A Day in the Life of a Forensic Pathologist

In this video, Associate Professor David Ranson talks about the role of a Forensic Pathologist.

A day in the Life of a Forensic Pathologist

by Clinical Associate Professor David Ranson

It had been an average week.  It had been an average weekend.  Babies had been born.  No doubt there had been work, rest and play.  But there had also been death; death of loved ones, deaths in the family, death amongst friends.  Now it’s Monday morning and the grieving continues.  For many, indeed most, bereaved families there will be no need to contact the Coronial Services Centre.  Death from natural disease where the family’s treating doctor is able to provide a death certificate means that the death becomes a largely private affair managed by the family’s funeral director on behalf of the bereaved family and friends.  The Registrar of Births, Deaths and Marriages will receive the doctor’s death certificate and register the death and arrangements will be made at the crematorium or cemetery.  Religious advisors will prepare services and help family and friends.

For some families this simple private process will take on a public dimension.  Perhaps the death has been the result of an accident or an injury.  Perhaps death has come suddenly and unexpectedly so that the cause of death is unknown and no death certificate can be written.  Perhaps suicide or homicide is suspected. Perhaps the death has come to a prisoner in gaol or to a patient in hospital undergoing a surgical operation.  Perhaps an unknown body has been found in a ditch on a country road.  These are the type of deaths that are referred to the Coroner for investigation.  These are the people that will be admitted to the mortuary at the Victorian Institute of Forensic Medicine.  These are the loved ones our doctors will examine and on whom an autopsy may well need to be performed.

Over the weekend the mortuary forensic scientific staff have been busy receiving such bodies, taking blood samples, cleaning and preparing the autopsy rooms for the week’s work.  The surgical instrument trolleys are now laid out in rows covered by clean green surgical towels.  Now it’s Monday morning and in the Coroners Court of Victoria the case files are lined up and the phone is already ringing.  It’s the major collision investigation unit of Victoria Police there has been a fatality on the freeway. Another phone rings, funeral directors want to know when they can arrange the funeral of a man who died in his sleep on Saturday night.  The court registrars and forensic scientists in the mortuary are tired it has been a busy night.  Every body brought to the mortuary has had a whole body CT scan and a high resolution CT scan of the head, blood samples have been collected on admission for drug and serology testing. The night staff will be off duty in a few minutes but for the remainder of the day shift a hard day’s work is about to start.

There are now about one hundred bodies in the mortuary fridges.  There are already autopsies ordered on 15 cases.  It is 6.30 in the morning and the first pathologist arrives.  By 7.00am two others will have joined her and these “early birds” will be joined by the one of the mortuary liaison officers, a forensic nurse.  The new deaths reported to the Coroner will be reviewed by the duty pathologist and the duty nurse. Preliminary investigations will be undertaken including documentation of the medical histories of patients who have died in hospital and external examinations of the deceased which will be integrated with the CT scans and blood results.  Arrangements may need to be made for blood samples from hospital laboratories to be transferred to the laboratories at the Victorian Institute of Forensic Medicine for further forensic analysis. The duty pathologist will need to formally review hospital and general practice medical records as well as the police reports as to the circumstances of the deaths. The CT scans that have been performed by the forensic scientists need to be examined by the duty pathologist and some images referred to the duty radiologist.

The results of these investigations as well as any overnight toxicology testing of blood samples must be available prior to a meeting with the duty coroner who will decide on whether an autopsy is necessary in each case. When the autopsies are ordered by the coroner the duty pathologist and nurse must ensure that these cases are allocated to the staff specialist forensic pathologists and some times to particular pathologists who have special expertise in certain death types. Certain cases need to be selected for the pathology trainees and supervising staff forensic pathologists are allocated to all such cases.  Autopsies on individuals with infectious diseases such as Meningitis, hepatitis, tuberculosis or HIV must be grouped and conducted in special high risk case examination rooms.

A tired forensic pathologist and mortuary technician leave the “homicide” autopsy room.  A man had been stabbed in the early hours of Sunday morning and had died later that day in hospital.  While the police search for his assailant his body had been brought to the mortuary at the Victorian Institute of Forensic Medicine and a CT scan and autopsy performed.  With eighty stab wounds it takes a long time to describe the size, shape and location of each of the wounds. In addition the police from the homicide squad want to know the force required to cause each wound and how the victim was positioned when they were stabbed. Because it is thought that more than on assailant  was involved the pathologist needs to determine whether more than one knife was used and come to a conclusion as to which of the wounds actually caused the death.  As a result the pathologist and mortuary scientist have worked through Sunday night and the early hours of Monday morning.  They have probably had little sleep but they will now not have to perform any further autopsies that day!

