33 Forensic pathology General

33 Forensic pathology General Paragraph FORENSIC PATHOLOGY GENERAL... [33.70] Introduction: pathology and its subspecialties... [33.70] The role of the coroner... [33.80] Forensic pathology... [33.90] Training... [33.130] Forensic pathology skills... [33.180] Clinical skills... [33.190] Pathology skills... [33.200] Anatomical pathology... [33.210] Neuropathology... [33.220] Cytopathology... [33.230] Haematology... [33.240] Microbiology... [33.250] Immunology... [33.260] Molecular biology... [33.270] Chemical pathology and toxicology skills... [33.280] Legal skills... [33.290] Scientific skills... [33.300] Communications skills... [33.310] The role of the forensic pathologist... [33.350] Medical practitioner... [33.360] Specialist pathologist... [33.380] Death scene examiner... [33.390] Dead body examiner... [33.410] Forensic biologist... [33.420] Forensic radiologist... [33.430] Forensic toxicologist... [33.440] Forensic sociologist... [33.450] Medical detective... [33.460] Forensic pathology qualifications... [33.500] Forensic pathology organisations... [33.510] The aims of the forensic pathology investigation... [33.550] The conduct of a forensic pathology investigation... [33.600] The scene... [33.600] The mortuary... [33.610] Preliminary matters... [33.620] External examination... [33.680] 33-51 Update: 26

Expert Evidence Internal examination... [33.750] Post-autopsy procedures... [33.810] Special techniques... [33.830] Post-mortem artefacts... [33.900] Post-mortem lividity or hypostasis... [33.910] Artefactual bruising... [33.920] Anal dilatation... [33.930] Insect abrasions... [33.940] Animal injuries... [33.950] Rigor mortis and its forcible disruption... [33.960] Pulmonary collapse... [33.970] Aspiration of gastric contents... [33.980] Artefacts associated with resuscitation... [33.990] Artefacts associated with putrefaction... [33.1000] The interpretation of injuries... [33.1100] Introduction... [33.1100] Classification of injuries... [33.1110] Abrasions... [33.1120] Bruises (contusions, haematomata and haemorrhages)... [33.1130] Lacerations... [33.1170] Incised wounds... [33.1180] Stab wounds and punctures... [33.1190] Patterns of injuries... [33.1250] Assaults and falls... [33.1250] Self-inflicted injuries... [33.1260] Interpretation of homicidal stab wounds... [33.1310] Conclusions as to causation following an autopsy... [33.1400] [The next text page is 33-101] 33-52 Freckelton and Selby

Glossary abrasion injury of the superficial layers of the skin only (graze or scratch). adipocere body fat altered after death to a waxy soapy material. alteration deviation from the normal. It describes abnormal findings without assigning them to a distinct disease category. aneurysm a swelling or abnormal dilatation of the wall of a blood vessel. aneurysm an aneurysm is a focal dilation of the lumen of a vessel or of the heart. A true aneurysm (as compared to a pseudoaneurysm) will have thinned out or degenerated remnants of the original parent structure layers (ie, arterial intima, media or myocardium) in the wall of the aneurysm. anterior towards the front. aorta the major artery coming from the heart to supply the body with oxygenated blood. arrhythmia an alteration of the regular heart beat, either in time (rhythm) or force. Some arrhythmic alterations can be regarded as part of normal life, while others are pathological. There is clearly a grey zone in between. arteries high pressure blood vessels carrying oxygenated blood from the heart to the organs of the body. asphyxia restriction or obstruction of the supply of air (oxygen) to the body. autopsy the preferred term for the post-mortem examination of a body undertaken, inter alia, to identify the disease processes present in the deceased. avulsion a tearing away or apart of an anatomical structure. battered baby syndrome syndrome characterised by repeated infliction of injuries to a young child over a period of time. blood count determination of the blood cells in a definite volume of blood, in number, but also divided by type, including white blood cells and red blood cells. blood vessels the flexible tubes and pipes which carry blood around the body. bruise the presence of blood in tissues as a consequence of ruptured blood vessels. burn thermal chemical or radiation induced physical damage to body tissues. cardiac referring to the heart or a part of an organ nearest the heart. cardiac of, relating to, situated near, or acting of the heart; of, relating to, or affected with heart disease. cardiovascular of, relating to, or involving the heart and blood vessels. 33-101 Update: 26

EXPERT EVIDENCE coagulation the process of becoming viscous, jellylike, or solid, especially concerning the change from a liquid to a thickened state not by evaporation but by chemical reaction. In blood, this usually involves the alteration of soluble substances (such as proteins) into an insoluble form. contusion see bruise. contusion (in the context of cardiac injury) injury to tissue, usually with permanent damage such as laceration, as opposed to concussion. coronial autopsy an autopsy conducted under the authority of a coroner s request or order. cuts a slang or lay term encompassing lacerations and incised or stabbed wounds. death a process involving the ceasing of vital physiological functions of the cells, tissues, and organs of the body and the integration of these activities. decomposition the process whereby the body loses its structural integrity after death. defibrillation trial conducted in order to restore the rhythm of a fibrillating heart, using drugs, electrical impulses, or mechanical impulses. disruption the act or process of breaking apart or rupturing. dysfunction, disfunction impaired or abnormal functioning. fibrous tissue connective tissue containing collagen fibres and spindle shaped cells which are called fibrocytes and fibroblasts. forensic generally, relating to the law; jurisprudentially, relating to the courts. forensic autopsy see coronial autopsy. forensic medicine the application of the principles and practice of medicine to the needs of the law. forensic pathology the application of the principles and practice of pathology to the needs of the law. forensic science the application of scientific principles and practice to the needs of the law. haematoma collection of blood, haemorrhage (see bruise ). haemorrhage the action of bleeding. See also bruise. heart attack an acute episode of heart disease (as myocardial infarction) due to insufficient blood supply to the heart muscle itself, especially when caused by a coronary thrombosis or a coronary occlusion. hypostasis see post-mortem lividity. incised wound a wound which is longer than it is deep caused by a sharp-edged implement. infarction death of tissue due to interference with the blood supply. 33-102 Freckelton and Selby

GLOSSARY infarction the process of forming an area of necrosis in a tissue or organ resulting from ischaemia within the local circulation, such as obstruction by a thrombus or embolus, or compression of the vessel, or any other condition which may cause ischaemia. inferior situated lower down when the body is in the anatomical position. inflammation a local response to cellular injury that is marked by capillary dilation, leukocytic infiltration, redness, heat, pain, swelling and often loss of function and that serves as a mechanism initiating the elimination of noxious agents and of damaged tissue. inflammation the body s response to injury. internal carotid arteries arteries in the neck supplying blood to the brain. laceration a tear or split in the skin or other organ usually resulting from a blunt impact. laceration tear or split in tissue. laceration (heart, vessels) a torn or ragged wound; ie, the heart having different mechanical properties with regard to acceleration and deceleration, exerting forces on attached vessels, causing a laceration. lateral relating to structures further away from the midline plane of the body. lesion general term indicating a physically discrete pathological entity. lethal of, relating to, or causing death. media the middle coat of the wall of a blood or lymph vessel consisting chiefly of circular muscle fibres. medial relating to structures closer to the midline plane of the body. orbit space within the skull encasing the eye and surrounding soft tissue. pathology the study of disease. peripheral of, relating to or being blood in the systemic circulation (as opposed to central: of, relating to or being blood in the circulation of the heart or the great vessels). platelet one of the minute protoplasmic disks of vertebrate blood that assist in blood clotting. posterior towards the rear. post-mortem artefacts phenomena occurring after death which can be mistakenly interpreted as representing events in life (eg, lividity being confused with bruising). post-mortem examination see autopsy. post-mortem lividity a post-mortem phenomenon resulting from the settling of blood in the dependent parts of the body under the influence of gravity. post-mortem rigidity see rigor mortis. post-mortem staining see post-mortem lividity. putrefaction a particular form of decomposition involving the generation of various gases, fluids and foul odours. respiratory disease disease which affects the trachea or lungs or parts thereof. 33-103 Update: 26

EXPERT EVIDENCE rigor mortis a post-mortem phenomenon of muscular stiffening occurring at a variable period after death and eventually passing off. rupture the tearing apart of a tissue. stab wound a wound which is deeper than it is long usually caused by a sharp-pointed and sharp-edged implement. stasis slowing of the current of circulating blood. superior towards the head. tachycardia relatively rapid heart action, whether physiological (as during or after exercise) or pathological, usually faster than 100 beats per minute. tear to wound by or as if by pulling apart by force. tumour an abnormal mass of tissue that is not inflammatory, arises from cells of pre-existent tissue, and serves no useful purpose. Tumours can be classified as benign or malignant. vertebral arteries arteries in the soft tissues and spine of the neck supplying blood to the brain. wound disruption in the integrity of an organ or tissue. Jurisprudentially, a full thickness defect of the skin. [The next text page is 33-1101] 33-104 Freckelton and Selby

33 Forensic pathology General by Stephen Cordner MA, MBBS, BMed Sci, Dip Crim, DMJ, FRCPA, FRCPath David Ranson BMed Sci, BM BS, LLB, FRCPath, FRCPA, DMJ (Path) [The authors would like to thank Melbourne University Press and Professor V D Plueckhahn for permission to use extracts from Ethics, Legal Medicine and Forensic Pathology (2nd ed) by V D Plueckhahn and S M Cordner (1991), and Melbourne University Press for permission to use extracts from Forensic Medicine and the Law by D L Ranson (1996).] 33-1101 Update: 26

EXPERT EVIDENCE Author information Stephen Cordner is Professor of Forensic Medicine (Foundation Chair), at Monash University, Victoria. He is Foundation Director of the Victorian Institute of Forensic Medicine. The Institute is a statutory body established by the Coroners Act 1985 (Vic). It is responsible for forensic pathology and related services in Victoria and has teaching and research functions as well. Professor Cordner is a Fellow of both the Royal College of Pathologists of Australasia and the Royal College of Pathologists in the United Kingdom and member of the following societies: Australian Medical Association, British Association of Forensic Medicine, British Academy of Forensic Sciences, Australian and New Zealand Forensic Science Society, University of Melbourne Alumni Association, Police Surgeons Association of Great Britain, Association of Australasian and Pacific Area Police Medical Officers (associate member), Medico-Legal Society of Victoria, Medico-Legal Society (England), Association of Medical Directors of Victorian Hospitals, International Academy of Pathology and is a Fellow of the Royal Society of Medicine. Professor Cordner s main publication (with Professor V D Plueckhahn) is Ethics, Legal Medicine and Forensic Pathology (2nd ed, Melbourne University Press, 1991). David Ranson is the Deputy Director of the Victorian Institute of Forensic Medicine and Honorary Clinical Associate Professor of Forensic Medicine at Monash University, Victoria. He is an Associate in the Faculty of Law at Monash University and a Senior Associate in the School of Dental Science at the University of Melbourne. David Ranson is a Fellow of both the Royal College of Pathologists of Australasia and the Royal College of Pathologists in the United Kingdom and is a member of the following societies: American Academy of Forensic Science (associate member), Australian Academy of Forensic Sciences, Australian New Zealand Forensic Science Society, Australian College of Legal Medicine, British Academy of Forensic Sciences, British Association of Forensic Medicine, Police Surgeons Association of Great Britain, Association of Australasian and Pacific Area Police Medical Officers (associate member), Medico-Legal Society of Victoria, International Academy of Pathology, and Association of Clinical Pathologists. David Ranson s main publications are Forensic Medicine and the Law (Melbourne University Press, 1996), Anatomical Figuring: Forensic Body Chart Resource (Victorian Institute of Forensic Medicine, Melbourne, 1995) and (with Associate Professor J Clement) Cranio-facial Identification in Forensic Medicine (Hodder, 1998). 33-1102 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL Introduction: pathology and its subspecialties [33.70] There is often confusion about the nomenclature of the various disciplines in medicine and this is particularly true in the case of pathology, forensic pathology, forensic medicine and forensic science. Pathology is the study of disease. Therefore, in one sense, all doctors are engaged in aspects of pathology. The practice of pathology as a medical specialty is relatively new. Professional pathologists really became established in the medical workforce in the 20th century and the professional colleges and organisations that regulate the specialty have only been in place in the last few decades. The word forensic comes from the Latin forum which was the place of assembly for judicial and other public business. The word forensic, when used in a legal context by lawyers, means those skills of the law related to the courtroom itself and, in particular, those skills of advocacy. Forensic medicine is the name of the broad medical subject which applies the principles and practice of medicine to the needs of the law. It has six main areas: (1) forensic pathology; (2) clinical forensic medicine; (3) forensic psychiatry; (4) forensic dentistry; (5) forensic anthropology; and (6) medico-legal issues (medical jurisprudence). Just as medical sciences form a discrete area of expertise from the traditional physical sciences, forensic medicine should be differentiated from forensic science. The latter deals with matters such as ballistics, analysis of soil, paint, suspicious botanical specimens, chemical analysis, grouping of blood stains and the like. In some parts of the world, forensic medical and forensic scientific services are provided from within the one institution. In Britain and Australia, the two are usually separate and reasonably so since it is now beyond the capacity of any one individual to have sufficient understanding of both areas to control them properly. The aim of this chapter is to give an outline of the structure of the main areas of the specialty of forensic pathology and one of its subdisciplines, forensic neuropathology. The interpretation of injuries in both living and deceased persons is a specific area of forensic pathology expertise and is discussed in some detail as are some of the issues related to medical causation, as in the cause of death. Questions relating to the production, analysis and interpretation of autopsy reports will probably also require recourse to one of the standard textbooks and/or the advice of the report s author, or the advice of another forensic pathologist. 33-1103 Update: 26

[33.70] EXPERT EVIDENCE The role of the coroner [33.80] In order to examine the role of the forensic pathologist in death investigations, it is essential to understand the development of death investigation systems including the role the coroner plays in such jurisdictions. The office of coroner has its roots in Norman times where death investigation had associated with it important political and financial considerations. Coroners had responsibility for the collection of a number of fines and taxes that could be levied by the Crown in relation to certain types of deaths. Deodands comprised taxes paid to the Crown that were based on the financial value of the implement or object that had caused a person s unnatural death, so that if a person was run over by a cart, the cart or its value was forfeited to the Crown as a tax and the coroner was responsible for ensuring that the tax was paid. Similarly, the fine of presentment of Englishry was payable by a local community if the coroner found that a deceased person was not of English blood: see Freckelton (1993 ); Selby (1997); Selby (1992). The role of the coroner in criminal matters relating to death was limited, although the coroner had the ability to ensure that potential criminal matters were brought within the criminal justice system. The coroner s main function in relation to crime was to keep a check on the sheriff and to ensure that revenues such as fines reached the Crown. With regard to the prevention of deaths, the coroner had little or no direct function, although some early coroners made attempts to highlight hazards in the community and to reduce their impact. Over time, the coroner s role diminished and the office became an onerous one with the coroner having to pay many of the fees associated with the work out of his own pocket. Early coroners were not necessarily medically or legally trained, and many of the early coroners appointments were essentially political rather than professional. Today the focus of coroners in Australia differs from that of coroners in England and Wales. Much of the operation of the office of coroners in Australia is centred on prevention, with the coroner empowered to make broad recommendations surrounding the issues of public health and safety and judicial administration. Such an approach gives the coroner a dynamic function in contributing to the welfare of the community. In this modern framework the role of the full-time forensic pathologist has been revitalised. The forensic pathologist is involved not only with the investigation of suspicious deaths that may have a criminal connotation but with a wide range of natural and unintentional deaths. These investigations can lead to a greater understanding, and improvements in the health and safety of the community. In conjunction with the coroner, the forensic pathologist is a watchdog who maintains a constant surveillance on potentially fatal hazards in our society and ensures that preventable deaths are recognised and the issues surrounding them addressed. Forensic pathology [33.90] In order to appreciate the role of the forensic pathologist within the justice system, it is important to understand the manner in which forensic pathologists are recruited and trained for the services that they provide. Forensic pathologists are recruited from the medical profession, generally from among pathology specialists who practise in the field of anatomical pathology or histopathology. Specific training programs in forensic pathology are now emerging, but while the justice system has appreciated the needs of forensic pathologists for some time, it is only since the 1980s that the professional medical bodies responsible for the training and accreditation of 33-1104 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.100] pathologists have recognised the need for accreditation and training of full-time forensic pathologists. The need of the justice system in the United Kingdom for forensic pathologists was well stated in the Brodrick Report: According to the evidence received the basis of forensic pathology is the small amount of work which, although it is carried out on behalf of the coroner, is particularly the concern of the police Every police force needs to be able to call on the services of a specially experienced pathologist to help in the investigation of murder and other serious crimes against the person. Ideally, this person should be a pathologist with a sound training in morbid anatomy who has added to this general knowledge some additional skills, most notably the ability to detect, and give authoritative testimony about, unusual features of a dead body and the surrounding circumstances which may well be of evidential value. He should be able to command the facilities of a well-equipped pathological laboratory, be readily available on call to police and courts, and be prepared to travel at short notice anywhere in the area which he serves : Report of the Committee on Death Certification and Coroners (Cmnd 4810), 22.18. [33.100] While the fundamental principles of pathology applied in the work of the forensic pathologist are the same as those of the work of clinical pathologists, there is considerable difference in the nature of the work performed and in the mental and analytical processes applied. The forensic pathologist s focus is the end-point of the forensic investigation which is the judicial process, usually a criminal court trial or coroner s inquest. This is not to say that the forensic pathologist ignores broad community interests in relation to public health. Indeed, much of their work for the coroner involves a focus on issues of health and safety, and hazard recognition. The legal system has long accepted that there is indeed an essential difference between those pathologists engaged in clinical, hospital-related practice and those engaged in forensic pathology practice. In the Brodrick Report, this issue was addressed: Do the police need the services of a special kind of pathologist who can for the most part be distinguished from a clinical pathologist in a hospital? Do coroners need the services of the same kind of pathologist as the police? Our answer to the first question is an unequivocal Yes. We accept the view that while every forensic pathologist needs to be a competent morbid anatomist, the reverse statement does not follow: Many morbid anatomists will never have the inclination to undertake forensic work, ie, work for the police or the criminal courts. The nature of the problems most often encountered in criminal investigation is different from that most often encountered in clinical work. So are the circumstances in which the two kinds of pathologists are called upon to work. The Forensic Pathologist may be required in field work literally! There is also a difference between writing an opinion for a colleague, and giving evidence based on that opinion or being cross-examined on that opinion in the criminal court. There are pathologists who feel attracted to this particular kind of challenge and also have the ability to cope with it, and there are pathologists who do not feel this urge and who may not have the right attributes. We conclude that the difference between a clinical pathologist and a forensic pathologist is as much in the nature of the man as the nature of the work : Report of the Committee on Death Certification and Coroners (Cmnd 4810), 23.13 14. While it is certainly true that the difference between a clinical pathologist and a forensic pathologist is in the nature of the person performing the task as well as the nature of the work, it is not true to say that forensic pathology can be carried out only by medical practitioners with a certain type of personality! Instead, this personal aspect of the difference between clinical and forensic pathologists is accounted for by training and experience. The forensic pathologist has to be trained in, and develop an understanding of and aptitude for, the legal 33-1105 Update: 26

