Death Investigation Research Articles

COVID-19 and Sudden Unexpected Community Deaths in Lusaka, Zambia, Africa - A Medico-Legal Whole-Body Autopsy Case Series

BackgroundData from Africa regarding sudden and unexpected COVID-19 community deaths and underlying pathological, demographic, and co-morbidity features require definition.MethodsWe performed a case series of COVID-19-related deaths seen at Forensic Post-Mortem examination of sudden and unexpected Community Deaths in Lusaka, Zambia, Africa. Whole-body Post-Mortem examinations were performed according to Standard Operating Procedures. Patient demographics, history, co-morbidities, pathological gross and microscopic findings, and cause(s) of death were recorded. Variables were grouped as frequencies and percentages. Comparison of data was made with autopsy findings of hospital COVID-19 deaths.FindingsOf 21 COVID-19 decedents, 14/21 (66.7%) were male; 18/21, (85.7%) were below 55 years of age (mean age, 40 ± 12.3; range, 20-73). The median duration of symptoms was 1 day (range 0-2); 9/21 (42.9%) had co-morbidities, with hypertension and obesity being the most common. Main post-mortem findings were diffuse alveolar damage (DAD) (80.9%), saddle and shower emboli (38.1%, respectively), and pneumonia (14.3%). Pulmonary thromboembolism (76.2%), DAD (14.3%), and SARS-CoV-2 pneumonia (9.5%) were common causes of death.ConclusionsCOVID-19 is an important cause of death to consider in forensic investigations of sudden and unexpected community deaths. Risk factors for the younger age of COVID-19 deaths and thromboembolism need to be identified.

Strengthening home-based postnatal care of rural area of two districts of Haryana using mobile phone technology

Introduction: Home-based postnatal care (HBPNC) plays an important role in improving the survival of mothers and newborns by complementing facility-based care. In India, HBPNC was initiated in 2011 under National Rural Health Mission, but the coverage and quality of postnatal care still remain a challenge. In the present study, we describe the methodology used in strengthening the existing HBPNC by utilizing mobile phone technology. Material & Methods: The study was conducted in the rural population of two districts of Haryana in collaboration with the National Health Mission Haryana and Survival for Women and Children (SWACH) foundation. The Accredited Social Health Activists (ASHAs) in the study area were provided a mobile phone and training related to the use of mobile technology, their roles, responsibility, and the information to be shared through phone and its purpose. Results: Along with providing home-based post-partum care, a total of 120,654 births (from May 2015 to August 2019) with detailed outcomes of pregnancy have been reported to SWACH. Population-based birth defect surveillance, stillbirth surveillance, and investigation of neonatal deaths are being done successfully using the same platform. Deaths are also being investigated by verbal autopsy. Age- and stage-specific participatory learning groups for action have been created on mobile phones for pregnant women, postnatal mothers to provide support, and interactive education to improve the maternal, newborn, and child health. Conclusion: It is feasible to strengthen the existing HBPNC with mobile phone technology to improve maternal and child health further. Vital events can be captured on an ongoing basis through ASHA as a key informant.

Schmallenberg virus infection suspected in a calf born to an imported heifer.

Schmallenberg virus infection suspected in a calf born to an imported heifer.

Recognizing the Inherent Variability in Dipteran Colonization and Decomposition Rates of Human Donors in Sydney, Australia

