Autopsy Protocol

RECOMMENDATION:

All unnatural deaths should undergo autopsy, to find out cause of death; in particular

  • Frank case of homicide
  • Suicide or suspected case of suicide
  • Death due to road accident
  • Sudden and/or unexplained and/or unexpected death
  • Deaths during disaster – for cause of death as well as proper positive identification
  • Death as a result of Medical Negligence
  • Death in police custody
  • Death as a result of gross violation of human rights
  • Unidentified bodies
  • Skeletal remains

Doctors should perform his/her duty with dignity and conscience, with total independence and impartiality in decision-making. He/she should operate without any undue influence from law enforcement agencies and prosecutors.

I – Scene investigation

General principles:

Any death, obvious or unnatural, should be first reported to the competent authorities (Nepal police), who will decide further investigation to be carried out.

Doctor should be informed by the investigating officer and should visit the scene of death, if required, without any delay. He should coordinate with the investigating officer for transportation and other requirements.

Examination of the body:

Role of the police:

Police should carry out following tasks at the scene of death:

  1. The integrity of the scene and surrounding should be preserved by cordoning.
  2. Identity of all individuals present at the scene should be recorded.
  3. Dead body should be photographed as it is found.
  4. Any weapon or objects like, bullet, bullet case, cigarette butt, etc. found at the scene should be recorded and collected for investigations.
  5. Identity of deceased should be confirmed from next of kin, or a close relative, and and information the last known activities of the decedent should be obtained.
  6. The hands and feet of the deceased should be enclosed in paper bags, until it reaches the mortuary, to protect trace evidences.

Role of the doctor:

The doctor has the following duties while visiting the scene of death:

  1. Should have been informed of the Circumstances surrounding death by the investigating officer.
  2. Should undertake proper photographic documentation of the body.
  3. Record position of body in relation with fixed objects, record the clothing, all visible injuries and distribution of rigor mortis, livor mortis and state of decomposition.
  4. Photograph patterns of blood stains over the body and surrounding scene
  5. Collect all biological material required as evidence.
  6. Preliminary examination of body to be performed at the scene, ensuring dignity and confidentiality. This can be done by cordoning the area with bedsheets.
  7. Estimate time since death by analysing the state of rigor mortis, livor mortis and decomposition.
  8. Ensure transportation of the body to the morgue in a secure manner.

II – Autopsy physicians

It is a good practice to perform autopsies under supervision of qualified and competent medico-legal expert. While it may not be possible to have a medico-legal expert (forensic specialist) at site, it is always possible to consult with experts through telecommunications.

III – Identification

The general Assembly of Interpol in 1997, they have come up with the following criteria for the proper identification of the body during the Mass Disaster: Visual Recognition, Personal Effects, Physical Characteristics, Dental Examination, Anthropological Identification, Fingerprints and Genetic Identification.

Visual recognition
It is usually carried out by close relatives of the deceased or any person who has seen him / her recently.

Personal effects
Proper documentation of the clothings, personal belongings (jewellery, wrist watch, ID card, ATM cards) may help in narrow down the identification.

Physical characteristics
The external and an internal examination are recorded for physical characteristics.

Dental examination
Forensic odontologist or trained dentist should carry out proper examination of teeth and jaws.

Anthropological identification
In all skeletonised human remains anthropological identification becomes crucial.

Fingerprints
It is usually done by finger print experts and the doctor should assist in obtaining finger prints from deceased. However, mutilation of the fingers to collect fingerprint samples is not only barbaric but also unethical.

Genetic identification
When all measures for identification becomes inadequate, genetic identification should be carried out by an expert in DNA analysis. Caution should be taken to avoid contamination. It is essential to follow guidelines on proper storage of biological samples.

