INVITED REVIEW

What is a Complete Autopsy?

Evan W. Matshes MD FRCPC, Christopher M. Milroy MD FRCPC, Jacqueline L. Parai MD
FRCPC, Barbara Sampson MD PhD, R. Ross Reichard MD, and Emma O. Lew MD

ABSTRACT: Postmortem examinations have taken place over the past several thousand
years. Despite this, the definition of a “complete” autopsy remains nebulus and the subject of
controversy. Although ‘minimal autopsy practice standards’ have been published by profes-
sional bodies globally, recognition of, and adherence to those standards remains sporadic.
An underlying refutation that ‘autopsies can never be complete’ – the reductio ad absurdum
fallacy – has influenced many forensic pathologists’ opinions about autopsy. More pragmatic
pathologists attempt to balance the financial and workload burdens of autopsies with the
principles of adequacy and accuracy. Some medical examiners cite “statutory duty” as the
force guiding the nature and completeness of their work, and as such, external examinations,
Evan Matshes, MD FRCPC is
Assistant Chief Medical Examiner partial autopsies and other limited variants are substituted for complete autopsies. Although
for the Province of Alberta it is impossible to perform every conceivable test in any one autopsy, an evidence-based
(Calgary, Canada). approach guided by three forensic autopsy goals – statutory duty, the creation of a minimal
Author affiliations: Eastern Ontario
Forensic Pathology Unit, Ottawa, dataset for societal and governmental inquiry, and maintenance of practitioner competency –
ON (CM, JP), New York City Office ensure the completeness of any one postmortem examination.
of the Chief Medical Examiner (BS),
Office of the Medical Investigator KEYWORDS: Forensic pathology, Autopsy, Postmortem examination, Death certification, Death investigation
and Department of Pathology,
Albuquerque NM (RR), Miami-
Dade County Medical Examiner
Department, Miami, FL (EL).
Contact Dr. Matshes at: “Our statutory duty is to determine “the cause taken place for millennia, a tribute to the human
matshes@academicfp.com. of death”...I submit that statutory duty is not thirst for knowledge and truth. Despite the appar-
Acad Forensic Pathol enough! Our expected role goes beyond the ent ‘maturity’ of the procedure, the term “com-
2011 1 (1): 2-7 “what” and extends into the “why”. Should plete autopsy” as it is used in forensic pathology
https://doi.org/10.23907/2011.001
we help explain “why” we are truly serving the parlance remains controversial and seemingly
© 2017 community that pays for our service. It is not impossible to consistently define. Numerous
Academic Forensic Pathology International
enough to say “drowning” and ignore why it influences have lead to this reality including geo-
occurred or to opine “blunt head injury” and graphic differences in legislation, the varying
not question why the automobile driver lost prevalence of coroner (versus medical examiner)
control” (1). systems, and the effects of training and exposure
to different death investigation ‘cultures’. One
critical philosophical underpinning of medico-
-- Joseph H. Davis MD legal autopsies is their unique nature – they are
a medical procedure performed without family
consent, and sometimes against families’ wishes.
INTRODUCTION Although it is unlikely that any forensic patholo-
gist would argue against the significance of this
As a profession plagued by high workloads, a reality, how this is interpreted (and therefore put
paucity of trained and qualified practitioners, into daily practice) can be quite variable. For ex-
and limited resources, forensic pathology is fre- ample, some forensic pathologists feel that they
quently characterized by its ‘flexible’ standards should abort an autopsy when “a” cause of death
and unpredictable quality for services such as has been found, as the legal obligations of their
Page 2 • Volume 1 Issue 1

the autopsy. Postmortem examinations have autopsy have been met. In such a scenario they
consider it unethical to be further invasive with
the body than is necessary. Other forensic pathol-
ogists feel that if an autopsy is to be performed Statutory Duty
under the law, then their duty is to ensure that the
autopsy is thorough and accurate, and that “the”

Goals of a
cause of death is determined. Common ground
between these two opposing philosophies can be Creation of a
Complete

WHAT IS A COMPLETE AUTOPSY?