Introduction: Human decomposition is influenced by intrinsic and extrinsic factors including entomological activity, which can result in variability in the decomposition process. In death investigations, forensic entomology, the study of insects in a legal context, is the preferred method to estimate a post-mortem interval after pathologist methods are no longer applicable. The purpose of the current study was to document the primary dipteran colonization and rates of decay during the decomposition processes of human donors with known causes of death. Methods: Five consenting human donors were placed in a forested area at the Australian Facility for Taphonomic Experimental Research (AFTER) in Sydney, Australia, and allowed to decompose in a natural environment. Temperature and humidity were monitored hourly while other factors like colonizers and decomposition stage were recorded at each visit to the site. Thermal summation, called Accumulated Degree-Days (ADD), was calculated to compare the rates of decay. Results: Results show that no two donors followed the same rate of decomposition. There were instances of delayed dipteran colonization, which resulted in slowed decomposition rates. Differences in rates of decay between donors could also have been influenced by intrinsic factors such as size, clothing and peri-mortem treatments. Conclusions: This research supports the larger body of research involving the pre-colonization interval of insects, emphasizing the numerous variables that can affect colonization. Further research into the pre-colonization interval, and factors that affect it, should be performed using human donors to better understand how this knowledge can be applied to death investigations.

Magnitude of Sudden Infants Deaths, maternal mortality and Still Births in Pakistan

SIDS, SIUD, stillbirths and maternal mortality is an alarming condition in low income countries like Pakistan as Pakistan is a country with highest morbidity in such cases all over the world. Although research is ongoing across the globe to reduce the burden of such devastating situation but it continues to rise in Pakistan due to some known and unknown reasons. It is recommended that the pathophysiological basis of the SIDS should be investigated by continued research. To decrease the magnitude of SIDS, SIUD, stillbirths and maternal mortality in Pakistan numerous precautionary measures are required to be taken by NGOs, Government and policy makers. Trained healthcare professionals, midwives, traditional birth attendants should be sent to rural areas to help and increase awareness. A national center should be made on urgent basis to monitor and register such cases, provide health care facilities and guidance, make laws of compulsory investigation and autopsy of sudden death of fetus or infants and implement and enforce these laws. A databank should be made with preserved tissues of such victims for further diagnosis and research. Preventable stillbirths must be avoided by taking necessary measures.

Health Data Disparities in Opioid-Involved Overdose Deaths From 1999 to 2018 in the United States.

Objectives. To examine temporal trends in the classification of opioid-involved overdose deaths (OODs) and racial variation in the classification of specific types of opioids used. Methods. We analyzed OODs coded as other or unspecified narcotics from 1999 to 2018 in the United States using data from the National Vital Statistics System and the Centers for Disease Control and Prevention. Results. The total proportion of OODs from unspecified narcotics decreased from 32.4% in 1999 to 1.9% in 2018. The proportion of OODs from unspecified narcotics among African American persons was approximately 2-fold greater than that of non-Hispanic White persons until 2012. Similarly, the proportion of OODs from unspecified narcotics among Hispanic persons was greater than that of White persons until 2015. After we controlled for death investigation system, African American persons had a higher incidence rate of OODs from unspecified narcotics compared with White persons. Conclusions. There have been significant improvements in the specification OODs over the past 20 years, and there has been significant racial disparity in the classification of OODs until about 2015. The findings suggest a health data disparity; the excessive misclassification of OODs is likely attributable to the race/ethnicity of the decedent.

Investigation of a child malaria death during COVID-19 pandemic in a hamlet of Angul district, Odisha (India)

Background: This study aimed to find out the cause of child death due to Plasmodium falciparum and associate co-morbidities in a hamlet of Garud village of central district of Odisha (India), Angul during the COVID-19 pandemic and to recommend necessary actions to prevent such unwanted death.Methods: A retrospective investigation was conducted bases on the death audit report of a female child belonging to Garud village of Angul district. Death was reported at the district headquarters hospital, Angul. Detailed history from the starting of first symptom till death with laboratory investigations were reviewed using the malaria death audit format of NVBDCP, Odisha. Along with in-depth interview with family members, mass screening using bivalent rapid test and slide test, treatment and malaria preventive measures were undertaken in the community.Results: During the COVID-19 pandemic, one child death was recorded due to falciparum malaria infection. Along with the child, all two family members were infected with falciparum. The family belongs to small hamlet with eight households and 39 population. All 39 populations were screened for malaria and out of these, 11 number people were found positive of falciparum.Conclusions: COVID-19 pandemic resulted the major societal disruption due to lockdown and shutdowns affecting routine health care which may be attributed to the death of a child even in a in a well-resource setting district of Odisha. In such pandemic situation much more attention need to be given on the traditional infectious diseases which may cause unnoticed death.

