Pressure sores: epidemiology, medico-legal implications and forensic argumentation concerning causality

Abstract

The aim of the present investigation was to identify the frequency and grading of pressure sores in a large series of unselected consecutive deceased subjects before cremation and to discuss aspects of the forensic argumentation concerning causality. A total of 10,222 corpses were examined prospectively over a 1-year-period (1998) for the occurrence, localization and grading of pressure sores. Epidemiological aspects (e.g. age, sex, underlying and contributing causes of death, place of death etc.) were taken from the death certificate. The mean prevalence of pressure sores was 11.2% (87.1% isolated sores; predominant localization of advanced grades on the sacrum in 69.6%). There was a positive correlation between the prevalence of sores and advanced age resulting in a clear female predominance in the age group of 80 years and over because of differences in life expectancy. A significant correlation was found between the prevalence of pressure sores and certain underlying diseases, e.g. trauma, senile dementia, neurological diseases, apoplexy and marasmus. Pressure sores of all grades were more frequently found in the deceased when a senior citizen's or nursing home was given on the death certificate as the domicile in the last period of life. The forensic argumentation for the causal relationship of a pressure sore as the focus of fatal infectious complications or septicemia has to be based on the results of clinical expertises and forensic investigations (evaluation of the institutional documentation of the patient's course, autopsy findings, histology, immunohistochemistry). The vast majority of physicians seem to pay only little attention to the potentially fatal outcome of pressure sores and fatalities associated with this condition are clearly underreported. From the point of view of social medicine, the prevalence of pressure sores in a defined population can be seen as a parameter for the quality of nursing and medical care. In bringing these fatalities to light, the field of legal medicine contributes to a general quality control of standards of nursing and medical care.

Serum procalcitonin (PCT): a valuable biochemical parameter for the post-mortem diagnosis of sepsis

“…Apart from the immunohistochemical detection of an enhanced pulmonary expression of different cellular adhesion molecules, such as P-selectin [20], E-selectin [32], VLA-4 and ICAM-1 [31] in sepsis-induced lung injury, there are no defined post-mortem markers for death caused by sepsis. These immunohistochemical investigations are not routinely used in forensic casework and as a result, clinical data and morphological findings that are to a great extent unspecific remain the diagnostic criteria in the postmortem diagnosis of death due to sepsis [26,28,30,33]. In a variety of forensic studies, the post-mortem determination of biochemical parameters has been recognized as useful in establishing the post-mortem diagnosis of the underlying cause of death, e.g.…”

Serial monitoring of interleukin-1?, soluble interleukin-2 receptor and lipopolysaccharide binding protein levels after death

“…Special constellations of death due to sepsis are frequently encountered in forensic autopsy practice, e.g., septic conditions following iatrogenic interventions or infected pressure sores [24,25]. Since in a number of such cases information about the circumstances of death or data of the deceased's symptoms prior to death are often not available at the time of the autopsy, especially when fatalities occurred out of hospital, and in addition, gross pathology and histology is, apart from the detection of septicopyemic abscesses, usually unspecific in sepsisassociated fatalities [26], the postmortem diagnosis of fatal sepsis is occasionally more difficult in medico-legal casework than it is in clinical pathology.…”

Postmortem measurement of serum procalcitonin concentration in Waterhouse-Friderichsen syndrome

“…Autopsy is still the final word in quality control and an important tool used in both research and medical education [9,11,12,14]. Detection of adrenal hemorrhage ( Fig.…”