[33.100] EXPERT EVIDENCE process of investigation in conjunction with knowledge of the scientific process of investigation. These two approaches to investigating matters are quite distinct and few scientists or medical practitioners have any real understanding of or feel for the legal investigative method. It is a knowledge of the role that legal systems play in society, as well as an understanding of the legal process and legal method, that distinguish forensic pathologists from their clinical counterparts. Certainly there are areas of specialist factual knowledge that forensic pathologists are familiar with that their clinical counterparts are not. However, simply acquiring factual knowledge on forensic issues will not provide a clinical pathologist with sufficient skills to undertake forensic work. [33.110] A practical result of this difference is that forensic pathology does not sit comfortably within a professional clinical pathology environment. Indeed, the operational requirements of forensic pathology mean that the service is usually more efficiently provided by specialist forensic pathologists working together. Such a structure enables the provision of a forensic pathology service for a range of clients on a 24-hour basis over large geographical areas. Such an organisational structure allows for: continuity of expertise in professional forensic pathology services; appropriate internal case review and audit; personal professional development; and concentration of expertise for the purpose of undergraduate and postgraduate training. In some jurisdictions, this centralised approach is the preferred organisational structure of forensic pathology, while in others this structure is combined with part-time practitioners who also have a clinical pathology role. The nature of forensic pathology and its workload is such that the service does not require a large number of medical practitioners in any particular jurisdiction. However, a continuous supply of a small number of experienced and well-trained medical practitioners is needed to provide timely and comprehensive forensic pathology services. In this regard, undergraduate and postgraduate teaching, as a result of affiliation with medical schools and the appropriate professional training colleges, is an important part of a forensic pathology service. Undergraduate and postgraduate training in medicine is supervised by medical schools and professional bodies such as the Royal Colleges whose focus is, of course, on the production of competent medical practitioners for the community. There is little emphasis on this area within the medical undergraduate curriculum. This is probably appropriate because only a few forensic pathologists are required. It is in the area of postgraduate training that forensic pathology training programs come into their own. Whereas the majority of universities and medical schools do not feel the need to develop training systems in forensic medicine and forensic pathology, there is little doubt that the legal system does express the need for such practitioners. In April 1989 the Home Office in the United Kingdom published the Report of the Working Party on Forensic Pathology (the Wasserman Report). Paragraph 1.1 stated: Forensic Pathologists play a vital role in the Criminal Justice system. Strictly speaking, their responsibility is simply to undertake the post mortem examination of bodies found in suspicious circumstances in order to establish, as far as possible, the cause of death. ( Suspicious circumstances are those in which there is suspicion of murder, manslaughter or infanticide.) In practice, however, it is often their professional judgment which determines whether a particular death is dealt with by the coroner by inquest as one due to accident, natural causes or suicide, or is investigated by the police as a preliminary to a 33-1106 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.130] criminal trial. To this extent theirs is the first step towards bringing to justice those responsible for the most serious crimes in our society. [33.120] Legal jurisdictions differ in the way they organise death investigation services and the relationship between a coroner and police investigators is at times complex. Some general rules, however, appear to be common, at least in Australia, New Zealand, England and Wales. The authority to investigate a death lies with a coroner and it is the coroner who institutes and authorises a pathologist to perform a post-mortem examination. The police have a similar duty to investigate a death and, with respect to certain aspects of the death investigation, they act as agents of investigation for the coroner. In this situation, the forensic pathologist is another co-investigator for the coroner. Where a matter involves direct criminal issues, much of the practical investigation is carried out by the police on behalf of the criminal justice system, a system in which the coroner plays little part. In these circumstances, there is a practical basis for concluding that the pathologist, in fact, is carrying out a service for the police investigators. In reality, a criminal investigation involves many phases. Traditionally, the forensic pathologist was involved in that phase of an investigation that is centred on a death or injury, and in particular the examination of an injured or deceased person to ascertain the nature and cause of their injuries. In practice, however, forensic pathologists play a wider role with respect to the criminal investigation. For example, they may become involved in the examination of scenes of death, or in the examination of suspects who may have inflicted injuries on the victim. They may evaluate medical records for medico-legal purposes, and examine the statements of other witnesses with regard to medical matters. They are certainly involved in the later stages of a criminal investigation, including the compilation of a brief of evidence and assisting with the evaluation and presentation of that evidence, both before and during court proceedings. Forensic pathologists in practice have a wider role than dealing with suspicious deaths. The vast majority of autopsies conducted by forensic pathologists involve unconfirmed natural deaths which society requires to be scrutinised and confirmed. The investigation of non-suspicious natural deaths, accidents (fatal incidents), deaths from suicide, and deaths from other forms of intentional and non-intentional injury form the vast majority of their case work. The information that can be gained from investigating these deaths is potentially very significant for the community. The role of the forensic pathologist in relation to suspicious deaths and the criminal justice system is the one most readily understood and appreciated by the community. However, this wider role with respect to autopsies in non-suspicious cases is far less defined and less understood by the lay, legal or even the general medical community. TRAINING [33.130] The analysis of the background and training of a forensic pathologist must take into account that forensic pathology is based on the techniques and skills of clinical pathology, in particular anatomical pathology, histopathology and morbid anatomy. Any substantial period of study and training will equip a clinical pathologist with the factual knowledge necessary in order to deal with the scientific investigatory issues that surround the work. The development of the necessary legal investigatory skills is more difficult. In the past, the majority of forensic pathologists gained these skills by experience. The very act of taking part in complex police investigations and in court processes within the coronial and criminal legal systems provides forensic pathologists with an insight into the legal investigatory process and the evidential requirements of the legal system. There have been several attempts to introduce training in legal methods into some undergraduate and postgraduate forensic medical courses. For example, in the undergraduate 33-1107 Update: 26

[33.130] EXPERT EVIDENCE course in forensic medicine at both Monash University and the University of Melbourne, students take part in moot (practice) courts and a number of joint law-medicine subjects are now available for undergraduates from the Faculties of Law and Medicine. Despite this, it is not easy for medical students to acquire knowledge and understanding of legal methods. Increasingly, medical practitioners who are interested in forensic medicine and forensic pathology are turning to the study of law itself to acquire these skills. Not only are all doctors becoming more aware of the legal issues surrounding medical practice but there has also been an increase in the number of medical practitioners who have obtained formal qualifications in law. [33.140] With regard to postgraduate training, there has been a considerable increase in the interest of the professional pathology organisations around the world in the specialty area of forensic pathology. The Royal Colleges of Pathologists of both Australasia and the United Kingdom offer specialist fellowship and membership examinations in forensic pathology. While accrediting examinations are now available in forensic pathology, training programs are still limited. A limited number of forensic pathology training posts have been available within pathology and forensic pathology departments, but these training positions have not usually been part of an organised national formal training program in pathology. The degree of organisation varies from place to place, and the lack of formal training programs has been recognised in a number of jurisdictions. The Wasserman Report stated (para 3.34): The qualifications of the overwhelming majority of forensic pathologists presently practising were acquired at their own expense and in their own time. There has never been a centrally managed training scheme, although Brodrick recommended one based on the National Health Service. The importance of formal training and accredited external examinations cannot be overemphasised. If society and the courts are to be assured that they are receiving expert opinion evidence from a person who has the necessary skills and knowledge, then the availability of accredited qualifications based on organised training is essential. [33.150] An example of the more formalised training supervised by medical colleges can be seen in this extract from the information booklet for trainees produced by the Royal College of Pathologists of Australasia. It states: In forensic pathology trainees must gain the following experience/knowledge: 1. Conduct under supervision of at least 500 coronial post-mortem examinations comprising a mix of adult and infant deaths and unexpected natural, accidental deaths, suicides, homicides and postoperative and anaesthetic deaths. 2. Training and experience in special autopsy procedures relevant to forensic pathology including: (a) the demonstration of the vertebral arteries, the cervical cord, the urethra and structures of the neck, (b) enucleation of the orbits, (c) neonatal and infant autopsy techniques, (d) identification techniques, (e) the collection of organs, tissues and fluids for toxicological examination. 3. A working knowledge of associated forensic fields including: 33-1108 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.170] (a) toxicology and its place in forensic pathology, (b) forensic radiology, (c) forensic odontology, (d) osteology, (e) forensic immunohaematology. 4. Attendance at scenes of suspicious and homicidal deaths including training in the principles of trace evidence collection and its preservation at the scene of death and at the post-mortem examination. 5. The use of biological and physical forensic sciences in assessing the mechanism and cause of accidental, homicidal and suicidal deaths and in reconstruction of the circumstances surrounding such deaths. 6. Giving factual and expert evidence in Australian courts of law. 7. The functions, operation and legislation relevant to the coronial and criminal justice systems, and the law relating to transplantation and the determination and certification of death in Australia and New Zealand. It must be remembered that these are minimum guidelines and that most candidates for fellowship of the college will exceed many of these requirements. [33.160] To qualify as fellows of the Royal College of Pathologists of Australasia in forensic pathology candidates sit a final written examination which covers both anatomical pathology (morbid anatomy) and forensic pathology. The final practical examinations include assessment of microscopic sections of human tissues in selected pathology cases, both anatomical and forensic case analysis based on the examination of photographs of crime and death scenes and autopsy findings. The Fellowship final examination also requires the candidate to present a case book in which ten coronial post-mortem examinations are described and annotated in detailed discussion papers. It also includes a viva voce in which candidates assess a variety of visual material as well as answering formal questions. Before this final examination can be attempted, candidates must have already passed preliminary examinations in basic pathological science and anatomical pathology which include both written and practical tasks. The diploma examination in forensic pathology at the Royal College of Pathologists of Australasia is made available for those college fellows who have already specialised in a branch of clinical pathology. This examination is focused specifically on forensic pathology and includes written, oral and practical examinations as well as the presentation of a case book. [33.170] The aim of professional examinations is to ensure that the candidate has reached a standard of proficiency which the profession recognises as being the minimum required to undertake competent professional practice in that field. In addition to their forensic skills, qualified forensic pathologists will have been assessed in the areas of clinical pathology, and in particular the subspecialties of anatomical pathology or histopathology. The acquisition of such professional qualifications does not exempt the pathologist from further study. Continuous professional education is now a requirement of most specialist branches of medicine; many of the Royal Colleges governing professional practice have set up or are setting up programs which require fellows and members to engage actively in ongoing educational activities in order to retain their professional accreditation. As courts require an 33-1109 Update: 26

[33.170] EXPERT EVIDENCE expert witness to prove his or her expertise each time that witness gives evidence, a witness who holds professional qualifications which requires involvement in a program of continuing professional education has an advantage in being able to prove that his or her knowledge is up to date. FORENSIC PATHOLOGY SKILLS [33.180] As a result of their training, forensic pathologists have a variety of specialist skills which they apply in their work. The basis of these skills is completion of a medical course, including appropriate clinical internship and a variety of other clinical appointments. As a result, the skills of a forensic pathologist cover a wide variety of subdisciplines in medicine and particularly subspecialties within pathology. These can be divided into clinical, pathological, and legal areas, together with general skills in science and communication. [33.190] Clinical skills Forensic pathologists are first and foremost medical practitioners. They have undergone a full undergraduate training course of five to seven years which has included both pre-clinical and clinical studies. All forensic pathologists have spent at least one year and, in some cases, several years working in clinical medicine within a hospital setting. Some will have spent a considerable time working in other clinical specialty areas within a hospital or, in some cases, in general practice and their knowledge in these clinical areas may be considerable. However, it should not be assumed that because of such experience they are currently experts in clinical medicine or that they have kept their clinical medical skills up to date. The rapidity of developments in clinical forensic medicine and therapeutics makes it difficult for practitioners who are not actively engaged in clinical medicine to maintain clinical medical skills. With the rapid increase in clinical subspecialties, any forensic pathologist s knowledge of clinical medical practice will necessarily be limited in most cases to general principles only. [33.200] Pathology skills Forensic pathology involves the application of basic pathology disciplines in a forensic or medico-legal setting. The pathological skills involved in forensic pathology can be divided into a number of areas: anatomical pathology, neuropathology, cytopathology, haematology, microbiology, immunology, molecular biology, chemical pathology and toxicology. These will be looked at in turn. [33.210] Anatomical pathology Various descriptive terms are applied to the skills encompassed within anatomical pathology. There are, indeed, distinct semantic differences between these terms, but for most practical purposes the type of professional specialisation and skill involved is the same. Some of these terms include anatomical pathology, histopathology, surgical pathology and morbid anatomy. Pathologists practising in these areas have skills in the macroscopic or naked-eye examination of diseased organs and tissues, and microscopic examination of human organs and tissues. Microscopic pathology examination, sometimes referred to as surgical histopathology, forms the bulk of the work of anatomical pathologists in a hospital setting. Pieces of human tissue, removed either at surgery or in sampling techniques such as biopsies, are processed in the laboratory. Thin sections are cut, placed onto glass microscope slides, and stained in order to reveal the nature of their cellular components. These sections of tissue are then examined by a 33-1110 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.230] pathologist under a microscope for the purpose of identifying whether there are any abnormalities present in the tissue, and if there are abnormalities, what type of disease is involved. The accurate determination of disease type is important for the future management of the patient and for short- and long-term prognosis. In addition to examination of biopsy material, large portions of organs, that are removed during surgical operations as part of a curative surgical procedure, are also examined by pathologists to ensure that the surgery has included the removal of all of the diseased tissue. In the case of operations for the removal of tumours, the pathologist also looks to see whether lymph nodes adjacent to the main tumour site are free from tumour or contain secondary deposits. Most forensic pathologists have completed full anatomical or surgical pathology training and therefore they are experienced in the performance of hospital autopsies as well as forensic pathology autopsies. In addition, they are skilled in the areas of microscopy of human tissues and the identification within those tissues of various types of human disease. This surgical pathology training gives the pathologist experience of a wide variety of other medical specialties. A surgical pathologist may have experience in dealing with biopsy material involving the diseases of children and the elderly. Obstetrics and aspects of maternal pathology and gynaecology, together with medical specialty areas such as thoracic or cardiac surgery, are other areas in which the hospital pathologist provides surgical pathology services. As a result, the hospital anatomical pathologist is exposed to a wide variety of medical and surgical material from many clinical subspecialties. In some cases, an anatomical pathologist gains specific additional skills in certain disease areas. For example, pathologists with a particular interest in diseases of the skin work closely with dermatologists and gain considerable dermatological knowledge. [33.220] Neuropathology Neuropathology is a discrete subspecialty within anatomical pathology. A neuropathologist is usually an anatomical pathologist who specialises in the organs and tissues that comprise the central nervous system, the peripheral nervous system and muscles. In a hospital setting, the neuropathology staff are involved with the clinical disciplines of neurosurgery and neurology. Neuropathologists deal with diseases of the brain, the spinal cord, the peripheral nerves and the muscles of the body. A large part of the work of neurosurgeons is management of trauma to the head and central nervous system. As a result, neuropathologists also deal with traumatic damage to the tissues of the central nervous system. The skills of neuropathology have a particular relevance for forensic pathology with regard to the processes involved in head injuries. While all anatomical pathologists are trained in aspects of neuropathology, forensic pathologists have a particular interest in traumatic neuropathology. A few forensic pathology centres include specialist forensic neuropathologists among their staff to deal with cases involving damage and injury to the central nervous system. The investigation of deaths from head injuries can involve identification of the type of forces applied to the head by reference to the pattern of skull fractures, the resulting damage to the brain, and the nature and extent of bleeding inside the skull. The field of forensic neuropathology is covered in more detail later in this chapter: see below, [33.1500]. [33.230] Cytopathology The processes for identifying diseases of the body involve examination of whole organs, specific tissues, and the cells that go to make up those tissues. The histopathologist or 33-1111 Update: 26

[33.230] EXPERT EVIDENCE anatomical pathologist who examines microscopic sections of tissues under the microscope, looks at tissues of the body where the cells are arranged in their normal anatomical configuration. Cytopathologists examine the cells of the body in isolation or in small clumps where the cells do not form part of an intact tissue structure. The cells are obtained through a variety of sampling processes: scraping of the surface of tissues, as in the examination of the cervix or neck of the uterus; aspirating fluids from various parts of the body; or aspirating solid tissue masses. A spatula or like object is used to scrape the surface of organs whereas a needle is used to aspirate cells or fluids containing cells from the body. The specimen or sample is usually concentrated and spread onto slides, and then stained and examined under the microscope. A large proportion of the work of the cytopathologist involves screening samples collected from people who have no obvious disease or illness. Screening attempts to discover diseases that have not yet made their presence known, so treatment can be started at an early stage. In the case of some diseases, particularly certain cancers, such early detection can result in effective cures. The role of cytopathology within forensic pathology is limited. However, a wide variety of cytological techniques are employed within forensic pathology and some tests for drowning and for the identification of spermatozoa employ procedures similar to those used in cytopathology. [33.240] Haematology Haematology involves the diagnosis and treatment of diseases of the blood and includes the examination of peripheral blood and the blood precursor cells found in the bone marrow. Blood and bone marrow can be examined using techniques similar to those of cytopathology. A number of other tissues and organ systems are closely related to the blood and are often included in examinations performed by haematologists. Lymph nodes, the spleen, the thymus, together with the bone marrow, are some of these additional systems. Haematology is a specific subspecialty of pathology, and many practitioners do not have an extensive background in anatomical pathology. Haematologists are often divided into two types of practitioner: those who deal with blood transfusion services together with the laboratory examination of blood and related tissues as part of a diagnostic service, and those who practice as physicians treating individuals with diseases of the blood and related organ systems. Some haematologists practise in both areas, and some undertake specialised work on areas such as bone marrow transplantation and blood transfusion. While the clinical aspects of haematology do not impinge greatly on the work of the forensic pathologist, many of the principles of the identification of blood and the determination of blood grouping used in forensic science and forensic medicine involve the same laboratory techniques and procedures. [33.250] Microbiology Microbiology is the branch of pathology that deals with the identification of micro-organisms that cause disease. Bacteria, viruses and fungi are just some of the agents which are dealt with by a microbiologist. Like other pathologists, the microbiologist deals with samples taken from the human body but, in addition, their work can involve the analysis of specimens taken from the environment. These samples are examined to determine which micro-organisms are present, and often the organisms are tested to see whether they are sensitive or resistant to antibiotics and other drugs. Like haematology, microbiology is a pathology discipline in which most practitioners have little training in anatomical pathology. Like haematologists, 33-1112 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.270] microbiologists can be divided into two types of practitioner: those who do laboratory work and those who do clinical work as infectious diseases physicians. Microbiology has a specific role to play not only in the diagnosis of infectious diseases, but also in the monitoring processes that take place in hospitals, looking for sources of hospital-acquired infection and ensuring that equipment and clean areas are, in fact, free from significant numbers of potentially infectious agents. While microbiology has limited application in the field of forensic pathology, all forensic pathologists understand basic microbiology principles and incorporate the results of microbiological testing into their medico-legal reports. Microbiological diseases play a part in a number of deaths investigated by forensic pathologists, and many of the individuals whose deaths form the subject of forensic pathological investigation have life-styles which involve current or previous infection with particular agents. A good example of this is death associated with overdose of intravenous drugs, where there is often evidence of prior infection with Hepatitis B, Hepatitis C or HIV. [33.260] Immunology Immunology has emerged in recent years as a key discipline within pathology. Immunological principles are applied in many of the other branches of pathology, including microbiology, haematology and anatomical pathology. Immunology has grown as a division of pathology and is now recognised as a major subspecialty. Immunologists study and test the function of the immune system of the body and the diseases that are associated specifically with immune system dysfunction. Many diseases involving the immune system present with symptoms that are relevant to other branches of pathology. For example, autoimmune diseases that attack the blood are often managed by haematologists, and immunological diseases affecting the skin are diagnosed in association with anatomical pathologists. Many of the techniques used to identify infectious micro-organisms rely on immunological principles. Understanding of the body s immune defence mechanisms has resulted in the identification of a number of specific disease processes involving the immune system alone. The overlap between molecular biology and immunology is considerable, and many people working in clinical immunology have close links with researchers and specialists dealing in the analysis of tumours and genetic diseases. With the advent of tissue transplantation and the matching of tissues between donors and recipients, the skills of the immunologist have come to the fore. There are a number of specific disease processes associated with individuals who have had tissue or organ transplants, and immunologists play a major part in the management of these diseases. From the perspective of forensic pathology, many of the techniques of immunology are used in the forensic testing processes. The serological tests and blood grouping tests that are a feature of forensic science and forensic medicine are based on immunological principles. In some difficult forensic pathology cases involving the identification of biological material and drugs, professional immunological expertise may be required. [33.270] Molecular biology Molecular biology is a specialised technique used by pathologists to examine tumours from both a research and diagnostic perspective. The use of DNA analysis in medical practice is growing. However, it is the use of molecular biology techniques in a forensic science that has captured the interest of the community and law enforcement agencies. While these techniques have great forensic significance, most of the the original research in this area was developed by 33-1113 Update: 26

