WELCOME TO THE WORLD

OF FORENSIC MEDICINE
Marie Cassidy
Professor of Forensic Medicine and
State pathologist
 FORENSIC MEDICINE

THE BRANCH OF MEDICINE THAT APPLIES

THE PRINCIPLES AND KNOWLEDGE OF THE
MEDICAL SCIENCES TO PROBLEMS IN THE
FIELD OF LAW
 FORENSIC
MEDICINE/PATHOLOGY

‘Scientific’ investigation of the cause of

injury and death in unexplained
circumstances particularly when
criminal activity is suspected
 FORENSIC SPECIALISTS
• Forensic pathologist
• ‘forensic’ pathologist/neuropathologist
• G.P.
• Police surgeon
• Accident and emergency doctor
• Forensic physician
• Paediatricians
• Forensic Psychiatrist
 FORENSIC SPECIALISTS
• Forensic pathologist - suspicious deaths
• ‘forensic’ pathologist- nonsuspicious deaths
• Neuropathologist – head injuries, brain damage
• G.P.- injured or deceased patients
• Police surgeon-prisoner, drink driver, victim
• Accident and emergency doctor - injured
• Forensic physician - a/a, sexual crimes
• Paediatricians- any abnormality in children
• Forensic Psychiatrist- prisoners
 FORENSIC EXAMINATIONS
• WOUNDS AND INJURIES
• SEXUAL ASSAULTS
• CHILDREN
• SCENE OF DEATH
• DETERMINATION OF DEATH
• CAUSE OF DEATH
• POSTMORTEM EXAMINATIONS
• COURT TESTIMONY AND REPORTS
 INVESTIGATION OF DEATHS
• To determine the cause and the manner of
death
• To identify the deceased if unknown
• To determine the time of death and injury
• To collect evidence from the body that can
be used to prove or disprove an
individual’s guilt or innocence and to
confirm or deny the account of how the
death occurred
 INVESTIGATION OF DEATHS
• To document injuries or lack of them
• To deduce how the injuries occurred
• To document any natural disease present
• To determine or exclude other contributory
or causative factors to the death
• To provide expert testimony if the case
goes to trial
‘Forensic pathology, DiMaio’
DEALING WITH DEATH

The doctor and death

 The dead patient

• History
• Examination
• Diagnosis of death
 Definition of DEATH

CESSATION OF LIFE IN A PREVIOUSLY

VIABLE ORGANISM
 DEATH

A DOCTOR MUST DECLARE DEATH

?duty of care to determine death

 DEATH
• Somatic death
• Molecular death
• Brain death
• Brain stem death

• NO law defines death

 SOMATIC DEATH

• Failure of the body as an integrated

system
• loss of circulation, respiration and
innervation
• for such a time impossible for life to return
• irreversible unconsciousness
 Somatic death
• Heart stops
no pulse, no heart sounds, flat ECG,
segmentation of blood in retinal vessels
• Lungs stop
no breathing, no chest movement
• Brain activity stops
• muscles floppy
• metabolism stops, body cools down
 Somatic death

• Auscultate for 4 to 5 minutes

• D.D. shock, hypothermia,
electrocution, depressant
drugs
 MOLECULAR DEATH
• Depends on susceptibility to oxygen
deprivation
• varies - important in organ harvesting
• brain most susceptible, 3 to 7 minutes
• wbcs may remain motile for up to 12hours
• muscles respond to stimuli for few hours
• skin viable for several days
• importance - transplants
 BRAIN DEATH

• CORTEX
• BRAIN STEM
• WHOLE BRAIN
 BRAIN DEATH

CORTICAL brain death

• deep coma
• brain stem functioning
 BRAIN DEATH
PERSISTANT VEGETATIVE STATE
• functioning brain stem but non
functioning higher centres
• respiratory centres functioning do not
require permanent assisted ventilation
• require parenteral feeding
• if heart protected from hypoxic damage
and nutrition sustained, may survive for
years
 BRAIN DEATH

BRAINSTEM INJURY
• COMA due to damage to the ascending
reticular activating system
• require assisted ventilation due to
failure of the respiratory motor system
• beating heart
 BRAIN DEATH

Severe irreversible cortical damage

+
Brain stem damage

WHOLE BRAIN DEATH

Beating heart donor

 Brain stem death tests
1. Absent pupillary response to light
2. Absent corneal reflex
3. No motor response within the cranial
nerve distribution and the limbs
4. Absent gag reflex
5. Doll’s eye phenomenon
6. No vestibulo-ocular reflexes
7. Persistent apnoea when ventilator
disconnected
Cause of Death
 Cause of death
“The pathologist is bound to rely in part on
what he/she is told of the events leading
up to death for functional lapses like fall in
blood pressure, cardiac arrythmia, spasm
of the glottis or vagal inhibition which leave
no trace at autopsy.”

Simpson
 THANATOLOGY

SUDDEN NATURAL DEATH

 Sudden Death

• Deaths at home
• Deaths in hospital
• Death outside
• Death in unusual circumstances:
place, position, appearance of body
 Sudden Death

• G.P. or Hospital doctor

• Medical history
• Treatment for recent illness
• Other information
 Sudden Death

• Natural death
• Accident
• Suicide
• Homicide
 Sudden Death

Age
• Children
• Teenager/young adult
• Adult
• Elderly
 Sudden Death

Children
• Stillbirths
• Congenital abnormalities
• Sudden infant death
syndrome
• Tumours
 Sudden Death

