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A wide variety of research studies suggest that breakdowns in the diagnostic process result in a staggering toll of harm and patient deaths. These include autopsy studies, case reviews, surveys of patient and physicians, voluntary reporting systems, using standardised patients, second reviews, diagnostic testing audits and closed claims reviews. Although these different approaches provide important information and unique insights regarding diagnostic errors, each has limitations and none is well suited to establishing the incidence of diagnostic error in actual practice, or the aggregate rate of error and harm. We argue that being able to measure the incidence of diagnostic error is essential to enable research studies on diagnostic error, and to initiate quality improvement projects aimed at reducing the risk of error and harm. Three approaches appear most promising in this regard: (1) using ‘trigger tools’ to identify from electronic health records cases at high risk for diagnostic error; (2) using standardised patients (secret shoppers) to study the rate of error in practice; (3) encouraging both patients and physicians to voluntarily report errors they encounter, and facilitating this process.

PurposeThe aim of this study was to assess whether there is a discrepancy between clinical and autopsy-based diagnoses in adult intensive care unit (ICU) patients.MethodsWe conducted a systematic review of cohort studies reporting on conventional autopsy-confirmed missed diagnoses. The discrepancy rate was per study calculated by dividing the number of patients with a missed diagnosis by the number of autopsies. Missed diagnoses were classified according to the Goldman classification as ‘major’ and ‘minor’ with major missed diagnoses further differentiated into Class I missed diagnoses (i.e., diagnoses that may have altered therapy or survival) and Class II missed diagnoses (i.e., diagnoses that would not have altered therapy or survival). Class I missed diagnoses constitute the primary outcome of interest. Pooled estimates for discrepancy rates (95% confidence intervals) were calculated using a mixed-effects logistic regression model with ‘study’ as random effect. Meta-regression was used to assess relationships between major discrepancy rates and autopsy rates, start year of study, and ICU type.ResultsForty-two studies were identified totaling 6305 analyzed autopsies and 1759 patients with missed diagnoses. The pooled discrepancy rates for Class I and major missed diagnoses were 6.5% (5–8.5) and 19.3% (15.3–24), respectively. Meta-regression analysis revealed that autopsy rate was inversely associated with discrepancy rate. Class I discrepancy rates did not change over time. Burn and trauma ICUs had lower discrepancy rates as compared to medical ICUs, possibly because of higher autopsy rates.ConclusionsMissed diagnoses remain common in ICUs. A higher autopsy rate does not reveal more major diagnostic errors. These data support a clinically driven autopsy policy rather than a systematic autopsy policy.

Background Suicide deaths are significantly under-reported in Pakistan due, in part, to the absence of a national registry of suicide and stigma resulting from its illegal status until recently. Past studies of suicide by forensic autopsy have focused on larger cities. We aimed to identify the pattern of suicidal deaths in five rural districts in Punjab Province of Pakistan. Methods The data included all autopsies performed for suspected suicide in five districts of Punjab province (Bhakkar, Okara, Nankana Sahib, Khanewal and Khushab) over five years between January 2018 and December 2022, identified through collaboration with the Surgeon Medicolegal Punjab Office and district medico-legal officers. Demographic information and post-mortem toxicological findings were collected through a pre-designed proforma based on previous research. Results A total of 205 autopsies due to suspected suicides were identified. Most were aged under 30 years (133/205, 64.9%) and the male-to-female ratio was observed as 1.1:1. The most common methods overall were ingestion of poisonous substances (80/205, 39%; 18.5% of men and 61.9% of women) and hanging (75/205, 36.6%; 46.3% of men and 25.8% of women). Kala-pathar (paraphenylenediamine hair dye) was the most common ingested poison (41/80, 51.3%) followed by aluminium phosphide (formulated as 56% of 3 g fumigant wheat pills). Domestic conflict was the most common motive identified. Conclusions This retrospective review of suicide autopsy cases in five districts of the Pakistan Punjab showed that poisoning was the most common means of suicide, particularly with paraphenylenediamine hair dye. There is need for systematic collection of such data from all districts across Pakistan, which can lead to the development of a national suicide registry. This will allow official reporting of suicide deaths on a national level to help guide development and monitoring of an effective suicide prevention strategy.

