Virtopsy approach: Structured reporting versus free reporting for PMCT findings

Abstract

Introduction: While post mortem CT (PMCT) serves as increasingly wide-spread tool for pre-autopsy examination in forensic medicine, the scope and role of reporting should follow legal requirements as set out by law and landmark court decisions. We initially used free form reporting, but after a hyoid fracture was missed and not reported in a case of manual strangulation, and after a range of other less serious incidents, we switched to a structured reporting system. Methods and material: Twenty randomly chosen PMCT reports of each of the two types (free form, structured reporting containing 108 items) were checked for explicit reporting of absent or present findings of an arbitrary list of findings of forensic relevance. Results: Free form reports contained 13% to 75% of forensically relevant findings, depending on the specific finding that was checked. Structured reports did contain 100% of the items that were tested even though the system that we used would yield a “not checked” entry if left untouched by the user. Discussion: Unchecked or unreported data has the capacity to act as a liability rather than an asset given that no jurisdiction specifically requires court appointed experts to partially ignore data for possible later analysis and interpretation. Wasting time on irrelevant findings while missing crucial data is a real risk particularly when radiologists enter the field of forensic medicine. Structured reports then can remedy the problem through acting as a guideline. Even though this study has limitations as only two very different techniques were compared, considering structured reporting in a comprehensive fashion is strongly recommended both on study results and legal considerations.