Investigation using Forensic Pathology Beyond the Autopsy

PreventingErrorsinDeathInvestigation

usingForensicPathologyBeyondthe

Autopsy

ElizabethA.Laposata,MD,FCAP,FASCPForensicPathology&LegalMedicine,Inc.

Providence,RhodeIslandELaposataMD@FP-LM.com

ElizabethA.Laposata,MD,FCAP,FASCP

• DiplomateoftheAmericanBoardofPathology– Anatomic&ForensicPathology

• Over35yearsexperience– AssistantmedicalexaminerinSt.Louis,Delaware,Philadelphia

– ChiefMedicalExaminerStateofRhodeIsland– President,ForensicPathology&LegalMedicineanindependentmedicolegalconsultingpractice

Beyondtheautopsy

• Analyzingallforensicevidenceandfactsofthecase– DNA– Traceevidence– Ballistics– Toolmarks– Fingerprints– Surveillancevideo– Crimescenereportsandphotographs– Autopsy

©ForensicPathology&LegalMedicine,Inc.,2017

Medicalexaminer’soffice

• Autopsydonetoprofessionalstandards– PhotographsandX-Rays–Medicalinterventions– Histology– Toxicology

• Medicalhistory• Scenephotographs• Witnessstatements

©ForensicPathology&LegalMedicine,Inc.,2017

Pathologyexpert

• Autopsydonebyqualified,experienceddoctorwithlicensetopracticemedicineandboardcertifiedinforensicpathology

• “Weseeonlywhatweknow.”-JohannWolfgangGoethe

©ForensicPathology&LegalMedicine,Inc.,2017

Sixquestionstobeansweredfromexaminationofthebody

1. Whoisthevictim?2. Whendidthedeathand/orinjuriesoccur?3. Wherewasthescene;whatwerethe

circumstances?4. Whatinjuriesarepresent?5. Whichinjuriesaresignificant?6. Why&howweretheinjuriesproduced?

From:AdelsonL(1974)PathologyofHomicideCharlesC.Thomas; Springfield,IL

©ForensicPathology&LegalMedicine,Inc.,2017

Beyondtheautopsy

• Usetheforensicpathologist’straininginclinicalmedicinediagnosistoanalysisallthefactsofthedeathinvestigationusing

– Inferentialthinkingorreasoningtodevelopadifferentialdiagnosis

©ForensicPathology&LegalMedicine,Inc.,2017

Usingamedicalmodeltopreventerrorsindeathinvestigation

• Whydodoctorsinclinicalmedicinemakemistakes?

• Answer:deductivereasoning

• Whatdotheydoaboutit?

• Answer:inferentialreasoning

©ForensicPathology&LegalMedicine,Inc.,2017

Deductivereasoning(nodifferentialdiagnosis)

• Top-downlogicgivenafactorfinding

• Aconclusionbasedonafundamentaldictumknowntobetrue

Finding

©ForensicPathology&LegalMedicine,Inc.,2017

Deductive:top-downlogic

• Patientswithinfectionhavehighwhitebloodcellcounts

• MypatienthasahighWBCcount

• Diagnosis:Mypatienthasaninfection– Startantibiotics;cultureblood,urine,cerebrospinalfluid;placeinisolation

FINDING

©ForensicPathology&LegalMedicine,Inc.,2017

Inductivereasoning(createsadifferentialdiagnosis)

• Bottom-uplogic• Generatesalistofpossiblewaysacertainoutcomecouldhavebeenproduced

Inductivereasoninggeneratesideas

Finding

Ideasastopossiblecauses

©ForensicPathology&LegalMedicine,Inc.,2017

Inductivereasoning:bottom-uplogic

• Createadifferentialdiagnoses

• HowmanywayscouldmypatientdevelopahighWBC?

• MypatienthasahighWBCcount

infection leukemia drugreaction autoimmunedisease acutestressreaction

©ForensicPathology&LegalMedicine,Inc.,2017

Case1:childwithabdominaltrauma

©ForensicPathology&LegalMedicine,Inc.,2017

Casesensitivematerialomittedfordistribution

Case2:ManwithStabWounds

Casesensitivematerialomittedfordistribution

©ForensicPathology&LegalMedicine,Inc.,2017

Case3:DeathAfterFightwithPolice

Casesensitivematerialomittedfordistribution

©ForensicPathology&LegalMedicine,Inc.,2017

Case4:NakedWomanDeadonGroundOutsideHouse

Casesensitivematerialomittedfordistribution

©ForensicPathology&LegalMedicine,Inc.,2017

BarrierstoInductiveReasoning

• Groupthink• Bias• Silos• Prematureclosure• “Wicked”problems

©ForensicPathology&LegalMedicine,Inc.,2017

Workwiththeforensicpathologistatthebeginningofthecase

• Dismantlesilosandshareinformation

• Developalistofdifferentialdiagnosesbyusinginductivereasoning

• Utilizetargetedtestingtogetanswersthatareprobative

©ForensicPathology&LegalMedicine,Inc.,2017

CasesforInformationSharingandInferentialReasoning:

Howelsecouldithaveoccurred?

• Triage– Highprofilecases• Deathsofchildrenandinfants• Deathsincustody• Deathsofindividualsofpublicinterest

– Complexcaseswithmultipledatapointsortypesofevidence

©ForensicPathology&LegalMedicine,Inc.,2017