Natural, Unexpected Deaths: Reliability of a Presumptive Diagnosis*

Abstract

We retrospectively analyzed 100 deaths because of suspicions and concerns expressed by the family. We compared the preautopsy cause of death, as determined by a thorough review of the clinical data and circumstances, to the autopsy-derived cause of death. In the majority (91/100), the preautopsy and postautopsy proximate causes of death were in agreement. In 9%, the autopsy provided information that resulted in a proximate cause of death different than anticipated. In four instances, the manner of death also was incorrect and was determined to be an accident rather than the originally presumed natural. No homicide or suicide would have been misclassified. In another nine instances, where the premortem and postmortem proximate causes of death were in agreement, the autopsy provided a specific mechanism of death. With a quality initial medicolegal death investigation, a subset of sudden deaths in adults may be reliably certified without an autopsy.

Undetected patricide: Inaccuracy of cause of death determination without an autopsy

“…Despite modern imaging techniques, the autopsy along with all information available coming from the medical history, scene survey and circumstances of the death, is still considered the gold standard for determining the cause and manner of death. 18 The risk of misclassification is high when a cause/manner of death is not supplemented with data from autopsy and scene survey. A retrospective study on death certificates found that 34% of the cases had no proximate or a totally wrong cause/manner of death.…”

“…23 Unfortunately the majority of trauma and violent deaths are still certified without an autopsy because of cost containment and increased confidence in modern imaging techniques. 18,21,26,27 Therefore, misdiagnoses as well as misinterpretation of medical findings are inevitable.…”

“…Unfortunately in Italy majority of traumatic and violent deaths are certified without autopsy and this seems to occur also in those countries where external examination of the body is the most common method used to investigate medico-legal deaths or where investigation can proceed with a forensic autopsy only if a crime is suspected or the manner of death is unclear. 18,21,38 In Italy a significant amount of medico-legal investigations (especially for deaths resulted from trauma following suicide or accidental events like motor vehicle crashes, domestic or occupational accidents) are restricted to an external body examination without subsequent autopsy and/or a crime scene survey even if the event is uncertain. We are talking about 4e5% of all deaths (approximately 580.00 per year) which means with an optimistic estimation there are at least some thousand of forensic autopsies per year that should be performed in every traumatic and violent case.…”

Human prion diseases and the risk of their transmission during anatomical dissection

“…However, asymptomatic patients who may be infected with prions, or patients showing early but unreported clinical signs recorded with other more common causes of death (in particular sudden deaths, e.g., stroke or heart failure) represent a potential risk route of exposure of prion‐infected human material into anatomical research laboratories. The accuracy of death certificates and reliability of presumptive diagnosis in natural unexpected deaths reveal up to one‐third of recorded causes of death may be incorrect (Nielsen et al, ; Gill and Scordi‐Bello, ). The discrepancy between death certificate recorded cause of death and actual cause of death may have prompted the falling use of autopsy and pathological examination to be reversed (Roulson et al, ).…”

Are Statutory Requirements Followed in the Certification of Traumatic, Unexpected, and Unattended Deaths in Missouri?

“…When a medical examiner or coroner (ME/C) is contacted, typically when a death is not due to natural causes, accuracy of death certificate information increases but remains imperfect . Manner of death (MOD) on death certificates is categorized as natural (i.e., when the body ceases to function of its own accord) or external/not natural (i.e., accident, suicide, homicide, undetermined).…”