Young adults
• Suicide
• Accidents - RTAs
• Homicides
• Natural
 Sudden Death

Adults
• Natural
• Accidents - RTAs
• Homicides
• Suicides
 Sudden Natural Death

In the developing world sudden cardiac

death remains the major cause of
death

Adults and elderly

• Cardiovascular disease
• Cancer
 SUDDEN NATURAL DEATH-
cardiac causes
• CORONARY ARTERY DISEASE, ischaemic
heart disease, atheroma, thrombosis, dissection,
‘bridging’, acute MI, cardiac tamponade, stress
associated
• HYPERTENSIVE HEART DISEASE, acute LVF,
arrythmia
• CARDIOMYOPATHY, dilated/congestive,
hypertrophic (commonest genetic cause of
sudden death), genetic
• VALVULAR HEART DISEASE, ‘floppy’ mitral
valve, aortic valve stenosis
 SUDDEN NATURAL DEATH
• MYOCARDITIS
• AORTIC DISSECTION -
hypertension/heredity/inflammation,
Marfan’s
• Arrhythmogenic Right Ventricular
Dysplasia –genetic – MRI – 20% sudden
cardiac deaths – cardioverter/defibrillator
• RUPTURE OF AORTIC ANEURYSM
 SUDDEN NATURAL DEATH

PHYSIOLOGICAL –
• Wolff-Parkinson-White,
• long QT syndrome, ion channelopathy–
congenital (inherited as a dominant gene)
or acquired
(antipsychotic/antiarrhythmic/allergy drugs,
electrolytes, toxins, hypothermia, anorexia
nervosa, dieting with liquid protein diets)
 SUDDEN NATURAL DEATH-
CNS causes
• EPILEPSY - SUDEp
• SUBARACHNOID HAEMORRHAGE -
berry aneurysms
• INTRACEREBRAL HAEMORRHAGE-
hypertension
• INTRACRANIAL PATHOLOGY
ASSOCIATED WITH ACUTE
HYDROCEPHALUS OR EPILEPSY -
tumours,meningitis
 SUDDEN NATURAL DEATH
PSYCHIATRIC PATIENTS,

Schizophrenics +/- phenothiazine,

Neuroleptic malignant syndrome
 SUDDEN NATURAL DEATH
• EPIGLOTTITIS
• PULMONARY THROMBOEMBOLISM
• ASTHMA
• HAEMOPTYSIS, T.B., tumour
• SPONTANEOUS PNEUMOTHORAX OF
THE NEWBORN
 SUDDEN NATURAL DEATH
• HAEMATEMESIS, rupture of oesophageal
varices, duodenal ulcer
• CHRONIC ALCOHOLICS, acute fatty
degeneration of the liver
• ADRENAL HAEMORRHAGE, septicaemia
 SUDDEN NATURAL DEATH –
other causes
• AIR EMBOLISM
• FAT EMBOLISM
• AMNIOTIC FLUID EMBOLISM
• Ruptured ectopic pregnancy
• Toxic shock syndrome
• Sudden death in Diabetes – IHD, CM, hypo or
hyperglycaemia
• Sudden death in alcohol
• Commotio cordis
 Sudden death
Sudden adult death syndrome
‘SADS’
Sudden
Arrhythmic
Disease Syndrome
 Sudden Death

The negative autopsy

 SADS
• Sudden unexpected death in an adult
• no signs or symptoms prior to death
• postmortem shows no anatomical cause
of death
• specialised pathology examinations
negative e.g. neuropathology
• toxicology negative
• bacteriology etc. negative
• presumed cardiac dysrrhythmia
 SADS

Now agreed to be due to

acute onset of a chaotic
rhythm in the heart
 SADS

Risk factors include

• A family history of unexplained sudden

death in a relative under 40years
• Unexplained fainting in young people
• Approx 1000 cases/year in UK
 SADS
Differential Diagnosis
• ARVD – abnormal ECG, anatomical
changes may not be obvious at
postmortem; 30-50% have a family
history
• Disorders of the Ion Channel – Long QT
syndromes, Brugada Syndrome (south
east Asia), Catecholaminergic
Polymorphic Ventricular Tachycardia
(AD; Finland and Italy)
 SADS

Treatment

• Defibrillation

• Implantable defibrillator
 Sudden adult death

Sudden death during sporting

activities
 Sudden death in sport
• Males > females
• USA - 1 : 133,000 males
• USA - 1 : 800,000 females
• usually underlying, undiagnosed
congenital heart disease
• cardiomyopathy most common
• anomalous coronary circulation
• viral myocarditis
• > 40 years - coronary artery disease
 Child Deaths
50% due to Natural causes
Genetic or congenital disorder
Cot death - SIDS
Infections
Neoplasms
CNS disorders

U.K - risk of abnormal baby = 1:40

 Child Deaths
50% of Neonatal deaths occur in first
2 days
Prematurity
Hypoxia
Congenital Abnormality
Birth Injury
Still Birth
 S.I.D.S
(Cot Death)
The sudden death of any infant or young child,
which, from the case history, is unexpected, and
in which a thorough postmortem examination
fails to demonstrate an adequate cause for the
death.
It is a diagnosis of exclusion
 S.I.D.S
Features
Age - 2 weeks to 2 years
few after 9 months
male>female
Time - during sleep
80% found dead by 6am
weekends>weekdays
COLDER months
 S.I.D.S
Features
Prematurity
low birth weight
twins
urban>country
Lower social classes
Poor social classes
Young mothers/single parent/smoker
 Theories
Sleeping position
Over heating
pvc mattresses
sleep apnoea
viruses-cause or incidental
small size of larynx
trace metal deficiency
allergy to cow’s milk
abnormal nervous conducting system to heart
excess Na in feeds
overhead electric cables
nuclear power stations
 Theories
Autopsy Findings

1. Nothing
2. Non- specific findings
froth at mouth
petechial haemorrhages
congestion of lungs
3. Manifest illness- NOT SIDS