Abstract
In 1956 Dr. Alan Moritz wrote a timeless manuscript entitled “classical mistakes in forensic pathology”. This treatise on the common personal and systemic failings within death investigation is considered by many to be a seminal work within the field, and all medical examiners would benefit by reviewing it annually. This brief manuscript reviews case examples where pathologists fail by substituting intuition for scientifically defensible fact, or by jumping to conclusions based on a limited data set. Without a doubt, forensic pathologists err, but it is when those pathologists refuse to accept or learn from their mistakes that they become a danger to the cause of justice.
In 1956 Professor Dr. Alan Moritz, Director of the Institute of Pathology, Western Reserve University, Cleveland, Ohio presented a keynote address to the American Society of Clinical Pathologists entitled Classical Mistakes in Forensic Pathology, a result of his experience and that of other forensic pathologists in practice in the United States at that time (1).
His article is as true today as it was thirty-seven years ago. Most of the mistakes he lists are errors of omission: failures to do something which should have been done. Errors of omission were common in United States because most areas of this vast country were not served by pathologists who were experienced in forensic pathology.
Most of the states had elected coroners without qualifications. They would contract with a local pathologist, unskilled in forensic pathology, if they deemed an autopsy were necessary. The normal procedure was to conserve money by not requiring an autopsy.
As a result, most errors were those of omission, failure to understand the objectives of a medicolegal autopsy, failure to perform a complete autopsy, failure to understand post-mortem changes, failure to photograph and describe external abnormalities, poor retention and preservation of specimens for toxicological study and so forth.
Such errors tend to weaken the evidence against criminals by creating questions of the sufficiency of evidence against a presumed criminal.
This article, Classical Mistakes in Forensic Pathology, should be required reading at least once per year by all pathologists, regardless of experience.
Today the United States has much greater numbers of experienced forensic pathologists, experienced in the sense that they repeatedly perform autopsies in medicolegal cases. Many of the elected coroner systems have been replaced by medical examiners, pathologists appointed to perform medicolegal investigation of death. In many states elected coroners have regional forensic pathologists available for autopsies.
The United States still has wide variation in the systems of medicolegal death investigation. However, there appear to be an increasing number of errors particularly prevalent amongst experienced forensic pathologists.
Professor Moritz, in a section entitled Mistake of Substituting Institution for Scientifically Defensible Interpretation states “This brings me to one of the most dangerous mistakes in forensic pathology, and one that is particularly prevalent among experienced forensic pathologists …” “This Sherlock Holmes type of expert may see certain bruises of the neck and conclude without doubt that they were produced by the thumb and forefinger of the right hand of the strangler … He ignores the essential component for proof of the correctness of any such scientific deduction, namely, the non-occurrence of such lesions or changes in control cases … It is difficult to estimate how much harm is done by these people. The ordinary hospital pathologist is not accustomed to being so continuously unchallenged as to permit him to acquire a full blown God-complex of the kind I am discussing … It is only the full-time forensic pathologist who is likely to become accustomed to having his opinions go virtually unchallenged.”
Over the past few years I have encountered several cases where full-time forensic pathologists have rendered opinions which resulted in accusations of murder or misconduct even though no murder or misconduct had occurred. The cases all had one thing in common, a full-time forensic pathologist who rendered an opinion based more on intuition rather than scientifically defensible evidence.
Some problems involved personality such as a great ego. Some are accentuated by inadequacies of the investigative system in which the pathologist works. Some medical examiner or coroner systems have not improved but continue to operate in the same manner as they did when first created. For example, the printed forms utilized in one medical examiner system in a large city in the United States were not improved in seven decades. Only recently did that system bring in a chief medical examiner from outside the office to reform and improve the system.
The responsibility of the forensic scientist, whether pathologist, toxicologist, firearms examiner or other, is to perform analyses and to render truthful and sound opinions so that the guilty shall be properly prosecuted and the innocent not be accused.
Basic to this is integrity which has been lacking in some professed courtroom scientists. Professor Starrs of George Washington University, in an illuminating publication entitled “Monte-banks Among Forensic Scientists” reveals names and escapades of scientists whose avarice led to their downfall. Common to many of these were falsification of credentials, claimed academic degrees which they failed to achieve (2).
Even well intentioned forensic scientists can produce erroneous opinions especially when faced with unusual situations where evidence is incomplete or the circumstances are unique. They may be faced with facts that they never before considered. Under these circumstances their conclusions may be wrong due to inexperience. A problem with such opinion errors is that police, prosecutors and judges are poorly equipped to recognize the discrepancies and may accept the scientist's report as adequate when, in fact, it was not. The Australian dingo dog case is an excellent example and worth study by all who work in the justice system (3).
The following cases exemplify some of the problems which occur when pathologists substitute intuition or jump to conclusions based upon a limited data base. A common error is over reliance upon non-contributory data (4). For example, fractured ribs may be highly significant in one set of circumstances but rib fractures associated with cardiopulmonary resuscitative (CPR) procedures upon a victim of sudden cardiac death are of no diagnostic significance (5).
