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Dead Reckoning

Dead Reckoning

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Published by Douglas Page
Dig this. Criminal foul play and medical malpractice often go undiscovered until post-exhumation autopsy.
Dig this. Criminal foul play and medical malpractice often go undiscovered until post-exhumation autopsy.

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Categories:Types, Research, Law
Published by: Douglas Page on Jun 13, 2009
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08/08/2009

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Forensic Magazine® | Articles | Dead Reckoning
 
Dead Reckoning
 
Douglas Page 
 
Summer 2004 
 Criminal foul play and medical malpractice often go undiscovered unless post-exhumation autopsy isperformed. Declining autopsy rates is the likely culprit. In the years following World War II, about halfof all hospital deaths were routinely autopsied. Now the number is under 10 percent, mostly becauseautopsies are costly and not generally reimbursable. In addition, hospitals and physicians fearmalpractice litigation could result from autopsy findings that conflict with conclusions on the deathcertificate.A recent university study found that forensic exhumations frequently are successful in discoveringinconsistencies in cause of death as determined by authorities at the time of death. The study, whichappeared in the April 2004 issue of the International Journal of Legal Medicine, found that majordeviations between the cause of death as stated on the death certificate and as diagnosed afterautopsy existed in nearly 40 percent of forensic exhumations performed in Münster, Germany. Thepercentage of misdiagnoses may be even higher."The real number of undetected homicides is difficult to estimate, but the cases reported definitelyrepresent just the tip of the iceberg,” according to the study's lead author, Bernd Karger, MD, Instituteof Legal Medicine at the University of Münster.One reason for so many buried homicides is the local system of postmortem examination, whereevery physician in Germany is bound by law to externally examine a corpse and to fill out the deathcertificate. “But many physicians lack knowledge and experience, and perhaps even interest, inthanatology to perform postmortem examinations according to established standards,” Karger said.
Low Autopsy Rate
Another reason for undiscovered crime is the low autopsy rate. Only 1.2 to 1.4 percent of all fatalitiesin the Münster area are autopsied by a specialist in legal medicine, compared to 3.4 percent in Munichand 20 percent in the U.S. Approximately one-fifth of the 2.4 million deaths in the U.S. each year areinvestigated by medical examiners and coroners, accounting for approximately 450,000 medico-legaldeath investigations annually, according to the Institute of Medicine. The lower German autopsy rateequates, then, to higher exhumations.Karger's study reports on a total of 155 exhumations performed from 1967 to 2001, each evaluated
http://www.forensicmag.com/Article_Print.asp?pid=9 (1 of 4)6/12/2009 3:04:46 PM
 
Forensic Magazine® | Articles | Dead Reckoning
retrospectively on the basis of autopsy report, police report, and death certificate. Histology andtoxicology were performed in most cases. Postmortem intervals varied from 8 days to 8 years.“The cause of death could be clearly determined in 103 cases (66.5 percent) and histology ortoxicology was decisive in 40 percent,” Karger said.Some findings were discernable using immunohistochemistry after considerable postmortem intervals,such as acute myocardial infarction after one year and pneumonia after two years. A diazepamintoxication was determined after 4.5 years.Major deviations between cause of death as stated on the death certificate and as diagnosed afterautopsy existed in 57 cases, or 37 percent. Karger concluded that exhumations were frequentlysuccessful for recovering evidence which should better have been collected immediately after thedeath of the individual. Further, exhumations can also be regarded as an instrument to evaluate thequality of death certificates and death investigations, he said.
In Perspective
Any research that shows that nearly 40 percent of exhumations expose a wrongful cause of deathmay at first read like an indictment of medical examination practices. But the study must be read inproper light.“The authors state that few autopsies are performed in their area, thus exhumations are more frequentand therefore more useful,” said Dr. Moses S. Schanfield, chair of the Department of ForensicSciences, The George Washington University.The U.S., with its system of medical examiners and coroners, is different. Most states require that allunattended deaths, as well as suspicious deaths, be autopsied, which does not appear to be the casein Münster.“The results of the Karger study are not surprising as almost all of the autopsies (146 of 155, or 94percent) were ordered by the courts or prosecutors. Thus, there appeared to be some prior basis ofuntoward death,” Schanfield said.
Modern Equipment
The craft of autopsy - practiced by humans for 2,400 years and modernized by Germans in the 19thcentury - may itself be dying. The percentage of autopsies has fallen dramatically in the U.S. over thelast half century.In the 1950s, nearly half of all patients who died in U.S. hospitals were autopsied. Now it variesbetween 5 percent and 13 percent, due in large part to restricted hospital budgets and modernimaging techniques like CT and MRI scanners, which are believed to be so proficient at picturinginternal pathology that invasive procedures are no longer as necessary.
http://www.forensicmag.com/Article_Print.asp?pid=9 (2 of 4)6/12/2009 3:04:46 PM
 
Forensic Magazine® | Articles | Dead Reckoning
While exhumations may be rare in the U.S., it is not unusual for any domestic autopsy to findinaccuracies in the stated cause of death. “You could write an article about doing 155 consecutiveautopsies at Presbyterian Hospital in New York City, or at the UCLA Medical Center, and the answerwould be about one-third of the time the autopsy would find the wrong diagnosis stated on the deathcertificate,” said celebrated pathologist Michael Baden, MD, Chief Medical Examiner for the New YorkState Police, and New York City's Chief Medical Examiner from 1961-1986.Even with the aid of modern imaging modalities like CT and MRI, autopsies will find missed significantdiagnosis in 30-40 percent of cases, Baden said.
Final Cut
Exhumation autopsies are normally only performed in the U.S. when issues of medico-legalsignificance arise. “I don't know how they missed that many homicides in Münster,” Baden said. “Tomiss children who've been battered, injuries from blows from beer bottles, and gunshot wounds thatwere not identified indicates that the bodies were poorly examined to begin with.”Baden said that would be unusual in this country, because if there is any thought of homicide then anautopsy is performed before burial. There are exceptions, however. Exhumation autopsies are doneon suspected serial deaths, such as when several babies die in one family, when a husband has anumber of wives die mysteriously, or one nurse is the common denominator in an inordinate numberof hospital deaths.“When the first baby suffocates or the first spouse is poisoned, you don't know that,” Baden said. “Butafter a series of deaths then we may do exhumations because of the suspicion that's raised that wasnot present when the first death occurred.” In other cases, a second, later, autopsy may be beneficial.“Even when a body has been previously autopsied, it is still possible to find lots of information thatwas missed during the first one,” Baden said. Baden used the example of civil rights leader MedgarEvers, who was shot in the back in 1963, a few weeks before President Kennedy was murdered. “Ittook 30 years and an exhumation of Evers’ remains 28 years after death to gather enough evidence togo to trial and convict the shooter,” Baden said.Medical examiners, however, are not in the business of solving murders. The role of the medicalexaminer is to determine what happened, not who did it. The body contains a wealth of information,even 28 years after burial. It took 30 years to get further information that led to the conviction of ByronDe La Beckwith in the Evers matter.“A second autopsy can pick up information that's focused, when you know what you're looking for,because you now have more information than at the time of the first autopsy,” stated Baden.Exhumations can be helpful because traces of most poisonous drugs can be found in the body longafter death. “That's one of the reasons we do exhumations here, because poisons weren't properlytested for,” Baden said.
Lack of Standards
http://www.forensicmag.com/Article_Print.asp?pid=9 (3 of 4)6/12/2009 3:04:46 PM

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