IV – General considerations:

  1. All medico-legal autopsies should follow the integrity of medical ethics and ensure dignity of the deceased.
  2. It is always a good practice to give an opportunity to the relatives, to grieve and to pay their respect for their loved one before autopsy.
  3. Minimum measures should be taken before commence of autopsy examination:
  • Give each body a unique case number:  (viz FM 074-0001)
  • Note the date and time of receipt of body
  • Note the date, time and place of autopsy
  • Note the date, time, reference number and authority from whom requisition letter was issued
  • Record the name of experts, assistants and any persons present at the time of autopsy with their proper designation
  • All relevant findings should be photographed with a scale and case number with and without clothing
  • After undressing, clothing and personal belongings should be recorded and any damages should be verified to correspond with injuries over the body
  • X-ray examination should be considered in cases of firearm injuries and charring of the body (for identification and location of foreign objects) and suspected child abuse (for hidden different stage of healing fracture bones).
  • All body orifices should be examined before internal examination and swab taken, if indicated, for biological trace evidence.
  • All medical records must be obtained, if the deceased has been treated at the hospital.

V – Autopsy procedures:

Preliminary for Autopsy examination:

  1. Authorization letter
  2. Registration
  3. Photography
  4. External examination
  5. Internal examination
  6. Ancillary investigation
  7. Cause of death
  8. Handover of the body with dignity
  9. Autopsy report

1. Authorization letter

The necessary documents authorizing the examination, from Nepal Police, as well as other documents including लासजाँच प्रकृति मुचुल्का and घटनास्थलमुचुल्का as well as medical record, if available, should be acquired.

In all case of found dead and sudden death, history should include:

  1. Circumstances of death:
    1. Date and Time
    2. Place of death (e.g. at home, at rest, after ingesting medication or food, during exercise)
  2. Whether death occurred under suspicious circumstances
  3. Past medical history
    • General state of health,
    • Significant past medical disease (e.g. hypertension, diabetes, Ischemic heart disease, malignancy, sickle cell disease, Chronic Obstructive Pulmonary Disease (COPD), Tuberculosis, Chronic renal failure, occupational lung disease, peptic ulcer disease, inflammatory bowel disease, psychotic or depressive diseases)
  4. History of medication
    • Anti-psychotic drugs
    • Cardiac drugs.
  5. History of narcotic drug or alcohol abuse
  6. Family history:
    • Ischemic heart disease
    • Genetically transmitted disease
    • Emphysema
    • Diabetes
    • Hypertension etc.
  7. History of recent surgical interventions
    • Cardiac surgery
    • Interventional cardiac procedures
    • Barium enema
    • Endoscopic procedures
    • Bronchoscopic biopsies,etc.
  8. Investigation findings
    • ECG findings
    • Serum electrolytes
    • Blood urea/ serum creatinine
    • Radiological findings (Chest X-ray, ultrasonography, CT scan)

2. Registration

All the body brought into the mortuary should be registered with a unique identification code. The unique identification code could include

FM – 2074 – 0123

Identification code for institute
E.g. – FM – Forensic Medicine
Year of examination
E.g. – 2074 – 2074 B.S. (or 2074/01 – Baisakh 2074)
Case number
E.g. – 0123 – Case # 123 for the year 2074

  • The body should be tagged with label bearing the unique identification code. If the body is to be stored in a cold chamber, labels should be tagged to the body as well as the body bag.
  • The labels used should be written in permanent, indelible ink on a water proof tag.
  • The personal details should not be included on the tag. The personal details should be registered on a registration form as provided in Annex-A of the National Guidelines on Autopsy Examination.
  • The documents should all be included in a folder and confidentiality maintained.

3. Photography

Photography should be carried out in a systematic and clock-wise manner and overall view, midrange and close up should be taken in every case.

  • Overall view – for seeing relationship of body or injury with other objects.
  • Mid range- relationship photograph with other immediate body part.
  • Close-up – for detail of injury or item in view.
  • All photographs should be taken with reference number and scale.