[33.270] EXPERT EVIDENCE research pathologists studying the way in which human DNA and genes contributed to the origin of diseases, particularly autoimmune diseases and cancer. [33.280] Chemical pathology and toxicology skills Chemical pathology, sometimes referred to as medical biochemistry, can also encompass the field of toxicology. There are chemical pathologists who specialise in the area of toxicology, but most doctors working in chemical pathology deal principally with biochemical testing of human samples for indicators of natural disease. Like haematologists and microbiologists, chemical pathologists tend to practise in one of two areas, diagnostic services or clinical practice in the field of metabolic diseases. In clinical practice, chemical pathologists provide therapeutic advice and treatment for enzyme and hormonal disorders and for the management of individuals with complex biochemical abnormalities, including patients who require treatment in intensive care units. Many of the specialist analytical methods used in chemical pathology involve immunological techniques, and the chemical pathologist has an important role to play in neonatology and paediatrics by providing screening tests for a variety of genetic disorders involving biochemical abnormalities. The field of toxicology uses many of the techniques of analysis that are found in the chemical pathology laboratory. The toxicologist does not generally measure natural body substances but analyses human tissues for the presence of drugs and other chemical agents that may have been taken into the body. Many hospital chemical pathology departments analyse body samples for the presence of drugs and, in fact, provide a limited toxicology service, usually to support medical treatment and diagnosis of poisoning or adverse drug effects. Many aspects of advanced toxicological analysis and interpretation lie outside the everyday work of the chemical pathologist. However, all pathologists have been trained in basic toxicology in relation to therapeutic and non-therapeutic drugs. From the perspective of forensic pathology, chemical pathology and toxicology is an important related discipline. Toxicological analysis is a routine part of most forensic autopsies. Homicides, suicides and motor vehicle accidents are perhaps the most common cases in which drug analysis is involved. However, there is a wide variety of apparently accidental deaths, including those associated with work and recreation, where toxicology and drug analysis are important in analysing the circumstances of the death. As a result of this, forensic pathologists are regularly required to incorporate the results of toxicological analysis in the conclusions that they reach regarding autopsy findings and cause of death. The professional forensic toxicologist and forensic pathologist are required to work closely with each other in many investigations. Forensic pathologists and forensic toxicologists are often to be found working in the same organisation. The integration of these two disciplines, with a high level of communication, provides an ideal environment for the investigation of problematic suspicious deaths. [33.290] Legal skills The area of knowledge that distinguishes forensic pathologists from their clinical colleagues is their understanding of legal process, medical law, court procedures and the rules of evidence. While doctors who engage in civil injuries work are also familiar with court processes, the remainder of the medical profession has little contact with the legal system and consequently has little knowledge of the legal principles involved in civil and criminal cases. Many forensic pathologists have gained their knowledge of the legal system through long experience of working with it. Most forensic pathologists agree that a sound knowledge of the legal principles that underlie their forensic work is of value in improving the quality of service they 33-1114 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.300] provide for the legal system. In general, the legal profession also is more comfortable dealing with those medical practitioners who are familiar with, and regularly participate in, the legal process. A medical practitioner can read a simple text on criminal law and at the end of it understand the basic principles. However, to understand the background and detail of the operation of legal systems and legal investigative processes requires a much wider-ranging study of the law or a long period of exposure to and experience of working in the legal system. The training of medical practitioners is based on the scientific method and the scientific investigative process. While the legal system uses the scientific investigative process in some areas, its operation is fundamentally based on a legal investigative process that differs both in structure and philosophy from the processes of scientific investigation. It is the appreciation of this that distinguishes forensic medical practitioners from their non-forensic colleagues. An understanding of the nature of the legal investigation process and the role of the medical practitioner within it, both before and during a judicial hearing, enables the forensic medical practitioner to play an effective part in the judicial process. The main skill that forensic practitioners have in relation to their knowledge of legal process is the ability to communicate medical fact and opinion, within the confines of the rules of evidence, to a tribunal composed largely of lay people. Medical practitioners are becoming increasingly better trained in the skills of communication, both at an undergraduate and postgraduate level. However, the skills they are taught relate largely to communicating with patients and with scientific and medical colleagues. These communication skills, while important and relevant, do not take into account the rules of evidence and legal procedure that constrain the way in which forensic medical practitioners communicate their findings to a court or tribunal. A fundamental understanding of the legal process and the rules of evidence can make all the difference in communicating matters of scientific fact and opinion during judicial proceedings. [33.300] Scientific skills When assessing the skills of the forensic pathologist, it is important to remember that, as doctors with a general background and training in medicine, their early training both at secondary and tertiary level has been heavily based on the physical sciences. All medical students study science either before or at the time of entering a medical course and in many medical schools the first year of undergraduate medical teaching includes further study of physics, chemistry, mathematics and biological sciences, although these are oriented towards the needs of medical practitioners. The remainder of undergraduate pre-clinical and clinical training relies upon the knowledge of scientific principles, and such basic scientific knowledge is further developed and reinforced during a medical course. For a forensic pathologist, many of these areas of general scientific knowledge take on a special relevance. General principles of physics apply to ballistics, and chemistry and biology have particular relevance to toxicology and chemical pathology. Principles of mathematics, including the use of statistics, apply across the board. Forensic medical practitioners should remember that they have specialist knowledge in many of the general sciences but that the extent of their knowledge will vary depending on their educational background. In the same way, it is important for lawyers to recognise that medical practitioners have a basic general scientific background which will, on occasions, enable them to give opinion evidence as experts in certain non-medical, scientific areas. 33-1115 Update: 26

[33.310] EXPERT EVIDENCE [33.310] Communications skills As discussed earlier, skill in medico-legal communications is a particular attribute of forensic pathologists. Such skill does not arise solely from experience in forensic pathology or formal training in witness techniques. The reason that doctors often make good witnesses is that communication with patients in a medical consultation lies at the heart of the practice of medicine. Through their undergraduate training and additional years of postgraduate training, doctors develop and rely upon communication skills. The term bedside manner is used by lay people to describe a doctor s performance as a communicator. Regardless of the nature or type of medical consultation, a variety of communication skills are employed. Doctors are familiar with techniques to overcome barriers to communication. They are aware of the deliberate use of silence, confrontational, and summarising techniques. When one examines these skills, it becomes clear that many of the communication skills involved in medical consultations are similar to the skills of barristers examining or cross-examining witnesses in court. In practical terms, individuals in a jury are very similar to patients in a medical consultation. Their range of medical knowledge, intellectual ability, scientific background, attention and commitment, mirrors closely the range found by doctors when dealing with patients. As a result, the skills that a doctor uses to communicate with a patient can be used to great effect in communicating with a jury. Forensic medical practitioners communication skills are not confined to oral performance. Written communication is a feature of medico-legal work, and the formulation of appropriate medico-legal reports that meet the needs of the legal system is a basic task performed by the forensic pathologist. Medico-legal reports differ from ordinary medical reports in a variety of ways. Medico-legal reports do not have a fixed format, but vary in their style and design according to their legal purpose. However, there is a basic structure to such reports, which can assist in their use by the justice system. Just as there is a need to develop forensic medical oral communication skills, there is a continuing need to develop forensic medical written skills. The forensic pathologist, by training and experience, is usually well versed in the compilation of appropriate medico-legal reports and this can be of considerable assistance to other doctors who from time to time are required to provide medical reports to be used within the justice system. THE ROLE OF THE FORENSIC PATHOLOGIST [33.350] We have looked at the skills acquired by forensic pathologists in their training and experience. In what ways, then, do forensic pathologists utilise their skills in everyday practice? In order to understand this, we need to identify the various roles that forensic pathologists take in their work and the services they provide. Forensic pathologists, like many medical specialists, take on a number of roles including those of: medical practitioner, specialist pathologist, death scene examiner, dead body examiner, forensic biologist, forensic radiologist, forensic toxicologist, forensic sociologist and medical detective. These will be looked at in turn. [33.360] Medical practitioner Most forensic pathologists do not take part in clinical medical practice involving the diagnosis of illness and disease or the provision of surgical and medical treatment. They are nonetheless medical practitioners, committed to the maintenance of good health within the community. The forensic pathologist retains the basic medical skills in clinical diagnosis and therapeutics. In providing an autopsy service for the coroner and other individuals involved in the health and 33-1116 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.370] justice systems, the forensic pathologist is involved in analysis of clinical, diagnostic and therapeutic issues as well as broad public health issues including occupational health and safety. The media, the lay community and indeed a number of medical and legal professionals tend to view the forensic pathologist as being concerned only with criminal justice aspects of death investigation. In reality, deaths involving a suspicion of criminal activity represent a small percentage of the work of the forensic pathologist. While the forensic pathologist remains a watchdog on the lookout for criminality during death investigations, most work involves deaths associated with natural disease and unintentional traumatic injury. These deaths have important considerations for public health policy and health service planning as well as for community health and safety. Community health and public health are subspecialties in the area of clinical medical practice. Forensic medicine, particularly in Europe, had its origin in the work of the public physicians, doctors who had responsibility for public health and general public medical services in city states during the Renaissance and after. The justice system turned to these early public health physicians in order to obtain medical services to assist in the investigation of crimes, particularly crimes against the person. In time, the office of public physician formed the basis of the public and university institutes of forensic medicine that developed in Europe. These European developments were also seen in Scotland, where the early university departments of forensic medicine were joint departments of public health. This early association of forensic medicine and pathology with public health was gradually lost, but forensic medical institutes are returning to this field by becoming involved in issues of public health, occupational health and community health. The forensic pathologist in the course of everyday work identifies natural disease processes within all sections of the community. In order to completely identify natural disease in an autopsy, the pathology investigation has to be comprehensive. In many cases, the identification of a cause of death at autopsy is straightforward. However, in order to identify and recognise all the natural disease processes that are present and to assess their relevance both for the death and the ante-mortem symptoms, a thorough autopsy examination is required. In those legal systems where the forensic autopsy simply provides a cause of death, the quality of information obtained from autopsies may be limited. However, the coronial system in the more modern jurisdictions has a responsibility to find not only the cause of death, but also the circumstances of the death, and any factors that contributed to it, including those associated with the operation of the health and legal systems. The autopsies performed within these jurisdictions provide much more information. In reality, no cause of death can be satisfactorily ascertained at autopsy without ensuring that the autopsy investigation has been thorough enough to exclude potentially significant but rare natural diseases. In autopsies where the death is the result of an unnatural process, in particular deaths from intentional injuries such as homicides, it is essential to accurately assess, document, and in some circumstances exclude, the influence of natural disease processes. In criminal cases, the forensic pathologist is often asked to assess the degree to which a pre-existing disease might have contributed to the traumatic death. [33.370] In view of the substantial decrease in the number of hospital non-forensic autopsies performed in many jurisdictions around the world, the capacity for the non-forensic autopsy to contribute to knowledge regarding the prevalence of disease processes within the community has become limited. Forensic autopsies in Victoria now account for half of all autopsies performed within the State. The findings arising from these autopsies have a major part to play in providing information on disease prevalence and the outcome of therapeutic interventions. Current screening processes performed as part of an autopsy help to identify the prevalence of infectious diseases such as Hepatitis B, Hepatitis C and HIV. 33-1117 Update: 26

[33.370] EXPERT EVIDENCE As well as playing a part in providing information regarding physical disease, an efficient forensic pathology service can contribute a therapeutic service to the health service community. Tissues, such as corneas, heart valves, skin and bone, are taken from cadavers at the time of autopsy and made available to surgeons for transplantation; thus forensic pathology practitioners contribute to a fundamental therapeutic service. On a broader basis, most deaths are associated with a family and friends who require information regarding the death in order to complete their grieving. Where family and friends have concerns regarding a death, the forensic pathologist can arrange to meet them and inform them of the results of the pathological examination and the conclusions that can be arrived at regarding the circumstances of the death. While not all families wish to discuss a death with the forensic pathologist, those that do often find the consultation helps their grieving process. While in most cases the practice of a forensic pathologist is limited to investigating death, forensic pathologists as medical practitioners play a wider role with regard to specialist examination of the living. In a limited number of cases where injuries are concerned, forensic pathologists often make a clinical assessment of individuals in order to document injuries and analyse their cause. This role overlaps the services provided by specialist forensic physicians. In fact, there are many forensic pathologists who also practise clinical forensic medicine to a greater or lesser degree, and become particularly involved in the wider issues surrounding physical and sexual assault. Many of the fundamental principles of forensic pathology overlap with those of clinical forensic medicine. There is increasing recognition of the considerable advantages to be gained by integrating forensic medical services so that forensic pathologists and clinical forensic physicians can work as a team to assist the justice system. [33.380] Specialist pathologist Most forensic pathologists are qualified clinical pathologists, and indeed their work calls upon the basic scientific knowledge of pathology as well as the skills and knowledge associated with each of the major branches of clinical pathology. As we have seen, forensic case work can involve recognition and understanding of the principles of haematology, microbiology, chemical pathology, immunology, and anatomical pathology or histopathology. In this regard, forensic pathology can be seen as an applied area of clinical pathology which has its primary focus on the delivery of information to the legal system regarding the medical issues surrounding the causation and the circumstances of a death. [33.390] Death scene examiner The forensic pathologist s work extends beyond the routine performance of autopsies and the presentation of the results to the coroner and the courts. The case investigation for a forensic pathologist is initiated by a death; the investigation process includes analysis of information relating to the deceased person prior to death, together with examination and analysis of the scene and environment in which the person died or was found dead. In allegedly suspicious deaths, the death scene is examined by a team of individuals that comprises police officers, forensic scientists, forensic pathologists and other specialist examiners such as forensic anthropologists (for investigation of grave sites and the analysis of skeletal remains). A variety of other individuals are also involved in the examination of a scene of a suspicious death including surveyers, photographers and video-camera operators. In most cases after a dead body is found in suspicious circumstances, a forensic pathologist is called to the scene not only to examine the body and provide initial information to the investigators, but also to study the environment in which the body lies. The investigation of the 33-1118 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.410] environment of the death helps the pathologist in coming to conclusions regarding the subsequent macroscopic and microscopic autopsy findings. In many cases, by virtue of training and long experience in attending at death scenes associated with crimes, the forensic pathologist can contribute directly to the crime scene examination and provide initial advice in some areas of forensic science, including biological trace evidence and ballistics. The inclusion of specialist forensic scientists from a wide variety of disciplines within the death scene investigation team is important, and the forensic pathologist may well have a part to play in helping to determine the appropriate specialists that may be required. [33.400] Forensic pathologists usually include details of their crime scene investigation in the autopsy report. In doing so, however, they usually refer to those elements of the crime scene that impinge directly or indirectly upon the characteristics of the deceased person. In most circumstances, it is the police crime scene examiners or forensic scientists who complete the remaining examination of a crime scene and deal with all of the matters not directly related to the body. The amount of information that can be gathered from a crime scene is considerable. The correlation of the appearances of a death scene with the findings at autopsy may be of crucial significance in reconstructing the circumstances surrounding the individual s death. For example, suppose an individual is found face down in a domestic kitchen with an external head injury that upon autopsy is revealed to be associated with an underlying haemorrhage around the brain; the injury could have been caused either by an attack by another person, or by a fall. Close examination of the scene of death may reveal blood and hair on the sharp edge of some furniture, suggesting that the individual was injured in a fall. Alternatively, blood and hair on an implement such as a potential weapon might suggest that the injuries were caused by the deliberate action of another person. This integration of both the physical examination of the dead body with the physical examination of the environment in which the body is found is of crucial significance in the reconstruction of the events surrounding a death. [33.410] Dead body examiner The media and most of the lay public recognise the forensic pathologist as a dead body examiner. As we have just seen, the pathologist performs a preliminary examination of a body at the death scene (or the place in which the body is found). The formal examination of a dead body occurs, of course, during the process of the autopsy. But the autopsy is more than an external and internal examination of the body. The processes involved in carrying out an autopsy covers a wide range of activities, and can include radiology and fluoroscopy as well as endoscopic techniques for examining the interior of the body without formal dissection. The scope of examination of a body at the scene of death depends on the circumstances, but in most cases, some initial information can be gathered from the position of the body, the presence or absence of any rigor mortis or post-mortem hypostatic lividity (discoloration of the skin), and the temperature of the body. A body that is fully clothed or otherwise wrapped and partly concealed, may be difficult to examine adequately at the scene, and no definitive conclusions regarding the nature of the death should be made until the body has been examined fully at autopsy and the necessary follow-up tests have been completed. In some cases, it may be possible for a pathologist, on examining a body at the scene of a suspicious death, to raise the possibility that the death is, in fact, the result of a natural disease process. There are situations where a pathologist is confronted with an apparently suspicious scene of death eg, one involving substantial blood loss but evaluation of the body at the scene reveals that alcohol may have played a part. In this example the death may have occurred as a 33-1119 Update: 26

[33.410] EXPERT EVIDENCE result of complications of alcohol-related liver disease, where, eg, cirrhosis of the liver can cause varicose veins to form in the gullet or oesophagus which can lead to profuse vomiting of blood. In other situations, individuals have been found covered in blood which appears to have come from the region of their head and which was thought to have been caused by trauma to the head. In a number of these cases the blood has been identified as coming from the nose and mouth and the bleeding has been shown to be the result of lung tumours or tuberculosis eroding into major blood vessels. Clearly, an autopsy will ultimately resolve these situations, and an efficient and timely autopsy service can be of great benefit to the coroner, police and other investigators. The process of the forensic autopsy is discussed below: see [33.600]. However, it is in this specific field of death investigation that the forensic pathologist has almost sole responsibility. The efficiency of this service and the provision of timely information from the pathologist to co-investigators, such as the police, may result in better focusing of police investigation. In the case where a suspicious death is rapidly confirmed as being the result of natural disease, the information provided by the forensic pathologist can prevent the waste of expensive police time. [33.420] Forensic biologist Forensic biology is one of the core divisions of forensic science. Forensic biology services are for the most part provided through major institutes of forensic science, and a number of these exist in association with institutes of forensic medicine. The overlap between forensic biology and forensic pathology has, in the past, been considerable. Many forensic pathology departments and institutes have provided forensic biology services and in some jurisdictions, forensic biology services are provided by biologists and pathologists together. Given the background of the training of a forensic pathologist and the concentration upon basic biological principles in undergraduate medical training, it is not surprising that there are many areas in which a medical practitioner has the necessary expertise to take part in forensic biological service work and to give expert evidence in the field of forensic biology. Pathologists with their knowledge of clinical haematology have a basic understanding of the serology that forms part of the work of a forensic biologist. Similarly, the anatomical pathologist has usually trained for several years beyond basic medical training in the area of microscopy of human tissues and cells, and therefore has the necessary expertise to engage in many of the areas of forensic biology that involve microscopy of human tissue, including, eg, the identification of spermatozoa in forensic samples. Despite this similarity in basic knowledge and overlapping areas of expertise, many aspects of forensic biology go far beyond the boundaries of knowledge of the average clinical pathologist. In some of these areas, forensic pathologists have particularly developed his or her skills so that he or she further overlaps the expertise of the forensic biologist. Clinical pathologists are involved in a wide variety of new and developing techniques. For the anatomical pathologist, the advent of electron microscopy and immunohistochemistry have revolutionised the way in which pathologists gain an understanding of disease at a cellular and sub-cellular level. Molecular biology techniques are also increasingly used in routine clinical pathology. Interestingly enough, the same developments have also made their mark in forensic biology. Today, molecular biology involving the analysis and comparison of DNA is one of the great success stories of forensic biology, and forensic pathologists are well equipped to analyse and comment on the general use of these techniques. 33-1120 Freckelton and Selby

[33.430] Forensic radiologist FORENSIC PATHOLOGY GENERAL [33.450] All medical practitioners are involved in the examination of radiographs or x-rays of patients. Indeed, while most doctors do not take radiographs, the examination of radiographs is part of normal medical practice. Nevertheless, a wide variety of radiological studies require special techniques, and specialist radiologists are able to deduce much more information from radiographs than would be expected of the ordinary doctor. Clinical radiology is a major medical specialist area, providing both routine and specialist diagnostic services. It uses a variety of techniques, including plain x-ray films, computerised axial tomography (CAT) scans, and magnetic resonance imaging. All forensic pathologists are involved in the examination of x-rays, but their expertise varies considerably. There are some who have made a special study of forensic radiology, while others rely on referral of radiographs to specialist clinical radiologists who have developed a special interest in forensic radiology. The application of radiology techniques to forensic pathology is very broad. Occasionally forensic radiology may assist in determining the cause of death, while in other cases it may be used particularly to help with human identification and to assist with the location and retrieval of foreign material within the body. There are many advantages to undertaking a radiological study of a deceased person prior to autopsy. While radiology does not always reveal pathology that is later detected at autopsy, it can be the best technique for identifying some pathological processes in particular pneumothoraces, air embolism and some musculoskeletal injuries. [33.440] Forensic toxicologist Medical pharmacology and therapeutics form part of the basic education of all legally qualified medical practitioners. Knowledge of drugs and their normal and abnormal effects on the human body are fundamental to medical practice. While most doctors understand the toxic effects of therapeutic and some non-therapeutic drugs, details regarding the wide range of substances that are dangerous to the human body exceeds the knowledge of most doctors. It is scientists specialising in forensic toxicology who screen and analyse human tissues for drugs and toxins. Forensic pathologists, perhaps more than any other discipline group within medicine, have a specific interest in this area. This is because the forensic pathologist has to determine issues relating to the cause of death and circumstances of death of individuals. Where such deaths are apparently the result of toxic substances, then a forensic pathologist must collect the appropriate body samples and together with a forensic toxicologist arrange for the most appropriate analysis. Forensic toxicology cannot be treated in isolation when it comes to investigating deaths and determining cause of death. In practice, the pathway by which forensic toxicologists contribute to the death investigation is a complex one. While the scientific reports of toxicologists are provided directly to the courts, the investigation of the medical cause of death remains the responsibility of the forensic pathologist. It is essential therefore that the forensic pathologist receives the toxicology report and integrates that report and its findings into the overall medical report on the death. Finally, the integrated forensic medical report, including the toxicology report, is provided to the courts and the justice system. There are many occasions when a forensic pathologist is able to give the majority of the expert toxicological evidence, particularly where such evidence is straightforward. However, in many cases the nature of the toxicology information is such that it requires a specialist toxicologist to deliver the evidence before the court. [33.450] Forensic sociologist It may seem strange to consider forensic sociology in the list of roles carried out by forensic pathologists. In practice, however, forensic pathology has to deal with issues of human 33-1121 Update: 26

