Paper 4: Second autopsy - a bane or a boon!
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Received: July 16, 2003
Accepted: November 27, 2003
Ref: Sharma L, Khanagwal V.P., Sirohiwal B.L., Paliwal P.K., and Yadav D.R.  Second autopsy - a bane or a boon!  Anil Aggrawal's Internet Journal of Forensic Medicine and Toxicology, 2003; Vol. 4, No. 2, (July - December 2003): ; Published: November 26, 2003, (Accessed: 

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  : EMBASE Accession Number: 2004204910


Dr. Luv Sharma, Lecturer Dr. Vijay P. Khanagwal, Reader Dr. Basant Lal Sirohiwal, Associate Professor Dr. P.K. Paliwal, Associate Professor Dr. D.R.Yadav, Professor & Head
Luv Sharma
Vijay P. Khanagwal
Basant Lal Sirohiwal
P.K. Paliwal
D.R.Yadav

Second autopsy - a bane or a boon!

Dr. Luv Sharma, Lecturer; Dr. Vijay P. Khanagwal, Reader; Dr. Basant Lal Sirohiwal, Associate Professor; Dr. P.K. Paliwal, Associate Professor; Dr. D.R.Yadav, Professor & Head,

Department of Forensic Medicine
Pt. B.D. Sharma Postgraduate Institute of
Medical Sciences, Rohtak-124001
Haryana, India.


Abstract

Usually the initial postmortem examination on bodies is carried out in India by Medical Officers in the periphery or by Forensic experts. This "referral" system is prevalent all over the country by which a medical officer refers a dead body to the nearest Forensic specialist/department if he/she cannot come to a definite opinion regarding cause of death. Many a times the medical officer, due to lack of Forensic knowledge, fails to see wounds or injuries on the body which would be a routine job for a forensic expert. Most of the referred cases coming to Forensic departments are due to extensive putrefaction of the body, however sometimes deliberate or unintentional overlooking of clearly visible injuries is done by the medical officers. This leads to travesty of justice to the dead person; relatives of the deceased then request for a re-postmortem. The results of the re-postmortem of the body usually has a totally different outcome than that of the first autopsy. In this paper is discussed a case report in which the medical officer at a district hospital conducted a postmortem examination on the dead body of a young man with the opinion that death was caused due to a railway accident. Later on the re-postmortem conducted in this department revealed a totally different story..

Keywords

Second postmortem, Referral

Introduction

The word "Autopsy" is derived from two terms "autos" i.e. self and "opsis" i.e. view (self view) of a dead body (Parikh C.K. 1999). Many a time, a postmortem examination is carried out on a dead body and opinion formed thereof regarding cause, manner and time of death. Sometimes certain avoidable/unavoidable circumstances arise compelling a second postmortem examination on an already autopsied body. These "circumstances" can be lack of forensic knowledge of the first team, non-seriousness in trying to find cause of death or disgust and resultant superficial autopsy conducted by the doctor while examining a putrefied/mutilated body. Another set of conditions can be those involving financial/political considerations. Corruption on the part of the doctor or bending backwards to oblige a politician having a vested interest in the case can also lead to incomplete/improper initial autopsy.

It is thus important that whichever pathologist tackles each type of case should be trained and experienced in that particular field. Unfortunately either due to lack of staff, and resources or because the system is deficient, medico legal autopsies especially of major criminal cases are frequently preformed by pathologists inexperienced in forensic procedures (Knight B, 1991).

Another aspect important here is that in many homicides a second autopsy is performed by another pathologist acting on behalf of the defense lawyers representing the accused (Knight B, 1991).

The present case was of a young adult male found dead alongside a railway track with his limbs amputated. There was a gross difference in the method and results of the first and second postmortem examinations which are detailed in this paper.

Case History

A dead body of a young male was brought to our department for expert post mortem examination a few months back by the railway police. The individual had been found dead along side the railway tracks some days before and the initial post mortem examination was carried out in a general hospital by a state medical services doctor. Surprisingly, instead of referring the body straightaway to our department, the medical officer carried out an autopsy and opined the neck to be amputated, head crushed, the upper limbs and lower limbs amputated with bleeding present. It was surprising because it was against the usual practice followed by state medical services/peripheral medical officers who normally refer every "difficult" case to the medical college quoting lack of forensic knowledge or excessive putrefaction. The current case fell in the category of "difficult" cases.

