Forensic medicine natural death

DR.AB.HALIM MANSAR
1Dr. Ab. Halim Mansar

OBJECTIVES:
- most fundamental objectives of an inquest is
to ascertain facts pertaining to the death i.e
who the dead person was, when did he die,
where did he die and how did he die?

-Answers to these Qs are obtained from
inquiry, post mortem examination(p.m.e)
-Deaths due to (dt) MVAs + homicide
invariably end up in a p.m.e,
in other sudden, unexpected + unnatural
deaths the body may be released without an
autopsy if there is sufficient evidence +
materials to satisfy the Coroner/ Magistrate
on the cause, manner + circumstances of
death.

THE MEDICO-LEGAL AUTOPSIES
INQUEST
all deaths dt unnatural causes + deaths
believed to be dt natural causes but where
the medical COD is not certain / known are
subjected to an inquest.
According to Section 330 of the Criminal
Procedure Code (CPC) of Malaysia
is a preliminary inquiry conducted by a
Coroner / a Magistrate

OBJECTIVES:
*An inquest is not a trial
-There is no complainant/ defendant + at the
conclusion of the inquest, a verdict is arrived
as to whether death was dt a natural,
accidental, suicidal/ homicidal cause
-The authority in M’sia, (the Magistrate plays
the role of the Coroner) which conducts the
inquest will order a doctor to perform a
medico-legal autopsy.
-In sudden, unnatural + violent deaths, the
police institute the inquest + executes the
power to order a p.m.e by issuing the form
Pol.61

OBJECTIVES:
*Consent from relatives of the deceased is
not required.
-In a sudden unexpected death, only a doctor
after a p.m.e may be able to determine the
COD.

DEATHS OCCURRING UNDER THE FOLLOWING
CIRCUMSTANCES ARE SUBJECTED TO AN INQUEST:
1. All unnatural, suspected unnatural, violent deaths, e.g
homicides

2. Deaths apparently from nat. causes but where the
exact medical COD is not known.

3. Any death caused by an accident arising out of the
use of a vehicle/ which was caused by an aircraft / rail
accident

4. Any death arising out of industrial employment, by
accident, industrial disease /industrial poisoning

5. Any death due to poisoning (alcohol intoxication,
coal gas, insecticides, barbiturates,etc)

6. Any death where the circumstances would seem to
indicate suicide

7. Deaths following anaesthesia, surgery/ any
medical investigative procedure

8. Any death resulting from an accident in the
home, hospital/ institution/ any public place.

9. Any death apparently caused by neglect
(e.g.malnutrition)
10. Deaths in custody such as in police custody,
remand prison, prisons, rehabilitation centers,
detention camps etc

11. Deaths in mental institutions, asylums, etc.

12. Deaths associated with pregnancy, abortion,
childbirth etc. (maternal death)

13. Any death of a newborn child whose body is
found

14. Death of a child from suffocation (including
overlaying)

15. Deaths of foster children

16. Any death as a result of a fire/ explosion

17. Death by drowning

18. Any death (occurring not in a house) where
deceased’s residence is unknown

MALAYSIAN CRIMINAL PROCEDURE CODE (CPC)
CHAPTER 20- INQUIRIES OF DEATH
Meaning of “cause of death.”

328. In this Chapter the words “cause of death”
include not only the apparent COD as ascertainable
by inspection or p.m.e of the body of the deceased,
but also all matters necessary to enable an opinion
to be formed as to the manner in which the
deceased came by his death + as to whether his
death resulted in any way from, / was accelerated
by, any unlawful act / omission on the part of any
other person.

Difficult Autopsies
Body found in water.
Body found by the road-side
Decomposed body
Skeletonised body
Body fragments
Severely charred body
Mass disaster
Anesthetic and post-operative deaths
Child deaths
Deaths in young adults
Maternal deaths.

The Medico-Legal Autopsy.
• Autopsy is only one part of death
investigation. Body, history
and scene are equally important.
Each of the three aspects of the death
investigation process are equally important.
• Scene:
-Attendance by police officers,forensic
pathologist, forensic scientist.
- The aim is to collect the maximum
information with minimum disturbance.
- Photography,videos,trace evidence

History:
-Social- from relatives,friends,police.
-Medical-from GP,hospital notes. Often
indicates the likely cause of death.
-Psychiatric-from GP,hospital notes. May
indicate possibility of suicide.
- Autopsy authority:

-Police or Coroner(Magistrate).
- “Police 61” form(Permintaan Pemeriksaan
Mayat).

Identification
 Visual(relatives).
Circumstantial(address,car,papers,cards,key
s,cloths).
 Medical( scars,teeth,x-rays,DNA).
 Fingerprint.

Personal effects and clothing
By contrast with the hospital autopsy, the examination
of personal effects and clothing is an integral part of
the medico-legal autopsy providing information on life
style, events leading to death, and often the actual
cause of death.
Clothing findings are correlated with historical and
scene information, e.g. appropriateness of clothing,
source of stains, trace materials. Clothing findings
must also be correlated with other autopsy data, e.g.
injuries, source of blood stains.

