Complications in determining cause of death

As discussed in the previous lesson by Dr Cordner, cause of death is a subjective interpretation of a set of circumstances. This article further explains the complications in determination of cause of death and how it can vary among pathologists.

Determination of the cause of death is a retrospective assessment and cannot be tested. There are a number of cases where cause of death is difficult to determine and the interpretation of the medical history and the circumstances of death would vary amongst pathologists. A few examples of situations where difference of opinion regarding cause of death may arise are as follows:

Where the injury or disease is not sufficient in itself to cause death but death has occurred

In such situations, there may be a substantial delay between the injury and death. Consequently, it is difficult for a forensic pathologist to arrive at a conclusion regarding the cause of death and hence they should provide their conclusions along with the limitations of their findings.

For example, a case where an individual suffered from a stab wound to the abdomen. The victim gets medical attention and undergoes surgery. A year after his successful surgery, he begins developing bouts of abdominal pain every few weeks, which gets worse. While on his way to the hospital he starts vomiting profusely, becomes unconscious and dies by the time he reaches the hospital. Autopsy discovers that a large loop of bowel has become twisted around some scars that have formed because of the stab wound and following the surgery. This caused the bowel to die due to lack of blood supply, leading to bowel contents leaking into the surrounding cavity. There is no question that his death is related to the stab wound and most forensic pathologists would include the stab wound in the cause of death. But what if the same thing happened 10, 20 or 30 years later? Would it make a difference to the cause of death? Leave your thoughts in the comments below.

Where non fatal injury precipitates death in a relatively short time from natural causes

For example, a bar fight between two men, one of whom is about 50 years old. During the fight, the 50 year old man collapses and no one is able to resuscitate him due to which he dies on the spot. During the autopsy, only abrasions on the face are observed. Internal examination reveals that this man had an enlarged heart, high blood pressure and narrow coronary arteries (coronary atherosclerosis). The deceased was unaware of his medical condition and that stress and strain from a bar fight could lead to his heart malfunctioning. Forensic pathologists could write the cause of death differently in such a case. One may simply write it as ‘coronary atherosclerosis’ and the other may write it as ‘coronary atherosclerosis in a man involved in a fight’.

Where the cause of death is completely dependent upon interpretation of the circumstances

In such cases forensic pathologists might give the cause as ‘undetermined’, especially when medical records might not be available. For example, deaths involving infants where there is absolutely no significant disease or any injury found even after careful post mortem examination. Can the death of this infant said to be a result of sudden infant death syndrome? (i.e. the unexpected death of an infant <12 months of age while sleeping, where post mortem investigation does not reveal a cause of death) Could the baby have been caught up in bedding? Was the baby accidentally smothered while sleeping with one or both parents? Was the baby deliberately smothered? Could the baby have died of a genetically determined heart arrhythmia? The autopsy cannot tell the difference between any of these, although deliberate smothering may leave signs.