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.

Some findings were discernable using immunohistochemistry after considerable postmortem intervals, such as acute myocardial infarction after one year and pneumonia after two years. A diazepam intoxication was determined after 4.5 years.

Major deviations between cause of death as stated on the death certificate and as diagnosed after autopsy existed in 57 cases, or 37 percent. Karger concluded that exhumations were frequently successful for recovering evidence which should better have been collected immediately after the death of the individual. Further, exhumations can also be regarded as an instrument to evaluate the quality of death certificates and death investigations, he said.

In Perspective
Any research that shows that nearly 40 percent of exhumations expose a wrongful cause of death may at first read like an indictment of medical examination practices. But the study must be read in proper light.

“The authors state that few autopsies are performed in their area, thus exhumations are more frequent and therefore more useful,” said Dr. Moses S. Schanfield, chair of the Department of Forensic Sciences, The George Washington University.

The U.S., with its system of medical examiners and coroners, is different. Most states require that all unattended deaths, as well as suspicious deaths, be autopsied, which does not appear to be the case in Münster.

“The results of the Karger study are not surprising as almost all of the autopsies (146 of 155, or 94 percent) were ordered by the courts or prosecutors. Thus, there appeared to be some prior basis of untoward death,” Schanfield said.

Modern Equipment
The craft of autopsy - practiced by humans for 2,400 years and modernized by Germans in the 19th century - may itself be dying. The percentage of autopsies has fallen dramatically in the U.S. over the last half century.

In the 1950s, nearly half of all patients who died in U.S. hospitals were autopsied. Now it varies between 5 percent and 13 percent, due in large part to restricted hospital budgets and modern imaging techniques like CT and MRI scanners, which are believed to be so proficient at picturing internal pathology that invasive procedures are no longer as necessary.

While exhumations may be rare in the U.S., it is not unusual for any domestic autopsy to find inaccuracies in the stated cause of death. “You could write an article about doing 155 consecutive autopsies at Presbyterian Hospital in New York City, or at the UCLA Medical Center, and the answer would be about one-third of the time the autopsy would find the wrong diagnosis stated on the death certificate,” said celebrated pathologist Michael Baden, MD, Chief Medical Examiner for the New York State Police, and New York City's Chief Medical Examiner from 1961-1986.

Even with the aid of modern imaging modalities like CT and MRI, autopsies will find missed significant diagnosis in 30-40 percent of cases, Baden said.

Final Cut
Exhumation autopsies are normally only performed in the U.S. when issues of medico-legal significance arise. “I don't know how they missed that many homicides in Münster,” Baden said. “To miss children who've been battered, injuries from blows from beer bottles, and gunshot wounds that were not identified indicates that the bodies were poorly examined to begin with.”

Baden said that would be unusual in this country, because if there is any thought of homicide then an autopsy is performed before burial. There are exceptions, however. Exhumation autopsies are done on suspected serial deaths, such as when several babies die in one family, when a husband has a number of wives die mysteriously, or one nurse is the common denominator in an inordinate number of hospital deaths.

“When the first baby suffocates or the first spouse is poisoned, you don't know that,” Baden said. “But after a series of deaths then we may do exhumations because of the suspicion that's raised that was not present when the first death occurred.” In other cases, a second, later, autopsy may be beneficial.

“Even when a body has been previously autopsied, it is still possible to find lots of information that was missed during the first one,” Baden said. Baden used the example of civil rights leader Medgar Evers, who was shot in the back in 1963, a few weeks before President Kennedy was murdered. “It took 30 years and an exhumation of Evers’ remains 28 years after death to gather enough evidence to go to trial and convict the shooter,” Baden said.

Medical examiners, however, are not in the business of solving murders. The role of the medical examiner is to determine what happened, not who did it. The body contains a wealth of information, even 28 years after burial. It took 30 years to get further information that led to the conviction of Byron De La Beckwith in the Evers matter.

“A second autopsy can pick up information that's focused, when you know what you're looking for, because you now have more information than at the time of the first autopsy,” stated Baden. Exhumations can be helpful because traces of most poisonous drugs can be found in the body long after death. “That's one of the reasons we do exhumations here, because poisons weren't properly tested for,” Baden said.

Lack of Standard
Many believe we'd have a better chance of proper testing if standards were established. Steve Nunez, program manager in the University of New Mexico Office of the Medical Investigator, is another expert not shocked at the Karger findings. “Given the system of postmortem examination described in the German jurisdiction during the time period cited, the findings are not that surprising,” said Steve Nunez.

Some standards for proper death scene investigation and examination of remains do exist. However, death investigation in any given political jurisdiction only as good as the laws that require and define it, and the expertise, infrastructure, and financial resources provided to manage it, Nunez said.

One purpose the Karger study may serve is to illustrate the need for more stringent forensic pathology standards for determining time of death, methods of performing autopsies, and how tests are performed. Baden believes there should be an attempt to get international standards so that all forensic pathologists proceed in a similar manner in a given type of investigation.

“While uniform standards might be hard to establish, it's important that the crime scene be investigated properly, with a search for trace evidence, then a standardized autopsy be conducted, with proper toxicology tests,” Baden said.

Those steps could be developed into international standards, just as hospital conducted, non forensic autopsy procedures have been standardized, he said. Most forensic and medico-legal experts agree that some standardization policies need to be established.