5 - The Autopsy

Question 1

What is a coroner?

Answer 1

An independent judicial officer of the crown who has a statutory duty to investigate the circumstance of certain categories of death for the protection of the public.

Question 2

What are the cases that must be reported to the Coroner?

Answer 2

• Cause of death is unknown
• The deceased has not been seen by the certifying doctor either after death or within the 14 days before death
• Death was violent, unnatural or suspicious
• Death may be due to an accident (whenever it occurred)
• Death may be due to neglect by self or others
• Death may be due to an industrial disease or due to the deceased persons employment
• Death may be due to an abortion
• Death occurred during an operation or before recovery from the effects of an anaesthetic
• Death may be a suicide
• Death occurred during or shortly after detention in police or prison custody
• Death may be related to poisoning

If in any doubt the case must be discussed with the Coroner’s office.

Question 3

What does a Coroners autopsy do?

Answer 3

Conducted to establish the cause of death

Once Coroner has the cause of death his remit is over

Question 4

What are the reasons for a hospital autopsy?

Answer 4

Allows a very thorough examination of the deceased, the extent of their disease, their treatment and its effects

Question 5

Pros for doing a hospital autopsy

Answer 5

Audit – Major discrepancies between stated cause of death and actual cause of death
Monitoring effectiveness of new treatments e.g. complex congenital heart disease.
Teaching e.g. unrivalled clinic pathological correlation.
Research e.g. knowledge of variant CJD relies heavily on study of post mortem brain tissue.

Question 6

What can death certificate data be used for?

Answer 6

Death certificate data used for epidemiology

i.e. Accurate morbidity and mortality data is needed to monitor the nations health, to direct the allocation of scanty resources and to detect environmental risks.

Question 7

What are the 2 types of autopsy?

Answer 7

1. Hospital

Consent must be obtained from the relatives. With the relevant consent, any material can be taken.

2. Coroners

No consent of family needed (but their wishes should be considered)
Material can only be taken if it bears upon the cause of death (with Coroner’s permission)

Question 8

Death certificates. 3 important facts

Answer 8

1. Filled in for any death
2. Taken to Registrar (of Births, Deaths & Marriages) by family
3. Scrutinised and must be correct before registration of death possible

Question 9

What are the parts of a death certificate that must be filled in?

Answer 9

1a Immediate cause of death (must be filled in)
1b Predisposing factor
1c Predisposing factor
2 Other factors contributing to but not directly leading to death
E.G. – 1a Gun shot wound to head or
1a Haemopericardium
1b Myocardial infarction
1c Ischaemic heart disease
2 Hypertension

Question 10

What are the natural causes of sudden unexpected death (in the community)?

Answer 10

Cardiovascular Disease

• Coronary artery disease
• Hypertensive heart disease

Central nervous system

Respiratory system

Gastrointestinal Tract

Question 11

Natural causes of sudden unexpected death

CORONARY ARTERY DISEASE

Answer 11

Cardiac Arrhythmia is usual mode of death (irregular heartbeat)
Severe coronary artery atherosclerosis is most common anatomical finding
Usually in 2 or more major vessels

Other possible findings…

• Myocardial scarring
• Coronary artery thrombosis
• Acute or subacute MI (myocardial infarction)

If arrhythmia is the mechanism of death the diagnosis is one of exclusion, full autopsy must be conducted and severe coronary atherosclerosis must be the major finding. (In such cases cause of death usually stated as1a Ischaemic heart disease)

Question 12

Natural causes of sudden unexpected death

HYPERTENSIVE HEART DISEASE

Answer 12

Usually accompanied by coronary artery atherosclerosis

Cardiomegaly with symmetrical left ventricular hypertrophy

Acute cardiac arrhythmia is usual cause of death

Question 13

Other Cardiac Causes of Sudden Unexpected Death?

Answer 13

• Cardiomyopathy
• Myocarditis
• Structural anomalies (e.g. bridging)
• Floppy mitral valve
• Aortic stenosis (usually calcific)
• Conduction abnormalities (e.g. long QT syndrome)

Vascular System
-Ruptured aortic aneurysm associated with atherosclerosis & hypertension

Question 14

Natural causes of sudden unexpected death

CENTRAL NERVOUS SYSTEM

Answer 14

Non traumatic subarachnoid haemorrhage:
(Usually due to Berry aneurisms, 2-4% adults, 90% silent until rupture 2/3 symptomatic between 40 & 65 years old)

Intracerebral haemorrhage:
10-30% of all strokes most common cause is hypertension.

Epilepsy

Question 15

Natural causes of sudden unexpected death

RESPIRATORY SYSTEM

Answer 15

Pulmonary embolus

Asthma

Question 16

Natural causes of sudden unexpected death

GASTRO INTESTINAL TRACT

Answer 16

(Not usually unexpected or sudden)
Bleeding Oesophageal Varices
Bleeding Ulcers
Pancreatitis

Question 17

What are the causes of Sudden Unexpected Death (in the community)? NOT NATURAL

Answer 17

Drugs (alcohol)

Trauma

Question 18

Causes of Sudden Unexpected Death (in the community)- (Not Natural)
ALCOHOL

Answer 18

Not usually a cause of sudden unexpected death (but can be in alcoholics).
Often associated with GI problems.
Often alcohol related damage goes with drug use so think of drugs when you see it.

Question 19

Causes of Sudden Unexpected Death (in the community)- (Not Natural)
TRAUMA

Answer 19

Self induced

Caused by others

Question 20

What is a bruise? (Contusion)

Answer 20

A blunt trauma injury. Occurs alone (skin intact) or is associated with other injuries.

You can bruise after death (but usually small and lie on dependant parts).

Not everything is a bruise: e.g. Pink areas may be due to hypothermia.

Question 21

How are bruises formed?

Answer 21

An extraversated collection of blood which has leaked from damaged small arteries, venules and veins but not capillaries.
Occur more easily where skin is lax. Fragility of vessels, coagulation state etc all effect bruising.

May take hours or days to form. May get patterned bruises (can see better with special light sources). Deep bruising may never be seen on the surface.

Question 22

What is an abrasion?

Answer 22

A graze or scratch. The most superficial of blunt trauma injuries.

Confined to the epidermis (strict definition) but may actually extend into the superficial dermis due to skin anatomy).

Can occur before and after death

Due tangential force – may have a distal skin tag eg. Friction burn, or Vertical force eg Stamp – no distal skin tag.

Abrasion examples – Friction burn, Car radiator, Flooring, Whip, Stamp.

Question 23

What is a laceration?

Answer 23

A split to the skin. The result of blunt force overstretching the skin. Usually pass through the full thickness of the skin. They are deep and will bleed.

Margins ragged with crushing and bruising. “Bridging fibres” arch across the skin defect.

Common where skin can be compressed between the force and underlying bone e.g. Scalp, elbow, shin.

Rare over soft fleshy areas e.g. Buttocks, breasts. A laceration shows poor reproduction of the object causing it.

“Flaying” – tangentially applied force leading to a horizontal laceration.

examples – Fall, Punch, Stick, Hammer, Bomb, Wheel of car (flaying).

Question 24

What are Cut and Stab wounds?

Answer 24

CUT (or slash)
The length of the injury is longer than its depth.

STAB (or penetrating injury)
The depth of the wound is greater than the width.

BOTH

• Caused by an object with a sharp or cutting edge
• Usually a knife but can be anything eg a broken glass or bottle or a piece of metal.
• Edges are clean and well demarcated. Minimal injury to surrounding tissue.

Information about weapon type can be gained from the wound but beware of over interpretation.