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6 The AUTOPSY
6.1 Standard
At the mortuary, the pathologist will:
a) ensure that the body is that for which the pathologist has authorisation to conduct an autopsy and has been properly identified as agreed with the Procurator Fiscal
b) if trace evidence was not taken at the scene, ensure that as far as practicable there is no opportunity for contamination of the body from any fixture, fitting or person at the mortuary
c) take, or supervise the taking of, any necessary trace evidence not taken at the scene
d) ensure that any manipulation of clothing once removed from the body takes place over the body wrapping, so that any evidence shed from the clothing will not be lost
e) make an examination of the body in a manner that both addresses all evidential issues that may be raised by the case and, if possible, ensures that the dignity of the deceased and ethical issues relating to the deceased and the family are accommodated
f) be able to justify all examinations having regard to the context of the case and remembering that, in a criminal investigation, there may be interested parties other than the family. One party's needs must not be accommodated to the detriment of other parties subject to the primacy of the criminal investigation
g) note any significant features of the body that reveal something out of the ordinary, whether or not they appear immediately relevant to the cause of death
h) note if relevant parts of the body have been examined and no abnormality found, because the negative finding may be equally significant
i) where there are findings of apparent significance that can be demonstrated visually, ensure that photographs are taken so that others can see them for themselves at a later date
j) retain any material relevant to the cause of death and/or that may assist in the resolution of issues (whether for inclusion or exclusion of possibilities) that foreseeably may arise during the investigation of the death, including those that can be anticipated at trial
k) ensure that all production labels necessary to ensure the chain of custody of samples removed for evidential purposes are signed at the time of the post mortem examination
l) In the light of the information provided by the SIO and Procurator Fiscal, summarise for the SIO and procurator fiscal the salient autopsy findings, their interpretation, and their significance in the context of the apparent circumstances
m) complete the medical certificate of cause of death as soon as practicable.
Pathologists must record full details of the autopsy and must document their own actions as well as the actions of others that may be significant to their examination.
6.2 Code of practice
The Scottish Government and the College recommend that all pathologists follow the Guidelines on Autopsy Practice3 published by The Royal College of Pathologists in 2002.
6.2.1 Approach to the autopsy
Having equipped themselves as far as they can with information about the likely issues to be resolved, pathologists will be ready to embark upon the actual examination. They will need to note any significant features of the body where their findings reveal something out of the ordinary, whether or not this appears immediately relevant to the cause of the death. They will also need to record carefully the fact that they have examined relevant parts of the body and found no abnormality, because a negative finding may turn out to be as significant as one that is positive.
Techniques employed during the dissection, or during any subsequent investigation, should as far as practicable be accepted and well established procedures. Pathologists must be able to defend the use of any novel or unorthodox technique both to their colleagues and to the wider criminal justice system.
Wherever possible, and particularly where it is relevant to the investigation, the forensic pathologist should have access to the medical history of the deceased before the autopsy is commenced. Where such records are not forthcoming, the pathologist will need to decide in consultation with the Procurator Fiscal whether it would be sensible for the autopsy to be postponed until the information becomes available.
6.2.2 General considerations
Autopsies should only be conducted in mortuaries that have adequate facilities and safety procedures (see below). Where mortuary facilities are deemed to be inadequate, the pathologist should consider whether the examination should be performed at that location and, if necessary, discuss the matter with the Procurator Fiscal/police. The location should have modern autopsy equipment, including accurate weighing apparatus for both organs and for the whole body. There should be access to equipment for radiological examination, and to a radiologist's opinion in due course.
The examination should not normally be conducted without the assistance of skilled mortuary technical staff. The pathologist should brief the anatomical pathology technician ( APT) on the nature of the case and their tasks. An experienced APT or similar person can assist with the dissection at the discretion of the pathologist, but must be under the control and supervision of the pathologist at all times. Technical staff may, for instance, open the head under the pathologist's supervision.
Continuity of identity from the scene of discovery should be carried out at the start of the examination and the formal identity should be confirmed to the pathologist if the identity is known. If unknown, it should be identified by reference to where and when it was found.
In suspected homicides, the Procurator Fiscal, the SIO (or an appropriately designated officer) will normally be present throughout the autopsy so that they can appreciate the autopsy findings and answer any questions that may arise about the circumstances of the case.
Appropriate SOCOs and CID should also be present. It is essential that all personnel present in the autopsy room should be subject to full precautions to protect them from infective hazards and to avoid any contamination of the body or clothing. The number of individuals in the autopsy room should be kept to a minimum.
6.2.3 Needs of relatives
The autopsy must be carried out in a manner consistent with medical ethics and respecting the dignity of the deceased. Proper consideration must be given to the needs and wishes of relatives and others who may wish to view the body. If practicable, consideration should be given to close relatives being given an opportunity to see the body before the autopsy, but only after relevant trace evidence has been taken. Before such a viewing is undertaken, there should be discussion between the pathologist, the Procurator Fiscal, the SIO and the family liaison officer ( FLO) so that the relative is fully informed, for example, of any features that might cause distress. If the viewing is to take place after the autopsy, the pathologist should consider whether any dissection, which may render viewing of the body by relatives distressing, may be postponed to a time when all such viewings have been made.