difficult to find. An interesting brief discourse
on the subject is located in the UK report of the Minimal
Shipman Inquiry (2).
Autopsy Dataset
At the center of the controversy is a very real and
complex concern: how does any system of death Maintenance of
investigation balance the reality of suboptimal
funding and limited staffing with the concept of
Competency
adequacy? Following closely then is the neces-
sity to define adequacy – a definition that may be
plastic depending on whether the discussion per- Figure 1: All forensic pathologists are charged with the
tains to adequacy within one’s office, within the same three basic duties – statutory duty (accurate determi-
profession, from the perspective of defense con- nation of cause [and often manner] of death), the creation of
sultants, etc. Statutory duty is frequently cited as a minimal dataset with societal and governmental value, and
the force guiding a medical examiner’s assess- the maintenance of personal competency through exposure
ment of autopsy need, and furthermore, the de- to a broad variety of autopsy material.
gree of thoroughness to be achieved at autopsy.
We would like to illustrate that the completeness tional circumstances (4). Although NAME’s Fo-
of an autopsy cannot be considered solely from rensic Autopsy Performance Standards detail the
the perspective of statutory duty, but rather from minimal standards for evaluation of all external
a more well-rounded approach that also includes surfaces of the body and all internal organs, they
the necessity to produce a dataset of value for do not expressly forbid partial autopsies. How-
societal and governmental inquiry, and the duty ever, it should be pointed out that in specific
to maintain professional competency through reference to limited examinations, the NAME
exposure to a broad variety of autopsy material Standards Committee states that it “recognizes
(Figure 1). that some circumstances may justify a “limited”
internal examination, in which case the rationale
PRACTICE RECOMMENDATIONS FROM for such shall be documented”.
PROFESSIONAL ORGANIZATIONS
AUTOPSY COMPLETENESS AND THE DUTIES OF
Major professional bodies in North America and
A MEDICAL EXAMINER
the United Kingdom have published practice
guidelines for autopsy and forensic patholo-
gists. The three groups referenced in this work “The performance of a competent autopsy is
(the National Association of Medical Examiners mandatory whenever a death, whether resultant
[NAME], The Canadian Association of Patholo- from injury, disease, or a combination of both,
gists Forensic Pathology Section, and the Royal contains some element of actual or potential
College of Pathologists) all agree, at a minimum, forensic dispute…The key word in the forgo-
that best practice is to perform a thorough ex- ing thesis is competent, i.e., complete, profes-
ternal examination, followed by both an in situ sionally performed, and accurately observed. A
evaluation, and removal and dissection of the sloppily done, incomplete autopsy is worse than
brain (along with its coverings), and the thora- none because it leads all too frequently to er-
coabdominal and pelvic viscera (3-5). See Table roneous conclusions. Such conclusions, based
1 for additional information. Nowhere in the rec- as they are on the presumably reliable and ra-
ommendations of these international bodies is a tional fact-finding procedure of the postmortem
partial autopsy promulgated to be part of a high examination, are notoriously difficult to over-
quality death investigation. The Royal College of come or eradicate. The tragic consequence of a
Pathologists asserts that all medicolegal autop- poorly performed, partial or superficial autopsy
sies are to be “high quality examinations”, and is an unjust or unrealistic verdict, a flaw in what
should be as “full [an] examination as possible” should be the seamless garment of Justice” (6).
(3). The Canadian Association of Pathologists
Forensic Pathology Section states that “partial -- Lester Adelson MD
autopsies…should only be performed in excep-
Matshes et al. • Page 3
 Table 1: Comparison of opinions on autopsy ‘completeness’ – a review of published practice standards
from North America and the United Kingdom (3-5).
INVITED REVIEW

Professional Body Statement about autopsy ‘completeness’

National Association of Medical Examiners (NAME) “Because some findings are only ascertained by in situ in-
spection, the scalp and cranial contents must be examined
before and after the removal of the brain so as to identify
signs of disease, injury, and therapy… The muscles, soft
tissues, airways, and vascular structures of the anterior
neck must be examined to identify signs of disease, injury,
and therapy… Because some findings are only ascertained
by in situ inspection, the thoracic and abdominal cavities
must be examined before and after the removal of organs
so as to identify signs of disease, injury, and therapy…
The major internal organs and viscera must be examined
after their removal from the body so as to identify signs of
disease, injury, and therapy.”

