“The Silent Causes: Why Some Autopsies Can’t Reveal the Truth”

Need for Autopsy in every death –

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While the need for autopsy in every death is strongly vouched for, what is more important to ascertain – is the cause of hindrance for an apt & impeccable Autopsy Report. The most significant reason is ‘Negative Autopsy’.

The ‘Negative Autopsy’ is a detailed post-mortem exercise which unsolicits the actual cause of death.

Negative Autopsy finds a mention, when time lapse is a striking factor. Putrefaction and autolysis evolve within the corpse; the morphological patterns of the tissues get obliterated hence; leading to obscure findings regarding the cause of death. Other reasons, causing ‘’Negative Autopsy’s” are:

• several pathologies, usually of cardiac cause and called sudden cardiac death.

• In infants and young people, both long QT syndrome and catecholaminergic polymorphic ventricular tachycardia.

Autopsies which are not able to detect the cause of death after a macroscopic/naked eye examination are labelled as ‘macroscopically negative’. To identify a potential cause of death, these cases need further investigations with toxicological analysis as well as histological studies.

In about 20% of cases cause of death is unclear after dissection of body in view of minimal, indefinite or no findings at all end called as obscure autopsy. In these cases, detailed laboratory examination of different materials / samples from the body and verbal autopsy can lead to cause of death. There may be no adverse medical history, the gross examination may reveal nothing abnormal and histological, toxicological & microbiological screening remains unrewarding. The case can be attributed, as ‘unascertainable’. Such cases may be termed as cases of negative autopsy. The rate may also vary according to the competency, personality and seniority of the doctor conducting the autopsy.

In cases where a doctor offers a cause of death without the benefit of autopsy findings, the error rate is of the order of 25-50%, even in hospital deaths. A survey conducted has demonstrated that a less experienced doctor is often hesitant to show failure in providing a cause of death, feeling that it reflects upon his ability; whereas the more experienced doctor is less inhibited towards the same. If the death is due to interaction of multiple factors, as in case of anaesthetic deaths, it may become difficult to determine the correct liability of each.

If an autopsy identifies no conclusive cause of death, in an apparently healthy individual within an hour of symptom onset or within 24 hour from the last time the person was seen alive, then these cases are defined as Sudden Unexplained Death (SUD).

Again, Obscure Autopsy is which there is a minimal, indefinite or no findings at all and do not reveal any definite cause of death. Commonly these types of deaths are due to obscure natural causes and are a source of confusion to the autopsy surgeon.

Some common causes/ reasons for obscure autopsy are:

• Functional failures like epilepsy, acute asthma, acute left ventricular failure, septicaemia, and deaths precipitated by emotions, stress, etc.

• Natural diseases in which the pathological process is conspicuously not evident.
• Death precipitated by emotional stress and strain acting on a previously diseased heart or any other organ, the existence even unknown to the victim.
• Death occurring from functional failures, e.g., epilepsy, strokes, etc.

• Biochemical disturbances like uraemia, hypo & hyperglycaemia, hypocalcaemia, electrolyte imbalance as in potassium deficiency etc.

• Endocrine dysfunctions such as adrenal insufficiency and thyrotoxicosis or myxoedema.
• Concealed trauma in the form of Concussion, blunt injury to the heart, blast effect without any external injury and electrocution without any external mark.

• Poisoning cases such as delayed subtoxic or narcotic poisoning, dosage mismatch or maladministration of anestheticover, neurotoxic or cytotoxic poisons and plant poisoning, etc.

• Other causes like reflex vagal inhibition, incompatible blood transfusion, air embolism, allergic reactions, anaphylactic deaths etc.

It is well known that the aims of a forensic autopsy depend on the specific case. The first priority is always to determine the cause, manner, and time of death for the legal system, along with the identity of the deceased, but a medical examiner may also set the following objectives:

• to establish the pathological consequences of drug or toxin use or abuse,
• to determine whether any natural disease might have increased susceptibility to the effects of a drug or toxin,
• to collect trace evidence or any other evidence in order to reconstruct and interpret a chain of events, to assess whether death is due to acute workplace injury,
• to ascertain if there has been a lack of surveillance by a public health or federal institution,
• to verify if death is a result of complications associated with surgery, and to evaluate possible health malpractice.

To be continued…………………

Writer Suvro Sanyal

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