Death certification

• Who
o Registered medical practitioners
• Governing legislation
o Registration of Births and Deaths Act; Criminal Procedure Code
o Human Organ Transplant Act (HOTA); Medical (Therapy, Education and Research)
Act (MTERA)
o Interpretation (Amendment) Act
• Definition of death (Interpretation (Amendment) Act)
o Clinical death – Either/or
 Cardiac death: Irreversible cessation of circulation & respiration
 Brain death: Total & irreversible cessation of all brain function (unable to
exist as individual without support)
• Absent reflexes: gag, VOR, pupillary response, corneal reflex
• No spontaneous respiration, PCO2 > 50mmHg
• Not due to depressant drugs, hypothermia, metabolic/endocrine
factors (suspended animation)
• Special situations
o Cadaveric organ harvesting under HOTA/MTERA
 Laws
• HOTA: Opt-out. Exempted – murder/non-accidental death,
minor/mature >60, Muslim, M’sian/non-PR, mentally unsound.
• MTERA: Opt-in by self, spouse, son/child, senior/parent, sibling,
somebody else (guardian)
 Special provisions: Certification by 2 post-grad medical practitioners not on
harvesting/transplant teams, not involved in donor/recipient care
o Coroner’s case (death reportable to Coroner)
 Special provisions: Verbal consent from Coroner
• Procedure
o Issue Certificate of the Cause of Death (CCOD), which is exchanged for Certificate
of Registration of Death/burial permit
o Who: Attending medical practitioner (MO)
o When: Within 12h of death
o Procedure
 Personally examine patient
• Ascertain cardiac/brain death
• Check for marks, rule out unnatural causes
 History
• Unnatural causes
• Events leading to death
• Past medical history
o Format
 I(a) Immediate cause
(b) Antecedent cause
(c) Further antecedent cause
II Contributory causes
 E.g.
I(a) Acute myocardial infarction
II Diabetes mellitus type 2, systemic hypertension
 E.g.
I(a) Septicaemia
(b) Bronchopneumonia
(c) Bronchiectasis
o Conditions
 Circumstances consistent with natural causes
 One natural disease ordinarily sufficient to cause death
Coroner’s cases
• Types of cases investigated
o Sudden deaths; Manner of death unknown
 No medical attention/certificate
 Unknown medical causes
o Unnatural deaths
 Suicides
 Accidents (RTA, occupational/work-related, domestic)
 Iatrogenic death (following therapeutic complications)
 Death in custody/institutions
 Suspicious deaths (trauma – subdural haemorrhage, multiple injuries;
poisoning)
o Violent deaths
 Homicides
• Purpose of investigation
o Establish cause of death
o Establish culpability, support administration of justice
• Manner of investigation
o Medical personnel to leave all devices (catheters, drains) in situ for confirmation
of proper placement
o Viewing of body at CFM mortuary
o Post-mortem examination (autopsy/external examination) conducted on Coroner’s
order, medical report written
o Provide expert opinion (written/oral)
• Verdicts passed
o Death from natural causes
o Misadventure
o Suicide
o Murder by person or persons unknown
o Open
Autopsy
• Types of cases
o Coroner’s cases: Sudden – no medical attention/certificate; Unnatural – trauma,
poisoning, institutionalized; Violent
o Hospital deaths (suspected natural causes)
• Purpose: Establish cause of death, estimate time since death
• Procedure
o Consent
 Coroner’s order
 Identified (investigating officer, medical officer)
 Written consent from relatives
 Not claimed within 24h
o Preliminaries
 Examine clothing, articles
 Read clinical notes, Ix reports (haem, radio, biopsy) for clinico-pathological
correlation
o External examination
 Age, race, sex
 Nutritional, growth/development (height), hydration – dehydration/edema
 Skin changes – wounds, ulcers, scars, rashes, identifying marks (tattoos,
teeth, deformities)
 Post-mortem changes – rigor mortis, lividity, cooling, putrefaction
 Special examination
• Orifices for discharge
• Back
o Primary incision & exposure of organs
 Incision: From right, midline incision from symphysis menti to symphysis
pubis
 Peritoneal cavity – flulid
 Neck – haemorrhage/bruising (strangulation)
 Pleural cavity – test for pneumothorax, pleural fluid
