Paediatric forensic pathology

The death of a child or infant in suspicious circumstances is one type of case that has the potential for being particularly contentious for forensic pathologists, and the evidence base upon which opinions are based is weak in certain instances, not least those involving alleged 'shaken baby syndrome' or 'short distance falls'.

The Goudge Inquiry into paediatric forensic pathology services in Ontario, Canada demonstrates how 'bad things can get'. Aspiring forensic pathologists are recommended to visit the website for this Inquiry, which provides a unique insight into current thinking on the contentious issues, with transcripts of witnesses called to give evidence at the Inquiry, as well as some extremely interesting documents prepared by forensic pathology and legal experts for the Inquiry.

Of particular note are 'Paediatric forensic pathology: Limits and controversies', by the Victorian Institute of Forensic Medicine, Australia, 'Medical mistakes and miscarriages of Justice' in the UK, 'Paediatric forensic pathology as forensic science', and 'Demonstrable reliability and expert forensic pathology evidence'. In addition, there is an excellent paper, again from the Victorian Institute, on 'A model Forensic Pathology Service', which gives more general guidance on how a modern forensic pathology service should operate.

All authors highlight the lack of 'evidence-based forensic pathology', particularly in those areas of paediatric practice that are commonly in dispute at trial. The Welsh Child Protection Systematic Review Group is attempting to address this need, and have performed systematic reviews of the literature for abusive bruising, fractures, burns and oral injuries/bites, as well as currently finalising a review of non-accidental head injury, and undertaking a review of retinal haemorrhages. It remains to be seen whether such evidence makes its way into expert opinions and court proceedings.

Fire deaths

One category of death that often causes interpretative problems for forensic pathologists is the fire death.

A useful summary of the issues raised by such deaths has been recently published, highlighting the need to establish the deceased's identity and, in the pathological assessment of the body, to determine whether the deceased was alive at the time of the conflagration, why they could not extract themselves from the fire, and what the cause (and manner) of death appears to be.

In England and Wales, fire deaths are often investigated by coroner's pathologists with little (or no) training in forensic pathology; the approach taken in some cases rests on the assumption that there are no attendant suspicious circumstances, and it is only when the post mortem blood carboxyhaemoglobin level is returned from the laboratory as zero % that a review of the post mortem findings indicates some other cause of death than 'exposure to fire smoke and fumes'.

Whether this situation would occur in jurisdictions in which forensic pathologists perform all such post mortem examinations is unclear, but it behoves the autopsy-performing pathologist to consider the possibility that their 'fire death' is not related to exposure to the products of fire but is, in fact, a concealed homicide, and that the pathological assessment - and documentation of the findings - is capable of scrutiny should the 'worst-case scenario' unfold later in the course of the investigation.