Table Of ContentGuy N. Rutty
Editor
Essentials of
Autopsy Practice
Reviews, Updates,
and Advances
123
Essentials of Autopsy Practice
Guy N. Rutty
Editor
Essentials of Autopsy
Practice
Reviews, Updates, and Advances
Editor
Guy N. Rutty
Robert Kilpatrick Building
East Midlands Forensic Pathology Unit
Leicester, Leicestershire
United Kingdom
ISBN 978-3-319-46996-6 ISBN 978-3-319-46997-3 (eBook)
DOI 10.1007/978-3-319-46997-3
Library of Congress Control Number: 2017931970
© Springer International Publishing AG 2017
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Preface
When conceived the Essentials series was intended to keep all involved in the inves-
tigation of death abreast of changes not only within this field but also allied medical
and science specialities which could have a bearing upon the investigation of the
death. Some of the chapters in each edition are also selected to identify areas of
practice for which references are available from a spectrum of reference sources,
but not necessarily in a handy to access, informative, and concise monologue. In
this seventh edition in the series, I have tried to again identify subject matter and
authors from across the world and bring them together to consider a broad range of
topical subjects where changes in practice have recently occurred to assist trainees
and consultant, generalist and specialist, and the new multi-disciplinary team alike
in keeping up to date with practice within the field of death investigation. As the
area of dating of wounds has changed since the subject was addressed in a previous
edition, I have, for the first time, revisited this subject, providing an updated chapter
in this field of practice from the authors of recent research-based publications. The
remaining subjects covered in the edition again embrace the multi-disciplinary
approach required for death investigation, and address advances in the field of
forensic radiology imaging, pathology, and toxicology. I also provide a chapter
from the world of clinical medicine related to cardiopulmonary resuscitation. I have
chosen to do this as I feel that it is important for those investigating the death to be
aware of clinical processes and procedures that may occur to an individual immedi-
ately before death which may have a bearing on the subsequent autopsy findings. I
hope, as with other editions of this series, that Essentials continues to provide an
educational and practice resource for all involved in the investigation of death.
Leicestershire, UK Guy N. Rutty, MBE
v
Contents
1 The Role of Cross-Sectional Imaging in the Investigation
of Childhood Deaths ........................................ 1
J. Ciaran Hutchinson, Neil J. Sebire, and Owen J. Arthurs
2 Vertebral Artery Trauma .................................... 23
Beng B. Ong and Nathan Milne
3 Death in Crowds ........................................... 43
Guy N. Rutty, Nathaniel Cary, and William Lawler
4 New Psychoactive Substances ................................ 59
Paul R. Smith and Stephen R. Morley
5 Horse- Related Injuries and Deaths ........................... 87
Guy N. Rutty and Emma C. Cheshire
6 Cardiopulmonary Resuscitation .............................. 111
Jerry P. Nolan and Jasmeet Soar
7 The Dating of Injury; The Five Step Approach.
A Clinical Method to Enlighten Forensic Aspects ................ 157
Frank R.W. van de Goot and Judith Fronczek
Index ......................................................... 179
vii
Contributors
Owen J. Arthurs, MB, BChir, PhD, MRCPCH, FRCR University College
London Institute of Child Health and Great Ormond Street Hospital for Children,
London, UK
Nathaniel Cary, MA MD MBBS FRCPath DMJ FFFLM Unit 12, The
Quadrangle, Grove Technology Park, Wantage, Oxfordshire, UK
Emma C. Cheshire, BSc, MSC, PhD East Midlands Forensic Pathology Unit,
University of Leicester, Leicester, Leicestershire, UK
Judith Fronczek, MD, PhD Centre for Forensic Pathology (CFP)/Symbiant,
Amsterdam, The Netherlands
J. Ciaran Hutchinson, MRes, MBBS, DipFMS Department of Histopathology,
University College London Institute of Child Health and Great Ormond Street
Hospital for Children, London, UK
William Lawler, OBE, MD, FRCPath, MFFL Emeritus Home Office Pathologist,
Dyke Farm, Greenholme, Penrith, Cumbria, UK
Nathan Milne, MBBS, FRCPA, IFCAP, MFFLM, MACLM Queensland
Health, BrisbaneQLD, Australia
Steve R. Morley, MBBS MD MRCP FRCPath LLM ERT Leicester Royal
Infirmary, Leicestershire, UK
Jerry P. Nolan, MB, ChB, FRCA, FFICM, FRCP, FRCEM (Hon) School of
Clinical Sciences, University of Bristol, Consultant in Anaesthesia and Intensive
Care Medicine, Royal United Hospital, Bath, UK
Beng B. Ong, MBBS, MPath, DMJ, FRCPA, FFFLM Forensic and Scientific
Services, Queensland Health, Queensland, Australia
Guy N. Rutty, MBE MBBS MD FRCPath FFFLM FCSFS, DipRCPath(Forensic)
East Midlands Forensic Pathology Unit, University of Leicester, Leicester, Leicestershire, UK
ix
x Contributors
Neil J. Sebire, MB BS BClinSci MD FRCOG FRCPath Department of
Histopathology, University College London Institute of Child Health and Great
Ormond Street Hospital for Children, London, UK
Paul R. Smith, PhD, FRCPath Leicester Royal Infirmary, Leicestershire, UK
Jasmeet Soar, MA, MB, BChir, FRCA, FFICM, FRCP Anaesthesia and Intensive
Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
Frank R.W. van de Goot, MD, PhD Centre for Forensic Pathology (CFP)/
Symbiant, Amsterdam, The Netherlands
Chapter 1
The Role of Cross-Sectional Imaging
in the Investigation of Childhood Deaths
J. Ciaran Hutchinson, Neil J. Sebire, and Owen J. Arthurs
Introduction
As autopsy practices continue to evolve, new imaging techniques are introduced.