Background Neuroinflammation often develops in sepsis along with increasing permeability of the blood-brain barrier (BBB), which leads to septic encephalopathy. The barrier is formed by tight junction structures between the cerebral endothelial cells. We investigated the expression of tight junction proteins related to endothelial permeability in brain autopsy specimens in critically ill patients deceased with sepsis and analyzed the relationship of BBB damage with measures of systemic inflammation and systemic organ dysfunction. Methods The case series included all (385) adult patients deceased due to sepsis in the years 2007–2015 with available brain specimens taken at autopsy. Specimens were categorized according to anatomical location (cerebrum, cerebellum). The immunohistochemical stainings were performed for occludin, ZO-1, and claudin. Patients were categorized as having BBB damage if there was no expression of occludin in the endothelium of cerebral microvessels. Results Brain tissue samples were available in 47 autopsies, of which 38% (18/47) had no expression of occludin in the endothelium of cerebral microvessels, 34% (16/47) developed multiple organ failure before death, and 74.5% (35/47) had septic shock. The deceased with BBB damage had higher maximum SOFA scores (16 vs. 14, p  = 0.04) and more often had procalcitonin levels above 10 μg/L (56% vs. 28%, p  = 0.045) during their ICU stay. BBB damage in the cerebellum was more common in cases with C-reactive protein (CRP) above 100 mg/L as compared with CRP less than 100 (69% vs. 25%, p  = 0.025). Conclusions In fatal sepsis, damaged BBB defined as a loss of cerebral endothelial expression of occludin is related with severe organ dysfunction and systemic inflammation.

IntroductionThe Irish Office of the State Pathologist (OSP) provides a forensic pathology service for cases of criminal, suspicious or unusual deaths as referred by the coroner. This study aims to review the paediatric and perinatal deaths referred to the OSP and compare them to existing standards and data.MethodsA retrospective cohort study was conducted on all paediatric and perinatal cases (<18 years) referred to the OSP from 2018 to 2022. Postmortem examination (PME) reports were reviewed in line with the Royal College of Pathologists guidance. Case data results were then analysed independently and alongside previously published data for 2012–2017.Results65 cases were identified. Confirmed homicide accounted for the highest proportion of referred cases at 31% (n=20). Sudden infant death syndrome (SIDS) was the key cause under 1 years old (n=10/13). 91% of postmortem reports (2018–2022) met reporting standards. Paediatric and perinatal referrals remained consistent when comparing 2012–2017 to 2018–2022. Areas of inconsistency were in the area of SIDS and the inclusion of anthropometric reference values. PMEs involving forensic pathologists (FPs) and paediatric/perinatal pathologists (PPs) produced variations in reporting.ConclusionHomicide was the leading cause of referred cases at 31% over 2018–2022 and 29% between 2012-2022. While the OSP provides a high standard service, key areas of improvement include the reporting of SIDS, the anthropometric reference values and the integration of PP and FP reports. Analysis of child mortality data and statistics in Ireland would be improved with the implementation of a single reporting database.

In sudden cardiac death, an autopsy is an essential step in establishing a diagnosis of inherited cardiac disease and identifying families that require cardiac screening. To evaluate aspects of post-mortem practice in Europe, a questionnaire was designed and circulated to both clinical and forensic pathologists. There was a 48% response rate and information was obtained from 17 countries. The results showed a wide variety in the management of sudden cardiac death, with a general tendency towards a lack of thorough investigation. In up to 40% of cases, autopsies were not performed in subjects less than 50 years who may have died from cardiac disease. Reasons for this were lack of finance and lack of interest from police, legal authorities, and doctors. Only 50% of pathologists seem to follow a standard protocol for autopsy examination, apparently due to lack of expertise and/or training. When autopsies were performed, histology and toxicology were almost always taken, genetic studies were generally available and retention of the heart for specialist study was usually permitted. Our results suggest that although the standard of practice is appropriate in many centres, many more cases should have autopsies, especially in sudden deaths in subjects less than 50 years.

Mortality statistics are critical to determine the burden of disease. Certain causes of death are prone to being misclassified on cause of death certificates. This poses a serious risk for public health and safety, as accurate death certificates form the basis for mortality statistics, which in turn are crucial for research, funding allocation and health interventions. This study uses generalised estimating equations and regression modelling to investigate for which cause of death categories suicide and accident deaths are misclassified as. National mortality statistics and autopsy rates from North America and Europe covering the past forty years were analysed to determine the associations between the different causes of death in cross-sectional and longitudinal models. We find that suicides and deaths by accidents are frequently mutually misclassified. We also find that suicides are frequently misclassified as drug use disorder deaths, in contrast to accident deaths, which are not misclassified as drug use disorder deaths. Furthermore, suicides do not seem to be misclassified as undetermined deaths or ill-defined deaths. The frequency of misclassification shows that the quality of death certificates should be improved, and autopsies may be used systematically to control the quality of death certificates.