6.2.4 Involvement of other specialists
Pathologists must consider whether they have the appropriate expertise to perform an autopsy in the circumstance of that case and request the attendance of an appropriate expert if necessary. Pathologists must cooperate in an appropriate manner with such experts.
If investigation of the case requires the assistance of other specialists, for example a paediatric, cardiac or neuropathologist, it is the responsibility of the pathologist to make appropriate recommendations to the SIO and Procurator Fiscal. If that expert cannot attend, the pathologist must seek advice from the expert to determine what material might be required for later examination and interpretation, and ensure it is recorded and/or preserved in an appropriate manner.
6.2.5 Photography
It is the duty of the pathologist to ensure that adequate photographs are taken of the whole body and of all wounds or other abnormal features before commencement of dissection. Photography in the mortuary should only be carried out under the supervision of the pathologist. Pathologists may take their own photographs, both at the scene and in the mortuary, but the report must indicate that such photographs exist.
Where there are findings of apparent significance that can be demonstrated visually, these should normally be photographed so that others will be in a position to see for themselves at a later date. It will be particularly important to record the condition of the body in situations in which the examination will itself interfere with the finding and thus prevent anyone else from assessing the significance of the finding.
Copies of all photographs taken during the post mortem examination and relevant locus photographs should be provided to the pathologists as soon as possible after the examination to facilitate the preparation and timely submission of the post mortem examination report to the Procurator Fiscal.
6.2.6 Radiology
Radiological examination should be part of the examination of all cases of suspected non-accidental injury in children, in all sudden infant deaths and in all appropriate deaths involving firearms or explosives. It can also be of considerable assistance in the examination of badly burnt or decomposed bodies and may be appropriate in other instances. The pathologist will be responsible for advising on the need for such examination and the assistance of a consultant radiologist where necessary.
Fluoroscopy or comparable techniques may sometimes be helpful for screening and picking up projectiles in cases of gunshot wounds and injuries from explosives.
6.2.7 Autopsy notes
Comprehensive contemporaneous notes are essential and should be taken of every procedure undertaken. Such notes may be written or dictated. Where appropriate, notes should be accompanied by diagrams.
Notes must include the time, date and place of the autopsy. If not otherwise recorded it would be good practice to record the names of all those present at the autopsy, with an indication of the role of each one in the mortuary.
6.2.8 Removal of clothing
Any clothing on the body must be removed carefully, preferably without cutting, and placed in appropriate bags with due care to avoid contamination. This should be done after trace evidence has been removed from the accessible areas of the body, particularly the hands (unless they are bagged). Although detailed examination of the clothing is a matter for the forensic scientist, the pathologist should check it for damage such as cuts, which may influence the conclusions to be drawn from the examination of the body. Any such manipulation of the clothing should take place over the wrapping material so that any shed evidence is not lost. In some instances, tapings should be taken from the surface of the clothing before removal; this is usually done by a forensic scientist or SOCO. It is important in some instances that serial photographs should be taken as each garment is removed.
Adequate notes must be made of the procedure and the findings.
6.2.9 Collection of trace evidence from the body
The pathologist must ensure, if all samples have not been taken at the scene, that there is no opportunity for contamination of the body from any fixture, fitting or person at the mortuary. Samples should be taken after discussion with the Procurator Fiscal, the SIO and appropriate experts. Only where these discussions indicate that samples are not considered necessary should they be omitted; such discussions should be documented.
Where samples may be of value, reference should be made to the list of samples noted in paragraph 5.2.10, 'Scene of discovery of the body' .
Clearly, in some cases the autopsy is not carried out until after a period in hospital, in which case the collection of some or all specimens may be pointless.
6.3 Autopsy procedures
6.3.1 Measurements
Metric measurements should be used. Imperial measurements are still felt to be more readily understood by the court, especially in the case of larger measurements such as body height and body weight. If the imperial equivalents are not stated in the report, the pathologist must be prepared to provide them when giving evidence.
6.3.2 External examination
The description of the body should include age, sex, build, height, ethnic group, weight, nutritional state, skin colour and special characteristics such as scars, tattoos, etc. Notes should also include the length, colour and distribution of hair and beard; the presence or absence of petechiae in the face and neck and the appearance and length of the fingernails.
If not already dealt with at the scene, rigor mortis should be systematically tested for if potentially of relevance to the case.
Signs of treatment should be recorded. Medical devices should not be removed from the body before the autopsy.
6.3.3 Examination of injuries
All injuries must be described by shape, exact measurements, direction, edges and angles. The location relative to anatomical landmarks and, if appropriate, the height above the heel should be measured. In cases of multiple repetitive injury, it may be appropriate to describe groups of injury.