Minimum photographs in routine cases are:

  • Scene photographs if scene is visited by Medical Officer or given by Investigative Officer (print/cd/pendrive).
  • Photograph indicating condition of body with clothing when brought.
  • Total body photographs – Front, back and both sides
  • Routine –
    1. Face
    2. Face and trunk
    3. Groin and thigh
    4. Lower limbs from front
    5. Back of body
  • Specific – Injury/lesion in relation to body; close-up shots
  • Cause of death findings

4. External Examination

  • Length and build
  • Complexion
  • Colour of the hair and eyes
  • Secondary sexual characteristics
    • Male – Beard and moustache, axillary hair, pubic hairs and external genitalia
    • Female – Breast, areolas and nipple.
  • Identification Marks:
    • Scars
    • Tattoos
    • Moles etc
  • Signs of treatment
    • ECG leads
    • IV canulation
    • DC fibrillator marks etc.
  • Any obvious disabilities (e.g. amputated limbs, contractures)
  • General examination
    • Pallor
    • Jaundice
    • Cyanosis
    • Swelling of the limbs
    • Xanthelasma
    • Rashes
    • Petechial haemorrhages etc.
  • Post-mortem changes
    • Rigor mortis (jaw, neck, all joints)
    • Livor mortis (site, colour and fixed or blanched)
    • Signs of decompositions (purging, greenish discoloration, gaseous distension, marbling, skin peeling, etc.)
  • Description of Injuries:
    • Type (blunt/sharp/burn/firearm)
    • Size (two dimensions in cm /length x width)
    • Anatomical site
    • Exact location (from fixed land mark, e.g. From top of head and ante/posterior-midline)
    • Age of injury (colour / signs of healing)
    • Contamination (extraneous materials, e.g. dirt, vegetation, etc.)
    • Edge (clean cut/ irregular/ ragged)
    • Depth (anatomical layer, e.g. skin, subcutaneous, muscle or bone deep)
    • Direction (anatomical plane e.g. forward/downward/medially/ laterally/ horizontal/vertical/etc.)
    • Pattern /Shape (imprint of objects), etc.

5. Internal Examination

(Evisceration:- Leutelle method/Virchow method/Ghon method/Rockystansky method: depending on case and doctor)

a) Examination of chest cavity:

Pleural cavity

  • Examine for the nature of the effusion
    • Color of fluids
    • Blood stained
    • Pus
    • Whitish (chylous)
  • Examine for Pneumothorax
  1. Pleural cavity
    • Examine for the nature of the effusion
      • Color of fluids
      • Blood stained
      • Pus
      • Whitish (chylous)
    • Examine for Pneumothorax
  2. Examination of the heart:
    • The pericardial cavity
      • Effusions
      • Adhesions
      • Hemopericardium
    • Examine right atrium, right ventricles and great vessels
      • Air embolism
    • The great vessels
      • Inspect for origin
      • Transect for thrombi or emboli
    • The major coronary arteries and their branches
      • Origin and its distribution
      • Occlusion
      • Calcification
      • The coronary arteries are cut at 3mm intervals transversely to look for occlusion, obstruction by thrombi and calcification
      • The aorta, pulmonary artery and coronary ostia should be examined for any abnormalities.
    • Cardiac chambers can be opened using
      • Inflow and out flow method (cut open in direction of normal blood flow)
      • Long axis method (cut apex to base)
      • Short axis (cut perpendicular to interventricular septum)
        • The ventricle should be cut at 1 cm intervals from apex to mid ventricular level and cut open in the direction of blood flow to look for
          • Symmetry
          • Ischemic/ hemorragic lesions
          • Fibrosis
          • Thrombi
          • Aneurysms
          • Hypertrophy
    • The atria should be opened into and the valves should be checked for
      • Thrombi
      • Vegetations
      • Valvular abnormalities
      • Congenital abnormalities
      • Abnormality of the valve rings, (e.g. bicuspid valves)
      • Valve rupture/ papillary muscle rupture in ischemic heart disease
    • The weight of the heart should be measured after emptying the cardiac chambers and correlated with age, sex and body weight of the individual
    • The thickness of the myocardium should be measured in the posterior wall of the left ventricle (approximately 1 cm below the mitral valve) and at the septum
    • Representative blocks from lesions in the myocardium of the posterior wall of the left ventricle and septum in cases of ischemic heart disease and cardiomyopathy.
    • Other relevant tissue based on observations
  3. Examination of the lungs:
    • Pleura
      • Adhesions (past infection)
      • Nodules
      • Plaques (asbestosis)
      • Tumour (e.g. mesothelioma)
    • Each lung should be separated across the main bronchi at the level of bifurcation of the trachea.
    • Trachea-bronchi should be longitudinally cut open up to look for
      • Collected secretions
      • Foreign bodies
      • Dilatation (bronchiectasis)
      • Inflammation (Bronchitis)
      • Mucus plugs
      • Casts and mass (tumour)
    • Lungs should be examined externally for
      • Haemorrhagic spots (in asphyxia)
      • Pleural thickening (past infection)
      • Adhesions (infection)
      • Puckering (underlying tumour)
    • Lungs should be cut in the coronal plane from hilum to the pleura, washed and examined for
      • The consistency of the cut surface
      • Areas of consolidation
      • Abscesses
      • Apical cavities
      • Fibrosis
      • Emphysema
      • Caseous necrosis, and mass (tumor)
    • Presence of enlarged hilar nodes, their consistency and the presence of caseation should be noted.
    • Each lungs should be weight after dissection.