 Pericardial cavity – fluid, pulmonary embolism in pulmonary artery
 Organs – inspect & palpate for gross pathology
o Removal of organs (Rokitansky method)
 Intestines – cut mesenteries/mesocolon, DJ junction, rectum; remove en
masse
 Testes – pull out of scrotum through inguinal canal
 Tissues of neck, thorax, abdomen, pelvis – free organs from attachments,
divide vessels; remove en masse
 Weigh organs
o Brain
 External incision: Coronal through scalp, reflect scalp anteriorly
 Skull – Fractures; saw horizontally/chisel open vault
 Dura – Sagittal sinus; remove dura
 Brain – cut CN and blood vessels close to base of skull; remove brain
 Spinal cord removed if indicated
o Dissection of organs
 Open & examine large arteries/veins, airways, esophagus/GIT/bile ducts,
hollow organs (bladder, female genital tract)
 Section solid organs
• Tongue, thyroid, heart, liver, pancreas, suprarenal/kidneys,
prostate, ovaries
• Brain
o Special examinations – obtain specimens for
 Histology
 Bacteriology (microscopy, culture) – smears, swabs
 Toxicology – urine
o Autopsy report
 Biodata, date/time of death
 Abstract of clinical notes
 Post-mortem notes
 External examination
 Internal examination
 Cause of death, discussion
Sudden death
• Definition
o Sudden or unexpected death
o Apparent good health/conditions not expected to die from
• Causes
o Pathological findings
 Cardiovascular*
• Coronary artery disease – atherosclerosis/thrombosis, dissection
• Myocardium – ischemia/infarction, infective myocarditis (viral,
bacterial), inflammatory myocarditis (rheumatic), cardiomyopathy
(alcoholic, dilated, congestive)
• Valves – MVP, infective endocarditis, rheumatic valvular disease,
aortic stenosis (degenerative/scarring)
• Conduction defects
• Vessels – hypertensive heart disease, ruptured aortic aneurysm
(dissecting, atherosclerotic)
 Respiratory
• Vascular - haemorrhage (lung Ca, TB, bronchiectasis), pulmonary
embolism
• Mechanical – pneumothorax
• Infection – pneumonia
• Inflammatory/autoimmune - asthma
 CNS
• Vascular – haemorrhage, ischemia (cerebral infarction)
• Infection – meningitis/encephalitis
• Functional – epilepsy
 GI
• Vascular – haemorrhage (ulcers, Ca), ischemia (volvulus)
• Infection
• Inflammatory – pancreatitis
 Reproductive system
• Vascular – haemorrhage (ruptured ectopic)
• Infection – sepsis
 Metabolic/Endocrine
• Thyrotoxicosis
• DKA/HHNK coma
o Sudden death syndromes
 Sudden unexpected infant death: Unknown cause after post-mortem +
histology/toxicology (Dx of exclusion)
• Occurs in 2–10mth males, premature
• Multifactorial – asphyxia, ventricular failure
 Sudden unexpected nocturnal death: Negative post-mortem + toxicology
• Occurs in young adult males, foreign workers, during sleep
• Multifactorial – genetic; myocarditis, conduction defects;
intraalveolar haemorrhage, Pseudomonas infection;
thiamine/potassium deficiency
 Anaphylaxis: Life-threatening allergic reaction
• Allergens: Insect bites, food, drugs
• Pathogenesis – airway edema
Ancillary investigations
• Purpose
o Negative autopsy – pathology insufficient to account for death
Gross pathology inconclusive, need histopathology (e.g. viral myocarditis)
o Exclude poisoning/OD
o Guide special forensic investigations:
 Firearms/explosive injuries
 NAI
 Iatrogenic deaths
• Types
Type of investigation Purpose
Laboratory
• Histopathology - Disease features not visible on gross
pathology
• Biochemistry/toxicology - Routine screening
- r/o poisoning
- r/o OD (subtherapeutic, therapeutic, toxic
doses), alcohol interactions
- ADR in iatrogenic deaths
- Fire deaths – inhalation
• Microbiology (Microscopy, culture, - r/o infectious causes of death
serology)
• DNA profiling (Restriction fragment - Sexual assault, homicide, hit&run accidents –
length polymorphism, PCR-based short identify perpetrators, exculpate innocent
tandem repeats) - Identify remains
- Principle: Locard’s principle of exchange
Contact b/w 2 objects causes transference
of trace material onto each other
(every contact leaves a trace)
Imaging
• Plain X-ray, CT - Pre-autopsy to guide investigations