“The [NAME Standards] Committee recognizes that

some circumstances may justify a “limited” internal
examination, in which case the rationale for such shall be
documented.”

Canadian Association of Pathologists “All medicolegal autopsies should include removal, ex situ
dissection and examination of the brain and the thoracoab-
dominal organs. The neck organs including the hyoid bone
and tongue and the pelvic organs should also be dissected
and examined. The major organs and tissues should be ex-
amined using standard dissection methods, but the precise
technique is left to the discretion of the pathologist. All
major organs should be weighed and macroscopic lesions
should be described… Partial autopsies (postmortem
examination with limited or focused internal examination)
should only be performed in exceptional circumstances.”

Royal College of Pathologists (United Kingdom) “…the College stands firmly for as full examination as
possible within the agreed consent and Coronial authoriza-
tion. Where an autopsy is considered necessary after prop-
er investigation of the circumstances of death, that autopsy
should be a high quality examination, which addresses all
the questions that may be raised by the death.... [and the]
brain should be examined in all post-mortems authorized
by a Coroner…”

In his time-honored paper “Classical Mistakes in autopsies. An alternative view is that forensic au-
Forensic Pathology” (7), Moritz lists a series of topsies are problem-oriented and guided by the
errors encountered with frequency in death in- needs of the case as dictated by findings from
vestigation. Amongst them, “the mistake of not the scene, history and along the course of the
being aware of the objective of the medicolegal autopsy. A more structured and scientific answer
autopsy”, and the “mistake of performing an in- is that in forensic pathology, any one autopsy is
complete autopsy” rank first and second. Moritz complete when the three obligate duties of an au-
goes so far as to say that “a partial autopsy is al- topsy have been met: statutory duty, creation of a
ways a mistake in a medicolegal case”. However, minimal dataset, and maintenance of practitioner
in practice, uniform agreement does not exist to competency.
differentiate a complete autopsy from a partial
autopsy. For example, is an autopsy incomplete STATUTORY DUTY
if the conduction system is not examined? Is it
incomplete if the face is not dissected? Is it in- All forensic pathologists are charged with the
complete if materials are not obtained for molec- duty to offer a medical opinion about the cause
ular studies? At the root of these questions is the of death, and the circumstances under which the
title of this paper, what is a complete autopsy? decedent met their demise. A forensic pathologist
The broad stroke answer to this question is sur- functioning as medical examiner has the further
prisingly simple – a complete autopsy has taken duty to certify the death in law, making official
place when every conceivable test has been per- (and often public) record of their determinations.
formed on any one body. This academic answer Intrinsic to the concept of a forensic pathologist’s
is of limited value as no practitioner will ever be statutory duty is accuracy. As such, the statutory
able to perform every conceivable test on any duty of forensic pathologists is to accurately de-
one case. From a certain perspective then, some termine the cause of death. Ideally, careful and
might argue that all forensic autopsies are partial thorough documentation permits diagnostic ac-
Page 4 • Volume 1 Issue 1
curacy between two (or more) pathologists re- ancillary studies – histology and toxicology.
viewing the same case (see the Independently
Reviewable Autopsy Report below) – equally as Ultimately, statutory duty can only be met with
important, though, is the opportunity to form fair careful consideration of all information available
contradictory opinion(s) when properly docu- to the pathologist, and with careful selection of
mented evidence permits such an action. In this appropriate tests. To promote accuracy, a foren-
way, errors introduced into the primary assess- sic pathologist electing autopsy of a given body

WHAT IS A COMPLETE AUTOPSY?

