Commentary on: Beer T, Bäckström B, Ottosson A, Rietz A, Michard J-F, Loisel J, et al. The utility of histology in assessing the cause of death in medico-legal autopsies in selected trauma deaths: Suspension-, immersion-, fire-, and traffic-related. J Forensic Sci. doi: 10.1111/1556-4029.15193. Epub 2023 Jan 16.

Abstract

See Original Article here See Author’s Response here Editor, It was with interest that we read the study on the use of routine histology in trauma-related deaths such as suspension-, fire-, immersion-, and traffic-related [1]. The authors concluded that in the assessment of causes and manners of death, histology did not contribute to the assessment in a meaningful way, since the cause of death was changed only in a small proportion of cases, 0.5%–4% [1]. The main objective of a forensic autopsy is to uncover hidden homicides, as far as we know such cases are rare. In 2021, there were 113 deaths due to lethal violence in Sweden according to the Swedish Council for Crime Prevention [2]. Still, in Sweden, we performed 5727 forensic autopsies in the year 2021 [3] making the homicide yield 2.0% (113/5727). However, we could estimate that in 50 cases per year, the forensic autopsy is of importance to discover or to correctly assess the cause and manner of death in those homicides, bringing the yield down to 0.9% (50/5727). This percentage is like those obtained in the study [1]. But, despite this, the forensic autopsy is not in question because the rule of law in our modern society depends on the citizens’ trust that each questionable death is thoroughly investigated by the authorities. We recognize that our example is not totally fair since we compare the use of the forensic autopsy in unnatural deaths to the use of histology in selected trauma deaths, but we argue that the comparison highlights the implied cost–benefit analysis. The authors refer to a statement in Swedish law “the sampling of tissues should be necessary to fulfill the purpose of the autopsy” [1, 4] implying a restrictive attitude toward tissue sampling in forensic autopsies. In our opinion, the purpose of the autopsy is not only to determine the cause and manner of death but also to ensure that the assessment is robust to later scrutiny. A forensic autopsy is often performed in the initial stages of a police investigation. At any later stage, the circumstances surrounding the case might change, which underlines the importance of a generous approach to ancillary analyses. If circumstances are such that a forensic autopsy is invoked, this trumps a potential need for a clinical autopsy. Highlighting that the forensic autopsy in some cases needs to cover aspects in the realm of the clinical autopsy. Also, other aspects such as communication with next of kin and training might need to be considered. If the incentive behind a more restrictive approach to tissue sampling is economic, this calls for a more nuanced discussion about the system in which the forensic autopsy is performed. Perhaps, greater efforts should be made in selecting the right cases for the forensic autopsy, or aspects in the administration of the forensic autopsies should be optimized. We perceive that the authors are of the opinion that a forensic autopsy requires a high level of competence, and that each case is unique, to which we fully agree. Hence, in each case, an experienced forensic pathologist is to make the decision on which ancillary investigations, for example, toxicology, histology, which are to be called upon. But the study highlights a disagreement in at which rates an ancillary investigation is redundant and we argue a generous approach to tissue sampling for histological evaluation.