[33.450] EXPERT EVIDENCE behaviour in settings which involve violence and death. There is no doubt that forensic pathologists acquire considerable expertise in certain areas of criminology and in respect of certain community social settings. A knowledge of police culture, prison culture, drug culture and other particular subcultures is a feature of the professional experience of forensic pathologists. The very nature of their work with regard to the investigation of suspicious and non-suspicious deaths involves them with many of these subgroups of society. A variety of sociological issues cause enormous community concern. Many of these are associated with the work of forensic pathologists: deaths in custody, violence associated with control agency response, deaths associated with failures of health professionals including health and social services, suicide and the influence of mental health on crime and social violence. Forensic pathologists investigate deaths that occur in a wide variety of social settings. In many cases the social setting contributes considerably to the death, and this is an area of particular interest to some forensic pathologists. [33.460] Medical detective Forensic pathologists, more than all other specialists in medical practice, are medical detectives. Acting as co-investigators for a coroner or the police, forensic pathologists play a far wider role than just providing an autopsy report. They are often involved in all phases of a death investigation and form part of the detective team which analyses the circumstances of a death. This role of medical detective is often glorified in the media, and in such productions the forensic pathologist is often elevated to the key player in the investigation. This is certainly not the case in practice. Despite the media portrayal of the forensic pathologist as a high-profile medical sleuth, the reality is that the forensic pathologist participates on an equal basis with all other specialist investigators in the team investigating the death. From the description of the roles taken by forensic pathologists and the services they provide, it can be seen that the work of the forensic pathologist is not limited to the narrow confines of the autopsy. The role of forensic pathologists must be viewed in relation to the health and legal community needs which they attempt to meet. The forensic pathologist is far more than a simple medical examiner or pathologist for the coroner. His or her unique range of skills and expertise overlaps many of the traditional scientific, medical and legal compartments and as such can be a highly effective and efficient resource for medical and legal services. FORENSIC PATHOLOGY QUALIFICATIONS [33.500] Forensic pathology is a subspecialty of pathology. Medical practitioners in Australasia are awarded the Fellowship of the Royal College of Pathologists of Australasia after successfully completing five years of supervised training in a training program of the College. Alternatively, the College may recognise pathology training undertaken overseas. The Fellowship or other recognised training means that the holder is a pathologist and entitled to practise any or all of the subdisciplines of pathology (eg, microbiology, haematology, anatomical pathology, cytopathology, biochemistry, immunology, forensic pathology etc). The National Specialist Qualification Advisory Committee of Australia (1989) lists the following qualifications as sufficient to enable the holder to practise pathology (and hence forensic pathology) in Australia subject to the College s approval of the holder s training: (1) Fellowship of the Royal College of Pathologists of Australasia; (2) Diploma in Clinical Pathology of the University of Sydney; (3) Membership or Fellowship of the Royal College of Pathologists (Great Britain); 33-1122 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.500] (4) Certificate in Anatomic and/or Clinical Pathology of the American Board of Pathology; (5) Fellowship in Anatomical Pathology, General Pathology, Haematological Pathology, Medical Biochemistry or Medical Microbiology of the Royal College of Physicians and Surgeons of Canada; (6) Fellowship in Pathology of the College of Medicine of South Africa; or (7) Master of Medicine (Pathology) of the University of Cape Town. It is interesting that it is still the case that non-specialists (ie, a medical practitioner either without pathology qualifications or not in a pathology training program) are permitted to perform coronial autopsies. This is what Harvey Littlejohn, doyen of British forensic pathologists, had to say in the first learned address to the newly formed Medico-Legal Society in London in 1902: Let us now consider the question of who should make the medico-legal post-mortem. Should it be any medical practitioner or should it be a person of recognised experience and capacity to perform the duty irrespectively of other considerations? It would be ludicrous if it were not such a serious matter to reflect that in this advanced age and in an enlightened and humane country the law still permits any medical practitioner to be summoned to make a post-mortem examination, without any regard to his knowledge, his previous experience or his capacity to fill the duty thus imposed on him. If it was ludicrous in 1902, how much more so is it 90 years later? In fairness to the situation in Australasia and Singapore, it should be said that the law has not changed in England, although in practice few, if any, coronial autopsies there would now be conducted other than by pathologists or pathology trainees. In September 1989, the Council of the Royal College of Pathologists of Australasia approved the following two resolutions put to it by its Forensic Committee: (1) That the autopsy is a specialised procedure and should only be undertaken by a pathologist or a medical practitioner under the supervision of a pathologist. (2) That the public has a proper and significant interest in the results of autopsies in homicides and suspicious deaths (including deaths in custody) and these should only be undertaken by full-time forensic pathologists or (because of constraints of distance or resources) by a pathologist in communication with a forensic pathologist. In the latter instance it would be desirable that the pathologist had undergone a period of supervised training in forensic pathology in an institution recognised by the College for that purpose. A pathologist employed primarily as a forensic pathologist but who has some non-forensic duties is regarded as a forensic pathologist for the purposes of these resolutions. In Australia, there is no formal national register of specialists. The Medical Council of New Zealand, however, has a Specialist Registration Subcommittee. This committee is responsible for assessing the qualifications, training and experience of applicants seeking registration as a specialist. In Singapore, specialist certification is the responsibility of the Academy of Medicine. The requirement for certification is that the person be a member of the Academy. Membership is available not less than seven years after graduation and three years after obtaining a recognised higher degree, which time must be spent in accredited departments.the General Medical Council in the United Kingdom now includes on the register information about a doctor s specialist accreditation. 33-1123 Update: 26

[33.500] EXPERT EVIDENCE FORENSIC PATHOLOGY ORGANISATIONS [33.510] There are a number of professional associations and organisations around the world that represent or include forensic pathologists. Many of these are organisations that also include forensic scientists such as the Australian Academy of Forensic Sciences, the British Academy of Forensic Sciences and the American Academy of Forensic Sciences. Other groups have a more directly medical focus and these include the Royal Medical Colleges such as the Royal College of Pathologists of Australasia which has a forensic pathology discipline advisory committee. This puts forensic pathology on the same footing as the other disciplines of anatomical pathology, chemical pathology, haematology and microbiology. In addition to these wider groups of professionals, the service organisations including government departments, universities and institutes also represent forensic pathologists at a local level. Table 1 gives the addresses and contact people of forensic pathology service organisations in Australasia and Singapore. TABLE 1 Some forensic pathology organisations in Australia, New Zealand and Singapore Forensic pathology organisation Contacts AUSTRALIA Victoria Victorian Institute of Forensic Medicine 57-83 Kavanagh Street South Melbourne VIC 3205 Ph: (03) 9684 4444 Fax: (03) 9682 7353 New South Wales NSW Institute of Forensic Medicine 42-50 Parramatta Road Glebe NSW 2037 Ph: (02) 9660 5977 Fax: (02) 9552 1613 Forensic Pathology Unit Department of Anatomical Pathology Westmead Centre Westmead NSW 2145 Ph: (02) 9845 7592 Fax: (02) 9891 4998 Queensland Director: Professor S M Cordner MA FRCPA, FRCPath Deputy Director (Forensic Pathology): A/Prof D L Ranson FRCPA, FRCPath, LLB Director: A/Prof J M N Hilton FRCPA Deputy Director (Forensic Pathology): Dr J Duflou FRCPA M Med Path (Forens) (Cape Town) Senior Forensic Pathologist: Dr P Ellis FRCPA 33-1124 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.510] Forensic pathology organisation Laboratory of Microbiology and Pathology State Health Laboratory GPO Box 495 Brisbane QLD 4001 Ph: (07) 3274 9019 Fax: (07) 3274 9007 Contacts Director: A/Prof A J Ansford FRCPA Deputy Director: A/Prof C P Naylor FRCPA, FRCPath South Australia Forensic Science Centre 21-23 Divett Place Adelaide SA 5000 Ph: (08) 8226 7715 Fax: (08) 8226 7777 Forensic Pathologists: Dr R A James FRCPA Dr J D Gilbert FRCPA Western Australia Department of Forensic Pathology Queen Elizabeth II Medical Centre Nedlands WA 6009 Ph: (08) 9346 3333 Fax: (08) 9346 3133 Director: Dr C Cooke FRCPA Northern Territory Pathology Department Royal Darwin Hospital Casuarina NT 5792 Ph: (08) 8922 8067 Fax: (08) 8922 8843 Forensic Pathologist: Dr K A P Lee FRCPath Tasmania State Forensic Pathology Unit Royal Hobart Hospital Hobart TAS 7008 Ph: (03) 6238 8611 Fax: (03) 6222 8980 Director: Dr T Lyons MRCPath, FRCPA NEW ZEALAND Auckland 33-1125 Update: 26

[33.510] EXPERT EVIDENCE Forensic pathology organisation Department of Forensic Pathology Medical School University of Auckland Private Bag 92019 Auckland Ph: (09) 373 7999 Fax: (09) 373 7459 Contacts Associate Professor: T Koelmeyer FRCPA Director Forensic Pathology Unit: Dr A Cluroe FRCPA Christchurch Department of Forensic Pathology Christchurch School of Medicine University of Otago PO Box 4345 Christchurch Ph: (03) 364 0590 Head: Dr M D Sage FRCPA SINGAPORE Institute of Science & Forensic Medicine Outram Road Singapore 0316 Ph: 221 6800 Fax: 229 0749 Director: Professor Chao Tzee Cheng FRCPath, FRCPA The aims of the forensic pathology investigation [33.550] The aims of the forensic pathology investigation are generally not well understood. Very often it is thought (and not only by lawyers) that the sole contribution of the pathologist is to provide the cause of death. On occasions, such a limited view has been to the detriment of the investigation. The aims of the forensic pathology investigation are: (1) To discover and identify the pathological processes present in the deceased. (2) To relate these processes to the known medical history to make conclusions about the causes of symptoms and signs observed in life and then to make conclusions about the medical factors contributing to death. (These two aims are the same as for hospital autopsies; that is, autopsies in deaths not reportable to the coroner where permission from relatives has been obtained in accordance with the relevant jurisdiction s Human Tissue Act.) (3) To confirm or determine the identity of the deceased person. (4) To determine the medical cause of death from the analysis of the medical history, the circumstances of the death and the medico-pathological examination of the deceased. 33-1126 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.600] (5) To contribute to the reconstruction of the circumstances surrounding the death. Where these circumstances are important or likely to be in dispute, then this will require consideration of the scene of the death as well as the relevant autopsy observations, many of which may be of trivial medical consequence. (6) To record all the relevant observations and negative findings in such a way that they can be used to effectively communicate the information obtained from the autopsy to the court and legal agencies. If the documentation is comprehensive, it should come close to providing another pathologist with the information needed to put that person in the same position as the pathologist performing the autopsy. It is the addition of the fifth principle (above) which sets forensic pathology apart from hospital-based pathology practice. The criminal law and coronial processes are usually more interested in the circumstances surrounding the death or injury than they are in the medical aspects of the death or injury. The forensic pathologist, therefore, becomes familiar with those aspects of the scene of the death or event and those aspects of the autopsy which allow conclusions and inferences to be made about the surrounding circumstances. Furthermore, the forensic pathologist has only one opportunity to make and record all the observations that will allow answers to be given to issues that have not even surfaced at the time of the autopsy. This is particularly important in homicides, suspicious deaths and deaths in custody where the factual information about the circumstances is almost always incomplete and often changes with time. This anticipation of possible future issues can be a difficult exercise and there will be occasions when observations that could have been made will be overlooked because it did not seem relevant or the issue did not surface in the mind of the pathologist at the time of the autopsy. [33.555] In order meet these aims, all the stages of a death investigation must be carried out in a meticulous manner. In most cases, the identification of the deceased at autopsy is straightforward. However, where identification of the deceased is unknown, it is essential that the autopsy procedures used provide the best information possible on all of the features that may be of use in determining identity. As discussed above (see [33.550]), the autopsy serves many purposes and in order for as many of these as possible to be accommodated, the pathologist as the medical investigation agent of the coroner must co-ordinate the activities of all forensic body examiners to ensure that they work as a team. The conduct of a forensic pathology investigation THE SCENE [33.600] The examination of the scene can be the most critical part of a death investigation. For example, a scattered skeleton was found in a dense forest 20 metres from a track, and the only clothing present at the scene was a long scarf, knotted into a ligature. It was not until a pathologist attended the scene that it was apparent that the scarf was positioned around the cervical (neck) vertebrae. If the remains had simply been put in a bag and taken to a mortuary, the relationship between the ligature and the neck would have been lost. The benefits of the forensic pathologist attending the scene of the death have not always been fully appreciated. Scene examination from a medical perspective can make a fundamental contribution to conclusions relating to the circumstances surrounding the death. Often it is not the observations that can be made about the body at the scene that are the most important. Take the situation where a male is found dead lying on the floor at his home with a large pool of blood present around his head. It is often difficult to examine a body in this situation 33-1127 Update: 26

[33.600] EXPERT EVIDENCE adequately at the scene. Examination of the room in which the body lies may reveal other information that can help to explain the death. The identification of medical prescriptions or letters of appointment to hospital clinics may provide important information regarding the medical history of the deceased man. Examination of the bathroom medicine cabinet or the refrigerator may reveal his current medication and this may also give an insight into his past medical problems and/or his recent medical problems. If such an examination of the room revealed that the man was attending a liver clinic and was receiving medication to help manage chronic liver disease, a forensic medical practitioner may be able to deduce that the blood around the head is possibly not due to an assault but rather the result of a complication of cirrhosis of the liver, namely oesophageal varices, or varicose veins of the oesophagus, which can rupture causing torrential loss of blood and death. In view of the expertise that the pathologist can bring to scenic examinations, the forensic pathologist is often asked in court to comment in some detail on certain aspects of death scene including, eg, matters such as the significance of patterns of blood staining. No forensic pathology organisation in Australasia and Singapore has the capacity to attend death scenes other than homicides, suspicious deaths or other events of particular significance. The tyranny of distance and limited resources will prevent the routine attendance by a forensic pathologist at even these deaths in the larger States. In some circumstances, consultation between the investigators and the forensic pathologist may obviate the necessity of a forensic pathologist attending the scene. The functions of the forensic pathologist at the scene can be described as follows: (1) If the first medically qualified person at the scene, to certify the fact of death. (2) To become familiar with the physical characteristics of the scene and the position of the body in relation to those characteristics. (3) To assess the requirements for the taking of trace evidence from the body or clothing. (This may require removal of the clothes from the body at the scene and securing them after photographic recording of the undisturbed scene.) (4) To make an initial assessment of the injuries present and any damage or derangement to clothing. (5) To make observations relating to the time of death if this is an issue (subsequent conclusions are only of investigative, not probative, value). (6) To make appropriate records of the observations made and ensure that photographs of relevant findings in relation to the body have been taken. (7) To identify items of medical significance within the scene including evidence of medical treatment and/or attempts at resuscitation. As can be inferred from this, it is desirable for a forensic pathologist to attend all suspicious death scenes.where an injured person has been removed from the scene for continuation of resuscitation or treatment and subsequently dies, it becomes a matter of discretion whether or not to attend the scene. Often this will still be useful in the same way as when a court adjourns to visit a scene to better inform itself of the environment in which the events took place. After the scene examination, the body is removed to the mortuary. The arrangements for this vary from jurisdiction to jurisdiction. In Victoria, undertakers contracted to the government perform this task; whereas in metropolitan Adelaide, the function is performed by the mortuary technical staff. In the case of deaths that may result in criminal charges being laid, the body will normally be escorted to the mortuary by police. 33-1128 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.630] THE MORTUARY [33.610] The performance of an autopsy involves a series of medical tasks nearly all of which are similar to those performed in some aspects of clinical medical practice. Indeed, the basic elements comprising all medical examinations are similar. [33.620] Preliminary matters The first element of an autopsy is the identification of the goals or purpose of the examination. These goals may differ from case to case and depend upon the basis of the autopsy request. A coroner may have a different purpose in mind from that of the police, the family or a treating clinician. Each may be separately seeking answers to their own questions. It is up to the pathologist performing the autopsy to assure him or herself of the questions at issue so that he or she can orientate the examination appropriately. Before commencing the physical examination of the body, the pathologist should be given access to all available information about the medical history of the deceased and the circumstances surrounding the death. Such information may well affect the way the autopsy is conducted and will determine in the pathologist s mind whether or not to make particular observations. The experienced pathologist will, of course, always have in the back of his or her mind that, because of the informal nature of the information usually supplied, it will bear a variable relationship with the facts that subsequently emerge. It cannot be overstressed that the value of any particular autopsy is in direct proportion to the quantity and quality of information provided to the pathologist before he or she starts the examination. On occasions, it may be prudent to delay the autopsy until sufficient information about certain matters has become available. [33.630] Where the examination of the body is likely to involve many different specialists, the forensic pathologist must plan the autopsy in collaboration with the other investigators including the forensic odontologists, the forensic anthropologists/osteologists and the police. This will ensure that the technical procedures carried out are complementary and do not interfere adversely with each other. For example, in the case of procedures used in facial identification, it would be possible for some aspects of facial dissection to interfere with forensic radiology and photographic requirements. If the jaws are resected before skull or dental radiographs are obtained, the relationship of the dental and facial structures cannot be used as a point of comparison with radiographs that may have been taken in life. The sequence of examination procedures is therefore of considerable importance and should never be left to chance. Whether the autopsy is being performed for medico-legal or clinical reasons, some universal basic goals exist. These include the identification of the deceased, the discovery of significant disease processes and the determination of the pathological states and injuries that have lead directly or indirectly to the death. In the case of hospital autopsies, most of the disease processes and the cause of death will be known in advance. (Indeed, if the cause of death is unknown the death must be referred to the coroner.) The main goal of the hospital autopsy is focused on determining the extent of the disease process and the effects of treatments provided in life. At the same time as investigating the death, the physical autopsy provides an opportunity for the collection of education material for medical teaching and research. These autopsies require that consent for the procedure is given by those having legal control of the body who in turn must ensure, in some jurisdictions, that relatives do not object. In practice these requirements are met by obtaining the consent of the next of kin. In contrast to this, a medico-legal autopsy can be performed on the instructions of the coroner and without consent 33-1129 Update: 26

[33.630] EXPERT EVIDENCE being obtained from the next of kin. This situation applies in the case of autopsies that are conducted principally to identify the deceased. There are instances where the next of kin or other relatives can object to a coroner ordering an autopsy, but these are rarely applicable where the identity of the deceased is unknown. [33.640] Prior to the examination of a body at a mortuary, the pathologist may have already carried out a superficial examination of the body in the place in which it was found. The scope of examination of a body at the scene of death depends on the circumstances, but in most cases, some initial information can be gathered from the position of the body, the presence or absence of rigor mortis or post-mortem hypostatic lividity (discoloration of the skin), and the temperature of the body. A body that is fully clothed, or otherwise wrapped and partly concealed, may be difficult to examine adequately at the scene, and no definitive conclusions regarding identity of the deceased or the nature of the death should be made until the body has been examined fully at autopsy and the necessary follow-up tests have been completed. The next process involved in an autopsy is the retrieval and evaluation of information relating to the past medical history of the deceased. While this is important in all forensic autopsies, the collection of ante-mortem records is a specific phase in the processes involved in disaster victim identification and these proceedures are a good illustration of the principles involved. [33.650] Mass disaster involving loss of life can be conveniently divided into two types, open disasters and closed disasters. Open disasters refer to the situation where there is no record of the names of the individuals who may have been killed; an example of such a situation might be a major train crash. Anyone in the community might be on a particular train and it is not until friends and relatives report them missing that the investigators have an idea of who the deceased might be. In a closed diaster there is a record of all people who might be involved. An example of a closed disaster might be a plane crash where a list of passengers is immediately available from the airline. Clearly the task of identifying individuals involved in a closed disaster is much simpler as the ante-mortem investigation team know where to go to get their information. This ante-mortem information may include family and personal details such as information regarding last known activities as well as background information on, eg, work history, clothing and personal effects and family background. Medical details such as previous radiological examinations, drug history, and previous surgical or dental procedures are also important. While in many cases police investigators provide this information, it is often important for the pathologist and odontologist to be able to request particular information from or to speak with any dental or medical practitioners who have been involved with these suspected individuals prior to death. The ante-mortem information collected should include actual medical and dental practitioners files as well as photographs and radiographs of the suspected individuals taken in life. In routine coronial autopsies this collection of ante-mortem records is far more limited; however, collection of medical notes and/or witness statements is essential if the pathologist is to be able to reconstruct the circumstances of the death. Before the deceased s body is physically examined, it is necessary to carry out a number of preliminary investigations. This may involve the taking of specialist radiographs, blood tests for infectious diseases and/or photographs. Where the body is not too severely damaged, the deceased may have their fingerprints recorded or an attempt may be made to have them visually identified by a friend or a member of their family. These preliminary matters may take some time to complete before the physical autopsy can be commenced and efficient co-ordination of the whole process by the coroner is essential. 33-1130 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.650] Post-mortem radiology Radiographic studies play an important part in the forensic autopsy and are particularly relevant in injury cases, firearm-related deaths or where the identity of the deceased is unknown. Comparison of post-mortem radiographs with clinical radiographs taken in life can result in identity being established with a very high degree of certainty. The shape of the frontal sinuses and dental structures are highly individual features and make post-mortem radiography of the head almost mandatory in autopsies on unknown individuals. It is important to co-ordinate the radiological examination with the remainder of the autopsy procedures in order to minimise the risk that one process will interfere with another. For example, if the head is first opened with a saw, later radiographs of the frontal sinuses of the skull will be much more difficult to interpret. Similarly the process of embalming a body may cause artefactual trauma and introduce air and fluids into body cavities, changing the radiological appearance (as well as interfering with toxicological analysis of body fluids). As commented on above ([33.430]) radiological procedures are an important preliminary investigation in the forensic autopsy. Radiographs are useful when attempting to identify the presence of foreign material in a body or when trying to identify the extent and location of injuries that may require detailed analysis during the internal examination of the body. Health and safety Taking part in autopsy procedures necessarily involves some personal risk. This is particularly true when the identity and background of the deceased are unknown. Both physical injury and communication of infectious agents are potential hazards. Individuals infected with one of the types of infectious viral hepatitis, HIV or tuberculosis pose special risks. However, it should not be forgotten that commensal organisms (common bacteria present in every body) can pose a threat to the operators if these organisms are inoculated into their body tissues via a cutaneous injury. In deaths that have occurred as a result of major trauma, foreign materials present on or in the body may puncture protective clothing including surgical gloves and represent a significant hazard to the examiners. Any object, whether a part of the body or foreign material, that can cause a cutaneous injury needs to be identified in advance and countermeasures instituted. Working with bodies that are very cold or frozen poses a particular risk, as the operator s sense of touch and fine movement may become impaired. Control of the production of fluid splashes and aerosols during the autopsy should be given similar attention as these can also transmit infectious agents. As well as physical injury being associated with the risk of transmitting infectious agents to the operator, other physical hazards can occur. The very act of moving heavy bodies and body parts can cause back and limb injuries and these need to be avoided by the use of appropriate equipment and assistance. Chemical injuries to an operator can also occur if the body is contaminated and this can occur in a number of major disaster incidents and industrial deaths. Hydraulic fluids, caustic and corrosive chemical as well as gas and radiation hazards must be anticipated and countermeasures instituted at the appropriate time during the investigation. Deaths occurring in a setting of military action or terrorist activity may also involve complex, highly toxic chemical contamination as well as explosive hazards from retained weapon projectiles and other explosive devices. Post-mortem radiology Radiographic studies play an important part in the forensic autopsy and are particularly relevant in injury cases, firearm-related deaths or where the identity of the deceased is unknown. Comparison of post-mortem radiographs with clinical radiographs taken in life can 33-1131 Update: 26