b) Examination of the abdominal cavity:

Examine for

  • Collection of fluids
  • Collections of pus
  • Blood and clots
  • Stomach contents/Faecal matter
  • Rupture of a hollow viscus
  • Evidence of recent surgical intervention
  • Presence of mesenteric nodules, or tumour deposits
  1. Examination of Gastrointestinal system
    • The mouth, tongue and oesophagus should be examined for
      • Ulcers
      • Injuries
      • Mass/Tumours
    • The stomach
      • Separated at the cardiac and the pyloric ends.
      • Placed in a container and opened along the greater curvature.
      • The contents of the stomach should be collected, the colour, smell and presence of blood should be noted, and the contents collected and sent for further investigation if necessary.
      • The internal surface of the stomach should be examined for erosions, ulcers and mass (tumor)
  2. Examination of the intestines:
    • The entire intestine (small and large) should be cut open and the cut surface examined for injury, ulceration, strictures, toxic dilation, volvulus, gangrene and tumours.
    • The mesentery should be examined for haemorrhage, injury and tumour deposits.
  3. Examination of the Hepato-biliary System and Pancreas
    1. Liver
      • Should be separated, weighed and sliced at 1cm intervals.
      • Note the colour and consistency of the liver.
      • Examine for injury, fatty change, cirrhosis, cystic lesions and primary or metastatic tumour.
      • The gall bladder is dissected with the biliary tract up to the opening at the duodenum.
      • The patency of the biliary tract, presence of stones or tumour in the gall bladder or biliary tract is noted.
    2. The pancreas
      • Should be opened in the longitudinal axis.
      • Examine the pancreas for haemorrhage, necrosis and tumours
      • Representative samples from suspected areas including the hilar region.
  4. Examination of the Spleen 
    • The spleen
      1. Should be separated at the hilum and weighed.
      2. Should be sliced at 1 cm intervals.
      3. Examined for rupture, infarction, diffuse nodularity, and focal lesions.
  5. Examination of the kidneys, ureters and bladder
    • The kidneys, ureters and bladder can be dissected en- bloc or separately.
    • The kidneys are separated from the adrenals and each kidney weighed separately.
    • The renal artery is examined for stenosis.
    • The capsule of the kidney should be stripped and the surface examined for:
      1. Nodularity
      2. Scarring
      3. Cysts
      4. Petechial haemorrhages
      5. Abscess formation
    • The kidneys should be cut open longitudinally and examined for
      1. Calculi
      2. State of the pelvis
      3. Corticomedullary demarcation
      4. Caseation
      5. Abscess formation, or tumour
    • The ureters are opened longitudinally and examined for
      1. Patency
      2. Calculi
      3. Pus
      4. Focal lesions
      5. Tumour
    • The bladder contents should be syringed out and the bladder cut open to look for
      1. Injury
      2. Calculi
      3. Hypertrophy of the bladder wall
      4. Haemorrhage or tumour
  6. Examination of the pelvic organs
    • After the completion of abdominal evisceration, the prosector first give a diamond shaped incision over the skin enclosing the external genitalia.
    • The incision should penetrate into the deep soft tissue bounded laterally by ischio-pubic rami, anteriorly by the pubic symphysis, and posteriorly by the coccyx.
    • The internal incision is given along the pelvic inlet, enclosing the pelvic organ.
    • The rectum and adjacent soft tissues are dissected away from the sacrum and urinary bladder is dissected away from the pubis.
    • The pelvic organs including the bladder, urethra and rectum, with vagina, cervix, uterus, fallopian tubes and ovaries in the female, and the prostate and the testes in the male are dissected out.
      1. Uterus, fallopian tubes and ovaries
        • The uterus should be weighed and examined for:
          1. Evidence of pregnancy
          2. Abortion
          3. Products of conception
          4. Foreign bodies
          5. Instrumentation
          6. Rupture
          7. Haemorrhage
          8. Placental parts and tumours
        • The fallopian tubes should be examined for ectopic pregnancy or tumour
        • The ovaries should be weighed and examined for corpus luteum, cysts or tumour
        • The entire block can be subjected for histopathological analysis to rule out any pathological lesions or product of conception.
      2. Prostate and testes:
        • The prostate should be dissected out through the abdomen after making an incision at the pelvic outlet, weighed and examined for tumour
        • The testis is removed by making a small incision in the inguinal canal and pushing the testes out of the inguinal canal.

