The Medicolegal Autopsy: The Public’s Health Insurance Policy

 

The medicolegal or forensic autopsy performed by the forensic pathologist represents an important quality assurance tool for optimizing public health exemplified in the following scenarios:

  • Sudden death at home with 4-day history of abdominal pain and distention
    • Postmortem diagnosis: Clozapine-associated toxic megacolon with spontaneous perforation and acute peritonitis
  • Sudden death at home with history with history of implanted cardioverter defibrillator (ICD ) placement for idiopathic cardiomyopathy of undetermined etiology
    • Postmortem diagnosis: Cardiac sarcoidosis
  • Hospital death following admission and treatment for presumed endocarditis with history of drug abuse
    • Postmortem diagnosis: Respiratory failure due to tooth asphyxia
  • Sudden death at home following hospital admission, treatment, and discharge for presumed asthma attack
    • Postmortem diagnosis: Sudden cardiac death due to hypertrophic cardiomyopathy
  • Sudden death at home with 4-day history of abdominal pain following flu vaccination
    • Postmortem diagnosis: Acute peritonitis caused by perforated diverticulum
  • Sudden death at home 7 days after abdominal hernia surgery
    • Postmortem diagnosis: Bowel perforation by surgical mesh with acute bacterial peritonitis
  • Sudden death in infant following hospitalization for respiratory failure of uncertain etiology
    • Postmortem diagnosis: Oxycodone poisoning
  • In-hospital death following admission with treatment for heroin overdose
    • Postmortem diagnosis: Overdose by acrylfentanyl

These scenarios include death circumstances that fall under the purview of the Medical Examiner or Coroner (ME/C). They are representative of instances in which the medicolegal or forensic autopsy  can highlight diagnostic incongruencies, uncover missed diagnoses, and provide clarification as to the cause of death. The autopsy report along with toxicology and other relevant reports are generated by the ME/C’s office. Reports associated with in-hospital deaths are sent to hospitals upon request, destined to be incorporated into the medical record. The  hospital morbidity and mortality conference serves as the educational platform for review and discussion of valuable medical information contained not only in hospital autopsy reports but also in medicolegal autopsy reports.

As fewer hospital autopsies are being performed, the medicolegal autopsy will become the barometer of public health, and by necessity, the forensic pathologist’s role as “watchkeeper” will  continue to evolve. As a practitioner of medicine, the forensic pathologist utilizes the medicolegal autopsy as his/her main tool in the application of medicine and pathology to uncover previously unknown entities and uses expertise to provide clarity to juries as triers of fact. The medicolegal autopsy can disclose many things including:

  • Pathologies correlated with vague or unrecognized signs and symptoms 1,2,3
  • Emerging drugs of abuse 4,5
  • Peri-procedural and therapeutic complications 6
  • Child/Elder abuse and neglect 7

 

The medicolegal autopsy facilitates health optimization through prompting better monitoring for adverse medication reactions, use of comprehensive hospital drug screening tests, recall of medical devices and medications 8, modification of medical procedures, and legal resolution utilizing expert medical testimony.

References:

  1. Armstrong EJ. Multivisceral sarcoidosis: an unexpected finding in a water-related death. Am J Forensic Med Pathol. 2013:34(1):11-15.
  2. Armstrong EJ. Hiding in plain sight: clinically unrecognized fatal tooth asphyxia revealed by the forensic autopsy. Am J Forensic Med Pathol. 2016;37(1):14-20.
  3. Armstrong EJ, Jenkins AJ, Sebrosky GF, Balraj EK. An unusual fatality in a child due to oxycodone. Am J Forensic Med Pathol. 2004;25(4):338-41.
  4. Guerrieri D, Rapp E, Roman M, et. al. Acrylfentanyl: another psychoactive drug with fatal consequences. Forensic Sci Int. 2017:e21-29.
  5. Daniulaityte R, Juhascik MP, Strayer KE, et. al. Overdose deaths related to fentanyl and its analogs-Ohio, January-February 2017. MMMR Morb Mortal Wkly Rep. 2017;66(34):904-08.
  6. McGuire AR, DeJoseph ME, Gill JR. An approach to iatrogenic deaths. Forensic Sci Med Pathol 2016;12(1):68-80
  7. Collins KA, Presnell ES. Elder neglect and the pathophysiology of aging. Am J Forensic Med Pathol. 2007;28(2):157-62.
  8. fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/HerniaSurgicalMesh/default.htm

 

More information on the relevance of the medicolegal autopsy to Public Health and patient care can be found in Chapter 5 in: Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner.

For a direct link, click on:

https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408

 

 

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