In the case of closed injuries, such as bruising, the colour should be noted. Local skin incision may be appropriate in the assessment of bruising.
Skin reflection may be necessary in some parts of the body, but unnecessarily mutilating dissections and destructive examinations should be avoided. Any dissection that does take place must be of such type that the body can adequately be reconstructed. All dissection carried out at autopsy must be justified in the context of the case. There should be a low threshold for the examination of subcutaneous tissues for evidence of bruising, particularly in dark-skinned individuals where bruising may not be apparent at the skin surface.
It is often important to dissect the face from the underlying facial skeleton. If the whole dissection is performed skilfully and carefully, the face can be replaced with little significant distortion.
6.3.4 Internal examination
Pathologists should adhere to the Guidelines on Autopsy Practice issued by The Royal College of Pathologists. The standard of internal autopsy dissection must be comprehensive. In addition to the forensic aspects of the examination, careful attention must be paid to any features that may be relevant to natural disease or medical intervention.
Incisions should be appropriate in relation to the nature of the case.
The state of body cavities should be described and the amount of fluid or blood in each cavity should be measured.
All organs must be dissected and accurately and adequately described with weights of major organs. Other measurements should be recorded as appropriate.
The appearance and approximate volume of the contents of the stomach and bladder should be recorded.
Examination of the generative organs must not be omitted.
6.3.5 Collection of internal specimens at autopsy
Pathologists must ensure that all necessary samples are taken for toxicology and are properly preserved. They may need to discuss with an experienced toxicologist what specimens may be required. Pathologists should also be aware of the effect on samples of any medical intervention, such as blood transfusion or the administration of drugs prior to death, on specimens taken at the autopsy. These should be discussed in the autopsy report.
Blood should be taken from a peripheral vein, preferably the external iliac or femoral, the site of collection being recorded in the pathologist's notes.
Control samples, for example for DNA examination, should be collected and retained according to the instructions given by the responsible forensic science laboratory.
In addition, pathologists must consider whether other types of microscopic or other laboratory examination will be necessary, and whether samples for these purposes should be taken at autopsy. In some circumstances, pathologists will decide that tissues or organs need to be retained for later examination. In such instances, they must make appropriate arrangements, including informing the Procurator Fiscal responsible for the body.
6.3.6 Post-mortem histology
A histological examination should be made, by the pathologists themselves, of the major organs (assuming that they are not heavily decomposed) in all suspicious deaths. Histology is of value in confirming, evaluating and sometimes revising the course of natural disease processes that may have contributed to the cause of the death. Other samples should be taken for histological examination depending on the circumstances of the case, e.g. for the purposes of ageing injuries. The reasons behind any decision not to undertake a histological examination must be adequately recorded, in order that the pathologist may be in a position to defend this decision if required.
6.3.7 Health and safety issues
The pathologist has a role in advising on health and safety in the post-mortem room. However, it is recognised that other professionals present will be expected to follow their own guidelines and the pathologist cannot be held responsible for any breaches in adherence to those guidelines by others present. The pathologist is expected to set an example in matters of health and safety.
All those involved will be expected to take very serious account of the pathologist's directions, particularly when dealing with a recognised or potential high-risk case.
Any autopsy room used for the examination should be fit for purpose and should reach accepted safety standards and hold (or at least be working towards) CPA ( UK) Ltd or equivalent accreditation. A properly trained APT should be in attendance.
The Health and Safety Executive's ( HSE) view is that any autopsy where 'infective disease cannot safely be excluded' should be treated as a high-risk case, and this will include a high proportion of suspected homicides. The pathologist should take careful account of local standard operating procedures .
6.3.8 Retention of material after autopsy
Retention of material, particularly organs, removed at autopsy may cause considerable distress to bereaved relatives, and the pathologist must consider very carefully whether such material needs to be retained and for what purpose.
The Forensic Pathologist shall make provision, so far as possible, for the preservation of material which in their opinion bears upon the cause of death for such period as the Procurator Fiscal thinks fit. Blocks and slides will be preserved unless the Procurator Fiscal consents to the destruction of such material.
It is important to allow families who have had a post-mortem examination instructed by the Procurator Fiscal the opportunity of authorising the use for purposes such as education and research of any organs or tissues retained as a result of the examination, provided these are no longer required for the Fiscal's purposes. The Human Tissue (Scotland) Act 2006 provides that tissue samples retained should become part of the deceased's medical record once the Fiscal has indicated that they are no longer required for his or her purposes, and can be used for diagnostic purposes and audit without the authorisation from the nearest relative, and for research, education and training provided those uses have been properly authorised and provided also that ethical approval is in place.
The Act also allows for the possibility that whole organs no longer needed for the Fiscal's purposes could be used for education, training or research provided proper authorisation has been given for these uses. The Act extends the hierarchy of relatives to include someone who had a long-standing professional relationship with the deceased person.
The Act also sets out the basis on which organs retained from a post-mortem examination instructed by the Fiscal can continue to be kept in existing holdings.
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