Potential for minimally invasive radiologic procedures in cases of cultural and/or family objection to autopsy

It is considered conventional wisdom that 3-cavity post-mortem examination (+/– toxicology and postmortem CT) gives the most information in death investigation. However, coroners in New Zealand (and at least parts of Australia) have increasingly been required to take into account the wishes of next of kin regarding any objections to autopsies. Various groups, including indigenous populations, may be opposed to autopsy due to cultural, religious, or personal beliefs; and in such cases the coroner may direct a lesser post-mortem limited to external examination of the body. Clinical radiology regularly utilises many image-guided, minimally invasive techniques for diagnostic or therapeutic purposes. This presentation looks at the potential of some of these techniques for cases where there is objection to full autopsy and a lesser post-mortem has been directed. Examples include obtaining samples for toxicology, biopsy of lesions, minimally invasive vascular access, and contrast enhanced imaging studies.

Metonitazene in the United States-Forensic toxicology assessment of a potent new synthetic opioid using liquid chromatography mass spectrometry.

Metonitazene is considered a new psychoactive substance (NPS) and emerging potent synthetic opioid, causing increased public health concern beginning in 2020. Metonitazene joins a growing list of new synthetic opioids (NSOs) contributing to deaths among people who use drugs in the United States and other parts of the world. Metonitazene (a 2-benzylbenzimidazole analogue) first appeared in mid-2020 in the recreational drug supply and subsequently began proliferating in death investigation casework towards the end of 2020. Screening and metabolite discovery were performed by liquid chromatography quadrupole time-of-flight mass spectrometry. Quantitative confirmation was performed by liquid chromatography tandem quadrupole mass spectrometry. Metonitazene was confirmed in 20 authentic forensic postmortem cases with an average concentration in blood at 6.3 ± 7.5ng/ml (median: 3.8ng/ml, range: 0.5-33 ng/ml, n = 18) and in urine at 15 ± 13 ng/ml (median: 11 ng/ml, range: 0.6-46 ng/ml, n = 14). Metonitazene was the only opioid identified in 30% of cases but was also found in combination with fentanyl (55%) and NPS benzodiazepines, opioids, and hallucinogens (45%). Medical examiners included metonitazene as a drug responsible for the cause of death, and the manner of death was always ruled to be an accident. The metabolism of metonitazene was found to be similar to that of isotonitazene, a closely related analogue. Toxicology laboratories and death investigators should ensure that metonitazene is included in forensic testing protocols, all while remaining vigilant for subsequent NSOs to emerge.

Evaluation of the Compatibility of Ethyl Glucuronide and Ethyl Sulfate Levels to Assess Alcohol Consumption in Decomposed and Diabetic Postmortem Cases.

The aim of the study is to evaluate the contribution of ethanol metabolite detection in postmortem cases by showing the connection between the presence of ethanol metabolites, which are indicators of alcohol consumption, and the detection of potential postmortem ethanol formation in decomposed and diabetic cases. Determination of ethanol consumption before death is often one of the most important questions in death investigations. Postmortem ethanol formation or degradation products in the blood make it difficult to distinguish antemortem consumption or postmortem formation of ethanol and eventually may lead to misinterpretation. Decomposed bodies and diabetic cases are vulnerable to postmortem ethanol formation due to putrefaction, fermentation or other degradations. Ethyl glucuronide (EtG) and ethyl sulfate (EtS) are two metabolites of ethanol produced only in the antemortem time interval. In this study, EtG and EtS levels in urine and vitreous humor samples of 27 postmortem cases, including diabetic and degraded bodies were compared to ethanol results of their blood, urine and vitreous humor samples. EtG and EtS in urine and vitreous humor were analyzed by liquid chromatography-tandem mass spectrometry, and ethanol was assayed by routine headspace gas chromatography-flame ionization detector. These cases were devoid of other influences from forensically relevant drugs, so ethanol and/or glucose were among the only positive findings in these cases. The results of this pilot study indicate the postmortem ethanol concentrations do not correlate with the measured EtG and EtS values but are beneficial in rulings of accidental or natural deaths. This preliminary study gives additional data to help distinguish between antemortem ethanol intake and postmortem formation. EtG and EtS were well correlated positively with antemortem ethanol use instead of forming spontaneously in samples from decedents who are decomposing or have a history of diabetic hyperglycemia.