External Examination
-This is a detailed head to toe examination
of a naked body, documenting stains and
soiling, general and specific individualising
characteristics,postmortem
changes(temperature,lividity,rigor
mortis,putrefaction).
-The location, extent and type of staining or
soiling of the body are described.

Injuries
All injuries are described systematically either
by grouping them according to anatomical
location or in numerical order.
 Injuries are described as to their type, (bruise,
abrasion laceration,incised wound,puncture of
stab wound,gunshot wound,burn,fracture),
location,size,shape and colour.
Internal injuries are described in continuity
with the related externally apparent injuries.
Old injuries are segregated from recent
injuries.

- Signs of medical intervention.
-Medical intervention is described under a
separate heading. This includes all medical
equipment attached to,or accompanying the
body.
-External surgical incisions are described in
continuity with internal evidence of surgery.

Internal examination
The internal examination is systematic description
of natural disease and recent injuries. Negative
observations are included,e.g. no pulmonary
thrombo-emboli,no significant coronary
atherosclerosis,etc.

Other examinations
-Any special dissections,(neck dissection),or further
examination of organs(brain after formalin fixation),
together with microscopic, biochemical and
toxicological studies shoulder also be described.
Definition
-Mechanism of death: the physiological or biochemical
derangement produced by the above cause, which is
incompatible with life: i.e. how the disease or injury
leads to death.
-Manner of death: explains how the cause of death came
about : I.e. whether natural, accident, suicide, homicide
or undetermined/unascertained. The manner of death
as determined by the forensic pathologist is an opinion
based on the facts concerning the circumstances leading
up to and surrounding the death in conjunction with the
findings at autopsy and the laboratory tests.

SUDDEN AND UNEXPECTED
NATURAL DEATH
Although from the description above given a natural
death cause no obvious criminal or accidental, it
nevertheless becomes of some concern to the forensic
pathologist simply because of the difficulty or even
impossibility to furnish a certifiable cause of death
The numerous causes of sudden natural death may
conveniently be classified according to the different
anatomical systems of the body.

Definition
- Death within 24 hrs from onset of symptoms
- Some accepts : death within 1 hrs of onset of symptoms
- An unexpected witnessed death (nat. causes wit/out preexisty
disease than occurs within 6 hrs of onset of symptoms
- Cor. Heart Disease > 75 % of sudden Cardiac Deaths
other Cardiac conditions : = 20 % of cases
COD remains unknown : 1 – 2 % of cases

Cardiovascular System
Deaths resulting from diseases and disorders of the
circulatory system account for the vast majority of
sudden natural deaths.
They are considered under diseases of the vessels, the
heart muscles and the heart valves.
In some cases there is an overlap from one system to
another.

Ischemic heart disease
Interruption or interference with the blood flow to the
heart along the coronary arteries will have profound
effects on the heart itself
In the extreme-the heart will suddenly cease functioning
In less extreme, areas of the heart will fail which in turn
causes a chain reaction and finally the complete heart
failure.
At autopsy, one or more of the main branches of the
two coronary arteries may show of severe disease
process. There will be a deposition of soft white or
yellow necrotic fatty material on the lining of the arteries

Hypertensive Heart Disease
An enlargement of the left ventricle of the heart with
accompanying increase in the thickness of the muscle wall will
result in a raise blood pressure, frequently to a level twice as
high as normal.
So that, rupture of vessels is frequently seen in the presence
of hypertension – raised blood pressure. Example: rupture of
a cerebral artery.
The cardiac enlargement almost limited to the left ventricle,
the three remaining usually within normal size.
In many cases the cause for cardiac enlargement is unknown,
when the term primary or essential hypertension is used.

Death occurs quite suddenly and unexpectedly.
There may be an incident of exertion, anger, emotion
and stress but equally the death may follow a period of
rest.
One reason for a sudden collapse and death is that the
mass of heart muscle has outstripped its own blood
supply.

Aortic Valve disease
Sudden death result because of the hyperthrophied left
ventricle to force the blood through the diseased and
narrowed valve.
An alternative reason is that the disease process may
spread out from the valve and impede the entry of blood
into the ostia of the nearby coronary arteries.

RESPIRATORY SYSTEM
The main causes are massive haemorrhage in the air
passages, pneumothorax, infections and asthma.

Haemorrhage in the Air
Passages
When a massive haemorrhage occurs into the major air
passages death results from an obstruction to normal
respiratory gaseous exchange.
Erosion of a large pulmonary vessel by a malignant tumor
or by an expanding pulmonary infection.
Example: Tuberculosis, produces a massive bleed and
death follows very shortly
In former years the frequency of syphilitic aortic
aneurysms in the thorax means that many would erode
into a bronchus leading to a rapid death

Pneumothorax
The spontaneous rupture of an emphysematous bulla on
the periphery of a lung. e.g.: following a bout of coughing
or straining during some physical exertion, can be lead to
a massive escape of air into one of the pleural cavities.
The vacuum normally present is lost and there is an
immediate collapse of the affected lung.
In the absence of special medical equipment death may
rapidly ensue, especially if there is concomitant disease in
the other lung in the heart.