[33.650] EXPERT EVIDENCE result in identity being established with a very high degree of certainty. The shape of the frontal sinuses and dental structures are highly individual features and make post-mortem radiography of the head almost mandatory in autopsies on unknown individuals. It is important to co-ordinate the radiological examination with the remainder of the autopsy procedures in order to minimise the risk that one process will interfere with another. For example, if the head is first opened with a saw, later radiographs of the frontal sinuses of the skull will be much more difficult to interpret. Similarly the process of embalming a body may cause artefactual trauma and introduce air and fluids into body cavities, changing the radiological appearance (as well as interfering with toxicological analysis of body fluids). As commented on above ([33.430]) radiological procedures are an important preliminary investigation in the forensic autopsy. Radiographs are useful when attempting to identify the presence of foreign material in a body or when trying to identify the extent and location of injuries that may require detailed analysis during the internal examination of the body. Health and safety Taking part in autopsy procedures necessarily involves some personal risk. This is particularly true when the identity and background of the deceased are unknown. Both physical injury and communication of infectious agents are potential hazards. Individuals infected with one of the types of infectious viral hepatitis, HIV or tuberculosis pose special risks. However, it should not be forgotten that commensal organisms (common bacteria present in every body) can pose a threat to the operators if these organisms are inoculated into their body tissues via a cutaneous injury. In deaths that have occurred as a result of major trauma, foreign materials present on or in the body may puncture protective clothing including surgical gloves and represent a significant hazard to the examiners. Any object, whether a part of the body or foreign material, that can cause a cutaneous injury needs to be identified in advance and countermeasures instituted. Working with bodies that are very cold or frozen poses a particular risk, as the operator s sense of touch and fine movement may become impaired. Control of the production of fluid splashes and aerosols during the autopsy should be given similar attention as these can also transmit infectious agents. As well as physical injury being associated with the risk of transmitting infectious agents to the operator, other physical hazards can occur. The very act of moving heavy bodies and body parts can cause back and limb injuries and these need to be avoided by the use of appropriate equipment and assistance. Chemical injuries to an operator can also occur if the body is contaminated and this can occur in a number of major disaster incidents and industrial deaths. Hydraulic fluids, caustic and corrosive chemical as well as gas and radiation hazards must be anticipated and countermeasures instituted at the appropriate time during the investigation. Deaths occurring in a setting of military action or terrorist activity may also involve complex, highly toxic chemical contamination as well as explosive hazards from retained weapon projectiles and other explosive devices. [33.680] External examination In a homicide or suspicious death, the external examination will usually take considerably more time than the internal examination. The process of describing, measuring, recording and photographing the injuries and other features on the body is very time-consuming. Photography Photography is particularly valuable in enabling another pathologist at a later stage to be put in the best possible position to come to his or her own conclusions. 33-1132 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.710] As a general rule, at the autopsy in a homicide or suspicious death, photographs should be taken of: the face; the clothed body (back and front); the unclothed body (back and front); regional photographs, demonstrating injuries or other points of importance; close-up views of individual identifying marks or physical characteristics; close-up views of individual injuries of importance; and internal findings of significance. Where relevant, a measuring scale and the case number should be included in photographs of injuries. It should be borne in mind that complications can arise when trying to assess the size of an injury in a photograph by reference to the tape measure in it. This is because many body surfaces are not flat and thus they defeat the two-dimensional capacities of routine photography. A variety of techniques can be used to overcome this limitation. The use of circular discs on the skin adjacent to the injury can help to determine whether the photograph has been taken perpendicular to the relevant skin surface. Trace evidence Depending on the circumstances, the collection of trace evidence may be of importance. The first stage of the physical examination of a body involves removal of clothing, jewellery and any other wrappings from the body, followed by inspection of the external surface of each region of the body. In doing this, great care must be taken not to lose any trace evidence that may be trapped in hair, or adhering to the surface of the skin. The clothed and unclothed body and injuries should be inspected for foreign material which may have been left by an assailant or weapon. Samples for gunshot residues should be taken before commencement of the autopsy. There are very good reasons for doing this as early as possible, preferably at the scene, to avoid the artefacts and contamination associated with numerous people having access to the body and its subsequent removal and transport to a mortuary. For evidential purposes, all items removed from the body must be documented, including being described and photographed before being collected in a controlled, safe and secure manner for later possible forensic examination. Among other procedures, this involves labelling and logging of specimens in such a way that a continuous chain of custody of the item is maintained from the time of its collection until its appearance in court as an exhibit. [33.710] One of the fundamental differences between the forensic and the hospital autopsy is the time spent on the external examination. In the forensic autopsy, this time will frequently be considerably more than that spent on the internal examination as it often will provide answers to critical questions about the circumstances surrounding the death. The internal examination must never commence until a full external examination of a deceased body has been made. It must include both the anterior and posterior aspects of the body and the various body orifices. The following should be noted and recorded where relevant: the age, sex and race of the deceased; lividity and its distribution, post-mortem rigidity, decomposition; 33-1133 Update: 26

[33.710] EXPERT EVIDENCE the height, weight, general development and nutrition; pigmentation of skin and whether it is general (eg, jaundice or bronzing ) or local (as in significant naevi, petechiae and tattoos); signs of resuscitation, medical or surgical intervention; signs of trauma, whether old or recent, including the presence of scars, abrasions, wounds, injection sites, lacerations, fractures and bruises; signs of chronic intravenous drug abuse; the presence on the body surfaces of abnormal masses of tissue, malformations, deformities or other abnormalities; eye colour, as well as the state of the conjunctivae and the presence of petechiae, haemorrhages, jaundice or congestion; and evidence of trauma, bruising or other abnormality revealed by examination of all orifices and of the perineum. Such orifices include the external ears, the nasal passages, the mouth, the vagina and the anus. A very detailed examination of the genitalia and anus is required where sexual activities are suspected. In forensic pathology practice it is often convenient to separate the processes of external examination of the body into the examination of the head and neck from the examinations of the trunk and limbs. In deaths involving physical assault, the head is very often the focus of the attack and consequently may receive a very large number of applications of force. Detailed assessment of head and neck injuries is critical in forensic pathology practice and the basis of this examination is covered below. Cranio-facial region The biggest impediment to the satisfactory examination of the head is the presence of the head hair. In order to examine the scalp, it is often necessary to completely shave the head. If this is not done the pathologist may miss external evidence of head trauma. Because of the presence of bone immediately beneath the skin over the head, the scalp can take on the impression of the surface of the object that struck it. Such patterned abrasions, if correctly recorded by means of photographs and charts, can be useful in identifying the object that inflicted the injuries. Much of the external examination of the head is very similar to the general external medical examination performed on the living. Indeed, similar medical and dental equipment can be used. For example, auroscopes may be of use in examining the nose and the mouth as well as the ears. The ordinary characteristics of faces with which we are all familiar should be noted. These include features such as eye and hair colour, skin pigmentation, facial hair, shape of ears, nose and lips. In addition, the appearance of hair style and the distribution and type of cosmetics on the face should be described. Evidence of previous medical treatment and injuries including scars as well as marks such as tattoos must also be noted as these can assist with confirming identification as well as corroborating other information from medical records or witness statements. In the case of a forensic autopsy, detailed injury descriptions are crucial if the pathologist is to assist with reconstructing the circumstances surrounding the infliction of head injuries and effectively present such evidence in court. In this regard the use of charts, diagrams and photographs to record the observations and findings is essential. Great care must be taken not to lose trace evidence that may be present in the external ears, the nose or within the mouth. Such material may be foreign to the body or comprise body tissues 33-1134 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.740] such as fragments of bone or teeth. Where the body is grossly decomposed, there is a risk that easily detached structures may be lost from the body during handling and transportation. Teeth are a good example of such vulnerable structures and every care must be taken to ensure that they are not lost during body recovery. In the case of badly burnt remains, the skeletal tissues themselves may become carbonised. In this state the bony and dental hard tissue remains may be extremely friable and brittle; as a result they may need to be stabilised with resins, glues and/or waxes before the body remains are handled. Post-cranial region The external examination of a body in a forensic autopsy concentrates as much on the extraneous material as it does on human tissues. Such an examination therefore includes not only the surface of the body, but also all of the clothing, jewellery and other foreign material that may be present. The identification of paint flakes, soil, grime and vegetable matter on the surface of the body may be of considerable importance in an investigation, and collection of that material for further forensic examination may be required. Similarly, the nature of jewellery, its type and position on the body, can be significant. In some cases, the presence of jewellery may contribute to particular injury patterns; in other cases, it may be a unique personal item that can help to confirm the identity of an individual. A record of the basic morphometric features of the body is an essential element to all autopsies. In routine cases this may simply take the form of measurements of height and weight. However, in the case of some autopsies, additional measurements will need to be made. In the case of skeletal remains, morphometric assessment of key portions of the skeleton are relevant for anthropological assessment of race, sex, height and age. While measurements of a body are difficult to obtain with a high degree of precision, it is important to at least record the weight and size of the body. Height, or crown heel length, is only one of a variety of morphometric values that can be determined from a body. The use of multiple measurements as a technique for the identification of an individual is only of historical importance today but isolated measurements can still be of value in distinguishing between a small number of different individuals. For example, shoe and hat size may be a good discriminator between some individuals. [33.740] The process of external examination at autopsy involves the largest organ of the body, namely the skin. The presence of old and recent injuries to the body surface is of particular interest to the forensic pathologist but the recording of patterns of pigmentation, tattoos, hair distribution and the presence of dermatological diseases can be of considerable importance in determining the identity of an individual. The hands and feet may show anatomical features acquired as a result of particular occupations and the loss of digits is a useful identifying characteristic. Documentation of rigor mortis (the stiffening of muscles after death) and livor mortis (the discolouration of the skin caused by the settling of the blood in dependent blood vessels after death) are also important but in bodies showing advanced decomposition these features are often obscured. The description of wounds is critical to any forensic medical examination, whether the subject is deceased or living. Descriptions of all injuries should be recorded in detail in the autopsy notes, using terms that are objective rather than subjective. For example, an injury might be objectively described as a red zone of skin measuring 5 cm in diameter with areas of brown and yellow discolouration within it and having an indistinct border. A subjective description of this same wound might be a 5 cm bruise showing signs of ageing. The advantage of an objective description of a wound is that it does not presuppose the cause or nature of the injury. 33-1135 Update: 26

[33.740] EXPERT EVIDENCE While cumbersome, such objective descriptions are of particular use to other medical experts who may be seeking alternative explanations for the injury. Descriptions of identifying marks, wounds and injuries should always be given by reference to the patient in the standard anatomical position: the body standing erect and facing forwards, with the arms by the side and the palms of the hands facing the front. This standard body position provides a constant reference point for terms such as superior, inferior, anterior and posterior, and provides consistency in the description of such marks on the body. The position of marks and wounds on the body should also be located by reference to fixed bony landmarks wherever possible. This is preferable to using soft tissue landmarks such as the umbilicus or the nipples. The position of such characteristics can be measured in relation to bony prominences such as the tibial tuberosity, the iliac crest or spinous process. In describing a wound, the forensic medical examiner takes note of its site, its size, its shape and its surrounds. The colour, contour, course and contents of a wound should also be recorded. In addition to these general descriptive features, the forensic examiner should comment on other characteristics such as the depth of the wound and the nature of its borders. The general principle for describing injuries in forensic autopsies is that the description in the notes made following an accurate forensic medical examination should assist in the identification of the individual and in the reconstruction of the events in which the injury occurred. As a result, it is vital that the recording of injuries and identifying features should be optimum. Charts, x-rays, photographs and videos should be used where appropriate. [33.750] Internal examination On completion of the external examination, an internal examination is carried out. This part of the autopsy involves an examination of each of the body s main cavities and the organs within them. These cavities include the cranial, thoracic and abdominal cavities, but in addition areas such as the head, the face, the neck, the spine, the limbs, the pelvis and the genitalia are also examined. The basic instruments used in these procedures are the same as those used in routine surgery. While the exposure of the body contents is more extensive during an autopsy, the way in which incisions are made and the organs dissected is again only a minor modification of routine surgical techniques. The internal examination of the body may be performed in a variety of ways as detailed below. In practice, the method chosen will depend on the medico-legal issues that need to be addressed and the state of the human remains (burnt, decomposed, traumatised or skeletonised). [33.760] The conduct of the internal examination of the body at autopsy involves a systematic examination of the organs and tissues found within the body cavities and the solid tissues forming the musculoskeletal system. The recording of this process may be documented using an anatomical or body system approach. In either case a high degree of importance is placed on the use of objective descriptive terms in the report that are later interpreted in relation to their significance regarding the presence of injury or disease. The cranial cavity, the thorax, the abdomen and the pelvis comprise the regions of the body that receive the most attention during the internal examination. Not only are the major organs from these cavities examined but also the walls of the cavities themselves are assessed for characteristic features and signs of disease. The visual inspection of internal body organs is only one part of the physical autopsy process. Some diseases only involve alterations to the microscopic appearances of body tissues. In other 33-1136 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.770] cases a disease will be visible first as a microscopic change to the body tissues that precedes any changes to the naked eye appearance of the relevant body organ. An example of the latter can be seen in the case of myocardial infarction, one of the pathological processes that can cause a heart attack. This pathology occurs when parts of the heart muscle are starved of blood and die. It may take several days of survival for the dead areas of heart muscle to become visible to the naked eye and if the patient dies before this, the macroscopic autopsy may be unrevealing. However, the microscopic signs of damage are visible much earlier (in the case of electron microscopy after a matter of hours) and therefore it is essential that the heart muscle is examined under the microscope. In practice the only way to ensure that these issues are covered is to perform routine microscopy on all body tissues. Of course, it is logistically impossible to examine all of each tissue microscopically but adequate sampling can be achieved so that the best possible pathology detection rate is established. [33.770] With some body organs, macroscopic examination at the time of the physical autopsy is particularly difficult. Organs such as the brain and the spinal cord are so soft and fragile that they may be damaged and distorted by the process of the dissection and tissue sampling. In these cases it is often necessary to process the organs by fixing them in a preservative solution in order that they can be made more rigid and capable of detailed dissection. In the case of brain diseases or trauma this is generally advisable although there are exceptional circumstances when dissection of the brain can be performed without fixation. These comments relating to the brain are also applicable to other body organs in particular circumstances of disease so that it may be necessary to retain such organs during the physical autopsy and fix them for further examination. Unfortunately, the fixation process can take some time to render the organ suitable for specialist examination. In the case of solid organs such as the brain, it may take several weeks for fixation to be completed. This can result in difficulties in respect of the disposal of the body of the deceased. Families usually require that the funeral take place within a few days of the death and as a result in some cases the body may have to be buried or cremated without the organs that are undergoing fixation. For many families this poses no significant problem. In many ways the situation is no different from the situation where a person leaves hospital after surgery with a diseased part of their body having been removed and sent to the pathology department for pathological examination. What is important in both of these situations is that, following the completion of the specialist pathology examinations, the tissues or organs are disposed of in a safe, secure and decent manner. For some families, however, the fact that a deceased person has been buried or cremated without all of their organs is distressing and amounts to an incomplete disposal of their loved one. In these cases it is often possible to arrange for a second small funeral-like process for the remaining tissues and organs after they have been examined. As well as demonstrating the presence of disease or injury, the autopsy can reveal the extent of the disease and some of the effects of treatments that have been provided. However, many disorders are the result of functional disturbances of body systems that involve abnormalities of vital responses. Unless these abnormal responses have caused macroscopic or microscopic structural changes in the body tissues, they will not ordinarily be detected by the physical autopsy. The same is true in association with deaths due to some drugs and poisons. Although such chemicals can cause visible alterations to body organs, in many cases the changes are non specific and toxicological tests will have to be performed on tissues and fluids collected from the body during the physical autopsy in order to identify them. In both these cases the physical autopsy may reveal no specific visible abnormalities. It is only by analysing the circumstances of the death, including the medical history, and collecting samples from the body for testing, that the death can be understood. 33-1137 Update: 26

[33.770] EXPERT EVIDENCE Dissection procedures The incisions used to undertake the internal examination vary according to the circumstances and among pathologists. The safest procedure, the one most likely to identify the injuries of particular forensic interest while at the same time minimising artefact, commences with the scalp. The incision commences immediately behind the ear and passes through the mid-temporal regions to the same point behind the other ear. The scalp is then reflected forwards to the orbital ridges and backwards to the deep occipital region. The skull cap is then removed, preferably leaving the dura intact. The dura is incised, exposing the brain, which is then removed. The removal of the brain at this stage of the autopsy will assist drainage of blood from the head and neck and so minimise possible artefactual bruising during dissection of the neck. The dura over the base of the skull is then removed. The incisions behind the ears are continued down the anterolateral aspects of the neck across the mid-clavicle to the midline just below the sternal notch. At the midline the incision continues down to the symphysis pubis, skirting the umbilicus. The skin of the neck is then reflected in the subcutaneous plane at least to the mandible, and possibly to the inferior margins or the orbit when the determination of the presence, or accurate delineation, of facial injuries is of particular significance. The skin of the chest and abdomen is likewise reflected in the subcutaneous plane to maximise the detection of bruises in these areas. The peritoneum is then incised in the midline and the anterior abdominal musculature is freed from the costal margins so that the abdominal contents are fully exposed. The skin of the chest having been reflected, the pectoral muscles are then freed from their costal and clavicular attachments exposing the ribs. At this point the pleural cavities can be assessed for the presence of air between the lungs and the chest wall (a pneumothorax). Several techniques can be employed including aspiration of pleural contents through a water trap, opening part of an intercostal space under water and dissecting the intercostal musculature to inspect the parietal pleura directly for the presence of visible surface lung markings. After the pathologist has checked for pneumothoraces, the sternocleidomastoid muscle is then reflected from its sternal and clavicular attachments. The sternoclavicular joints are incised and the ribs are cut, allowing removal of the sternum with attached portions of ribs and costal cartilages. At this point the surface of the mediastinum and the lining of the chest can be examined and any fluids in the pericardium (the sack around the heart) or within the pleura cavities can be measured and collected. Should the examination of the neck be of particular importance, the thoracic organs can then be released below the thoracic inlet, allowing blood to drain from the neck to minimise artefactual bruising during the in situ neck dissection. The strap muscles of the neck can then be reflected, and the hyoid bone and thyroid cartilage can be inspected, having been subjected to minimal interference by the prosector. When such a detailed examination of the neck is not of particular importance, the removal of organs can proceed directly. The oral contents are freed by removing the floor of the mouth from its mandibular attachments. The pharynx is then dissected from its prevertebral attachments and the structures of the neck dissected away from the cervical vertebrae, making a conscious decision whether to include the carotid arteries. (In appropriate circumstances, leaving the external carotid arteries intact may be a consideration in relation to subsequent embalming.) The common and internal carotid arteries are then explored. [33.790] There are various techniques which can now be used to remove and subsequently examine the internal organs. The three main variations are as follows: (1) Examining the organs in situ and then dissecting them out one by one. This technique basically follows that elaborated and used by Rudolph Virchov in the 19th century. 33-1138 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.790] This technique is rarely used today. However, it may still have some value in situations where only a limited autopsy is permitted by law. A further modification of this procedure involves the taking of biopsies of major body organs while they remain in situ. In the case of high-risk cases where transmission of infectious disease is a substantial hazard of the autopsy, such an approach may be reasonable. However, the biopsy autopsy allows for only a very small part of the body organs to be examined with a consequent severe reduction in the amount of information that can be obtained. (2) Removing groups of organs that are anatomically related to each body cavity and functionally related to specific body systems (ie, cardiovascular system heart and great vessels; pulmonary system lungs, trachea, larynx and diaphragm). These organ clusters or dissection blocks are removed together and dissected without disturbing their anatomical relationship. This technique is sometimes referred to as the modified Virchov procedure. The five principal groups of organs removed comprise: (a) the central nervous system; (b) the small and large intestines together with the mesentery; (c) the contents of the thorax and neck including the tongue, larynx, trachea, oesophagus, heart, thoracic aorta and lungs; (d) the stomach, duodenum, liver, biliary apparatus, pancreas and spleen; and (e) the kidneys, ureters, bladder, rectum and internal genitalia. The modified Virchov technique is widely used by pathologists today. It is more commonly used in hospital autopsy practice but is equally applicable to forensic case work. Its principal advantage is that it allows the pathologist to examine more of the internal organs while they are still in the body and so still retain their attachments to the walls of the body cavities. Upon opening the chest and abdominal cavities, the small bowel (jejunum and ileum) and large bowel, excluding the rectum, is removed, allowing greater exposure of the remaining abdominal organs in situ within the abdominal cavity. This permits direct visualisation of the relationship of any penetrating injury to the skin of the abdomen with injuries to the internal organs, evidence which may be lost if all the internal organs are removed en masse. The next step involves dissection of the front of the neck, as described above. The tongue is released from the floor of the mouth and brought down through the underside of the lower jaw (mandible). The soft palate is separated from the hard palate and all of the soft tissues of the anterior and lateral compartments of the neck, including the oropharynx and larynx, are dissected free from the cervical spinal column. Next the lungs are reflected forwards allowing the posterior chest wall and the diaphragm to be examined in relation to any disease or injury to the heart, mediastinum and lungs. At this point the oesophagus may be tied off to prevent loss of gastric contents, the lower thoracic aorta and oesophagus and inferior vena cava transected and the neck tissues and chest cavity contents removed. To remove the remainder of the abdominal contents, the bowel mesentary is then dissected from the anterior wall of the aorta up to the level of the coeliac axis. The spleen, pancreas and liver are then mobilised and removed as one block with the mesentary and stomach, leaving the diaphragm intact in the body. Finally the kidneys are reflected medially from each side and the pelvic peritoneum is freed from the pelvic wall and the iliac arteries and veins, urethra, rectum (and vagina or prostate) cut so as to enable removal of the entire pelvic contents in continuity with the aorta, bladder, ureters and kidneys. In cases of suspected genital injury, the external genitalia, anus and 33-1139 Update: 26