Review of: Spitz and Fisher’s medicolegal investigation of death: Guidelines for the application of pathology to crime investigation, 5th Edition

Review of: Spitz and Fisher’s medicolegal investigation of death: Guidelines for the application of pathology to crime investigation, 5th Edition

Feasibility of using tissue autolysis to estimate the postmortem interval in horses.

Estimation of the postmortem interval (PMI) is a poorly studied field in veterinary pathology. The development of field-applicable methods is needed given that animal cruelty investigations are increasing continually. We evaluated various histologic criteria in equine brain, liver, and muscle tissue to aid the estimation of PMI in horses, which is central to forensic investigations of suspicious death. After death, autolysis proceeds predictably, depending on environmental conditions. Currently, no field-applied methods exist that accurately estimate the PMI using histology in animals or humans through quantification of autolysis. Brain, liver, and skeletal muscle from 12 freshly euthanized horses were held at 22°C and 8°C for 72 h. Tissues were sampled at T0h, T1h, T2h, T4h, T6h, T12h, T24h, T36h, T48h, T60h, and T72h. For each tissue, we quantified 5 to 7 criteria associated with autolysis, based on the percentage of microscopic field involved. Each criterion was modeled, with temperature and time as independent variables. Changes were most predictable in liver and muscle over the first 72 h postmortem. The criteria for autolysis that were present most extensively at both temperatures were hepatocyte individualization and the separation of bile duct epithelium from the basement membrane. The changes that were present next most extensively were disruption of myofiber continuity, hypereosinophilia, and loss of striation. Brain changes were highly variable. The high statistical correlation between the parameter "autolysis" and the variables "time/temperature", indicates that autolysis is progressive and predictable. Further investigation of these criteria is needed to establish histologic algorithms for PMI.

Dying in the Margins: A Literature Review on End of Life in English Prisons

This paper explores dying in English prisons. Whilst often conflated, death and dying are conceptually different. While there is increased attention given to the investigation of deaths in custody, and the impact of prison deaths on healthcare staff and custodial staff, little attention has been paid to the experience of dying people themselves. Post-death investigations tell us little about dying experiences of the dying. This paper reviewed the literature on dying in English prisons and highlights this clear gap in knowledge. Four types of dying will be discussed in this paper: (1) suicide, (2) dying in older age, (3) deaths post-release, and (4) COVID-19 deaths. The importance of providing good end-of-life care and palliative care in prison is acknowledged in the literature, but this only shows awareness of the needs of a particular part of the prison population. To understand the complexities and nuances of dying in prison, all voices need to be included in research, otherwise what is left post-death of a person who died in prison is a Fatal Incidence Report. More empirical research is needed to illuminate the diversity of prison deaths and the lived reality of those dying behind locked doors.

Legal Frameworks: A Starting Point for Strengthening Medicolegal Death Investigation Systems and Improving Cause and Manner of Death Statistics in Civil Registration and Vital Statistics Systems.