c) Examination of cranial cavity:

  • The scalp incision is made joining the mastoid processes across the vertex and the scalp reflected making note of any hemorrhage or other abnormalities. The skull is opened with a saw by a horizontal incision at the level of glabella, extending backwards at the level of pterion, up to the occiput
  • The tentorium, blood vessels and nerves at the base of the skull are cut and the brain separated from the spinal cord at the deepest level while supporting the brain with palms and fingers.
  • The tentorium is examined for haemorrhages.
  • The Circle of Willis should be carefully dissected out and opened longitudinally to examine for thrombosis, atherosclerosis and aneurysms.
  • The brain should be weighed and examined externally for areas of haemorrhage, injury, flattening of gyri and narrowing of sulci in cases of increased intracranial pressure.
  • The levels of the slices should include the anterior margin of the temporal lobe, anterior margin of the optic chiasma, mammilary bodies, midbrain at the posterior end of the substantia nigra, and occipital lobe.
  • The slices should be examined for
    1. Asymmetry
    2. Areas of haemorrhage
    3. Cystic lesionsThe slices should be examined for
    4. Cavity formation from infarction
    5. Ventricular dilatation
    6. Blood in ventricles
    7. Abscesses
  • The cerebellum is cut in the coronal plane and the nuclei examined for haemorrhages and infarction
  • The brain stem is sliced at 4mm intervals and examined for haemorrhages, infarctions and tumour.

d) Examination of the spinal cord:

  • Examination of spinal cord not routinely carried out, it is performed in special circumstances where pathology of the spinal cord is suspected.
  • Posterior approach of spinal cord examination the body is placed face down on the autopsy table.
  • A midline skin incision is made from the occiput to the buttocks.
  • The posterior vertebral muscles are separated up to the vertebral column.
  • The posterior laminae with their interconnecting ligaments are cut with a saw and the posterior wall of the spinal cord is removed.
  • The spinal cord should be carefully dissected out.
  • Better result can be obtained by examined after fixation in formalin for weeks.
  • It should be cut at 4mm slices or less and examined for the suspected pathology.

6. Ancillary investigation:

  1. For toxicological analysis
    • Peripheral blood
    • Stomach with its entire content
    • Each half of kidneys
    • At least 200gms of right lobe of liver
    • In case of advance decomposition muscles can be preserved for toxicological analysis
    • (Collect and preserve in saturated sodium chloride solution)
  2. For histological examination
    • Sample taken from solid organs (depending on requirement)
      1. Brain
      2. Heart
      3. Lungs
      4. Kidney
      5. Spleen
    • (Collect and preserve in formalin).
  3. X-ray examination should be considered-
    1.   All suspicious case of child abuse
    2. Firearm injuries
    3. Charred body
    4. Death from explosives injuries
      • All the biological samples must be collected in tightly closed jars, well preserved and sealed with labeling and transported, strictly maintaining chain of custody.

7. Release of the body;

  • The body should be hand over to the family member in a dignified manner, after medico-legal examination has been completed by the doctors.