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PreventingErrorsinDeathInvestigation
usingForensicPathologyBeyondthe
Autopsy
ElizabethA.Laposata,MD,FCAP,FASCPForensicPathology&LegalMedicine,Inc.
Providence,[email protected]
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