Medicolegal death investigation systems, which generally fall within one of three types-medical examiner, coroner, or law-enforcement-led systems-investigate deaths that are unnatural or suspicious. The current quality of cause of death statistics on deaths investigated within medicolegal death investigation systems globally limits effective public health response. A starting point to strengthening global medicolegal death investigation systems and improving the quality of cause and manner of death reported to civil registration systems is through a strong legal framework. Two resources, the United Nations Statistics Division Guidelines on the Legislative Framework for Civil Registration, Vital Statistics and Identity Management and the Global Health Advocacy Incubator Legal and Regulatory Toolkit for Civil Registration, Vital Statistics and Identity Management, present recommendations and provide guidance to country stakeholders in reviewing and revising their medicolegal death investigation legal frameworks. Physician determination of cause and manner of death, defined criteria for case referral to the medicolegal death investigation system, an amendment process, and investigation collaboration are four core considerations for medicolegal death investigation system legal frameworks. A strong medicolegal death investigation legal framework is a necessary starting point, but it is not sufficient for ensuring the timely, accurate, and complete reporting of cause and manner of death in national vital statistics.

Inconsistencies in Overdose Suicide Death Investigation Practice and Potential Remedies Using Technology: A Centers for Disease Control and Prevention Consultation Meeting Summary.

It is widely accepted that suicides-which account for more than 47 500 deaths per year in the United States-are undercounted by 10% to 30%, partially due to incomplete death scene investigations (DSI) and varying burden-of-proof standards across jurisdictions. This may result in the misclassification of overdose-related suicides as accidents or undetermined intent. Virtual and in-person meetings were held with suicidologists and DSI experts from five states (Spring-Summer 2017) to explore how features of a hypothetical electronic DSI tool may help address these challenges. Participants envisioned a mobile DSI application for cell phones, tablets, or laptop computers. Features for systematic information collection, scene description, and guiding key informant interviews were perceived as useful for less-experienced investigators. Wide adoption may be challenging due to differences in DSI standards, practices, costs, data privacy and security, and system integration needs. However, technological tools that support consistent and complete DSIs could strengthen the information needed to accurately identify overdose suicides.

Five-year overview of fatal thermal and electrical burns in Johannesburg, South Africa

Thermal and electrical burn injuries affect millions of people globally each year. South Africa is a developing country where fatal fires are common. Despite the pervasiveness of fatal thermal and electrical burns in South Africa, there is a paucity of information regarding the frequency of such fatal burns in the City of Johannesburg. We aimed to describe the demographics and frequency of fatal thermal and electrical burn cases received at the Johannesburg Forensic Pathology Services Medico-Legal Mortuary for medico-legal death investigations, and compare the burn mortality rates between Johannesburg and those reported in Cape Town, Pretoria, and Mpumalanga. This study was a 5-year (2010–2014) retrospective review of 185 forensic medico-legal case files of fatal burns (156 thermal burn cases and 29 electrical burn cases) received at the Johannesburg Forensic Pathology Services Medico-Legal Laboratory. The demographics at the greatest risk of fatal burns in Johannesburg, South Africa are black (2.11 per 100 000) and male (1.03 per 100 000) individuals, and those in the 30–39-year age group (3.6 per 100 000). Children aged 0–9 years had a high mortality rate due to thermal burns (3.44 per 100 000). The most common type of fatal burns is thermal in nature, as a result of flames (1.62 per 100 000). Electrical burns are relatively rare (0.3 per 100 000). Burns are prevalent in the winter months, most notably in August. Burn wounds are common on the head, chest, back, and abdomen. Johannesburg has an overall lower burn mortality rate and incidence frequency than Cape Town, Pretoria, and Mpumalanga. This study is the first to report on fatal burns in Johannesburg, South Africa.Significance:
 
 A description is provided of fatal thermal and electrical burns of individuals whose deaths were investigated at the Johannesburg Forensic Pathology Services Medico-Legal Mortuary.
 The results highlight the demographic groups at risk of fatal burns in Johannesburg, South Africa.
 Johannesburg has a lower fatal burn incidence and mortality rate than Cape Town, Pretoria, and Mpumalanga; however, young people, particularly male individuals, are at greatest risk.