[33.790] EXPERT EVIDENCE perineum may be removed in continuity with this block using a modified version of the surgical procedure of abdomino-perineal resection. With removal of the five organ blocks, dissection of each can take place in a similar manner to the third technique described below. (3) Removal of the contents of the neck, the thorax and the abdomen together with the aorta and diaphragm, in one large mass in a technique that has been attributed to Rokitansky and later to Leutille. The technique is commonly employed in forensic autopsies. Mobilisation of the neck structures is followed by the freeing of the diaphragm from its attachments. The pelvic organs can be manually separated as a whole from their bony attachments and then incised at the pelvic floor. Then, preferably with assistance, the organs can be removed as a whole by finally incising the attachments to the vertebral column. The bulk of the pluck can be reduced substantially by removing the small and large bowel first. This is simply done by cutting through the proximal jejunum (taking care to secure both incised ends of the jejunum if the contents are important for toxicological or microbiological analysis) and freeing it, the ileum and colon by cutting the root of the mesentary or preferable the mesentary adjacent to the bowel wall. The tissue mass is routinely dissected beginning posteriorly and working forwards. This technique preserves the relationships of organs enabling the whole length of the aorta and oesophagus, stomach and intestines to be examined intact and in relation to the surrounding organs. [33.800] In general, whatever the method used, it must be systematic and planned. All organs must be weighed in grams and the weights must be recorded. Abnormalities in the orientation and relationship of the various organs to their neighbours should be noted. In recording findings, accurate descriptions should be made of what is actually seen rather than interpretations or assumptions made about the lesion or abnormality. Before completing the autopsy, the prosector must ensure that all necessary specimens for laboratory and toxicological analysis, as well as all photographs and/or x-ray films which may be of assistance, have been taken. When there is doubt concerning the findings, whole organs should be retained for further study or for consultation with others. The physical autopsy is not complete until the body of the deceased person has been restored to a state where the family as part of their funeral tradition can view it. The technical and scientific staff who are employed in assisting in this task are usually highly skilled and experienced. They are aware of the needs of the funeral industry and a number will also be qualified embalmers. In all cases the aim is to restore the outward appearance of the deceased to that visible before death. In deaths from severe trauma, specialised restorative techniques may be required to repair areas of the body damaged before the autopsy. Similarly, if large amounts of structurally significant tissue has been collected for investigation or for transplantation, such as the spinal column or the pelvis, more extensive restorative work will be required. In most cases relatively little restoration is required because the routine procedures employed in a standard autopsy are intrinsically non-disfiguring. Reconstruction of the head and neck including the face are critical tasks which, because of the sensitivity given to facial injuries, must be carried out with utmost attention to detail. Given that a complete and thorough dissection of the face is not inconsistent with satisfactory reconstruction of a body after autopsy, there should be no reluctance on the part of the pathologist to carrying out such a dissection. When dissection of the face is limited to the soft tissues only, little alteration in facial outline should be expected. However, where the dissection involves not only the soft tissues but also the facial skeleton, then restoration of facial shape and form can be more difficult. In this situation it may be prudent for the 33-1140 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.830] pathologist to obtain photographs of the body prior to autopsy and also photographs of the individual in life prior to cranio-facial injury and death. [33.810] Post-autopsy procedures Following the completion of the restoration and reconstruction of the body, it is washed, wrapped and stored awaiting collection by the family s funeral director. However, even at this stage various issues have to be kept in mind. The body must be stored in a safe and secure environment. Unless the body is being stored for several weeks, it should not be allowed to become frozen but must be kept cold enough to delay significant decomposition. This can be more difficult to achieve than is often realised since some deaths are associated with rapid onset and progression of decomposition even in otherwise ideal environments. When should a body be returned to the family for disposal? In theory, a complex autopsy could take months to complete. However, in practice the physical autopsy takes a few hours in most cases. This means that the performance of an autopsy, whether for medical or medico-legal reasons, should not introduce any significant delay to a family s funeral arrangements. Of course, even when the body of the deceased has been returned to the family the autopsy process continues. There are chemical and toxicological tests to complete, histological specimens to be examined under the microscope and case conference discussions to be held. All of these processes take time and it would be usual for it to take between two and six weeks for the final report on the death to be available. Despite this, limited information is usually available from the pathologist immediately following the autopsy and in most circumstances pathologists are happy to speak to family members or their personal medical practitioners about the interim findings. Record of findings The timely completion of an accurate and informative final autopsy report is an essential aspect of post-autopsy procedures. Such reports have to be clear and understandable to the various groups who require autopsy information. Unfortunately, the varied nature of the people who need the information makes it difficult to phrase an autopsy report in appropriate terms. For example, a family member may need information in non-medical language while the deceased s medical specialist may require more precise medical information. In the case of autopsies where people from different backgrounds all need access to the report, real communication problems can arise. In practice, the pathologist finds that he or she is working for several clients who each differ in their approach to the death investigation. Even though, strictly speaking, a forensic pathologist is working solely for the coroner, he or she must keep in mind that the autopsy report may eventually make its way into the criminal or civil justice systems. [33.830] Special techniques The face Dissection of the face is not an uncommon procedure during the forensic autopsy. It may be required in a variety of suspicious death investigations particularly in those where facial injury has occurred or where human identification is an issue. At first glance, it may be thought that the dissection of the face will be associated with permanent disfigurement with consequent change in the visible identifying characteristics of the face. In practice, such a degree of disfigurement of the face is rarely the result of autopsy dissection. In situations where 33-1141 Update: 26

[33.830] EXPERT EVIDENCE complaints are made that the face has been altered as a result of the autopsy, examination of the allegation usually reveals that there was prior facial damage and disfigurement with alteration of the face before the autopsy commenced. In many forensic cases the family will not have seen the body of the deceased prior to the autopsy and as a result they can confuse the effects of the autopsy procedure with injuries that the deceased suffered prior to death. The soft tissues of the face need to be examined carefully in a variety of autopsies including those performed for both clinical and forensic purposes. In the clinical autopsy it may be necessary to dissect the soft tissues of the face in order to identify disease in structures such as the salivary glands, muscle and soft tissues. Skin pathology may need to be explored and where skin tumours have invaded the deeper structures, facial dissection may be required in order to determine the extent of direct tumour spread. Examination of the structures such as the lining of the mouth, including the tongue, the nose, the nasopharynx and the oropharynx will require a degree of facial dissection. In the forensic autopsy soft tissue dissection of the face may be required in order to identify areas of soft tissue and bony trauma. Again oral structures may need to be dissected and the region of the lips, the nose and the eyes may require specific examination for injury. The forensic autopsy also often involves an examination of the subcutaneous tissues of the face in order to identify areas of bruising corresponding to regions of externally applied force. In forensic autopsy practice injuries to the face are a common feature of the pattern of trauma in cases of interpersonal violence. [33.840] In addition to soft tissue dissection, examination of the bony tissues of the face may be required. Again in the clinical autopsy, pathology in the overlying soft tissues may have spread to involve the underlying bony tissues of the face. Specific areas of the facial skeleton of the skull may need to be dissected in some detail. Bone tumours involving the skull including the dental structures may require detailed dissection involving removal of portions of bone in order for the extent of the disease to be determined. Specific structures such as the sinuses and the deeper regions of the nose and orbits require special dissection techniques. In the forensic autopsy it may be necessary to examine the bony tissues of the face in order to determine the extent and nature of trauma to the face. Fine fractures of the facial skeleton may be difficult to determine on x-ray. For this reason facial dissection should be carried out in all autopsies where the deceased has suffered a facial injury. Gross trauma to the facial skeletal structures is a feature of many forensic autopsy subjects. Firearm injuries to the face are particularly destructive of the facial skeleton and the exploration of these injuries can involve the dissection and removal of large portions of the mandible and the maxilla. [33.850] In autopsies where the identification of the deceased person is unknown, it is necessary to make a detailed record of the mouth by means of detailed charts, photographs, radiographs and descriptions of dentition so that these can be used for comparison purposes. In many cases it may be possible to obtain this information by direct visual inspection of the inside of the mouth. However, in some cases it may be necessary to disarticulate the lower jaw (mandible) in order to expose the dental structures. In some cases it may also be necessary to remove the maxilla. The detailed dissection of the tissues and structures of the neck is linked to the examination of the soft tissues and hard tissues of the face. In practice, the dissection of the neck in the routine autopsy can be seen as a preliminary process to the more extensive procedures involved in facial dissection. Prior to the detailed dissection of the face it is often useful to have concluded 33-1142 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.870] the remainder of the macroscopic autopsy. As with dissection of the neck, the prior removal of the thoracic organs and the brain allows the blood within the soft tissues of the head and face to be drained. This results in the soft tissues of the face becoming relatively free of blood allowing the pathologist to dissect the tissues with good visualisation of both soft and hard tissues. External genitalia In certain forensic autopsies dissection of both male or female genitalia may be required. In practice, however, it is female genitalia that most often require detailed dissection. Deaths from violence where a sexual assault has occurred require detailed assessment in order to reconstruct the circumstances in which interference with the external and internal genitalia took place. If forensic specimens of vaginal contents are required for forensic biological assessment, such as vaginal swabs, these are best taken prior to the dissection of this area. It is preferable for such swabs to be taken prior to the internal examination of the body to reduce the risk of further contaminating the vulva and vagina with other body fluids. Following the removal of the internal abdominal organs, the external and internal genitalia may be removed in continuity. It is essential that during the removal of the internal abdominal organs the pelvic organs are retained. This is best achieved using the modified Virchov dissection procedure which leaves the kidneys, aorta and pelvic contents in the body. [33.870] To remove the internal and external female genitalia aligns the midline abdominal incision is extended at its inferior end down over the pubis on each side of the vulva. The incision can involve the most superior medial aspects of the proximal thighs and should be continued posteriorly so that the perineum and anus are included within the segment of skin to be excised. On completion of the skin insertion, the pubic symphysis may be opened by incising the cartilage. This allows for greater access to the floor of the pelvis through which the internal genitalia will be removed. From above, the uterus, rectum and bladder can be freed from their pelvic peritoneal attachments and passed through the floor of the pelvis beneath the inferior pubic rami. On removal of the dissection specimen it is possible to examine the vulva, vagina and uterus in detail and to identify the characteristics of any mucosal injury. The paediatric autopsy Despite the difference in size, autopsies in the case of infants and young children are performed in a very similar manner. The same instruments are used in most instances. However, smaller scissors and other surgical instruments may be required to dissect particular organs. It is important to obtain a set of scales capable of weighing organs of the relevant size to at least the nearest gram. The external examination is performed in a similar manner to that of the adult. However, in the case of newborn infants it is important to document the presence of any congenital abnormalities. Body morphometry must be documented in detail as this may provide important information regarding the child s development. The examination of the eyes, ears, nose and mouth must be carried out meticulously to check for features of congenital abnormality such as cleft palate or choanal atresia. Opening of the body of an infant at autopsy is performed in a similar manner to the adult except that the lower portion of the abdominal incision is often extended on either side of the umbilicus to form an inverted Y shaped incision that extends down into both groins. This approach is usually restricted to autopsies on foetuses or small infants who have died in the 33-1143 Update: 26

[33.870] EXPERT EVIDENCE perinatal period. A variety of specialised autopsy techniques can be carried out in the infant particularly to assist in the detection of congenital anomalies. Removal of whole organs with post-removal fixation and examination allows for detailed dissection of these structures to be performed using an operating microscope. The collection of tissues and specimens for post-mortem microbiological analysis has particular relevance in the case of the infant autopsy as it is important to exclude infectious disease as a cause of the sudden and unexpected death. [33.890] The sudden infant death syndrome (SIDS) is perhaps the most common cause of unexpected death in infants investigated by paediatric or forensic pathologists. Over the years this so-called syndrome has received considerable attention. The definition of SIDS has undergone considerable remodelling over the years but in essence it is still a syndrome based on exclusion, the key criteria of which is the absence of significant pathological features that might be expected to cause death. Perhaps the most critical point issue for forensic pathology is that this diagnosis can only be made when all significant natural disease has been excluded following a thorough post-mortem examination of the body. Despite this emphasis on the absence of significant pathology, there is a characteristic pattern to many of these deaths. The majority occur between the ages of two and five months and there is often a short medical history of a cold or a gastro-intestinal illness. Typically, the child is found dead in their cot in the morning. In the past, studies have shown that these deaths are more common in infants who have been bottle fed and whose mother smokes. While significant pathology is not identified at autopsy, a number of minor abnormalities may be detected being of a degree and type that would not be expected to ordinarily cause death. In carrying out an autopsy in the case of a cot death, it is essential to rule out a homicide or a traumatic accident. Petechial haemorrhages may sometimes be seen at autopsy. However, these are not usually present to the degree that might be expected had the child been asphyxiated. Careful examination of the whole body for signs of trauma of the type seen in a child abuse or battered baby syndrome case must be made. Post-mortem radiology must be used to detect old or recent fractures. Features such as signs of neglect, bruises or burns of various ages and avulsion of hair must be considered as highly suspicious, particularly when these occur in infants who are too young to acquire these injuries themselves as a consequence of normal activity. POST-MORTEM ARTEFACTS [33.900] Post-mortem artefacts are findings at autopsy which may mimic ante-mortem phenomena but which arise either de novo after death, or during the handling of a body after death, or occur during or as a result of autopsy procedures. There are several such artefacts and the following list is by no means exhaustive. [33.910] Post-mortem lividity or hypostasis This is simply a differential staining or discolouration of the dependent parts of the body due to the settling of blood in skin blood vessels under the influence of gravity. In a body lying on its back for a period after death, the hypostasis will be distributed over the back of the head, chest, abdomen and limbs. A body left hanging for a period after death develops hypostasis circumferentially in the legs and lower portions of the arms. If a body is moved shortly after hypoststic lividity appears, the blood will move resulting in a change in the distribution of the pattern of lividity. At a variable time after death, the hypostasis becomes fixed and this phenomenon is occasionally useful to demonstrate that a body has been moved after death (or 33-1144 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.960] more specifically, moved after fixation of the hypostasis): see Figure 1 [33.2690]. To the untrained eye, lividity can mimic bruising, particularly since it can have a blotchy character. This is a common problem for people viewing their deceased relatives and could also contribute to misinterpretation of photographs of deceased persons by jurors, and even lawyers. [33.920] Artefactual bruising This is a common occurrence and may cause particular difficulty in interpretation when it occurs in the structures of the neck in a suspected strangulation. Most commonly, such bruising is subserosal, but blood in these circumstances may track back between muscle bundles and sometimes it may be impossible to distinguish with certainty, between a real and artefactual bruise. Draining the neck prior to dissection will do much to obviate this phenomenon, as will noting and recording each bruise as it is observed so that the subsequently developing artefactual ones can be discounted. Diffusion of blood into the perinephric tissues as a consequence of the removal of the abdominal organs may also simulate ante-mortem haemorrhage. Artefactual bruising is a different phenomenon from so-called post-mortem bruising which may occur as a consequence of heavy blunt impacts to the cadaver. In such bruising, there is a relatively small bruise in association with significant tissue damage. [33.930] Anal dilatation The anus may appear dilated after death, and more so as the post-mortem interval increases. Assessment of possible anal interference depends upon the demonstration of abrasions, bruises, lacerations, and oedema and the results of swabs taken for the constituents of semen and not on the assessment of any visible dilatation. [33.940] Insect abrasions Within a few hours of death, ants may cause abrasions which may be confused with ante-mortem injury. Such abrasions are usually numerous, small and irregular and often involve skin areas which are normally protected from injury. The cause of such abrasions is usually apparent if the scene of death is visited. [33.950] Animal injuries Small rodents, dogs and cats can rapidly remove tissue from bone on cadavers. Uncovered areas such as the face and hands are common targets. Such damage may be extensive but should not be confused with ante-mortem injury due to the absence of haemorrhage and significant bony damage, and the observations of teeth marks at the margins of what is usually a localised area of tissue loss. Decomposed bodies may also be attacked by animals who may be able to carry off portions of the body that can be relatively easily detached such as the hands and feet. Bodies immersed in water may show extensive soft tissue damage as a result of the action of small marine crustacea and fish. [33.960] Rigor mortis and its forcible disruption Rigor mortis or post-mortem stiffening of muscles occurs in the earlier part of the post-mortem period. It is due to the breakdown of the sophisticated mechanism in muscle fibres allowing them to both shorten and lengthen the basis of the contraction of the muscles. The time of onset and passing of rigor mortis, as with the time of onset of hypostasis and its subsequent 33-1145 Update: 26

[33.960] EXPERT EVIDENCE fixation, have been used to assist in determinations of the time since death. While such determinations may be of assistance to investigators, the degree of precision required by courts in particular cases is such that the coarse and broad conclusions that can be made will rarely be of assistance. (The contribution of body temperature to resolving the question of the time since death is also only of investigative rather than probative value. A detailed consideration of this is beyond the scope of this chapter and can be found in most major forensic pathology texts.) Rigor mortis itself is not regarded as mimicking any ante-mortem phenomenon, but its forcible disruption may. In the arms this may cause rupture of the biceps muscle or bone fractures, with seepage of blood from the site of damage. To the unwary, such post-mortem damage may give rise to suspicion of ante-mortem injury. Appropriate inquiries will usually reveal that there has been interference with the body by people such as undertakers or the police, of which the prosector was not made aware. Exceptionally, a phenomenon known as instantaneous rigor mortis or cadaveric spasm may occur. Classically, this happens in deaths associated with extreme emotional or physical exertion and, in such circumstances, the position of a limb in life may become fixed at death rather than assuming a position determined by gravity (the musculature in normal circumstances relaxing at the time of death). Examples include weed clasped in the hand of a drowned person and the hand of a victim of a homicidal stabbing around the blade of the knife protruding from his chest. [33.970] Pulmonary collapse A pneumothorax can only be diagnosed with certainty at autopsy if the opening of the chest is observed by the pathologist, by radiology or by the direct demonstration of air in the pleural cavity. The lungs can collapse rapidly after opening the chest at autopsy, and unless one of the above procedures has taken place, it can be very difficult to refute the suggestion that the observed pulmonary collapse was, in reality, an artefact. [33.980] Aspiration of gastric contents The movement of gastric contents into the trachea (wind pipe) and airways of the lungs is a phenomenon that can occur during life or after death. Gastric contents are highly irritable to the lungs and airways and the inhalation of such material in life can cause inflammation and bronchospasm. The aspiration of gastric contents can cause death as a result of laryngospasm, bronchospasm or cardiac arrythmia. Such aspiration occurs most commonly in a setting of intoxication. However, despite the fatal nature of gastric aspiration, it has been long recognised that gastric contents may move passively from the stomach and oesophagus (gullet) into the airways after death. The simple movement of a dead body during transportation can result in such a pseudo-aspiration and as a result the diagnosis of aspiration of gastric contents should be made carefully after consideration of all the surrounding circumstances. [33.990] Artefacts associated with resuscitation Autopsy findings associated with prior emergency resuscitative measures are common and varied, and it is most important that they be correctly interpreted in suspicious and allegedly homicidal deaths. A careful history of attempted resuscitation must be obtained before autopsy in order to determine not only what special investigations may be indicated but also what lesions may require cautious interpretation. In some deaths, it may be impossible to state categorically that certain injuries were or were not the result of either professional or inexpert resuscitative measures. The following injuries (see Table 3) have been reported in association 33-1146 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.990] with emergency resuscitation prior to death. TABLE 3 Injuries associated with emergency resuscitation 1 Site Nature of injury Cause of injury Chest Bruising Cardiac massage Nostrils, neck and chin Compression and disruption of subcutaneous fat Patterned abrasions Fractures of ribs and/or sternum with variable degrees of haemorrhage (not in young children) Fingernail abrasions and bruising Cardiac massage Defibrillation paddles Cardiac massage Pinching nostrils and/or holding lower jaw Neck soft tissues Bruising Mouth-to-mouth resuscitation Neck larynx Neck, cubital fossa, precordium etc Fractures of hyoid bone and thyroid cartilage Needle puncture marks Resuscitation or laryngoscopy Vascular catheterisation and/or injections Conjunctiva Petechial haemorrhages Cardiac massage Eyes Retinal haemorrhages Cardiac massage Gastro-intestinal tract Oesophageal perforation Heimlich manoeuvre Stomach rupture Jejunum rupture Mesenteric laceration Gastric rupture and haemorrhage Mesocolon haemorrhage Transverse colon perforation Hepatic artery laceration Pancreatic haemorrhage Liver laceration Heimlich manoeuvre Heimlich manoeuvre Heimlich manoeuvre Cardiac massage Cardiac massage Cardiac massage Cardiac massage Cardiac massage and abdominal compression Cardiac massage 33-1147 Update: 26