There is a problem with the scheduling of autopsies.  One of the pathologists who had been allocated cases that day had been subpoenaed to give evidence in a murder trial some time that week and now the police have rung in to say he is needed in court this morning.  The forensic nurse juggles the cases on the autopsy list.  “If we move him to start his cases early he can do the autopsy on the decomposed body found in the city apartment and the suspected heroin overdose with Hepatitis C at 7.30 which should give him time to get to the Supreme Court by 10.00 o’clock.  But someone else will have to supervise the pathology registrar at 11.00.”  The Coroners’ staff have been ringing families to inform them about what is happening with the investigation of death of their loved ones and letting them know that they can request a review of the coroners decision to order an autopsy. In several cases the request for an autopsy has been changed to a request for an external examination of the body only.  It looks like today’s autopsy list will have to be changed again.

In the mortuary, forensic scientists are preparing bodies for autopsy.  Further blood samples are being collected, labelled and placed in sealed tamper proof forensic security bags for transportation to the laboratories upstairs.  Bodies are measured and weighed.  A forensic scientist wheels a body on a trolley into the main autopsy room from the radiology room.  The X-rays and the mortuary CT scans are now stored on the computerised case management system.  The deceased had been the pilot of a light aircraft that crashed whilst on a short flight.  He and his two passengers were killed.  The pathologist brings up the mortuary CT scan and X-rays of his hands on the computer screen next to the body. The scans will help the pathologist determine whether the pilot was actively engaged in trying to control the aircraft at the time of the crash.  The on-call forensic dental team have already been contacted and asked to come to the mortuary later that day to examine all three victims so as to identify them from their teeth and dental records.  All three bodies are burnt beyond recognition and there is little or no tissue suitable for DNA analysis.

The “early birds” have now finished their autopsy dissections and are dictating their reports; a driver of a car that hit a tree, a pedestrian hit by a truck, a golfer struck by lightning, a forty year old and a twenty year old who hanged themselves. A toddler who was found face down in the backyard swimming pool, an old lady who died in her nursing home bed, but who had fallen the previous day, a man found dead in his car in a lane way and a woman who may have overdosed on her antidepressant medication.

The pathologist subpoenaed for court has already been and gone.  The bodies of the two cases he autopsied have been reconstructed, washed and placed in a refrigerated room awaiting collection by the family’s funeral directors.  Although badly decomposed, examination revealed that the older man had probably died of ischaemic heart disease and the young man with hepatitis showed the all too characteristic scars and needle puncture marks at the front of the elbow indicating “recreational use of illicit drugs!”

Its 11 o’clock and the second group of forensic pathologists arrive in the mortuary to begin their cases.  The trainee pathologists are completing their autopsies and presenting their findings to the last of the “early birds” as the new group of autopsies gets underway.  The “early birds” leave the mortuary and a group of medical students arrive for a teaching session in the Institute’s lecture theatre.  They are late!  The pathologist who was to have been teaching them has left and now one of the pathologists in the second group will have to leave the mortuary to take over the lecture, she is not happy!.

The quality management group meeting started at 11.00 am.  No time for a shower, the pathologist who heads the pathology section at the Institute takes off his surgical gown and hurriedly gets dressed, doing up his tie as he leaves the change room.  He runs upstairs and downloads the digital audio files of his dictated report drafts on to the computer system.  He runs downstairs to the meeting room, the door closes.