Case 1 – CPR Artifact not Recognized
A prominent attorney suffered a fractured femur in a frontal automobile collision. On hospital day one and two he was alert, afebrile and in traction. On day three he had hemoptysis, patchy lung infiltrates and mild fever. On day four he had tachycardia, higher fever, suffered cardiac arrests and was subject to CPR on two separate occasions. Hypoxic brain damage occurred. Fat embolism syndrome was diagnosed. He was maintained on a respirator for three more days. Prior to pronouncement of death he had forty minutes of energetic resuscitative attempts. A separation of liver capsule plus liquid blood in the peritoneal cavity were interpreted by the forensic pathologist as unrecognized trauma to the liver eight days earlier despite no evidence of vital reaction in the liver (5). A malpractice lawsuit ensued against the treating physicians.
The pathologist, although a full-time employee of a death investigative system, had not been critically trained nor supervised. Apparently the agency did not depend upon clinical records or circumstantial events but relied too much on misinterpretation of autopsy findings.
Case 2 – CPR Artifact not Recognized
A woman was found, apparently following an epileptic seizure, which her head caught between the mattress of the bed and the adjacent night stand. She could not be revived despite extensive resuscitation both at the scene and in the hospital. Following death her eyes were donated to the eye bank for corneal transplantation. The pathologist opined that she had been beaten about the right eye (not recognizing the artifactual hemorrhage from removal of the eyes) and also stated that she had been strangled (not recognizing the tiny mucosal haemorrhages of the hypopharynx and larynx caused by endotracheal intubation).
The husband was charged with murder. Fortunately, defense witnesses pointed out the errors. The prosecutor sent case records to me for review. It was quite clear that the original pathologist was in error.
Subsequently, the falsely accused husband initiated a lawsuit against the pathologist who died before the civil case could be adjudicated.
Case 3 – Shotgun Suicide Called Murder
A woman was found by her boyfriend. Her head was burst open and brain and blood soiled the scene. She had shot herself in the mouth with the boyfriend's illegal sawed off shotgun. He panicked and fled with the shotgun. The pathologist did not recognize the mouth entry and opined that the residual defect of the face, when facial tissues were placed back together, was evidence that the shotgun was fired from a distance of several meters. The boyfriend was arrested, tried, convicted and served two years in prison before an appellate court reviewed the evidence and opinions rendered by myself and other forensic pathologists that the original pathologist was in error.
A suicide note in the victim's handwriting had been found at the scene. Despite this exculpatory evidence the prosecutor had relied upon the erroneous conclusion of the original pathologist.
Case 4 – Homicidal Strangulation that was Not
An elderly, wealthy, chronically ill, alcoholic and drug addicted woman was found prone with her neck resting in a loop of telephone wire hanging down from the bedside table. Police thought she had accidentally strangled while crawling across the floor toward her cane. The pathologist found internal neck haemorrhages and a cracked superior horn of the thyroid cartilage. He immediately opined murder by strangulation. Subsequently, the son-in-law was charged with murder. Microscopic study revealed the contusions inside the neck to be infiltrated with neutrophils. This injury had occurred the night before when a drunken brawl erupted and her daughter had thrown her to the floor. After a highly publicized trial the son-in-law was acquitted by the jury.
The problem with this case was twofold, too quick a judgement by the pathologist plus a lack of familiarity with the facts of the case. The pathologist had been wrongly informed that the telephone cord had been wrapped around the neck.
Case 5 – a Starved Child but was it the Mother's Fault?
This was a most complex case and has been previously reported (6). It involved a Down's Syndrome infant with duodenal atresia. After seventy days of hospitalization and repair of the atresia, the mother was persuaded to take the child home. She neglected to bring the child back to the clinic and the child subsequently died.
It was extremely malnourished and it seemed clear that the mother was at fault. Subsequently, an experienced pediatric pathologist, called by the public defender, pointed out that the chances of survival under the best of conditions was doubtful because weight gain during the seventy hospital days was poor in relation to other infants of like birth weight. Also, the hospital personnel had neglected to arrange for home visits with a readily available public health nursing service. The poor mother had no means of transportation to the clinic. The consultant pediatric pathologist, the defense attorney, the prosecutor and myself reviewed the case and concluded that the mother should not be charged with homicide but only neglect in order to furnish her supervision and assistance from the child protective services.
This error occurred in my own office and exemplifies that an extremely complex case may involve subtle clinical problems. Our lesson is that we forensic pathologists should seek assistance from our clinical colleagues when faced with cases of great clinical complexity.
The above cases exemplify some of the problems pointed out by Moritz in his classical article. All of us should learn by experience. As Moritz points out in this paper “The factual material upon which this discussion is based is derived from several sources. First are the mistakes that I have made. In the course of 30 years, their number and variety have become formidable”. After 38 years of full-time forensic pathology practice, I can also say the same. If we learn from our errors, that is fine. To refuse to learn from mistakes is unforgivable and a great danger to the cause of justice.