ment of the case can be corrected. should be thorough and carefully document all
pertinent positives and negatives. Statutory duty
Intrinsic to the concept of accuracy in effectuat- can be effectuated in some cases by external ex-
ing statutory duty are the principles of thorough- amination only (so-called sign-outs, view-outs
ness and competency. Consider the example of a or externals). Consider the case of an 80-year-
previously healthy 14-month-old boy found dead old man who is found dead on the sofa, with a
in the care of his maternal uncle after the uncle Nitrospray container in his hand, and a past his-
called 911 simply asking for a hearse. External tory of coronary artery bypass grafting for severe
examination of his body revealed only petechiae coronary artery disease. Consideration of the
of the bulbar and palpebral conjunctivae, and the circumstances of death and past medical history,
periocular skin. Autopsy including the brain and together with an unremarkable external exami-
thoracoabdominal organs did not reveal injuries nation should obviate legally mandated autopsy.
or significant natural disease. Layered anterior Accuracy is addressed in such cases by careful
and posterior neck dissections demonstrated only documentation of all information made available
faint ecchymoses of superficial anterior neck to the pathologist who elects not to perform an
strap muscles. However, a facial dissection dem- autopsy, including detailed information from ex-
onstrated numerous ecchymoses along the border ternal examination of the body.
of the mandible, the bilateral parotid glands and
the soft tissues deep to the oral mucosa, none of THE ‘MINIMAL’ DATASET
which were otherwise visible. Based on this in-
formation, law enforcement officers performed a The concept that forensic pathologists must cre-
directed interrogation of the uncle, who admitted ate a ‘minimal dataset’ of value to society and
to compressing the boy’s face and neck until he government embraces the idea that as physicians,
had stopped moving. In this example, the autop- our medical role extends beyond the determina-
sy was not complete without the face dissection. tion of an anatomic cause of death. Although
No amount of deliberation over the anatomy of some forensic pathologists argue that their role
the brain, neck and thoracic organs could have is guided totally (or near-totally) by their statu-
revealed evidence that pressure was applied to tory obligation to determine cause of death, none
the mouth, face and upper neck. would argue against documenting a shoe imprint
on the back of a person shot in the head, nor
Another example is that of a 45-year-old alcohol- would they argue against collection of specimens
ic who was found dead in his bathroom, slumped as part of a sexual activity kit. Although neither of
over the edge of the bathtub with his neck sig- these activities will necessarily contribute to the
nificantly hyperflexed against the opposing edge determination of cause and/or manner of death,
of the bathtub. External examination of his body they may provide data of great value to law en-
showed only a lividity pattern that was consistent forcement, the criminal justice system and oth-
with the position of the body at the scene. An au- ers. Similarly, a forensic pathologist who diagno-
topsy did not reveal injuries or significant natural sis a ruptured aortic dissection in a 23-year-old
disease. Toxicology revealed 0.18 g/dL of etha- woman may consider their statutory obligation to
nol in iliac vein blood (0.21 g/dL in ocular fluid be complete, but they have not served the family
and 0.25 g/dL in the urine). Although macro- without identifying the connective tissue disease
scopic anomalies were not identified at the time that was the underlying cause of the dissection.
of dissection, and an apparently obvious cause
of death was evident at the scene (positional as- Consider the example of a mother and her 9-year-
phyxia), routine histologic sections of the heart, old daughter found dead, apparently dumped in a
lung, liver and kidneys were obtained. Review of roadside body of water. Both had prominent fa-
the heart slide demonstrated severe lymphocytic cial and ocular petechiae, and faint ligature marks
myocarditis. Given this, the man most likely died on their necks. Routine internal examination of
suddenly as a consequence of his cardiac inflam- their heads and trunks did not reveal an anatomic
mation, and collapsed into a position that was cause of death or significant natural injury. An-
otherwise entirely consistent with a death due terior and posterior neck dissections revealed
to ethanol-induced positional asphyxia. In this features in keeping with ligature strangulation.
example, the autopsy was not complete without Layered full-body soft tissue dissections of the
Matshes et al. • Page 5
 daughter revealed numerous deep ecchymoses of During each autopsy the pathologist must make
the shoulders and extremities, and a deep multi- decisions about the necessity for special dis-
layered ecchymosis in the left small of the back. sections and additional studies. Each decision
INVITED REVIEW