- Firearms/explosives deaths
- NAI
Special forensic investigations
• Firearms
o Plain X-ray (2 views), MSCT - Locate projectile; retrieve
- Trajectory/pattern (shotgun – snowstorm)
- Reconstruct body regions
• NAI in children
o Pre-autopsy X-ray/radiography - Skeletal survey for fractures, metabolic
disease, congenital abnormalities
- Bone age
- Subdural haemorrhage
o Retinal examination - Retinal haemorrhages in shaken baby, HI
o Histopathology - Disease features not visible on gross
pathology
o Toxicology - r/o poisoning
Iatrogenic deaths
• Definition
o Associated with/following medical intervention – medication, procedures
(diagnostic/therapeutic)
• Medico-legal
o Reportable to Coroner
o Need post-mortem
 Cause of death
 Relationship to therapeutic intervention; Negligence
o Conclusions (Monthly mortality reviews)
 Category A: Iatrogenic injury, probable cause for concern
 Category B: Probable iatrogenic injury, possible cause for concern
 Category C: Death from natural causes, no cause for concern
o Considerations
 Reasonable standard of care: Indications, precautions, treatment of
complications
 Professional competence
 Informed consent – disclosure, autonomy
• Evaluation
o Clinically anticipated
o Direct/indirect cause
o Acceptable risk
o Errors – systemic/individual
• Types
o Procedural: Surgical Cx, anaesthetic Cx, other invasive procedures (drains, biopsy,
IR
 Procedural
• Haemorrhage (trauma, thromboprophylaxis, DIC),
thromboembolism/ischemia (AMI, PE/fat embolism/amniotic fluid
embolism, NEC)
• Infection (sepsis, pneumonia, UTI, peritonitis)
• Obstetric Cx (HI from instrumental delivery)
• Operative errors: retained instruments, wrong side, wrong patient
 Anaesthetic
• Hypoxic encephalopathy (failed intubation, airway obstruction,
regurgitation)
• Cardiac failure, (atropine, thiopentone, propofol), shock,
arrhythmia/arrest
• ADR (malignant hyperthermia from suxamethonium/halothane)
o Non-procedural
 ADR: Undesirable effects exceeding anticipated therapeutic properties
• Type A: Predictable dose-dependent
o Haemorrhage
• Type B: Idiosyncratic
o Systemic: Anaphylaxis
o CVS: Myocarditis
o HPB: Hepatitis, hepatocellular necrosis
o GU: Nephrotoxicity
o CNS: Neurotoxicity
o Skin: SJS/TEN
• Common drugs: Antibiotics (penicillin, cephalosporins,
aminoglycosides), sulfa drugs, malaria (chloroquine), TB (rifampicin,
isoniazid), psychoactive (lithium/phenytoin/carbamazepine,
haloperidol/risperidone, barbiturates, amphetamines), cytotoxics
(methotrexate, cyclosporin, bleomycin), contrast medium
• Drug interactions
 o Synergistic effects (e.g. warfarin + NSAIDs, alcohol + BZD/
amitryptiline)
o CYP inhibitors/inducers
• Administration errors
o Overdose (multiple prescriptions, inadequate instructions,
excess administration)
o Wrong MOA (e.g. iv KCl, adrenaline, theophylline; intrathecal
vincristine)
 Transfusion reactions
o Other: Radiology (diagnostic/therapeutic)
o Complex/combined
Traumatic injuries
• Purpose
o Medicolegal: Establish criminal offence, civil liability --> penalties
 Violence (assault/battery, grievous hurt, domestic, child abuse, sexual)
 Accidents (RTA, industrial)
 Unnatural (suicide, drugs)
 Police pre/post interview
o Interpret injuries
 Type
 Age (colour), mechanism (pattern)
 Severity, suffering, residual disability
 Contributory causes – natural disease, victim
o Document (written, drawing, photography, X-ray)
• Types of injuries
Injury Definition Mechanism
Superficial
• Abrasion Damage to superficial Friction, blunt force
epidermis
• Bruise/contusion Extravasation of blood into Blunt force
subcutaneous tissues
• Burn Heat injury Fire, heated objects
• Scald/wet burn Heat injury Heated liquid, chemical
Penetrating
• Laceration Full thickness penetration of Blunt force, traction
skin, irregular margins
• Incision Full thickness penetration of Cutting implement
skin, neat sharp edges, longer
than deep
• Stab wound Full thickness penetration of Implement
skin, neat sharp edges, deeper
than long
• Missile injuries e.g. Penetrating or non- Projectile
gunshot entry/exit penetrating injuries
wound
• Bite mark