Estimation of postmortem interval in myocardial stab wounds and firearm injuries: An immunohistochemical comparative study using C5b-9 and cardiac Troponin C

BackgroundEstimation of postmortem interval (PMI) is a critical component of forensic death investigations. C5b-9 and cardiac Troponin C (cTnC) have the potential as markers for myocardial damage and can be suitable markers for determination of PMI. The aim of current study was to estimate different postmortem intervals using C5b-9 and cTnC detected by immunohistochemical technique in stab wounds and firearm injuries of the heart. Materials and MethodsCardiac tissue samples from 70 forensic autopsy cadavers were obtained from XXXXXXX morgue, processed, for histopathological examination as well as immunohistochemical detection of C5b-9 and cTnC expression. The surface area of the positive C5b-9 and troponin C immune reactive cardiac tissue was measured morphometrically then the data were used to construct multiple regression equations for the estimation of PMI. ResultsHistopathological autolytic changes occurred in all groups and increased in intensity with the increase in the PMI in stab wound and firearm injury groups. These findings were supported by immunohistochemical morphometric analysis. Constructed equations to estimate PMI were highly accurate especially those combining both markers. ConclusionC5b-9 and cTnC can be considered reliable indicators of myocardial damage and can be used either separately or in combination for accurate estimation of PMI.

Ammonia Exposure: A Review of Six Cases.

Exposure to high doses of ammonia gas can result in lethal injuries to humans. This case series presents 5 fatalities and an injured individual, caused by acute ammonia exposure, which occurred in the rubber industry. One of the fatalities and the survivor were reported in an incident of ammonia gas cylinder explosion, whereas the other 4 fatalities were accidentally exposed to gaseous ammonia, where they had started working at a reopened rubber factory that had been abandoned for a long time. Autopsy, scene investigation, and the toxicological findings of the deceased and the clinical forensic examination of the survivor revealed corrosive burns on the skin and the oropharynx, diffuse alveolar damage, and high level of ammonia in blood and the scene. These cases highlight how the comprehensive death investigation helps the forensic practitioner to conclude ammonia exposure as the cause of death/injury where there is a possibility of gas inhalation.

Oral Autopsy – Dental Surgeon’s Perspective

Background: Autopsy is routinely performed by the coroner in all medico-legal cases but the dental expertise is rarely sought. However, oral autopsy involving careful visual examination, imaging and laboratory methods can aid in solving the enigma associated with legal aspects of crime scene and death investigation. Aim: To illustrate the importance of oral autopsy during routine post-mortem examination. Data Sources: Pub-Med, Google Scholar search engines were used to extract the data. Conclusion: Oral autopsy performed as an adjuvant to regular autopsy procedure will definitely benefit in the legal investigation related to visually identifiable, decomposed, burnt or skeletonized corpse.

Long-Term Effects of a Comprehensive Police Suicide Prevention Program.

. Background: Mishara and Martin (2012) reported decreases in suicides 12 years after implementation of a police suicide prevention program. Aims: We aimed to determine whether suicide decreases were sustained 10 years later. Method: We examined coroners’ investigations of police deaths from 2009 through 2018. Results: From 2009 to 2018, Montreal suicide rates increased but this was not significantly different from the previous 12 years and the rate for other Quebec police remained significantly higher than Montreal (p < .006). The 22-year Montreal postprogram rate was significantly lower than the preprogram rate (p < .002), and the 22-year rate for other police during the same years was not significantly different from earlier. Limitations: Uncontrolled factors may have influenced the rates, including the 11% increase in women in the Montreal police. The observed mean aging of the Montreal police personnel would have been expected to bias toward finding increases in suicides. However, the maintenance of decreases in suicide rates was observed. Conclusion: The decrease in suicides observed 12 years after the program was sustained for another 10 years, and appears related to the program. Rates for comparable police remained higher. A continuing comprehensive suicide prevention program tailored to the context may reduce suicides for extended time periods.