The medical officer further described all viscera including stomach "healthy" and gave cause of death as "coma due to injuries to brain and brain stem secondary to head injuries and hemorrhage" with all injuries including amputation injuries described "seeming" to be ante mortem in nature. He further opined that the injuries "could be" caused by railway injuries.

Later, the relatives of the deceased heard from some reliable witnesses that the deceased accompanied by his friend (both of which worked in a factory) arrived at the railway station (near which the body was later recovered) on the night of the incident and ate and drink there at a dhabha (Roadside motel/restaurant very popular in North India). They were leaving at around 10:30-11.00 P.M. when they were stopped by a group of men who seemed to know them and later on were thrashed by them. Both of them lost consciousness. A few hours later the friend of the deceased recovered. He was surprised to see that his friend (the deceased) had vanished. He then returned to his house in a pretty bad shape but could not say anything about the whereabouts of the deceased. Fearing some foul play, the father of the deceased requested for a repeat postmortem and thus the body was brought to our department.

Details of the second autopsy

As is the mandatory procedure in all such cases, we studied the inquest papers in great detail and made inquiries from both the police and relatives. The police had taken photographs of the body at the scene of crime (railway station where the body was found initially). We requested for those photographs as well (Illustration I). The photographs clearly showed the neck to be intact in contrast to what the medical officer had mentioned in the post mortem report.

The deceased shortly after recovery from alongside railway tracks at the nearest railway junction
Illustration I: The deceased shortly after recovery from alongside railway tracks at the nearest railway junction (Click to enlarge)

On inspection, the body showed no signs whatsoever of any post mortem examination. No incision, no cuts, no stitches, no nothing! In fact it had not been touched by the medical officer who had so painstakingly written his post mortem report. The body was received in 7 separate parts namely:-

1. Major part of vault of the skull was separated from rest of head at a level corresponding to supra orbital margin all around. Bone margins of skull thus separated showed multiple fractures yet were loosely attached to one another. The edges of broken bone were rough and uneven.

2. Both the upper limbs were transacted at a level 3 cm below tip of shoulders (bilaterally). The Humerii were exposed and transected at the same level.

3. Right hand was transected and separated from rest of right upper limb at the level of wrist. Lower ends of both bones forearm on right side were transected and exposed at same level.

4. Both thighs were transected and separated from rest of the lower limbs at a level situated 12 cm above knee joint with both femurs transected and exposed at same level.

In all above separations, margins were rough and irregular and no infiltration of blood was seen in exposed trabeculae of fractured bones. As is clearly observed from the above description all the so-called rail track injuries were post mortem.

On inspection of the neck area which was totally intact (and not "amputated" as described by the medical officer), the following injuries were seen:

(a) Diffuse contusion of size 2x1 cm in front of neck (anterior) on right side about 3 cm to right of midline which was obliquely placed. Roughly oval in outline. On dissection, base was found to be congested while underlying neck structures were ecchymosed deep down.

(b) Diffuse contusion in left side of neck, 5 cm to left of midline, of size 4.5 x 3 cm which was obliquely placed and with an irregular outline. On dissection, base was congested with underlying neck structures ecchymosed.

On dissection of neck, the hyoid bone was seen to have an internal compression fracture at the junction of outer 1/3rd and inner 2/3rd on right side with infiltration of blood into trabeculae of fractured bone.

(c) Multiple diffuse contusions over anterior chest wall on both sides of sizes varying between 4 x 2.5 to 2 x 0.5 cm. Underlying tissues were ecchymosed.

The stomach and other viscera were congested with stomach containing about 100 cc of brownish fluid with gastric mucosa congested.

Thus with the detailed examination of the body it was concluded that the deceased had first been poisoned, then throttled and his dead body was laid in a railway track to get transected by a train thereby showing cause of death to be suicide.