[33.990] EXPERT EVIDENCE Site Nature of injury Cause of injury Splenic rupture acute and delayed Cardiac massage Cardiovascular system Right atrial rupture Cardiac massage Respiratory system Various other cardiac lesions Ruptured ascending aorta Coronary artery dissection Pneumothorax and pulmonary barotrauma Cardiac massage Cardiac massage Cardiac massage Cardiac massage 1 Leadbeatter and Knight (1988). [33.1000] Artefacts associated with putrefaction Such artefacts should not cause problems to experienced prosectors. The swollen, discoloured and bloated faces of putrefaction may mimic severely bruised oedematous faces. Marbling of veins, particularly along the jugular veins, may be interpreted by the inexperienced as bruising. Putrefactive juices oozing from various orifices have been confused with ante-mortem injury (the two, of course, may co-exist). Hypostasis in the scalp of a putrefying body may be confused with bruising. As decomposition progresses, skin defects associated with maggot infestation may appear and these can be difficult, with any degree of certainty, to distinguish from ante-mortem injuries. This is particularly so in the earlier stages of putrefaction because it is areas of injury which are infested first. The interpretation of injuries INTRODUCTION [33.1100] This is one of the particular areas of expertise of a forensic pathologist. Lawyers, as do the public in general, often invest all medical practitioners with this expertise. However, most doctors are mainly interested in the medical consequences of injuries, because it is those which must be diagnosed and treated, and not the causes of injuries. The orientation of treating doctors is almost exclusively towards the medical management of injuries. A different orientation, different observations, and a different analysis are required to come to conclusions about the cause of an injury or injuries. Because a forensic pathologist is interested in making a contribution to the reconstruction of events surrounding a death, he or she has learnt the observations that are required to make conclusions about the causes of injuries. Questions about the cause of injuries are often confusions of the following two questions: (1) By what object was a particular injury caused? (2) In what manner (accidentally, by assault or by self-infliction) was the injury or injuries caused? The answer to the first question requires a knowledge of the classification and characteristics of 33-1148 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.1120] the different types of injuries. Frequently, this alone will be sufficient to deal with the issues in a particular case. However, it is often necessary to consider the second question. This arises when determination of the cause of individual injuries has not dealt with the issue of the manner of their infliction. In these cases, it is the pattern of the injuries taken as a whole which needs to be analysed and this may lead to clear conclusions as to accident, homicide or suicide. By pattern of injuries is meant an analysis of the number, type and distribution of injuries over the body. A classic example of the consequences of the confusion between these two questions is in the Peden case: Molomby (1981, p 4ff); Cordner (1990); Pounder (1990). In this 1922 case, a married woman was found dead in her bedroom with multiple deep incised wounds to the front of the neck (ie, a cut throat). The husband, who was unpopular with the wife s family, was arrested for murder on the basis of the medical practitioner s analysis which was concentrated on the injuries to the neck. He felt it was not possible for such injuries to be self-inflicted. Had he gone on to ask himself question (2) above, he may have been moved to consider more carefully the total picture which included the absence of any injuries elsewhere. It is most forensic pathologists experience that homicidal cut throats are the coup de grace following a number of other stabbed and/or incised wounds. The absence of any other such injuries (plus a greater experience of the potential of severe neck wounds to be self-inflicted) is a major pointer to self-infliction. The consequences of the medical practitioner s analysis in this case were: (i) an inquest with an adverse finding against the husband; (ii) at the first trial, a hung jury; (iii) conviction at a second trial; (iv) appeal to the Court of Criminal Appeal lost; (v) appeal to the High Court lost; and (vi) release following consideration of new expert evidence at a Royal Commission. (Interestingly, these six steps took 12 months!) This very same issue homicide versus suicide in a death from a cut throat was at the heated centre of one of the cases considered by the Royal Commission into Aboriginal Deaths in Custody. Failure to record the findings appropriately, and particularly relevant negative findings, complicated matters. In summary then, to analyse the cause of injuries properly, there must be an understanding of: (1) the classification and characteristics of injuries; and (2) the patterns of injuries. CLASSIFICATION OF INJURIES [33.1110] It is vital that injuries are correctly classified because this immediately indicates something about causation. Leaving aside gunshot wounds (which are a special form of compound injury) and injuries associated with heat, cold, electricity and chemicals (burns), the common classification of injuries is abrasions, bruises, lacerations, incised wounds and stab wounds. [33.1120] Abrasions Abrasions are superficial injuries damaging, technically, only the epidermis (the outermost layer of the skin). However, if there is deeper injury to the dermis causing bleeding but the abrading component is predominant, the injury is still classified as an abrasion. Although they may indicate significant internal trauma, abrasions are not usually serious from a medical point of view, but they can be of considerable medico-legal importance. For example, an 18 year old man was found hanging in his cell while on remand for murder. Apart from a ligature mark 33-1149 Update: 26

[33.1120] EXPERT EVIDENCE around his neck, the only other injuries found were two scratch abrasions on the front of the left wrist. They were consistent with having been caused by a plastic knife found in the cell. The front of the wrist is a site of election for self-inflicted injuries reflecting a suicidal intent and the injuries, although trivial in themselves, were a significant supporting factor for the conclusion that the death was a suicide. Abrasions are common and generally can be subclassified into four groups: (1) Scratches: These are caused by sharp objects such as fingernails, pins or thorny bushes. Careful examination with a hand lens may give an indication of the direction of the scratch as the skin in front of the object is pushed ahead in the direction of movement of the object. There is generally a clean area at the commencement of the scratch and tags at the ends. (2) Grazes: These are usually caused by an oblique contact with rough surfaces resulting in a general, but usually irregular, removal of a skin surface. The direction of the graze is shown by the surface skin tags. Grazing is present in many situations, including falls and motor vehicle accidents. It may result from a brushing contact of the victim with the ground, or from dragging of the victim. Glancing injuries by an object such as a football boot, even when delivered through clothing, may cause grazing. The softer and smoother the offending instrument, the less likely a graze is to result. (3) Friction abrasions: These may be caused by cords or ropes, which will both indent and rub the surface of the skin when applied by tying and pulling. Various ligature marks in hangings and bindings are examples. Vital changes may not necessarily be obvious either on the skin surface or in the subcutaneous tissues immediately on infliction, but drying of the rubbed skin will cause the mark to become much more obvious, and it will often take on an appearance of brown paper or parchment. Any associated bruising may accentuate a friction abrasion some hours after infliction. (4) Imprint abrasions: These result from impact with an object with such a degree of force that the pattern of the object is imprinted on the skin by virtue of compression of the epidermis. Examples are the tread of a car tyre on a pedestrian, a seat belt or steering wheel abrasion on the chest of drivers involved in motor vehicle accidents, the weave of coarse fabric intervening between an offending force and the skin, and imprints of beads or a necklace during throttling. Particles of foreign material such as road grit, paint or oil may be retained in an abrasion, and their recovery may be of great importance in the interpretation of the nature and mechanism of the injury. The distinction between an abrasion sustained during life and one occurring after death can be difficult, and the use of histological techniques may help. Because of the superficial nature of abrasions, bleeding into tissues does not usually occur unless the scraping action responsible has been associated with a concomitant direct forceful impact in the same area. When haemorrhage occurs into adjacent tissues, it is supportive evidence that such abrasions were sustained during life. When seen on the surface of a dead body, an abrasion usually differs from that seen on a live patient, in that the abraded epidermis after death becomes leathery and dark in colour. In addition, abrasions, like bruises, may become more obvious as time passes after death, and especially when the body has been refrigerated. [33.1130] Bruises (contusions, haematomata and haemorrhages) Bruises may be defined as haemorrhages in or beneath the skin, produced by the escape of blood from vessels, but without discontinuity of the overlying skin. They occur generally as 33-1150 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.1130] the result of blunt trauma. The interval of time between injury and the appearance of the bruise in the living ranges from seconds to many hours. It varies with the rate of seepage of blood from the damaged blood vessels under the skin, the size of the vessels damaged and the type of tissue involved. A faint bruise may become more apparent several hours after death and much more pronounced a day or two after death. For these reasons, it is often of great value to re-examine both living and dead victims, with injuries with medico-legal significance, 24 to 48 hours later. Frequently, small or faint contusions, such as fingertip bruises, which may indicate a struggle or restraint, become more obvious. At autopsy this precaution may be obviated by subcutaneous dissection. The size and apparent severity of a bruise are not necessarily related to the amount of force applied, and the appearance of a bruise may be modified by the following factors: (1) The condition, type and texture of tissue involved: When the skin is loose, as around the eyes, bruising will occur much more easily and will be more extensive. This applies also where there is excess of subcutaneous fat. Conversely, if the skin is strongly supported by fibrous tissue, bruising will be considerably less or even absent. When there is good muscle tone, as in the abdominal wall of boxers, bruising may be minimal even with severe trauma. The compression of skin or tissue against bone will increase the likelihood of a bruise occurring. (2) The age of the person involved: Infants and elderly persons tend to bruise more easily than young and middle-aged adults. In infants, it is because of the looseness and delicacy of the skin itself and the nature of the subcutaneous fat. The elderly often have a loss of subcutaneous fat and poorly supported blood vessels. (3) The presence of concurrent disease which may increase any bleeding tendency: There are a number of medical conditions which can alter the way the body responds to bleeding following an injury. Some of these will alter the appearance of bruises or lead to the formation of abnormally large bruises from a given injury. Genetic disorders such as haemophilia result in impairment of blood clotting mechanisms. Major blood loss can also result in increased bruising following injury and this can also occur where the patient has been treated with multiple blood transfusions. A variety of disorders affecting the blood and bone marrow (where the blood cells originate) may cause increased bruising. These include leukaemias, platelet disorders and bone marrow failure. (4) Gravity shifting: Gravity shifting of the extravasated blood may occur and result in the bruise appearing some distance from the point of injury, as is seen on occasions at the back of the knee or lateral lower thigh following fracture of the femur. It is typically seen in the periorbital haematoma that occurs following a laceration or bruise to the eyebrow or nose when blood from either of these injuries seeps through the loose tissues around the eyes. Age of a bruise Even the experienced examiner can usually give only a very approximate indication of the age of a bruise from its appearance. It is virtually impossible to attain any real degree of accuracy. A fresh bruise immediately after injury is usually red, but within several hours, and according to its size and depth, it may change to dusky purple. During the next two to six days, in the healing stages, the haemoglobin from the escaped red blood cells starts to undergo chemical changes, and the purplish colour of the recent bruise in a living person will change to a brownish colour. The latter colour then gradually passes through green to yellow with the bruise ultimately fading in one or more weeks depending on its initial size. The rate at which 33-1151 Update: 26

[33.1130] EXPERT EVIDENCE these colour changes occur depends partly also on the state of health and on the age of the victim. Elderly persons generally have a poor capacity for absorption of breakdown products of haemoglobin, and their bruising may last for weeks and sometimes months before final absorption occurs. Special types Tramline bruises, as their name suggests, comprise two parallel lines of bruising separated by a strip of unbruised skin: see Figure 4 in Chapter 41, Clinical Forensic Medicine [41.1260]. The importance of diagnosing tramline bruising relates to its causation. These bruises are caused by the single application of force to the body by a rod-like object or linear edged object. The reason that one application and of force gives rise to two parallel lines of bruising relates to the way in which the skin is compressed by the object. When a rod-like object strikes in the body, the skin making initial contact with the object is compressed, forcing blood out of the small blood vessels. As the object continues to push against the body, the skin and soft tissue on either side of the object becomes stretched causing the small blood vessels in these areas to be torn. The bleeding from these vessels gives rise to two parallel lines of bruising in the skin separated by an unbruised region which was the area of skin initially compressed by the rod-like object. [33.1160] Suction bruises are often seen in the region of the head and neck and are sometimes described as love bites. They are caused by the skin being sucked into the mouth. As a result of the pressure changes within the blood vessels of the skin and the entrapment of blood in the small vessels of the skin, the engorged small blood vessels bleed, giving rise to an oval or circular area of bruising which has indistinct borders and a granular appearance to its surface. Occasionally as the skin is drawn into the mouth an abrasion injury will be caused by the skin scraping across the undersurface of the teeth. [33.1170] Lacerations Lacerations are tears or splits, usually in the skin, but which can occur in any organ or tissue, and are the result of blunt trauma. They are to be differentiated from incised wounds. This important differentiation means that there is no place in forensic medicine for the word cut because this does not distinguish between a laceration (a consequence of blunt trauma) and an incised wound (a consequence of sharp trauma). The simple difference may itself be the key issue in a particular case. The many varieties of lacerations may occur from criminal incidents or from accidental injury and are the result of splitting, tearing or stretching of the skin and underlying structures. They are rarely the result of direct self-infliction. Lacerations may closely resemble incised wounds in areas of the body, such as the eyebrows and shins, where the skin is in close apposition to bony prominences. Close examination of such injuries, aided by a hand lens, will often distinguish between lacerations and incised wounds, as there is almost invariably crushing of the wound margins, abraded skin edges and tissue bridges. On hair-covered areas, hairs may be forced into the wounds, with inversion of the wound edges and bruising in the immediate vicinity. If the difference cannot be determined, then this should be stated. The site, direction and undermining of a laceration may be of great importance when reconstructing the circumstances of an event. Lacerated wounds of the scalp bleed profusely, and the consequent blood-spattering at the scene may assist also in reconstructing the way in which a laceration occurred. The nature of the weapon used to inflict a laceration may be difficult to determine, but associated injuries and foreign material which may be found in the depth of the wound may all assist in identifying possibilities. 33-1152 Freckelton and Selby

[33.1180] Incised wounds These are injuries which are longer than they are deep and are caused by any object with a sharp edge, whether the edge is linear or pointed. Such objects range from knives and razor blades to fragments of glass, metal or china and sometimes edges of paper or grass. Incised wounds may superficially resemble lacerations, but the edges are generally sharply defined, even if sometimes rucked-up, as may occur in areas where the skin is not under tension, or as a result of a jerking movement of the instrument involved. Incised wounds tend to gape more and to bleed more freely than do lacerations, although fatal haemorrhage is relatively uncommon unless large arteries or veins are incised. The dangerous features of incised wounds depend largely upon the site and depth. Injuries to the neck, groin, cubital fossa and wrist, where there are large vessels near the surface, are potentially dangerous. It is often difficult to deduce any more about the nature of the weapon used to produce incised wounds than its probable bluntness or sharpness. It is important to differentiate between homicidal and suicidal incised wounds. A useful observation is that very frequently preliminary attempts occur in self-inflicted incisions. The typical throat or wrist cutting in suicide will frequently show several tentative incisions parallel to the fatal one as the victim either gathers courage to make a final attempt or becomes familiar with the initially underestimated toughness of the skin. When examining incised wounds, it is most important to record the following systematically: (1) the location, number and dimensions of all wounds inflicted; (2) the orientation, course and depth of each wound; and (3) the shape and edge characteristics of the wounds and the apparent sharpness of the weapon used. (This is assessed by carefully examining the edges of the wound with a hand lens of five to ten magnification and noting any bruising or serrations on the skin edges.) [33.1190] Stab wounds and punctures FORENSIC PATHOLOGY GENERAL [33.1190] By definition, the depth of a penetrating injury, such as a stab wound, is greater than its width, and in this fact lies much of the potential danger to life of such injuries. There is often little external haemorrhage, but almost invariably severe internal haemorrhage occurs in stab wounds that prove fatal. The common sites for fatal stab wounds are in areas where there are major vascular structures such as the chest, abdomen and neck. Stab wounds may be caused by both blunt and sharp objects. The appearance of the external wound may be that of an incision or a laceration depending on the characteristics of the object forced into the body; occasionally mixed incision lacerations occur when a sharp object is twisted when in the body, tearing the wound edge. Stab wounds usually provide more information at autopsy, concerning the type of weapon used, than superficial incised wounds because the cross-sectional appearance of the weapon may be left in the skin or other tissue. If the thrusting agent has a square end, then the external injury may be cruciate in appearance. Wounds across the fingers, palm or arms of the victim may occur in homicidal stabbings from attempts to ward off an assailant. These are referred to as defence wounds. Because of the elasticity of the skin, the width of a stab wound may be less than the width of the blade of the weapon used if the stabbing is straight in and out. Stab wounds may be occasioned either from a blade or spike being driven into a person or from a body pressing or falling against such an object which is rigidly held in position. The complete examination should include and record as much of the following information as applicable: 33-1153 Update: 26

[33.1190] EXPERT EVIDENCE (1) site and nature of defects in clothing; (2) site and relative position of wounds on victim, perhaps including the height of each wound from the heel of the victim, and its distance to the right or left of the midline; (3) the nature of each wound, including its minimal and maximal width, shape and direction; (4) depth of penetration, including the tissues and viscera penetrated; (5) apparent direction of penetration and presumed force. All measurements must be accurate and the results of the examination must be recorded factually at the time and supported when possible by photography. Many stab wounds gape after infliction, and it is most important, when examining these wounds, to approximate the gaping edges to re-establish the anatomical relationships of the skin of the edges that existed before injury. Measurements of the dimensions of gaping wounds before such restoration are virtually useless in assessing the width and thickness of the blade which inflicted the injury. After approximation of the edges, the wound will appear longer. The interpretation of the significance of penetrating wounds depends on close collaboration between the police and the pathologist. The court requires the establishment of the relationship between the suspected weapon when found and the nature of the wound. It is not usually possible to say, on purely pathological grounds, that a particular weapon must have caused a particular injury. Stab wounds caused by a sharp, thin object, such as a needle or a hat-pin, could be easily overlooked in a cursory external examination after an unexpected sudden death. It is possible for undetected homicides to occur by this means, especially when the wound is inflicted at the base of the skull. So, too, the external lesion may not be observed until some internal puncture or bleeding gives rise to suspicion. The external bleeding in such victims is usually minimal. Cases of this type are very likely to be a natural unexpected sudden death on cursory external examination. Needle stabbings are also recognised as a method of infanticide. Multiple stab wounds do not necessarily rule out suicide, even when each wound appears to be potentially fatal in itself. As mentioned previously, the site may be of great importance in deciding that a stabbing was probably homicidal and not suicidal in nature. Suicide by stabbing is uncommon. Even in Japan, suicide by penetrating injury constitutes less than 2 per cent of total suicides. During the ten year period 1958 to 1967, only 3 per cent of suicides in Australian males were occasioned by penetrating or cutting injuries. The left anterior part of the chest is the most common site selected for suicidal stabbing. The force required to drive an object into the body is a factor of considerable forensic interest. Clearly if the path of the stab wound includes bone and the bone has been damaged, then a great deal of force will have been involved. Where no hard tissues are included in the wound track it is more difficult to assess the degree of force used. The sharpness of the object is a relevant consideration as a blunt-ended object will require more force in order for it to be driven into the body. Perhaps the most significant impediment to a sharp object being driven into the body is the clothing. The thickness and weave of the clothing involved will be an important consideration when assessing the degree of force used. The next tissue which impedes the passage of a sharp object is the skin. Particular regions of the body differ in regard to the thickness of the skin and the resistance it offers to a blade. Once an object has passed through clothing and through the skin, very little additional force is required for it to incise and stab through the soft tissue of the body. Body fat and solid parenchymal organs such as the 33-1154 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.1250] liver, spleen, kidneys, heart and lung offer little resistance. Firmer fibrous connective tissues, however, offer increased resistance followed at the higher end of the spectrum by cartilage and lastly bone. PATTERNS OF INJURIES [33.1250] Assaults and falls Comments and conclusions about the cause of individual injuries follow their correct classification according to the characteristics described above. However, it must be said that it is rarely possible to say that a particular injury must have been caused by a particular object or in a particular way. More often, the cause of a particular injury can only be given in relatively non-specific terms (eg, blunt impact, scrape against a rough surface) and, in these circumstances, the pattern of injuries needs to be considered. The use of body diagrams to record injuries is an invaluable aid to the identification of these injury patterns. In cases of possible assault, the various patterns of injury associated with victims, aggressors and accidental falls should be considered. Combinations of the patterns are common. In cases where there are too few injuries to constitute a pattern, the fact that there are very few injuries may itself be of value in relating them to the stated cause. Many assaults, and almost all fatal assaults, are associated with one or more falls and it may often be difficult to refute the suggestion that a particular injury may have been due to a fall. In fact, this may have to be conceded for each of a number of injuries in a particular case. The analysis of the cause of the injuries, however, must also include the pattern in relation to the supposed circumstances. For example, the presence of a bruise on the back of the head and/or an oral laceration with bruised lips is not compatible with a simple fall on to a flat surface, although any one of the individual injuries could have been occasioned in this way. Table 4 lists the common features of the patterns of injuries in victims, aggressors and accidental falls. TABLE 4 Patterns of injury in assaults and falls Injuries in victim Injuries on aggressor Injuries in accidental falls Number Proportional to the duration and severity of attack Type Fist fight Bruises, abrasions, lacerations (NB: patterned abrasions with rings, gloves) Proportional to the method of assault, its severity, and effectiveness of the defence mounted by victim; often few present and fewer than victim Bruises, abrasions, small lacerations. Other methods of assault: proportional to efficiency of attack Proportional to number of falls; simple fall from a standing height: few injuries Bruises, abrasions, occasionally laceration(s) (severity: not usually severe in simple falls but skull fractures can result when even a simple fall is not broken) 33-1155 Update: 26

