Criminal foul play and medical malpractice often go undiscovered unless post-exhumation autopsy is performed. Declining autopsy rates is the likely culprit. In the years following World War II, about half of all hospital deaths were routinely autopsied. Now the number is under 10 percent, mostly because autopsies are costly and not generally reimbursable. In addition, hospitals and physicians fear malpractice litigation could result from autopsy findings that conflict with conclusions on the death certificate.

A recent university study found that forensic exhumations frequently are successful in discovering inconsistencies in cause of death as determined by authorities at the time of death. The study, which appeared in the April 2004 issue of the International Journal of Legal Medicine, found that major deviations between the cause of death as stated on the death certificate and as diagnosed after autopsy existed in nearly 40 percent of forensic exhumations performed in Münster, Germany. The percentage of misdiagnoses may be even higher.

"The real number of undetected homicides is difficult to estimate, but the cases reported definitely represent just the tip of the iceberg,” according to the study's lead author, Bernd Karger, MD, Institute of Legal Medicine at the University of Münster.

One reason for so many buried homicides is the local system of postmortem examination, where every physician in Germany is bound by law to externally examine a corpse and to fill out the death certificate. “But many physicians lack knowledge and experience, and perhaps even interest, in thanatology to perform postmortem examinations according to established standards,” Karger said.

Low Autopsy Rate
Another reason for undiscovered crime is the low autopsy rate. Only 1.2 to 1.4 percent of all fatalities in the Münster area are autopsied by a specialist in legal medicine, compared to 3.4 percent in Munich and 20 percent in the U.S. Approximately one-fifth of the 2.4 million deaths in the U.S. each year are investigated by medical examiners and coroners, accounting for approximately 450,000 medico-legal death investigations annually, according to the Institute of Medicine. The lower German autopsy rate equates, then, to higher exhumations.

Karger's study reports on a total of 155 exhumations performed from 1967 to 2001, each evaluated retrospectively on the basis of autopsy report, police report, and death certificate. Histology and toxicology were performed in most cases. Postmortem intervals varied from 8 days to 8 years.

“The cause of death could be clearly determined in 103 cases (66.5 percent) and histology or toxicology was decisive in 40 percent,” Karger said.