Proficient consultation practices between a general forensic pathologist and a neuropathology specialist may prove valuable in medico-legal cause-of-death investigation. Detailed data on the current use of neuropathology consultations in medico-legal autopsies are scarce. The aim of this retrospective register-based study was to provide a breakdown of medico-legal autopsy cases associated with a neuropathology consultation in Southern Finland over the period 2016—2022. An electronic information system of the Forensic Medicine Unit, Finnish Institute for Health and Welfare, was queried for cases that underwent a medico-legal autopsy at the Helsinki office and had a neuropathological examination performed by a consultant neuropathologist. Numerous detailed characteristics of the cases were collected, and the overall significance of neuropathology consultation for the cases was assessed. The statistical approach was descriptive. A total of 216 medico-legal autopsies with a neuropathology consultation were performed over the study period. Most cases involved a full neuropathological examination (97.7 %) of a male decendent (68.5 %; age at death 0—96 years). Traumatic brain injury was the most frequent consultation theme (45.4 %), followed by epilepsy (18.1 %), hypoxia-ischaemia (14.8 %), and neurodegeneration (14.8 %). Two most often reported findings were hypoxic-ischaemic injury (76.4 %; often mild and terminal) and cerebral oedema (36.6 %). In the majority of cases, the consultation was likely to guide the selection of the underlying cause of death (64.8 %), and in a third of cases also the manner of death (32.4 %). In addition, most consultations provided the forensic pathologist with other information that was considered significant for the case (67.6 %). In conclusion, medico-legal cause-of-death investigations have clearly benefited from the neuropathology consultation practice in Southern Finland over the recent years. Descriptive and comparative analyses of neuropathology practices in other medico-legal institutions are warranted. •We studied 216 medico-legal autopsies with a neuropathology consultation from Southern Finland.•The two most common neuropathology consultation themes were traumatic brain injury and epilepsy.•The consultation was likely to guide the selection of the underlying cause of death in most cases.•Most consultations provided the forensic pathologist also with other significant information.

We conducted a retrospective national mortuary based study to identify all adult female homicides (18 years and older) and all child homicides (boys and girls < 18 years) in 2009 in a randomly selected, proportionate sample of mortuaries. Victim, perpetrator and crime data were collected in three processes: from the mortuary register, the autopsy report and from police with the identification of sexual homicides validated across the data collection processes. Among the 2670 (95% CI: 2311-2979) adult women killed in 2009, 494 (95% CI: 406-574) were identified as sexual homicides which was 19.8% (95% CI: 17.6-22.0) of all adult female homicides and among 1277 (95% CI: 1091-1462) children killed in SA, sexual homicides were found in 104 (95% CI: 77-132) of the child homicides which was 8.7% (95% CI: 10.9-11.2%) of these murders. Strangulation was the most common cause of death for both children and adult females. A distinct age and sex pattern was found among children with only 1% boy child death identified as a sexual homicide and 92% of all the child sexual homicides were among girls. Strangulation was the most common manner of death among children (35.5%) and perpetrators were seldom strangers. However, no difference in the proportion of convictions between the sexual homicides and non-sexual homicides were found for both adult females and children. Rape homicide is not a rare event in South Africa, with one in five female homicides and nearly one in ten child homicides identified with an associated sexual crime. These high prevalences are amongst the highest levels reported in the literature with our study among the few reporting on the epidemiology of child sexual homicide. Reducing mortality is an important policy goal for South Africa and for the rest of the world and the prevention of female and child homicide is an important part of attaining this goal.

Background According to the World Health Organization (WHO), there were 1.19 million road traffic accident (RTA)-related deaths in 2021, with a significantly higher death rate in developing countries than in developed countries. Objective To assess the distribution of causes of death and associated organ injuries in RTA-related fatalities. Methods This retrospective cross-sectional study was conducted at the Department of Forensic Medicine and Toxicology of Saint Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia. This study included 207 autopsies of RTA-related deaths. Results Among the 198 victims, 70.7 percent were males and 29.3 percent were females, with a mean age of 36.65 (years). The leading causes of death were craniocerebral injury (36.9%) and polytrauma (14.6%). The majority (49%) died in the prehospital setting, 37.9% at the hospital, and 5.6% at home. Pedestrians were the most affected (71%), followed by passengers (16%). Urban areas had a higher incidence of accidents (58.1%). All victims had soft tissue injuries, with 75.3% sustaining head injuries, 58.6% sustaining musculoskeletal injuries, and 51% sustaining thoracic injuries. Conclusion Addressing RTA-related deaths requires a multifaceted approach involving various stakeholders. Building a prehospital emergency service, providing first aid training, and continuous professional development training to health professionals are also important.