This contusion, although not in-and-of-itself le- should be evidence-based. Although the phrase
thal was of critical importance during the trial as evidence-based often suggests the need to make
it corroborated witness statements that the per- decisions based on scholarly literature, it should
petrator was observed to kneel on the girl’s back also (perhaps more importantly) be taken to indi-
while strangling her with a ligature. cate that the evidence presented to the patholo-
gist (the history, the scene, external examination
The creation of a minimal dataset can be broadly findings, and progressively evolving autopsy
summarized in terms of the two types of autop- findings) was used to guide the development of
sies performed by forensic pathologists – autop- the autopsy. Thus in this context, these evidence-
sies of discovery, and autopsies of confirmation. based decisions allow for tremendous custom-
Autopsies of discovery include classic examples ization of any given case. This customization,
such as sudden death of an infant, sudden death in though, should not be misconstrued as an excuse
a young man who was swimming, and the death to routinely perform partial autopsies. Intrinsic
of a woman found dead, bound and gagged in to the concept of the minimal dataset is the need
a forest. Autopsies of confirmation may include to rule-in or rule-out broad categories of injuries
examples such as a man with an apparently self- and disease after examining the major organs and
inflicted gunshot wound of the chest, the driver tissues of the head and trunk. For example, if dis-
and passenger of a car involved in a single ve- section reveals that a brain or heart are macro-
hicle collision, and the death of a man found in scopically normal, literally thousands of poten-
an alley with a tourniquet on his upper arm, and tial causes of death have been eliminated.
a syringe in his antecubital fossa.
MAINTENANCE OF COMPETENCY
In both types of cases, the pathologist must ac-
curately determine the cause of death, and un- Some forensic pathologists practice in systems
cover evidence that will allow them to answer of death investigation that choose not to autop-
unanticipated future questions. In doing so the sy some broad categories of death. Examples
pathologist must perform dissections and special include occupants of crashed motor vehicles,
studies to address critical issues unique to each pedestrians struck by cars and suicides. The fo-
case. In the case of the woman found dead in a rensic pathologist who “never” autopsies an en-
forest, standard autopsy techniques may be ap- tire category of death may find themselves chal-
propriately followed not only by anterior neck lenged by a case where the differential diagnosis
dissection, but posterior neck and back dissec- includes that particular category that he/she never
tions, soft tissue dissections of the extremities, autopsies. For example, “are the neck injuries in
and possibly even a face dissection. In such a this decedent compatible with suicidal hanging?”
case, should it be determined that she died as a Given the inability of forensic pathologists to
result of some interpersonal violence (strangula- perform randomized, controlled, double-blinded
tion, blunt trauma, etc.), the extent and severity studies on injuries, much of a pathologist’s per-
of trauma is as critical as the cause of death itself. sonal dataset comes from extensive experience
In the case of the driver and passenger of a motor autopsying deaths where injuries were caused
vehicle, critical legal issues may arise if the car’s by a known mechanism. For example, testifying
occupants were married so that disposition of the about the degree of force necessary to cause a
estate is dependent upon who died first. In such a particular injury in a child is often aided by draw-
case, the discovery that the driver died instantly ing comparisons to injuries found in children dy-
of an atlanto-axial dislocation with spinal cord ing as occupants in a crashed motor vehicle, on
transection, and that the passenger died with 3 children who die after being struck by a car, or
liters of liquid blood in the abdominal cavity in even after having fallen from a great height.
association with a splenic laceration, may have
significant implications for family members. Al- Although one’s personal requirement to maintain
though medicolegal autopsies are not performed competency should not take precedence in any
for families per se, the results of autopsies should one case over factors such as family concerns
serve families. For example, family members are about autopsy, it should be considered carefully
not served if the pathologist fails to consider the by those who write legislation (federal, state-
genetic etiologies of a natural disease, if the pa- wide, etc.), office policies, and by pathologists
thologist cannot fully explain a child’s death, or who only rarely autopsy certain categories of
if the pathologist fails to collect evidence or fully death.
characterize the extent of injuries in a homicide
Page 6 • Volume 1 Issue 1

and this impacts prosecution or sentencing.

