Autopsy report-general
Author:Terrill L. Tops, M.D.
Last author update: 1 January 2013
Last staff update: 24 May 2024 (update in progress)
Copyright: 2003-2024, PathologyOutlines.com, Inc.
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Table of Contents
Definition / general | Differences from nonforensic autopsies | Undetermined cases | High profile cases | Demographics of the decedent | Circ*mstances of death | Identification | Cause of death | Manner of death | Preliminary investigation | External examination | Internal examination | Evidence of injury (examples) | Microscopic examination | Additional procedures | Standard sections (CNS) | Sample gross description (CNS) | Sample microscopic description (CNS)
Cite this page: Tops TL. Autopsy report-general. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/forensicsautopsygeneral.html. Accessed May 27th, 2024.
Definition / general
- Completing a forensic autopsy report is an art in itself
- Everything, including the decedent's demographics, circ*mstances of death, external examination, clothing / personal effects, medical intervention, radiographic imaging, evidence of injury, internal examination, microscopic examination, specific organ system pathology consultation, final autopsy diagnosis, and opinion sections should complement one another in a cohesive manner
- No two autopsy reports are the same; keep an open mind for each case
- If using a template, take care to make the appropriate changes to suit each case
- Cause of death (COD) is usually straightforward, but the manner of death (MOD) and mechanism of death tend to be more challenging
Differences from nonforensic autopsies
- Forensic autopsies emphasize identification of deceased, time of death, proper handling of evidence, recognition of injuries and pathological conditions that may be relevant to the court case
- For homicide court cases, an autopsy report is only one piece of the pie
- Law enforcement investigators, attorneys, forensic science experts (e.g., trace evidence, fingerprints) and other expert witnesses will fill in the rest
- Depending on the jurisdiction, the cover page of a forensic autopsy report includes: demographics of the decedent, circ*mstances of death, identification, cause of death and manner of death
Undetermined cases
- Having an autopsy report with an undetermined cause and undetermined manner of death (undetermined / undetermined) is very rare; only if all evidence at autopsy is inconclusive
- Frequency of undetermined cases: not more than 1% - 2% of all autopsy cases done by a forensic pathologist in one year
High profile cases
- Conduct "VIP" / high profile cases as if you would routinely perform like any other case to avoid unnecessary mistakes
- Depending on the case, high profile or difficult autopsies should be checked by another forensic pathologist for accuracy
- FP should be board certified in at least anatomic and forensic pathology for competency measures
Demographics of the decedent
- Decedent: person who died (a legal term)
- Include full name, autopsy number, social security number, age, date of birth, date of death, date of autopsy performed, place of death and date of autopsy report completed
Circ*mstances of death
- Events that occurred prior to the person's death, such as when last seen alive, prior hospitalizations, and pertinent positive / negative evidence to support COD / MOD
Identification
- Antemortem / postmortem fingerprint, dental, radiographs or DNA comparison is objective evidence and is added to evidence from pictures, driver license or other unique identifiers (e.g., tattoos or amputations)
Cause of death
- Drowning, gunshot wound to the chest, acute myocardial infarction, multidrug toxicity (overdose), undetermined, etc.
Manner of death
- Accident, homicide, natural, suicide or undetermined
Preliminary investigation
- Circ*mstances of death need to be reported by the forensic pathologist (FP) based on information provided by law enforcement personnel who are familiar with the death scene
- Depending on the case, the FP can obtain crucial information at the death scene or by a phone call to law enforcement investigators
- Asking specific questions related to the case will help provide clues to Cause / Manner of Death (COD / MOD)
- Specific questions related to the decedent's past (medical history, recent surgeries, state of mental health, drug / alcohol abuse, etc.) may reduce the need to perform a complete autopsy when only toxicology analysis is required to determine COD / MOD
External examination
- Overall: state body weight, height, age, body temperature, rigor and lividity
- Head / neck: describe hair color, facial hair, eye color, oral cavity, ear canals, nose, lips and teeth
- Torso: describe chest, abdomen, back, anus and genitalia
- Extremities: describe upper / lower limbs and fingernails / toenails
- Miscellaneous: describe tattoos, ID tags, medical / surgical intervention, etc.