Infections
Whilst most chest and lung infections can produce a
severe illness which may lead on slowly to death, there
are few bacterial and viral infections, which can produce
sudden and unexpected deaths in very short time
Example1: a sports master at large school used to spend
his lunchtime break playing indoor football with some of
the other teacher before returning to their classes for
the afternoon. After a quarter of an hour the game
finished and the member of staff went to the changing
room to find the sports master dead on bench.

Example 2: A young man, shortly to be married, was
decorating his future home one evening after a day’s work
along with his father. The young man said that he had some
tightness across his chest and that he would not continue
painting. His father completed what he was doing and joined
his son in another room 20 minutes later, where he found him
dead.
In both these cases, there was an acute hemorrhagic
bronchopneumonia.- Culture and virological studies showed a
florid viral infection.
Chronic bronchitis can also on occasions cause a sudden
death.

Asthma
Asthma is the sudden and prolonged spasm of the
smooth muscles in the walls of bronchioles.
The bronchospasm causes sever constriction of the air
passages.
In the case, the death is due to respiratory failure in the
exchange of oxygen and carbon dioxide within the lungs.
This may due to obstruction in the airways, restriction in
the ability to expand the lungs, allergic neuromuscular
problems and ventilation abnormalities.

CENTRAL NERVOUS SYSTEM
Nearly always caused by hemorrhage which may occur
either within the brain, or outside within the meninges

Cerebral Haemorrhage
This is often referred to as cerebrovascular accident,
although the word accident is a msnomer
The massive bleed usually occurs either within the basal
ganglia or more distally in the internal capsule.
The hemorrhage is associated with raised blood
pressure, so that the victim is usually an elderly person
with hypertensive heart disease and widespread
arteriosclerosis, especially of the cerebral arteries.
May also occur in other sites such as pons or the
cerebellum but they are much less frequently seen.

Circulatory, non-hemorrhagic
causes
The formation of a cerebral thrombus in one of the
cerebral arteries at the base of the brain, or in a smaller
within the brain may cause loss of consciousness leading
to death within a short time. The thrombus is usually
formed in association with a localized plaque of
arteriosclerosis.
A most unusual cause is that of a cerebral embolus,
which may arise from an area of thrombus formation
within the cavity of the heart, passing upwards to the
brain via one of the carotid arteries.

Epilepsy
Epileptic sufferers may die during a prolonged single
seizure or more usually during a series of repeated
seizures termed status epilepticus
Death is due to asphyxia if the epileptis ceases to breathe
or aspirates regurgitated vomit, or has an airway
obstructed by the tongue.

GASTROINTESTINAL SYSTEM
A Massive bleed may occur when a gastric or duodenal ulcer
erodes through the sub mucosal tissues and into an artery
lying close by.
The profuse bleeding may pass down the intestinal tract
emerging from the anus, or it may enter the stomach and be
vomited up, or more frequently it will pass in both directions.
Another form of dramatic fatal bleeding occurs when varicose
and distended veins at the lower end of the esophagus
become eroded and burst. This usually occurs in a patient
who had developed severe fatty change or even cirrhosis of
the liver brought about by chronic alcohol use.

Fatty change to the liver can also produce a sudden
death but the exact mechanism remains unknown.
In some cases there is microscopic evidence of fat
embolization to the lungs or even the heart or brain.
Equally there may be a sudden disturbance to the nearby
pancreas and insulin activity.

OTHER SYSTEMS
In pregnancy, sudden deaths are usually associated with
haemorrhage.
The rupture of an extra-uterine pregnancy may produce a
massive intra-abdominal haemorrhage which on occasions
has caused death.
Premature separation of a placenta previa may both cause
severe exsanguinations unless there is medical aid.
Attempts at abortion by inexpert persons may cause death
either by perforation by the instrument of a major vessel,
or by causing pulmonary embolus by means of air, chemical
fluids or the release of amniotic fluid into the blood stream.

The adrenal gland may be a related to a sudden death as
a result of bilateral adrenal haemorrhage produced during
a meningococcal septicemia
Usually, there is evidence of the bacterial infection
elsewhere followed by adrenal collapse and death.

SUDDEN DEATH FROM
UNKNOWN CAUSES
There is nothing more frustrating and no case remains so
memorable, than a death for which there is no
demonstrable cause
All pathologists of cases where, after autopsy, toxicology,
bacteriology, virology, histology and a review of the
history of the case with all the professional concerned,
there is no reasonable cause to be found.
One very special group of deaths which still remains a
mystery is the sudden death in infancy syndrome.

These deaths invite further research into their causation:
1. reflex cardiac deaths during or following minor surgical or
medical procedures
2. the strange deaths of apparently fit and healthy young
persons during some sport or game
3. on a worldwide scale the deaths of healthy persons who
have been cursed to die.

Thank you

Forensic medicine natural death

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (20)

Semelhante a Forensic medicine natural death

Semelhante a Forensic medicine natural death (20)

Mais de MBBS IMS MSU

Mais de MBBS IMS MSU (20)

Forensic medicine natural death