Later on the investigating agencies caught the culprits who confessed to the crime and stated the similar sequence of events (as opined by us) that ultimately led to a horrible death and subsequent concealing and planting of evidence. The deceased was hobnobbing with the factory authorities on one side and with the union on the other and this led a faction of mill workers and the management to get him out of the way.

Summary And Conclusions

The certified pathologist has received advanced training in recognizing and interpreting diseases and injuries in the human body. It is this knowledge that enables the medical examiner/coroner to make significant contributions to the homicide investigation (Geberth V.J., 1993). Unfortunately in our setup, the medical officers posted at district hospitals have scant knowledge of forensic pathology and are totally ignorant about the term "medico legal autopsy".

The "medico legal" or "forensic" autopsy which is performed on the instructions of the legal authority responsible for the investigation of sudden, suspicious, obscure, unnatural, litigious or criminal deaths. As already mentioned partial or incomplete autopsies are very commonly done by inexperienced doctors in peripheral hospitals. Partial autopsies have no place in forensic pathologic practice and the files of any busy medico legal office contain innumerable examples of cases in which complete autopsy placed a death in a totally different light from that postulated initially. Occasionally one reacts or hears about bodies being exhumed for second or third "autopsies". Performing a second autopsy, in addition to being emotionally traumatic to the decedent's family and expensive, indicates that the original autopsy was either incompletely carried out, incorrectly observed or erroneously interpreted (Adelson L, 1974).

Thus it should not be overemphasized that the performance of an autopsy should ideally be only carried out by a pathologist who has been trained in the techniques. Furthermore medico legal autopsies should only be carried out by pathologists who have training and experience in forensic pathology, either as a career or as an addition to their pathology training (Knight B. 1991). Sadly in our country, forensic medicine is not a preferred specialty and there are few specialized forensic pathologists, the number even fewer in district and peripheral hospitals. The "tradition" of simple referral on grounds of "highly putrefied bodies" or "the cause of death cannot be opined at this level" further complicates matters.

The inexperienced medical officer, not having even touched the body, God knows why, wrote down a postmortem report and tried to opine the cause and manner of death to be railway accident and suicidal respectively. It seems, he did not even can to see the body properly as he described the neck to be transected! Had he had even a cursory look at the neck, he would have been able to see the bruises caused by manual strangulation. The absence of infiltration of blood at transected ends of limbs (as described to be amputated and ante mortem by him) was also missed by him. The police had provided him photographs (see illustrations I and II) taken after recovery of the body clearly showing the neck to be intact. Such carelessness, whether intentional or not, deserves to be condemned.

Thus the second autopsy was a not only a boon for proper justice to the deceased by also a bane as it showed clearly the lack of initiative and knowledge on the part of Medical Officer and also that if the initial postmortem had been carried out in proper sequence and procedure the unnecessary harassment of deceased relatives could have been avoided.

The health authorities must make basic training in forensic medicine compulsory for doctors posted in state medical services to avoid such "medico legal sacrilege" in future.

REFERENCES


1. Knight B. (1991). The forensic autopsy. In: Forensic Pathology. 1st Ed. London: Edward Arnold, p. 2-3.
2. Geberth V.J. (1993). The autopsy. In: Practical Homicide Investigation - Tactics, Procedures and Forensic Techniques. 2nd Ed. London: CRC Press, p. 419.
3. Knight B. (1991). Medical aspects of death. In: Simpson's Forensic Medicine. 10th Ed. London: ELBS, p. 21-7.
4. Parikh C.C. (1999). Medico legal autopsy. In: Parikh's Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology. 6th ed. New Delhi: CBS Publishers and Distributors, p.85.
5. Adelson L. (1974). The medico legal autopsy. In: Pathology of Homicide. Springfield: Charles C. Thomas, p.11.

*Corresponding author and requests for clarifications and further details:
Dr. Luv Sharma
45/11-J, Medical Enclave,
Rohtak-124001 (Haryana)
India
Ph.: 91-1262-51165
E-mail: drluvksharma@yahoo.com

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