- Clothing: describe any defects to support cause of death (COD)
- Body surface: state anything to suggest evidence of cause of death, such as gunshot wounds, blunt trauma, sharp force injury, illicit drug residue, anasarca, obesity, emaciation, sexual assault
Internal examination
- General:
- Organs need to be weighed
- All lesions need to be measured in 3 dimensions, if possible
- Evidence of Injury does not need to be repeated in each organ system; a statement such as "see 'evidence of injury' above" will suffice
- Natural causes of death are usually found in this section of the autopsy report: body cavities, head / CNS / neck, cardiovascular system, respiratory system, hepatobiliary system, gastrointestinal system, genitourinary system, lymphorecticular system, endocrine system, and musculoskeletal system
- Body cavities: state any abnormal pericardial, thoracic or abdominal fluid acumination
- Head / CNS / neck: look for lesions involving the scalp, calvarium, dura mater, falx cerebri, leptomeninges, cerebral hemispheres, gyri / sulci, cut sections of brain, brain stem, cranial nerves, major blood vessels, CSF, cerebellum, atlanto-occipital joint, thyroid cartilage, hyoid bone, larynx, tongue, etc.
- Cardiovascular system: epicardial surface, coronary arteries (distribution, patency versus occlusion, and wall thickness), myocardium (LV / RV / septum) thickness, valves, endocardium, aorta, renal vessels, mesenteric vessels, etc.
- Respiratory system: upper airway, mucosa, pleural surfaces, pulmonary parenchyma, vasculature, etc.
- Hepatobiliary system: hepatic capsule, liver parenchyma / vasculature, gall bladder serosa / mucosa, etc.
- Gastrointestinal system: esophagus, gastric mucosa, small bowel, colon, appendix, pancreas, etc.
- Genitourinary system: renal capsule(s), cortical surface(s), cortical / medullary parenchyma, bladder, male organs (testes, prostate), female organs (ovaries, uterus), etc.
- Lymphorecticular system: splenic capsule, splenic parenchyma, regional lymph nodes, etc.
- Endocrine system: pituitary gland, thyroid gland, adrenal glands, etc.
- Musculoskeletal system: muscle and bone structures
Evidence of injury (examples)
- This section usually contains both external and internal descriptions of injury
- Gunshot wounds (GSW): list each GSW trajectory separately, determine how many entry (penetrating) / exit (perforation) wounds, range of fire, soot / stippling, trajectory, recovery of projectile(s), state in proper order of anatomic landmarks injured by each GSW, hemorrhage, etc.
- Blunt force injuries from motor vehicle accident (MVA): trace evidence collected on body (e.g., paint chips or glass), pattern contusions / abrasions, fractures, lacerations, avulsions, hemorrhage, etc.
- Stab wounds: cuts, incisions, defense wounds, determine the knife's sharp verses blunt end in each skin wound, depth of wound, organs affected, hemorrhage, etc.
- Additional injuries: minor lesions that are attributed by the mechanism or cause of death
Microscopic examination
- Useful for documenting natural disease or gross lesions histologically (e.g., gunpowder residue)
- Describe what is seen microscopically; do not state diagnosis in this section
Additional procedures
- This section may include neuropathology or cardiovascular consultation reports, toxicology reports, autopsy attendance roster, etc.
Standard sections (CNS)
- Spinal cord (2 - 3 levels), medulla, pons, midbrain, cerebellum, hypothalamus, basal ganglia, hippocampus, thalamus, parietal cortex, occipital cortex, cingulate gyrus, superior temporal gyrus, paracentral cortex and pituitary
Sample gross description (CNS)
- The scalp and skull are entered in a standard biparietal, postauricular manner
- The dura is intact and the sagittal sinus is patent
- The prefixation brain weight is __ grams
- The formalin fixed brain weights __ grams
- The cerebral and cerebellar hemispheres are symmetrical with no masses, areas of discoloration or gross lesions identified
- There is no evidence of midline shift
- There is no uncal, subfalcine or tonsillar softening or grooving
- The sulci / gyri are unremarkable, with no atrophy identified
- The leptomeninges are thin, translucent and without hemorrhage
- The circle of Willis is intact, with no atherosclerotic plaque
- Coronal sections of the cerebral hemispheres show well delineated gray and white matter structures
- The ventricles are symmetric and not dilated
- Distal blood vessels are unremarkable
- Axial sections of the midbrain, pons and medulla are symmetrical with well delineated gray and white matter structures
- The substantia nigra and locus ceruleus are well pigmented
- The aqueduct and fourth ventricle are unremarkable
- Parasagittal sections of the cerebellum show well delineated white and gray matter structures with prominent folia
- The pituitary is removed from the sella and is grossly unremarkable
- The spinal cord is removed by an anterior approach
- Axial sections of the spinal cord are symmetric with well delineated gray and white matter
Sample microscopic description (CNS)
- The spinal cord shows...
- The midbrain, pons and medulla show mild neuronal loss and gliosis consistent with the patient's age
- The cerebellum, basal ganglia and thalamus are unremarkable
- The hippocampus shows no senile plaques or neurofibrillary tangles
- The cerebral neocortex is unremarkable
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