopsy can be performed.

Making certain that the person being autopsied is, in fact, the person he/she is supposed to be is of utmost importance, no matter what type of autopsy is being performed. In virtually every hospital autopsy performed, the decedent’s identity is already known and well-documented via identification bracelets and within the medical records that accompany the body. In contrast, a very important aspect of every forensic autopsy involves the positive identification of each decedent.

Depending on the structure of the death investigation system, this very important task may be the official responsibility of different entities. In certain jurisdictions, the legal responsibility rests with non-pathologist death investigators (coroners or non-pathologist medical examiners), while in other offices, the responsibility rests with those performing the autopsies. In either case, all persons and offices involved should work together to ensure positive identity in every case.

Frequently in hospital autopsies, the cause of death is already known, and the autopsy is performed to attempt to answer specific questions that family members or physicians have regarding the case, such as disease extent, effectiveness of therapy, etc. For these reasons, hospital autopsies are frequently limited to the examination of certain body parts. In addition, the complete medical record is usually available to the pathologist prior to hospital autopsy performance. As a result of this the “background information” being readily available prior to autopsy, a pathologist can perform the autopsy with specific focus. In contrast, while the cause of death may be obvious in certain forensic cases and a certain amount of background information may be available prior to examination, forensic autopsies are usually performed with the intent of documenting all findings, rather than being focused on a single issue or two. Frequently in forensic work, all of the important background information, as well as all of the questions that will eventually be asked regarding a specific case, are not known when the autopsy is being performed.

In general, if resources allow, the most thorough postmortem forensic examination involves a complete autopsy (head, neck, and trunk), although different office and practitioner policies and protocols may allow for limited dissections in specific case types.

Another major difference that exists between hospital and forensic autopsies is the fact that, in many hospital autopsies, the external examination is relatively unimportant, whereas in forensic cases, the external examination can frequently be one of the most important aspects of the case. As such, photography is a key component of the forensic autopsy, whereas it is usually considered optional in the hospital autopsy.

Certain other procedures and tests are common in forensic cases, but quite rare in hospital cases. The two most common are toxicology testing and radiography (X-rays). A significant percentage of forensic cases will have positive toxicology tests (drugs are detected), which will, in many cases, be an important factor in determining the cause of death. Likewise, a significant percentage of forensic cases also require radiography. Various specialized dissections can occur in either type of autopsy, but are probably more common in forensic cases. These include anterior (front) neck dissections, posterior (back) neck dissections, spinal cord examination, eye removal and examination, dissection of the deep veins of the legs, etc.

“Fixing” organs or tissues in formalin (a preservative solution containing formaldehyde) prior to dissecting them is a procedure that can occur with either type of autopsy, although it is probably more common in hospital cases, where many pathologists were trained to “fix” the organs prior to detailed dissection. In forensic cases, however, it is not unusual in certain cases to choose to fix a particular organ prior to sectioning, with the brain and heart being the most common organs in which this is done. It is important to note here that formalin fixation will change the appearance of tissues, usually causing a darker, less shiny appearance (this is obvious when comparing photographs of “fresh” organs to those of “fixed” organs), and will also cause the tissues to become more firm, thus making dissection a bit easier.

A final difference between hospital and forensic autopsies involves those who actually perform, or assist with, the autopsy. In many hospital-based pathology practices, pathology assistants (PAs) are employed to assist pathologists with many functions. In some practices, they are responsible for performing the “gross” part of the autopsy, with pathologists only performing histologic (microscopic) examinations. However, this is not acceptable practice in forensic autopsies.