[33.1250] EXPERT EVIDENCE Injuries in victim Injuries on aggressor Injuries in accidental falls Kick Larger bruises, abrasions (NB: patterned abrasions with sole of shoe or heel), lacerations Other type Depending on weapon: stabs, incised wounds with knives; punctured wounds; blunt weapons, pieces of wood, crowbars, etc; scratch abrasions, fingernail impressions, ligature marks Frenzied or uncontrolled attack with knives, eg, may cause aggressor to injure himself or herself Grouping May be collected, but irregularly so Site Aggression injuries May be localised Directly resulting from assault Usually random 33-1156 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.1250] Injuries in victim Injuries on aggressor Injuries in accidental falls Face: chin, mouth (inside lips for small lacerations, bruises), cheeks, eyes, nose, ears Scalp: especially with blunt instruments (NB: scalp tenderness or even bruising following hair-pulling) Neck:(NB: counter pressure bruises on back of neck) Chest: knee marks, counter pressure bruising on back, fist blows, kicks (especially laterally and back) Legs: kicks Arms: fingertip bruises around upper arms and wrists where grabbed and shaken Relatively protected areas, eg, root of ear, inner canthus, perineum injuries here suggest possibility of kicks Defence injuries Arms: especially forearms and hands as victim tries to ward off or grab offending weapon. Injury varies according to the instrument (eg, fist, foot, blunt instrument, knife, glass) Legs: seen, eg, when victim curled on ground and being kicked Clothing Damage is usually proportional to severity and method of attack. The collection of trace evidence such as fibres, hairs, blood spatters and other stains from clothing may be most important Backs of fingers and hands, especially if contact has been made with the teeth or bony prominences. Must also consider whether they result from a fall or are defence injuries From victim Hands and forearms: scratch abrasions from fingernails Face: scratch abrasions from fingernails Injuries as for victim depending on effectiveness of defence (NB: bite marks) Damage proportional to effectiveness of defence: there may be little or no damage. Trace evidence such as blood spatters, fibres and hairs must be looked for Prominences: occiput, forehead, zygomatic arch, nose, chin, shoulders, elbows, hips, knees (surfaces with projections may injure relatively protected areas) May be involved. Collection of trace samples may be of value 33-1157 Update: 26

[33.1260] EXPERT EVIDENCE [33.1260] Self-inflicted injuries There are four categories of self-inflicted injuries, which have different patterns: suicidal; self-mutilation (these may be either by psychiatrically disturbed individuals, or to precipitate medical treatment as in the case of some prisoners); self-inflicted injuries mimicking an assault; and scarification (of decorative or totemic significance, and in Australian Aborigines as signs of remorse). As a general rule, lacerations and bruises are rarely self-inflicted. Suicidal injuries Suicidal injuries usually occur in what are called sites of election. Sites involving incised wounds from sharpened implements such as razors include the wrists, front of elbows and forearms, front and sides of neck and occasionally the groin. Wounds may be single but are often multiple and grouped together, and there may be a regularity or symmetry to the pattern. For example, the wounds are often parallel to each other, and often of similar severity, although there may be a number of tentative marks adjacent to the more significant wounds. The injured site, by definition, must be accessible. The clothing is usually spared. It is not usually difficult to distinguish a suicidal and homicidal cut throat. The former often has the characteristic tentative or hesitant relatively superficial incisions, usually at the lateral end of the deeper wounds. The presence of other suicidal injuries, the absence of injuries associated with an assault together with circumstances indicating a suicide, including the location of the weapon, will assist with resolving the issue. Suicidal stab wounds may be accompanied by tentative marks. Vanezis and West (1983) reported on 21 fatal cases of self-stabbing. In 15 cases, tentative or hesitation injuries were present. In a further two cases, such marks were evident in the clothes but not on the body, emphasising the importance of examining the clothing. Often the clothing is completely spared. The common sites of election are the chest and abdomen, the exact location sometimes depending on the victim s knowledge of anatomy. Self-mutilation Psychiatrically disturbed individuals who mutilate themselves are usually suffering from a significant psychotic illness. The injuries can occur in any of the sites mentioned above for suicidal injuries, but in other sites also relating to the disturbed thought content of the psychiatric illness. The bizarre nature of such injuries has a wide range, but is the hallmark of self-mutilation as opposed to suicidal injuries eg, stabbings of the eye, genital mutilation or genital amputation. The injuries usually reflect the individual s disordered state of mind rather than a direct attempt to commit suicide. Self-mutilation in order to precipitate medical treatment may occur in places of compulsory detention where circumstances, perhaps combined with a degree of psychological disturbance, may lead to an incentive to change one s environment by means of achieving self-injury to the extent that admission to hospital may be necessary. Apart from self-injury by means of incised wounds, there are often other methods which include the ingestion of toxic substances, drugs etc. See Figure 6 in Chapter 41, Clinical Forensic Medicine, [41.1280]. Self-inflicted injuries mimicking an assault The frequency of this class of injury is increasing because of the availability of compensation for criminal injuries. The pattern is usually easy to detect when the examiner is alert to the possibility. The principal features of the imitative assault and genuine assault are compared in 33-1158 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.1310] Table 5. TABLE 5 Characteristics of imitative and genuine assault injuries Imitative assault Genuine assault Localisation Possibly confined to one side of the body Multiple injuries clustered together Sensitive areas (eg, eyes, mouth) are avoided Injury type All injuries may be of a single type Injuries may suggest a single causative agent Bruises and lacerations are rare Injury severity Of similar severity Other No defence injuries If multiple, confinement to one side of body unusual If multiple, generally more widespread Sensitive areas are included in the more random distribution If multiple injuries, often a mixture of types Mixture of injuries can be associated with a range of causative agents Bruises and lacerations are common If multiple, injuries usually vary in severity Defence injuries are common Scarification Such injuries are common in a borstal or other custodial environment and possibly have, in those subcultures, decorative or totemic significance if they are not simply an expression of low self-esteem and disregard. Such injuries may include significant acts of self-mutilation including the excision of parts of the body. The etching of names, initials and terms of abuse in the skin in a manner resulting in scarring is a more minor example of these behaviours. Self-tattooing probably has a similar significance in some cases. [33.1310] Interpretation of homicidal stab wounds Stab wounds, with firearm injuries, are the most common cause of death in homicides in Australia. Frequently, the pathologist is called on to make conclusions as to the characteristics of the offending weapon, the force used in the assault and to re-create some of the dynamics of the incident itself. These can all be difficult and require careful consideration of sound autopsy information. Width of the blade The edges of the wound in the skin must be opposed at the time of measurement. Because of the elasticity of the skin, this measurement may be slightly less than the width of the offending instrument if the wound has not been artificially widened during insertion or removal of the 33-1159 Update: 26

[33.1310] EXPERT EVIDENCE weapon. Examination of the wound will not usually allow any conclusion to be made about whether or not it has been artificially widened. Similar measurements in tissues that are not elastic (eg, pleura, pericardium) allow some conclusions about the blade s width at different points along its length. Length of the blade The length of the blade will always be difficult to determine with any precision. Unless it can be said that a knife was inserted to the hilt, it will not be possible to establish the length of the blade. Abrasions surrounding the wound may indicate contact with the hilt, and such abrasions may say something about the characteristics of the knife. Sometimes the nature of bruising surrounding the wound may suggest contact with the hand gripping the weapon, although this must be differentiated from haemorrhage tracking along tissue planes from the wound. The length of the wound track can only be given as an estimate if it involves soft tissue alone, because soft tissues can easily be compressed so that a particular length of blade can produce a longer track. Further complications can arise because the soft tissue may have been in a different position at the time of the wound s infliction than is the case at the time of autopsy. The position of the lungs, the heart and abdominal viscera alters considerably during ordinary respiration, let alone during the dynamics of rapid movements and exertion. The firmest conclusion about the length of a wound track can be made when it terminates in bone or cartilage. Nature of the blade Often, but by no means always, it is possible to come to conclusions about whether the blade was single- or double-edged. The presence of a squared-off end to the skin wound indicates a single-edged weapon, although the absence of such a finding does not exclude it. This assessment is difficult if the edges of the wound have dried or if the cutting edges are blunt. The force used As described above, apart from the clothes, bone and cartilage, skin is the toughest impediment to the passage of a knife. In stab wounds it is the sharpness of the point of the knife, together with the force used, that determines the ease of passage of the knife through the skin. Assessment of force used, however, is always difficult to convey. It is useful to confine oneself to using a scale of one to ten or of mild, moderate and severe force. On the latter scale, in ordinary circumstances, a stab wound involving soft tissue only could be said to require at least moderate force. Distortions to the wound Nicks in the skin wound, disturbing the outline of a pure ellipse, may indicate one of three causes. First, as is quite common, the knife may have been withdrawn at a different orientation to the body compared to its insertion. Secondly, this different orientation may be the result of the body inadvertently turning on the knife or because of the assailant twisting the knife. The conclusion will depend on an assessment of the number of nicks and their severity. Thirdly, the possibility that the knife has been reinserted after partial withdrawal may also complicate the assessment. Again, the appearances of reinsertion may be mimicked by the body s movement onto the knife. Conclusions as to causation following an autopsy [33.1400] One of the main aims of the autopsy is to come to a conclusion as to the cause of death. In most cases the cause of death is not difficult to determine following the completion 33-1160 Freckelton and Selby

FORENSIC PATHOLOGY GENERAL [33.1400] of a detailed autopsy. However, it should be remembered that the case is only complete when the autopsy findings are considered together with a full medical history and details of the circumstances of the death. What, in fact, happens in coming to a conclusion in a routine case is that a cause of death discovered at the autopsy which accords with the medical and circumstantial history is elevated to the cause of death. An immediate corollary of this is that the establishment of causation has the potential for problems. At one end of the philosophical spectrum is the view that the cause must be both sufficient and necessary for the effect. That is, X is only the cause of Y if X is always followed by Y, and also, Y does not occur unless X has occurred. On this basis, pathologists would be restricted to coming to conclusions about the cause of death to those cases where the lesion was clearly incompatible with life; eg, decapitation or disruption of the heart. At the other end of the spectrum is the view that the cause of an event is the sum total of the conditions in which the event occurred. In this view, it is not strictly correct to isolate one of the conditions as the cause exclusive of the others. This could, eg, in the case of a death from carcinoma of the lung in a heavy smoker, lead to smoking and all its antecedents (eg, personality, upbringing, advertising etc) being included in the cause of death. The issue is simplified to some extent for the pathologist by being confined to the medical cause of death. However, a pathologist may properly rely on information other than the autopsy findings in coming to his or her conclusion about the medical cause of death. Such reliance should be mentioned in the report. The situations where forensic pathologists strike most problems in coming to conclusions about the cause of death may be summarised as those cases where: (1) there is a time delay between injury and death; (2) the circumstances of a non-fatal injury precipitate death from natural causes; (3) decomposition obscures the effects of injuries and/or accompanying natural disease; and (4) the cause of death is completely dependent upon the interpretation of the circumstances. The greater the causal difficulties for the pathologist, the more the cause of death should be given in descriptive rather than a prescriptive form. This fits well with the pathologist s role as an expert witness which, as far as possible, is not to decide those issues which are primarily a matter for the court, ie, the connection of acts of commission or omission by one party to the death of another. In being descriptive and explaining his or her views, and the basis for them, the pathologist puts the court in the best position to make its decision. [The next page is 3-271] 33-1161 Update: 26

[33.1400] EXPERT EVIDENCE 33-1162 Freckelton and Selby

FIGURE 1 [33.2690] Figure 1 Hypostasis [33.2690] The body of this woman was found on the verge of a bitumen car park. Hypostasis of the backs of the legs indicates that she has been moved at some stage after her death. There were some drag marks on the bitumen and subsequent investigations revealed she had been killed elsewhere, and after some hours, taken by car and dumped. Freckelton & Selby 3-271 Update 13

FORENSIC PATHOLOGY Update 13 3-272 Freckelton & Selby

FIGURE 2 [33.2700] Figure 2 Base of skull [33.2700] Base of skull showing anterior cranial fossa (a), middle cranial fossa (b), posterior cranial fossa (c), foramen magnum (d) and cervical spinal cord (e). Freckelton & Selby 3-273 Update 13

FORENSIC PATHOLOGY Update 13 3-274 Freckelton & Selby

FIGURE 3 [33.2710] Figure 3 Side view of brain [33.2710] Side view of brain showing frontal lobe (a), temporal lobe (b), brainstem (c), cerebellum (d) and spinal cord (e). Freckelton & Selby 3-275 Update 13

FORENSIC PATHOLOGY Update 13 3-276 Freckelton & Selby

FIGURE 4 [33.2720] [33.2720] Figure 4 Base of brain Base of brain showing base of frontal lobe (a), base of temporal lobe (b), pons (c), medulla (d), cerebellum (e), cervical spinal cord (f), olfactory nerves (g), internal carotid arteries (h). Freckelton & Selby 3-277 Update 13

FORENSIC PATHOLOGY Update 13 3-278 Freckelton & Selby

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[33.1400] EXPERT EVIDENCE 33-1166 Freckelton and Selby

Suggested reference materials There are a large number of texts providing general reference material on forensic pathology. Many other texts are available that provide more detailed information on specialist areas of forensic pathology such as gunshot wounds or neck injury. The following texts would be of great assistance to legal practitioners and would be a useful reference set in the library of a legal firm: Bennett KA, A Field Guide for Human Skeletal Identification (Charles C Thomas, 1987) Busuttil A and Jones JSP, Deaths in Major Disasters: The Pathologist s Role (Royal College of Pathologists, 1990) Byard RW and Cohle SD, Sudden Death in Infancy, Childhood and Adolescence (Cambridge University Press, 1994) Clement J and Ranson DL (eds), Cranio-facial Identification in Forensic Medicine (Hodder, 1998) Di Maio VJM, Gunshot Wounds: Practical Aspects of Firearms, Ballistics and Forensic Techniques (Elsevier, 1985) Di Maio DJ and Di Maio VJM, Forensic Pathology (Elsevier, 1989) Evans KT, Knight B and Whittaker DK, Forensic Radiology (Blackwell Scientific, 1981) Froede RC (ed), Handbook of Forensic Pathology (College of American Pathologists, 1990) Golding J, Limerick S and Macfarlane A, Sudden Infant Death: Patterns, Puzzles and Problems (Open Books, 1985) Gonzalez-Crussi F, Three Forms of Sudden Death: And Other Reflections on the Grandeur and Misery of the Body (Picador, 1987) Gordon I, Shapiro HA and Berson SD, A Guide to Forensic Medicine Principles (Churchill Livingstone, 1988) Gresham GA, A Colour Atlas of Forensic Pathology (Wolfe Medical Publications Ltd, 1975) Gresham GA, Colour Atlas of Wounds and Wounding (MTP Press, 1986) Gresham GA and Turner AF, Post-Mortem Procedures: An Illustrated Textbook (Wolfe Medical, 1969) Hart D and French H (eds), French s Index of Differential Diagnosis (Wright, 1985) Hendrix RC, Investigation of Violent and Sudden Death (Charles C Thomas, 1972) Hill RB and Anderson RE, The Autopsy: Medical Practice and Public Policy (Butterworths, 1988) Karch SB, The Pathology of Drug Abuse (CRC Press, 1993) 33-2101 Update: 26

EXPERT EVIDENCE Knight B, Legal Aspects of Medical Practice (Churchill Livingstone, 1992) Knight B and Henssge C (eds), The Estimation of the Time Since Death in the Early Postmortem Period (Edward Arnold, 1995) Knight B, Forensic Pathology (Edward Arnold, 1991) Knight B, The Post-Mortem Technician s Handbook: A Manual of Mortuary Practice (Blackwell Scientific, 1984) Knight B and Simpson K, Simpson s Forensic Medicine (Edward Arnold, 1991) Knight B, The Coroner s Autopsy: A Guide to Non-criminal Autopsies for the General Pathologist (Churchill Livingstone, 1983) Knight B, Forensic Pathology (Edward Arnold, 1991) Mant AK (ed), Taylor s Principles and Practice of Medical Jurisprudence (13th ed, Churchill Livingstone, 1984) Mason JK, British Association of Forensic Medicine, Forensic Medicine: An Illustrated Reference (Chapman and Hall Medical, 1993) Mason JK, Forensic Medicine for Lawyers (3rd ed, Butterworths, 1995) Mason John Kenyon (ed), Paediatric Forensic Medicine and Pathology (Chapman and Hall Medical, 1989) Mason JK (ed), The Pathology of Trauma (Edward Arnold, 1993) Plueckhahn VD and Cordner SM, Ethics, Legal Medicine & Forensic Pathology (2nd ed, Melbourne University Press, 1991) Polson CJ, Gee DJ and Knight B, The Essentials of Forensic Medicine (Pergamon, 1985) Ranson DL, Anatomical Figuring: Forensic Body Chart Resource (Victorian Institute of Forensic Medicine, 1995) Ranson DL, Forensic Medicine and the Law (Melbourne University Press, 1996) Selby H (ed), The Aftermath of Death: Coronials (Federation Press, 1992) Selby H (ed), The Inquest Handbook (Federation Press, 1997) Spitz WU and Fisher RS (eds), Spitz and Fisher s Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation (Charles C Thomas, 1993) Stone E and Johnson H, Forensic Medicine (Waterlow, 1987) Vanezis P, Pathology of Neck Injury (Butterworths, 1989) Watson AA, Forensic Medicine: A Handbook for Professionals (Gower, 1989) Wecht C, Curriden M, Wecht B, Cause of Death (Penguin Books, 1993) Wetli CV, Mittleman RE and Rao VJ, Practical Forensic Pathology (Igaku-Shoin, 1988) 33-2102 Freckelton and Selby

Bibliography BIBLIOGRAPHY Cordner S, The Peden Case and Expert Witnesses (1990) 153 Medical Journal of Australia 643 Freckelton I, The Offıce of Coroner in The Laws of Australia (LBC Information Services, 1993 ), HEALTH AND GUARDIANSHIP 20.10 Gordon Q, Shapiro HA and Berson SD, Forensic Medicine: A Guide to Principles (3rd ed, Churchill Livingstone, 1988) Knight B, The Post-Mortem Technician s Handbook: A Manual of Mortuary Practice (Blackwell Scientific, 1984) Knight B, Forensic Pathology (Edward Arnold, 1991) Knight B and Simpson K, The Coroner s Autopsy: A Guide to Non-criminal Autopsies for the General Pathologist (Churchill Livingston, 1983) Knight B and Simpson K, Simpson s Forensic Medicine (Edward Arnold, 1991) Leadbeatter S and Knight B, Resuscitation Artefact (1988) 28 Medicine, Science and the Law 200. Cited in VD Plueckhahn and SM Cordner, Ethics, Legal Medicine and Forensic Pathology (2nd ed, Melbourne University Press, 1991) Littlejohn H, The Medico-Legal Post Mortem Examination (1902) 1 Transactions of the Medico-Legal Society 14 Mant AK (ed), Taylor s Principles and Practice of Medical Jurisprudence (13th ed, Churchill Livingstone, 1984) Molomby T, Who Killed Hannah Jane (Griffin Press, 1981) National Specialist Qualification Advisory Committee of Australia, Lists of Recommended Medical Specialties and Appropriate Qualifications, No 17 (Australian Government Publishing Service, 1989) Plueckhahn VD and Cordner SM, Ethics, Legal Medicine and Forensic Pathology (2nd ed, Melbourne University Press, 1991) Polson CJ, Gee DJ and Knight B, The Essentials of Forensic Medicine (4th ed, Pergamon Press, 1985) Pounder DJ, The Peden Case: An Australian Forensic Disaster (1990) 153 Medical Journal of Australia 712 Selby H, The Aftermath of Death: Coronials (Federation Press, 1992) Selby H (ed), The Inquest Handbook (Federation Press, 1997) Spitz WV and Fisher RS, Medicolegal Investigation of Death Guidelines for the Application of Pathology to Crime Investigation (2nd ed, Charles C Thomas, 1980) Vanezis P and West IE, Tentative Injuries in Self Stabbing (1983) 21 Forensic Science International 65, cited in VD Plueckhahn and SM Cordner, Ethics, Legal Medicine and Forensic Pathology (2nd ed, Melbourne University Press, 1991) [The next text page is 33A-1] 33-2103 Update: 26

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