The duty pathologist and the duty forensic nurse make their way to the morning meeting with the duty coroner to discuss the new cases recently admitted to the mortuary.  The pathologist has performed a preliminary examination and has read the medical records, examined the bodies externally, reviewed the post-mortem CT scan and overnight toxicology reports.  A preliminary report has been prepared for the coroner. A middle aged man had collapsed at work in the machine shop.  The grief councillors who have been talking to the family tell the coroner that the wife cannot bear the thought of him undergoing an autopsy and the coroner is sympathetic.  Unfortunately, despite obtaining his general practitioner’s medical records it appears the man was not suffering from any known disease that might be expected to cause him to die suddenly.  In addition his work mates believe that he was using some electrical equipment at the time he collapsed and that the area was wet.  They believe that he may have been electrocuted.  The pathologist explains to the coroner that if there was a large amount of water around there may not be any electrical burns to the surface of the body.  Occupational health and safety, civil and criminal issues could arise in relation to this case.  While criminal and civil litigation matters are not necessarily the concern of the coroner, the way in which the man met his death remains unclear.  The coroner agrees that he will have to order an autopsy to help resolve these issues.

The next case involves a family whose little six year old daughter was hit by a car while riding her bike in the street.  The child had been taken to hospital and the medical records include the results of the emergency surgery and the results of the X-rays and CAT scans.  The pathologist advises the coroner that the information contained in the medical records would appear to disclose the cause of death and that the external examination of the body revealed a pattern of injury that was typical of the circumstances in which the accident was alleged to have occurred.  Satisfied, the coroner agrees that no internal autopsy examination need be performed.

It is lunch time and in the Institute’s lecture theatre a talk is being given by a police officer from the drug squad describing the current position in relation to illicit drugs available in Victoria.  An active discussion takes place between the toxicology staff, pathologists and the visiting speaker regarding their experiences of deaths associated with the use of illicit drugs.  In the middle of the talk the pathologist who had to give evidence in court that morning hurries into the lecture theatre.  It had been a straight forward court case but he has been in the witness box for two and a half hours.  The lecture ends and staff discuss a potential research project regarding deaths from drugs of abuse with the speaker.

Unfortunately several of the pathologists from the second shift in the mortuary have missed the lecture.  It was a busy morning.  Families and funeral directors have been ringing the Coroners Courts staff all morning asking when they can collect the body of the deceased and organise their funeral.

The pathology staff moves upstairs to their offices.  The microscope slides and toxicology results from the cases they performed in the last few weeks have been arriving from the laboratory and must now be examined and incorporated within the final autopsy report.  Often the death will have to be completely re-evaluated.  A complex ‘medical case’ is causing problems.  The young woman died following laparoscopic surgery apparently from a rare complication of this procedure.  This case requires a trip to the library in order to research this complication and to find out how many cases have been reported in the medical literature.  The case also merits a search of the Institute’s database and an application to the National Coroner’s Information System to see if other similar cases have been investigated by a coroner in Australia.

Upstairs in the trainees room, pathology registrars and fellows are clustered around a “multi-header microscope” that allows nine people to view microscope slides simultaneously.  The supervising pathologist is responsible for reviewing autopsy cases performed by trainees and assisting in the completion of their final autopsy reports.

It’s the middle of the afternoon; grim faced parents arrive at the reception desk.  They have come to see the pathologists who performed the autopsy on their daughter.  The girl’s two brothers are with them.  The pathologist comes down and greets them and they move to the meeting room where they are offered a cup of tea and are joined by the grief counsellor and a coroner’s court registrar.  Carefully the pathologist asks them how she can help and having heard their questions takes them through the autopsy report explaining what was done and what the findings mean.  Often there is anger.  Often there are tears.

The phone rings in the coroners’ court initial investigation office.  A mother has just found her baby dead in its cot.  She had put it down for a sleep after she had fed it that morning and found it dead at lunchtime.  The child and mother were taken to the children’s hospital by ambulance and arrangements are now being made for one of the forensic technicians to attend at the scene of the death and to examine the cot and the room in which the child died.  The forensic pathologist on call is notified that an autopsy may be required the next day as the circumstances of the death are not clear and another child in the family had previously been notified to child protection services.  Arrangements are made for the child to be transported from the hospital to the mortuary and for a specialist paediatric pathologist to be available to assist the forensic pathologist the next day.  In the meantime the mother and child spend some time together at the hospital in the care of the nursing and support staff so that final farewells can be said.

The scope of the work for the next day is becoming clear.  New deaths are being reported to the coroner.  Autopsy reports are being finalised.  Meetings arranged.  Subpoenas received.  Phone calls made.  A man has been shot and has just died in hospital.  The “homicide” pathologist grabs the keys to the on-call car and looks forward to another night without sleep.  The work of the forensic pathologists goes on.

Death investigations described in this article are fictional and are not based on any true case.