THE INDEPENDENTLY REVIEWABLE AUTOPSY and between offices and individual practitioners
REPORT will continue to blur opinions on the definition
of a complete autopsy in any one case. A “com-
For many years the mantra of the bombastic fo- plete” autopsy in which every conceivable test
rensic pathologist was “it is what it is, because I is performed cannot occur in forensic pathology.
say it is”. With increased societal and legal ex- However, an autopsy can be said to be complete
pectations for death investigation systems, those when it allows for the accurate determination

WHAT IS A COMPLETE AUTOPSY?

days are over (8). The work product of the fo- of cause and manner of death (statutory duty),
rensic pathologist is frequently subject to review when it facilitates the collection and documenta-
by outside experts. With growing appreciation of tion of evidence and determines the underlying
internal and external quality assurance reviews, nature of disease or injury (creation of a minimal
second opinions are being sought routinely by dataset for societal and governmental inquiry),
some systems of death investigation. To that end, and allows practitioners to obtain and maintain
an autopsy report alone is no longer an adequate experience with a broad variety of case material
form of documentation. The age of digital pho- relevant to daily practice, and of value in the in-
tography has made autopsy photography more terpretation of complex cases (maintenance of
readily available, and as such, pathologists now competency). When asked to triage cases toward
have the capacity to produce pertinent photo- or away from autopsy, a pathologist is forced to
graphs to supplement their reports (9). make decisions based on the totality of evidence
available to them at a particular point in time.
The independently reviewable autopsy report is When autopsy is selected, the pathologist must
best viewed conceptually as all of the primary then make decisions about evidence collection
materials utilized by the forensic pathologist. and dissection, guided by policies (when they
One of the authors of this paper (Matshes) has exist) in combination with findings revealed in
elected not to produce autopsy reports per se, but real-time. Rather than arbitrary selection of tests
rather death investigation summary documents and procedures, we recommend that patholo-
that instead summarize and make reference to gists make autopsy decisions based on consider-
the totality of primary documentation reviewed ation of these three prevailing goals of a forensic
during the course of a death investigation. Such autopsy.
documents include, but are not limited to reports
produced by death scene investigators, law en- ACKNOWLEDGEMENTS
forcement, EMT’s, hospital records, gross find-
ings at autopsy, ancillary studies (histology, Dr. Michael Pollanen is appreciated for the in-
toxicology, radiology, etc.), photographs, etc. sight he provided through numerous thoughtful
Furthermore, the report details who had contact discussions.
with the body and in what capacity, what special REFERENCES
procedures were performed and when (e.g., the
strap muscles of the anterior neck are evaluated 1) Davis JH. The future of the medical examiner system.
in a step-wise fashion after removal of the brain), First Milton Helpern Laureate Award address, National
and what organs and tissues were retained for Association of Medical Examiners, Hawaii, September,
further study. The totality of this documentation 1991. Am J Forensic Med Pathol 1995 Dec; 16(4):265-9.
constitutes an independently reviewable death 2) Shipman Inquiry. Death Certification and the Invest-
igation of Deaths by Coroners. 3rd Report. : (2004).
investigation record that facilitates confirmation
of diagnoses and conclusions on secondary re- 3) Guidelines on Autopsy Practice: Report of a Working
Group of the Royal College of Pathologists(2002).
view. Alternatively, errors can be detected and
4. Guidelines for Medicolegal Autopsies in Canada:
corrected when internal or external review is Canadian Association of Pathologists: Forensic
undertaken. Pathology Section(2008).
5) Peterson GF, Clark SC. Forensic autopsy performance
Ultimately an excellent forensic pathologist is standards. Am J Forensic Med Pathol 2006 Sep;
one who selects appropriate ‘tests’ based on the 27(3):200-25.
totality of available case data, is technically ca- 6) Adelson L. Symposium on autopsy and the law. The
pable of performing those tests (or consults ap- anatomy of justice. Bull N Y Acad Med 1971 Jul;
propriate experts), thoroughly documents their 47(7):745-57.
work (i.e., creates an independently reviewable 7. Moritz AR. Classical mistakes in forensic pathology.
Am J Clin Pathol 1956 Dec; 26(12):1383-97.
document), and then formulates an opinion that
is appropriate given all available evidence. 8. Davis JH. Medicolegal death investigation. In: Dolinak
D, Matshes EW, Lew EO, editors. Forensic pathology:
principles and practice. Amsterdam ; Boston: Elsevier/
CONCLUSION Academic Press; 2005. p. xxii, 690 p.
9. Oliver W. Considerations for gross autopsy photography.
Significant variance in practice standards within
Matshes et al. • Page 7

Acad For Path 2011; 1(1):epub.