Imaging has long played a part in the investigation of suspicious childhood deaths,
largely because of the nature of occult fractures being only identifiable through
skeletal survey radiographs. Cross-sectional imaging is now more readily available
in most institutions, including post mortem multi-detector computed tomography
(PMCT) and magnetic resonance imaging (PMMR). Whilst the majority of the
evidence- base for their use is likely to come from a non-forensic setting, the added
value of PMCT and PMMR to forensic investigations will become clear over time.
This chapter is divided into four sections:
1. Paediatric autopsy practice, the nature of childhood deaths and why post mortem
imaging is increasingly appealing
2. Imaging modalities and their advantages and disadvantages
3. Use of cross-sectional imaging in specific circumstances (trauma, non- accidental
injury, hanging, etc.)
4. Additional benefits of cross-sectional imaging (post mortem interval,
modeling)
J.C. Hutchinson • N.J. Sebire
Department of Histopathology, UCL Institute of Child Health and Great Ormond Street
Hospital for Children, London, UK
UCL Institute of Child Health, London, UK
O.J. Arthurs (*)
UCL Institute of Child Health, London, UK
Paediatric Radiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
e-mail: [email protected]
© Springer International Publishing AG 2017 1
G.N. Rutty (ed.), Essentials of Autopsy Practice,
DOI 10.1007/978-3-319-46997-3_1
2 J.C. Hutchinson et al.
Paediatric Autopsy Practice
The death of a child needs to be handled with due care, attention and sensitivity for all
parties concerned. Many childhood deaths are unexpected, and require investigation in
order to correctly identify the circumstances leading to the death. The current gold stan-
dard medical investigation is the full paediatric autopsy, which under the direction of a
pathologist incorporates the clinical history of the deceased, detailed external examina-
tion, photography, skeletal radiographs, placental analysis (where appropriate), microbi-
ology and other ancillary investigations as appropriate. The ultimate role of autopsy is to
determine the underlying cause and mechanisms of death, or in the case of stillbirths and
fetal demise, to provide a unifying diagnosis which may have significance for the man-
agement of future pregnancies or implications for other family members.
The perinatal pathology skillset requires specialist and detailed knowledge of the
pathology and patterns of diseases specific to childhood, an understanding of fetal and
infant development, and familiarity with a wide range of genetic syndromes, prenatal
diagnostic techniques and placental pathology. The pathologist needs to be able to
perform autopsies across a range of clinical scenarios including early fetal loss, spon-
taneous abortion, termination of pregnancy for fetal abnormality, stillbirth, intrapar-
tum death, sudden unexpected death in infancy, and other settings such as specific
cardiac, hepatic or metabolic disease. This includes an awareness of the appropriate
imaging investigations available, an understanding of the newer radiological tech-
niques such as PMMR, the ability to request radiology appropriate to the case and to
appreciate the importance of obtaining expert radiological opinion (e.g. RCPath cur-
riculum) [1]. The following chapter will focus on the recent advances made that would
encourage the use of CT and MRI in future paediatric autopsies.
Whilst the numbers of fetal, stillborn and infant deaths in any country are rela-
tively small in comparison to overall adult deaths (around 1–2 % of total UK deaths
are stillbirths, infants and children), this group still represent a significant clinical
issue. This is largely because of the large impact that this small group has on paren-
tal bereavement, genetic counselling, and planning of future pregnancies. The peri-
natal and paediatric autopsy has two additional external pressures relative to those
in adults. The first is that the majority of perinatal autopsies are “consented”, i.e.
parents consent to the autopsy rather than being directed by a coroner or medicole-
gal investigation. The second is the reluctance of parents to accept the invasiveness
of the traditional autopsy process. Perinatal autopsy is perhaps unique in the medi-
cal world in therefore being primarily driven to meet expectations first and fore-
most, with medical or clinical outcomes as a secondary issue.
Childhood Deaths
Since 1 April 2008, Local Safeguarding Children Boards in the UK have had a
statutory duty to review deaths of all children from birth (excluding still born babies)
up to 18 years old, who are normally resident within their area (Child Death Review
